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O1.

1 of two approaches (parallel imaging-PI, and compressed sensing-CS) shows promise for
A Systematic Comparison of Different Techniques to Measure Clot Length in reducing acquisition times by factors of ≥2×. In volunteers PI and CS techniques were evalu-
Patients with Acute Ischemic Stroke ated 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
Qazi, A1, 3 Eesa, M1, 2 Qazi, E1, 3 Goyal, M2, 1 Demchuk, A1, 4, 3 Menon, B1, 4, 3; 1. Calgary 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
Stroke Program, Calgary, AB; 2. Department of Radiology , Calgary, AB; 3. University of
method was used to successfully speed up time-of-flight MRA in a group of AIS patients.
Calgary, Calgary, AB; 4. Department of Neurology, Calgary, AB
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
Introduction: Clot length on CT/CTA has been used to predict recanalization with thrombolytic
imaging approaches hold much promise for reducing acquisition time in AIS. Acquisition time
treatment in patients with acute ischemic stroke(AIS). We compared different techniques of
reductions of >2x are possible.
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).
O1.3
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
Validation of pCT-derived parameters on H215O-PET measured CBF in
lumen length within M1-MCA segment to length of contralateral patent M1-MCA segment. ischemic stroke
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 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,
for categorical variables and Intra-class Correlation Coefficient(ICC type2, single measure). A
Berlin, Germany
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.
Background: The accuracy of perfusion computed tomography (pCT) based relative
Measuring length of hyperdense sign on NCCT is fairly reliable. Direct clot length measure-
maps of cerebral blood flow (rCBF-CT), cerebral blood volume (rCBV-CT), mean transit
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ments on CTA are only reliable if done on 24mm CTA slices using MIP. Conclusion: Reliability time (rMTT-CT) and time to peak (rTTP-CT) in acute stroke remains a matter of de-
of clot length assessment and its interaction with treatment type in predicting recanalization bate. We validated these relative maps on quantitative CBF measurement by 15O-water
depends on the type of imaging modality and technique used. CTA remains the best tool to positron emission tomography (CBF-PET) with respect to penumbral flow (< 20 ml/100g/
measure clot length. min). Methods: pCT was performed on a Philips 64-row CT scanner (6 mm slice thick-
ness, 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 as-
sessed 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 hypoperfu-
sion 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.

O1.2
New Approaches to Fast Stroke Imaging with Magnetic Resonance O1.4
Optimizing Acute Stroke Imaging for Maximizing Information and Minimizing
Yerly, J2 Lauzon, M1 Lebel, R3, 1 Sevick, RJ1 Barber, PA1 Frayne, R1; 1. University of Acquisition, Post Processing and Interpretation Times: Analysis of Data From
Calgary/Foothills Medical Centre, Calgary, AB; 2. CIBM/CHUV-MR, Lausanne, Switzerland; PROVE-IT, a Prospective Imaging Cohort Study
3. General Electric Healthcare, Calgary, AB
Menon, B; Almekhlafi, M; Demchuk, A; Goyal, M; University of Calgary, 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 Introduction: To compare utility and efficiency of perfusion CT (PCT) with multiphase
requires a long acquisition. In contradistinction, non-contrast-CT imaging can provide a rapid CTA (mCTA) in making treatment decisions in patients with acute ischemic stroke.
assessment of hemorrhage/ischemia. Decreasing acquisition time for MR would remove this Methods: mCTA (patent pending) is a new technique capable of identifying site of arterial
drawback. Potentially the total scan time for a fast MR protocol might rival the time re- occlusions and degree of pial collateralization distal to occlusion better than conventional
quired for combined non-contrast CT, CTA and CT-perfusion scans. Methods: Application of CTA. Data is from PROVE-IT, an ongoing prospective cohort study of patients with acute
emerging MR image acceleration techniques can speed-up AIS assessment. A ­combination 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 AS-
PECTS 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 treat-
ment 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 interpre-
tation and being unaffected by patient motion are advantages in the acute stroke milieu
when compared to PCT.

O1.5
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

e1
e2  Stroke  December 2013
Background: The clinical significance of periodic limb movements during sleep (PLMs) is 2007 (p=0,002). Les analyses ajustées pour les caractéristiques et la gravidité des patients montrent
­unknown. PLMs are associated with transient but significant increases in night-time blood un majeur suivi du dépistage de la dysphagie parmi les cas admis en neurologie (OR : 5,28, IC 95%,
pressure and autonomic hyperactivity; emerging evidence suggests a link with vascular dis- 1,35 à 20,6) et/ou dans les centres de plus de 300 admissions/année par AVC (OR : 4,31, IC 95%,
ease. While obstructive sleep apnea (OSA) may be associated with white matter hyperintensi- 1,04 à 17,8) ainsi que de l’éducation au patient/famille quand le patient est admis en fin de semaine
ties (WMH), the relationship between PLMs and WMH is unclear. Methods: We prospectively (OR : 1,62 IC 95%, 1,03 à 2,54). Discussion : L’évolution dans le suivi des recommandations montre
recruited high-risk TIA or minor stroke patients who presented within two weeks of their acute que la qualité des soins infirmières aux personnes ayant subi un AVC s’améliore progressivement en
cerebrovascular events. Patients underwent polysomnography as well as magnetic resonance Catalogne. Toutefois, une amélioration de certaines recommandations est possible. Ainsi, il s’avère
imaging (MRI) or computed tomography (CT) of the brain. Polysomnography was scored accord- nécessaire de renforcer et promouvoir des interventions plus ciblées et spécifiques.
ing 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 O2.1
ARWMC and age, gender, infarction volume, vascular risk factors (VRFs), prior vascular events, Improved Methods for Longitudinal Motor Mapping After Stroke in Mice:
polysomnography parameters, cognition and neurological status. Significant variables were en- Automated Movement Tracking with Accelerometers, and Chronic EEG
tered 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 Recording in a Bilateral Cranial Window Preparation
with stroke. VRFs included: hypertension (50%), hyperlipidemia (51%), diabetes (23%), and prior
Silasi, G; Harrison, T; Boyd, J; LeDue, J; Murphy, TH; University of British Columbia,
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 Vancouver, BC
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 associa- Longitudinal motor mapping through optogenetic stimulation of the mouse cortex can be used to
tion with the ARWMC. Conclusions: PLM index was positively associated with the extent of reveal cortical reorganization following stroke. Here we present a refined set of procedures for
white matter hyperintensities. Whether PLMs are implicated in the pathogenesis of WMHs or are repeated light-based motor mapping in ChR2-expressing mice implanted with a bilateral cranial
simply a marker of vascular disease remains uncertain. Future studies should explore causal- window and a chronic EEG electrode. Light stimulation was delivered sequentially to over 400
ity with vascular disease, and whether treatment of PLMs reduces incident vascular disease. 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
O1.6
mW produced well-defined maps that were centered approximately 0.7 mm anterior and 1.6
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

Interprovincial Collaboration for Creating Stroke Units in Western Canada 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
Kamal, N1 Suddes, M2 Collier, T3 Hill, MD2 Dawson, A4 Calder, J3 Harris, D1 LoChang, J1 Newton, the forelimb representations in one hemisphere, we did not see the emergence of new cortical
D5 Foster, D6 Harrison, K4 Seeley, L7 Arsenault, S8 Hennessy, B9 Aikman, P1; 1. Stroke Services sites in the injured hemisphere. Instead, movements of the impaired forelimb could be evoked
BC, Vancouver, BC; 2. Calgary Stroke Program, Calgary, AB; 3. Royal Inland Hospital, Kamloops,
by stimulation of the ipsilateral (uninjured) hemisphere. Smaller strokes targeted to a portion
BC; 4. Fraser Health Authority, Surrey, BC; 5. Saskatoon Health Region, Saskatoon, SK; 6.
of the forelimb motor map did not decrease the total area of forelimb motor representation but
Vancouver Island Health Authority, Victoria, BC; 7. Interior Health Authority, Kamloops, BC; 8. Van-
produced more disorganized maps as measured by the local spatial correlation of each map
couver Coastal Health Authority, Vancouver, BC; 9. Northern Health Authority, Prince George, BC
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
Background: Stroke Unit (SU) care holds the strongest evidence for reduced mortality and dis-
function, our bilateral preparation affords a within-subject control for anesthetic levels during
ability due to stroke. However, according to the 2011 Canadian Stroke Network’s National Stroke
mapping by comparing motor output between the intact and injured hemispheres.
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 O2.2
the Collaborative is for teams to work towards the creation of new SUs or to improve SU care where The Role of Neurovascular Coupling in Stroke Recovery
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; Lake, EM1 Stanisz, G1, 2 Stefanovic, B1, 2; 1. Sunnybrook Health Science Centre, Toronto, ON;
establishing the team; ensuring clinical best practice; creating processes for team communica- 2. University of Toronto, Toronto, ON
tion managing transitions; ensuring patient engagement; and establishing quality improvement
mechanisms. Pre and post self-reports of care against best practice is collected through electronic Background: This work combines MRI with behavioral testing to assess the effect of well-
polling during the Learning Sessions. Teams submit outcome and process data and report on their timed, low-dose alpha5-subunit-GABA R antagonism (using L-655,708) on recovery in a
progress. Results: Ten teams have enrolled representing the entire province of BC and Saskatoon. well established model of focal ischemia . By administering a selective GABA-antagonist, we
Teams are either working at the hospital or health authority level. Thus far, plans are under way for attempt to support the restoration of normal neuronal activity by ameliorating hypo-excitability
the creation of 64 new SU beds in BC, and 12 beds recommended for Saskatoon Health Region. in the chronic stage of recovery. Methods: 6 adult male Sprague Dawleys received intracortical
Results will be presented demonstrating the progress made with respect to change in self-report injections of endothelin-1. MRI was performed prior to stroke and at weekly intervals following
of best practice, teams’ progress, and the impact on process and outcome measures. Conclusion: ischemia for 3 weeks. Beginning 7 days following stroke, and continuing for 14 days, animals
The creation of new SUs is possible through an interprovincial collaborative approach with partici- received subcutaneous pills containing 1.5mg L-655,708 in 58.5mg of HPMV, NTreated=3,
pation from BC, the Calgary Stroke Program, and the Saskatoon Health Region. This is possible or 60mg of HPMV, NControl=3. Results: The pronounced deficit in reaching ability seen 1
by utilizing the Collaborative approach and through a structured framework for creating new SUs. week following ischemic insult improved significantly more (p=0.0097) in the treated group.

O1.7
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
Abstracts From the 4th Canadian Stroke Congress, 2013  e3
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 het-
erogeneous 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.

O2.3
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 inverse-
ly 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 lipopro-
teins. CEC was determined by incubating HDL in cAMP-stimulated J774 mouse peritoneal
macrophages for 6 hours. Specific cholesterol efflux was obtained by subtracting total ef-
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flux 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 asymp-
tomatic 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 ≥ O2.5
90 days since event (n=11, beta=4.48, P=0.01), after adjustment as described above. Conclu- Quantitative CBF Measurement with CT Perfusion: Is it Correct to Correct the
sion: These results suggest that CEC is inversely associated with severity of carotid stenosis Partial Volume Averaged Arterial Input curve with Venous Output Curve
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. 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
O2.4
Multi-modality Neuroimaging in a Porcine Model of Endothelin-1 Induced 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
Cerebral Ischemia: Defining the Acute Infarct Core 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 vol-
d’Esterre, C1 Aviv, R1 Fainardi, E3 Lee, T4; 1. University of Calgary, Calgary, AB; 2. Sunnybrook
ume averaged. We investigated the validity of this assumption in acute stroke patients. Method:
Health Sciences Centre, Toronto, ON; 3. Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy;
Twelve CT Perfusion studies from stroke patients admitted from March to April 2013 in which
4. University of Western Ontario, Robarts Research Institute, Lawson Health Research , London, ON
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
Background: CT perfusion (CTP)-derived parameters and MR-diffusion weighted imaging
respectively) are larger than the limiting resolution (< 1 mm) of the scanner, AIF measured in
(DWI) are currently used to delineate infarct volume; however, reversibility of such defects them would be minimally affected by partial volume averaging and hence can be used to test the
has been demonstrated for both modalities. Methods: Ten domestic pigs had a CTP scan prior above assumption. A circular region of interest (ROI) of diameter 1.4 mm was placed in either
to intracranial injection of endothelin-1 (ET-1;0.01mL/kg) into the left striatum. CTP scans the intracranial ICAs or the basilar artery to generate time density curves. The curve with the
at 30min, 1hr, 1.5hrs were done to monitor ischemic progression. A second dose of ET-1 highest peak was accepted as the AIF. A similar sized circular ROI was placed at the posterior
(0.01mL/kg) was injected at 2hrs from the first injection. Twenty minutes after the second ET-1 portion of the superior sagittal sinus in all slices. The venous curve with the highest peak was
injection, 18F-FDG was injected(300-380MBq). The animal was moved to a 1.5T MRI scanner accepted as the VOC. The areas under the AIF and VOC were calculated. Results: The ratios of
where DWI was performed. The animal was then moved back to the CT scanner for a final the AIF and VOC areas among the twelve CT Perfusion studies were significantly greater than 1.0
CTP/PET acquisition within 10 minutes of the DWI. The brain was quickly removed and stained (P<0.01; mean ± SD: 1.8 ± 0.7) leading to CBF values that were 1.8 times smaller on average.
with tetrazolium-chloride (TTC). The infarct volume defined by low intensity TTC stain, low CBF Conclusions: Retrograde flow from collaterals likely causes breakdown of the VOC based partial
(<9.3ml•min^-1•100g^-1), low CBV (<1.07ml•100g^-1), DWI hyper-intensity and low 18F- volume correction method resulting in significant underestimation of CBF.
FDG uptake were determined. Linear regression was used to correlate the infarct volume mea-
sured 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.
O2.6
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 (rela- Intracerebral Hemorrhage in Rat Causes Edema and Raised Intracranial Pressure
tive 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 Hiploylee, C; Colbourne, F; University of Alberta, Edmonton, AB
overestimated the TTC-infarct core in 66% and 58% of cases, while CTP-CBV, CBFxCBV and
Background: Intracerebral hemorrhage (ICH) sometimes leads to life-threatening elevations in
FDG-PET all underestimated the final infarct volume in 100% of animals. The CBF/CBV mis-
intracranial pressure (ICP) that arise from the hematoma mass effect and edema. Whereas not
match was observed within 4/12 DWI lesions, and 3/12 TTC defined infarcts(Figure). The CBF/
all patients experience large changes in ICP, it remains a significant concern and predictor of
CBV mismatch may not represent penumbra during the acute stroke setting.
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 ap-
pears 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
e4  Stroke  December 2013
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.

O2.7
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 ar-
rest. 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 ex-
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hibits 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 inhibi-
tory transmission is more likely due to failure of inhibitory synaptic transmission, rather than
structural damage.

O3.1
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 tasks. A rate score was calculated for each task and averaged across all tasks bilaterally. Paired
lead to new biomarkers of recovery after stroke. We aimed to characterize the relationship samples t-tests and multiple regression analyses were performed to examine hemispheric dif-
between measures of white and gray matter structure within the primary cortical motor out- ferences and evaluate the association between brain structure and arm function. Significant
put system and paretic arm function in chronic stroke. Twenty-seven individuals with chronic hemispheric differences in corticospinal tract FA and precentral gyral thickness were observed
(>6months) stroke (mean age:65±9.7 years,6F) underwent a single magnetic resonance imag- (both p<0.0005). WMFT scores also differed between paretic and non-paretic arms (p=0.003).
ing scan and completed an assessment of upper extremity motor function (Wolf Motor Func- Ipsilesional tract FA explained a significant amount of variance in paretic WMFT scores after
tion Test or WMFT). A high-resolution T1 and a 60-orientation high angular resolution diffusion accounting for age and post-stroke duration (R2=0.44, p=0.013). Cortical thickness did not ex-
imaging scan were acquired and processed using the Freesurfer image analysis suite and Ex- plain an additional significant amount of variance in motor function. Hemispheric differences in
ploreDTI software package. Bilateral precentral gyral thickness and mean fractional anisotropy measures of gray and white matter structural status were observed. Only ipsilesional descend-
(FA) of the corticospinal tract were extracted for analysis. Fiber tractography was performed
ing motor output tract status was positively associated with paretic arm function in chronic
using a tensor-free fiber orientation algorithm. The WMFT consisted of fifteen timed movement
stroke. These imaging techniques may be used in future work to predict and evaluate response
to rehabilitation.

O3.2
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 function-
ally damaged but not destroyed by the stroke. Measurement of cortical dysfunction in perile-
sional 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 activ-
ity 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,
Abstracts From the 4th Canadian Stroke Congress, 2013  e5
namely median frequency (MF) and multiscale entropy (MSE). Decreases in these quantities may ful clinical trials of adults have shown that functional electrical stimulation (FES) therapy
identify dysfunctional cortex. Results: Compared to controls, stroke patients exhibited signifi- can restore voluntary arm and hand function in people with severe stroke; however, the
cant decreases in MF and MSE in tissue surrounding the core lesion. MSE was a more specific literature failed to identify trials in which FES was used in a paediatrics stroke popula-
indicator of perilesional abnormalities, as MF was also affected by general changes seen in tion. As such, this study was designed to examine functional changes in the upper limb
aging. Furthermore, reduced complexity of resting signals in perilesional cortex was correlated of severe chronic paediatrics stroke patients following intensive FES therapy, consist-
with reduced responsiveness in a language comprehension task. ing of task-specific upper-limb movements with a combination of preprogrammed FES
and manual assisted motion. Methods: Four severe chronic paediatric stroke participants
Conclusions: Perilesional “slowing” can be accurately mapped and quantified using MEG. were ­assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality
This technique offers a new way to assess “functional lesions” in stroke and also progressive of Upper Extremity Skills Test, Paediatric Evaluation of Disability Inventory, and Assisting
disease. 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
O3.3 Function Test components of 14.5 for object manipulation (P = .042), 0.78 Nm for instru-
Telehealth for Speech-Language-Swallowing Post Stroke: 500 Camera Hours mented 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).
Baird, AJ1 Smook, C2; 1. SpeechWorks Inc, Winnipeg, MB; 2. Northern Regional Health Conclusion: FES therapy with upper-limb training may be an efficacious intervention for pae-
Authority, Thompson, MB diatric patients with severe stroke.

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 O3.6
no adult speech-language pathology services for the region and those requiring assessment A Longitudinal View of Emotional Vitality of Caregivers of Stroke Survivors
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 patholo- Barbic, SP; Bartlett, SJ; Rodriguez, A; Mayo, NE; McGill University, Montreal, QC
gist 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 Mani- Background: Caregiver emotional vitality (EV) may be an important modifiable target for
toba Patient Access Network provided the opportunity to investigate the impact of assessment intervention by rehabilitation professionals to improve health outcomes of both caregivers
and weekly treatment provided using telehealth services. The purpose of this presentation is themselves and the individual who experienced a stroke. Objectives: The overall aim was
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

to report the outcomes of those assessments and subsequent therapies. Participants for the to contribute to the understanding of the stroke caregiving experience by taking a longitudi-
program were selected from an existing caseload or were referred from health care providers nal view of EV. The specific objectives were to estimate the extent to which (i) caregiver EV
both in either the acute or chronic phase. All participants with communication disorders were changes in the first caregiving year; and (ii) estimate the extent to which caregiver charac-
assessed using standardized tools, scheduled for weekly therapy sessions and given an iPad to teristics and the functional profile of the care recipient impacts a caregiver’s EV in the first
complete homework activities. The NRHA staff was trained to screen for swallowing disorders year. Methods: Data came from an inception cohort of caregivers (n=409) that was followed
and refer as indicated to speech-language services for recommendations. Of 31 participants, over the first post-stroke year. Group-based trajectory modelling (GBTM) was used to identify
11 were treated for aphasia, 8 were treated for dysarthria, 8 were treated for cognitive linguistic distinctive groups of individuals with similar trajectories. Time-specific EV was plotted from the
deficits, and 8 were treated for swallowing disorders post stroke. For those with aphasia, all first time of assessment (one month post-stroke) to 12 months. Dual trajectories were used to
post testing results trended upwards. Subjective improvements were reported with all those estimate concordance between trajectories of EV and baseline health-related characteristics
with dysarthria. There were no reports of pneumonias in participants assessed for swallowing
of the caregiver and the care recipient. Results: Five trajectories of EV were identified. Four
disorders. Conclusions: Speech and language treatment provided once a week using telehealth
trajectories maintained their baseline low EV level, and one showed deterioration over time.
produces positive outcomes in people post stroke in all stages of recovery. Providing these
Given the s­ coring range of the EV measure was 0-44 (with higher scores indicating higher
services by telehealth is an acceptable and cost effective solution for stroke treatment provided
EV), all trajectories had baseline means that fell below a total score of 30, with 78% of the
by speech-language pathologists.
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,
O3.4 lending preliminary support for the need to incorporate regular assessment of caregiver EV and
Imaging Correlates of rTMS Treatment for Post-Stroke Aphasia: a Randomized personal mastery throughout the caregiving experience.
Controlled Study

Thiel, A1 Anglade, C2 Hartmann, A3 Heiss, W4, 5; 1. Jewish General Hospital, Montreal, QC; O3.7
2. Universite de Montreal, Montreal, QC; 3. Rehanova, Cologne, Germany; 4. Max-Planck
Communication and Mobility After Locked-In Syndrome: a Review of Twenty-Five
Institute for neurological researc h , Cologne, Germany; 5. McGill University, Montreal, QC
Cases
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 Beaudoin, N1 De Serres, L1 Martel, N1 Poissant, L1 Rochette, A2 Robert, G1 Nicolaidis, A1;
be augmented through modulation of activity in language networks by repetitive transcranial 1. Institut de réadaptation Gingras-Lindsay de Montréal , Montréal, QC; 2. Ecole de
magnetic stimulation (rTMS). Here we report the results of a first randomized and controlled réadaptation Université de Montréal, Montral, QC
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 sub- Background: Persons afflicted with Locked-In Syndrome (LIS) present with the most severe
acute post-stroke aphasia. Within 4-8 weeks after stroke, patients were randomized to a 10 day level of disability that can occur following a stroke. Few Canadian data have documented the
protocol of 20 minutes inhibitory 1Hz rTMS over the right posterior inferior frontal gyrus (pIFG) functional outcome of these patients. In this study, communication and mobility has been spe-
or sham stimulation followed by 45 minutes of deficit specific SLT. Language network activity cifically addressed. Methods: Twenty-five patients presenting LIS had been followed by the re-
was measured with O-15-water Positron Emission Tomography during verb generation before habilitation team at the Montreal Gingras-Lindsay Rehabilitation Institute. The majority received
and after treatment. Total left and right hemisphere network activity was quantified by activation specific training to access and use technology for optimal independence. We documented their
volume indices (AVI) with positive indices indicating larger networks in the left-hemisphere and neurologic and functional evolution over a period up to twenty years. Result: In spite of con-
negative indices larger volumes in the right hemisphere. Language performance was assessed siderable motor disabilities, many patients achieved a high level of autonomy to communicate
using the Aachen Aphasia Test battery (AAT). Results: Global AAT score change, was signifi- and to control a motorized wheelchair. Patients with incomplete LIS who had recuperated motor
cantly higher in the rTMS group (t-test, P=0.003). The rTMS effect was strongest for the subtest function of one hand were more likely to use a manual joystick. Classic LIS patients may recu-
naming (2 factor RM-ANOVA, P=0.002) but a trend was also observed for comprehension, to- perate minor movement of head and of one finger or one toe. Some of them succeed using a
ken-test and writing (P<0.1). Patients in the rTMS group activated proportionally more voxels in cephalic control to drive a wheelchair (40%) and a head mouse emulator to access a computer
the left-hemisphere (positive AVI) after treatment than before compared to sham treated patients (25%). Others presenting even more limited movement need a more sophisticated interface. We
(2 factor RM-ANOVA, P=0.027 within group, P=0.045 between groups).There was a moderate will present a short video of two patients using computerized interfaces to activate a scanning
but significant linear relationship between post-treatment AVI and global AAT score change system permitting combined computer-supported communication and safe wheelchair control.
(r2 = 0.19, P=0.04). Conclusions: Inhibitory rTMS over the right pIFG in combination with SLT Conclusions: Advances in technology can improve autonomy for LIS patients. Considering
favors the recruitment of left hemispheric language networks and significantly improves lan- the strong will to live expressed by those patients and their involvement in social and familial
guage recovery in subacute ischemic stroke. endeavors, access to rehabilitation for independent communication and mobility are strongly
recommended for all LIS patients.

O3.5
Functional Electrical Stimulation Therapy for Upper-Limb Motor Recovery in O4.1
Pediatric Stroke Patients with Severe Long-Term Impairment Accreditation Canada’s Stroke Distinction Program: a Quality Improvement
Strategy
Kapadia, NM1 Popovic, MR1, 2; 1. Toronto Rehabilitation Institute, Toronto, ON; 2. University of
Toronto, Toronto, ON 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,
Background: The average annual incidence of stroke in children is 2.7 in 100 000, many Kingston General Hospital, Kingston, ON; 2. MacKenzie Health, Richmond Hill, ON;
of which result in permanent residual cognitive and/or physical impairments. Success- 3. Accreditation Canada, Ottawa, ON
e6  Stroke  December 2013
Background: Accreditation Canada’s Stroke Services Distinction Program recognizes centres care ranged from $654 to $983. The average LOS in inpatient rehabilitation was 37.1 days
that demonstrate clinical excellence and outstanding commitment to leadership in stroke care (range 29.5 – 45.5). On average, 7% (range 4-12%) of patients in rehabilitation fell into the
and prevention in relation to Canadian Best Practice Recommendations for Stroke Care. Kingston mildest rehabilitation patient group (RPG 1160); costing an estimated total of $2.5M annually.
General Hospital (KGH) and Mackenzie Health (MH), recently received Stroke Distinction Awards. Conclusion: Regional data confirm previous research suggesting that variation in stroke care
Method: The Distinction program requires: 1) Achievement of evidence-based standards; 2) exists between Ontario’s LHINs and that opportunities exist in all regions for better application
Achievement of performance indicator thresholds; 3) Implementation of current stroke protocols; of evidence-based, cost-effective care.
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 O4.5
rigorous requirements. Datasets were used to plan and monitor targeted improvements includ- Impact of Culturally Congruent Evidence-Informed Chronic Disease Management
ing attention to data quality through independent chart audit. Common quality improvement (QI) Program on Hypertension Management in First Nation Communities in Ontario
methodologies were used. Teams worked closely with the Accreditation Specialist in prepa-
ration for the survey. Results: At KGH, focused process improvements resulted in increased Tobe, S1 Von Sychowski, S2 Kandukur, K2; 1. Sunnybrook, Toronto, ON; 2. Heart and Stroke
stroke unit utilization and dysphagia screening rates with decreased in-hospital stroke mortality Foundation of Ontario, Toronto, ON
and 30-day readmission rates. Sub-analysis of complication rates by age and stroke type pro-
vided information on those at most risk of complications, providing the basis for continuing QI. Objectives: The objective of the Aboriginal Hypertension Management Program (AHMP) is to
MH enhanced integration of best practice stroke care across the organization through policy demonstrate a sustainable, evidence-informed chronic disease management program that
implementation and staff engagement. Both centres realized data quality improvements (e.g. enables knowledge integration into the practices of primary care providers and improve man-
dysphagia screening). Heightened awareness of Best Practices and increased interprofessional agement of essential hypertension in first nation communities. Design and Methods: The
team collaboration were observed. Collaboration with Accreditation Canada resulted in a quality Studywas conducted in five first nation communities in Ontario. The program was imple-
improvement cycle for the process itself. The ongoing requirement to submit performance indi- mented on-reserve in collarboartion with local health care organizations. The chronic disease
cators semi-annually drives sustained QI. Conclusion: Pursuit of Stroke Distinction is a catalyst management toolkit included culturally congruent tools for both health care providers (flow-
for driving change and improving stroke care delivery processes and outcomes. Participation in sheet, BpTRU, database repository) and patients (posters, educational video and booklets). All
this program provides an effective means to prepare Ontario centres for 2013-14 Quality Based the tools were developed based on the feedback from clients and health care provider from
Procedures for stroke care. 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-
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O4.2 informed AHMP, to adapt to local circumstances. Results: In total, 231 patients were enrolled
Stroke Competency Framework: a Quality Improvement Approach to Healthcare in five first nation communities, and of these, 177 had a diagnosis of hypertension. Mean BP
Provider Education 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-
Cole-Haskayne, A1 Garnier, S2 Grant, M1 Suddes, M1; 1. Calgary Stroke Program, Alberta Health analysis showed statistically significant change in mean BP among those whose SBP was
Services, Calgary, AB; 2. St. Paul Healthcare Centre, St Paul, AB 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).
Background: Healthcare provider education was one of seven key improvement themes that Conclusion: There was a significant blood pressure lowering among those with elevated
emerged from Alberta Stroke Improvement (ASI), a provincial quality improvement initiative systolic blood pressure at baseline after introducing an evidence-informed, interprofessional
in 2011-12. The ASI Education Working Group was established to develop a competency- culturally congruent, chronic disease management program for hypertension in first nation
based healthcare provider education framework and provide recommendations for imple- communities.
mentation to the Cardiovascular Health and Stroke Strategic Clinical Network. Methods:
A literature review and survey of existing competency frameworks was conducted. Stake-
holder feedback was obtained at ASI learning sessions. Stakeholders requested that the O4.6
framework focus on best practice, be inter-professional, link learning resources, identify A Geoinformatic Analysis of the Impact of Telestroke on Access to Stroke
core and advanced competencies, be applicable and accessible to urban and rural sites, Thrombolysis in Ontario
provide direction around certification and facilitate performance management. Existing com-
petency frameworks did not address all criteria. Process mapping was used to direct the Jewett, L2, 3, 1 Connolly, BJ1 Sahlas, DJ1; 1. McMaster University, Hamilton, ON; 2. Population
development of a Canadian alternative. Stroke experts, clinicians, educators and managers Health Research Institute, Hamilton, ON; 3. Hamilton Health Sciences, Hamilton, ON
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 Background: Ontario is Canada’s most populous province, with 13,366,300 people in the 2011
stroke health care providers across the continuum of care. The master list ensured a stan- census. The Ontario Stroke System is comprised of 11 regional stroke centres and 17 district
dardized and coordinated approach to developing competency checklists that are specific stroke centres and is further augmented by Telestroke linkages between many of these centres
to discipline and practice settings. Each competency is linked to key learning resources and as well as 10 additional Telestroke sites. We undertook a geoinformatic analysis of access to
knowledge transfer tools. Electronic learning resources are linked directly where available. stroke thrombolysis, in order to evaluate the impact of the Ontario Telemedicine Network’s
The framework allows staff, educators and managers to select areas of focus and document Telestroke program. Methods: Population data by dissemination area was used (Statistics
progress toward achieving goals for performance accountability. Competencies suggested Canada, 2011) to overlay polygons created by Service Area Analysis using ArcGIS 10.1 (ESRI,
for orientation and ongoing professional development are differentiated. Conclusions: This 2012). The service areas are based on the Ontario Roads Network (DMTI, 2012) and Ontario Car-
framework standardizes expectations for competencies in stroke care and fulfills a quality tographic Boundaries (Statistics Canada, 2012). The established geographic regions are within
improvement priority. The competency framework and recommendations for implementation predefined driving times, towards stroke centres. Service areas with and without the impact of
and sustainability will be provided. The usability will be evaluated through focus groups and the Telestroke program were compared. Results: Availability of stroke thrombolysis in desig-
a representative sample will complete pre and post outcome measures to determine change nated stroke centres covers 96.03% of the province, leaving approximately 530,308 people in
in competence levels. 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
O4.3 4.5 hours), increasing to 2.16% with Telestroke, for an additional 91,313 people. Conclusion:
A Regional Assessment of the Economics of Stroke Care in Ontario 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
Meyer, MJ1 McClure, A2 O’Callaghan, C1 Kelloway, L1 Hall, R3 Bayley, M4 Teasell, R2; 1. Ontario the overall number of people with access to stroke thrombolysis as well as provides more rapid
Stroke Network, Toronto, ON; 2. Lawson Health Research Institute/ UWO, London, ON; access to hyperacute stroke treatment for over a million people, with direct benefits impacting
3. Institute for Clinical Evaluative Sciences, Toronto, ON; 4. Toronto Rehabilitation Institute, approximately 1 in 10 people in the province.
Toronto, ON

Background: In 2012, the Ontario Stroke Network (OSN) released an economic evaluation O4.7
of stroke care in Ontario suggesting that better application of best-practices could result in Vancouver Island Health Authority’s (VIHA) Strategic Plan to Ensure All Patients
up to $20M a year made available for re-investment in Ontario’s stroke system. The objec- Receive Care in Stroke Units
tive 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 Foster, D1 Crisp, R1 Kamal, N2; 1. Vancouver Island Health Authority, Victoria, BC; 2. Stroke
practices and costs of care. Methods: Data were collected from various sources including Services BC, Vancouver, BC
Canadian Institute for Health Information (CIHI) databases and Institute for Clinical Evalua-
tive Sciences (ICES) reports. Data were used to estimate annual stroke incidence in each Background: VIHA serves 768,000 people and faces significant population growth of people
LHIN, to track current care pathways, and to infer opportunities to improve the provision of over 75 years by as much as 17% by 2020. Further issues facing VIHA include a large rural area
evidence-based, cost-effective care. Results: Wide variation was noted in many areas of with islands and large water inlets. There are 2 tertiary hospitals, 1 regional hospital, 5 com-
stroke care across Ontario’s LHINs indicating numerous opportunities for improvement. On munity hospitals, and 5 rural/remote hospitals. A strategic approach is needed for acute stroke
average, acute patients spent 31.5% of their length of stay in alternate level of care waiting care in order to plan appropriately for the population growth and VIHA’s diverse geography.
for transfer to post-acute care (range 23% - 41%) and, on average, 18% of acute admissions Methods: VIHA’s strategic approach plans for three stroke units to serve the entire population.
were TIAs (range 12.6 – 28.7). The estimated average direct cost of acute care ranged from Victoria General Hospital will be a comprehensive level 1 stroke centre with both a stroke unit
$7,709 to $13,403 per patient across LHINs and the mean per diem direct cost of acute and a rehabilitation unit. It will co-locate stroke patients from South Vancouver Island. Nanaimo
Abstracts From the 4th Canadian Stroke Congress, 2013  e7
Regional General Hospital will provide intermediate stroke services for the Central Island with with 99% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect
an acute stroke cluster and a rehabilitation unit. Campbell River and District Hospital will also criteria and had these characteristics: mean age 72.0 (range 16-101), male 51.1%, mean time
provide intermediate stroke services with an integrated stroke cluster serving the North Island scene-to-hospital 16.7 min (range 0-92) with 15.1% >30 mins. The prehospital adverse event
and Comox valley. These changes will be supported through participation in a Stroke Unit Collab- rate was 14.7% (23.0% for those with transport time >30 mins) with the most common events
orative organized by Stroke Services BC with participation from across BC and Saskatchewan. being hemodynamic instability and drop in GCS. At the hospital, the 755 patients had a mean NIH
Collaborative Faculty are from BC and Calgary. Results: There have been tremendous strides Stroke Scale score 8.7, 23.8% received thrombolysis, 69.3% were admitted, 87.3% survived
made towards the creation of stroke units. To date, beds have been committed at three sites to discharge, and had a mean modified Rankin Score 2.3. Paramedics showed 97.9% accuracy
with teams working towards best practice. These sites have had strong participation in the in interpreting the criteria and excellent interrater agreement with kappa values ranging from
Stroke Unit Collaborative with over 25 stroke champions traveling to Vancouver to attend the 0.56 to 0.90 for redirect criteria and 0.94 for need to transport to a stroke centre. Conclusions:
face-to-face Learning Sessions, and attendance at the bi-weekly webinars. Conclusions: The In a large urban-rural area with 9 EMS services, we demonstrated accurate, safe, and effective
creation of stroke units within a health region is possible through internal and external enablers. implementation of the revised provincial Stroke Redirect Protocol. These revisions will allow
The internal enablers include executive support, hospital buy-in, stroke champion teams at each more stroke patients to benefit from early treatment.
site, and education initiatives. The external enablers include interprovincial Stroke Unit Collab-
orative, Canadian Best Practice Recommendations, and research grants.
PL2.3
Predictors of Stroke Recurrence in Patients with Recent Lacunar Stroke: Second-
PL2.1 ary Prevention of Small Subcortical Strokes (SPS3) Trial
An in-vivo, MRI-Integrated Real-Time Model of Active Contrast Extravasation in
Acute ICH 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
Aviv, RI1 Huynh, T2 Ramsay, D3 Huang, Y4 Liu, R2 Hynynen, K4; 1. Sunnybrook Health Sciences of British Columbia, Vancouver, BC
Center, Thornhill, ON; 2. Sunnybrook Health Sciences Center, Toronto, ON; 3. London Health
Sciences, London, ON; 4. Sunnybrook Research institute, Toronto, ON 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
Purpose: The spot sign or contrast extravasation (CE) within an intracranial hemorrhage (ICH) stroke. Methods: Multivariable analyses of 3020 participants with recent MRI-defined lacunar
is strongly associated with hematoma formation and growth. CE is emerging as the single strokes followed for a mean of 3.7 years with 243 recurrent ischemic strokes. Results: Prior
most important contributor to morbidity and mortality in ICH but represents a spectrum of
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

symptomatic lacunar stroke or TIA (HR 2.2, 95%ci 1.6,2.9), diabetes (HR 2.0, 95%ci 1.5,2.5),
contrast leakage. An animal model of CE is important to test existing and novel therapeutic 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 indepen-
interventions to inform present and future clinical studies. The purpose of this study was to dently predictive of recurrent ischemic stroke. Recurrent ischemic stroke occurred at a rate of
create the first animal model of CE in acute ICH. Materials and Methods: Animal experiments 4.3%/yr (95% CI 3.3, 5.5) in patients with prior symptomatic lacunar stroke or TIA (15% of the
were performed in accordance with institutional guidelines and approved by the Research cohort), 3.1%/yr (95%CI 2.6, 3.9) in those with >1 of the other 3 risk factors (27% of the cohort),
Institute Animal Care Committee. Each hemisphere of 18 Yorkshire male swine was insonated and 1.3%/yr (95%CI 1.0,1.7) in those with 0 to 1 risk factors (58% of the cohort). There were
with an MR-guided focused ultrasound system after infusion with 0.08ml/kg of Perflutren
no significant interactions between treatment effects and stroke risk status. Conclusion: In
lipid microspheres without and with mean arterial pressure elevation using 15mcg/kg/min
this large, carefully followed cohort of patients with recent lacunar stroke and aggressive blood
phenylephrine infusion. Following insonation dynamic contrast enhanced (DCE) MRI quanti-
pressure management, prior symptomatic lacunar ischemia, diabetes, Black race and male sex
fied the rate of contrast leakage. Animals were sacrificed after 2 hours and brains subjected
independently predicted ischemic stroke recurrence..
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 PL2.4
PCL (11.3; 6.3-23.2 vs 3.8; 1.1-3.1ml/min/100g; p<0.001). CE demonstrated a median (IQR) Cardiopulmonary Fitness is Associated with Regional Cerebral Grey Matter Perfu-
DCE contrast volume of 0.4; 0.1-1.3cm3 compared to PCL (0.04; 0.02-0.1cm3; p=0.01). The sion and Density in Adults with Coronary Artery Disease
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 Swardfager, W1, 2, 3 MacIntosh, BJ1, 2 Herrmann, N1, 2 Crane, DE1, 2 Saleem, M1 Ranepura, N1 Oh,
burst length and rate of contrast leak (KPS) (ρ=0.5 (95% CI 0.08-0.8); p=0.02). Conclusion: PI1, 2, 3 Lanctôt, KL1, 2, 3; 1. Sunnybrook Research Institute, Toronto, ON; 2. Heart & Stroke Founda-
We describe a novel MRI-integrated real-time swine ICH model of acute hematoma growth tion Centre for Stroke Recovery, Toronto, ON; 3. Toronto Rehabilitation Institute, Toronto, ON
and contrast extravasation.
Purpose: Cardiopulmonary fitness is associated with reduced risk of stroke, and it can confer
neuroprotective and cerebrovascular benefits. Patients with coronary artery disease (CAD) pres-
ent 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 imag-
ing 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 VO-
2Peak 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
PL2.2 (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 mul-
Implementation of the Revised Provincial Acute Stroke Redirect Protocol in Urban
tiple grey matter regions were associated with fitness at baseline and with greater fitness gains
and Rural Settings 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 be-
Stiell, IG1 Smaggus, K2 Clement, CM3 Sharma, M4 Socha, D5 Silvilotti, M6 Jin, A6 Perry, JJ1
tween fitness and reduced stroke risk is suggested.
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; PL2.5
8. Stroke Network of Southeastern Ontario, Kingston, ON; 9. The Ottawa Hospital, Ottawa, ON Prediction of Hematoma Expansion and Poor Clinical Outcome in Acute Intracere-
bral Hemorrhage: the PREDICT Hematoma Expansion Score
Background: The Ontario Stroke Redirect Protocol was recently revised to allow EMS to by-
pass to designated stroke centers if total transport time would be <2 hours and total time Huynh, TJ1 Demchuk, AM2 Dowlatshahi, D3 Gladstone, DJ1 Laupacis, A1 Kiss, A1 Hill, MD2
from ­symptom onset <3.5 hours. We sought to evaluate the impact, effectiveness, and safety Molina, CA4 Rodriguez-Luna, D4 Silva, Y5 Czlonkowska, A6 Lum, C3 Boulanger, J7 Gubitz, G8
of the revised Protocol. Methods: We conducted a 12-month multicentre, prospective cohort Bhatia, R9 Padma, V10 Roy, J10 Case, CS11 Jakubovic, R1 Symons, SP1 Aviv, RI1; 1. University of
study involving all pre-hospital patients presenting <6 hours with possible stroke symptoms. Toronto, Toronto, ON; 2. University of Calgary, Calgary, AB; 3. University of Ottawa, Ottawa,
Participating were 1,000 BLS and 300 ALS paramedics of 9 land EMS services, operating in ON; 4. Hospital Universitari Vall d’Hebron, Barcelona, Spain; 5. Dr Josep Trueta University
a catchment area of 10 rural counties and 5 cities. Paramedics completed a record form for Hospital, Girona, Spain; 6. Institute of Psychiatry and Neurology of Warsaw, Warsaw, Poland;
each case and, initially, a second paramedic independently completed the form. Outcomes and 7. University of Sherbrooke, Montreal, QC; 8. Dalhousie University, Halifax, NS; 9. All India
data analyses included redirect sensitivity and specificity, patient outcomes, adverse events, Institute of Medical Sciences, New Delhi, DL, India; 10. AMRI Hospital Kolkata, Kolkata, WB,
and interrater reliability with the kappa statistic. Results: We enrolled 1,277 eligible patients India; 11. Boston Medical Center, Boston, MA, USA
e8  Stroke  December 2013
Objective: Predictive models of hematoma expansion in intracerebral hemorrhage (ICH) (68.0%); lipid-lowering agents (65.7%); smoking cessation programs/medication (20.0%).
are important for risk stratification and guiding potential interventions. The spot sign is Approximately 10% of initial visits included cognitive screening. Readmission rates among
recently shown to potently predict ICH expansion and poor outcome however incorporation ischemic stroke/TIA patients seen at SPCs were 1.8% within 30 days and 2.9% within 90
of other clinical variables may improve prediction. We sought to identify clinical and radio- days of the SPC referral. Conclusion: The results show high rates of investigations and good
graphic predictors of hematoma expansion and to develop a practical integrated clinical outcomes compared to the expected course of a TIA/stroke following an ED visit. There are
score for expansion prediction. We secondarily evaluated the prognostic significance of significant opportunities for improvement, particularly with respect to timeliness of access to
the score for 3-month poor clinical outcome prediction. Methods: 219 ICH patients ≤6 SPCs, carotid interventions, smoking cessation, and cognitive screening.
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 lo- R.1
gistic regression identified independent clinical, laboratory, and radiographic predictors People After Mild Stroke or Transient Ischemic Attack – An Overlooked
of hematoma expansion (>6ml or >33%) and a clinical scoring system was developed Population from a Rehabilitation Perspective
from regression coefficients. Optimism adjusted c-statistic was examined using bootstrap
internal validation. Prognostic significance of the score for predicting 3-month poor clini- MacKay-Lyons, M; Dalhousie University, Halifax, NS
cal outcome (mRS 4-6) was performed using logistic regression. Results: A multivariable
model including CTA Spot Sign number, international normalized ratio (INR), baseline NI- Purpose: Although non‐disabling stroke (NDS) and transient ischemic attack (TIA) are con-
HSS, and time from ictus-to-baseline CT provided the greatest model fit and discrimina- sidered relatively benign conditions, they can actually signal further vascular events or death.
tion for hematoma expansion prediction (c-statistic: 0.803) and were incorporated in to a Understanding the clinical presentation of NDS/TIA is important in identifying effective sec-
clinical prediction score. Observed probability of expansion ranged from low (7% - 12%) ondary prevention strategies. The purpose was to describe the baseline profile of participants
to high probability (76 - 100%) based on score strata. Bootstrap internal validation dem- enrolled in the Program of Rehabilitative Exercises and Education to avert Vascular Events
onstrated an adjusted c-statistic of 0.755. The score independently predicted 3-month after NDS and TIA (PREVENT) Trial. Methods: Prior to randomization (PREVENT program/usual
poor clinical outcome (OR 1.17, 95% CI 1.05 – 1.31; p=0.021) after adjusting for age, care), 148 people early post‐NDS/TIA underwent assessment of comorbidities, vascular risks,
baseline Glasgow Come Scale, ICH volume, intraventricular hemorrhage presence, and exercise capacity, and walking endurance. Results: Participants were 65+/-10 years of age,
INR. Conclusions: The PREDICT Hematoma Expansion Score strongly predicts hematoma 66% male, body mass index of 30+/-6. Most prevalent co‐morbidities were arthritis (39%),
expansion and poor clinical outcome in ICH and appears promising as a risk stratification diabetes (21%), coronary artery disease (13%), and atrial fibrillation (12%). Resting systolic
tool for future potential interventions. 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
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>10 on Hospital Anxiety and Depression Scale. Although all participants were described as
P.3 ‘non-disabled’, 9% had low physical function and 13% moderate physical function (Short
Vitamin K Antagonists versus Antiplatelet Monotherapy and Risk of Subdural Physical Performance Battery). 28% were classified as inactive and 43% as moderately active
Hematoma: Meta-analysis of Randomized Clinical Trials (International Physical Activity Index), 39% had excessive fatigue (Fatigue Assessment Scale),
and 58% were ‘poor sleepers’ (Pittsburgh Sleep Quality Assessment). On stress testing 8%
Connolly, BJ1 Pearce, LA2 Hart, RG1; 1. McMaster University, Hamilton, ON; 2. Biostatistics were positive for ischemia. High variability was found in peak oxygen consumption (19.5+/-
Consultant, Minot, ND, USA 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:
Background: Subdural hematomas (“the other intracranial hemorrhage”) are an impor- A substantial proportion of this cohort demonstrated vascular comorbidities, hypertension,
tant bleeding complication of anticoagulation with oral vitamin K antagonists (VKAs), cognitive impairment, cardiac ischemia, and risk of second stroke. Clinical correlates included
but the risk associated with VKAs has not been defined. Purpose: To determine the reductions in physical activity, activity tolerance, sleep quality, aerobic capacity and walking
risk of subdural hematoma associated with VKAs vs. antiplatelet agents. Data Sources: endurance - all potentially modifiable through exercise interventions.
Randomized trials were identified by systematic review of the Cochrane Central Register
of Controlled Trials and other published systematic reviews. Study Selection: Random-
ized trials published since 1980 comparing VKAs with antiplatelet monotherapy were R.2
included. Data extraction: Two reviewers independently extracted data on study design Can we identify family caregivers in need of support from the health care
and subdural hematomas, with differences resolved by joint review and consensus. Re- system?
sults: 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 Cameron, JI1 Czerwonka, A1 Naglie, G2 Gignac, M3 Green, T4 Warner, G6 Bayley, M7 Silver, F5
unpublished data from 5 trials. Trial participants included patients with atrial fibrillation Cheung, A5 Phillips, S8 Huijbregts, M2, 9; 1. University of Toronto, Toronto, ON; 2. Baycrest
(4 trials), noncardioembolic stroke (2 trials), and heart failure/reduced left ventricular Centre for Geriatric Care, Toronto, ON; 3. Toronto Western Research Institute, Toronto, ON;
ejection fraction (2 trials). Mean participant age was 65 (range 61 to 82) years. The mean 4. University of Calgary, Calgary, AB; 5. University Health Network, Toronto, ON; 6. Dalhousie
achieved INRs ranged from 2.1 to 3.2. Antiplatelet therapy was aspirin (dose range 75 to University, Halifax, NS; 7. Toronto Rehabilitation Institute - University Health Network, Toronto,
1300 mg/d) except one trial each that tested trifusal 600 mg/d and clopidogrel 75 mg/d. ON; 8. Capital District Health Authority, Halifax, NS; 9. Family Service Toronto, Toronto, ON
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 Background: Family caregivers play a central role in stroke survivors’ recovery, rehabilita-
of subdural hematoma during VKA therapy ranged from 1.2 to 3.5 per 1000 patient- tion, and return to community living. Best practice guidelines recommend the provision of
years of observation. Conclusions: VKA use significantly increases the risk of subdural timely education and support for caregivers. The aim of this paper is to identify caregivers at
hematoma compared with antiplatelet monotherapy. The absolute increase with VKAs risk for depression during the acute stroke phase and, therefore, in need of support from the
averaged 1.5 per 1000 patient-years. 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 knowl-
P.5 edge about stroke, less mastery, less social support, more fatigue, and caregiving has more
Results from the Ontario Stroke Registry’s Audit of Secondary of an impact on their daily life. Methods: Participants included caregivers who consented
Stroke Prevention Clinics 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
Hall, R1 Khan, F1 Zhou, L1 Kelloway, L2 Sahlas, DJ3, 4 Silver, F7, 6, 5 Kapral, M7, 6, 5 Hall, R7, 2, 5; stroke phase, included: 1) indicators of stroke severity (e.g., Canadian Neurological Scale,
1. ICES, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. Hamilton Health Sciences, Barthel Index); 2) demographic characteristics; and 3) standardized measures (e.g., Mastery,
Hamilton, ON; 4. McMaster University, Hamilton, ON; 5. University of Toronto, Toronto, ON; Stroke Knowledge, Caregiving Impact and Assistance, and Depression). Linear regression
6. University Health Network, Toronto, ON; 7. Institute for Clinical Evaluative Sciences, was used to test the study hypothesis. Results: Caregivers (n=299) were 74% female with a
Toronto, ON mean age of 58 years. They reported more depression symptoms when they had less mas-
tery, experienced more fatigue, caregiving negatively impacts their life, and were younger
Background: Secondary Prevention Clinics (SPCs) were established in Ontario in 2001 to ex- and caring for a spouse (F (13,296) = 22.58, p<.001; adjusted R2=.48). Caregivers’ knowl-
pedite access to diagnostics, treatment, and risk factor education programs for patients at risk edge of stroke, level of assistance provided to the patient, patient illness severity and dis-
of stroke or recurrent stroke. There are currently 43 SPCs in the province. In 2012, the Ontario ability were not significantly related to caregiver depression. Conclusions: Young, spousal
Stroke Registry conducted an audit of the care provided at Ontario SPCs. Methods: Informa- caregivers with less mastery, who are fatigued, and are not able to participate in everyday
tion was collected on every patient that visited one of 40 SPCs between April 1, 2011 and activities are more likely to report depression and need support from the health care system.
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. R.4
Results: Of the 28,626 ED visits for suspected or confirmed stroke/TIA in Ontario, 21.3% Evaluating the Impact of Stroke Survivor & Caregiver Support Groups on
were subsequently seen in an SPC. The audit sample included 16,167 patients with 16,487 Successful Community Reintegration
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 Brown, G1 Belanger, A2 Martin, C1 Pratt, K2 Langstaff, C1 Brouillard, D2; 1. Stroke Network of
(22.2%), and diabetes (20.5%). Ninety-four percent of patients had neuroimaging and 83.9% Southeast Ontario , Kingston, ON; 2. Seniors Association - Kingston Region, Kingston, ON
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, Background: The human cost of stroke is universally understood to have significant and ongo-
were: antiplatelet therapy (94.4%); anticoagulant therapy (80.1%); antihypertensive therapy ing impacts on stroke survivors and caregivers. Effective community reintegration is a criti-
Abstracts From the 4th Canadian Stroke Congress, 2013  e9
cal enabler of quality of life and enhanced function for these individuals, potentially reducing morphology, and syntax. Each country proposed alternatives for unacceptable or unnatural
health system costs related to emergency room visits, hospital admissions and re-admissions. items. 2. The harmonized version underwent pilot testing in healthy older native speakers in all
The Canadian Best Practice Recommendations for Stroke Care highlight the impact of “refer- four countries, with documentation of expected or deviant responses to each item. 3. Revised
rals to community agencies, such as stroke survivor groups…” on individuals and the health items underwent repeat testing in healthy older native speakers in all four countries, to achieve
system. This project evaluated the impact of ongoing, professionally facilitated community a final version. Results: 1. Of the original 29 items, we revised 10 following international expert
stroke survivor and caregiver support groups. Methods: Pre-post comparative evaluation over review. 2. Pilot testing involved 76 participants (34 male; mean age 60 years, range 23-92; 51
a seven month period encompassed quantitative and qualitative domains including caregiver with postsecondary education) and resulted in revisions to three items. 3. Repeat testing of the
burden, caregiver well-being, stroke survivor well-being and overall satisfaction with the ser- three revised items involved 36 participants (15 male; mean age 56 years, range 32-84; 30 with
vices offered. Evaluation tools included the Stroke Impact Scale, the Montgomery Borgatta postsecondary education) and resulted in no further modification. Conclusion: We achieved
Caregiver Burden Assessment tool, a participant questionnaire as well as individual and focus international harmonization of the English LAST, ensuring linguistic naturalness and cultural
group interviews conducted by an objective third party. Results: Referral and activity rates appropriateness. We confirmed its linguistic validity in healthy older native speakers. Once vali-
increased with provision of system navigation and individual support. Positive effects of group dated in stroke patients, the English LAST will provide a much needed screening tool for aphasia.
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 VC.4
thinking and overall perceived recovery. A notable decrease was measured in both objective Imaging and Baseline Predictors of Cognitive Performance in Minor Stroke and
and subjective caregiver burden. Strong participant satisfaction and highly informative qualita-
TIA Patients at 90 Days
tive 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
Mandzia, JL1, 2 Smith, EE1, 2, 3 Horton, M1, 2 Hanly, P4 Barber, PA1, 2, 3 Godzwon, C1 Donaldson,
of professional psychosocial facilitation within a supportive community infrastructure. Con-
E1 Asdaghi, N5 Patel, S1 Aram, H1 Coutts, SB1, 2, 3; 1. Calgary Stroke Program, Calgary, AB;
clusions: Results support that professionally facilitated stroke survivor and caregiver stroke
2. Department of Clinical Neurosciences, University of Calgary, Calgary, AB; 3. Hotchkiss Brain
support groups may be significant contributors to perceived recovery, improved psychosocial
Institute, Calgary, AB; 4. Division of Respirology, Department of medicine,University of Calgary,
outcomes and successful community reintegration for both caregivers and stroke survivors.
Calgary, AB; 5. BC Centre for Stroke and Cerebrovascular Disease, Vancouver, BC

Background: Few studies have examined predictors of cognitive impairment following minor
R.6 stroke and TIA. We examined clinical and imaging features associated with poor cognitive
MRI-based Neuroanatomical Predictors of Dysphagia, Dysarthria, and Aphasia in outcome at 90 days. Methods: TIA or minor stroke (NIHSS<4) patients underwent cognitive
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

Patients with a First Acute Ischemic Stroke 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
Flowers, HL1 AlHarbi, M2 Silver, FL3 Mikulis, D2 Chakravarty, MM4 Fang, J5 Martino, R1; calculated for cognitive tests based on normative data; tests were analyzed as domains of
1. Department of Speech-Language Pathology, University of Toronto, Toronto, ON; 2. University memory (CVLT long delay free recall), executive function (EF; average of COWAS test FAS and
Health Network, Toronto Western Hospital, Toronto, ON; 3. Toronto Western Hospital, Toronto, Trails B) and psychomotor speed (PS; average of Trails B and Digit Symbol Coding). Depression
ON; 4. Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, ON; was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). Presence
5. Institute for Clinical and Evaluative Sciences, Toronto, ON 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.
Background: Dysphagia, dysarthria and aphasia occur frequently after stroke. We A p-value of ≤0.016 was chosen for statistical significance, correcting for testing of 3 sepa-
sought to identify MRI-based neuroanatomical predictors of these impairments early rate cognitive domains. Results: 86 patients were included, 74% male, 55% TIA, mean age
after ischemic stroke onset. Methods: We randomly selected 250 patients from a con- 65.2+12.2 and 14.2+3.3 years of education. 62% were DWI positive. 27.9% had moderate to
secutive cohort of ischemic stroke patients with MRI scans (N=716) from the Registry of severe OSA. Median Z-scores were: memory 0, EF -0.12 and PS +0.2. Mean CES-D was 7.9+8.
the Canadian Stroke Network’s database (2003–2008) in one stroke centre. We exclud- Cognitive scores were not significantly different based on diagnosis, cause and risk factors of
ed patients with dementia, brain tumour, neurosurgical interventions, or contusions. We stroke, OSA, DWI or WML volumes. EF scores correlated with baseline NIHSS (p=0.005) and
documented the presence of the acute lesion in 12 neuroanatomical regions of interest 90-day CES-D (p=0.004), and were lower in patients with 90-day mRS >0 (p=.017). EF <1
and extracted lesion volumes. We also identified concomitant neurological compromise, SD was associated with baseline NIHSS (p=0.016) and 90-day CES-D (p=0.002). PS scores
including brain atrophy, white matter disease, and prior covert stroke. Two raters in- correlated with baseline NIHSS (p=0.01) and CES-D (p=0.001), and were lower in patients with
dependently extracted all data, resolving discrepancies by consensus. We computed 90-day mRS >0 (p=0.004). Conclusion: Stroke severity, disability and depression predict poor
logistic regression analyses to identify predictors for each impairment. Results: 160 psychomotor and executive, but not memory test performance at 90 days.
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
VC.6
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 Incidental Small Acute Brain Infarcts Are Rare in Neurologically Asymptomatic
3.1, 95% CI 1.5–6.5), and insula (OR 2.6, 95% CI 1.2–5.8). Predictors of left-hemisphere Community-Dwelling Older Adults
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 super- Batool, S1 O’Donnell, M2 Teo, K2 Dagenais, G3 Poirier, P3 Lear, S4 Wielgosz, A5 Sharma, M2
ficial MCA territory (OR 3.3, 95% CI 1.04–10.5). Conclusions: We modeled neuroana- Stotts, G5 McCreary, CR1 Frayne, R1 Rangarajan, S2 Islam, S2 Yusuf, S2 Smith, EE1; 1. University
tomical predictors of dysphagia throughout the brain and extended previous findings for of Calgary, Calgary, AB; 2. McMaster University, Hamilton, ON; 3. Laval University, Quebec, QC;
dysarthria and aphasia in a large homogeneous sample of patients. Next, we will identify 4. Simon Fraser University, Vancouver, BC; 5. University of Ottawa, Ottawa, ON
more discrete neuroanatomical regions using voxel-based lesion symptom mapping.
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 mi-
VC.1 croinfarcts in their acute stage—prior studies report that 1-5% of cognitively impaired and 15%
International Harmonization and Pilot Testing of the English Language Screening 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
Test (LAST) 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
Flowers, HL1 Flamand-Roze, C2 Denier, C2 Roze, E3 Silver, FL4 Rochon, E1 Skoretz, SA1
Canadian sites. Participants were selected from population-based sampling within pre-defined
Baumwol, K5 Burton, L6 Brookes, K5 McGovern, A6 Harris, G5 Tyson, S7 Langdon, C8 Major, K5
postal code regions. A radiologist reviewed MRI DWI, ADC, FLAIR and T1-weighted sequences
Shaw, S1 Martino, R1; 1. Department of Speech-Language Pathology, University of Toronto,
for evidence of DWI hyperintensity consistent with acute infarction, with hypointensity on ADC as
Toronto, ON; 2. Service de neurologie, CHU Bicêtre, Assistance publique-Hôpitaux de Paris,
a supporting criterion. A second reader reviewed any questionable scans, with final diagnosis by
Le Kremlin-Bicêtre, France; 3. Département de neurologie, CHU Pitié-Salpêtrière, Assistance
consensus. DWI and ADC were missing in 10/803 (1.3%). Results: There were 793 participants
publique-Hôpitaux de Paris, Paris, France; 4. Toronto Western Hospital, Toronto, ON; 5. Sir
with MRI DWI: mean age 58.4±8.0 years; 260 (33%) were 60-69 years and 74 (9%) ≥70 years;
Charles Gairdner Hospital, Nedlands, WA, Australia; 6. Greater Manchester and Cheshire
326 were men (41%); 145 had hypertension (18%), 48 had diabetes (6%) and 57 were smokers
Cardiac & Stroke Network, Stockport, United Kingdom; 7. Stroke & Vascular Research Centre,
(7%). No definite DWI lesions were detected (0%; 95% CI 0% to 0.5%). Questionable faint DWI
University of Manchester, Manchester, United Kingdom; 8. Health Department of Western
Australia, Perth, WA, Australia 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
Background: The LAST is a unique bedside tool, designed to rapidly and reliably evaluate apha- without ADC hypointensity–a chronic small cavitated infarct, and a white matter T2-hyperinten-
sia during the acute phase of stroke. It may also complement stroke severity scales in the initial sity. Conclusion: In an unselected community population, incidental acute infarcts are rare on
evaluation of stroke patients. The LAST was developed and validated in French and subse- MRI DWI. Future research on incidental acute small infarcts should focus on at-risk populations.
quently 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 evalu- HS.2
ation, we collectively reviewed problematic items, selecting alternatives by expert consensus Improving Patient Outcome in Hyper-Acute Practices through
in four English speaking countries and in collaboration with the tool developers. 1. Experts in Real Time Audits
Australia, Canada, England, and the USA independently reviewed all 29 items for cultural ac-
ceptability and naturalness of language in multiple linguistic domains: phonology, semantics, MacIsaac, L; Reinholdt, F; Mackenzie Health, Richmond Hill, ON
e10  Stroke  December 2013
Background: Mackenzie Health, a District Stroke Centre, submits data to CIHI on key metrics tained (PA) if the goals were attained only at some of the follow up visits, not attained (NA) if the
for stroke. The data is reviewed monthly by the Stroke Quality Committee to monitor MH’s per- goals were never attained. Results: A total of 319 patients, qualified for the study. The average
formance against provincial benchmarks. The percentage of patients receiving tPA within 60 age was 69 and 55% were male. The table summarizes the results of the analysis. We defined
minutes dropped to 7.7% in Q3 2011-2012, with an increase in median door to needle times to optimal therapy as the control of all or some of the following three goals: hypertension, dyslipid-
70 minutes. The Committee recommended chart audits on every patient receiving tPA to identify emia and compliance with anti-thrombotic treatment.The control of individual risk factors, espe-
barriers and facilitators to meeting the benchmark. Methods: The Clinical Educator and Clinical cially hypertension was good. However, optimal therapy was only achieved in 22% of patients.
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 Completely Attained (CA), Partly Attained (PA), Not Attained (NA) Conclusions: Our study
promote understanding and generate buy-in. As a stroke expert, she was able to support patients showed that that there was reasonable attainment of therapeutic goals for stroke prevention in
and families and provide education. Chart audits were conducted and results shared with ED staff the McGill SPC over an average follow up of 15 months. Greater efforts will be needed in order
within 48 hours of thrombolysis. PDSA cycles were initiated to address barriers identi-fied in the to achieve optimal therapy.
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 leader-
P1.002
ship 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 Octogenarians Should Not Be Excluded From Acute Stroke Intervention Trials as
minutes. Conclusions: Engagement of ED staff facilitated uptake of best practices in hyper–acute Major Clinical Responses Common with Reperfusion
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 Nambiar, V; Almekhlafi, MA; Mishra, S; Desai, J; Eesa, M; Volny, O; Menon, BK; Demchuk, AM;
a flow sheet to improve compliance and decrease barriers to best practice. This process enhanced Goyal, M; Morrish, W; University of Calgary, Calgary, AB
team and inter-departmental collaboration benefitting pa-tients with stroke and their families.
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 vas-
HS.6 cular anatomy and a perceived poor potential for recovery especially in those with existing
Assessment of Delays in Presentation to Stroke Prevention Clinics After TIA or disability. We sought to assess the safety of the stentrievers technology in this patient popula-
Minor Stroke: a Preliminary Analysis tion. 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
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

Blacquiere, DP1 Bougoin, A2 Alhazzaa, M1, 3 Dowlatshahi, D1, 3 Perry, J1, 3 Sutherland, J1, 3 for IA stroke therapy in the absence of a pre-existing disability (Barthel index ≥90) or terminal
Sharma, M4; 1. University of Ottawa, Ottawa, ON; 2. Champlain Regional Stroke Network, illness. Results: The results are shown in the table. Octogenarians had a non-significant in-
Ottawa, ON; 3. Ottawa Hospital Research Institute, Ottawa, ON; 4. Population Health Research crease in the in-hospital mortality; all occurred in patients who did not reperfuse successfully.
Institure, Hamilton, ON 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
Background: Prompt referral and assessment in outpatient stroke prevention clinics (SPC) are age (p 0.8; figure). Conclusion: Octogenarians can be treated in a safe and fast manner when
associated with a reduction in stroke risk after transient ischemic attack (TIA) or minor stroke. selected carefully. The impact of age on long-term functional outcome was not assessed. Ex-
However, not all patients are seen within recommended times. We examined the records of cluding these patients from randomized trials of acute stroke therapy may need to be revisited
patients referred to SPC after TIA or minor stroke to determine the frequency, degree and rea- given the recent advances in the intra-arterial reperfusion technology and stroke patients care.
sons 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, tri-
age/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 in-
terim 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.

P1.001
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 isch-
emic 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 at-

CA % PA % NA %
BP Targets 119 71.6 17 6.1 62 22.3
LDL Targets 112 43.6 6 2.3 139 54.1
Antithrombotic 319 100 0 0 0 0
use
Smoking 40 76.9 0 0 12 23.1
cessation
Optimal 70 21.9 249 78.1
therapy
Abstracts From the 4th Canadian Stroke Congress, 2013  e11
P1.003
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 over-
emphasized. 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 rou-
tine 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 Conclusion: Our proposed technique provides wall contrast and can demonstrate ar-
median age was 64 years with a median NIHSS score of 18(iqr 9). The onset to IV needle time terial dynamics over the cardiac cycle. Tested in five normal subjects, DC fall within
was 130 minutes (iqr 111). All patients were treated via endovascular therapy with a median the expected range. Our technique could also image the dynamics of carotid artery
and mean times of IV needle to arterial puncture times of 46 and 49.7 minutes, respectively. wall components to provide detailed investigations of distensibility and its relation to
Of all treated with IV tPA, 39 patients (60.9%) had the arterial puncture within 60 minutes of stroke risk.
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
P1.006
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 Atrial Fibrillation Screening Using a Handheld ECG Device: Results from the Heart
trials may include the time needed to obtain consent for enrolment into the trial and the time and Stroke Foundation (HSF) “Be Pulse Aware” Campaign
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 Boyle, KO1 Morra, D1 Dorian, P1 McCrorie, A2 Haddad, P1 Taylor, L2 Grima, E3 Newman, D1
are shortened. 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
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

P1.004 Background: Early detection and treatment of atrial fibrillation (AF) could prevent many
strokes. New technology devices enable simple, rapid, inexpensive AF screening without
The Endocannabinoid Antagonist AM251 as a Method of Protection Prior to
requiring standard 12-lead ECG or medical personnel. We tested the feasibility and yield
Global Cerebral Ischemia: Implication for Dopamine Function, Neuronal Survival of a handheld ECG compared to manual pulse check at public screening events. Meth-
and Behavior ods: 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
Dunbar, MR; Azogu, I; de la Tremblaye, PB; Richardson, L; Plamondon, H; University of Ottawa, radial pulse palpation was performed by volunteer nurses/nursing students followed by
Ottawa, ON a 30 second single lead ECG rhythm strip by trained personnel (Heart Check™; Cardio-
Comm Solutions, Inc.). The primary endpoint was AF detection by pulse check compared
Background: Implications for the endocannabinoid system in global cerebral ischemia has not
to ECG with central blinded cardiologist adjudication. Results: Of 1334 participants
been clearly defined. Ischemia produces an excitotoxic environment that is severely damag-
(mean age 63 +/-13 years; history of hypertension in 20%), AF was detected by ECG
ing to neurons, causing degradation of cell membrane and ultimately cell death. Contradictory
in 28/1334 (2.1%): 10/1334 (0.7%) newly-detected AF and 18/1334 (1.3%) previously-
research suggests both the benefits and adverse effects of endocannabinoid on neurological in-
known AF. The prevalence of new AF increased from 6/747 (0.8%) in those aged ≥65
jury. Due to the excitotoxic nature of ischemic injury, and the mechanisms at play with endocan-
years to 3/197 (1.5%) in those ≥75 years and 2/75 (2.7%) in those ≥80 years. Of the
nabinoid agonists, such as increased transmission of dopamine and glutamate, it is suspected
new AF cases detected, 6/10 were potential anticoagulant candidates (CHADS2 score
that CB-1 endocannabinoid antagonists, such as AM251, may provide cell protection. Methods:
≥1). Of ECG positive patients with previously known AF and CHADS2 ≥1, 4/11 were not
40 male Wistar rats were separated into 4 groups (n=10/group). The first group of rats were
anticoagulated. Manual pulse check had low sensitivity (43%) and poor positive predic-
administered AM251 (2 mg/kg, i.p) 30 minutes prior to global cerebral ischemia (four vessel oc-
tive value (16%) for AF detection. An abnormal pulse was appreciated in only 12/28
clusion), while the second group were given AM251, 30 minutes prior to sham surgery. Finally
ECG-confirmed AF cases (including only 1 of the 10 new AF cases). Conclusions: In
the last two groups were given saline instead of AM251 and given either ischemia or the sham
a community screening setting, identification of AF with a handheld ECG device was
surgery. Behavioural testing included the open field test and elevated plus maze, which took
feasible and superior to pulse check. AF screening programs have potential to identify
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 guideline-based AF treatment candidates (both new AF cases and previously-diagnosed
function amongst groups. Thionin staining was used to evaluate post ischemic neuronal death. but untreated patients), with greatest yield in the elderly. Community AF screening
Results: Ischemia induced a significant reduction in dopamine within the mesolimbic circuit, should not rely on pulse checks alone.
including the ventral tegmental area, nucleus accumbens, CA3 & CA1 of the hippocampus, and
basolateral amygdala. These reductions in dopamine transmission by global ischemia were par-
tially or fully reversed by AM251 pretreatment. Furthermore, cell survival was increased in the P1.007
CA1 from treatment with AM251. Behavioural results indicate that AM251 reversed emotional A Novel Day-Unit Care Model for TIA and Minor Stroke Patients Improves Rapid
alterations associated with ischemia insult. Conclusion: The CB1 endocannabinoid antagonist Access to Care and Satisfaction with Care
AM251 facilitated recovery of deficits in dopamine function in the mesolimbic pathway, at-
tenuated ischemic CA1 cell death and regulated emotionality when given prior global cerebral Cayley, A2 Iyngarathasan, A2 Abraham, J2 Kalman, L2 Jaigobin, C2 del Campo, M2 Silver, F2
ischemia. 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
P1.005 occur within one week before stroke. Patients with a TIA require urgent assessment
Carotid Artery Distensibility Evaluation with Dynamic MR Imaging 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
Boesen, ME1, 3 Frayne, R1, 3, 4 Yerly, J1, 3 Lebel, RM2, 3; 1. University of Calgary, Calgary, AB; it is unclear if inpatient evaluation is optimal or necessary for this patient population.
2. Applied Sciences Laboratory, GE Healthcare, Calgary, AB; 3. Seaman Family MR Research Methods: We developed a high-risk TIA and Minor Stroke (TAMS) Unit to provide rapid
Centre, Calgary, AB; 4. Hotchkiss Brain Institute, Calgary, AB access to patient assessment, investigations, initiation of prevention strategies, and
stroke prevention education. The TAMS Unit patient assessments were based on a
Background: Carotid wall motion can provide insight into stroke risk. Detection of de- collaborative model led by stroke Nurse Practitioners and attending stroke Neurolo-
creased arterial distensibility could potentially guide early intervention. We have imple- gists. We evaluated the feasibility of this care model and assessed patient satisfaction
mented a retrospectively-gated black-blood MR acquisition to provide carotid wall images through a survey questionnaire. Results: Between Sept. 6, 2011 and Mar. 31, 2013,
over the cardiac cycle to evaluate distensibility measures. Methods: Eight axial slices were 265 patients were seen in the TAMS Unit. Median time from emergency department
prescribed over the carotid bifurcation in five volunteers. A standard black-blood MR ac- visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 35% of pa-
quisition was altered to retrospectively associate data acquired with different phases of tients and minor stroke (NIHSS < 4) in 30% of patients. For the satisfaction survey, 137
the cardiac cycle. One image of the common carotid artery was reconstructed for each questionnaires were mailed out to patients seen in the first year after the unit opened,
of sixteen phases. Left carotid artery cross-sectional areas were manually traced three with 60 (44%) returned – 52 (38%) were complete and included in the analysis. Overall,
times over on each image. Distensibility coefficients were calculated as: DC=2(Ds-Dd)/DdΔP 73% of patients strongly agreed and 27% agreed that they were satisfied with their
where Ds and Dd are systolic and diastolic diameters and ΔP is pulse pressure. Results: over-all visit. Sixty percent of patients strongly agreed and 36% agreed that they were
Carotid pulsation over the cardiac cycle was clearly demonstrated (see Figure of carotid provided with information about their condition. Over-all, patients were satisfied with
cross-sectional diameters over time). Maximum and minimum cross-sectional areas were their consultations with the stroke NPs and neurologists. Conclusion: Our novel TAMS
used to derive Ds and Dd. Mean DC was found to be 31.9±10.8MPa-1. This finding falls Unit is a feasible care model that provides rapid access to assessment and treatment of
within the range reported by Harloff et al. as 41.6±9MPa-1 using a different MR-based high-risk TIA and minor stroke patients. Overall, patients expressed strong satisfaction
method (Eur Radiol, 2009; 19:1470). with the care they received.
e12  Stroke  December 2013
P1.008 P1.011
Perfusion computed tomography for selection of patients with suspected acute Frequent Atrial Premature Beats Predict Occult Paroxysmal Atrial Fibrillation in
ischemic stroke for thrombolytic therapy—a systematic review and meta- Patients with Cryptogenic Stroke: Results From the Embrace Multicentre Trial
analysis
Gladstone, DJ1 Spring, M2 Dorian, P3 Thorpe, K3 Panzov, V3 Hall, J3 Vaid, H1 O’Donnell, M4
Burton, KR1 Dhanoa, D2 Aviv, R1 Moody, A1 Kapral, M1 Murray, K1 Laupacis, A1; 1. University of Laupacis, A3 Côté, R5 Sharma, M7 Blakely, J1 Shuaib, A8 Hachinski, V9 Coutts, SB10 Sahlas, DJ11
Toronto, Toronto, ON; 2. Fraser Health Authority, Surrey, BC 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 Investi-
Background: perfusion CT (CTP) imaging is increasingly being used for the diagnosis of acute gators17; 1. University of Toronto, Toronto, ON; 2. Trillium Health Centre, Mississauga, ON; 3.
ischemic stroke (AIS) as it is cheaper and faster than magnetic resonance imaging (MRI). St. Michael’s Hospital, Toronto, ON; 4. McMaster University, Hamilton, ON; 5. McGill - Montreal
While data from systematic reviews of UCT and MRI have been used to populate AIS imag- General Hospital, Montreal, QC; 6. University of Ottawa, Ottawa, ON; 7. Ottawa Hospital, Uni-
ing cost-effectiveness studies, none currently exist that provide estimates of outcomes for versity of Ottawa, Ottawa, ON; 8. University of Alberta, Edmonton, AB; 9. University of Western
patients selected by CTP imaging. Objectives: to determine the rates of outcomes (mortality, Ontario, London, ON; 10. University of Calgary, Calgary, AB; 11. Hamilton Health Sciences,
morbidity and symptomatic intracranial hemorrhage (SICH)) of AIS patients who are selected Hamilton, ON; 12. University of British Columbia, Vancouver, BC; 13. Université Laval, Quebec
for thrombolytic therapy using CTP imaging. Methods: we performed electronic searches in City, QC; 14. Vancouver Island Health Research Centre, Victoria, BC; 15. Kingston General Hos-
MEDLINE, EMBASE, the Cochrane Library, PubMed, and Google Scholar up to August 2012, pital, Kingston, ON; 16. Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON; 17.
unrestricted by language of publication and study methodology. We also performed manual Sunnybrook Research Institute and Li Ka Shing Knowledge Inst. of St. Michael’s, Toronto, ON
searches of included studies, bibliographies of relevant review articles and we searched the
gray literature for unpublished studies, which included theses, patents, health technology Background: Many ischemic stroke/TIA events are labeled ‘cryptogenic’ but may be due
reviews and conference proceedings. Two independent reviewers extracted study data and to undetected paroxysmal atrial fibrillation (PAF). To predict those most likely to have oc-
independently assessed risk of bias for each selected study. Results: fourteen studies met cult PAF, we investigated the association between atrial ectopic activity on Holter monitor
our inclusion criteria for a total of 479 patients. Mortality of CTP-selected AIS patients who and subsequent detection of PAF. Methods: We analyzed data from cryptogenic stroke/TIA
were treated within 3 hours was 17.6% (95% CI, 12.2-23.6%). Mortality of all CTP-selected patients without known AF enrolled in the 30-day cardiac monitoring arm of the EMBRACE
patients treated was 7.1% (95% CI, 1.8-15.5%). Favourable outcome (mRS score ≤ 2) for trial. Participants had baseline Holter monitoring that did not reveal PAF, followed by am-
patients treated within 3 hours and beyond 3 hours was 30.7% (95% CI, 8.4%-59.4%) and
bulatory cardiac monitoring for up to 30 days to detect PAF. In a preplanned multivariable
44.5% (95% CI, 0.6-29.5%), respectively. Rates of SICH for patients treated within 3 hours
logistic regression analysis, we assessed the association between the following Holter and
and beyond 3 hours were 5.4% (95% CI, 3.2-8.2%) and 4.7% (95% CI, 2.0-8.4%) respective-
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

clinical variables on the outcome of PAF detection: #atrial premature beats (APBs)/24h,
ly. Conclusions: the outcomes of CTP-selected AIS patients can be used in future studies of
#runs of atrial tachycardia <30 seconds/24h, age, and #prior strokes. Results: Among
CTP imaging cost-effectiveness relative to other neuroimaging modalities within AIS patients.
cryptogenic stroke/TIA patients (mean age 73±9 years), the median #APBs/24h on base-
line 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
P1.009
entire group, 45/287 (16%), PAF was found in 16/181 (9%) patients with infrequent APBs
Towards Patient-Tailored Perfusion Thresholds for Prediction of Stroke Outcome (<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
Eilaghi, A1 d’Esterre, C2 Lee, T3 Jakubovic, R1 Brooks, J1 Liu, RT1 Zhang, L1 Swartz, RH1 Aviv,
with >2 runs. In the regression model, #APBs was the only statistically significant predic-
R1; 1. Sunnybrook Health Sciences Centre, Toronto , ON; 2. Robarts Research Institute, London,
tor of PAF (p=0.0016). The probability of PAF increased steadily with increasing #APBs
ON; 3. Robarts Research Institute, University of Western Ontario, London, ON
(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
Background and Purpose: Multiple patient-specific clinical and radiological parameters impact
upon traditional perfusion thresholds used to classify/determine tissue outcome. We sought to de- have a high probability of occult PAF and may be particularly ideal candidates for pro-
termine whether modified baseline perfusion thresholds calculated by integrating baseline perfu- longed cardiac monitoring for PAF detection. Among those with >500 APBs/24h, 1 in 3 had
sion and clinical factors better predicts tissue fate and clinical outcome. Methods: Computed to- PAF detected on 30-day monitoring.
mography 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 P1.012
computed tomography perfusion parameters and follow-up FLAIR images. Optimal thresholds The University of Alberta Hospital Door-to-Needle (DTN) Process Improvement
transformed by clinical and radiological variables for grey matter and white matter tissue were de- Initiative; Significant changes Achieved Through Interdepartmental Collaboration
termined 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 Informa- Halabi, M1 Ghrooda, E2 Taralson, C1 Khan, K2 Amlani, S1 Shuaib, A2 Jeerakathil, T2; 1. Stroke
tion Criterion and logistic regression. Reproducibility of models was checked using bootstrapping. Program Edmonton Zone, Edmonton, AB; 2. Division of Neurology, University of Alberta
Results: Transformation of perfusion thresholds by clinical and radiological baseline param- Hospital, Edmonton, AB
eters 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 Background: Shortening door to needle times (DTN) for ischemic stroke thrombolysis re-
blood flow: 91%, 86%, absolute Tmax: 88%, 84%, relative mean transit time: 85%, 78% and mains a challenge. The literature demonstrates that feedback on performance to multi-
relative cerebral blood volume: 74%, 73%. Transformed thresholds enhanced the clinical 90-day disciplinary stroke stakeholders can reduce DTN times. For 17 years our centre has failed to
outcome prediction for cerebral blood flow, Tmax and mean transit time CTP maps. Conclusions: lower DTN times to sub 60 minutes. A new multifaceted process improvement initiative was
Transformation of baseline perfusion parameters by patient-specific clinical and radiological pa- implemented to streamline the DTN process Methods: April of 2012 marks the inception of
rameters significantly improves the accuracy of tissue fate and clinical outcome prediction. the DTN initiative. Stakeholders from the Emergency Department (ED), Stroke Service, and
Diagnostic Imaging (DI) were engaged and participated in this effort. Detailed process map-
ping was done collaboratively. Problem areas were identified. Specific solutions were de-
P1.010 vised, trialed, modified, and then re-trialed. Regular meetings were held with educators and
Oxford County Blood Pressure Education Program 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.
Gardner, LA1 Winter, J2; 1. Chief Nursing Executive, Alexandra Hospital, Ingersoll, ON; Cases were discussed on a weekly basis within the stroke team and DTN data was regularly
2. Oxford County Cardiac Rehabilitation and Secondary Prevention Program, Alexandra shared with stakeholders. Education sessions regarding this initiative were provided by the
Hospital, Ingersoll, ON stroke team to ED and DI staff. Statistical analysis involved linear regression and calcula-
tion of DTNs and confidence intervals for 4 time periods spanning 13 months. Results:
Program Summary: The Oxford Blood Pressure Education Program was developed to test The DTN initiative has rolled out an increasing number of components over 4 time periods.
the feasibility and effectiveness of an education and counselling intervention to improve Bottlenecks in the DTN process were identified then jointly and systematically managed
blood pressure control among hypertensive individuals diagnosed within three months prior resulting in a statistically significant declining trend in DTN (R = -2.43; p = 0.0006 for each
to recruitment, with no recent cardiovascular or cerebral vascular event, including those who subsequent month). DTN decreased significantly from 77 min (65,89) in April-July 2012 to
were already taking antihypertensive medication. The program initially targeted Oxford county 57 min (49, 65) in February-April 2013. Conclusion: The process improvement initiative
residents who did not have a family physician and sought treatment at a local emergency de-
enabled the development of a leaner process. This collaborative effort has aligned previ-
partment. Each participant was encouraged to bring a support person or family member. The
ously siloed departments allowing them to work towards a common goal. Future efforts will
demands placed on family physicians in the community, coupled with the physician shortage,
include engaging additional stakeholders such laboratory services.
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 P1.013
with hypertension and their family members, as well as any community member who has an Does Hospital Ischemic Stroke volume relate to Clinical Outcomes in the Ontario
interest in learning more about hypertension and management strategies. Again funded in Stroke System?
2011-12 through Ministry of Leisure and Recreation. Conclusion: The Oxford Blood Pressure
Education Program is a feasible, community-oriented program compatible with chronic dis- Hall, R1, 2 Fang, J1 Hodwitz, K1 Saposnik, G3, 1 Bayley, M4; 1. Institute for Clinical Evaluative
ease self-management, which was associated with reductions in blood pressure and other risk Sciences, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. St. Michael’s Hospital,
factors. These changes were significant statistically, clinically, and potentially, economically. Toronto, ON; 4. Toronto Rehabilitation Institute, Toronto, ON
Abstracts From the 4th Canadian Stroke Congress, 2013  e13
Better outcomes have been found among hospitals that treat high volumes of patients for but Groups 3D and 7D recovered only to the level of controls. These preliminary results suggest
specific surgical and medical conditions. We examined whether hospital ischemic stroke that contralesional inhibition initiated within hours after a cortical lesion is more beneficial to
(IS) volume was associated with 30-day mortality to inform regionalization plans. Using FY recovery of the paretic forelimb than the same inhibition protocol initiated 3 or 7 days following
2005/06 to 2011/12 CIHI DAD we calculated the average annual IS patient volumes among the lesion.
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 approxi-
mately one third of patients in each tercile. Hospitals were classified as small (<130), me- P1.016
dium (130 – 202) and large (>202). Multivariable hierarchical logistic regression was used Visualization of Nestin Signals Following Ischemic Injury and in
to account for patient clustering within hospitals. Overall, 70,895 patients were hospital- Neuroinflammatory Conditions
ized 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 Krishnasamy, S1, 2 Weng, YC2, 1 Kriz, J2, 1; 1. University Laval, Quebec, QC; 2. Centre de recher-
high volume hospitals. Higher volume hospitals admitted younger patients, mean (+/- SD) che du CHUL, Quebec, QC
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 dem- Introduction: Neruoinflammation is a process in which the brain responds to infections, dis-
onstrated similar prevalence of comorbid conditions with exception of, diabetes, cardiac eases and injuries, it occurs due to hypoxia and ischemia to a number of bacterial and viral
dysrhythmias, renal disease where small volume hospitals patients had lower prevalence infections. The inflammatory process in the neurogenic regions of the brain greatly alters the
(p < 0.0001). Overall 30-day risk-adjusted ischemic stroke mortality was 15.1%. Mortal- microenvironment of the neural stem cells and thereby influences the fate of these Neural
ity was 1.38 times greater (OR 1.38, 95% CI 1.21, 1.57) for patients cared for in small Progenitor Cells (NPGs). The mechanism, function and significance of the modulation of neu-
hospitals compared to patients cared for in high volume hospitals. There appears to be rogenesis during inflammatory processes remain to be elucidated. To address these ques-
an association between acute hospital IS volume and 30-day mortality in Ontario. Patients tions we generated a transgenic mouse model in which we can visualize the process of adult
admitted to hospitals with annual IS volumes greater than 15 but less than 130 per year neurogenesis from the brain of live animals using bio photonic/bioluminescence imaging and
are 38% more likely to die within 30-days than patients admitted to hospitals that see on high resolution CCD camera. Methods: Nestin-luc-GFP mice were subjected to 90 minutes
average 300 IS patients per year. 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
P1.014 we observed the up regulation of nestin bioluminescent signal at 24hrs, 3 days and 7 days,
Developing a Regional Model for Acute Stroke Unit Care - Submitted on Behalf of and signal was observed up to a month following the surgery. Chronic administration of LPS
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

the Fraser Health Stroke Strategy 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
Harrison, KJ1 Crozier, T2 Veldhoen, R2 Still, C2; 1. Fraser Health Authority, Langley, BC; 2. Fraser 7 days after stroke shows an increase of nestin and the nestin-driven GFP transgene expres-
Health Stroke Strategy, Surrey, BC sion 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
Background: In Fraser Health, one of Canada’s largest and fastest growing health regions, advantage of Nestin-luc/GFP transgenic mice to study the ischemic injury induced gliogenesis
stroke accounts for approximately 2100 hospital admissions annually—a figure that is an- and neurogenesis.
ticipated 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 P1.017
Steering Committee (FHSSC). Since its inception in 2005, the FHSSC has been focused on the Enhanced Dynamic Contrast Enhanced (DCE) MR for Brain Perfusion Imaging
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, Lee, E1, 2 MacDonald, M1, 2 Frayne, R1, 2, 3; 1. Biomedical Engineering, Hotchkiss Brain Institute,
ongoing quality improvement, and reduction in acute length of stay. On June 26, 2012 the University of Calgary, Calgary, AB; 2. Seaman Family MR Centre, Foothills Medical Centre,
start of this regional vision was realised with the opening of 12 acute stroke beds at Surrey Calgary, AB; 3. Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB
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 Background: MR perfusion measurements allow for derivation of tissue-level hemodynamic
created a robust ASU with staff empowered to use quality improvement methodology to estab- parameters (eg., cerebral blood flow) that are useful for diagnosis of cerebral ischemia. DCE ap-
lish a model of care that will be replicated across the region. Results: Through employing the proaches typically use fast T1-weighted MR imaging methods that exhibit, over a range, a near
Plan-Do-Study-Act (PDSA) methodology, front-line staff incorporated Canadian Best Practice linear relationship between signal intensity and contrast agent concentration. This observation
Recommendations to develop an acute care stroke model that has resulted in the standardiza- suggests the potential for more robust estimations of perfusion-derived parameters compared
tion of the following components: 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 pro-
1. patient/family and staff education sessions pose a technique for maximizing observed signal changes (ΔS=Scontrast-Sbaseline) during the
2. measurement and evaluation framework contrast agent bolus passage in less vascularized white matter tissues while preserving both
3. clinical decision tools (e.g. depression screen) spatial and temporal resolution. Methods: A DCE signal model was implemented that allowed
4. staffing mix 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 con-
Conclusion: This pilot project of the SMH ASU has allowed the FHSSC to develop a regional firmed predictions from the model using phantoms and stroke patients. Patients were scanned
model for acute stroke care that can be implemented in other regional hospitals to ensure con- using the DCE method with two TR/FA combinations during a single contrast injection. Results:
sistent, measurable and improved patient outcomes. 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
P1.015 observed in images for both the phantoms and stroke patients. Conclusions: Signal difference
Effect of Onset Time of Contralesional Cortex Inhibition Following an Ischemic in DCE perfusion imaging in WM can be increased by careful selection of TR and FA. More robust
Lesion in Rats 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
Jean-Charles, L1 Mansoori, B1 Touvykine, B1 Morse, l2 Quessy, S1 Dancause, N1, 3; 1. Université be implemented with accelerated imaging approaches.
de Montréal, Département de Physiologie, Montréal, QC; 2. Université de Montréal, Montréal,
QC; 3. Groupe de Recherche sur le Système Nerveux Central, Montréal, QC
P1.018
Following stroke, human imaging studies have shown that there is an early increase of activity Screening for High-Risk Comorbidities (Depression, Obstructive Sleep Apnea
in the contralesional hemisphere that progressively diminishes with time and recovery. Inhibitory and Cognitive Impairment) in the Stroke Clinic: The Need, the Challenges and a
neuromodulatory protocols have been applied to the contralesional hemisphere of stroke pa- Possible Solution (The Doc Screen)
tients 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 Lien, K1 Sicard, MN1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook
highest. Thus, our aim was to investigate the effect of onset time, the time between the lesion Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing
and the beginning of the contralesional inhibition, on motor recovery after cortical lesions. We Knowledge Institute, Toronto , ON
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 Background: Treatable comorbidities such as depression, obstructive sleep apnea, and cogni-
pump filled with muscimol, a GABA-A agonist, was connected to the cannula immediately (Group tive impairment (DOC) each affect up to 50% of patients post-stroke. Though these DOC condi-
0D), 3 days (Group 3D) or 7 days (Group 7D) after the lesion in 3 different groups. The pump tions worsen outcomes and quality of life, the associations amongst them are understudied.
continuously delivered muscimol for 14 days in all groups. Controls spontaneously recovered Routine screening is recommended, but is onerous and cannot be applied in all cases. There is
from lesions of similar size. The performance of both forelimbs was assessed with the Mon- a need for brief, valid tests to screen for these three comorbidities during the clinical encounter.
toya staircase test. In all experimental groups, there was decrease of grasping function with The objective of this research study is to develop a 1-page integrated screening assessment to
the non-paretic hand during the inhibition, confirming the effectiveness of muscimol. For the identify high-risk patients for each of the DOC conditions in large-volume urgent TIA/stroke clin-
paretic forelimb, there was an initial decrease of function after the lesion that progressively ics. Methods: A literature review was conducted for screening tools of DOC comorbidities. More
recovered with time. Group 0D recovered significantly better than controls by post-lesion day 28 than 50 tests were identified but few met inclusion criteria of brevity and utility for broad clinical
e14  Stroke  December 2013
application. Results: The DOC screen is a novel screening tool that combines depression, apnea Introduction: The presence of leptomeningeal collaterals are associated with improved
and cognitive screening tests (PHQ-2, STOP, and mini-MoCA, respectively). The screen has been outcome among patients with acute ischemic stroke. We sought to identify if the associa-
designed such that less contributory cognitive tasks (distracters) have been replaced with mood tion between recanalization after endovascular acute stroke therapy and favorable clinical
and apnea questions to maintain validity of the delayed recall task. Additionally, it employs more response is modified by the presence of good collateral flow assessed on baseline CT
sensitive executive function tasks (clock and abstraction). Scores for each disease can be as- angiography (CTA). Methods: Data are from the Keimyung Stroke Registry, a prospec-
sessed separately, and the total (out of 20) provides an overall “brain risk” score. Conclusion: tively collected dataset of patients with acute ischemic stroke from Daegu, South Korea.
Simple, reliable, evidence-based screening of DOC disorders is necessary and the novel screen Patients with M1 segment middle cerebral artery (MCA) +/- intracranial internal carotid
may facilitate this. While brief screens have been studied individually, it remains to be seen if artery (ICA) occlusions on baseline CTA from May 2004 to July 2009 who had baseline
the integrated measures prove to be feasible and valid. 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
P1.019 65.2±13.2 years, median NIHSS 14; IQR 8.5), median time from stroke onset to initial
National Survey of Neurologists for TIA Risk Stratification Consensus and 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 col-
Appropriate Treatment for a Given Level of Risk
lateral status and recanalization was relevant (p=0.048). Only patients with intermediate
Perry, JJ1 Losier, J1 Sutherland, J2 Stiell, IG1 Sharma, M3; 1. University of Ottawa, Ottawa, ON; 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
2. Ottawa Hospital Research Institute, Ottawa, ON; 3. McMaster University , Hamilton, ON
collaterals who do not achieve recanalization and patients with poor collaterals even if
Background: 5% of transient ischemic attack (TIA) patients have a subsequent stroke ≤7 days. 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
The Canadian TIA Score uses clinical findings of TIA patients to calculate subsequent stroke risk
using latest generation mechanical devices (stentrievers) among patients with good and
≤7 days. Our objectives assessed: 1) anticipated use; 2) component face validity; 3) risk strata
intermediate collaterals assessed on CTA at baseline could provide confirmatory evidence
for stroke ≤7 days; 4) actions required, for the Canadian TIA Score. Methods: We conducted
for IAT in acute ischemic stroke.
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 P1.023
Apixaban Versus Aspirin in Atrial Fibrillation Patients ≥ 75 Years Old: an Analysis
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

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. From the AVERROES Trial
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 Ng, K; Shestakovska, OO; Eikelboom, JW; Connolly, SJ; Yusuf, S; Hart, RG;
duration (90.1%), history carotid stenosis (92.6%), antiplatelet therapy (52.1%), gait disturbance McMaster University, Hamilton, ON
(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 Background: The AVERROES trial (mean participant age 70 years) compared aspirin with
≥400x109/L (39.7%), and glucose ≥15mmol/L (63.6%). 86.8% would use the Canadian TIA apixaban, a novel oral Xa inhibitor, in patients at moderate-to-high risk of stroke due to atrial
Score after validation. Using the 25th percentile (i.e. 75% of physicians would accept this degree fibrillation (AF) but were unsuitable for vitamin K antagonists (VKA). Most AF patients in the
of risk or more) defined: minimal-risk <1%, low-risk 1-5%, high-risk 5.1-15%, and critical-risk community are ≥ 75 years-old, and this age group has higher risks of both stroke and bleed-
>15% for subsequent stroke ≤7 days. Suggested actions include minimal-risk: ECG, optimize ing during antithrombotic therapy than younger AF patients. In these exploratory analyses,
blood pressure; low-risk: CT head, outpatient carotid imaging, echocardiogram; high-risk: im- we characterize further the effects of aspirin and apixaban in elderly patients. Methods: The
mediate carotid imaging, hospital admission, and critical-risk: echocardiogram on same day. AVERROES trial (n=5599) included 1898 patients ≥ 75 years with AF. We compared baseline
Conclusions: Neurologists will likely use a validated Canadian TIA Score. Most components characteristics and evaluated the effect of apixaban compared with aspirin on stroke and major
have high face validity. Risk strata are definable with prescribed actions. bleeding in patients ≥ 75 years versus patients < 75 years. Results: The absolute risk reduc-
tion 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 (rela-
P1.021
tive risk reduction 33%; P-value for age interaction = 0.04). Patients ≥ 75 years had higher
Community Exercise Partnership: Heart Wise Exercise for TIA and Minor CHADS2 score and lower mean GFR compared with patients < 75 years. Whilst the risk of ma-
Non-Disabling Stroke jor bleeding was higher in patients ≥ 75 years (2.2%/year on aspirin and 2.6%/year on apixa-
ban) compared with patients < 75 years (0.7%/year on aspirin and 0.8%/year on apixaban),
Morris, MR1 Bourgoin, A1 Gocan, S1 Harris, J2 Woermke, H3 Dyks, T1; 1. Champlain Regional there was no significant interaction with age. Summary: Patients ≥ 75 years who are unsuit-
Stroke Network, Ottawa, ON; 2. The Ottawa Heart Institute-Heart Wise Exercise, Ottawa, ON; able for VKA treatment have substantially greater benefit from apixaban than aspirin compared
3. Pembroke Regional Hospital, Pembroke, ON 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
Background: Physical activity (PA) is an important modifiable lifestyle factor in secondary pre- major bleeding and worse renal function.
vention 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 vas- P1.024
cular conditions. Methods: An innovative model was employed at Champlain Regional Stroke
The Effectiveness of Stroke/TIA Education Upon Discharge From the Stroke Unit
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, sys-
at the Grey Nuns Community Hospital
tematic PA prescription and referral to Heart Wise Exercise (HWE) community programs for
Pfeiffer, TL1 Avoledo, S1 Morrison, L2; 1. Grey Nuns community Hospital, Edmonton, AB;
patients seeking support with PA. University of Ottawa Heart Institute and Champlain Regional
2. Stroke Program, Edmonton Zone, Edmonton, AB
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
Background: The Canadian Best Practice Recommendations for stroke care indicates “educa-
at 24 HWE sites (11 rural, 13 urban) participated in targeted training for exercise after TIA/
tion is an integral part of stroke care that must be addressed at all stages across the continuum
MNDS. Health care providers at all four SPC’s in Champlain implemented standardized exercise
…” As part of the Alberta Stroke Initiative (ASI), a gap analysis completed in 2012 at the Grey
prescription pads which included Canadian Best Practice recommendations for PA and identified
Nuns Community Hospital (GNCH) Stroke Unit identified a lack of stroke education to patients
regional HWE programs. Fitness leaders who received training reported increased confidence
upon discharge. As a result, the GNCH Stroke Unit created a discharge process for the stan-
in providing safe and suitable exercise routines. Successes seen in the stroke program have
dardized Stroke/TIA Information Package developed by the Stroke Program, Edmonton Zone.
been replicated among regional diabetes programs. Challenges for program evaluation have
A pilot project evaluating the effectiveness of this process is currently underway. Methods:
included access to volumes of referrals and tracking program uptake. Conclusions: PA is an The new discharge process from the GNCH Stroke Unit consists of the bedside nurse providing
independent risk factor for stroke and other vascular conditions. As such, the systematic deliv- education by reviewing the content within the Stroke/TIA Information Package with all Stroke/
ery of counselling, education and support for physical activity is an important vascular health TIA patients. A checklist, secured to the front of the package, is completed by the bedside
prevention strategy. Research is needed to assess the impact of partnerships which couple nurse and signed off by the patient. Patients are encouraged to review the information package
standardized, patient-focused interventions with structured community programs supported by and bring it to subsequent Stroke Prevention Clinic (SPC) appointments. The SPC clinic nurse
trained fitness leaders. 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
P1.022 currently a pilot project at the GNCH Stroke Unit. Results have yet to be collected and analyzed,
CTA Collaterals Can Be Used for Patient Selection in Proximal Anterior Circulation but patient questionnaires received to date report satisfaction with the education provided. The
Occlusions Receiving IA Therapy 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
Nambiar, VK1 Sohn, S2 Quazi, E1 Mishra, S1 Quazi, A1 Kosior, J1 Demchuk, AM1 Hill, MD1 Best Practice Recommendations by providing standardized discharge education to all Stroke/TIA
Goyal, M1 Menon, BK1; 1. University of Calgary, Calgary, AB; 2. Keim Yong University, patients. Evidence of similar activities suggests that this process will contribute to a safer and
Keimyong, Korea more informed discharge.
Abstracts From the 4th Canadian Stroke Congress, 2013  e15
P1.025 Background: Depression, obstructive sleep apnea and cognitive impairment (DOC) each affect
Acute Ischemic Stroke Care Path and Pre-Printed Orders Education 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
Ram-Ditta, D; Fraser Health Stroke Strategy, Surrey, BC 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
An InterProfessional team in Fraser Health developed an Acute Ischemic Stroke Care Path that Neurological Disorders and Stroke (NINDS) and Canadian Stroke Network (CSN) has emphasized
utilized elements of 48/6 (Mandated by the BC Ministry of Health to assess 6 components in the need to develop cognitive screening tools that can be applied in a 5-minute assessment. The
48 hours). In addition, the carepath incorporated best practice standards from the Stroke Best objective of this study is to determine the feasibility of implementing a simple, evidence-based,
Practice Guidelines 2010. The carepath presently is for nursing. It is being trialled at our only 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
stroke unit and four cohort units in acute care for a period of 3 months. It will be revised and
project is to determine whether 85% of eligible patients can complete the DOC screening assess-
will be available for use in our medicine program. The education session has been designed to
ment in ≤ 5minutes. Methods: All consecutive new referrals to the Sunnybrook Stroke Prevention
be interactive, fun, and meaningful. The intent of the sessions are to foster the nurses ability
Clinic who were English-speaking and non-aphasic were eligible to be screened. The clinical care
to critically think about why certain elements are important to assess and treat in the stroke team were trained in administering the screen and given a stopwatch. The total number of patients,
patient. Even though there is a core curriculum, each cohort site’s needs have been assessed, number screened and the time for completion were logged. Results: Over eleven months, 934
and the education tailored to address the learning needs. A lesson plan has been developed for new referral patients were seen at the Sunnybrook Stroke Prevention Clinic. 205 patients declined,
each session and is interprofessional in nature. The education is Interprofessional in nature and were missed or were ineligible at first screen. Data from 729 screens have been collected; 86
includes education from Physiotherapy, Occupational Therapy, Pharmacy, Speech Language Pa- patients were excluded (30 were untimed, 55 non-English-speaking and/or aphasic), and 643 pa-
thology, Pharmacy, Nursing and the Regional Stroke Coordinator. Even though the education is tients were included. Feasibility analysis showed 89% (95% CI: 86.1%-91.0%) of eligible patients
in progress, the evaluations has been very positive. The education is based on the needs of each completed the screen in ≤ 5minutes (range 1.8-11.5 minutes, average 4.2 minutes, S.D. =1.45).
cohort site, and incorporates members of the interprofessional team such as physiotherapy, Conclusion: Systematic screening of depression, obstructive sleep apnea, and cognitive impair-
occupational therapy, speech language pathology and pharmacy when the need has been iden- ment in ≤ 5minutes is feasible in a high volume stroke/TIA clinic using the DOC screen.
tified by the manager and educator. The care path and pre-printed orders are also discussed.

P1.029
P1.026 One-Year Experience of a Carotid Intervention Quality Assurance Initiative using
Targeting the Rgma/Neogenin Pathway to Promote Neuronal Regeneration a Carotid Revascularization Performance Feedback Letter
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

Following Stroke
Somji, M1 Gould, L2 MacRae, L2 Carlino, K2 Murty, N1, 2 Szalay, D1, 2 Wells, J1, 2 Sahlas, DJ1;
Shabanzadeh, AP; University of Toronto, Toronto, ON 1. McMaster University, Hamilton, ON; 2. Hamilton Health Sciences, Hamilton, ON

Membrane proteins play critical roles in many biological processes. Here we developed a series Background: Carotid revascularization, usually carotid endarterectomy (CEA) is a highly effec-
of peptides to alter the role of the extracellular ligand Repulsive Guidance Molecule RGMa and tive strategy for secondary prevention of stroke in patients presenting with symptomatic carotid
its receptor (Neogenin) on diseased neurons. To assess the role of these peptides in Stroke, we artery stenosis. However, the absolute risk reduction is extremely dependent upon timing of
have used several in-vivo stroke models, including a thromboembolic stroke model in rats which surgery, with maximum benefit if CEA is performed within two weeks of symptoms. Data from
utilizes a distal internal carotid artery occlusion with a clot, and a model of retinal artery stroke. the Registry of the Canadian Stroke Network indicates that median time to surgery in Ontario is
To get insight into the cellular mechanisms involved after addition of our peptides, we developed 25 days, with only one-third of patients receiving CEA within 2 weeks. Methods: A quality assur-
in-vitro stroke models (Oxygen and Glucose Deprivation model). Here, we show that providing ance initiative including the development of a carotid revascularization performance feedback
RGMa, to neurons promoted cellular survival in retinal and cerebral stroke models. Because we letter was designed in order to foster self surveillance of elements related to achieving target
have showed that RGMa requires activation by the enzyme SKI-1, we also tested whether or not 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 interven-
a specific inhibitor for this enzyme can promote functional recovery following Stoke (see im-
tion. Results: Forty-three patients underwent carotid revascularization for symptomatic disease
ages 1 and 2 ) . Interestingly, animals treated with this inhibitor significantly neurological deficit
over a period of one year. Twenty-four patients were initially referred to a Stroke Prevention
improvement following MCAO. This was accompanied by a reduction of the infract volume and
Clinic (SPC), whereas 19 patients were instead referred directly to either a vascular surgeon or a
brain edema size. Together our results reveal that targeting the RGMa/Neogenin pathway may
neurosurgeon. Mean time from index clinical event to surgery was 28 days for patients referred
provide therapeutic opportunities for the treatment of Stroke. 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
P1.027 revealed two distinct clinical pathways for patients presenting with symptomatic carotid artery
Frequency of Atrial Arrhythmias in Stroke: Prolonged Monitoring of Cardiac disease. The clinical pathway involving referral to a SPC was associated with more efficiencies
Rhythm for Detection of Atrial Fibrillation After a Cerebral Ischemic Event in achieving target times for best practice. This validates and emphasizes the importance of
(PEAACE) Study SPCs in managing this population at a high risk of stroke recurrence.

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, P1.030
AB; 2. University of Alberta, Department of Medicine, Division of Cardiology, Edmonton, AB Dedicated Stroke Care Reduces Stroke Mortality Rates

Background: Recent studies suggest that prolonged cardiac monitoring may identify paroxysmal Tebbutt, TD; Grand River Hospital, Kitchener, ON
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 pre- Background: Grand River Hospital (GRH) has been a District Stroke Centre serving Waterloo/
senting with a TIA or stroke where preliminary investigations (including a Holter) did not show atrial Wellington since 2003 and has been administering tPA since 2004. We implemented a 12 bed
fibrillation. Methods: Prospective non-randomized study of patients with TIA and acute stroke acute stroke unit in 2004. The 30 day stroke mortality rates at GRH have been higher than the
between July 2012 and May 2013 where Spider Flash-t™ Monitors (Sorin Group, Italy) were at- provincial benchmark. This prompted quality improvement initiatives to decrease our stroke
tached to the patients for prolonged monitoring. Clinical events were evaluated with a specifically mortality rates. Methods: Chart audits were completed which indicated there was opportunity
designed ‘arrhythmia score’ and the recordings were initially reviewed by the study team and then for improvement in our coding. A dedicated stroke coder was implemented and targeted educa-
tion was provided to our hospitalists who care for patients on our acute stroke unit. Interdisci-
by the study cardiologist. The duration and frequency of PAF was recorded and the results were
plinary staff training was implemented focusing on the Canadian Neurological Scale, dysphagia
conveyed to the referring stroke neurologist. Results: In 54 patients (duration of monitoring 10 (±4)
screening, early mobilization, DVT prophylaxis, falls assessments and safe transfers. Results:
days), there were 17 patients (31%) with PAF (AF >30 seconds 5 patients, AF >3 sec and <30 sec
Results demonstrate a trend towards decreased mortality rates, decreased hospital acquired
12 patients). Paroxysmal atrial tachycardia was detected in additional four patients and atrial flut-
pneumonia and decreased readmission rates. GRH is now below the provincial benchmark for
ter in an extra two patients. In three PAF, was evident with concomitant symptomatic large vessel stroke mortality. Conclusion: Grand River Hospital was successful in significantly decreasing
carotid disease. The diagnosis of PAF leads to initiation of anticoagulant treatment in 12 patients. stroke mortality rates utilizing a multi-faceted approach. A designated stroke unit with dedi-
Conclusions: Prolonged cardiac monitoring for detection of atrial arrhythmias increases the yield cated interdisciplinary staff promotes stroke expertise and facilitates targeted stroke education.
for PAF. Previous studies have focused on patients with cryptogenic stroke. Our study shows that A dedicated stroke coder promoted improved quality of stroke data.
PAF and other arrhythmias are present with similar frequency in patients where additional mecha-
nisms may account for the etiology and often results in changes in treatment.
P1.031
The Study of Hyperintense Flair Vessel (HVS) Sign Reversal On FLAIR MRI In
P1.028 Acute Strokes with Proximal Vessel Occlusions, Does It Make Us Any Wise?
The “Doc” Screen: Rapid, Routine Screening for Depression, Obstructive Sleep
Apnea and Cognitive Impairment is Feasible in Stroke/TIA Clinics Adatia, S1 Almekhlafi, M1 Nambiar, V1 Trivedi, A1 Sohn, S2 Menon, B1; 1. Foothills Medical
Hospital, Calgary , AB; 2. Keimyong University , Daegu, Korea
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 Background and Purpose: Hyperintense vessels (HV) have been observed in fluid- attenuated
Knowledge Institute, Toronto, ON inversion recovery imaging (FLAIR) MRI sequence in patients with acute ischemic strokes in
e16  Stroke  December 2013
r­egion of diffusion positivity .They have been linked to slow flow in collateral arterial circulation P1.034
and proximal arterial occlusions. We aim to study the reversal of HVS on 24 hours MRI and its Optogenetic activation of mouse cortical inhibitory interneurons is sufficient to
relation to successful recanalization. Methods: We reviewed 148 patients from prospectively increase local blood flow
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 Anenberg, E; LeDue, J; Murphy, TH; University of British Columbia, Vancouver, BC
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 Interplay between various cell types in the brain orchestrates the recruitment of blood flow in
showed reversal. Interrator agreement was accepatble. (Kappa 0.92) Baseline characteristics like accordance with local activity. Coupling alterations in blood flow, and presumably oxygen deliv-
age, sex, NIHSS, diabetes and smoking was comparable. The patients were offered intravenous ery, with levels of neuronal activity is essential for normal brain function; however, the underly-
tpa, intra arterial therapy (lytic/ mechanical thrombectomy) or both based on case basis. 30/35 ing mechanisms involved in this regulation are unclear. Studies suggest a role for astrocytes,
reversal group underwent IV wtih IA, all had successful recanalization (TIMI 2/3 on angiogram pericyctes, pyramidal neurons and interneurons in controlling cerebral blood flow. Here we use
). In the non reversal group, 38/63 patients had IV with IA. 16 showed complete recanalization optogenetic techniques, cell type selective excitation, to investigate whether direct activation of
(42%). (p<0.005) The initial infarct volume, infarct growth (24 hours) and mRS at 3 months was inhibitory interneurons can alter blood flow. By imaging through a polished reinforced thinned
comparable in both. In the multivariate analysis model for prediction of reversal of this sign, suc- skull window, we have observed that direct photostimulation of inhibitory cells in vivo in VGAT-
cessful recanalization emerged as the prime factor. (p=0.006 ;OR6.21) No effect of age, time to mhChR2-YFP BAC transgenic mice alters levels of cortical blood flow and activity. With 3.3 mW
MRI, time to treatment was seen. Conclusion: The reversal of HVS after successful recanalization of 473nm light, 100ms of 100Hz 5ms stimulation led to a 9.15±1.08% increase in the laser
does indicate that these vessels represent sluggish flow due to proximal large vessel occlusions. speckle signal within 1.9 s (n=3). Similar increases in blood flow assessed by laser speckle
This sign can be used as a surrogate marker for presence of large vessel occlusions. To our best (10.04±0.03%) were achieved with 4 s of sensory stimulation (n=2). Intrinsic optical signals were
knowledge, our group is the first ever to describe its reversal with recanalization. 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 ∆R/R% within 1.2 s (n=5). Signal overshoot,
P1.032 which is proposed to consist largely of HbO2 increase and deoxyHb decrease (Malonek and Grin-
Cerebral Microbleeds Causing Acute Focal Deficits: Evidence From a CADASIL vald, 1996) reached a maximum of 0.205±0.032 ∆R/R% within 3.2 s (n=5). Sensory stimulation
Patient led to an initial dip of similar amplitude to direct optogenetic stimulation (-0.020±0.004 ∆R/R%
within 1.2 s) but a smaller overshoot (0.024±0.008 ∆R/R% within 4.8 s) (n=3). These data sug-
Vitali, P; Boghen, D; Daneault, N; Guillon-Letourneau, L; Poppe, AY; Notre-Dame Hospital, gest that the activation of interneurons is sufficient to mediate elevations in cortical blood flow.
Montreal, QC
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

Background: Cerebral microbleeds, thought to reflect minor leakage from fragile arterial mi- P1.035
crovessels, visualized on gradient-echo MRI sequences, are classically considered as clinically Characterization of the Regenerative Response of Endogenous NPCs Following
silent. However, some recent case reports provide evidence that microbleeds can cause fo- an ET-1 Induced Focal Ischemic Injury in the Adult Mouse Cortex
cal 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 Bartlett, RF; Roome, RB; Xiong, J; Vanderluit, J; Memorial University of Newfoundland,
no vascular risk factors presenting with sudden onset of severe headache, vertigo, nausea, St. John’s, NL
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 Background: The neural precursor cell (NPC) population of the subventricular zone (SVZ) in
after suffering from a number of strokes. Neuro-ophthalmological examination early post-onset the adult mammalian brain has been the subject of great interest, specifically for their potential
revealed left hypertropia, clockwise torsion of the eyes, right head tilt and counter-clockwise to aid neural regeneration. NPCs have the ability to differentiate into the 3 cells of the central
rotary nystagmus and upbeat nystagmus in primary position. This was interpreted prior to the nervous system – neurons, astrocytes and oligodendrocytes. However, although NPCs migrate
MRI as consistent with an ocular tilt reaction possibly due to a lesion nearby the left Interstitial to the site of injury after an ischemic insult as differentiating neuroblasts, the majority of them
Nucleus of Cajal (INC). An extensive investigation of a posterior circulation stroke was carried undergo apoptosis and fail to contribute towards regeneration. Methods: To test if enhanced
out. Results: CT angiography and serological investigations for stroke in the young adult were survival of these neuroblasts can assist in the repair of an infarct, we propose to selectively
normal. However, brain MRI showed classical radiological findings of CADASIL disease with manipulate the expression of the anti-apoptotic gene, Mcl-1. Our lab has recently developed a
extensive leucoencephalopathy involving both temporal poles and several old lacunar strokes. reproducible focal ischemic injury model in the adult mouse forelimb motor cortex. Using this
Notch3 mutation analysis is pending. Surprisingly, no acute ischemic lesion was observed on model, I am investigating the acute peak proliferative response of NPCs when they differentiate
DWI sequences, in particular in the brainstem, excluding an acute ischemic stroke. However, to neuroblasts and begin to migrate towards the focal ischemic injury. This can be achieved
gradient-echo sequences showed a pattern of multiple subcortical microbleeds. In particular, through the use of BrdU, a proliferation marker, and doublecortin, a marker for neuroblasts, im-
one microbleed was strategically located in the rostral midbrain, in a region next to the left puta- munohistochemistry. Additionally, I have further characterized the progression of the injury, this
tive INC. Conclusions: The observations in this single case support the view that microbleeds includes assaying the neuronal, glial and vascular health post injury. Results: I have shown how
may be associated with acute focal neurological deficits and suggest a possible novel patho- NPCs in the SVZ react to an ischemic insult during the first week post injury, this gives greater
physiological mechanism underlying the clinical spectrum of CADASIL disease. 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
P1.033 window for manipulation is crucial to determine when to transfect NPCs with Mcl-1 and assess
Development of a Walk-in Code Stroke Protocol for Community Hospital the extent of neuroblast survival and possible regeneration. This will help identify a role for NPCs
Emergency Departments in Toronto to promote neural repair in the adult brain following ischemic injury.

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 P1.036
West Stroke Network, Toronto, ON; 4. Toronto Stroke Networks, Toronto, ON; 5. Toronto Functional Neuroimaging markers of Cerebral Small Vessel Disease effects
Emergency Medical Services, Toronto, ON on cognition
Background: Since 2005, the Memorandum of Understanding for Medical Redirect and Repa- Dey, AK2, 4, 5 Turner, G2, 1 Black, SE3, 6, 7 Levine, B5, 6, 8; 1. Department of Occupational and Reha-
triation of Acute Stroke Patients within Toronto Area (MOU) ensures that acute stroke patients bilitation Sciences, University of Toronto, Toronto, ON; 2. Heart and Stroke Foundation Centre
accessing Toronto Emergency Medical Services (TEMS) are screened for potential eligibility for for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, ON; 3. Centre for Stroke
hyperacute intervention and transported directly to a Regional Stroke Centre (RSC). The MOU sup- Recovery at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON;
ports coordinated access to time-sensitive stroke services not available at community hospitals. . Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON;
Not all patients activate EMS and instead use their own transportation to arrive at a community 5. Rotman Research Institute, Baycrest Centre, Toronto, ON; 6. Department of Medicine
hospital emergency department (ED). For patients assessed by community ED physicians who re- (Neurology), University of Toronto, Toronto, ON; 7. LC Campbell Cognitive Neurology Research
quire RSC services, the lack of a formal process for expedited transfer to a RSC has limited access Unit, Toronto, ON; 8. Department of Psychology, University of Toronto, Toronto, ON
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 Background: Cerebral small vessel disease (CSVD), characterized by distributed ischemic white
community hospitals. Working with physician and staff from community hospital EDs, RSCs, To- matter damage, is associated with cognitive dysfunction and contributes to dementia risk. While
ronto EMS, and Toronto Stroke Networks, a new Walk-in Code Stroke Protocol (WCSP) was devel- most research investigating CSVD effects has focused on the relationship between structural im-
oped. The protocol, implemented on December 3, 2012 includes standardized screening criteria aging measures and cognitive decline, there has been relatively little research investigating the
and communication protocols, clear target timelines and a system failure reporting mechanism effects of CSVD on functional brain imaging measures in correlation with behaviour. Method:
to support quality improvement. Results: From December 2012 to March 2013, 50 patients were Here we present a systematic review of papers since 1990 that have studied the mechanism
transferred from 12 community hospital EDs to RSCs under the new WCSP, representing 14% of by which CSVD may affect cognition using functional neuroimaging techniques (8 fMRI, 6 EEG
acute stroke EMS transports. 90% of EMS pick-ups occurred within the 9-minute target time and studies). Results: Converging evidence from fMRI studies suggest that relative to healthy con-
9 process-related issues were reported. Ongoing evaluation of the WCSP will monitor 1) system trols, CSVD patients demonstrate impaired deactivation of the posterior cingulate cortex (PCC)/
performance to ensure compliance and identify opportunities for improvement and 2) impact on precuneus - a critical mode in the default mode network (DMN) - as well as decreased func-
patient outcomes including t-PA administration rates. Conclusions: An improved standardized tional connectivity in several networks associated with attention, working memory and auditory
system of coordinated and equitable access to hyperacute stroke services for patients who arrive and language processing. In contrast, enhanced connectivity to the PCC, mainly through the
at non-RSC hospitals has been achieved across Toronto. Tools and resources developed may be temporal-parietal cortex, has been reported and hypothesized to reflect a compensatory adap-
transferable to other hub-and-spoke stroke care settings. tion. Delayed neurovascular coupling in the dorsolateral prefrontal cortex (DLPFC) has also been
Abstracts From the 4th Canadian Stroke Congress, 2013  e17
reported. Regarding electrophysiological measures, several studies have also reported a cor- in predicting HT in patients with AIS treated with and without rtPA. Methods: Thirty patients
relation between white matter damage and widespread slowing of EEG rhythmicity. Specifically, with AIS were examined within a mean time of 3.6 hours of documented symptom onset. Both
severity of ischemic white matter damage has been associated with increased delta power, FLAIR and KPS MR imaging were performed. Two raters (blind to HT) independently identified
decreased alpha2 power and a relative increase in theta/alpha1 band power ratio. Among event- FLAIR hyperintensity with reference to the DWI lesion. KPS coefficients in the stroke lesion
related potentials (ERPs), N2 and P3 are of particular interest with prior research showing de- were estimated for all patients, and the sensitivity and specificity for both FLAIR hyperintensity
layed latency in those with white matter damage. Conclusion: Building on the aforementioned and KPS value in predicting HT were calculated. Results: FLAIR hyperintensity was identified
results as well as studies of top-down attention regulation, future investigations should utilize a in 12 patients (40%, 3HT, 9 non-HT). There was no statistical significant difference in HT oc-
multimodal approach that combines the strengths of fMRI and EEG techniques and pair it with currence between FLAIR positive and negative patients. The sensitivity and specificity of FLAIR
multivariate analytical tools that are more powerful than traditional univariate tests. 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,
P1.037 0.72-1.0) and a specificity of 0.80 (CI, 0.584-0.919). Conclusions: The results of this study
Total Plasma Adiponectin Concentrations and AdipoR1 and AdipoR2 Gene suggest that FLAIR hyperintensites are frequent findings in AIS patients and are not associated
Expression are Associated with Features of Plaque Instability in Patients with 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
Carotid Atherosclerosis
them for thrombolytic therapy.
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 P1.040
The Effect of β-Amyloid on the Severity and Prognosis of Hemorrhagic Stroke
Background: With the increasing burden of atherosclerosis and stroke on society it is criti- Patients
cal 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, Nakase, T; Sasaki, M; Suzuki, A; Research Institute for Brain & Blood Vessels, Akita, Japan
are associated with coronary artery disease and carotid-intima media thickness. The current
study investigated the association between circulating adiponectin and its receptors (AdipoR1/ Background: It has been investigated that β-amyloid (Aβ) might affect on the neurological
AdipoR2) and features of plaque instability. Methods: Patients scheduled for carotid endar- severity of Alzheimer disease. Moreover, Aβ was reported to relate to the vulnerability of brain
terectomy were recruited from the Royal Victoria Hospital, Montreal, Quebec. Blood samples arteries. However, the influence of Aβ on the severity and outcome of acute stroke patients has
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

were collected pre-operatively to determine total adiponectin levels using ELISA. The area of not been fully understand. This study was aimed to explore the effects of Aβ on the neurological
maximum stenosis of each carotid plaque obtained was stained with hematoxylin and eosin severity and the prognosis of acute intracranial hemorrhagic stroke (ICH) patients. Methods:
and immunostained for the detection of CD68 (macrophages/foam cells), and von Willebrand Acute ICH patients were consecutively asked to participate in this study between June 2011 and
Factor (vWF, neovascularization). Two vascular pathologists blindly categorized the plaques ac- September 2012. Then, consented patients were enrolled (n=52, average age 66.9 year-old).
cording to AHA classifications and semi-quantitative scales. Total RNA was extracted from the ICH lesion was confirmed by brain computed tomography on admission. Aβ40 and Aβ42 were
tissues and AdipoR1/AdipoR2 mRNA expression was analyzed via qRT-PCR. Results: Patients measured from blood samples acquired on admission. Neurological severity was assessed by
(n=190) with less infiltration of foam cells in their plaques had higher levels of total circulating NIH stroke scale on admission and at one month. Results: The amount of Aβ40 was distributed
adiponectin (12.26 ± 6.74 μg/ml) when compared to patients with greater infiltration (8.99 ± between 2.7 and 96.6 pmol/L (mean±SD: 22.0±20.2 pmol/L). If all cases were classified into
6.97 μg/ml; p=0.010). AdipoR1 expression was significantly lower in plaques with neovascu- low and high amount of Aβ40 (Low40 group: less than 20 pmol/L and High40 group: higher than
larization (p=0.023). AdipoR2 expression was found to be progressively lower in plaques with 20 pmol/L, respectively), the percentage of deep cerebral hemorrhage was significantly abun-
greater instability, with a significant difference between Grade 1 (most stable) and Grade 4 dant in High40 group compared with Low40 group (p=0.021: 87.5% and 54.3%, respectively).
(most unstable) plaques (p=0.044). In addition, plaques that had an intact cap and no presence The amount of Aβ42 was not detected in 67.3% of all patients (Low42 group). The average
of thrombus had significantly higher expression of AdipoR2 than plaques with ruptured caps amount of Aβ42 in remaining 17 cases was 5.2 pmol/L (High42 group). The mortality was higher
and presence of large thrombi (p=0.010). Conclusion: Patients whose plaques were character- in High42 group compared with Low42 group (p=0.059: 23.5% and 5.7%, respectively). There
ized as unstable were found to have lower plasma levels of total adiponectin, and lower mRNA was no significant relation between the amount of Aβ and the neurological severity. Conclu-
expression of AdipoR1 and AdipoR2. These results suggest a potential role for adiponectin and sion: Aβ40 could affect on the fragility of deep brain arteries, and Aβ42 might influence on the
its receptors in the development of plaque instability. vulnerability of neurons in the hemorrhagic stroke patients.

P1.038 P1.041
Acidosis Overrides Oxygen Deprivation to Maintain Mitochondrial Function Spreading Depolarization After Stroke is Supported by the Alpha1 Isoform of
Na/K-ATPase
Khacho, M; Tarabay, M; Khacho, P; Patten, D; MacLaurin, J; Park, D; Bergeron, R; Harper, M;
Slack, R; University of Ottawa, Ottawa, ON Petrin, DA; Ventura, NM; Peterson, NT; Tse, MY; Andrew, R; Pang, SC; Jin, A;
Queen’s University, Kingston, 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 Background: The mechanisms which promote spreading depolarization (SD) in the post-stroke
of mitochondria is an early event in injuries relevant to stroke and is believed to be a key con- brain remain unclear. We examined the role of Na/K-ATPase isoforms in supporting SD after
tributor in the demise of neurons following an ischemic insult. Furthermore, studies have shown stroke. Methods: Following focal cerebral ischemia in male C57BL/6J mice, 350 µm live brain
that promoting fusion restores neuronal viability during ischemia. Thus identification of strate- slices were incubated in artificial CSF (aCSF) at 34 oC and then exposed for 20 minutes to either
gies to promote mitochondrial fusion would provide invaluable therapeutic potential. Here we control solution (aCSF) or ouabain at 1 µM (to selectively block alpha2 and alpha3 isoforms of
show that acidification of the extracellular milieu, a physiological consequence of hypoxia within Na/K-ATPase) prior to SD induction by oxygen glucose deprivation (OGD). The propensity of the
the ischemic penumbra, triggers the rapid elongation of mitochondria in neurons. Acidosis- tissue to undergo SD was assessed by observing changes in SD onset latency and wavefront
mediated mitochondrial elongation protects neurons from death in an in vitro model that mimics velocity as reflected in tissue light transmittance in the ipsi- and contralateral hemispheres.
the ischemic penumbra. Elongation of mitochondria, in neurons allowed to undergo the natural This was compared to SD induced by exposure to 100 µM of ouabain, in this case, blocking the
course of acidification during hypoxia, is achieved through the activation of a dual program that alpha1,2 and 3 isoforms of Na/K-ATPase. The mRNA expression of the Na/K-ATPase isoforms
both inhibits fission and promotes fusion. Preventing the pH-dependent elongation of mitochon- ATP1a1 (alpha1), ATP1a3 (alpha3) and ATP1b1 (beta1) in the post-stroke brain was examined
dria by inhibiting the fusion machinery results in mitochondrial fragmentation and a significant by real-time quantitative PCR. Results: Following stroke, OGD-induced SD was delayed by 33%
increase in neuronal death. Interestingly, mild acidosis is known to provide neuroprotection (p < 0.001) and SD wavefront velocity was decreased by 42% (p = 0.016) in the peri-infarct
during ischemia, however the mechanism was not completely understood. We now propose tissue compared to the contralateral hemisphere. Blockade of all Na/K-ATPase isoforms with
that extracellular pH is a neuroprotective agent that acts as a physiological trigger to rewire the 100 µM ouabain abrogated these differences in SD onset and wavefront velocity but preferential
dynamics of mitochondria and promote survival. blockade of the alpha2 and 3 isoforms with 1 µM ouabain did not alter SD characteristics com-
pared to the control aCSF solution. ATP1a1 and ATP1b1 mRNA expression was diminished in the
post-ischemic hemisphere, whereas ATP1a3 expression was unaffected by ischemia. Conclu-
P1.039 sions: Peri-infarct tissue has a decreased susceptibility to spreading depolarization. Blockade
Predicting Hemorrhagic Transformation in Acute Ischemic Stroke Patients: FLAIR of the alpha1 but not alpha2/3 isoforms of Na/K-ATPase promotes SD in the post-stroke brain,
vs. Quantitative Permeability Coefficient (KPS) and decreased expression of the alpha1 and beta1 isoforms may contribute to endogenous SD
resistance in peri-infarct tissue.
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 P1.042
Neurology, University of Toronto, Toronto, ON; 5. Hospital for Sick Children, Toronto, ON Endothelin-1 Mediated Ischemic Injury in the Mouse Forelimb Motor Cortex is
Associated with Specific and Measurable Behavioural Deficits
Background: Recombinant tissue plasminogen activator (rtPA) decreases mortality and im-
proves functional outcomes in patients with acute ischemic stroke (AIS) but is also associated Roome, RB1, 2 Bartlett, RF1, 2 Jeffers, M1, 2, 3 Xiong, J1, 2 Corbett, D1, 2, 3 Vanderluit, J1, 2;
with a higher risk of hemorrhagic transformation (HT). Both FLAIR hyperintensity and quanti- 1. BioMedical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St John’s,
tative permeability (KPS) MR imaging have been proposed to help identify patients at higher NL; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Ottawa, ON; 3. Dept. Cellular &
risk of HT. The purpose of this study is to compare the utility of FLAIR hyperintensity and KPS Molecular Medicine, University of Ottawa, Ottawa, ON
e18  Stroke  December 2013
Background: Currently, there is excitement in manipulating neural precursor cells, as they mi- sustained NMDAR activation and excitotoxicity. As NMDAR-dependent excitotoxicity is sug-
grate toward cortical infarcts and differentiate into neurons and glia. To assess functional recov- gested to depend on subunit composition and subcellular localization of receptors, we sought
ery by neural regeneration after an ischemic injury, a reproducible focal injury model is required. to determine how the trafficking of distinct NMDAR subtypes is altered by sustained NMDAR
Here, the ability of Endothelin-1 (ET-1), a vasoconstrictive peptide, was assessed in producing activation. A treatment with a high concentration of glycine alone transiently depressed evoked
behavioural deficits post-ischemia. Though mice develop smaller infarcts than rats in response NMDAR-mediated currents from CA1 pyramidal neurons. To identify potential subunit-specific
to ET-1, a wealth of transgenic mouse strains exist which can be used to study a variety of rules of this behaviour, we developed a live-cell imaging assay to quantify surface NMDARs
therapeutic interventions post-ischemia, making a focal ischemic injury model in mice attrac- expressing phluorin-tagged NMDAR subunits. With this approach, we observed that glycine in-
tive. Methods: A focal ischemic lesion was produced by intra-cortical injections of ET-1 into duced a preferential internalization of GluN2A-containing NMDARs. Intriguingly, evidence from
the forelimb motor cortex (FMC). Mice were tested on the mouse staircase and cylinder tasks at both imaging and electrophysiological experiments suggests that the high glycine treatment
time-points post-surgery and euthanized at 2 or 4 weeks. Histology was performed to analyze the induced a transient internalization of synaptic receptors, but a persistent internalization of extra-
volume, shape and depth of the injury site. Doublecortin (Dcx) and BrdU immunohistochemistry synaptic NMDARs. At present, it is unclear whether these trafficking behaviours represent natu-
was performed to label migrating NPCs. Results: Focal ischemic cortical injury is associated with ral neuroprotective strategies employed by neurons or rather whether they contribute to toxicity.
behavioural deficits. Reaching deficits in the mouse staircase test correlated specifically with The development of a mechanistic and molecular framework of these cellular phenomena will
damage to the anterior FMC, highlighting functional subdivisions within the FMC. A sensitive novel allow us to distinguish between these possibilities.
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 dam-
age the anterior forelimb motor cortex. BrdU and Dcx double-positive cells within the injury site P1.046
indicated that NPCs had migrated successfully from the SVZ. Conclusion: Here, I have developed Pharmacological Inhibition of VEGFR-2 Has Differential Effects on Behavioral
a reproducible model of focal ischemia with measureable behavioural deficits which lends itself to Recovery and Cortical Remapping Dependent on Presence or Absence of
a variety of experimental regenerative therapies for the treatment of ischemic stroke. Deficits are
Diabetes During Stroke
pronounced acutely post-ischemia but persist over time with larger ischemic injuries.
Tennant, KA; Thompson, K; Lockhart, K; Brown, CE; University of Victoria, Victoria, BC
P1.043 Diabetes is associated with a higher risk of stroke and a poor prognosis for recovery. Previ-
What Strokes Tell Us About Consciousness ously, 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 repre-
Shamy, MC; Glannon, W; University of Calgary, Calgary, AB sentations onto intact peri-infarct areas. We have recently used longitudinal in vivo two-photon
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

imaging to show that the brain’s vascular response to stroke (increased blood flow velocity and
Background: Explaining what consciousness is, and how it may arise from the brain, has been a dilation of vessels) takes weeks to normalize in diabetics, while the non-diabetic vascular re-
subject of human study for thousands of years. Given the localized loss of neurological function that sponse normalizes within days. Based on these data and our pilot studies showing abnormal
is the hallmark of ischemic stroke, it is possible that lessons from the clinical study of stroke may expression of vascular endothelial growth factor (VEGF) and its receptors in the ischemic diabetic
help to explain both the nature of consciousness and its relationship to neuroanatomy. Methods: brain, we hypothesized that pharmacological inhibition of VEGF signaling at a clinically-relevant
We address a series of questions around whether, and how, strokes affect consciousness. We relate time point after stroke would lead to greater behavioral recovery and increased cortical remap-
the findings of clinical stroke medicine to the theoretical frameworks within which consciousness is ping in diabetic mice. Diabetic and non-diabetic mice underwent behavioral testing for 10 weeks
currently analyzed: substance dualism (the brain and mind are causally non-interacting), property following photothrombotic stroke. Subcutaneous injections of SU5416, a selective inhibitor of
dualism (the mind is a product of the brain, but cannot be explained by brain processes), epiphe- VEGF receptor 2 (VEGFR-2), or vehicle were given every 3 days, beginning 3 days after stroke, for
nomenalism (the mind is a product of the brain but cannot interact with the brain), and physicalism a total of 8 weeks. 14 weeks after stroke, voltage-sensitive dye imaging was conducted to resolve
(the mind is equivalent to physical properties of the brain). Results: We argue that the clinical neu- the extent of remapping of the forelimb sensory representations. SU5416 treatment of diabetic
roanatomy of ischemic stroke provides the basis for understanding consciousness as a function of mice after stroke improved short and long-term behavioral recovery compared to vehicle-treated
the brain and as a function of brain functions. This theory unites physicalism and property dualism, diabetics. This was associated with a trend towards improved cortical responsiveness to forelimb
and rejects structural dualism and epiphenomenalism. Conclusion: We propose a new theory of touch. In contrast, SU5416 treatment of non-diabetic mice after stroke caused a worsening of
consciousness based on experience from stroke neurology. Moreover, we seek to bridge the meth- behavioral deficits and cortical responsiveness. In summary, these results suggest that inhibition
odological and linguistic gap that has for too long divided philosophy from clinical neuroscience. 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.
P1.045
Subunit-Specific Modulation of NMDAR Trafficking by Glycine in Central Neurons
P1.047
Soares, CA1 Khacho, P1 Lee, KF1 Geddes, SD1 Bergeron, R1, 2 Béïque, J1; 1. University of Ottawa, Pharmacological Blockade of Volume-Regulated Anion Channels (VRAC) by
Ottawa, ON; 2. Ottawa Hospital Reasearch Institute, Ottawa, ON; 3. Heart and Stroke Founda- DCPIB Provides Protection Against Hypoxic-Ischemic Neuronal Injury In vivo and
tion Centre for Stroke Recovery, Ottawa, ON
in vitro
NMDA type glutamate receptors are present at excitatory synapses and are composed of tet-
Turlova, E1 Zhao, L2 Alibrahim, A1 Wang, G2 Sun, H1; 1. University of Toronto, Toronto, ON;
ramers of GluN1 and GluN2 subunits (primarily GluN2A and GluN2B in hippocampus). These
2. Sun Yat-sen University, Guangzhou, China
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 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.

P1.048
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 dur-
ing a stroke. Collateral blood flow is a critical predictor of clinical prognosis after stroke and
Abstracts From the 4th Canadian Stroke Congress, 2013  e19
response to recanalization, but data on collateral dynamics and the efficacy of collateral thera- rehabilitation expertise could better serve people with communication limitations in real-life
peutics is lacking. Here, I will discuss our work evaluating the efficacy of two novel approaches environments.
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 P1.051
optically record blood flow in leptomeningeal collaterals in clinically relevant animal models of A Comparison of Rural versus Urban Stroke Survivors Treated with a Home-
ischemic stroke. We demonstrate that transiently diverting blood flow from peripheral circulation based, Specialized Stroke Rehabilitation Program
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 thromboem- Allen, L1 Richardson, M1 McClure, A1 Meyer, M1, 2 Ure, D3 Jankowski, S3 Teasell, R4, 1;
bolic MCAo. Increased collateral flow restores blood flow in distal MCA segments to baseline 1. Lawson Health Research Institute, ARGC , London, ON; 2. Western University, Department of
levels during aortic occlusion and persists for over one hour after removal of the aortic balloon. Epidemiology and Biostatistic, London, ON; 3. St. Joseph’s Health Care, London, ON;
Similarly, intra-arterial (intra-carotid) administration of the nitric oxide donor sodium nitroprus- 4. St.Joseph’s Health Care, Department of Physical Medicine and Rehabilitation, Parkwood
side induces significant vasodilation and improves leptomeningeal collateral circulation without Hospital, London, ON
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 Background: Rural living has been demonstrated to have an effect on a person’s overall health
an adjuvant or stand alone therapy for acute ischemic stroke, this data provides support for fur- status, and rural residing individuals often have decreased access to health and specialized
ther development and translation of collateral therapeutics including transient aortic occlusion. rehabilitation services. The aim of this study was to determine if there are differences in re-
covery from stroke between urban and rural-dwelling stroke survivors accessing an in-home,
community-based, interdisciplinary, stroke rehabilitation program. Methods: Data from a cohort
P1.049 of 919 stroke survivors receiving care from three Community Stroke Rehabilitation Teams be-
Lifetime Stress Cumulatively Programs Brain Transcriptome to Impede Stroke tween January 2009 and December 2012 was analyzed. This program delivers stroke rehabili-
Recovery and Is Ameliorated by Tactile Stimulation tation 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
Zucchi, FC1, 2 Yao, Y1 Ilnytskyy, Y1 Robbins, JC1 Soltanpour, N1 Kovalchuk, I1 Kovalchuk, O1 linear regression analyses were performed to determine if rural vs. urban status was a signifi-
Metz, GA1; 1. University of Lethbridge, Lethbridge, AB; 2. University of Mato Grosso State, cant predictor of discharge and 6-month health outcomes, controlling for scores at baseline.
Caceres, MT, Brazil 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
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Prenatal stress is a critical variable affecting lifetime health, including stroke risk and out- Ontario. No significant difference on the Functional Independence Measure (FIM), the Stroke
come in adulthood. Beneficial experiences may offset the influence of adverse early experi- Impact Scale (SIS) Physical, Memory, Communication, and Social Participation domains, the
ence and programming of health outcomes by stress. Here we investigated if tactile stimu- Caregiver Assistance and Confidence Scale (CACS), or the Bakas Caregiver Outcomes Scale
lation attenuates the effects of early life stress on behaviour and recovery from ischemic (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,
lesion in a rat model. Prenatally stressed adult male rats underwent focal ischemic motor
with urban residents making slightly greater improvements. Rurality was also a significant pre-
cortex lesion while being tested in skilled reaching and skilled walking. One group of rats
dictor of outcome on the Emotion domain of the Stroke Impact Scale at both discharge (p=0.040)
experienced cumulative postnatal stress by restraint in adulthood. Tactile stimulation, as
and follow up (p=0.0002), with rural residing individuals experiencing greater positive gains.
an analogue to human massage therapy was applied to attenuate adverse early influences
Conclusions: When provided with access to a home-based, specialized stroke rehabilitation
and promote post-lesion motor recovery. Animals that experienced both prenatal stress and
program, rural dwelling stroke survivors make and maintain functional gains comparable to
stress in adulthood displayed the most severe motor disabilities after the lesion. Additionally,
their urban-living counterparts.
tactile stimulation offset cumulative prenatal and postnatal stress by promoting recovery
from ischemic lesion and reducing activity of the hypothalamic-pituitary-adrenal axis activ-
ity. Prenatal stress programmed brain gene expression linked to major cellular pathways
and epigenetic markers of brain homeostasis. Cumulative effects of stress increased the
P1.052
diversity of pathways. Ischemic lesion mainly up-regulated gene expression patterns, while Perceptual Influences of Visuospatial Neglect During Negotiation of Obstacles
these were mainly down-regulated by tactile stimulation. Our results suggest that the sec-
ond half of pregnancy in the rat represents a critical phase of fetal sensorimotor system Aravind, G; Lamontagne, A; McGill University, Montreal, QC
development. Cumulative effects of adverse and beneficial lifespan experiences interact with
Rationale: In our previous study1, we observed that individuals with visuospatial neglect
disease outcomes and brain plasticity. These findings show that beneficial experience later
(VSN) collided with moving obstacles while walking. Whether these collisions occurred due to
in life can reverse programming by early adverse experience to modulate physiology, be-
perceptual deficits of VSN or locomotor deficits attributed to stroke, was unclear. In this study,
haviour, transcriptome and cerebrovascular health. Acknowledgements: This research was
we evaluated the ability of individuals with VSN to avoid moving obstacles during a joystick
supported by Alberta Innovates - Health Solutions (AI-HS; FZ and GM), Preterm Birth and
task uninfluenced by locomotor capacity. Methods: Twelve participants previously diagnosed
Healthy Outcomes funded by the AHFMR/AI-HS Interdisciplinary Team Grant #200700595
with VSN post-stroke were assessed on the Bells test. They were also tested in a virtual
(GM), Hotchkiss Brain Institute (FZ), Norlien Foundation (FZ), and the Canadian Institutes of
environment with a target and 3 obstacles, one of which randomly approached from head-on,
Health Research (GM).
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 avoid-
ing the obstacle using a joystick with their unaffected hand (joystick task). Detection times
P1.050 (perceptuo-motor task), collision rates and onsets of strategy (joystick task) were examined.
Fostering community participation for persons with aphasia and their family Results: Based on number of omissions on the Bells test, participants were classified as
members: What we are doing, what we can do better in rehabilitation 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
Alary Gauvreau, C1 Anglade, C2, 3 Massicotte, J2 Perreault, C2 Kehayia, E4, 3 Michallet, B5, 3 Le contralesional and head-on obstacles compared to ipsilesional obstacles. A trend was ob-
Dorze, G2, 3; 1. Jewish Rehabilitation Hospital, Laval, QC; 2. University of Montreal, Montreal, served where the VSN+ groups showed largest detection times, onset of avoidance strategies
QC; 3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, QC; and rates of collisions, followed by the Inattention+ and VSN- groups. Conclusion: Along with
4. McGill University, Montreal, QC; 5. Université du Québec à Trois-Rivières, Trois-Rivières, QC 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 approach-
Background: Aphasia affects approximately 30% of stroke victims. Client-centered rehabili- ing from their neglected side and head-on. This suggests that the Bells test is not sensitive
tation is offered for optimizing recovery and independence. However, after discharge, people in detecting perceptual deficits involved during functional tasks such as obstacle-negotiation.
with aphasia report not being ready to participate in their community. Their relatives also Moreover, presence of collisions in a joystick-driven avoidance task not influenced by lo-
mention not knowing how to care and help their loved one. The aim was to understand how comotor capacity, suggesting perceptual deficits do contribute to poor obstacle-avoidance
rehabilitation could improve outcomes for people with aphasia and their family members with abilities in post-stroke VSN.
respect to social participation. Methods: Eight persons with aphasia and eight of their rela-
tives 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 P1.055
and available for viewing while the discussion went on. Later, all of statements were analyzed Traduction et validation de l’Overt Behaviour Scale (OBS) en français : l’Échelle
qualitatively. Results: Most participants expressed the need to easily access the physical des comportements observables
environment and to communicate effectively for satisfying participation in shopping malls.
Participants formulated few suggestions about improving rehabilitation in spite of minor dis- Godbout, D; Gagnon, J; Ouellette, M; Drolet, J; Kelly, G; Simpson, G; Centre de réadaptation
satisfaction with their experience. However, a new vision of rehabilitation using shopping Lucie-Bruneau, Montréal, QC
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 ac- Contexte : Les qualités psychométriques de l’échelle OBS sont reconnues. Elle est utilisée dans
cording to their need for independence. Therapeutic activities could be held in malls, thus les études anglo-saxonnes évaluant les troubles du comportement de la clientèle cérébrolésée.
real-life settings. Speech-language therapists could evaluate the effects of therapy in authen- La traduction et la validation de l’OBS s’imposait car il existe peu d’outils disponibles en français
tic communication settings. Conclusions: If patients and their families do not feel adequately pour évaluer ces dimensions comportementales post atteintes cérébrales. Méthodologie :
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 Phase 1 : Comité d’expert par méthode du consensus pour assurer la rigueur de la traduction/
shopping mall could be used as a rehabilitation setting. In doing so, interdisciplinary stroke adaptation de l’instrument OBS nommé l’ÉCO (Échelle des comportements observables). Les
e20  Stroke  December 2013
deux versions (OBS/ÉCO) soumises (avec inversion des énoncés) aux cliniciens évaluant les the ability to assess short and long-term sequelae of this disease process and associated in-
clients présentant un trouble du comportement au moins léger. terventions. miFunction is a scale that approaches the evaluation of disability comprehensively,
and in accordance with current, internationally accepted understandings of stroke.
Phase 2 : les cliniciens complètent également une batterie de questionnaires et tests pour es-
timer la validité divergente et convergente de l’ÉCO.
P1.058
Échantillon : Screening for the Blues: Implementing a Depression Screening Tool in the Acute
Stroke Population
•• 29 participants (21H; 8F), âgés de 20 à 70 ans
•• Ayant subi une lésion cérébrale datant de 5 mois à 44 ans Cheung, T; Cayley, A; University Health Network, Toronto, ON
•• suivis en 6 centres de réadaptation (et 1 association de TCC) à Montréal.
Outils d’évaluation Purpose: As a Regional Stroke Centre of Ontario, we are committed to evidence-based practice
•• Instruments pour mesurer des concepts divergents) : le NRS; l’Inventaire du fardeau; le and the promotion of nursing excellence through the implementation of RNAO’s Best Practice
questionnaire sur la qualité de vie Guidelines. Depression is recognized as one of those best practice guidelines. Depression is
•• Instruments pour mesurer des concepts se rapprochant des troubles du comportements : known to have a debilitating effect on many areas of one’s quality of life. In the stroke popula-
le MPA I-4 et le SATCé tion, depression affects 40% of all stroke patients. The screening and assessment of depres-
sion in the stroke population is currently not a regulated process on the stroke unit. Research
Résultats préliminaires : Les résultats aux indices de l’OBS sont fortement corrélés (r>.9) indicates identification of depression is most critical in the acute phase of a stroke as it has been
avec ceux obtenus à l’ÉCO. On ne détecte pas de relations significatives entre les résultats à directly linked with post-stroke recovery. Approach: The approach utilized for this initiative was
l’ÉCO et le fonctionnement cognitif, affectif et moteur (NRS), le fardeau (IDF) ainsi qu’avec la to implement two validated depression screening tools in the stroke in-patient population. The
qualité de vie (QPSQV) et les capacités (sous-échelle du MPAI-4). Des corrélations modérées Patient Health Questionnaire (PHQ-9) was used for non-aphasic patients, and the Stroke Aphasic
sont relevées entre les données à l’ÉCO, celles à 4 des dimensions du SATC et aux mesures Depression Questionnaire (SADQ-10) was used for those with aphasia. Results: All nurses who
d’adaptation psychologique et de participation sociale incluant des énoncés comportementaux worked on the in-patient unit received educational sessions on the two tools and implemented
(du MPAI-4). Conclusions : Les résultats indiquent que l’ÉCO est une traduction valide de its use on all admitted stroke patients after day 3 of stroke onset. The results of this initiative
l’OBS. Les faibles corrélations entre les résultats à l’ÉCO et ceux obtenus aux mesures du include: increased nursing awareness of post-stroke depression prevalence; early detection and
fonctionnement suite au TCC vont dans le sens de sa validité divergente. Les corrélations plus treatment of post-stroke depression; and improved inter-professional collaboration within the
fortes entre les résultats et les mesures d’adaptation psychosociale donnent des indices de sa stroke team. Implications: Knowledge gained from this initiative resulted in a standardized,
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validité convergente. evidence-based approach to depression screening and assessment of stroke patients. Recom-
mendations 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
P1.056 from acute care to the community; improving one’s capacity for rehabilitation; and decreasing
Perturbation Motor Corrections Correlate with Features of Reaching and length of hospital stay.
Proprioception Impairments Post-Stroke

Bourke, TC; Queen’s University, Kingston, ON P1.059


Talk Isn’t Cheap: Reviewing the Amount of Therapy Provided to Stroke Patients
Limb afferent feedback is used for perception of our limb geometry and for motor control. Stroke with Communication Disorders
can damage sensory and motor regions of the brain leading to impairments of upper limb func-
tion. Our previous work found that deficits in position sense were independent of deficits in Churchward, K1 Hill, MD2 Knox, D1 Lindland, K3; 1. none, Calgary, AB; 2. University of Calgary,
reaching performance. This independence is surprising given that limb afferent feedback plays Calgary, AB; 3. Alberta Health Services, Calgary, AB
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 Background: There is a threshold effect or a minimum “dose” of treatment required to dem-
using three distinct behavioural tasks. Subjects with subacute stroke (n=18) and non-disabled onstrate significant gains as measured by standardized tests of language impairment. Lim-
controls (n=79) were assessed in a KINARM exoskeleton robot. A postural perturbation task ited research exists regarding which patients (i.e. type and severity of communication deficits,
measured how quickly subjects can respond to a perturbation and accurately return to their start time post stroke,) would benefit the most from high “dose” treatment. We investigated current
target (no vision of hand following perturbation). A limb matching task assessed the perception speech-language treatment (SLT) received and outcomes achieved locally by stroke patients
of limb position by measuring the mismatch between one arm moved by the robot and the with communication deficits. Methods: A convenience sample of 70 English-speaking patients
subject’s mirror matched limb configuration with their other arm (no vision throughout task). with first-ever stroke resulting in aphasia, apraxia of speech and/or dysarthria was recruited in
A visual-guided reaching task assessed the use of vision and proprioception to reach quickly the sub-acute stage (ie. 3-14 days post stroke). A speech-language assessment battery which
and accurately to a target. Both arms were assessed in each task and a number of parameters included scoring of the AusTOMS for speech and language, the Western Aphasia Battery (where
captured the spatial and/or temporal aspects of task behaviour. In agreement with our previous appropriate) and the ASHA Communication Quality of Life Scale was administered within 7 days
results, reaching and position matching deficits were largely independent in this sample. Most of study enrolment and was repeated 12-14 weeks later. Severity was measured using the Aus-
impairments in reaching parameters were significantly correlated with impairments in perturba- TOMs speech and/or language impairment scales. Speech-language pathologists and therapy
tion corrections. In contrast, the majority of impairments in limb matching parameters were assistants reported minutes of direct 1-1 SLT provided to study patients across the continuum
significantly independent of impairments in perturbation corrective parameters. One exception of care (i.e. acute in-patient, tertiary in-patient, and community/outpatient programs) during
was that perturbation response endpoint error was significantly correlated with limb matching the study period. Results: Patients in the greater severity group (n=8) received 29 min (15.2)
variability (r=0.43, p<8.8x10-4). 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
Overall these results suggest impairments in integrating feedback into motor corrections being working day during the study period. Conclusions: The “dose” of therapy received by patients
related to motor impairments and independent of proprioceptive impairments. 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 impair-
ment. Overall, the dose of SLT received by the majority of patients is below the minimum amount
P1.057 of treatment recommended in the literature for aphasia.
Comprehensive Assessment of Disability Following Stroke: Initial Validation of
the miFunction Scale
P1.060
Burley, T; Green, T; University of Calgary, Calgary, AB Characteristics of Recovery After Stroke: a Focus on Cognitive,
Mood and Physical Function
Background: Advances in thrombolytic therapy, endovascular intervention and specialized unit
care for stroke have significantly reduced its mortality and morbidity delivering nearly eighty per- Cohen, EJ1 Danells, CJ1, 3 Moreno, HA2 McIlroy, WE2, 1; 1. Centre for Stroke Recovery, Toronto,
cent of survivors back to their homes and communities. Current established assessment tools ON; 2. University of Waterloo, Waterloo, ON; 3. Sunnybrook, Toronto, ON
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), Background: Most stroke recovery has been limited to individual domains of recovery. The
researchers at the University of Calgary developed a functional outcome scale (miFunction) to changes across domains and interaction between these aspects of recovery, are likely important
assist with the comprehensive evaluation of disability following stroke, based on activity limita- to gain a complete understanding of determinants of recovery post stroke. The objective of this
tions. Methods: This is a pilot study, utilizing a cross-sectional validation and reliability design to work was to establish the association between different domains of recovery after stroke. Meth-
assess the usefulness of the miFunction scale. The cross-sectional validation and reliability de- ods: Patients were selected from the Centre for Stroke Recovery Rehabilitation Affiliates Longi-
sign involves sampling a target population of stroke survivors at a minimum of 60 days following tudinal Stroke database based on completion of assessments and time post stroke. At baseline
their event. Two clinicians evaluate participants using the miFunction scale as an assessment (0-45 days post) there were 141 participants. The following assessments were selected: 2
of inter-observer reliability (Cohen’s Weighted Kappa). Further, the clinicians assign participants minute walk (2mw), Berg Balance Scale(BBS), CES-D, FIM and MoCA. Determination of impair-
with a score on a previously validated instrument for assessment of stroke disability (Modified ment was concluded by using measure specific cut-off scores. Results: At baseline, there was
Rankin Scale) as an assessment of convergent validation (Pearson’s Correlation Coefficient). significant frequency of impairment in all measures (MoCA-83%, 2MW - 79%, BBS - 77%, FIM
Results: Initial inter-observer reliability and convergent validation results will be presented. Im- - 64%, CES-D - 33%). More than 45% of the individuals were impaired in 4 or more measures
plications for the incorporation of miFunction into a larger study for further evaluation will be and 9% were impaired in only one domain. By 1 year after stroke the prevalence of impairments
explored. Conclusions: As science and technology for stroke management progress so too must by domain decreased (MoCa-60%, 2MW - 39%, BBS - 26%, FIM - 7.7%, CES-D - 29%). Only
Abstracts From the 4th Canadian Stroke Congress, 2013  e21
10% were impaired in more than 4 domains and 35% were impaired in only one domain. These Originally used in other clinical disciplines such as physiotherapy, geriatrics and mental health,
relationships remained approximately the same after 2 years following stroke. Conclusions: it has been adapted for use with various communication disorders (Schlosser, 2004). Using
Findings from this work emphasize the importance of multiple domains of recovery after stroke. a five point scale, GAS allows the clinician to set graduated, personalized target outcomes
The prevalence of individuals with impairment in multiple domains is important as such profiles predicated upon the client’s observed baseline. Method: The authors have trialed the use of
may influence recovery. The work reinforces the need to understand the impact that changes in GAS for people with chronic aphasia within both a life-participation-focused group program
one domain may have on others. Knowledge of the multivariate nature of recovery may help to and a recovery-focused intensive treatment program. Goals were established taking into ac-
influence both assessments and interventions after stroke. count 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
P1.061 systematically increasing the challenge presented to clients with aphasia. Examples will be
The Development and Integration of a Comprehensive Spasticity Management shared. Conclusions: GAS can help clinicians to set functional and measurable language goals
Clinic – Benefits to Patients, Physicians, Health Professionals, and Management for individuals with chronic aphasia, and can be a sensitive marker of change in functional
communication.
Czajka, T; Hammer, A; Hamilton Health Sciences-Regional Rehabilitation Centre, Hamilton, ON
Disclosure: All four authors receive income from Columbia Speech and Language Services, Inc.,
The Comprehensive Spasticity Management (CSM) clinic located at the Hamilton Health Sci- the agency at which the work described in this poster was completed.
ences, 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 profes- P1.064
sional resources, within ambulatory activity that occurs at the Rehabilitation Centre. This pre- Recovery From Action Naming Anomia in Chronic Aphasia: Study on Therapy
sentation will outline how we developed the CSM clinic, and integrated it into existing patient Induced Neuroplasticity with 3 Participants
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 Durand, E1 Marcotte, K2 Ansaldo, A1, 2; 1. CRIUGM, Montreal, QC; 2. Universite de Montreal,
includes the development of service delivery “teams”, common data collection systems, and Montreal, QC
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 suc- Context: Approximately 30% of stroke survivors are left with persistent language impairments.
cessfully developed into a comprehensive approach towards the management of spasticity. Aphasia is a language deficit that results in communication disabilities; reduced social par-
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Our data demonstrates continued gains in client progress and improvements in our attention ticipation secondary to language loss may in turn lead to isolation, and depression. Anomia is
to client centred goals. Initial results from our satisfaction questionnaire demonstrates that the most frequent and pervasive aphasic symptom across aphasia types. Recovery from apha-
patients prefer a team approach and feel that it meets their clinical needs better. Our refer- sia depends upon the brain’s potential to regain function. Aphasia therapy may contribute to
ral data demonstrates an increase in referrals, and stroke survivors represent the majority of triggering this potential; however, our understanding of the links between neuroplasticity and
new referrals. In addition this clinic has demonstrated benefits in other areas. These include aphasia therapy remain limited. In our recent fMRI study , a group of participants with aphasia
improvements in the following: job satisfaction , professional growth, opportunity for inter- (PWA) recovered the ability to name nouns following Massed-Semantic Feature Analysis therapy
professional communication, patient care outside of the CSM clinic, transitions from inpatient (M-SFA); the recovery was correlated with neurofunctional changes reflecting therapy-induced
to ambulatory therapy, and referrals to other ambulatory services. Plans for future activities neuroplasticity. The present study, reports the results of M-SFA with actions verbs and it unveils
have been initiated and will be described. 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
P1.062 M-SFA, until 80% of improvement with treated action verbs was attained. Event-related fMRI
Recommendation for using dance as an adjunct therapy in stroke rehabilitation 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
Demers, M1, 2, 3 McKinley, P1, 2, 3; 1. McGill University, Montreal, QC; 2. Jewish Rehabilitation was found with untreated verbs. However, participants’ families felt an improvement in every-
Hospital, Laval, QC; 3. Centre for Interdisciplinary Research in Rehabilitation of the Greater day communication. Action naming improvement was associated with significant activation of
Montreal, Montreal, QC 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
Background: Dance can be use as an adjunct therapy in rehabilitation to target balance, func- to trigger brain plasticity and improve the ability to naming verbs in the case of chronic Broca’s
tional mobility, mood, self-consciousness; a modified dance intervention was shown to be feasi- aphasia. Moreover, neurofunctional data suggest that the recruitment of specific viable network
ble and realistic in the context of functional intensive rehabilitation for individuals with sub-acute is connected to the nature of the therapy.
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 implementa-
tion of dance classes in clinical practice. The objective of this study is to provide evidence- P1.065
based guidelines for implementing dance classes in a rehabilitation setting. Methodology: This Effects of a Dual Task on AFO-Supported Gait in Individuals with Poststroke
presentation is part of a larger research study targeting the dissemination of knowledge about Hemiplegia
the therapeutic use of dance in post-stroke rehabilitation. Based on the Canadian Stroke Recom-
mendations and the scientific literature on dance for individuals with disabilities, a dance inter- Parker, K1 Clifton, K2 Adderson, J1 Mountain, A2 Eskes, GA2; 1. Capital District Health Authority,
vention has been developed for individuals with sub-acute stroke, and specific guidelines have Halifax, NS; 2. Dalhousie University, Halifax, NS
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 Background: Individuals with post stroke hemiplegia are often prescribed an ankle-foot orthosis
sub-acute stroke, the following specific elements must be taken into consideration: participant (AFO) to help maintain dorsiflexion during walking. Walking is an attentionally demanding task
safety, choice of music and dance movements, inclusion of a learned two-minute choreography, and the impact of wearing an AFO has not been evaluated under dual task conditions. The pur-
and gradation of the exercise in order to include participants with poor sitting or standing bal- pose of this study was to evaluate the effect of wearing an AFO on walking while under dual task
ance, cognitive and/or language deficits, as well as hemiparesis. Conclusion: Based on the conditions. Methods: Eighteen individuals (M(SD) age = 61.2 (14.2) yrs, 12 males) with post
experience acquired by the development of a dance class for individuals with sub-acute stroke, stroke hemiplegia and AFO use for at least 6 weeks were tested while walking with and without
a few recommendations are presented to ensure the safety and provide the right challenge for an AFO, with and without a secondary working memory task (auditory 2-back). Order of the 4
each participant. Those recommendations can facilitate the implementation of a dance class walking conditions was randomized. Mean and variability of gait temporal-spatial parameters
on a stroke unit. 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
P1.063 length (paretic side: 45.4 vs 41.1 cm, p<.01; non-paretic side: 41.6 vs 35.0 cm, p<.001). Per-
The Use of Goal Attainment Scaling for Setting, Monitoring and Upgrading forming the n-back task while walking reduced both velocity (51.6 vs 46.9 cm/s, p<.001) and
Language Goals in the Treatment of Chronic Aphasia 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
Duke, W1 Bains, R1, 2, 3 Ferdinandi, A1 Tittley, L1; 1. Columbia Speech and Language Services, time, accuracy) was equivalent across conditions. Conclusions: Wearing an AFO provides ben-
Vancouver, BC; 2. Provedence Health Care, Vancouver, BC; 3. University of British Columbia, efits to walking as measured by velocity and step length. Cognitive-motor interference (CMI) was
Vancouver, BC 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,
Background: Speech-Language Pathologists have long struggled with translating results of as seen by equivalent CMI across AFO conditions. Interventions aimed at reducing CMI during
standardized aphasia assessment batteries into specific, measureable, achievable, realistic walking may be of benefit to optimize mobility in AFO users.
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 P1.066
clinicians set specific functional goals and monitor progress. Such assessments may also not Hemiplegic Shoulder Pain Following Stroke: Risk Factors for the Different
have the sensitivity to measure the ongoing “subtle-but-important changes” (Schlosser, 2004) Etiologies and Their Outcomes
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. Fox, MA; Mountain, A; McDonald, A; Phillips, S; Dalhousie University, Halifax, NS
e22  Stroke  December 2013
Background: Hemiplegic shoulder pain (HSP) has been estimated to occur in 48% to 84% of Montréal métropolitain (CRIR)- Centre de réadaptation Lucie-Bruneau, Montréal, QC; 3. Réseau
people with stroke. The etiology of HSP can broadly be described as neuropathic (HSP-Np) or provincial de recherche en adaptation-réadaptation (REPAR), Montréal, QC
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: Contexte : Les services de réadaptation doivent inclure les proches de personnes ayant subi un
Charts of 177 patients admitted to an inpatient tertiary stroke rehabilitation service during a three AVC comme le stipulent les “Recommandations canadiennes pour les pratiques optimales de
year period were reviewed. Stroke patients with HSP were identified and classified according soins de l’AVC”. Il est difficile de déterminer si de telles recommandations sont appliquées, entre
to etiology (HSP-Msk or HSP-Np). Univariate statistical analysis was used to see if there were autres pour les proches de personnes ayant subi un AVC avec aphasie. En effet, ces derniers
any identifiable differences in risk factors and outcomes for the goups with HSP and without. présentent davantage de symptômes dépressifs que les proches de personnes ayant subi un AVC
Results: Of the 177 charts reviewed (M:F 102:75) 62 patients (35%) had HSP. Of these 62 patients, sans aphasie, bien que l’expérience clinique suggère qu’au congé de la réadaptation, ils sont
27 (44%) had HSP-Msk and 35 (56%) HSP-Np. In univariate analysis Chedoke McMaster stage satisfaits des services reçus. Une meilleure compréhension de leur expérience de la réadaptation
of recovery of the hand and arm <4 (stratified verses > 4) at admission or discharge (p<0.0001) favoriserait une offre de services adaptée à leur situation. Le projet visait donc à identifier les élé-
and the use of a mechanical lift at any time during admission (p=0.003) was associated with HSP. ments déterminants dans l’expérience vécue par les proches de personnes aphasiques pendant
Sex, presence of diabetes, stroke etiology (hemorrhagic or ischemic), presence of neglect and la réadaptation. Méthodologie : 12 proches de personnes devenues aphasiques à la suite d’un
discharge home were not different between the group with HSP and without. When the groups with AVC ont été individuellement interviewés moins de 3 mois après le congé d’une des phases de la
HSP-Msk and HSP-Np were compared individually against the group without HSP the Chedoke réadaptation. Ces entrevues ont été analysées qualitativement. Résultats : La condition néces-
McMaster stage of recovery at admission and discharge remained significant for both while use of saire à la satisfaction des proches envers la réadaptation est que les services doivent répondre à
mechanical lift remained significant only for HSP-Np (p=0.009). Conclusion: Hemiplegic shoulder leurs besoins en tant qu’aidant, c’est-à-dire avoir ce qu’il leur faut pour prendre soin du survivant
pain is a common complication following stroke. In our retrospective chart review only Chedoke de l’AVC. Parallèlement, les proches ont d’autres besoins liés à leur bien-être personnel, tel que
McMaster Stage of recovery at admission and discharge (HSP-Msk and -Np) and use of mechani- du support, et relationnel, tel qu’avoir une bonne communication avec la personne aphasique. Or,
cal lift during admission (HSP-Np) were associated with hemiplegic shoulder pain. 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
P1.067 rôles que peuvent prendre les proches afin qu’une offre de services visant aussi à répondre à
Measurement of Functional Outcomes Using the Goal Attainment Scale in a leurs besoins personnels et relationnels paraissent légitime aux proches.
Comprehensive Spasticity Management Clinic

Gallagher, S; Sasaki, A; Ismail, F; Boulias, C; West Park Healthcare Centre, Toronto, ON P1.070
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

A Comparison of Stroke and Acquired Brain Injury Rehabilitation Randomized


Context: Spasticity is a component of the Upper Motor Neuron Syndrome which significantly Controlled Trials
impacts active or passive function. Focal spasticity can be treated effectively with chemode-
nervation; however, reduction of spasticity does not automatically imply treatment success. McIntyre, A; Kwok, C; Aubut, J; Janzen, S; Richardson, M; Hussein, N; Teasell, R; Lawson
Evaluation of treatment outcomes should involve functional changes and goal attainment as Health Research Institute, London, ON
opposed to measures of impairment and symptoms alone. One way of quantifying achieve-
ment of goals is through the Goal Attainment Scale (GAS). The GAS is a tool which scores Objective: The rehabilitative needs for acquired brain injury (ABI) and stroke survivors may have
the extent to which a patient’s goals are achieved in the course of their intervention. Both commonalities. Therefore, the objective was to compare the proportion of intervention-based ran-
tasks and scores are individually set around one’s current and expected levels of perfor- domized controlled trials (RCTs), their sample size, and methodological quality between the stroke
mance. GAS allows measure of functional outcome, vs. traditional impairment level scales. and ABI rehabilitation literature. Methods: The Evidence-Based Review of Acquired Brain Injury
The comprehensive spasticity management clinic at West Park Healthcare Centre (WPHC) (ERABI) and the Evidence Based Review for Stroke Rehabilitation (EBRSR) databases were used
began implementing the GAS with all patients in the fall of 2012. Findings: The GAS has been to identify all published RCTs in each corresponding field. RCTs were categorized, when possible,
completed with 210 patients in the spasticity clinic at WPHC. The GAS is completed in the first into motor, cognitive, medical complications, or psychosocial intervention groups. The number,
clinic visit for new patients and at treatment visits for returning patients. 83% of our patients sample size, and Physiotherapy Evidence Database (PEDro) score for each RCT was collected.
had achieved their goals at follow-up. Goals were scored as achieved if patients scored 0 or Results: A total of 148 ABI and 965 stroke rehabilitation RCTs were identified. Of the RCTs for
above on the GAS. 16% of patients could not complete the GAS due to cognitive or language stroke, 625 were categorized as motor, 133 as cognitive, 108 as medical complications, and 99
deficits. 54% of the goals are classified as passive goals, and 46% as active goals. Clinical as psychosocial intervention RCTs. Comparatively within ABI, 24 motor, 65 cognitive, 26 medical
Relevance/Conclusion: GAS encourages communication and collaboration between multi- complications, and 33 psychosocial RCTs were found. While the emphasis within stroke literature
disciplinary team members; and patient involvement. Goals are more likely to be achieved if is placed on motor studies (64.8%), the greatest concentration of ABI RCTs was within cognitive
patients are setting them. 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.
P1.068
Post-stroke Aphasia Therapy in Bilingual Speakers: Cross-Linguistic Transfer
Effects P1.071
The Methodological Quality of Randomized Controlled Trials in Stroke Rehabilita-
Ghazi Saidi, L; Ansaldo, A; CRIUGM, University of Montreal, Montreal, QC tion Literature

Background: Among the most devastating consequences of stroke, aphasia is character- McIntyre, A; Janzen, S; Richardson, M; McClure, A; Hussein, N; Teasell, R; Lawson Health
ized by impaired language production and comprehension. In multilingual contemporary Research Institute, London, ON
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 Objective: To evaluate the methodological quality of intervention-based, randomized controlled tri-
question of which language to treat is a longstanding issue in the aphasiology domain. als (RCTs) published in the stroke rehabilitation literature using the Physiotherapy Evidence Data-
This issue is particularly relevant given that language therapy in a second language is not base (PEDro) tool. Methods: All RCTs published from 1973 to 2012 from the stroke rehabilitation lit-
always available. There is evidence that language therapy effects can sometimes transfer erature were reviewed and included. RCTs that could be appropriately categorized as either a motor,
across languages; however, the mechanisms favoring cross-linguistic transfer are poorly cognitive, medical complications or psychosocial were grouped. Each study was evaluated using the
known. Aim: This paper reviews the evidence on cross-linguistic therapy effects in bilingual PEDro tool; scores for each of the 10 quality ratings (e.g., yes=1 or no=0) and the cumulative score
aphasia therapy, with a focus on those factors that can modulate cross-linguistic therapy (maximum10) were recorded to allow for individual item analysis. Results: A total of 1063 RCTs
(CLT) effects in bilinguals with aphasia. Methods: Collected from the following databases: were included with an overall mean PEDro score of 6.2 ± 1.5. 62.5% of the total sample was rated
Medline, ASHA, Cochrane, Aphasiology Archive, Evidence-Based Medicine Guidelines, NHS as “good” quality (scores 6-8). Among all RCTs combined, the criteria least likely to be satisfied
Evidence, PsycBite et Speechbite, with the key words bilingual, aphasia, cross-language, on the PEDro included: blinding therapists (9.8%), blinding participants (25.5%), intention to treat
generalization, cognates, naming treatment, and transfer, fifteen articles (two systematic analysis (27.6%), and concealed allocation (34.9%). Conversely, baseline comparability (91.7%) and
reviews and 13 case studies) with details on pre and post therapy bilingual aphasia profiles between-group results comparisons (94.7%) were the most frequently satisfied criteria. Of the 965
in adults suffering from anomia, describing therapy frequency and procedures in sufficient intervention-based studies (motor n=625, cognitive n=133, medical n=108, psychosocial n=99),
detail to make them replicable and discussing variables influencing the presence or ab- psychosocial RCTs had the greatest mean PEDro score (6.6 ± 1.4). Medical complication interven-
sence of cross-linguistic transfer effects were analyzed. Results and Conclusion: Effects tion RCTs had the greatest proportion of “excellent” (14.8%; scores 9-10) and “poor” quality studies
of word similarity, structural language overlap, therapy approach, language of therapy (L1 (6.5%; scores <4). Conclusions: The results indicate that certain quality criteria are often not satis-
VS L2), cognitive control, and pre and post therapy proficiency factors are discussed, and fied and may introduce greater bias. Since the evidence provided from RCTs is used to guide clinical
a series of cues to develop intervention procedures favoring cross-linguistic transfer of practices, the methodological quality of studies should be considered when interpreting results.
therapy effects are proposed.

P1.072
P1.069 Anatomical Correlates of Proprioceptive Deficits Following Stroke in Humans: a
L’expérience de la réadaptation de l’AVC avec aphasie telle que vécue par les Case Series
proches
Kenzie, JM1 Semrau, JA1 Findlater, SE1 Herter, TM2 Scott, SH3 Dukelow, SP1; 1. The University
Hallé, M1, 2, 3 Le Dorze, G1, 2, 3; 1. École d’orthophonie et d’audiologie, Faculté de médecine, Uni- of Calgary, Calgary, AB; 2. University of South Carolina, Columbia, SC, USA; 3. Queen’s
versité de Montréal , Montréal, QC; 2. Centre de recherche interdisciplinaire en réadaptation du University, Kingston, ON
Abstracts From the 4th Canadian Stroke Congress, 2013  e23
Background: Proprioception refers to the ability to detect the relative position and move- not cause a significant decline in episodic autobiographical memory retrieval per se. Rather,
ment of our body in space. After stroke, individuals with significantly impaired proprioception MP lesions cause a deficit in the control and direction of retrieval and discourse lapses
tend to have poor functional outcomes. Newer robotic techniques for measuring propriocep- in global coherence. The maximal overlap in the anteromedial left prefrontal cortex cor-
tion now provide more reliable and accurate quantification of proprioception than traditional responds with this region’s involvement in switching attention between internal (self) and
clinical techniques. We are conducting a large prospective longitudinal study measuring pro- external (environmental) stimuli.
prioceptive 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 P1.075
a preliminary case series from our larger ongoing study displaying the types of propriocep- Validation of a Novel Computerized Test Battery for Automated Testing
tive 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 Levine, B1, 2, 3 Bacopulos, A1 Anderson, ND1, 4, 3 Black, SE2, 5 Davidson, PS6 Fitneva, SA7 McAn-
the internal capsule, primary somatosensory cortex and parietal association areas. Meth- drews, M3, 9 Spaniol, J10 Jeyakumar, N1 Abdi, H11 Beaton, D11 Owen, AM8 Hampshire, A8;
ods: Neuroimaging was performed on 10 subjects 2-10 days post-stroke. Assessment of 1. Rotman Research Institute, Baycrest, Toronto, ON; 2. Department of Medicine (Neurol-
proprioception and visually guided reaching in the upper extremities was completed using a ogy), University of Toronto, Toronto, ON; 3. Department of Psychology, University of Toronto,
KINARM robotic exoskeleton within the same time frame. Lesion location was compared with Toronto, ON; 4. Department of Medicine (Psychiatry), University of Toronto, Toronto, ON;
robotic task performance. Results: Subjects with thalamic damage demonstrated significant 5. Sunnybrook Health Sciences Centre, Toronto, ON; 6. School of Psychology, University of
proprioceptive deficits with mild to moderate deficits in visually guided reaching. Damage Ottawa, Ottawa, ON; 7. Department of Psychology, Queen’s University, Kingston, ON;
to the posterior limb of the internal capsule resulted in varying degrees of proprioceptive 8. Department of Psychology, University of Western Ontario, London, ON; 9. Toronto Western
and/or reaching deficits. Subjects with damage to primary somatosensory cortex (S1) and Research Institute, Toronto, ON; 10. Department of Psychology, Ryerson University, Toronto,
parietal cortex showed the most severe deficits in both proprioception and reaching tasks. ON; 11. School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
Conclusions: Proprioceptive deficits were consistently observed following lesions of brain
structures classically thought to be involved in proprioception. However, damage to similar Computerized tests offer an adjunct to standardized neuropsychological tests, especially for
areas in different patients did not necessarily result in identical deficits. In this sample, speeded information processing, attention, executive functioning, and memory, which are of pri-
damage to S1 and posterior parietal cortex most significantly impacted performance on all mary importance in many brain diseases. We assessed the validity of computerized tasks of these
robotic tasks. 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)
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

P1.073 analysis resulted in one significant latent variable accounting for 93% (p<.001) of the cross-block
Improving Rehabilitation Intensity - A Common Sense Approach 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
Lawhead, KE; Windsor Regional Hospital - Tayfour Campus, Windsor , ON 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.,
Background: Stroke patients should receive a minimum of 3 hours of direct task-specific 2012). Standardized tests that significantly contributed included WASI Block Design and Matrix
therapy by an interprofessional stroke team a minimum of 5 days per week. Stroke patients Reasoning, the Rey Auditory Verbal Learning Test, Trail Making A and B, and the Symbol Digit Mo-
on the Inpatient Rehabilitation Unit at Windsor Regional Hospital, were receiving 2-3 hours dalities Test. Based on this analysis, a reduced computerized battery (less than 30 min in duration)
of therapy per day and the transfer of skills to their daily routine was sub optimal. Staff was composed of the CBS and face-name tests was identified, which accounted for 61% of the vari-
frustrated as they often competed to see patients during peak times in the day, despite ance in the full 2-3 hr neuropsychological test battery. Using PLS-Regression, we found that this
nursing reporting that there are times in the day and on weekends when patients are not reduced computerized battery was comparable to the full neuropsychological battery at predicting
engaged in activity. This has led to changes in our care delivery model to improve access to age (r’s = .78 and .75 for the neuropsychological and computerized batteries, respectively). In con-
care and therapy intensity. Methods: A multidisciplinary working group undertook a LEAN clusion, an automated, 30-min computerized battery of tests of attention, memory, and executive
approach to reduce inefficiencies and improve access to therapy. We reviewed a day in functioning is comparable to a 2-3 hr battery of paper-and-pencil tests in terms of its latent struc-
the life of a patient. We engaged Nursing, Physiotherapy, Occupational Therapy, Speech ture and relation to age. Such a battery could be applied in large-scale testing or as a repeatable
Language Pathology, Social Work, Psychology, Recreational Therapy and Dietary staff to screening battery for assessing cognition where access to neuropsychological services is limited.
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 P1.076
efficient and interprofessional. Patients are engaged in their recovery and participating in Using a Triage Tool to Facilitate Access to Rehabilitation for Persons with Stroke
activities outside of traditional therapy hours. Evening and weekend programs continue to
expand as the Program develops. Conclusion: By implementing inpatient home exercise Linkewich, E1 Sharp, S2 Willems, J3 Levy, C4 Tahair, N5 Bayley, M6; 1. North & East GTA Stroke
programs and group classes to supplement on on one therapy sessions, patients have in- Network, Toronto, ON; 2. Toronto West Stroke Network, Toronto, ON; 3. South East Toronto
creased access to care, education and have taken personal accountability for their recovery. Stroke Network, Toronto , ON; 4. GTA Rehab Network, Toronto, ON; 5. Toronto Stroke Net-
Staff has increased the transfer of functional skills into daily routines. Interprofessional care works, Toronto, ON; 6. University Health Network - Toronto Rehab, Toronto, ON
has broadened throughout the Unit, and therapists use their time with patients to teach and
practice the new and more complex skills. Background: In creating a standard of care, the Toronto Stroke Flow Initiative (Stroke Flow) identi-
fied the need for standardized acute referral processes aligned to common rehab admission cri-
teria. Stroke severity data from the National Rehabilitation Reporting System (FY12-13 Q1-3) indi-
P1.074 cated 60% of inpatient rehab admissions in Toronto were moderate, 17% mild and 22% severe.
The Frontal Lobes and Autobiographical Memory: A Focal Lesion Study 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 sup-
Levine, B5, 3 Khuu, W5 Black, SE3, 2 Schwartz, ML3, 2 Alexander, MP7; 1. Rotman Research port clinical decision making for early referral to appropriate rehab. Methods: Acute and rehab
Institute, Toronto, ON; 2. Sunnybrook Health Sciences Centre, Toronto, ON; 3. University of leaders considered the provincial expert panel recommendations and existing referral frameworks
Toronto, Toronto, ON; 4. Department of Medicine (Neurology), University of Toronto, Toronto, (Ottawa and Hamilton) in collaboratively developing the triage tool. Understanding that broader
ON; 5. Rotman Research Institute, Baycrest, Toronto, ON; 6. Harvard Medical School and Beth system changes are required for a full transition to the new model of rehab, initial implementation
Israel Deaconess Medical Centre (Neurology), Boston, MA, USA; 7. Harvard Medical School and focused on patients with an early AlphaFIM® of 60-80. Communication and education to support
Beth Israel Deaconess Medical Centre (Neurology), Boston, MA, USA this practice change facilitated the February 2013 implementation. Results: Baseline data (Janu-
ary - August 2012) for patients referred with an early AlphaFIM® of 60-80 indicated only 66%
Most research on the functional neuroanatomy of autobiographical memory has entailed were accepted to rehab, 15% were declined and 8.5% had a decision pending. It is expected that
functional neuroimaging, which is unable to distinguish regions that are activated in associa- transition barriers for this group should be minimal unless special needs are identified. Reasons for
tion with autobiographical memory tasks from those that are necessary for autobiographi- decline included: special needs that could not be met (10%); more appropriate for slow stream re-
cal memory task performance. In this respect, patients with focal lesions provide crucial hab (29%), and limited sitting tolerance and balance (14%). Monitoring of decline rates and reason
information. We assessed the effects of focal frontal lesions due to strokes and tumors for decline will be ongoing. Further evaluation will be conducted at 6 months post-implementation.
in distinct functional-anatomical sectors on autobiographical memory using the Autobio- Conclusion: The triage tool supports a standard of practice across organizations. A common stan-
graphical Interview (AI), which reliably separates categories of episodic and non-episodic dard of practice for rehab referral and management of patients with AlphaFIM® 60-80 have been
autobiographical memory. Twenty-three focal lesion patients in the stable phase of recovery established between referrers and rehab providers. This tool is transferable to other geographies.
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 cogni- P1.077
tion (left lateral patients were excluded due to the speech demands of the AI). Episodic and Assessing Depressive Symptoms in Subarachnoid Hemorrhage and Treated and
non-episodic (internal and external) detail scores were derived from text-based analysis of Untreated Unruptured Aneurysm Patients
the transcribed protocols. MP patients generated significantly more details that were not
pertinent to the specified event (external details) compared to control participants. Patients Maher, ME1 Macdonald, R2, 1 Schweizer, TA2, 1; 1. University of Toronto, Toronto, ON;
with RDLF lesions were only marginally significantly impaired for internal details. Lesion 2. St. Michael’s Hospital, Toronto, ON
overlap of patients with an excess of external details indicated a focus in the left anterome-
dial prefrontal cortex. Production of external details was correlated with non-perseverative Background: The CES-D and the HADS-D are two brief self-report scales that are valid and
errors on the Wisconsin Card Sorting Test (WCST). In conclusion, focal frontal damage does reliable for assessing depressive symptoms in many populations, including stroke. The goal of
e24  Stroke  December 2013
this study was twofold: 1) to determine the presence of depressive symptoms in aneurysmal Objective: To examine the evolution of stroke rehabilitation literature with respect to num-
subarachnoid hemorrhage (aSAH) compared to unruptured intracranial aneurysm (UIA treat- ber, sample size, and quality of randomized controlled trials (RCTs) over the last four de-
ed and untreated) patients and 2) to determine which scale is best to use in these groups. cades (1973-2012). Methods: The Evidence-Based Review of Stroke Rehabilitation (EBRSR;
Methods: 117 outpatients were recruited from the Neurovascular Clinic at St. Michael’s Hospital http://www.ebrsr.com) is a review of RCTs in stroke rehabilitation. RCTs were categorized
to complete both the CES-D and the HADS. We assessed 3 groups: aSAH (n=47), UIA treated into one of five groups based on intervention type: motor, cognitive, medical complica-
(n=30) and UIA untreated (n=40). Cutoff scores of 16 (CES-D) and 8 (HADS-D) were used. tions, psychosocial, and “other”. Data on author(s), year of publication, sample size, and
Results: Proportions of patients scoring above cutoffs were: 42.6% (CES-D) and 19% (HADS-D) Physiotherapy Evidence Database (PEDro) score were compiled. Statistical analyses were
of aSAH, 40% (CES-D) and 23.3% (HADS-D) of UIA treated and 22.5% (CES-D) and 15% (HADS- conducted using GraphPad Prism (V6.01). Results: 1063 RCTs met inclusion criteria (mo-
D) of UIA untreated patients. aSAH patients scoring above the CES-D cutoff had average HADS-D tor n=625; cognitive n=133; medical complications n=108, psychosocial n=99, other
scores below cutoff (average score= 7.30); UIA treated and UIA untreated patients above the =98) with motor intervention RCTs accounting for 58.8% of the total. The number of RCTs
CES-D cutoff had average HADS-D scores of 8.69 and 8.33 – only slightly above the cutoff published each year grew between 1973 and 2012, with 35.9% all RCTs published in the
point. Conclusions: Based on these results, the HADS scale may be preferential to use in aSAH last five years. Overall, motor studies had the smallest median sample size (median =
and UIA (treated and untreated) patients. It requires less time to complete than the CES-D and 32; P < 0.017). Between two five-year time brackets, 1973-1977 and 2008-2012, there
measures symptoms of depression and also anxiety – which is highly prevalent in stroke popula- was no statistically significant increase in median sample sizes among all RCTs combined
tions. Previous research has shown that the CES-D is influenced by anxiety symptoms in addi- (P = .8427). Overall, psychosocial studies had higher mean PEDro scores when com-
tion to producing a high number of false positives in the general population. These factors may pared to motor (P = .002) and cognitive (P = .036), but not medical complication studies
be reflected in the high number of patients in this study that fell at or above the CES-D cutoff. (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 rehabilita-
tion has increased significantly over the past four decades, with an associated increase in
P1.078 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
Analysis of Fmri Neurofeedback of the Primary Motor Cortex as a Function of
reported outcomes.
Time During Kinesthetic Motor Imagery

Mansur, A1 Chiew, M2 Tam, F3 Schweizer, TA1 Graham, SJ3; 1. Li Ka Shing Knowledge Institute,
P1.081
St. Michael’s, Toronto, ON; 2. FMRIB, Nuffield Department of Clinical Neurosciences, Oxford,
United Kingdom; 3. Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, ’Training the Trainers’ - the Process of Effectively Moving Evidence-Based Func-
Toronto, ON tional Electrical Stimulation (FES) Into the Clinical Realm
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

Background: Functional MRI neurofeedback (fMRI-NF) is a novel tool that can enable self-reg- Miller, S1 Gollega, A2 Dukelow, S2; 1. Alberta Health Services - Peter Lougheed Centre, Calgary,
ulation of brain activity. By depicting brain activation patterns during performance of imagined AB; 2. Alberta Health Services, Calgary, AB
movements, fMRI-NF can potentially assist in determining whether patients with focal neurologi-
cal deficits are candidates for motor imagery (MI) therapy. Previously, we performed fMRI-NF Background: In March, 2012, an FES Work Group was formed with ‘champions’ from acute,
with kinesthetic MI in 13 right-handed healthy subjects and 5 controls. Subjects were instructed tertiary and outpatient sites in the Calgary Zone of Alberta Health Services to develop practical
to mentally simulate a unilateral finger-tapping task while receiving NF from the primary motor skills in using functional electrical stimulation (FES) with stroke patients. The FES Work Group
cortices to increase a lateralization metric of brain activity. Only 6 out of 13 subjects were good consisted of occupational therapists, physiotherapists and physiatrists with expertise in stroke
responders, who showed increased activity in the task positive network that correlated with rehabilitation. Methods: An initial meeting was held to determine timelines for knowledge
task performance. Here we focus on the differences in temporal evolution of brain networks transfer and establish the primary goal of the group which was to build a ‘critical mass’ of
recruited in the good and poor responders in left and right hand imagery tasks. Methods: Pre- clinicians with practical experience using FES across the Calgary Zone. In house in-servicing
processed data were subjected to a general linear model (GLM) to create parametric maps for 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
both region-by-region analyses and whole-brain ANOVA analyses. Results: For right hand tasks,
FES equipment was acquired across different sites to ensure consistent use in the Calgary Zone
poor responders had minimal motor activation that was stagnant over the four runs of fMRI-NF.
across inpatient and outpatient centres. A 2 day course was developed in-house with an exter-
Conversely, good responders had high visual-spatial and motor activation from the first run
nal speaker with advanced training in the use of FES. FES Work Group members helped facili-
with increasing involvement of the inferior frontal gyrus and thalamus over time. For left hand
tate the course and assisted in the practical workshops. A survey was done of all participants
tasks, poor responders showed more activation than good responders. Conclusion: This work
to look at ways of improving the FES course. Following this, a 1 day course was developed,
supports that good candidates for fMRI-NF involving imagery must possess strong visual-spatial
with in-house teaching by the FES Work Group. Results: The time from formation of the group
and focused attention skills. Hemispheric differences in brain activity during fMRI-NF may have
to the development of an in-house course and consistent training of ~ 50 therapists across
implications for use of fMRI-NF with MI therapy in populations with focal deficits. More research
the Calgary Zone was ~ 1 year. Based on surveys of participants post 1 day course, > 90 %
is required with a larger sample of left-handed and right-handed individuals, as part of assess-
rated the course as excellent. The use of therapists as facilitators with the course was rated as
ing the role of fMRI-NF applied to MI and stroke.
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.
P1.079
Are the Randomized Controlled Trials in Stroke Rehabilitation Underpowered?
P1.082
McIntyre, A; McClure, A; Richardson, M; Janzen, S; Hussein, N; Teasell, R; Lawson Health Self-Identified Goals: Investigating Areas of Unmet Need for Individuals with
Research Institute, London, ON
Stroke Using the ICF
Objective: Many stroke rehabilitation interventions produce small to moderately sized treatment
Nalder, EJ1 Bottari, C2 Damianakis, T4 Hunt, A3 Dawson, D1, 3; 1. Rotman Research Institute,
effects. Randomized controlled trials (RCTs) that enroll a small number of participants may be
Baycrest Hospital, Toronto, ON; 2. Université de Montréal, Montreal, QC; 3. University of
unable to detect such effects and result in false, non-reproducible conclusions. Therefore, the
Toronto, Toronto, ON; 4. University of Windsor, Windsor, ON
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
Background: Despite evidence for the efficacy of stroke rehabilitation in the chronic phase
RCTs published between 1973 and 2012 were included for review. Sample sizes from all RCTs
of recovery, many survivors report unmet service and psychosocial needs. A clear knowledge
were recorded. Where possible, RCTs were grouped based on intervention type (i.e., motor,
of the self-identified goals of stroke survivors is critical to ensure service planning is congru-
cognitive, medical complications, psychosocial). To detect a moderate treatment effect of 0.5 ent with the priorities of service users. The International Classification of Functioning (ICF)
with the significance level (alpha) set at 0.05 and power (1-beta) set at 0.8, a total sample size core data set for stroke was developed to provide a common framework for describing health
of 128 individuals (64 per group) is required. Results: 1063 RCTs met inclusion criteria with a related experiences post-stroke. However, this framework has not been validated in terms
mean sample size of 176.4±1002. 17.2% of all RCTs included a sample size of at least 128 of how it aligns with self-identified goals of stroke-survivors. This paper aims to 1) describe
individuals. 965 RCTs could be further classified as motor (n=625), cognitive (n=133), medical self-identified goals of stroke survivors and 2) determine the extent to which individuals’ goals
complications (=108), and psychosocial (n=99) interventions. The mean sample sizes among link to the ICF. Methods: Data were collected from 24 participants with stroke on average 3.5
the groups varied considerably: motor –x = 87.4±574.4; cognitive –x = 329.1±1042.2; medical years post-event, as part of a larger randomised controlled trial. The Canadian Occupational
complications –x = 227.8±547.5; and psychosocial –x = 126.9±117.9. The proportion of RCTs Performance Measure (COPM) was used to elicit stroke-survivor’s goal statements. Qualitative
that included a sample size of at least 128 individuals was 6.9% for motor, 19.9% for cognitive, content analysis was used to thematically analyse goals and map content to the ICF framework.
26.9% for medical complications, and 33.3% for psychosocial intervention RCTs. Conclusions: Results: Twenty-four stroke-survivors identified 125 rehabilitation goals even many years
It appears as though a substantial portion of the stroke rehabilitation literature is underpowered. post-event. All goals were readily classified using the ICF and indicated a need for supports
Larger trials, particularly for motor interventions, are necessary. 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 re-
P1.080 lated to impaired body functions; most common were neuromusculoskeletal and movement
The Evolution of Stroke Rehabilitation Research 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.
McIntyre, A1 Richardson, M1 Janzen, S1 McClure, A1 Hussein, N1, 3 Teasell, R1, 2, 3; 1. Lawson The ICF framework is a useful tool to illustrate the broad rehabilitation needs of individuals
Health Research Institute, London, ON; 2. University of Western Ontario, London, ON; 3. St. with stroke and may inform service planning and evaluation towards addressing the long-term
Joseph’s Healthcare, London, ON needs of stroke survivors.
Abstracts From the 4th Canadian Stroke Congress, 2013  e25
P1.084 Background: The neuromuscular control of standing balance is known to be impaired after
The HNHB Community Stroke Rehabilitation Model - a Component of an stroke. The purpose of this study was to explore the role of anticipatory reactions in responding
Integrated Stroke Recovery System that Crosses the Continuum From Acute to 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)
Community
by leaning as far forward as possible about the ankles without lifting the heels. External loads
Pagliuso, SA; MacRae, L; The HNHB Community Stroke Rehabilitation Working Group; Hamilton of 2% of body weight were applied at the level of the hips to perturb the subject anteriorly. Ten
Health Sciences, Hamilton, ON 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
Background: A gap identified in the HNHB LHIN was the lack of access to community stroke re- lateral gastrocnemius), center of pressure (CP) measurements, and electrodermal activity (EDA;
habilitation, especially in rural areas. Therefore a working group(WG) was assembled to develop measurement of physiological arousal) were taken. Results: Subjects post-stroke have lower
a Community Stroke Rehabilitation Service Model(CSRM) as a component of a stroke recovery LOS in the paretic leg compared to the non-paretic leg and healthy controls. During investigator-
system that crosses the continuum. The service model will be aligned with the Canadian Best triggered external load drops, the CP excursion in people with stroke moved anteriorly similar to
Practices for stroke care and the Stroke Reference Group, provide improved access and be controls (~80% LOS), although the peak CP excursion was reached quicker in controls. In the
transferable to other LHIN communities. The goals of the model are achieving improved access subject-triggered condition, healthy subjects showed a reduction in the CP excursion; however,
to evidence based community outpatient stroke rehabilitation, improved client outcomes, reduc- this was not demonstrated post-stroke. The relative activity of soleus compared to medial and
tion of hospital lengths of stay and integration of outpatient stroke services. Methods: In order lateral gastrocnemius was lower in the paretic muscle than in the non-paretic leg or controls.
to develop this model the WG engaged in the following process: Both triggered conditions elicited an increase in EDA in stroke compared to controls. Conclu-
sions: Subjects post-stroke had higher physiological arousal during the external perturbations in
- Defining the ‘eligible’ population and identifying the number of individuals that would be both types of triggered conditions. Whereas healthy subjects changed their motor performance
eligible. when the perturbation was self-triggered, the subjects post-stroke did not. The soleus muscle
- Identifying client streams and best practice guidelines for each. appeared to be more compromised than the gastrocnemius heads. Together these findings
- Completing an environmental scan which revealed 8 models for review. further illustrate the impairments of neuromuscular control of standing balance.
- 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. P1.087
Results: The WG have developed a model that incorporates the strengths of all the models Effect of Intensive Functional Electrical Stimulation Therapy on the Upper Limb
reviewed. Which includes the following: Motor Recovery After Stroke: Single Case Study of a Chronic Stroke Patient
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- Strong link with District and/or Regional Stroke Center, an ISU and with primary care
- Dedicated care coordination Kawashima, N1, 3, 2 Popovic, MR3, 2 Zivanovic, V3, 2; 1. Research Institute of National Rehabilita-
- Time to first visit within 72 hours tion Center for Persons with Disability, Saitama, Japan; 2. University of Toronto, Toronto, ON;
- Consistency of Stroke Team Members 3. Toronto Rehabilitation Institute, Toronto, ON
- Assessment for CSR within 24-48 hours
- Care Pathway based on Best Practice Recommendations that incorporate opportunities for Purpose: Previous successful randomized controlled trials show that functional electrical stimu-
reassessment lation (FES) therapy can restore voluntary arm and hand function in people with severe stroke.
- Stroke Expertise The purpose of this study was to examine neuromuscular changes occurring in the upper limb of
- Equitable Access people with severe stroke following intensive FES therapy, consisting of task-specific upper-limb
- Strong link with CCAC movements with a combination of preprogrammed FES and manual assisted motion. Methods:
- Standardized reporting requirements 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
Conclusions/Next Steps: 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
Implementation of a pilot project and development of an evaluation framework. 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)
P1.085 and decreased Modified Ashworth Scale scores (from 3 to 2 for the hand and 4 to 3 for the arm).
“Normal” Functional Balance Does Not Necessarily Imply Recovered Standing Coordination between shoulder and elbow joints during the circle-drawing test improved consider-
Balance Control, as Measured with Posturography in Individuals with Stroke ably 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
Patterson, KK1, 2 Mansfield, A2, 1 Inness, E2, 1 McIlroy, WE3, 2, 1; 1. University of Toronto, Toronto, observed in people with severe stroke following intensive FES therapy can be attributed to (a)
ON; 2. Toronto Rehab - University Health Network, Toronto, ON; 3. University of Waterloo, regained ability to voluntarily contract muscles of the affected arm, (b) reduced spasticity and
Waterloo, ON improved muscle tone in the same muscles, and (c) increased range of motion of all joints.

Background: The Berg Balance Scale (BBS) is a functional balance measure commonly used
during stroke rehabilitation1. However, BBS scores can improve without concomitant improve- P1.088
ment in physiological postural control measures2. The purpose of this study was to compare Change in Rehabilitation Clinicians’ Practices Related to Upper Limb Manage-
forceplate measures of standing balance between individuals post-stroke scoring above and ment Post-Stroke Over the Past Year: Do Changes Align with Best Practice
below a ‘normal’ BBS score. Methods: Demographic variables, BBS scores, Chedoke McMaster Guidelines?
Stroke Assessment (CMSA) leg and foot scores and forceplate measures of quiet standing bal-
ance (percentage of body weight on the paretic limb and root mean square of centre-of-pressure Purohit Jadav, R1, 2 Korner-Bitensky, N1, 2 Menon, A1; 1. McGill University, Montréal, QC; 2.
for antero-posterior and medio-lateral displacement) were extracted from 168 inpatient rehabili- Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR),
tation charts. Individuals were divided into two groups: BBS score above or below a normative Montreal, QC
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 Background: Upper limb motor impairments are prevalent after stroke. Although there is a re-
ANOVAs and Fisher’s tests. Results: Forty-two (25%) individuals had BBS > normative value. cent version of Canadian Best Practice Guideline 2010 (CBPG-2010) integrating precise and up-
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 dated information about upper limb assessment and management post-stroke, it is unknown if
vs 4.2±1.2, p<0.001) and shorter length of stay (31 ± 11 days vs 40±15 days, p<0.001 ) than occupational therapists (OTs) and physical therapists (PTs) have introduced any changes to their
individuals with BBS < normative value. The two groups did not differ in age, days post stroke management of upper limb dysfunction. Thus, the aim of this study is to explore change (or lack
or the proportion of individuals scoring within the normative CIs for forceplate measures. Dis- thereof) in upper limb management post-stroke by OTs and PTs in a 12 month period in 2012,
cussion: Individuals post-stroke achieving “normal” BBS scores are not more likely to exhibit as well as facilitators and barriers related to change using a standardized tool, the Professional
recovered standing balance control as measured by posturography with respect to healthy CI Evaluation & Reflection on Change Tool (PERFECT tool). (available online at www.strokengine.
values. These individuals may employ compensatory strategies that allow superior BBS perfor- ca/) Methods: A convenience sample of 25 PTs and 25 OTs, working in inpatient stroke rehabili-
mance which belies continued underlying balance impairment. tation 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
References: Blum L et al. Phys Ther. 2008;88:559-566. Garland SJ et al. Arch Phys Med Rehabil. changes in clinical practice over a 12 month period according to four components of patient
2003;84:1753-1759. Steffen TM et al. Phys Ther. 2002;82:128-137. Prieto TE et al. Biomedical management as measured using the PERFECT: problem identification, assessment, treatment
Engineering. 1996;43(9):956-966. Mansfield A et al. Clin Biomech. 2011;26:312-317. 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
P1.086 limb management post-stroke will be presented. Additionally, key facilitators of evidence-based
Influence of Knowledge of Perturbation on Standing Balance Post-Stroke 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 contrib-
Pollock, C1 Vieira, T2 Gallina, A2 Ivanova, T1 Cantor, Z1 Garland, S1; 1. University of British utes to our understanding of the uptake of the evidence specific to upper limb management
Columbia, Vancouver, BC; 2. Laboratory for Engineering of the Neuromuscular System (LISiN), post-stroke and assists in planning knowledge translation (KT) interventions that promote the
Politecnico di Torino, Torino, Italy implementation of evidence into practice.
e26  Stroke  December 2013
P1.089 examined for changes in CBF over time, after a total grey matter normalization to remove global
Clinical-Research Platforms as a Model of Knowledge Translation to Promote CBF effects. Results: In repeated-measures analyses, there was a significant time x intensity
Best Practices in Stroke Rehabilitation 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
Richards, CL1 Nadeau, S2 Fung, J3 Rossignol, S4 Doyon, J4; 1. Université Laval and CIRRIS exercise intensity (P = 0.098, P = 0.069, respectively), with higher CBF being observed following
Research Center, Quebec, QC; 2. Université de Montréal, Montreal, QC; 3. McGill Universityand the cycling bout, and in the moderate-intensity trial. No effect was noted in the middle frontal,
CRIR Research Center, Montreal, QC; 4. Université de Montréal, Montreal, QC precentral, or postcentral gyri; caudate nucleus; or precuneus regions. Conclusions: Prelimi-
nary results suggest that the insular and hippocampal brain regions have relative increases in
Background: The Canadian Institutes of Health Research-funded Sensorimotor Rehabilitation CBF following cycling, which appear to last at least one hour post-exercise. Moderate exercise
Research Team unites researchers from Université de Montréal, Université Laval and McGill intensity may be necessary to achieve this increased perfusion. Funding: HSF Centre for Stroke
University, 3 Research Centers and the stroke units of 3 Rehabilitation Centers (RC) in Quebec. Recovery Hakim Innovative Stroke Research Award.
Led by 5 Principal Investigators (PIs), it includes 25 researchers (neuroscientists and clinical re-
searchers) 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 op- P1.092
timize rehabilitation and to develop and evaluate innovative therapeutic approaches. Methods: Challenges in Opening the Black Box of Rehabilitation Services in Quebec
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 Poissant, L1 Rochette, A1 Ahmed, S2 David, I3 Lebrun, L3 Lindsay, P4 Swaine, B1; 1. Université
the gaps between current practice and best practices, clinicians responded to a questionnaire de Montréal, Montréal, QC; 2. McGill University, Montreal, QC; 3. Centre de recherche interdis-
on the SurveyMonkey web-platform and patient charts were audited. Information on intensity ciplinaire en réadaptation, Montreal, QC; 4. Canadian Stroke Network, Toronto, QC
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 Background: The contribution of rehabilitation to reduce disability, limitations and restrictions
gait and balance analysis, evaluation of pain, and imagery. Results: In each RC, a baseline on of persons with stroke and facilitate the resumption of meaningful roles is well documented.
the type and intensity of interventions has been documented. The gap analysis has identified While there is agreement that rehabilitation makes a difference, little is known on the type of
areas for improvement with the help of the clinical researchers. More importantly, CRPs are services provided by the different rehabilitation providers across the continuum of care. Through
being implemented as all the RCs are now collecting information on the patients using similar partnership with the Quebec Ministry of Health and Social Services (MSSS), our team proposes
outcome measures, and patient evaluations in the laboratories have commenced to inform the to: i) capture gaps between current rehabilitation practice and the Canadian recommendations,
clinicians. Conclusions: The CRPs, in addition to informing clinical practice, and creating a data and, ii) characterize rehabilitation services (who, when, what and how). Methods: An audit
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

bank of standardized outcomes, are now ready to embark in clinical research projects whereby tool and a questionnaire were developed using various sources of information (experts, Stroke
the clinicians will carry out innovative interventions inspired by interactions among the team guidelines, INESS reports, etc). The audit tool will be pilot tested in six organizations (two acute
members. The challenge in upcoming years will be to demonstrate the benefits of these CRPs care hospitals, two rehabilitation hospitals and two out-patient rehabilitation centres). The
on rehabilitation outcomes. 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
P1.090 on the challenges in documenting potential gaps and variability to known stroke guidelines.
The Proposed Quebec Rehabilitation Stroke Strategy: a Patient-Centered Conclusions: This pilot project is a first step towards a provincial audit of rehabilitation services
Approach From Onset to Community Integration to be conducted in the fall to determine the portray of stroke rehabilitation pre-implementation
of the stroke care continuum.
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
P1.093
Background: As part of the development of the Quebec Stroke Strategy a Committee that The influence of a single bout of aerobic exercise on speed of processing and
brought together experts in different aspects of the rehabilitation continuum, from acute care to muscle activity in stroke
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 Sage, MD1 Roy, E2 Brooks, D1 Beyer, KB2 McIlroy, W2; 1. University of Toronto, Graduate
by visio-conference and also worked in sub-committees between February 2012 and January Department of Rehabilitation Science, Toronto, ON; 2. University of Waterloo, Kinesiology
2013. In addition to reading previous reports and key publications, the committee invited experts Department, Waterloo, ON
to give presentations on subjects such as: stroke units, prevention, community integration, ge-
riatric trajectories, and telerehabilitation. Perceptions of patients and caregivers as well as clini- Background: Research in healthy individuals suggests that aerobic exercise may prime the
cians of the present rehabilitation continuum were obtained by focus groups and a web-based central nervous system (CNS) and if delivered to stroke patients prior to neurorehabilitation
questionnaire, respectively. Results: The findings revealed numerous areas for improvement: may facilitate neurological recovery by augmenting the state of the CNS at the time of active
communication, trajectories, evaluations, therapeutic approaches, length of stay in acute care rehabilitation. The objective was to provide an understanding of the influence of a single ses-
and in-patient rehabilitation and outpatient rehabilitation services. The Committee proposes a sion of lower-limb aerobic exercise on upper-limb reaction time (RT) and amplitude of muscle
patient-centered model inspired by the Canadian Stroke Strategy adapted to the Quebec system. activity within a stroke population. Methods: Fourteen stroke participants (mean age=54.9,
Key elements include: well defined outcome measures, uniform best practices and trajecto- median 56 days post-stroke) performed 20 minutes of lower-limb aerobic exercise (mean heart
ries, standardisation of the care and services offered, services to support persons post stroke rate=54.4% of age-calculated max). Upper-limb simple and choice RT was evaluated pre-, dur-
and their caregivers living in the community. Structural elements are: stroke units, prevention ing and immediately post-exercise using both limbs. Participants either extended their wrist
clinics, a rehabilitation triage system, an early supported discharge system, a patient-support or flexed their biceps (depending on functional ability) in response to a target arrow which
coordination system, systematic follow-ups and community integration programs with strong pointed left or right (only one direction for simple RT). RT was measured using electromyog-
links to primary care services. Guiding principles include: patient empowerment and shared raphy (EMG) onset. EMG activity was also used to evaluate amplitude of contraction. Results:
decision-making, caregiver participation, accessibility of services for all with a rehabilitation During exercise, the non-statistically significant trend was for slower RT and maintenance of
potential, continuity in evaluations, therapy and services, and long-term follow-up of patients to EMG amplitude. After exercise, mean simple RT was 21 and 15ms faster for the affected and
promote maintenance of gains. Conclusions: The committee report was submitted May 1st to non-affected arms respectively; however, across the group this was not statistically significant.
the MSSS. Implementation of the recommendations will provide Quebec with a patient-oriented Within-subject analysis revealed 3 individuals with significantly faster RT (≥19%) after exercise
rehabilitation continuum based on best practices that promotes the community reintegration of and 6 others with moderately faster RT (>3.5%). The threshold of 3.5% was considered sig-
persons post stroke. nificant 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
P1.091 appears to be impacting the ability to detect statistically significant group differences despite
Moderate Aerobic Exercise Acutely Increases Cerebral Blood Flow to the Insula seemingly large RT changes. There is a need to reveal the individuals or task-related determi-
and Hippocampus in Chronic Stroke nants that may account for the exercise effects after 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 P1.094
Predicting Language Recovery after Stroke Using Variability of Performance and
Background: Aerobic exercise, as a tool in stroke rehabilitation, improves peak aerobic fit- Complexity of Functional Connectivity
ness 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 con- Schmah, T1 Duncan, ES2 Yourganov, G3 Zemel, RS4 Small, SL5 Strother, SC3; 1. University
trasted to offer insight into post-stroke exercise prescription. Methods: Six participants (56 ± 15 of Toronto, Toronto, ON; 2. Departments of Cognitive Science and Neurology, University of
years of age; 2 women) were recruited at the chronic stage of stroke recovery (14 ± 3 months) California, Irvine, CA, USA; 3. Rotman Research Institute, Baycrest, and Institute of Medical
and participated in three exercise sessions. The first session involved a symptom-limited cardio- Science, University of Toronto, Toronto, ON; 4. Department of Computer Science, University of
pulmonary assessment of peak fitness. Subsequent sessions involved 20-minute exercise bouts Toronto, Toronto, ON; 5. Departments of Neurology, Neurobiology and Behavior, and Cognitive
on a semi-recumbent cycle ergometer, randomized between 50 % (light) or 70 % (moderate) Sciences, University of California, Irvine, Irvine, CA, USA
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 Background: A fifth of people with stroke have persistent aphasia. In a longitudinal study of
points (~ 30 and 55 min) following, exercise. In this preliminary analysis, 7 brain regions were aphasia treatment, we hypothesized that language improvement would be predicted by intra-
Abstracts From the 4th Canadian Stroke Congress, 2013  e27
individual variability (IIV) of performance and complexity of brain functional connectivity. Meth- spectively. When diagnosis of cognitive impairment was defined as impairment in two domains
ods: 15 individuals with aphasia due to stroke completed 6 weeks of intensive therapy in which of the Cognistat, MMSE sensitivity and specificity was 43.6% and 95.2%, respectively, while
they repeated words and phrases presented audiovisually. Repetition accuracy was tested im- MoCA sensitivity and specificity was 90.1% and 19.1%, respectively. Discussion: MMSE had
mediately before and after the treatment. All words were scored on a 5-point scale, with IIV poor sensitivity and good specificity while MoCA had good sensitivity but poor specificity when
measured by standard deviation. Immediately before treatment, we acquired whole-brain BOLD compared to Cognistat as the gold standard. Based on these results, the MoCA appears to be
functional MR images, incorporating one “imitation” run, in which subjects viewed and repeated the superior screening tool based on greater sensitivity.
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 imple-
mented in FSL Melodic (Beckmann & Smith): Laplace approximation to Bayesian evidence (LAP) P1.097
and Minimum description length (MDL) . Pretreatment performance mean and IIV, pretreatment Default-Mode Network’s Implication in Language and Therapy-Induced Recovery
fMRI metrics evaluated on task and rest runs separately, and age and time since stroke onset in Chronic Aphasia
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 Tremblay, FB1 Marcotte, K1 Durand, E1, 2 Ansaldo, A1, 2; 1. Université de Montréal, Montreal, QC;
on imitation runs (only) together with the behavioral variables, explained 44% of the variance in 2. Institut Universitaire Gériatrique de Montréal, Montréal, QC
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 The alteration of large-scale neural networks not primarily known to be implicated in language
imitation runs). Lower mean performance,higher IIV and higher LAP predicted greater improve- may explain the pervasive disorders occurring after stroke’s localised lesions, namely aphasia.
ment. None of the metrics of resting state fMRI were predictive of improvement. Conclusions: It is observed that the default-mode network (DMN) is engaged in semantic processing and
Aphasia treatment outcome can be predicted from pretreatment performance mean and IIV and that the disruption of its functional connectivity is associated with cognitive and semantic dis-
pretreatment task-based fMRI, with higher IIV and higher complexity of functional connectivity orders in different neuropathologies. Even though its implication in language production is still
associated with greater improvement. unclear, the DMN exhibits neuroplastic changes in conjunction with language recovery induced
by therapy in chronic aphasia.
Reference:
Nine subjects (5 men and 4 women) who have chronic aphasia secondary to a left-hemisphere
Beckmann, C.F., Smith, S.M. IEEE Transactions on Medical Imaging, 2004 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
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

P1.095 Feature Analysis (SFA). The groups undergo two fMRI sessions, prior- and post-treatment, dur-
Influence of Cognitive Deficits on the Ability to Use Feedback for Arm Motor ing picture naming. Functional connectivity data is then processed using spatial Independent
Recovery in Chronic Stroke 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
Subramanian, SK; School of PT and OT, McGill University, Montreal, QC 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
Background: Feedback provision during training is an essential component of motor learning observed in the LN, the DMN’s functional connectivity increases in conjunction with the behav-
that improves upper limb motor recovery in individuals post-stroke. Along with sensorimotor im- ioral improvement, and it is predictive of therapy benefits. Still, the integration values of the
pairments, stroke survivors have cognitive impairments (depression, memory, attention, men- DMN and the LN are highly correlated during picture naming. Moreover, noun and verb naming
tal flexibility, problem‐solving, visuoperception) which can influence motor learning. However, exhibit distinctive functional connectivity within the DMN. Functional connectivity measures of
whether cognitive impairments limit the ability to use feedback for motor recovery remains un- the DMN unveil its contribution to semantic processing and its implication in language recovery
clear. We evaluated whether and to what extent cognitive deficits are associated with the ability after aphasia therapy.
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). P1.098
Terminal auditory feedback was provided about movement speed (knowledge of results) and Implementing a Formal Procedure for Team Decision-Making Based on an Algo-
trunk displacement (knowledge of performance). Changes in movement kinematics (movement rithm for Screening Driving Ability and the Need for On-Road Assessment
speed, elbow extension (ElbExt), shoulder horizontal adduction (ShHor), shoulder flexion (ShFl)
and trunk displacement) were assessed before, immediately after (POST) and 3mos (RET) af- Gauthier, J3, 1 Tremblay, L1 Couve, M1 Hazel, M2 Rioux, M2 Higgins, J3, 4 Beaudoin, N2, 3 Crabb,
ter task practice. Depression and cognitive functioning were assessed with a comprehensive S2 Lachance, K2 Leclaire, H2 Gagnon, A2 Guerrera, R2 Patenaude, C4; 1. Institut de réadaptation
neuropsychological examination. Repeated-measures ANOVAs analyzed changes in kinematic Gingras-Lindsay-de-Montréal, Montréal, QC; 2. IRGLM, Montréal, QC; 3. Centre de recherche
outcomes. Multiple regression analyses estimated the strength of the association between ki- interdisciplinaire en réadaptation du Montréal métropolitain site IRGLM, Montréal, QC; 4.
nematic changes (dependant variables) and cognitive scores (predictors). Results: Participants Université de Montréal, Montréal, QC
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 Background: According to a survey among rehabilitation professionals from the neurology pro-
to the PE group. Individuals who had fewer deficits in memory, cognitive flexibility and lower gramme at Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM), screening for driving
depression levels made greater improvements in kinematics immediately after training (POST). ability and the need for on-road assessment is difficult and informing a client they should not be
Kinematic improvements were retained (RET) better in those who had higher memory scores, driving is a delicate matter and should not be the burden of one person. Since stroke typically
visuoperception ability and lower depression levels. Conclusions: Cognitive ability was associ- causes an array of deficits that can affect driving ability, all rehabilitation professionals should be
ated with the capacity to use feedback for upper limb motor learning and recovery. Information involved in the evaluation, in the decision making as well as in informing the client and their fam-
about cognitive deficits can help clinicians select the most appropriate interventions to maximize ily. Methods: A variety of different tests routinely used by the team and validated in the literature
arm motor recovery post‐stroke. 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. Re-
P1.096 sults: An algorithm detailing important aspects to be assessed for driving ability was developed
The Sensitivity and Specificity of the MoCA and MMSE as Compared to the Cogni- and integrated into an interdisciplinary grid. A formal procedure comprising the systematic filling
stat in a Stroke Rehabilitation Population 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
Friedman, L2 McClure, A2, 3 Speechley, M4 Teasell, R1; 1. Department of Physical Medicine and assessments and identification of all possible deficits that could lead to an inability to drive and a
Rehabilitation, Schulich School of Medicine and Dentistry, UWO, London, ON; 2. Lawson Health team decision. Conclusion: A procedure for screening driving ability by the systematic use of an
Research Institute, ARGC, London, ON; 3. St. Joseph’s Health Care, London, ON; 4. Western interdisciplinary grid that includes validated test items and based on a decision algorithm is now
University, Department of Epidemiology and Biostatistics, London, ON 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
Objective: To identify the better of two commonly used screening tools for detecting probable a united front for announcing a decision to a client.
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 Ex- P1.099
amination (MMSE) and Montreal Cognitive Assessment (MoCA) were administrated by an occu- Who benefits from intensive aphasia programs: Preliminary Outcomes from the
pational therapist, whereas the Cognistat was administered by a student investigator. Published InteRACT program
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 com- Wozniak, LA; Kostopoulos, EJ; Dalhousie University, Halifax, NS
pleted 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). Aphasia is a communication disorder affecting expressive language, auditory comprehension,
The mean age of the study sample was 67.6 (SD 15.1) years. Mean MMSE and MoCA scores reading and/or writing following brain injury. It has been reported that up to 35% of adults have
were 26.5 (SD 3.4) and 20.9 (SD 5.3), respectively. The mean Cognistat composite score (sum symptoms of aphasia following stroke.
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 Intensive therapy for individuals with aphasia has been supported in the literature. However, little
35.7% and 100%, respectively, while MoCA sensitivity and specificity was 90% and 33.3%, re- is known about the characteristics of individuals who attend these programs and what factors
e28  Stroke  December 2013
may predict who makes clinically significant changes when attending such a program. Since Background: Stroke patients were given educational information throughout hospitalization.
2002, Dalhousie University has run the Intensive Residential Aphasia Communication Therapy Duplicate and inconsistent information was provided. Expectations of information and topics
(InteRACT) program. The 4.5 week program offers 100+ hours of speech and language therapy to be covered were not set. Patient experience data showed opportunities for improving pa-
which facilitates community re-integration and promotes quality of life for individuals with apha- tient education and support. Stroke survivors felt they were not prepared for discharge and
sia and their communication partners. The program is structured with an interprofessional focus, did not have the right information. Methods: A multidisciplinary improvement team across the
providing physiotherapy and recreation therapy in addition to communication treatment. Individu- continuum was established and based on feedback from patients the “Patient and Family Pass-
als with aphasia must attend with a communication partner from home (family member or friend) port for Stroke” was created. The goal was to provide consistent information, improve patient
to support carry-over of strategies and techniques when the individual returns home. Pre and centred care throughout the continuum and patient safety. The Passport follows Canadian Best
post outcome data was analyzed for 71 patients who attended the program from 2002-2012. Practice Recommendations, and Accreditation Canada standards for excellence in stroke care.
Results showed that individuals who attend the program tend to be middle age and predominantly Staff documentation expectations outlined the information to be covered throughout the stay.
male. Three outcome measures which assess the impairment, activity and participation levels of Results: 1500 Passports have been issued since May 2012. The Passport saves staff time by
communication were analyzed; The Western Aphasia Battery (AQ), Communicative Activities of providing a complete package of education materials which can be individualized. It assists pa-
Daily Living and the Communicative Effectiveness Index, respectively. Clinical outcomes were tients with recovery and provides needed resources throughout transitions. Passports have been
analyzed for both statistical significance pre and post treatment as well as clinical significance. well received by patients, and staff. Surveys were conducted to assess patient experience and
It was found that age, gender and time post onset of aphasia were not significant predictors of satisfaction. A statistically significant increase in positive patient experience and higher rates of
improved outcome on measures of language ability or functional communication. The results positive experience were shown compared to other Provincial zones. Patient experience ratings
demonstrate that adults with aphasia in either the acute or chronic phase of recovery and of all show positive results 71-93%, regarding: understanding the stroke information and resources,
ages can continue to show positive improvements in language ability with intensive treatment. 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
P1.100 significantly in the last two years, but there has been a statistically significant reduction in the
Pharmacists as Care Providers for Stroke Patients: a Systematic Review 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.
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 P1.103
a variety of healthcare settings. Although evidence supporting their role in the care of patients Regional Acute Stroke Care in British Columbia’s Lower Mainland
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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 sum- Curry, M1, 2 Emes, D1 Hastings, R1; 1. Fraser Health Stroke Strategy, Vancouver, BC; 2. Univer-
marize the evidence evaluating the impact of pharmacist interventions on stroke patient out- sity of British Columbia, Vancouver, BC
comes. 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/ Background: Fraser Health is British Columbia’s most-populated regional health authority serv-
TIA were identified. A meta-analysis was not performed. Results: Twenty-six abstracts and ing over 1.6 million residents extending from the Vancouver suburb of Delta on the Pacific
full-text studies were included. The included studies provided evidence supporting pharmacist coast up the Fraser Valley to rural Boston Bar. Twelve hospitals operate in the region with all
interventions in multiple settings including: emergency departments, inpatient, outpatient, com- sites receiving cerebrovascular cases and with tertiary neurologic and neurosurgical care being
munity pharmacy, and long-term care settings. In the majority of the studies, pharmacist care provided at the Royal Columbian Hospital in New Westminster. Timely assessment and manage-
was collaborative with other healthcare professionals. Some of the pharmacist interventions ment of cerebrovascular disease has been shown to affect outcomes. Methods: All cases identi-
included participation in a stroke response team, assessment for thrombolytic use, medication fied as possible acute strokes at the time of Emergency Department triage in Fraser Health were
reconciliation, participation in patient rounds, identification and resolution of drug therapy prob- tracked starting in January 2013. The timing of initial symptom onset, emergency department
lems, risk factor reduction, and patient education. Examples of outcomes include a reduction in arrival, triage assessment, emergency physician assessment, computed tomography and, if ap-
time to thrombolytic administration, increased medication adherence, patient satisfaction, and plicable, time of angiography and intravenous thrombolysis administration were tracked across
blood pressure and/or lipid control. Conclusions: The available evidence suggests that a variety all sites. Other markers of quality acute stroke care were also tracked including whether pa-
of pharmacist interventions can have a positive impact on stroke patient outcomes. Further tients’ blood glucose levels were measured and recorded, whether a baseline electrocardiogram
research should be conducted to add to the current body of literature. 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
P1.101 the various hospitals in Fraser Health. Recorded compliance with markers of quality acute stroke
Delivering Cme Accredited Provincial Stroke Rounds in Ontario: How OREG Has care was suboptimal. Conclusions: In a large health region substantial variability in the time to
Made it Work From 2008 - Present assessment of acute strokes exists. Areas for improvement in clinical care have been identified.

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. Cham- P1.104
plain Regional Stroke Network, Ottawa, ON Knowing Each Other’s Work Across the Stroke Care System: Development of
Essential Professional Conversations for Seamless Care
Background: In 2008, Ontario Regional Education Group (OREG) launched a stroke education
series called Provincial Stroke Rounds delivered via videoconference. In its infancy, Rounds Darling, S1 Quant, S2, 5 Avinoam, G1 Fortin, J2 Skrabka, K8 Richardson, D3, 7, 4 Linkewich,
focused on acute care with Ontario’s stroke neurologists serving as expert presenters with the B2, 6 Willems, J8 Sharp, S1, 5; 1. Toronto West Stroke Network, Toronto Western Hospital,
target audience being physicians. The initiative has evolved to attract full representation of an University Health Network, Toronto, ON; 2. North & East GTA Stroke Network, Sunnybrook
interprofessional stroke healthcare team. Both presenters and attendees have varied clinical/ Health Sciences Centre, Toronto, ON; 3. Toronto Rehabilitation Institute, UHN, Toronto, ON; 4.
academic backgrounds and represent the stroke care continuum. Methods: Provincial Stroke Royal College of Physicians and Surgeons of Canada, Toronto, ON; 5. Department of Physical
Rounds occurs 6 times per year, as one hour didactic presentations. 11 Ontario Stroke Re- Therapy, Faculty of Medicine, University of Toronto, Toronto, ON; 6. Northern Ontario School of
gions share hosting duties and collaborate with Ontario Telemedicine Network (OTN) to support Medicine, Thunder Bay, ON; 7. Division of Physiatry, Faculty of Medicine, University of Toronto,
registration; videoconference platforms; archiving; and technical aspects. The Northern Ontario Toronto, ON; 8. South East Toronto Stroke Network, St. Michael’s Hospital, Toronto, ON
School of Medicine (NOSM) provides accreditation with 1 Mainpro-M1 credit and 1 hour Ac-
credited Group Learning Activity. Host regions follow a standardized step-by-step guide focused Background: People with stroke (PWS) experience fragmented care since multiple health care
on consistent organization; promotion and delivery of the program. A promotional poster is cre- providers (HCPs) are involved. System stakeholders also identified the time of patient transi-
ated and disseminated and participant handouts are provided. Evaluation forms, consisting of tions as an opportunity to significantly impact their quality of care. Specifically, verbal exchange
short answer and likert scale questions, are scanned/collated at NOSM for summary report between HCPs has been considered important for successful patient transitions by enabling
generation. Provincial education needs assessments have been conducted to determine learn- exchange and clarification of unique patient information; familiarity with other practice environ-
ing needs. Results: 36 live Rounds have been offered since 2008, with 40-60 provincial sites ments; relationship development and collaboration. Hence, to develop a system-wide initiative
joining each event. In 2012, approximately 1000 participants attended live events with 120 more to improve patient transitions, the Toronto Stroke Networks further explored HCP perceptions of
accessing archived webcasts at a later date. The topics chosen are timely, relevant, evidence- the impact of conversations on the care that they provide and transition experiences for PWS.
informed and span the stroke continuum. Technological difficulties using videoconference are Methods: Using an Appreciative Inquiry approach, 20 HCPs from across the Toronto stroke
rare and mitigated quickly. Participants state overall satisfaction with the learning opportunity. system were interviewed regarding their conversations with other HCPs at the time of patient
Conclusions: Provincial Stroke Rounds enables a wide reach to both urban and rural communi- transitions. Interviews were analyzed for themes to inform the development of a system-wide
ties in Ontario. By reducing professional isolation, and delivering timely and relevant stroke care initiative. Results: Themes identified included value in conversations, challenge of engaging
topics, Rounds enjoys a loyal following. Next steps include enhancing the knowledge transla- in conversations in a complex stroke care system, and the need to enable and enhance con-
tional value of the evaluation questions to include “Intent to Change Practice”. versations. 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
P1.102 were developed to enable and enhance conversations, effect positive change within the system,
Patient and Family Passport for Stroke: Information about Your Care, Treatment and improve transitions for PWS. Conclusions: The need to enable and enhance conversations
and Recovery 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. Antici-
Cole-Haskayne, AL; Beaver, L; Suddes, M; Darren, K; Foothills Medical Centre, Calgary, AB pated outcomes from EPC include an increase in cross-system conversations, enhanced rela-
Abstracts From the 4th Canadian Stroke Congress, 2013  e29
tional strength, increased comfort with/opportunity for interorganizational collaboration, greater into separate groups to address different learning needs. At the end of the session, participants
efficiency/effectiveness of patient care, more individualized care using hopeful language, and completed written evaluations that used a survey format with a five point Likert scale with op-
increased comfort at the next stage of the care journey for PWS. portunities 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%
P1.105 response rate). Of those evaluations completed, 97.5% rated the sessions and the components
Value Creation from Interprofessional Collaboration Among Stroke Healthcare as either excellent or very good. Written feedback was very positive with identified themes
Providers Using Social Media Technology 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
Fortin, JE1 Skrabka, K2 Avinoam, G3 Willems, J2 Sharp, S3 Linkewich, E1; 1. North&East GTA have created a positive momentum amongst clinicians caring for stroke patients. Partnering
Stroke Network / Sunnybrook Health Sciences Centre, Toronto, ON; 2. South East Toronto with front line staff in developing education that fits their needs is imperative to successful
Stroke Network / St. Michael’s Hospital, Toronto, ON; 3. Toronto West Stroke Network / Univer- learning. The sessions were relevant, practical and included active participation which, are key
sity Health Network -TWH, Toronto, ON principles in staff engagement and motivational learning.

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 P1.108
(IPC) goals of the TSNs Education and Knowledge Translation (KT) plan. This interactive KT model A Tool to Assess Language Barriers to Stroke Services: the Communicative
requires a dynamic and meaningful evaluation of value creation: “…learning enabled by commu- Access Measures for Stroke
nity 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 Kagan, A1 Simmons-Mackie, N2 Victor, JC3 Mok, A1 Sharp, S4 Linkewich, B5 Willems, J6
VCoP. Methods: An evaluation framework was developed to assess the efficacy of the VCoP as Conklin, J7; 1. Aphasia Institute, Toronto, ON; 2. Southeastern Louisiana University, Hammond,
a contributor to meaningful IPC of stroke healthcare providers across the TSNs. This framework LA, USA; 3. Institute for Clinical Evaluative Sciences, Toronto, ON; 4. Toronto West Regional
integrates key developmental evaluation and knowledge translation principles. Values were as- Stroke Network, Toronto, ON; 5. North East GTA Stroke Network, Toronto, ON; 6. South East
signed to participants’ descriptions of how specific aspects and experiences have influenced Toronto Stroke Network, Toronto, ON; 7. Concordia University, Montreal, QC
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 Background: Research and outcome evaluation targeting systems level change related to com-
members fit the target population of healthcare providers. Training sessions and activities were municative access to information and decision making for patients with stroke and aphasia is
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initiated across Toronto to build virtual competence and to prompt interprofessional networking limited by lack of an appropriate tool to quantitatively capture change. We developed and evalu-
and collaboration on the VCoP. Results: Preliminary results show increases in membership and ated a set of web-based Communicative Access Measures for Stroke (CAMS). CAMS comprises
feedback on the VCoP. Emerging themes emerged from initial feedback include: functionality, ac- three quantitative surveys for health care facilities from the perspectives of 1) policy makers, 2)
cessibility, and resources. Further results (quantitative and qualitative) will be captured to review frontline health care providers, and 3) people with aphasia (using a communicatively accessible
6 month outcomes . The cumulative effect of a set of narratives and value stories that inform pictographic version). Methods: CAMS development included extensive input from multiple fo-
further development of the VCoP and /or support effective collaboration on the VCoP will be the cus groups with experts from the field of stroke, aphasia, and communicative access. All ques-
marker of efficacy of this tool. Conclusion: With increasing membership, preliminary results have tions were trialed at a geriatric and long-term care rehabilitation hospital. The web platform for
concurrently informed the further development of the VCoP. The cumulative data at 6 months CAMS is comprised of forms specifically designed to minimize completion times using skip logic
will provide a response to the hypothesis that the VCoP is an efficacious KT tool to support IPC. 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/manag-
P1.106 ers, 33 frontline staff and 25 participants with aphasia) completed the questionnaires on two
Influencing System Change within North Simcoe Muskoka LHIN: Collaborating to occasions. Data were analyzed using kappa statistics and intraclass correlations for each item
Design a Model for Stroke Rehabilitation and Transition 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
Sooley, D; Tee, A; Central East Stroke Network - Royal Victoria Regional Health Centre, Barrie, ON 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
Background: Opportunities to advance stroke care were identified in North Simcoe Muskoka items had ICCs between 0.4 and 0.6. Conclusion: Preliminary findings suggest that CAMS has
(NSM) Local Health Integration Network (LHIN) through development of a business case (NSM relevance for health care facilities with an interest in quality care improvements for patients with
LHIN Stroke Rehabilitation Case for Change). In particular, the need for interprofessional stroke stroke and aphasia and others who ‘know more than they can say’.
units, earlier access to rehabilitation, increased intensity of rehabilitation and increased com-
munity 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 P1.109
address the fourth priority of community rehabilitation, Central East Stroke Network (CESN) has Peer support for stroke survivors: A pilot evaluation
collaboratively developed a NSM LHIN Stroke Rehabilitation and Transition Model. Methods: The
strategic approach focused on designing an integrated system that supports effective transitions Kessler, D1 Egan, M1, 2 Kubina, L1; 1. Bruyere Research Institute, Ottawa, ON; 2. University of
of stroke patients with an emphasis on linking care to appropriately resourced community re- Ottawa, Ottawa, ON
habilitation 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 Introduction: Peer support is a potentially cost effective way to enhance well-being and com-
patient stories. The future state map was then refined ensuring strategic alignment, considering munity reintegration of both recent stroke survivors and their peer supporters. Objectives: In-
local geography, demographics and resources, and was informed by leading practices from depth examination of a peer support program that provides acute care visits and telephone
other jurisdictions. A community engagement strategy validated the draft model. Results: A follow-up post-discharge. We examined a) type of support provided, b) benefits for the stroke
NSM LHIN Stroke Rehabilitation and Transition Model was developed with input from healthcare survivor and their care partners, c) potential harms to the stroke survivors, d) impact of providing
leaders, front-line providers, persons with lived experience, their caregivers, community orga- support on the peer supporter, and e) processes and resources required. Methods: Instrumental
nizations and the general public. This preliminary model will now be used to guide planning of case study. Semi-structured interviews were carried out with 16 stroke survivors and 8 care
community rehabilitation services. It positions the LHIN well for future planning with regard to partners immediately following hospital discharge and at 6-months post stroke to explore the
Health System Funding Reform which is expected to include community rehabilitation in future type of support provided, perceived impact of the program, aspects of the program found to
phases of Quality Based Procedures. Conclusions: The NSM LHIN Stroke Rehabilitation and be particularly helpful, and areas for development. As well, interviews were carried out with
Transition Model provides a framework to achieve best practice community rehabilitation and 6 peer supporters, 3 program co-ordinators and 4 health professionals to gather feedback on
reintegration for stroke survivors. The methodology used in its development demonstrates the the perceived impact of the program on the peer supporters, and the strengths and weak-
value of engagement and collaboration to design health system solutions. nesses of procedures used to select, train, monitor and support these individuals. In addition,
administrative data were reviewed to determine program resource requirements. Results: Emo-
tional, affirmation and information support were offered by the peer supporters. Peer visits were
P1.107 perceived as providing encouragement, motivation, validation and decreased feelings of being
The Benefits of Interprofessional Education (IPE) to Enhance Acute Stroke Car 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
Gill, S; Christie, L; Alves, M; Ellis, M; Kelly, J; Leone, A; Skinner, J; Skrabka, K; Willems, J; feeling that they had been able to make a difference in the lives of others. Involvement of the
St.Michael’s Hospital, Toronto, ON 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
Background: A key feature indicated for successful organized stroke care is “specialized in- survivors and a meaningful activity to longer term survivors.
terest 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 collab-
oratively with Registered Nurses (RN’s) and Clinical Assistants (CA’s) to develop an interprofes- P1.110
sional stroke education day. The education was driven by identified needs of front line stroke Organized Stroke Care in Ontario: Impact on Hospitalization and Mortality
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 Lumsden, JE1 Hall, R2 O’Callaghan, C3 Meyer, M3 Khan, F2; 1. The Ottawa Hospital, Ottawa, ON;
group education sessions led by the: Clinical Nurse Specialist, Speech Language Pathologist, 2. Institute for Clinical Evaluative Sciences, Toronto, ON; 3. Ontario Stroke Network,
Registered Dietitians, Physiotherapist, and Occupational Therapist. RN’s and CA’s were split Toronto, ON
e30  Stroke  December 2013
Background: In 2000, the Ontario Ministry of Health and Long-Term Care implemented a facilitates uptake of CVR programming, forming a bridge between clinic and community. Pa-
system of stroke care consisting of 11 Regional Stroke Networks. The goal was to improve tients are further referred to community services as needed. Results: The three year project
outcomes by reorganizing care to provide equitable access to evidence-based prevention established:
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 hospitaliza- •• a network of five hospital-based, NP-led SPCs;
tion and in-hospital mortality. Methods: Age and sex risk-adjusted annual admission and •• three new community based CVRPs;
in-hospital mortality rates reported in the Ontario Stroke Evaluation Report were compared •• increased capacity for clinician and patient education in chronic disease self-management
between 2003/04FY and 2010/11FY to estimate the number of stroke and transient isch- and
emic attack (TIA) hospital admissions and in-hospital deaths avoided during the 8-year •• community-based blood pressure screening clinics for high risk populations.
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 A 4% reduction in TIA admission rate was realized. Conclusion: This project received base fund-
hospitalization to 3 months were retrospectively estimated using BURST cost data and ing as of April 2012 becoming the Central LHIN Stroke Prevention Strategy.
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 P1.113
is equivalent to an estimated 3,779 fewer stroke/TIA hospital admissions in 2010/11FY A Large Community Hospital’s Multi-Disciplinary Approach to “Code Stroke”
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 Pawlowski, E; Hobbs, D; Halton Healthcare Services, Oakville, ON
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: Background: In the absence of a dedicated stroke response team, a large community hospital
During this 8-year period there were 16,000 fewer hospitalizations and 1,500 fewer in- in Oakville, Ontario identified the need to develop a process to expedite identification and treat-
hospital deaths observed than was expected for the Ontario population. Improvements in ment to improve outcomes in admitted patients suspected of experiencing an acute stroke.
patient outcomes and health system sustainability have coincided with the development Early identification and provision of therapies, where efficacy is clearly time dependent, can
of Regional Stroke Networks to implement evidence-based stroke prevention and care be achieved with a standardized process to elicit a coordinated team response. Methods: The
across Ontario. 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.
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P1.111
A Collaborative Regional Approach to Supporting Primary Care Providers in Results/Discussion: The experiences of the development, implementation and sustainment
Improving Vascular Health of a “code stroke” policy in this large community hospital will be discussed. Specific chal-
lenges and solutions related to nursing recognition of stroke, timely access to diagnostic testing,
Murphy, C1 Steacie, A8 Gordon, J2 Kerr, J3 Langley, H4 Martin, C1 McIntyre, M5 Moore, K6 physician response time and delivery of tPA will be highlighted. Conclusion: A “Code Stroke”
O’Leary, M7; 1. Stroke Network of Southeastern Ontario, Kingston General Hospital, Kingston, systemic approach to assessing, diagnosing and initiating care assists in eliminating the logisti-
ON; 2. Ontario Renal Network, Kingston, ON; 3. Belleville Queen’s Family Health Organization/ cal and human barriers that can affect the ability to deliver tPA in the absence of a dedicated
Family Health Team, Belleville, ON; 4. Southeast Regional Cancer Centre, Kingston General stroke response team.
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 P1.114
Canada Family Health Team, Brockville, ON Evidence-Informed Knowledge to Practice: Implementation of Stroke Best
Practices
Background: Southeastern Ontario (SEO) has higher than provincial rates for vascular dis-
ease risk factors. Members of a SEO Health Collaborative began innovative work in 2011 to Richardson, D1 Fortin, J2 Avinoam, G3 Skrabka, K4 Willems, J4 Sharp, S3 Linkewich, B2; 1.
support quality improvements in vascular health within primary care. The needs of primary Toronto Stroke Network, University Health Network, Toronto, ON; 2. North and East GTA Stroke
care providers in relation to improving vascular health were assessed and key priorities Network, Toronto, ON; 3. Toronto West Stroke Network, Toronto, ON; 4. Southeast Toronto
for action were identified. Opportunities to connect with new initiatives such as Ontario’s Stroke Network, Toronto, ON
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 ar- Background: The three Toronto Stroke Networks (TSNs) are comprised of 17 organizations and
eas. The findings were compiled into a report: “Vascular Health in Southeastern Ontario: therefore an uncountable number of healthcare professionals across the stroke care continuum.
A Focus on Primary Care”. The SEO Health Collaborative reviewed the findings and ranked The ‘Stroke Flow’ initiative provided a re-design of the stroke system, based on best practices.
the vascular health needs using a priority matrix. An action plan was developed to collab- Collaboration to enable the advancement of stroke care is a priority of the Greater Toronto Stroke
oratively begin to address key priorities. This plan included connecting with local Ontario Coordinating Committee (GTSCC), which provides overarching coordination and stewardship for
Health Links. Results: The ES and Think Tanks identified local primary care organizations the combined Toronto networks. Methods: Guided by the Graham’s Knowledge to Action Cycle
with well-functioning vascular health programs or services that could be shared. Common (KTA), armed with the results of the Stroke Flow project and a multipronged needs assessment
priority needs surfaced that informed the collaborative action plan. These included the need from practitioners in the networks, an Education and KT Implementation plan was developed to
for an integrated vascular health program within primary care, a common methodology for promote improved quality of care and outcomes for people with stroke. A key strategic action
continuous quality improvement, a mechanism to share successes across primary care or- towards implementation of Stroke Care Best Practice was the creation of an Education & Knowl-
ganizations and navigation tools to assist in linking to healthy living programs. Improved edge Translation (KT) Advisory. This team of invited experts in Education, Evaluation, KT and
use of the Electronic Medical Record was a mechanism frequently identified to help address Health Quality was tasked with enhancing systems collaboration and ensuring well-matched
these needs. Conclusion: The ES and Think Tanks provided direction for the development approaches in KT and QI. A cross system implementation committee (CSIC), comprised of invited
of a collaborative regional vascular health action plan with clear priorities. This provides the stroke champions from each organization provided grounding to their local context. Results:
SEO Health Collaborative and primary care organizations a framework for leading change The Education and KT advisory committee approved the Education and KT Implementation plan
across SEO. Mechanisms and opportunities to further improve vascular health continue to with strategic feedback to ensure evidence informed implementation. Key directives included
arise in relation to ongoing collaboration with Health Links and the Ontario Integrated Vas- sectioned roll out, iterative feedback and “member checking”, and engagement of front line
cular Health Coalition. providers. Monitoring of the roll out with flexibility was recommended to ensure realistic imple-
mentation 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
P1.112 checking has provided insight on the initial roll out of the TSNs Education and KT Implementation
From Project to Program: The Central LHIN Stroke Prevention Strategy plan. A structured evaluation will provide depth and direction on the actual value of the education
and KT implementation.
Murray, J; Mackenzie Health, Richmond Hill, ON

Background: Mackenzie Health is a District Stroke Centre providing cross-continuum stroke P1.115
services to York Region in Ontario A Stroke Prevention Clinic (SPC) was established in 2006, L’aquisition des connaissances après le suivi d’une formation spécialisée en
reducing the Transient Ischemic Attack (TIA) admission rate from 30% to 15%. In 2009, soins infirmiers aux personnes ayant subi un AVC, en Catalonge
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 Interdisciplin- Salvat-Plana, M1 Suñer, R3, 4, 2 Abilleira, S2 Gallofré, M2; 1. Pla Director Malaltia Vascular Cere-
ary and Community Approach to Emergency Diversion Through Stroke Prevention and Health bral. Catalan Stroke Programme, Barcelonne, Spain; 2. Stroke Programme, Health Department
Promotion. The purpose was to increase access to SPCs in the Central LHIN, reduce TIA of Catalonia (Plan Directeur des Maladies Cérébrovasculaires. Département de Santé de Cata-
admission rate as well as promote risk reduction and secondary stroke prevention. Method: logne), Barcelonne, Spain; 3. Faculté Sciences Infirmières. Université de Girona. Catalogne,
Aligned with the Ontario Framework for Chronic Disease Prevention and Management, the Girona, Spain; 4. Hospital Universitari Dr. Josep Trueta de Girona, Girona, Spain
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 Contexte : Depuis 2009, le groupe consultatif d’infirmières du Plan Directeur de Maladies céré-
recurrence rate for stroke. Once stabilized, SPC patients are referred to local Cardiovascular brovasculaires (PDMVC), en Catalogne, développe des stratégies pour améliorer la qualité des
Rehabilitation Programs (CVRP). Research demonstrates commonality in the risk factors for soins et services relatifs à l’accident vasculaire cérébral (AVC), comme la formation continue
stroke patients and cardiac patients as well as comparable outcomes . A Community Liaison aux infirmières. Le but de cette étude est de connaître l’effet d’un programme de formation
Abstracts From the 4th Canadian Stroke Congress, 2013  e31
portant sur les soins aux personnes ayant subi un AVC sur les connaissances des infirmières. •• Increasing capacity in the Rehabilitation Program through improving access and flow
Méthodologie : Un devis avant-après avec un seul groupe a été utilisé. Les infirmières ont suivi •• Reducing the cost of Rehabilitation services Conclusions: Efficient use of inpatient re-
un cours de 36 heures de formation sur les soins à donner aux personnes ayant subi un AVC. habilitation resources after stroke is supported by the availability of comprehensive and
Les connaissances ont été évaluées avant et après à l’aide d’un questionnaire développé par les coordinated outpatient rehabilitation. REDi is an effective model to facilitate early discharge
chercheurs (15 items, score 0-15 points). Les scores globaux entre les deux évaluations ont été to the community, increase access to rehabilitation, improve the efficiency of inpatient
comparés à l’aide des T-test et des chi-carré. Résultats : Une augmentation significative des rehabilitation, and support functional recoveryof appropriate stroke patients in an ambula-
connaissances des 35 (100%) participantes (p=0,000) a été observée entre l’évaluation initiale tory setting.
(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 connais-
sances de celles travaillant dans des unités conventionnelles de neurologie et de médecine VP.01
interne (moyenne: 10,2±1,2 vs 8,4±2,01). Les connaissances finales étaient similaires (p=0,1) Stroke Units in Ontario: The 2013 Ontario Stroke UNit (OSUN) Survey
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 Fan, I1 Ieraci, L1 Hall, R2 Kelloway, L3 van der Velde, G1 Rac, V1 Kapral, M4, 2 Bayley, M4 Krahn,
résultats du groupe qui ne travaille pas dans ces unités ont augmenté de 2,9 (1,7-4) points. M1; 1. THETACollaboroative, Toronto, ON; 2. ICES, Toronto , ON; 3. Ontario Stroke Network,
Aucune différence n’a été notée en ce qui concerne les années d’expérience. Conclusions : Une Toronto , ON; 4. UHN, Toronto , ON
augmentation significative des connaissances a été observée à la suite d’une formation spéci-
fique en soins de l’AVC. L’acquisition des connaissances est plus élevée chez les infirmières Patient admission to stroke units (SUs) is associated with lower morbidity and mortality. How-
travaillant dans les services moins spécialisés. ever, 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 improve-
P1.116 ment. The Ontario Stroke UNit (OSUN) questionnaire was administered as a telephone inter-
Engaging Rehab Providers in a discussion about Stroke Best Practices: The view with SU staff based on FY 2013. The survey determined Ontario SU characteristics, which
Edmonton Zone Rehab Summit 2012 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
Taralson, CL; Alberta Health Services Stroke Program Edmonton Zone, Edmonton, AB 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, examina-
Background: The Alberta Provincial Stroke Strategy (APSS) was mandated to advance stroke tion of the dedicated beds reported implied a different SU definition; some locations had no
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

prevention and care in Alberta. In December of 2010, APSS released an interim report, revealing dedicated beds reported. FTE information for stroke team resources was difficult to obtain.
areas of success and opportunities for improvement. The APSS Provincial Rehabilitation Coordi- Managers tended to include non-hospital staff (e.g. CCAC, district stroke coordinators, etc.) as
nator proposed a series of rehabilitation summits throughout the province, to encourage rehab “stroke team” resources creating discrepancies with the stroke team Canadian Stroke Strategy
providers to evaluate their practice in light of stroke best practices. Alberta Health Services (AHS) (CSS) criteria. Diagnostic equipment was often reported as being available irrespective of the
Edmonton Zone embarked on a day of review of Best Practice Recommendations. Participants corresponding location (i.e. equipment was on-site, or off-site). Meetings and staff education
from all stroke rehabilitation service delivery sites/programs across the care continuum were were difficult to document as meetings with patients varied case-by-case, or meetings were
invited to discuss opportunities for improving practice. Although coming from different practice held as hallway conversations (i.e. informal meetings). Education included both conferences and
experiences and settings, participants identified common challenges. Methods: An invitation to in-house talks, the frequency of which was difficult to determine. Ontario SUs have implemented
the Summit was disseminated throughout the zone, with particular focus on programs providing standard components of stroke care to varying degrees. Some SUs self-identify as a SU, how-
stroke services. Over 60 participants from a variety of professions and settings participated. ever, the characteristics of the stroke team and dedicated resources are different from the CSS’s
Keypad polling technology was used to allow participants to anonymously respond to how well criteria for establishing a SU. Greater standardization of necessary SU components is required.
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 VP.02
believed 13 of the 20 recommendations were regularly or consistently met in their area of The Use of an Audit-Feedback Loop to Address Adherence to Stroke Best Prac-
practice. The remaining 7 were predominantly “don’t meet” or “seldom meet”. Six projects tice Recommendations for Hypertension Management
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 Allen, L1 Janzen, SE1 Mehta, S1 Britt, E2 Meyer, M1 Teasell, R2; 1. Lawson Health Research
referral processes/criteria to access these programs”. Conclusions: Engaging care providers Institute, Parkwood Hospital, London, ON; 2. St.Josephs Healthcare, Parkwood Hospital,
in a face-to-face discussion increased awareness of available services and varying methods London, ON
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 Objective: This study aimed to improve blood pressure (BP) monitoring and the management
of this kind are being considered. 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
P1.117 was identified regarding the monitoring and management of hypertension. Guided by published
Rehabilitation Early Supported Discharge (REDi) - Improving the Rehabilitation knowledge translation principles, the research and rehabilitation teams collaborated on the de-
Service Model with Comprehensive and Coordinated Outpatient Services velopment and implementation of a hypertension strategy. Clinical uptake of the strategy was
evaluated 6-months post-implementation through a second chart audit of consecutive admis-
Parsons, J; Vance, S; Ng, V; Just, E; Doull, K; Dawson, A; Strategy, F; Fraser Health, Surrey, BC sions from May to November 2012. Abstracted information included: BP readings, leaves of
absence, and anti-hypertensive medications administered. Results: 120 charts were initially
Background: Access to rehabilitation services after stroke is a key component of promoting reviewed, and 124 in the evaluation audit. Overall, the mean number of days without BP be-
functional recovery. Best practice indicates a continuum of care is most appropriate, including ing taken/ recorded decreased significantly (p=0.0128) from the initial audit (M=4.9; 1-38,
inpatient, early supported discharge and outpatient services designed to meet care needs in SD=4.74) to the second audit (M=1.27; 1-2, SD=0.47). The proportion of patients, for the initial
the least restrictive setting and promote optimal functional recovery. Fraser Health staff identi- and evaluation audits, experiencing ≥1 hypertensive day was 73.3% and 87.15%, respectively.
fied that stroke survivors utilized inpatient rehabilitation services longer than necessary due to Of those who had at least one hypertensive day, 52.3% in the initial audit had ≥1 untreated day,
limited availability, delayed access, and lack of coordinated outpatient services. Methods: The and 44.4% of patients in the follow-up. However, there was no significant difference (p=0.0708)
REDi pilot aimed to shift the rehabilitation care delivery model to support early discharge and in the mean number of untreated days between baseline (M=4.43, SD=3.83) and post-imple-
functional recovery across the continuum. Using a logic model to design service delivery, the mentation (M=6.83; SD=8.07). Conclusion: Through the identification of an evidence-practice
REDi pilot was implemented in June 2011 and included: 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
1. A screening and referral process to promote early identification of inpatients that were establishing the value of, and expectation to, provide evidence-based care on the stroke unit.
appropriate for an early supported discharge program.
2. A Service Coordinator to support and facilitate transitions between rehabilitation settings.
3. A capacity expansion of comprehensive outpatient rehabilitation services with access to P2.001
a multidisciplinary team of Allied Health staff. Results: Evaluation of the service delivery Dynamic Characterization of CT Angiographic ‘Spot Sign’ in Intracerebral Hemor-
revealed that all intended outcomes identified in the logic model were achieved. rhage

Chakraborty, S1 Alhazzaa, M1 Wasserman, J1 Stotts, G1 Demchuk, A2 Aviv, RI3 Dowlatshahi,


Client benefits included: D1; 1. Universitty of Ottawa, Ottawa, ON; 2. University of Calgary, Calgary, AB; 3. University of
Toronto, Toronto, ON
•• Equal or greater functional improvements
•• More timely access to Rehabilitation Services Background and purpose: Static CT angiography is usually used to identify the intracerebral
•• Improved access to frequent, intensive, interdisciplinary outpatient therapy hemorrhage (ICH) spot sign. We used dynamic CT-angiography to describe spot sign character-
•• Reduced length of stay in an inpatient rehabilitation setting istics and measurement parameters over 60-seconds of image acquisition. Methods: We pro-
•• Reduction of impairment and prevention of disability, including the need for future care spectively collected consecutive patients with acute ICH presenting within 6 hours of symptom
and system resources. onset who underwent whole brain dynamic CT-angiography (dCTA). Spot parameters (earliest
•• System benefits include: appearance, duration, Maximum Hounsfield unit (HU), time to maximum HU, time to spot diag-
e32  Stroke  December 2013
nosis (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 forma-
tion during acute ICH; this is the first study to quantitatively describe spot sign formation and
morphology using dCTA.

P2.002
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
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

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 Background: Stentrievers can establish immediate by-pass effect by delivering blood to the isch-
2012. We dichotomized the patients into two groups based on intervention as: stent-retriever emic tissue once the stent is deployed. A potential factor that may introduce delays in achieving a
(group 1) and non-stent-retriever (group 2). Demographic and radiological characteristics and short imaging to first stentriever deployment time is the timing of the intervention. Method: This
clinical outcome were presented. A good outcome was defined as a 30-day modified Rankin is a longitudinal cohort of acute ischemic stroke patients treated with endovascular therapy in our
score < 2 or 10-point decrease in NIHSS. Symptomatic intracranial hemorrhage (ECASS-III defi- center between Jan 2011 to Dec 212. The imaging to first stentriever deployment time was defined
nition) and 30 days mortality were reported. Result: Twenty-three patients treated with stent- as the time from the completion of CT angiogram to the first angiographic run that shows that
retrievers were compared to 37 cases received other modalities (Penumbra, MERCI, angioplasty, the stentriever has been deployed in the target occluded artery. This time interval was compared
or intra-arterial tPA;either alone or in combination). There was a higher baseline median NIHSS between patients treated during the daytime hours (0700-1800 hours) vs. outside these hours.
score in the stent-retriever group (18 versus 16, p = 0.034). Overall, there were higher re- Results: 99 patients were analysed. The median imaging to first stentriever deployment time was
canalization rates in group 1 (87% vs. 51% in group 2, p = 0.005). Use of stent-retriever was 86 minutes (80.5 minutes during the daytime vs. 97 minutes outside these hours; U-test p value
associated with good 30 days mRS (78% vs. 43%, p = 0.008), lower mortality (4% vs. 32%, 0.038). The proportion of patients treated during daytime hours with imaging to first stentriever
p=0.011) and no symptomatic hemorrhages. Among patients with carotid “T” occlusions (52% deployment time < 120 minutes was 86% compared to 65.8% outside these hours (Chi-square p
in group 1 vs. 30% in group 2), stent retriever demonstrated higher recanalization rates (83% 0.02). The proportion of patients with successful reperfusion (TICI 2b or 3) treated during the daytime
vs. 38%, p=0.0123), favorable clinical outcomes (67% vs. 22%, p=0.036) and shorter time to was 76.7% compared to 76.9% outside daytime hours. The proportion with a favourable discharge
recanalization (69 vs. 191 minutes, p=0.0023). Conclusion: In this small cohort, using stent- modified Rankin Scale (mRS <3) in those with an imaging to first stentriever deployment time < 120
retriever offered better recanalization rate and clinical outcome with remarkable safety profile in minutes was 68% vs. 44% in those who did not meet that time (Chi-square p 0.018). Conclusions:
acute carotid “T” occlusions when compared to previous multimodal therapy. 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.

P2.003
Not All Successful Reperfusion PatiNot All Successful Reperfusion Patients Are P2.005
Equal: The Need for a TICI2c Scoreents Are Equal: The Need for a TICI2c Score A ‘Reduce-To-Quit’ Pilot Program for Smokers with Cerebrovascular Disease:
Transitioning Smokers to Set a Quit Date
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, Armstrong, A1 Reid, R1 Sharma, M2 Stotts, G2 Aitken, D1 Mullen, K1 Papadakis, S1 Gocan, S2
Saudi Arabia Bourgoin, A2 Laplante, M2 Houbraken, D2 Pipe, AL1; 1. University of Ottawa Heart Institute,
Ottawa, ON; 2. The Ottawa Hospital, Ottawa, ON
Objective: Many recent endovascular studies have used the TICI grading system for evaluating
Background: Smoking cessation is a life-saving intervention for patients with cerebrovascular
angiographic outcomes and have used TICI 2B and 3 for successful recanalization as long as
disease, however, only 35% of smokers with TIA or stroke are ready to make a quit attempt after
the final perfusion defect was < 50% of the MCA territory. We propose a new scoring system
their event. The aim of this review was to assess whether reducing daily cigarette consumption
that separates successful but incomplete reperfusion into 2 categories taking into account
leads to a quit attempt in those smokers who are not ready to quit. Methods: The Stroke Preven-
the size of the reperfusion defect. Methods: This is a longitudinal cohort including of anterior
tion Clinic (SPC) ‘reduce-to-quit’ (RTQ) pilot program offers smokers who have experienced a
circulation stroke patients treated using intra-arterial stentrievers in our center between Jan
stroke or TIA, and who are not ready to quit, a 4-week supply of nicotine replacement therapy
2011 to Dec 2012. Failed reperfusion was defined as per the standard TICI score (TICI 0-2a). (NRT) patch. Since December 2009, 181 smokers with stroke or TIA attending the SPC were
Successful reperfusion was defined as 2b: substantial perfusion with distal branch filling of ≥ not willing to set a quit date; 49 (27%) were willing to participate in the RTQ program. Results:
50% of territory visualized, 2c: near complete perfusion except for slow flow in a few distal Forty-nine individuals participating in the RTQ program were included in the current review (48%
cortical vessels, or presence of small distal cortical emboli, 3: complete perfusion with nor- male, mean age = 59.5 +/- 10.6). The average number of cigarettes smoked per day was 23.5
mal filling of all distal branches. Angiograms were scored by a single reviewer blinded of the +/-11.9. Eight-two percent of smokers in the program reduced the number of cigarettes they
patients’ outcomes. Results: In a cohort of 101 patients, 78 achieved successful reperfusion were smoking per day, the average smoker in the program reduced daily consumption by 13.2
(77.2%). The results of patients with successful reperfusion is presented according to the cigarettes (SD +/- 9.7). Overall, 15 smokers (30%) in the RTQ program set a quit date at one
reperfusion score (Table). The proportion of patients who had significant improvement of their month follow up, with those who had reduced cigarette consumption becoming “ready-to-quit”
clinical deficits in 24 hours (24-hour NIHSS score drop by 75%) was significantly higher with at a higher rate (33%) then those smokers who did not reduce their cigarette consumption
TICI2c reperfusion than those with TICI2b (50% vs. 24%, Fisher’s exact p 0.04). Conclusions: (22%). Of those RTQ patients who set a quit date, the abstinence rates (bio-chemically con-
Categorizing successful but incomplete reperfusion into 2 different classes according to the firmed) for those reached at follow-up were 25% and 38% at 6 and 12 months respectively.
area of perfusion defect has merits. In this cohort, there was evidence toward different short- Conclusions: The results from the RTQ pilot program suggest that offering treatment to smok-
term clinical and imaging outcomes in patients with TICI2b vs. TICI2c scores. These findings ers who are not ready to quit can lead to an increase in quit attempts as well as 6 and 12 month
need to be validated in larger cohorts. cessation success in this population.

P2.004 P2.006
Imaging-to- Stent deployment Time Interval Is Shorter during Daytime Hours’ Vs. Protocole d’interventions visant le dépistage et la prise en charge de
Evening Times in Endovascular Therapy for Acute Ischemic Stroke l’incontinence urinaire auprès de la clientèle ayant subi un AVC
Almekhlafi, MA; Desai, J; Nambiar, V; Mishra, S; Volny, O; Eesa, M; Demchuk, AM; Menon, BK; Balg, C1 Mathieu, S1 Rousseau, G1 Dallaire, M1 Dallaire, C2; 1. CHU de Québec - Hôpital Enfant-
Goyal, M; University of Calgary, Calgary, AB Jésus, Québec, QC; 2. Faculté des sciences infirmières - Université Laval, Québec, QC
Abstracts From the 4th Canadian Stroke Congress, 2013  e33
Problématique : Une proportion importante des patients ayant subi un AVC présente de Dowlatshahi, D1 Brouwers, B2 Demchuk, A3 Hill, M3 Aviv, R4 Ufholz, L1 Wintermark, M5 Hemphil
l’incontinence urinaire (40-60%) et près de 25% d’entre eux le seront encore lors du congé III, J6 Murai, Y7 Wang, Y8 Zhao, X8 Wang, Y8 Li, N8 Greenberg, S2 Romero, J2 Rosand, J2
de l’hôpital (Barrett, 2001, Cochrane, 2009). Le temps d’attente afin de recevoir l’aide requise Goldstein, J2 Sharma, M9; 1. University of Ottawa & Ottawa Hospital Research Institute, Ottawa,
et la crainte de ne pas pouvoir se retenir motivent certains patients à demander d’avoir une ON; 2. Massachusetts General Hospital, Boston, MA, USA; 3. University of Calgary, Calgary,
culotte d’incontinence alors que ce n’est pas requis (Pilcher & McArthur, 2012). Les recom- AB; 4. University of Toronto, Toronto, ON; 5. University of Virginia, Virgina, USA; 6. UCSF, San
mandations pour les pratiques optimales des soins de l’AVC (2010) préconisent par ailleurs le Francisco, CA, USA; 7. Nippon Medical School, Tokyo, Japan; 8. Capital Medical University,
dépistage et la prise en charge de l’incontinence (incluant la rétention urinaire) afin de prévenir Beijing, China; 9. Population Health Research Institute, Hamilton, ON
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 (in- Background: Hematoma expansion (HE) occurs in up to 40% of patients with intracerebral
firmières, infirmières-auxiliaires, préposés aux bénéficiaires), d’une entrevue de patients ayant hemorrhage (ICH), and predicts poor outcome. Contrast extravasation following CT-angiography
subi un AVC et vécu une expérience d’incontinence urinaire. Également, une revue succincte (CTA), termed “spot-sign”, identifies patients at risk of HE. However, the prevalence and predic-
de la littérature sera effectuée. Un devis de recherche d’interventions sera utilisé (Sidani et al., tive values of the spot sign varies across studies, possibly due to differences in onset-to-CTA
2012). Résultats : L’expérience tacite du personnel, les besoins de la clientèle et la revue de time. We performed a patient-level meta-analysis to define the relationship between onset-to-
littérature ont permis d’établir un protocole d’interventions applicable au contexte de pratique. CTA time and the predictive performance of spot-sign. Methods: We searched the Cochrane
Les résultats seront présentés de façon préliminaire. Conclusion : Cette démarche a un effet Central Register, the Cochrane Library Database, MEDLINE and EMBASE for studies of spot sign.
mobilisateur auprès du personnel soignant, et améliore la qualité des soins. 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
P2.007 1240 studies reviewed, 9 met criteria for analysis: we have received patient-level ICH spot-sign
Secular Trends in Ischemic Stroke Subtypes data from 8 countries and 16 centers (n=705). Prevalence of spot-sign decreased with increas-
ing onset-to-CTA time (p<0.001). The subset with follow-up scans used for HE analysis (n=582)
Bogiatzi, C1 Hackam, DG1 McLeod, I2 Spence, JD1; 1. Robarts Research Institute, Stroke revealed spot-sign performance was best in early time strata, whereas specificity and NPV were
Prevention and Atherosclerosis Research Center (SPARC), London, ON; 2. Western University, highest in late time strata. Spot-positive patients had greatest absolute HE in the earlier CTA
Department of Statistical and Actuarial Sciences, London, ON time strata (p<0.001). Conclusion: Prevalence, predictive values and magnitude of effect of the
spot-sign are dependent on onset-to-CTA timing.
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
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

over time. Limited information exists on the distribution of ischemic stroke subtypes in Canada. ICH
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
onset Mean
subtype classification was validated. Results: 3445 consecutive patients with mean age+SD to CTA Spot HE (mL)
of 64.76+14.9 were included; 51% were women, 81% had hypertension; 18% had diabetes; time N prevalence N Sensitivity Specificity PPV NPV spot +
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 <3 268 41.8% 236 60% 73% 61% 72% 23.5
other ischemic stroke subtypes decreased (p<0.01). Additional analyses showed a decrease in hours
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 3-6 219 19.6% 172 43% 90% 52% 86% 16.6
fewer strokes caused by large artery atherosclerosis and small vessel disease. Cardioembolic hours
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 recur- >6 218 13.8% 174 44% 93% 52% 91% 9.5
rent embolic stroke. hours

P2.009
[18F]-fluorodeoxyglucose, but not C-reactive Protein, is Related to Intraplaque P2.011
Inflammatory Burden in Human Carotid Plaque: A Sub-study of the Canadian Hypertensive Disorders in Pregnancy and Future Risk of Stroke: A Systematic
Atherosclerosis Imaging Network (CAIN) Review

Cocker, MS1 Mc Ardle, B1 Hammond, R2 deKemp, R1 Lum, C3 Youssef, G1 Yerofeyeva, Y4 Ganesh, A; Sarna, N; Mehta, R; Smith, E; University of Calgary, Calgary, AB
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; Background: Many risk factors are currently targeted in the primary prevention of stroke; how-
1. University of Ottawa Heart Institute, Ottawa, ON; 2. Western University, London, ON; ever, the role hypertensive disorders in pregnancy in predicting future stroke risk has yet to be
3. The Ottawa Hospital, Ottawa, ON; 4. Sunnybrook Research Institute , Toronto, ON; elucidated. Currently women are monitored throughout pregnancy for changes in blood pres-
5. Montreal Heart Institute, Montreal, QC; 6. Robarts Research Institute, London, ON sure, but no specific recommendations have been made regarding stroke-related screening or
preventative measures postpartum. In this regard, we conducted a systematic review to as-
Background: Inflammation underlies the development and progression of atherosclerotic sess whether women with a history of hypertension in pregnancy are more likely to experience
plaque. An actively inflamed plaque is considered to be a ‘vulnerable’ high-risk, rupture-prone stroke in later life compared to women with normotensive pregnancies. Methods: The electronic
lesion. It is imperative to develop surrogate biomarkers that enable for the early detection of dis- databases Medline and Pubmed were searched combining the MeSH terms “hypertension,
ease. C-reactive protein (CRP) is a marker of systemic inflammation and a risk factor associated pregnancy-induced”, “pre-eclampsia”,”eclampsia”, “HELLP syndrome”, or “toxemia” with the
with cardiovascular events. Alternatively, radiolabelled glucose or -fluorodeoxyglucose (18FDG) terms “Stroke” or “stroke, lacunar” using the AND modifier, with all terms auto-exploded, while
imaged with hybrid positron emission tomography (PET) and computed tomography (CT) may clinical trials registries and conference proceedings were similarly searched for unpublished
serve as an imaging-derived biomarker of inflammatory burden within plaque. In this investi- studies. This generated a total of 90 results in Medline and 172 results in Pubmed, of which 9
gation, we directly compared systemic CRP and 18FDG carotid uptake to intraplaque inflam- studies (2 prospective cohort, 4 retrospective cohort, 3 case-control) met inclusion criteria of
matory burden using CD68 immunohistology. Methods: Thirty-four patients (67±10 years, 27 involving women with hypertensive disorders in pregnancy; involving a prospective follow-up,
male) scheduled for carotid endarterectomy were prospectively recruited. Patients underwent retrospective review of records, or a case-control design; and reporting stroke as a clinical
FDG-PET and CT angiography of carotids. Prior to imaging, blood was collected for the assess- outcome. Results: There is consistent case-control and retrospective cohort evidence, both
ment of CRP. Maximum 18FDG uptake at the left and right internal carotids was quantified international and multi-racial, of an increased risk of stroke and of mortality from stroke in
and normalized to blood, resulting in a tissue to blood ratio (TBR). Following endarterectomy, women with hypertensive disorders of pregnancy, in particular for those with pre-eclampsia/
excised plaque was fixed, sectioned and immunostained for CD68. CD68 expression was quan- eclampsia, as demonstrated by both prospective cohort studies. There is weaker evidence of
tified semi-automatically. Results: Carotid endarterectomy was performed in 34 patients; one an increased incidence of stroke in later life with gestational hypertension alone. Conclusions:
patient received a 2nd carotid endarterectomy due to bilateral disease. Immunohistology was Hypertension in pregnancy likely carries an increased risk for stroke in later life, but the risk is
performed in 23 excised plaques. The extent of inflammation, as quantified with CD68 immu- much more significant for gestational hypertension associated with pre-eclampsia/eclampsia.
nohistology, was related to maximum 18FDG uptake (r=0.636, p=0.001). However, there was There may be benefit in targeting these women for close risk-factor monitoring and control
no association between CD68 expression and CRP (r=0.190, p=0.42). Furthermore, CRP was beyond the post-partum period.
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 in-
flammatory burden within high-risk carotid plaque. However, CRP may not be useful for detect- P2.012
ing vulnerable carotid plaque (based on histopathology and 18FDG uptake). Large prospective Effect of Chronic Resveratrol Pretreatment on Astroglial GFAP/GLT-1 Expression
outcomes-based studies are required. 18FDG may serve as a robust and direct biomarker of Following Global Cerebral Ischemia
carotid plaque vulnerability.
Girbovan, C; Pitre d’Iorio, M; Plamondon, H; University of Ottawa, Ottawa, ON

P2.010 Background: Perisynaptic astrocytes express important glutamate transporters, especially


The Predictive Ability of the CTA Spot for Hematoma Enlargement is Dependent GLT-1 to regulate extracellular glutamate levels and modulate synaptic activation. Evidence is
on Time Since ICH Onset: a Systematic Review and Patient-Level Meta-Analysis now accumulating that astrocytes play an active role in the pathophysiology of cerebral ischemia
e34  Stroke  December 2013
and that down-regulation of astroglial GLT-1 expression in the CA1 subfield of the hippocampus intervention follow-up. Testing measures include: 1) anthropometric characteristics; 2) cardiore-
may contribute to neurotoxic levels of glutamate post ischemia. Resveratrol (RSV), a naturally spiratory fitness test (VO2max); 3) fasting blood sample; 4) neuropsychological test battery; and
occurring polyphenol phytoalexin mainly found in grapes, has been shown to protect the brain 5) assessment of cerebrovascular reserve using transcranial Doppler ultrasound. All tests are
against ischemic injury. While a number of mechanisms of action of RSV in preventing neuronal conducted upon entry of the study (Phase 1A), 6-months following the first measurements for
damage have been proposed, it remains to be determined if the polyphenol affects astroglial second baseline measurements (Phase 1B), at the midpoint (3 months) and end of the aerobic
GLT-1 expression following an ischemic insult. The present study examined the effects of 21- exercise intervention, and finally 6-months following the completion of the aerobic exercise
day RSV pre-treatment (1 or 10mg/kg dose; i.p.) on GFAP and GLT-1 expression in the DG, CA1 intervention for the follow-up assessment. Results: Currently 162 participants are actively en-
and CA3 layers of the hippocampus 7 days following 10 min global ischemia. Methods: Male rolled in the study. Of these participants, 52 are in the baseline control phase, 55 are in the
Wistar rats were divided into five groups; sham/saline, ischemia/saline, ischemia /1 mg/kg RSV, aerobic exercise intervention, and 55 are in the follow-up phase or have completed the study.
ischemia/10 mg/kg RSV and sham/10 mg/kg RSV. 7 days post surgery, brains were perfused Conclusion: To our knowledge, this is the first study to investigate the effects of a six-month
and GFAP and GLT-1 immunohistochemical assessment performed. Results: Our findings indi- aerobic exercise intervention on cerebrovascular and cognitive function in a healthy older popu-
cated significant increase in GFAP expression in ischemic compared to sham-operated animals lation. The results of this study will provide physiologic mechanisms whereby exercise promotes
and a reduction in GFAP activation by RSV-treated rats in the CA1. Accordingly, ischemic rats benefits to cognitive function. In addition, the study may also promote the development of ad-
showed a downregulation of GLT-1 expression compared to sham-operated rats in the CA1, junct therapies to reduce the cognitive decline accompanied by normal brain aging.
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 P2.015
cerebral ischemia. 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
P2.013
Underuse of Cardiac Rhythm Monitoring After Ischemic Stroke and TIA: Missed Early therapeutic intervention post TIA (pharmacological, diagnostic, surgical) has been proven
Opportunities for Detection and Treatment of Atrial Fibrillation 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
Gladstone, DJ1 Fang, J2 Dorian, P3 Hachinski, V4 Mamdani, MM3 Laupacis, A3 Lindsay, M5 intervention by a stroke team member within 24 hours post TIA symptoms. This new program
E­ dwards, JD1 Spring, M6 Saposnik, G1 Silver, FL1 Kapral, M7 On behalf of the Investigators of will result in improved patient outcomes and decreased readmission to hospital. The new clinic
the Registry of the Canadian Stroke Network; 1. University of Toronto, Toronto, ON; protocol, devised in April 2010 resulted from a review of the Canadian Best Practice Recom-
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

2. Institute for Clinical Evaluative Sciences, Toronto, ON; 3. St. Michael’s Hospital, Toronto, ON; mendations for Stroke Prevention by the Stroke Team (District Stroke Coordinator, Neurologist,
4. University of Western Ontario, London, ON; 5. Heart and Stroke Foundation, Ottawa, ON; Acute Care Stroke NP and Stroke Prevention NP). The Stroke Team reviewed “Time from Referral
6. Institutional Affiliation: Trillium Health Centre, Mississauga, ON; 7. University Health Network to Initial Consult” and wait times averaged 14 days. With Canadian Best Practice Recommenda-
and Institute for Clinical Evaluative Sciences, Toronto, ON tions 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
Background: Detection and treatment of atrial fibrillation (AF) is a major goal in secondary referred to the Rapid Referral Program. Three key criteria must be met to be considered for
stroke prevention, but it is unclear how intensively ischemic stroke/TIA patients are screened for Rapid Referral: speech disturbance, unilateral weakness and symptoms occurring in the last 24
paroxysmal AF in practice. Guidelines recommend cardiac monitoring post-stroke, and current hours. Since the implementation of the Rapid Referral, 76.6% of urgent and emergent patients
evidence indicates that monitoring for substantially longer than 24h is often necessary to detect are seen within the recommended guidelines of 24 hrs and 72 hours respectively (1). Practice
paroxysmal AF. This provincial audit evaluated the type and duration of monitoring provided change based on Canadian Best Practice Recommendations for Stroke Prevention has allowed
post-stroke/TIA as a quality indicator for secondary stroke prevention. Methods: We analyzed the Niagara Health System to become a leader in preventative stroke care. As evidenced by
data from Ontario stroke centres in the Registry of the Canadian Stroke Network (07/2003- the Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention and Care
03/2009). We included consecutive patients presenting to hospital with a first acute arterial released in June 2013, Niagara Health System’s District Stroke Prevention Clinic is the high
ischemic stroke or TIA in sinus rhythm who were candidates for AF screening: no history of AF, performer for proportion of emergent and urgent SPC visits where the patient was seen within
no AF documented in hospital, no pacemaker, survival to discharge home or inpatient rehabilita- recommended guidelines. The concept of the Rapid Referral is a proven strategy to reduce wait
tion (discharges to nursing homes/palliative care excluded). Cardiac monitoring was captured times thereby improving quality of care.
through database linkages (Ontario Health Insurance Plan). Primary outcomes were the pro-
portion 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 P2.017
hospital; median LOS 3d ), 3213/11,153 (29%) received Holter monitoring within 90 days post- Accuracy of ICD-10-CA Codes to Identify Paediatric Stroke
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 Maclagan, L1 Khan, F1 Pontigon, A1 Kapral, M2 Hall, R2 deVeber, G1; 1. Hospital for Sick
was prescribed in 64/11,153 (0.6%). Subgroup results for TIA patients and elderly (aged >75 ­Children, Toronto, ON; 2. Institute for Clinical Evaluative Sciences, Toronto, ON
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 Background: The 2012 Ontario Stroke Evaluation Report estimates a paediatric stroke inci-
performed was limited to 24h, with very few patients undergoing prolonged monitoring. These dence of 5.9 per 100,000 population under the age of 18 in Ontario. Using the results of the
results may contribute to an overdiagnosis of stroke events as ‘cryptogenic’, an underdiagnosis 2010/11 OSA as the gold standard we determined the accuracy and yield of ICD-10-CA codes
of AF, and missed anticoagulant treatment opportunities for secondary stroke prevention. for paediatric stroke to characterize the process for identifying paediatric strokes using admin-
istrative 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
P2.014 Update and additional codes identified by a paediatric stroke neurologist. Cases were identified
The Brain in Motion Study: Progress Report 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 abstrac-
Tyndall, AV1, 2 Davenport, MH1 Wilson, BJ1 Burek, GM1, 2 Haley, E1, 2 Eskes, GA4 Friedenreich, tors reviewed the medical charts of the cases and determined if it was a true stroke/TIA based
CM5, 6, 7 Hill, MD2, 2 Hogan, DB9, 8, 2 Longman, R10, 2 Anderson, TJ11 Leigh, R1, 3, 12 Smith, EE8, 13, 2 on information in the medical chart. The overall and individual ICD-10-CA codes accuracy was
Poulin, MJ1, 7, 2; 1. Department of Physiology & Pharmacology, Faculty of Medicine, University of defined as the proportion of cases that were a true stroke upon chart review among all cases
Calgary, Calgary, AB; 2. Hotchkiss Brain Institute, University of Calgary, Calgary, AB; 3. Depart- selected for inclusion into the OSA. We calculated a yield for each ICD-10-CA code and yield
ment of Medicine, University of Calgary, Calgary, AB; 4. Departments of Psychiatry, Medicine was defined as the percentage of total true strokes captured by a specific code. Results: In
(Neurology), and Psychology, Dalhousie University, Halifax, NS; 5. Department of Popula- FY2010/11, 479 potential paediatric stroke/TIA cases were identified in CIHI-DAD or NACRS and
tion Health Research, Alberta Health Services-Cancer Care, Calgary, AB; 6. Departments of 136 (28%) were considered to be true strokes/TIAs. Accuracy rates of stroke-specific codes
Oncology and Community Health Services, Faculty of Medicine, University of Calgary, Calgary, ranged from 6.7 - 76.6% and yield ranged from 1.8% - 29.5%; highest accuracy and yield was
AB; 7. Faculty of Kinesiology, Calgary, AB; 8. Department of Clinical Neurosciences, Faculty achieved using I63. Non-specific codes ranged widely from 0-66.7% accuracy and 0-10.2%
of Medicine, University of Calgary, Calgary, AB; 9. Professor and Brenda Stafford Founda- yield. Conclusion: The accuracy and yield of ICD-10-CA codes in paediatric stroke is low and
tion Chair in Geriatric Medicine, Faculty of medicine, University of Calgary, Calgary, AB; 10. underlines the need for prospective data collection. Further work will explore other ICD-10-CA
Psychology, Alberta Health Services, Foothills Hospital, Calgary, AB; 11. Libin Cardiovascular codes or processes that may improve the identification of paediatric stroke using administrative
Institute of Alberta, Department of Cardiac Sciences, Calgary, AB; 12. Airway Inflammation databases.
Research Group, Snyder Institute for Chronic Diseases, Faculty of Medicine, University of Cal-
gary, Calgary, AB; 13. Departments of Radiology and Community Health Sciences, University of
Calgary, Calgary, AB P2.018
Stroke in Saskatchewan: A Regional Sample
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 Kwiatkowski, BM1 Bharadwaj, L2; 1. Royal University Hospital, Saskatoon, SK; 2. University of
a well-accepted modifiable risk factor for cerebrovascular disease and the decline in cognitive Saskatchewan, Saskatoon, SK
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 The latest evidence indicates that 50,000 Canadians will experience a stroke in 2013. The asso-
cerebrovascular function. Methods: 250 men and women aged 55 years and older are being ciated hospital, rehabilitation, and long term care of stroke patients place a significant burden on
recruited through poster, newspaper and media advertisements. The 18 month study consists our health care system. National statistics have been utilized in the development of guidelines to
of three 6-month phases: 1) baseline control; 2) aerobic exercise intervention; and 3) post- improve care and reduce the impact of stroke. Small less populated regions, such as Saskatch-
Abstracts From the 4th Canadian Stroke Congress, 2013  e35
ewan, may be underrepresented in national data utilized in the development of stroke prevention endocarditis (NBTE) and putatively arterial embolic disease (AED). The incidence of stroke as
and treatment strategies. A retrospective descriptive chart review was conducted to provide a the first presentation of occult malignancy is exceedingly rare, ranging from 0.4-3.0% (ischemic
profile of stroke and transient ischemic attack cases admitted to Royal University Hospital, re- stroke population). We present three such cases from our stroke unit that we have encountered
gional stroke centre for central and northern Saskatchewan, to determine similarity or difference within the past 12 months and discuss possible consequences for diagnostic procedures. Meth-
to national statistics and to assess the acute management of these cases as defined in the Cana- ods: A retrospective chart review was performed for all three cases that were diagnosed with
dian Best Practice Recommendations for Stroke Care (Canadian Stroke Network and Heart and solid tumor, occult malignancies in the setting of first acute embolic CVA. These cases were
Stroke Foundation of Canada, 2011). A randomized sample of 200 cases was selected for review then compared and contrasted to the available literature both on this specific subject and on
of adult stroke case records on personal demographics and healthcare performance through the the subject of stroke and malignancy in general. Results: According to the literature regarding
use of the measures provided in the guidelines. Similarities in the study results and national OMPS, the most common solid tumor primary site is pulmonary (30%) followed by colorectal
information on the type of stroke, risk factors, gender, and age were found. Other findings (15%), with adenocarcinoma being the most frequent histopathology. Equally, the most common
included rural inequality in access to treatment and an apparent underutilization of medications etiology of OMPS is NBTE followed by DIC; AED has not been clearly reported. Reported median
for the treatment of risk factors. There were no cases from remote regions that arrived within the survival was 4.5 months. Two of our cases had confirmed adenocarcinoma of the lung (one did
window for thrombolytic therapy. Hospital adherence to national guidelines comparing selected not undergo biopsy), one patient presented with NBTE whereas the other two had neither NBTE
indicators was met in most areas and exceeded in some. The remaining indicators provide an nor DIC and were presumed to represent AED. Two of the patients died within 6 weeks of diag-
opportunity for improvement and possibly more research. This regional information supplements nosis and had recurrent embolic events on antiplatelets/unfractionated heparin. One patient who
the available Canadian information and could be used to guide planning and care strategically survived beyond median survival time, responded to single antiplatelet therapy. Conclusions:
targeting Saskatchewan residents and increasing their potential for success. 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
P2.019 efficacy of antiplatelet and anticoagulation therapy in this population.
I Saw the Sign: Improving Stroke Awareness in Canada

LeGrand, C; Arango, M; Joiner, I; Heart and Stroke Foundation of Canada, Ottawa, ON P2.023
Degree of Ischemic Vasculopathy in Lateral Cholinergic Projections is Associated
Background: Stroke is a leading cause of death and disability in Canada. About 50,000 strokes with Set-Shifting Executive Dysfunction in Post-Stroke Cognitive Impairment
occur each year and over 315,000 Canadians are living with the effects of stroke. Early identifi-
cation of stroke signs and action to obtain immediate medical attention are critical to achieving 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,
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the best possible outcomes for those experiencing stroke. The Heart and Stroke Foundation 3
Scott, CJ1, 2, 3 Zhao, J1, 2, 3 Ramirez, J2, 1, 3 Graham, SJ2 Rangwala, N5 Marola, J5 Stebbins,
(HSF) has led the development and implementation of stroke public awareness campaigns GT6 Gibson, E1, 2 Lobaugh, NJ2 Stuss, DT1, 7 Nyenhuis, DL5 Kang, Y9, 8 Black, SE4, 3, 2; 1. Brain
in Canada. Despite efforts, research indicates that public knowledge of stroke signs remains Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto,
sub-optimal and that Canada lags behind other countries. While there are many contributing ON; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences
elements to successful recall and recognition, messaging is critical to an effective awareness Centre, University of Toronto, Toronto, ON; 3. L.C. Campbell Cognitive Neurology Research
campaign. Methods: A one-day meeting was convened to provide feedback to existing stroke Unit, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON; 4. Department of
signs campaigns. Meeting participants represented a broad cross-section of HSF staff, clini- Medicine, Division of Neurology, University of Toronto , Toronto, ON; 5. Hauenstein Neurosci-
cians/neurologists, cognitive, behavioural, communications and marketing experts from across ence Centre, Saint Mary’s Health Care, Grand Rapids, MI, USA; 6. Rush University Medical Cen-
Canada. Participants evaluated three stroke signs campaigns - ‘Suddens’ (Canada), Give Me 5 tre, Chicago, IL, USA; 7. Rotman Research Institute, Baycrest, University of Toronto, Toronto,
for Stroke (US) and F.A.S.T. (UK and Australia) - through a series of table exercises and large ON; 8. Department of Psychology, Hallym University, Seoul, Korea; 9. Department of Neurology,
group dialogue. Results: Research and clinical data indicate that motor and speech signs are Hallym University Sacred Heart Hospital, Seoul, Korea
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 mes- Background: Post-stroke cognitive impairment is typified by decreased processing speed and
saging contains too many elements. Evidence from the F.A.S.T campaign should be considered executive dysfunction. The potentially distinct influences of territorial stroke and subcortical
when developing future campaign messages. Conclusions: Improvements to HSF signs of ischemic vasculopathy (SIV) on these executive subcomponents are not well understood. Here
stroke campaign messages are advised. Shortening the number of signs and ensuring inclusion we use the Trail-Making-Test (TMT), which assesses processing speed (TMT-A) and set-shifting
of speech, motor and Act Now/call 9-1-1 elements are recommended to improve recall and executive function (TMT-B, and TMT-B-minus-A-time), to define these relationships. Methods:
recognition. The Foundation will use the feedback from the one-day meeting to inform develop- Neuropsychological testing and volumetric MRI from two independent stroke samples were
ment of future signs of stroke multimedia public awareness campaign. 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 adminis-
P2.020 tered. MRIs were processed using a semi-automated imaging pipeline, including stroke tracings
Emergency Department Transient Ischemic Attack Clinical Pathway: Improving and quantification of global white matter hyperintensities (WMH) volume. Cholinergic WMH were
Quality of Care and Patient Safety Using Etiology-based Triage assessed using the Cholinergic Pathways HyperIntensities Scale (CHIPS). Results: Linear re-
gression analysis of infarct volume, global WMH volume, and CHIPS, as predictors of TMT-A and
Treasurywala, K; Fung, W; Wang, A; Kolesnik, J; Cheung, J; Sahlas, D; Lin, D; McMaster TMT-B-minus-A-time, was performed, controlling for age, sex, education, global atrophy and
University, Hamilton, ON 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
Background: Recent evidence suggests tools such as the ABCD2 score can fail to identify only CHIPS was associated with TMT-B-minus-A-time (β=0.386, p=0.001, r2= 0.11). Similarly,
patients at high risk for recurrent stroke, including those in whom evidence-based interventions for CIS patients, infarction volume (β=0.267, p=0.015, r2=0.07) and global WMH (β=0.360,
for time-sensitive stroke mechanisms exist, such as carotid artery stenosis (CAS) or atrial fibril- p=0.003, r2=0.11) were associated with TMT-A, and only CHIPS was associated with TMT-B-
lation. Methods: A novel clinical pathway was devised based upon potential etiologic mecha- minus-A-time (β=0.413, p=0.001, r2= 0.15). Conclusion: Here we report, and replicate the
nisms, in order to better integrate Emergency Department (ED) management of patients diag- differential associations of processing speed and set shifting with cortical/subcortical lesion
nosed with Transient Ischemic Attack (TIA) with subsequent outpatient Stroke Prevention Clinic measures in two stroke cohorts. The degree of SIV within cholinergic projections was associated
(SPC) follow-up, with an emphasis on identifying symptomatic moderate to high-grade CAS. All with impaired set-shifting ability, while global SIV and infarction volumes were associated with
adult patients diagnosed with TIA in our ED and who were referred to our SPC from November reduced processing speed. This suggests that the cholinergic system could be a substrate for
5, 2012 to February 28, 2013 were prospectively identified and their clinical outcomes followed set-shifting executive function deficits and a target of cognitive neurorehabilitation and cholin-
for one month. A historical cohort of patients diagnosed with TIA in the ED prior to the protocol ergic pharmacotherapy.
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 P2.024
1 day, (p<0.001) despite more carotid ultrasounds being requested (77/81) Moreover, 96.3% of Cerebral Vasospasm and Delayed Cerebral Ischemia in Subarachnoid
those diagnosed with TIA in the ED had brain imaging compared to 86.2% prior to the protocol Hemorrhage: a Contemporary Case Series
(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 Ng, KH2, 1, 3 Algird, A1, 3 Martin, C3 Jichici, D1, 3 Sahlas, DJ1; 1. McMaster University, Hamilton,
agent compared to 46.2% prior to the protocol (p<0.001). Conclusions: Our clinical pathway ON; 2. Population Health Research Institute, Hamilton, ON; 3. Hamilton Health Sciences,
for ED patients evaluated for TIA is based upon potential vascular etiology of TIA and resulted in Hamilton, ON
an increase in patients undergoing brain imaging, expedited carotid imaging, and an increase in
prescription of antiplatelets, all prior to their SPC appointment . 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 cere-
P2.022 bral ischaemia (DCI) is defined as symptomatic vasospasm or infarction on CT attributed to
Should Patients with First Cryptogenic Stroke Undergo Routine Tumor Screening? vasospasm. Transcranial Doppler (TCD) monitoring enables identification of patients at risk of
developing DCI and triggers aggressive early medical treatment. Whilst TCD parameters for
Maynard, S; Thiel, A; Jewish General Hospital, Montreal, QC 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 ret-
Background: Occult malignancy presenting with stroke (OMPS) is predominantly thought to rospective consecutive case series of patients with SAH and subsequent DCI (22/98) admitted
be caused by chronic disseminated intravascular coagulation (DIC), non-bacterial thrombotic between April 2010 to March 2012 at the Hamilton General Hospital. Serial TCDs of the major
e36  Stroke  December 2013
intracranial vessels were performed and parameters including mean blood flow velocity (mBFV) Background: Unilateral hemodynamically significant large-vessel intracranial stenosis may be
were recorded for every patient. Results: 50% of intracranial aneurysms in this case series were associated with reduced BOLD cerebrovascular reactivity (CVR), an indicator of autoregulatory
anterior communicating artery aneurysms. 34 DCI events were confirmed on brain imaging, reserve. Reduced CVR has, in turn, been associated with ipsilateral cortical thinning and loss in
with 31 events involving the anterior circulation. Those patients with MCA DCI had average and cognitive function. These signs and clinical effects have been shown to be reversible following
median mBFV of 186 cm/s and 197 cm/s respectively (range 62 cm/s to 337 cm/s). In patients revascularization. Our aim was to study the effects of unilateral revascularization on CVR in
with ACA DCI, the average and median mBFV were 115 cm/s and 114 cm/s respectively (range both hemispheres in the presence of bilateral steno-occlusive or moyamoya disease. Meth-
64 cm/s to 175 cm/s). In patients with PCA DCI, the average and median mBFV were 102 cm/s ods: In this exploratory observational study, 20 patients with either moyamoya disease (n=14)
and 54 cm/s respectively (range 50 cm/s to 201 cm/s). Conclusions: TCD is a simple bedside or bilateral severe stenosis of the ICA (n=6) underwent BOLD CVR MRI at 3T (GE Healthcare,
test that can guide the management of patients following SAH at risk of DCI due to vasospasm. Milwaukee), and using RespirAct™ (TRI, Toronto, Canada) to control the PCO2 stimulus, before
Our case series involving contemporary intensive care management reports mBFV parameters and after unilateral revascularization (extracranial-intracranial bypass, carotid endarterectomy,
in patients with DCI following SAH in each of the major arterial territories. 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 improve-
P2.025 ment in CVR of the non-intervened hemisphere (0.140 ± 0.020 to 0.205 ± 0.011, P<0.01). Dis-
cussion: The interdependence of hemispheric blood flow is mediated by the interconnections
Meta-analysis of Albumin in Acute Stroke (ALIAS) Parts 1 and 2 Trials 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,
Palesch, YY1 Martin, RH1 Hill, MD2 Tamariz, D3 Jauch, EC1 Weng, Y1 Speiser, JL1 Woolson, RF1 as reflected in the CVR. Conclusion: Unilateral revascularization can improve vascular reserve
Barsan, WG4 Moy, CS5 Ginsberg, MD3; 1. Medical University of South Carolina, Charleston, SC, in the non-intervened hemisphere. Bilateral revascularization may not be necessary for restoring
USA; 2. University of Calgary, Calgary, AB; 3. University of Miami, Miami, FL, USA; 4. University global hemodynamic function.
of Michigan, Ann Arbor, MI, USA; 5. National Institute of Neurological Disorders and Stroke,
Bethesda, MD, USA
P2.028
Background: The international multicenter (including several Canadian sites) Albumin in Acute
Fallibility, History and Endovascular Stroke Trials: A New Perspective
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 on Equipoise
infused intravenously over 2 hours or to equivolemic normal saline similarly infused. The Part
Shamy, MC; Stahnisch, FW; Hill, MD; University of Calgary, Calgary, AB
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1 Trial had randomized 434 out of the expected maximum 1,800 subjects when it was termi-
nated due to safety concerns raised by the DSMB. During the subsequent year, upon analyzing
Background: Equipoise is an ethical principle that justifies the enrollment of patients into ran-
the safety data, some of the eligibility criteria were modified with a few minor changes to the
domized clinical trials (RCTs) on the basis of conflicted medical opinion, either on the part of
protocol, and the trial was re-started as a new study, i.e., as Part 2. After 841 of the anticipated
individual physicians or of the community. In light of the results of recent stroke trials that have
1,100 subjects were enrolled in Part 2, the DSMB recommended stopping the study because the contradicted the prevailing opinions of the community, we question the relevance of equipoise
pre-specified futility boundary was crossed. Methods: The primary outcome for both trials was to clinical trial enrollment, particularly in stroke. Methods: We apply examples from stroke
the favorable outcome defined as mRS 0-1 and/or NIHSS score 0-1 at 90 days from randomiza- medicine to demonstrate the limitations of equipoise that arise due to its reliance on medical
tion. Because the two trials were conducted under a similar protocol at mostly the same clini- opinion. We discuss the complex development and instability of medical opinion, in general and
cal sites and coordinated by the same group of investigators, we conducted one-stage meta- in relation to clinical trials. We review the justifications for RCT enrollment that are not related
analysis using the participant level data from both trials. As a sensitivity analysis, two-stage to opinion, and seek a more ethically and epistemically robust alternative. Results: We propose
meta-analysis, where the summary measures from each trial are combined, was performed. the “fallibility principle” as a new approach to ethical decision-making about RCTs that acknowl-
Results: In general, the baseline characteristics were similar between the trials overall as well edges the fallibility of every opinion and that contextualizes recent questions about the ethics
as between the treatment groups within each trial. These characteristics will be presented by of clinical experimentation within a broader perspective informed by the history of medicine.
trial and in aggregate along with the primary outcome analysis results from each trial and from Through the lens of fallibility, the dual ethical and epistemic imperative of medicine – providing
the meta-analyses. Conclusion: TBA since the results from the Part 2 Trial, and consequently, best care from best evidence – is conceived as a continuous challenge navigated through a
from the meta-analysis cannot be disclosed at this time. combination of humility, skepticism and caring. Conclusions: We propose a revision of equi-
poise 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
P2.026 a novel way.
Late Life Migraine Accompaniments Presenting to the Stroke Clinic: How Much
Investigation is Necessary?
P2.029
Pim, H; Aube, M; Cote, R; Vieira, L; McGill University, Montreal, QC Atrial Fibrillation Prediction Score in Cerebrovascular Disease

Background: Transient ischemic attacks (TIA) can be associated with a 10% risk of stroke in Shuaib, A1 Yaseen, I1 Ghrooda, E1 Mohammad, A1 Dobrowolski, P1 Hasan, M1 Hussain, G2
90 days and urgent investigation and treatment is recommended (1). Fisher described patients Ahmad, A1; 1. University of Alberta, Department of Medicine, Division of Neurology , Edmonton,
in the stroke age bracket with transient neurological symptoms, late-life migraine accompani- AB; 2. University of Alberta, Department of Medicine, Division of Cardiology, Edmonton, AB
ments (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 Introduction: Paroxysmal Atrial Fibrillation (PAF) is an important cause of preventable embolic
investigations. The decision as to what investigations are necessary, in these individuals, re- stroke. Recent studies have shown that PAF is much more likely to be diagnosed with prolonged
mains a common clinical problem. Methods: Our study will be nested within a larger retrospec- cardiac monitoring. We designed a PAF prediction score (including: Recurrent stroke, Pattern of
tive review of the files of all patients referred to the McGill University Stroke Prevention clinic infarction on imaging, Etiology ,Premature atrial beats and Palpitations) and tested in patients
with a diagnosis of TIA from 2008 to 2012. The clinic sees between 2500 and 3000 patients with TIAs and acute stroke. Methods: Patients seen at University of Alberta stroke program in
with per year. Patients with LMA will be identified by using a modification of the original Fischer whom Holter monitoring was negative for PAF were prospectively enrolled in a study to monitor
criteria for the diagnosis of LMA (2). Other symptoms that may help to support the diagnosis of for PAF between July 2012 and May 2013. A PAF prediction score (low, medium and high) was
LMA will be documented. We will evaluate the clinical symptomatology, vascular risk factors, tested to determine the risk for the arrhythmia. Results: 54 patients had 10 (±4) days of moni-
toring (SpiderFlash-t™ monitor, Sorin, Italy). PAF was seen in no patients with low score (0/5),
migraine history (where available), investigations carried out and their results. We will document
30% of patients with medium score (3/10) and 36% of patients with high score (14/39). In ad-
the incidence of vascular events and the treatment decisions made in these patients. Expected
dition, atrial flutter was seen in two patients with high score (embolic risk in 41% patients). The
Results: The study is ongoing and the final results will be presented at the Canadian stroke
diagnosis resulted in initiation of anticoagulation in 13 patients. Conclusions: The risk of poten-
congress. We expect to be able to demonstrate a correlation between certain clinical presenta-
tial PAF can be calculated with a clinical score. This may allow for the selection of patients where
tions and the risk of cerebrovascular events. Conclusions: We expect to demonstrate that a
more focused prolonged cardiac monitoring arrhythmias and change in prevention therapies.
careful history and follow up may obviate the need for extensive cerebrovascular investigations
in many patients with LMA.
P2.030
1. Johnston, S.C., et al., JAMA, 2000. 284: 2901-2906
2. Fisher CM. Can J Neurol Sci 1980;7:9-17 Sensitivities and Specificities of the Doc Screen for Depression, Obstructive Sleep
3. Wijman et al., Stroke. 1998;29:1539-1543 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
P2.027
Knowledge Institute, Toronto , ON
Unilateral Surgical Revascularization Improves Cerebrovascular Reactivity of
the Non-intervened Hemisphere in Patients with Bilateral Steno-occlusive and Background: 30-50% of patients post-stroke are affected by each of the following comor-
Moyamoya Disease bidities: 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.
Sam, K1 Poublanc, J2 Crawley, AP2 Fisher, JA1 Mikulis, DJ2; 1. University of Toronto, Depart- The primary objective of this study is to assess the validity of the DOC screen for identifying
ment of Physiology, Toronto, ON; 2. Toronto Western Research Institute, Department of individuals at high-risk of DOC conditions in a large-volume stroke/TIA clinic. Methods: The
Medical Imaging, Toronto, ON sensitivity and specificity of individual DOC sub-screens (PHQ-2 for depression, STOP for OSA
Abstracts From the 4th Canadian Stroke Congress, 2013  e37
and Mini-MoCA for cognitive impairment) were assessed compared to gold standard research Background: The literature classifies cervical artery dissection (CAD) into two etiological
assessments in consenting patients at the Sunnybrook Stroke Prevention Clinic. Results: Over categories: spontaneous or traumatic. This distinction is primarily based on presenting his-
eleven months, 205 patients consented to gold standard testing; not all patients completed tory, but recent studies and reports suggest that these groups share many similarities. Best
every assessment. The PHQ-2 sub-screen was both specific (88%) and sensitive (72%) com- evidence-based management for both spontaneous and traumatic CAD remains unclear, as
pared to the Structured Clinical Interview for the DSM-IV Depression Module (n=193). The mini- on-going randomized controlled trials are challenged by difficulties meeting sufficient power
MoCA was equivalent to the full MoCA in predicting cognitive impairment of ≥1 domain on the for conclusive results. We hypothesize that spontaneous and traumatic CAD are mainly dif-
neuropsychological test protocol (mini-MoCA, 52% specificity and 80% sensitivity; MoCA, 60% ferentiated by their respective risks for ischemic and hemorrhagic complications, and that
specificity and 81% sensitivity, n=170). Only 26% of enrolled patients consented to polysom- determination of this risk profile is key in devising a rationalized approach to management.
nography. Compared to polysomnography (n=47), the STOP sub-screen was sensitive (86%), Method: We reviewed the medical literature through MEDLINE and PubMed from 2003 to
but lacked specificity (30%). Conclusion: The PHQ-2 and mini-MOCA results are valid compared 2013, with review of references. The search was limited to “English language” and “Hu-
to gold standard assessments. They may be useful in the clinical setting for identifying those at man”, with exclusion of articles solely pertaining to intracranial dissections. Through articles
high-risk for depression and cognitive impairment. The low specificity of STOP, along with low identified, we compared and contrasted key characteristics between spontaneous and trau-
enrollment in polysomnographys highlights the need for additional simple OSA screening tools. matic CAD. Results: A total of 246 articles pertaining to spontaneous carotid or vertebral
The sensitivity for detecting OSA was adequate, and sensitivity is preferred for a screening tool. artery dissection, and 117 articles on traumatic ones, were identified. Review of reported
The DOC screen is a sensitive and valid tool to screen for depression, OSA, and cognitive impair- characteristics showed overlaps between spontaneous and traumatic CAD, including incit-
ment in the stroke population. ing 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 differ-
P2.031 ences and many similarities exist between spontaneous and traumatic CAD. Major distin-
tPA Door to Needle Reduction: The Impact of Nurse Stroke Specialists guishing 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.
Tebbutt, TD; Hammond, L; Grand River Hospital, Kitchener, ON This principle is likely key in devising a common rationalized approach to therapy for all
cervical artery dissections.
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 P2.034
General Site (GNG) of the Niagara Health System is a DSC in Central South. The Stroke Team Integrated Vascular Management Clinic (IVMC) – A Comprehensive Approach to
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

at GNG have consistently exceeded the provincial benchmark with door to needle times for Vascular Management
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 Shipley, C2 White, JL1 Hill, C1; 1. Peterborough Regional Health Centre, Peterborough, ON;
to determine if this model of care could be applied with success in another district that has 2. Peterborough Regional Vascular Health Network, Peterborough, ON
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 Background: In 2006, Haliburton Kawartha Pine Ridge (HKPR) was facing the future: a
Specialist model which includes several strategies: tPA feedback letters for internal stroke team rapidly aging, medically complex vascular patient population and limited resources in terms
members and Emergency Services Network (EMS) staff identifying door to needle times and of the availability of specialists to provide comprehensive assessment and treatment. The
patient outcomes, pre-alert by EMS, EMS transporting patient straight to CT, and offering ad- IVMC model was established in 2006 to streamline vascular referrals through a coordinated
ditional training for Emergency Department (ED) nurses utilizing Hemispheres which is an eight intake process. The goal of the clinic was to increase accessibility for patients in order to
module online stroke training program. Results: Grand River Hospital has reduced median door improve the detection, management and treatment of vascular disease while improving
to needle times from 72 minutes to 58 minutes since April 2011-December 2012. In addition, resource utilization through a collaborative, patient-centred approach. Method: IVMC is a
we have 33 ED nurses who have signed up for the online Hemispheres Stroke Education series. community-based, nurse led and physician supervised clinic designed to be responsive to
Conclusions: The Nurse Stroke Specialist model of care was successfully applied in Waterloo/ the needs of patients in the HKPR District presenting with a manifestation of any type of
Wellington and has facilitated more efficient and timely provision of tPA. This suggests that this vascular disease. Clinics included under the IVMC umbrella are: TIA Clinic, Chest Pain Fast
model of care is transferable and could be effective at other sites. 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 naviga-
P2.032 tion of patients through the vascular care continuum using standardized, evidence-based
FLAIR Hyperintense Vessel Sign on MRI brain (HVS) Does Not Predict Any protocols. In 2012/2013, over 3000 patients across the HKPR District were referred to IVMC
Intracranial Hemorrhage or Symptomatic Hemorrhage(sICH) in Acute Strokes Clinics for the detection, management and treatment of vascular disease. Partnerships
with Proximal Vessel Occlusions Treated with Intravenous or Intra-Arterial Lytic/ have been established between a variety of care providers to ensure effective integra-
Mechanical Therapy tion of acute, sub-acute, specialty and primary care for patients with all manifestations
of vascular disease. Conclusion: This comprehensive, community-based model of care
Adatia, S1 Almekhlafi, M1 Nambiar, V1 Trivedi, A1 Sohn, S2 Menon, B1 Al-sereya, A1; 1. Foothills has been effective in developing and deploying unique and highly efficient services within
Medical Hospital, Calgary , AB; 2. Keimyong University , Korea, Korea 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
Background and Purpose: Hyperintense vessels (HV) have been observed in fluid- attenuated intervention. The efficiencies achieved have resulted in improved coordination of care for
inversion recovery imaging (FLAIR) MRI sequence in patients with acute ischemic strokes in patients requiring multiple vascular investigations, ultimately improving patient outcomes
region of diffusion positivity .They have been linked to slow flow in collateral arterial circulation and reducing health care resource utilization.
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 P2.035
vessels on MRI in the region of diffusion restriction. Two independent/blinded clinicians iden- Chinese or South Asian Ethnicity is not Independently Associated with Delayed
tified it. sICH was defined by SITS-MOST criteria. Results: 59 patients had HVS and 36 did Treatment in Acute Stroke: Observations from the Vancouver Stroke Program
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/ Wilson, L; Mann, S; Murray, K; Yip, S; University of British Columbia, Vancouver, BC
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 Background: Various pre-hospital and hospital factors have been implicated in delaying time
had IA alone and 2 received both. (1 missing). The groups were comparable for rates of recanali- to treatment with tissue plasminogen activator (tPA) in acute ischemic stroke. However, in a
zation (TIMI 2/3). 8/36 patients in the non HVS group had any ICH and 1 had sICH. 22/59 had any multicultural city such as Vancouver, it is unclear if ethnicity is a predictor of a prolonged door
ICH and 5 sICH in the HVS group. (p=0.2785) In the multivariate regression analysis model for to needle time (DTN). Methods: A retrospective chart review was performed of all patients
prediction of sICH, high glucose levels, age and NIHSS emerged as significant predictors. For any (n=250) treated with tPA consecutively at Vancouver General Hospital (VGH) from January
ICH, glucose and initial NIHSS were significant. Conclusion: Presence of HVS is not uncommon 2009 to March 2011. Demographic features along with times of symptom onset, arrival, CT
in patients with proximal vessel occlusions. In present study, its presence was not significant for scan and treatment with tPA were recorded for Chinese, South Asians and all other ethnic
prediction of intracranial hemorrhage. Glucose levels , age and NIHSS were significant predic- groups (“Others”). As the 2013 AHA guidelines recommend a DTN of <60 minutes, multi-
tors of sICH. Larger sample with pretreatment MRI needs to be studied for correlation of HVS variate logistic regression analysis was used to determine independent variables associated
and intracranial hemorrhage. 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
P2.033 and p=0.12 respectively). Multivariate logistic regression identified only hospital transfer
Spontaneous or Traumatic Cervical Artery Dissection: a Distinction with (p<0.001) as an independent predictor of DTN less than 60 minutes. Ethnicity was not an
Therapeutic Impact? 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 isch-
Tsai, JP1 Swartz, RH1, 2; 1. Division of Neurology, Department of Medicine, University of emic stroke at Vancouver General Hospital. However, hospital transfer was shown to be an
Toronto, Toronto, ON; 2. Division of Neurology, Department of Medicine, Sunnybrook Health independent variable associated with a shorter DTN and this requires further study as it may
Sciences Center, Toronto, ON alter future local treatment protocols.
e38  Stroke  December 2013
P2.036 occlusion (MCAO). After 4 days of recovery, brain sections were histologically evaluated for
The Effect of Antalarmin on the Expression of Brain Derived Neurotrophic Factor infarct volume. Immunofluorescent analysis of astrocyte reactivity, microglial activation, Cx43
mRNA in the Hippocampus and Basal and Stessed-Induced CORT Secretion Fol- expression, vascular elements and apoptosis was also performed. A significant, ~2-fold, de-
lowing Transient Cerebral Ischemia in the Rat crease 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
Barra de la Tremblaye, P; University of Ottawa, Ottawa, ON 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
Background: Recently, we demonstrated persistent changes triggered by forebrain ischemia in MK4 animals, compared with WT mice. Consistent with the infarct volume data, a significant
in corticotropin releasing hormone (CRH) and CRH type 1 receptor (CRH-R1) immunoreactive reduction in cell death in the MK4 group was measured, compared to corresponding controls.
expression in the paraventricular nucleus of hypothalamus, central amygdala and the CA1 sub- This study suggests that inhibiting MAPK-Cx43 interaction is associated with neuroprotection in
region of the hippocampus. CRH-R1 receptors have been shown to mediate brain plasticity ischemic conditions.
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 hip- P2.039
pocampus following global cerebral ischemia. Methods: Male Wistar rats (N = 30) received The Cognitive Underpinnings of Confabulation Following Anterior Communicating
intracerebroventricular infusion of either Antalarmin (2µg/2µl) or saline 30 minutes prior to be- Artery (ACoA) Aneurysm Rupture
ing 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 Ghosh, V1, 2 Moscovitch, M1, 2 Gilboa, A1, 2; 1. University of Toronto, Toronto, ON; 2. Rotman
stress. Animals were killed 30 days after reperfusion and thymus, adrenal glands and seminal Research Institute, Baycrest, Toronto, ON
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 Background: Due to high sensitivity of the anterior communicating artery (ACoA) for aneurysm
significant differences between Ischemic and Sham groups. Only the seminal vesicles reduction rupture, and the relatively focal ventromedial prefrontal cortical (vmPFC) damage that ensues,
was prevented by Antalarmin administration in ischemic rats. However, persistent elevations in an associated triad of symptoms have been labeled the “ACoA syndrome” (Alexander & Freed-
basal CORT levels post ischemia were significantly reduced by Antalarmin at short and longer– man, 1984; Damasio et al., 1985; DeLuca, 1993). Recent evidence of vmPFC’s role in represent-
term intervals and after restraint stress. The expression of BDNF and TrkB mRNA was attenuated ing schemas (Kumaran et al., 2009; Tse et al., 2011; Van Kesteren et al., 2010) could account
in the hippocampus 30 days post ischemia, independent of antalarmin treatment. Conclusions:
for the most elusive of the ACoA syndrome symptoms: confabulation. This experiment probed
Our findings suggest that forebrain ischemia dysregulate the endocrine system with sensitized
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

the impact of vmPFC damage following ACoA rupture on schematic representation, specifically
CORT responses at multiple baseline time intervals and following acute restraint. This phe-
testing whether vmPFC lesions would differentially impact activation of a relevant schema and
nomenon was attenuated by a single Antalarmin administration prior to ischemia. Decreased
inhibition of an irrelevant one, even when memory was not required for the task. Methods:
hippocampal expression of BDNF and TrkB mRNA may play a role in functional deficits observed
following global ischemia. 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
P2.037
lures to the second schema. Results: Non-confabulating ACoA patients performed comparably
Identification of a Novel Transcription Regulator that Controls Macrophage to healthy adults: high accuracy overall and longer response latencies to reject lures related to
Polarization and Cholesterol Uptake 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
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; cingulate cortex—may have in part been responsible for the differing performance of patients
1. Ottawa Hospital Research Institute, Ottawa, ON; 2. Centre for Stroke Recovery, Ottawa, ON; with and without confabulation, as this region was spared in non-confabulating patients. Con-
3. University of Ottawa, Ottawa, ON; 4. Ottawa Hospital Research Institute, Centre for Stroke
clusion: The findings support the hypothesis that the sub-callosal cingulate cortex is pertinent
Recovery, Ottawa, ON; 5. University of Ottawa Heart Institute, Ottawa, ON
to confabulation (Schnider, 2003; Gilboa, 2004), and suggest that confabulation in these cases
of ACoA syndrome is associated with poor suppression of irrelevant schemas.
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 as-
sociation studies (GWAS) found that IRF2BP2 polymorphisms affect LDL-C levels. IRF2BP2 is P2.040
the co-repressor of interferon regulatory factor 2, a transcription factor that regulates innate im- Sex Differences in Cognitive Rehabilitation Efficacy in a Rat Model of Vascular
mune response and suppresses interferon alpha (IFNα) expression. IFNα primes macrophages Dementia
to become polarized to an M1 inflammatory phenotype (producing pro-inflammatory cytokines).
Macrophages can also become polarized to an M2 phenotype (producing anti-inflammatory Langdon, KD1 Granter-Button, S1 Harley, CW1 Moody-Corbett, F1 Peeling, J2 Corbett, D1;
cytokines) important for tissue repair, depending on other external stimuli. Macrophages are 1. Memorial University, St. John’s, NL; 2. University of Manitoba, Winnipeg, MB
important regulators of cholesterol metabolism and emerging evidence indicates that regula-
tion of M1/M2 polarization influences LDL-C uptake. Methods: To address how IRF2BP2 influ- Background: Dementia is a major contributor to morbidity throughout western society. To date,
ences macrophage handling of LDL-C, we generated a mouse model LysMCre/IRF2BP2flox that pharmacological interventions have provided modest benefit in treating resultant cognitive im-
specifically ablates IRF2BP2 in macrophages. Results: IRF2BP2 expression is elevated in M2 pairments. We report the evaluation of a treatment paradigm consisting of a combination of
macrophages and reduced in M1 macrophages. Ablation of IRF2BP2 in macrophages skews physical and cognitive activity (PA/CA) in both male and female rats using a well-characterized
polarization to the M1 phenotype, with elevated expression of TNFα and IL-1β. Quantitative model of vascular dementia. Methods: Early middle-aged (~6mo) Sprague-Dawley rats un-
RT-PCR analysis showed that IRF2BP2 suppresses the expression of scavenger receptors MSR1 derwent permanent bilateral carotid artery occlusion (2VO) and were exposed to either a com-
and SCARB1 that uptake LDL-C to macrophages. IRF2BP2 deficient macrophages accumulated bination of PA (voluntary wheel running) and CA (modified Hebb-Williams maze exposure) or
significantly higher levels of oxidized LDL-C. Importantly, altered nutrients and stress affected sedentary housing. Female animals were ovariectomized prior to 2VO, controlling for possible
IRF2BP2 expression in cultured cells and in the brain. Conclusion: IRF2BP2 is important to neuroprotective influences of estrogen. Learning and memory abilities were assessed using
control macrophage polarization and LDL-C uptake and is likely to affect susceptibility to stroke the Morris water maze. Results: Male PA/CA rats demonstrated significant cognitive improve-
injury. ments 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
P2.038 a result of 2VO. Interestingly, there were no differences between PA/CA and sedentary females
Loss of MAPK Phosphorylation of Connexin43 is Neuroprotective in Stroke in any of the learning and memory assessments, nor histopathological outcomes. Conclusions:
This study describes a cytoarchitectural abnormality of hippocampal CA1 neurons in early mid-
Freitas-Andrade, M1 Bechberger, J1 MacVicar, B2 Lampe, P3 Naus, C1; 1. Department of Cellular dle-aged male rats subjected to a surgical procedure that induces cognitive decline. A novel
and Physiological Science, Life Sciences Institute, University of British Columbia, Vancouver, combination of PA and CA promoted cognitive recovery, an area rarely explored in preclinical
BC; 2. Brain Research Centre, Department of Psychiatry, University of British Columbia, studies. Interestingly however, the positive effects were limited to male animals. Females did
Vancouver, BC; 3. Fred Hutchinson Cancer Research Center, Seattle, WA, USA 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
Astrocytic interactions involving gap junction proteins has been reported to be a mechanism ‘translational roadblock’ between basic and clinical science outcomes. The present results are
associated with neuronal survival in ischemic conditions. In astrocytes, gap junctions are com- intriguing because the differential response to the intervention may provide a means for identify-
posed primarily of the channel protein, Connexin43 (Cx43). These channels provide a substrate ing critical mechanisms underlying PA/CA rehabilitation efficacy.
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
P2.041
of Cx43. Recently, a study showed that in response to atherogenic stimuli and vascular injury, In Vivo Channelrhodopsin-2 Stimulation and Voltage-Sensitive Dye Imaging in a
Cx43 is phosphorylated at its C-terminus mitogen-activated protein kinase (MAPK) residues and Mouse Model of Stroke Reveals Preserved Functional Connections Posterior to
that this is a key regulator of vascular smooth muscle cell (VSMC) proliferation and vascular scar the Lesion
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 Lim, DH; LeDue, J; Mohajerani, MH; Murphy, TH; University of British Columbia, Vancouver, BC
Abstracts From the 4th Canadian Stroke Congress, 2013  e39
Background: Understanding the recovery of cortical function following stroke is important to dye extravasation in the peri-infarct cortex as a marker of BBB dysfunction. At 3 days follow-
develop treatment strategies. While it is known that cortical damage may extend beyond the ing stroke we found the cerebrovasculature in the diabetic peri-infarct cortex was significantly
stroke core to the peri-infarct region, direct functional assessment of this area has been chal- more permeable compared to controls. By 7 days there was no difference between groups and
lenging because most methods have relied on peripheral stimulation, which is limited to sensory leakage was resolved by 4 weeks. Since most angiogenic signals are transduced by vascular
or motor cortex activation, or have used invasive cortical stimulation, which may cause further endothelial growth factor receptor-2 (VEGF-R2), we assessed VEGF-R2 protein expression in
damage. Methods: Recently, we have developed a method to map functional connections in the peri-infarct cortex with immunohistochemistry and western blots. Diabetic mice exhibited
vivo with high spatial and temporal resolution using voltage-sensitive dye (VSD) imaging com- a heightened and abnormally prolonged expression of VEGF-R2 in peri-infarct vasculature. We
bined with Channelrhodopsin-2 (ChR2) stimulation in a transgenic mouse line (Lim et al., 2012). then asked whether administration of a VEGF-R2 inhibitor (SU4516) one hour post stroke could
Here, we examine long-term changes in functional connectivity after a stroke by discretely stim- restore BBB integrity. Diabetic mice treated with SU5416 had significantly lower vascular ex-
ulating multiple sites within the peri-infarct. Results: In animals with a stroke targeted to the travasation. Diabetic and non-diabetic mice receiving chronic administration of either SU5416
forelimb area of the primary somatosensory cortex (FLS1), the peak VSD response after sensory or vehicle injections were assessed with adhesive tape and horizontal ladder behavioral task
stimulation was significantly delayed and reduced, as expected from previous studies (Brown et following stroke. Preliminary testing indicates that VEGF-R2 inhibition may improve recovery in
al., 2009). The homotopic VSD response to photostimulation was reduced in amplitude, however diabetics. These results indicate that excessive post-ischemic loss of BBB integrity in diabetics
it was not significantly delayed, suggesting that the cortical and callosal connections activated is partially mediated by VEGF signaling, which can be ameliorated with inhibitors of VEGF-R2.
by the phostostimulation were still functional. To further examine which areas were most af- Given the deleterious effects of excessive plasma leakage on neuronal health, restoring BBB
fected by stroke, 25 cortical sites within the peri-infarct were targeted for photostimulation and integrity offers a promising approach to restore adaptive plasticity in diabetics following stroke.
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
P2.044
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. 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
P2.042
of Ottawa, Ottawa, ON
Do Reduced Leptomeningeal Collaterals in Humans Result in Leukoaraiosis,
Lacunes and Brain Atrophy? Background: Cerebral small vessel disease (CSVD) is a progressive condition and a major cause of
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

vascular dementia. An early pathological feature of CSVD is an increase in blood brain barrier (BBB)
Nambiar, VK1 Sohn, S2 Goyal, M1 Demchuk, AM1 Menon, BK1; 1. University of Calgary, Calgary, permeability. Ectosomes (microparticles) are small, membrane bound vesicles that are released into
AB; 2. Keim Yong University, Keimyong, Korea the circulation by a variety of cell types and have been found to increase in several cardiovascular dis-
orders. In the present study circulating levels of ectosomes were measured in a rodent model of CSVD
Introduction: We seek to identify if reduction in leptomeningeal collaterals results in leuko-
and some of their properties characterized in vitro. Methods: Chronic cerebral hypoperfusion (CCH)
araiosis, lacunar disease and brain atrophy. In addition, we seek to explore an association be-
was induced in male Long Evans rats by permanent bilateral common carotid artery occlusion. Cir-
tween amyloid angiopathy and reduced leptomeningeal collaterals. Methods: Data are from
culating ectosomes were examined by flow cytometry and electron microscopy. Purified ectosomes
the Keimyung Stroke Registry. Consecutive patients with M1 segment middle cerebral artery
were added to cultured rat brain microvascular endothelial cells, cell viability assessed by LDH assay
(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 barrier permeability assessed by measuring electrical resistance (TEER). BBB permeability was
and GRE) were included in the current study. Two raters assessed leptomeningeal collaterals on assessed in vivo using the Evans Blue assay. Results: Following the induction of CCH circulating lev-
baseline CTA by consensus, using a previously validated regional leptomeningeal score (rLMC). els of annexin V + and VE-cadherin + ectosomes were significantly elevated. When added to cultured
Brain volume=, volume of periventricular hyperintensity on FLAIR (PVH), number of lacunes endothelial cells ectosomes induced caspase 3-dependent cell death. A TNF-α receptor blocker and
(T1) and microbleeds (GRE) were assessed by consensus, blinded to collateral assessment. a neutralizing antibody against TRAIL significantly reduced apoptosis. When ectosomes were added
Brain volumes were measured using Quantomo and data analyzed using Stata 12.1. Results: to artificial endothelial barriers there was a significant decrease in electrical resistance and when
Baseline characteristics (n=120) were: mean age 67.3 years, median baseline NIHSS 14 (IQR injected into the circulation of unoperated rats there was an increase in BBB permeability. Conclu-
10) and median stroke symptom onset to CTA 118.5 minutes (IQR 117). There was a significant sions: Cerebral ischemia causes an increase in circulating ectosomes. Purified ectosomes induce
difference in PVH in those with poor collateral status vs. those without (median volume 7. 5 ml apoptosis in cultured endothelial cells and a reduction in TEER when added to artificial endothelial
vs 4.4 ml, p=0.04). No difference was noted in brain volume, number of lacunes or number of barriers. When injected into the circulation of unoperated rats the ectosomes cause a decrease in
microbleeds by collateral status. (Table 1) Nonetheless, we noted significant correlation be- BBB permeability. Ectosomes may be involved in the disruption of the BBB that accompanies human
tween brain volume, PVH and number of lacunes. Cerebral microbleeds were not associated CSVD and a variety of other neurological conditions and may participate in the progression of CSVD.
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 P2.045
with reduced collateral status potentially being causal. Insert 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 homeo-
stasis, 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 stain-
ing, we found that the infarct volume of the ischemic brains was significantly reduced in BNIP3
P2.043
knock-out mice compared to wild-type mice upon 3-7 days recovery. Furthermore, deletion
The Effects of Diabetes on Blood Brain Barrier Integrity and Functional Recovery of BNIP3 gene in cortical neurons of knock-out mice activated a robust autophagic response.
from Stroke 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
Reeson, P; Wang, J; Brown, CE; University of Victoria, Victoria, BC animals. Conclusions: Our results indicate that BNIP3 is an important upstream regulator for
both autophagy and apoptosis processes in delayed neuron damage in stroke.
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
P2.046
understand the vascular response to stroke, we induced a unilateral ischemic photothrombotic The Influence of Post-Stroke Lower-Limb Spasticity on the Control of Standing
stroke in the forelimb somatosensory (FLS1) cortex of diabetic and non-diabetic mice. Using Balance: Short-Time Cross-Correlation and Coherence Between Individual Limb
Evans blue, a fluorescent dye impermeable to an intact blood-brain-barrier (BBB), we quantified Centres of Pressure
e40  Stroke  December 2013
Singer, JC1 Mansfield, A1, 2, 3 Danells, CJ1, 3 McIlroy, WE1, 2, 4 Mochizuki, G1, 2, 3; 1. Heart and Rats with large lesions had greater behavioral deficits than rats with small lesions. The ip-
Stroke Foundation Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON; silesional M1 was bigger in rats with small lesions than with large lesions. No change was
2. Toronto Rehabilitation Institute, Toronto, ON; 3. Department of Physical Therapy, University observed in contralesional M1. Finally, size of the ipsi and contralesional premotor area changed
of Toronto, Toronto, ON; 4. Department of Kinesiology, University of Waterloo, Waterloo, ON 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
Background: Temporal synchronisation of force output from each lower-limb is an important in- both hemispheres. In the contralesional hemisphere, the reorganization of the premotor cortex
dex of standing balance control post-stroke1, which appears to be altered by post-stroke lower- is more sensitive to lesion size than is M1, and this area may play a greater role in postlesion
limb spasticity (LLS)2. While previous work has focussed on inter-limb temporal synchronisation recovery of the paretic forelimb or compensation with the non-paretic forelimb.
(time-domain), this study examines the time-varying fluctuations in inter-limb centre of pres-
sure (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 as- P2.049
sociated with post-stroke LLS. We hypothesized that individuals with LLS would exhibit greater Molecular Effects of Salt-Induced Hypertension on the Development of Acute
temporal desynchronisation, which would be associated with periods of reduced high-frequency Ischemic Stroke in Heterozygous ANP Gene-Disrupted (ANP+/−) Mice
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); Ventura, NM1 Peterson, NT1, 2 Tse, MY1 Wong, PG1 Jin, AY2, 1 Andrew, R1 Pang, SC1; 1. Queen’s
10 without spasticity, low impairment (No-LLS-LI)) was performed. Individual-limb and net-COP University, Kingston, ON; 2. Kingston General Hospital, Kingston, ON
displacements in both anteroposterior and mediolateral directions were calculated during 30
seconds of quiet-standing on adjacent force platforms. The time-varying relationship between Background: Hypertension (HT) is one of the leading risk factors for ischemic stroke. Although
individual limb COP displacements in the time- and frequency-domains was assessed using previous investigations have shown the role of HT in myocardial infarction (MI), the effect of salt-
short-time cross-correlation and magnitude-squared short-time coherence (MS-STC) functions, sensitive HT on cerebrovascular events during and after stroke is unclear. Thus our objective was
respectively. Average MS-STC was calculated within successive 1 Hz frequency bands (0-5 Hz). to assess cerebrovascular adaptations occurring in salt-induced hypertensive mice following acute
Results: The LLS group exhibited desynchronisation over a greater percentage of the trial dura- ischemic stroke. Four major vasoactive systems were targeted for this study - the natriuretic peptide
tion than the No-LLS or No-LLS-LI groups (52.4%;29.1%;7.1%;p<0.001). Contrary to our hy- system (NPS), nitric oxide system (NOS), renin-angiotensin system (RAS) and endothelin system
pothesis, time-varying inter-limb temporal synchrony was related to low-frequency (<1Hz) MS- (ETS), to better understand the role of salt-sensitive HT in the development stroke. Methods: Salt-
STC for all groups. There was no relationship between temporal desynchronisation and either sensitive ANP+/− mice were fed a high salt (HS) (8.0% NaCl) or normal salt (NS) (0.8% NaCl) diet for
the time-varying weight-bearing symmetry ratio or the net-COP displacement. Conclusions: 7 weeks to induce HT. Acute ischemic stroke was surgically induced by 30 min left middle cerebral
Reduced low-frequency, rather than high-frequency, MS-STC suggests that stroke patients with artery occlusion (MCAO) via intraluminal filament. Sham operated mice were used for control. Brain
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

and without LLS may experience difficulty modulating the affected-limb COP in response to slices (1mm) were obtained 24 hr post reperfusion and stained in 2,3,5-triphenyltetrazolium chloride
centre-of-mass dynamics3. While the precise mechanisms remain unknown, stroke patients (TTC). Infarct volume was measured using ImageJ software by two blinded observers. Systolic blood
with LLS appear to experience such challenges more frequently than those without spasticity. 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
1. Mansfield A, et al. NNR;2012;26:627-635. measured by real-time quantitative PCR in the fourth brain slice. Results: ANP+/− mice treated
2. Singer J, et al. Clin Biomech;2013,submitted. with HS developed HT, left ventricular hypertrophy and experienced significantly larger infarcts as
3. Zatsiorsky V. et al. Motor Control;1999;3:28-38. 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 expres-
P2.047 sion 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.
Dynamic Control of Pannexin 1 Expression Following Stroke

Swayne, L; Wicki-Stordeur, LE; Boyce, AK; University of Victoria, Victoria, BC


P2.050
Background: In the face of considerable cell death, the brain has a remarkable capacity for Hypothermia does not Influence Iron-induced Injury in Rat Models of
recovery following stroke. Currently, we are largely unable to optimize this innate process in part I­ ntracerebral Hemorrhage
due to knowledge gaps in our understanding of the underlying cellular and molecular mecha-
nisms. Pannexin 1 (Panx1) is a large pore ion and metabolite permeable channel that is thought Wowk, S; Ma, Y; Colbourne, F; University of Alberta, Edmonton, AB
to play a major role in mediating vulnerability of neurons in ischemia, in part through dysregula-
tion of ion fluxes and by initiating inflammatory responses that contribute to expansion of injury. Background: Hypothermia, used to treat cardiac arrest and neonatal hypoxic–ischemic encepha-
In addition to previously reported expression in mature neurons, and astrocytes, recent work lopathy, is undergoing clinical trials for ischemic and hemorrhagic stroke. Animal studies show a
from our lab indicates that Panx1 is also highly expressed in developing neurons and can modu- strong hypothermic neuroprotection against ischemia but little benefit for intracerebral hemorrhage
late their behaviours. Notably, Panx1 is activated by several stimuli in the post-stroke brain. (ICH). This is surprising because hypothermia attenuates several mechanisms of injury common
Given that activation of ion channels can often trigger changes in their expression levels, we to both stroke types such as inflammation and edema. This lack of benefit suggests hypothermia
investigated whether stroke-associated stimuli alter the expression of Panx1, as this could have 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
important implications for the innate recovery responses of several cell types following stroke.
from degrading erythrocytes. We evaluated whether hypothermia alters iron release and accumula-
Methods: To model stroke in mice in vivo, we induced photothrombosis in the sensorimotor
tion (i.e., hemoglobin breakdown), iron-induced cell death, and levels of iron-binding proteins and
cortex. We also examined the effects of a variety of stroke brain stimuli (elevated extracellular
antioxidants. Methods: Rats were given a striatal ICH and parenchymal non-heme iron levels were
potassium, adenosine triphosphate and oxygen and glucose deprivation) in several cell culture
measured either 3 or 7 days later. Behaviour was tested in those euthanized at 7 days. In all experi-
models. To determine Panx1 levels in these models, we used a combination of Western blotting
ments rats received either 72 hours of hypothermia (33°C; starting 12 hours post-ICH or 1 hour after
and live and fixed cell confocal immunofluorescence microscopy. Results: Here we provide
FeCl2 injection) or normothermia. A simplified model involving striatal injections of FeCl2 was used
evidence that Panx1 levels are dynamically regulated in a cell-type and region-specific way in
to evaluate iron-induced edema 1 and 3 days post-insult, as well as, tissue loss, neuronal degenera-
the post-stroke brain. These results were recapitulated in vitro. Conclusions: Together our data tion, and behavioural impairment 7 days post-insult. Finally, rats were given a striatal ICH and ferritin
indicate that Panx1 levels change over time following stroke and that this dynamic regulation and antioxidant levels were measured at 3 days. Results: Hypothermia did not delay the release
could play an important role in the innate repair and recovery processes. 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. Hy-
pothermia’s influence on ferritin and antioxidant levels is currently being analyzed. Conclusions:
P2.048 These results suggest that hypothermia is not targeting iron-mediated damage and it is possible that
The Effect of Cortical Lesion Size on the Reorganization of ispi and Contralesional hypothermia limits endogenous defense mechanisms (in progress). Through the use of combination
Motor Representations therapies, future research will focus on maximizing neuroprotection against ICH.

Touvykine, B1 Mansoori, BK1 Jean-Charles, L1, 2 Quessy, S1 Dancause, N1, 2; 1. Université de


Montréal, Montréal, QC; 2. GRSNC, Montréal, QC P2.051
Evaluating the Effectiveness of Southwestern Ontario’s Community Stroke
Following stroke, patients often have abnormal activation in the injured and intact hemispheres. Rehabilitation Teams
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 Allen, L1, 4 Richardson, M1 Meyer, M1, 4 Ure, D2 Jankowski, S2 Teasell, R3, 1; 1. Lawson Health
affects cortical reorganization in both hemispheres. We thus investigated how the size of cortical Research Institute, ARGC , London, ON; 2. St. Joseph’s Health Care, London, ON;
lesions influences the reorganization of the caudal and rostral forelimb areas, the rat’s equiva- 3. St.Joseph’s Health Care, Department of Physical Medicine and Rehabilitation, Parkwood
lent of the primary motor cortex (M1) and a premotor area respectively, in both the ipsi and con- Hospital, London, ON; 4. Western University, Department of Epidemiology and Biostatistic ,
tralesional hemispheres. In adult rats, endothelin-1 was used to induce lesions of either small or London, ON
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 Introduction: The Community Stroke Rehabilitation Teams (CSRT) provide a community-based
28 after lesion induction. At the end of the recovery period, the cortical organization of M1 and interdisciplinary approach to stroke rehabilitation. Our objective was to assess the effectiveness
the premotor cortex was evaluated with intracortical microstimulation techniques. Motor maps of the teams with respect to functional and psychosocial outcomes experienced by clients served
of animals with small and large lesions were compared to each other and to normal, control rats. by these teams. Methods: Functional and psychosocial outcome data was available at intake and
Effective lesion size was confirmed with histological reconstruction. discharge from the program, as well as at six-month follow up. Repeated measures ANCOVA and
Abstracts From the 4th Canadian Stroke Congress, 2013  e41
paired t-tests were performed as appropriate to assess patient changes between time points for de médecine, Université Laval, Québec, QC; 3. School of Physical and Occupational Therapy,
each outcome measure. Results: Data was available for 919 individuals (55% male) with a mean Faculty of Medicine, McGill University, Montreal, QC; 4. Feil-Oberfeld Research Centre,
age of 69.3 (±13.1) years. Significant improvements were found between intake and discharge Jewish Rehabilitation Hospital site of Centre for Interdisciplinary Research in Rehabilitation,
on the Hospital Anxiety and Depression Scale total score (HADS)(p<0.0001), HADS Anxiety sub- Montreal, QC
scale (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 par- After stroke, individuals with good clinical recovery of their affected arm may still report
ticipation (p<0.0001), memory (p=0.012), and physical (p<0.0001) domains of the Stroke Impact decreased use in ADLs. Decreased use may be associated with undetected deficits identi-
Scale (SIS). These improvements were maintained at 6 month follow up. Improvements on the fied when individuals attempt higher-order motor tasks requiring complex coordination.
Reintegration to Normal Living Index were significant between intake and discharge (p=0.037). One higher-order motor task, avoiding obstacles while reaching, commonly occurs in ev-
Follow up data was not available for this measure. Conclusions: Results indicate that the CSRT’s eryday environments but is not routinely assessed by clinical scales. We hypothesized that
were highly effective at improving the functional and psychosocial recovery of patients after stroke. well-recovered people after stroke would be less successful in avoiding an obstacle in the
Importantly, these gains were maintained at 6 month follow-up after discharge from the program. reaching path compared to healthy controls. Obstacle avoidance ability during reaching
Additional analyses are planned to further explore the impact of the CSRTs on patient recovery in a virtual environment was compared between groups. The environment simulated a
and the caregiving experience. This study shows the benefit of interdisciplinary outpatient stroke commercial refrigerator with shelves and sliding doors. Subjects reached as fast as pos-
rehabilitation provided in the patient’s home on functional and psychosocial outcomes. sible 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 with-
P2.052 out hitting the door. Overall success rates, movement performance and quality variables
Understanding the Experience of People with Communication Disability After for unobstructed (T), successful avoidance (Succ), and failed avoidance (Fail) trials were
Stroke Outside Their Home in Transaction Situations 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
Anglade, C1 Croteau, C2 Le Dorze, G2, 3; 1. Université de Montréal - CRIR - CRLB, Montréal, QC; subjects were successful >65% of the time. For both groups, successful door avoidance
2. Faculté de médecine-Orthophonie et audiologie Université de Montréal, Montreal, QC; was characterized by changes in the trajectory path occurring closer to the starting posi-
3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, QC tion. 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
Rationale: People with communication disability (PWCD) after stroke show decreased social controls to achieve success. Results suggest that stroke subjects had residual movement
participation, including fewer outings (Dalemans, De Witte et al 2010). However, few reports deficits revealed through a challenging motor task. The potential of using challenging
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017

concern how PWA communicate outside their home intransactional situations with unfamiliar tasks to identify higher order motor control deficits should be considered when assessing
people. Since such transactions occur in natural communication contexts (Traverso, 2009), post-stroke motor recovery.
we anticipate that they will differ from traditional communication assessments undertaken by
speech and language pathologists (SLP). Objectives: 1) Describe how PWCD interact/commu-
nicate when shopping; 2) understand the experience of PWCD when shopping; 3) understand P2.055
the experience of shop-keepers when interacting with PWCD; 4) engage SLPs in reflecting on “Care” and “Cure”
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 Barreau, J; Belson, L; Villa medica, Montreal, QC
in rehabilitation. Design: We will undertake multiple qualitative case studies with PWCD. Par-
ticipants WCD will be accompanied individually by the researcher during visits at two shops and
The aim of the study was to measure patients’ expectations of Villa Medica Rehabilitation
interactions will be recorded as they occur naturally in a shopping outing. The researcher will
Hospital in terms of humanism: the “care”. The survey was conducted from June to December
employ participant observation for the analysis of the live portion of data collection and conver-
2012. Data collection was made possible through questionnaires given to interested patients
sational analysis for the filmed interactions. After each transaction, a short qualitative interview
and was stored using Excel 2010. Statistical analysis were made using SPSS 16.0 for Win-
will be conducted with shopkeepers to determine his/her views of the interaction with the PWCD.
dows. Divided in two strata, the questionnaire looked, in the first place, patients’ satisfaction;
Before and after each outing, a semi-structured interview will be conducted with participants
while it opened, in the second place, to the patients’ expectations in terms of humanism. Three
with PWCD to understand their experience. As the results emerge, these will be provided to SLP
indices emerged. The first index is the “active listening”. 80 % of the questioned patients
participants who will be invited to reflect upon them and discuss practice options for such com-
munication interactions. Preliminary results from this Ph.D. research project will be provided. 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
Scope: This project will help to understand the experience of PWCD in natural communication second index is the “group talk”. 20 % of the patients expressed a desire to share with one (or
situations and influence aphasia/dysarthria rehabilitation. 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
P2.053 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 interdis-
Effect of BMI on Inpatient Rehabilitation Outcomes after Stroke ciplinarity: is it only controlled by the sharing of expertise or, more exactly, is it unified by the
principle of humanism?
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 P2.056
associated with increased lengths of stay (LOS) and decreased FIM® efficiency. However, a grow- Validation de contenu d’un outil d’évaluation de la compréhension syntaxique de
ing body of clinical data suggests a survival benefit (e.g., decreased mortality rates) for overweight personnes ayant une aphasie
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 Bergeron, A3 Bourgeois, M3 Fossard, M2 Desmarais, C1 Lepage, C3; 1. Université Laval,
in findings, this study sought to examine the impact of BMI on inpatient rehabilitation LOS and Québec, QC; 2. Université de Neuchâtel, Neuchâtel, Switzerland; 3. Institut de réadaptation en
functional outcomes following stroke using a large pan-Canadian dataset. Methods: Using data déficience physique de Québec, Québec, QC
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/ L’aphasie est la perte partielle ou totale du langage qui peut survenir à la suite d’une lésion céré-
m2), normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), moderate obesity (30 - 39.9 kg/ brale. Les personnes ayant une aphasie peuvent présenter des difficultés de compréhension
m2), and severe obesity (≥40 kg/m2). A Poisson regression model was used to analyze the effect touchant spécifiquement les phrases. La recherche a montré que le processus de compréhen-
of BMI group on LOS when adjusted for age, sex, stroke type, number of pre-admit comorbidities, sion de phrases se fait en plusieurs étapes, et que les personnes avec une aphasie peuvent
discharge destination, province of residence, socio-economic status, and presence of depression, éprouver des difficultés à l’une ou l’autre de ces étapes. Or, en clinique, ces distinctions sont
hypothyroidism, congestive heart failure, hypertension and diabetes. Results: Patients in this study rarement prises en compte lors de l’élaboration des épreuves d’évaluation. Pour pallier cette
sample had a mean age of 69.9 years. After adjusting for multiple covariates, overweight and mod- lacune, un nouvel outil a été créé à l’Université Laval : la « Batterie d’évaluation de la com-
erately obese patients demonstrated shorter LOS compared with those in the normal BMI group préhension syntaxique » (Caron, LeMay & Fossard, 2010). L’objectif de la présente étude a été
(both p<.0001), whereas LOS was significantly longer in underweight (p<.0001) and severely de documenter la validité de contenu de la batterie. Pour ce faire, un questionnaire de validation
obese (p<.01) patients compared to normal-weight patients. Moderate and severely obese patients a été élaboré afin d’évaluer différents aspects de la batterie tels que la clarté des consignes
experienced the greatest increases in FIM® scores from admission to discharge. Conclusions: Fol- et des images, la qualité des items-tests et la pertinence clinique. Trois chercheurs et neuf
lowing stroke, overweight and moderately obese patients had shorter stays in inpatient rehabilita- orthophonistes ont été sollicités pour compléter le questionnaire. Les données recueillies ont
tion with equivalent functional improvements compared to patients with a BMI in the normal range. 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
P2.054 choix de certains items-test, la formulation des consignes et la configuration des grilles de nota-
Residual Motor Deficits Revealed Using a Complex Reaching Task in Individuals tion du test. L’équipe de recherche a effectué les modifications à l’outil initial afin d’en arriver à
with Good Arm Recovery After Stroke 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
Baniña, MC3, 4 McFadyen, BJ2, 1 Levin, MF3, 4; 1. Centre Interdisciplinaire de Recherche en d’intervention plus spécifiques. Des étapes ultérieures de validation et de normalisation sont
Réadaptation et Intégration Sociale, Québec, QC; 2. Département de réadaptation, Faculté également envisagées.
e42  Stroke  December 2013
P2.058 largest improvements in their ABC, there were no related improvements in the other domains.
Common Forms of Vascular Cognitive Impairment in a Canadian Inpatient Stroke Conclusions: Confidence is often overlooked in assessments post stroke and may be an in-
Rehabilitation Sample dependent factor contributing to functional outcomes. Longitudinally, the lack of association
between physical recovery and change in confidence supports the idea that confidence is not
Carter, SL1, 2 DeFreitas, VG1; 1. QEII Health Sciences Centre, NS Rehabilitation Centre, Halifax, simply a product of physical ability and is a potentially important and independent characteristic
NS; 2. Dalhousie University, Halifax, NS that may influence stroke recovery.

Background: Canadian best practice recommendations for stroke care include screening and
assessment for vascular cognitive impairment (VCI). Specific forms of VCI may be under-identi- P2.061
fied in Canadian inpatient rehabilitation units given high screening rates but low comprehensive A Randomized Controlled Study Assessing the Effectiveness of Aphasia-Friendly
assessment rates (McClure et al., 2012). Identifying common forms of VCI in inpatient settings Schedules on Therapy Attendance
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 Collins, D1 Marcoux, C1 Modha, G1 Poirier, B1 Silverberg, ND1, 2 Louie, S1; 1. Vancouver Coastal
who completed a brief neuropsychological assessment (NAB Screening Module). Two cases Health-GF Strong Rehab, Vancouver, BC; 2. Division of Physical Medicine & Rehabilitation,
were excluded due to language barriers. Mean age was 55.4 years, mean education was 12.3 Faculty of Medicine, University of British Columbia, Vancouver, BC
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 Background: A person living with aphasia faces language-based barriers, analogous to people
subtest scores; correlates of low scores were investigated via Pearson-r. Results: Compared with physical disabilities living in inaccessible environments. Although stroke rehabilitation
to age and education-corrected norms, impairment rates were highest on indices of attention/ centers are physically accessible, clients with aphasia may have difficulty navigating them.
speed (A/S; 51%) and executive functions (EF; 24%), with lowest mean scores on timed can- Frequent tardiness or missed therapy appointments may limit rehabilitation gains. The pur-
cellation subtests. Mean indices of language, memory, and visuospatial skills were average. pose of this study was to compare the ability of clients with aphasia in an inpatient stroke
34% of the sample scored < 5th percentile on a summary index of global cognitive function. rehabilitation setting to independently attend therapy appointments when provided with a
Speeded attention and mental flexibility was strongly correlated with global cognitive function picture-based schedule versus a traditional text-based schedule. Methods: A parallel group
(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 open-label design was utilized. Twenty seven participants with post-stroke moderate to severe
cognitive function was also correlated with simple speeded attention and sequencing (Trails A aphasia, as indexed by the Boston Diagnostic Aphasia Examination, were randomly assigned to
r=-0.46, p<0.01). A/S and EF indices correlated modestly with letter fluency (r=0.42 p<0.01 a control group (text-only schedule; n=15) or an experimental group (picture and text schedule;
and r=0.36 p<0.05, respectively); only EF correlated with animal fluency (r=0.43, p<0.01). n=12). Over the 15-day study period, therapists completed an attendance record for each par-
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Conclusions: A/S and EF are most frequently affected in a Canadian inpatient stroke rehabilita- ticipant. The primary outcome was the proportion of independently attended therapy sessions.
tion sample, consistent with domain-specific classification rates in chronic stroke (Stricker et al, Independent attendance could involve physical assistance by another person if directed by the
2010). These findings guide targeted cognitive rehabilitation programming for inpatient stroke participant. Results: The intervention effect was not significant (F=2.02, p=.17), with a trend
survivors. 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
P2.059 from this pilot study suggest that the addition of pictures to a text-based therapy schedule may
The Journey to Better Stroke Care at North York General (NYG) 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
Chin-Curtis, LA; Carley, T; Ramdeyall, S; Villar-Guerrero, E; North York General, Toronto, ON with more severe aphasia.

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 P2.062
improve outcomes for newly diagnosed stroke patients by aligning with Canadian Best Practice Development of a Clinical-Research Platform: Baseline Portrait of the Intensity
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
of Interventions in the Stroke Unit of the Institut de Réadaptation en Déficience
team assessment, as time and resources permitted 5 days/week, completion of the Alpha-FIM Physique de Québec (IRDPQ)