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
Patients with Acute Ischemic Stroke
Qazi, A1, 3 Eesa, M1, 2 Qazi, E1, 3 Goyal, M2, 1 Demchuk, A1, 4, 3 Menon, B1, 4, 3; 1. Calgary
Stroke Program, Calgary, AB; 2. Department of Radiology , Calgary, AB; 3. University of
Calgary, Calgary, AB; 4. Department of Neurology, Calgary, AB
Introduction: Clot length on CT/CTA has been used to predict recanalization with thrombolytic
treatment in patients with acute ischemic stroke(AIS). We compared different techniques of
measuring clot length on CT/CTA to identify the most reliable method. Methods: 4 1 patients
with M1-MCA occlusions from INTERRSeCT, a prospective imaging based cohort study of
AIS patients, were included. Hyperdense sign was measured on NCCT(5mm slice thickness).
Clot length was measured on CTA at 3mm and 24mm-slices in the axial and coronal plane
by:1) measuring the non-visualized segment of M1-MCA and 2) calculating ratio of residual
lumen length within M1-MCA segment to length of contralateral patent M1-MCA segment.
Two readers analyzed all images independently and were blinded to CTA when reading NCCT.
Level of concordance between raters for each method was calculated using Cohen’s kappa
for categorical variables and Intra-class Correlation Coefficient(ICC type2, single measure). A
method has high inter-rater reliability if the level of concordance is high. Results: Measuring
residual lumen ratio on CTA(3mm) is the most reliable technique for measuring clot length.
Measuring length of hyperdense sign on NCCT is fairly reliable. Direct clot length measure-
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
ments on CTA are only reliable if done on 24mm CTA slices using MIP. Conclusion: Reliability
of clot length assessment and its interaction with treatment type in predicting recanalization
depends on the type of imaging modality and technique used. CTA remains the best tool to
measure clot length.
O1.2
New Approaches to Fast Stroke Imaging with Magnetic Resonance
Yerly, J2 Lauzon, M1 Lebel, R3, 1 Sevick, RJ1 Barber, PA1 Frayne, R1; 1. University of
Calgary/Foothills Medical Centre, Calgary, AB; 2. CIBM/CHUV-MR, Lausanne, Switzerland;
3. General Electric Healthcare, Calgary, AB
Background: A guiding maxim in acute ischemic stroke (AIS) treatment is ‘time is brain’.
Rapid imaging and prompt diagnosis are essential. MR can provide important information but
requires a long acquisition. In contradistinction, non-contrast-CT imaging can provide a rapid
assessment of hemorrhage/ischemia. Decreasing acquisition time for MR would remove this
drawback. Potentially the total scan time for a fast MR protocol might rival the time re-
quired for combined non-contrast CT, CTA and CT-perfusion scans. Methods: Application of
emerging MR image acceleration techniques can speed-up AIS assessment. A ­combination
e1
reducing acquisition times by factors of ≥2×. In volunteers PI and CS techniques were evalu-
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
number of AIS imaging sequences and in volunteers, the combination of CS and the SENSE
PI method performed the best of the evaluated acceleration techniques. The Sparse-SENSE
method was used to successfully speed up time-of-flight MRA in a group of AIS patients.
Image quality was preserved, and no major image artifacts were introduced. Figure shows
an AIS patient with an occluded right middle cerebral artery. Conclusions: Accelerated MR
imaging approaches hold much promise for reducing acquisition time in AIS. Acquisition time
reductions of >2x are possible.
O1.3
Validation of pCT-derived parameters on H215O-PET measured CBF in
ischemic stroke
Heiss, W1 Zaro Weber, O1, 2 Sobesky, J2; 1. Max Planck Institute for Neurological Research,
Cologne, Germany; 2. Center for Stroke Research and Dept. of Neurology, Charite Berlin,
Berlin, Germany
Background: The accuracy of perfusion computed tomography (pCT) based relative
maps of cerebral blood flow (rCBF-CT), cerebral blood volume (rCBV-CT), mean transit
time (rMTT-CT) and time to peak (rTTP-CT) in acute stroke remains a matter of de-
bate. We validated these relative maps on quantitative CBF measurement by 15O-water
positron emission tomography (CBF-PET) with respect to penumbral flow (< 20 ml/100g/
min). Methods: pCT was performed on a Philips 64-row CT scanner (6 mm slice 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.
O1.4
Optimizing Acute Stroke Imaging for Maximizing Information and Minimizing
Acquisition, Post Processing and Interpretation Times: Analysis of Data From
PROVE-IT, a Prospective Imaging Cohort Study
Menon, B; Almekhlafi, M; Demchuk, A; Goyal, M; University of Calgary, Calgary, AB
Introduction: To compare utility and efficiency of perfusion CT (PCT) with multiphase
CTA (mCTA) in making treatment decisions in patients with acute ischemic stroke.
Methods: mCTA (patent pending) is a new technique capable of identifying site of arterial
occlusions and degree of pial collateralization distal to occlusion better than conventional
CTA. Data is from PROVE-IT, an ongoing prospective cohort study of patients with acute
ischemic stroke at our center. All patients undergo NCCT followed by mCTA and PCT.
Two readers interpreted NCCT and mCTA by consensus. Results: In 70 patients (median
age 67, 49.3% male), median baseline NIHSS was 10 (IQR 13), median onset to CT time
in those with witnessed stroke onset was 101 mins (IQR 138) and median baseline 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
 e2  Stroke  December 2013
Background: The clinical significance of periodic limb movements during sleep (PLMs) is
­unknown. PLMs are associated with transient but significant increases in night-time blood
pressure and autonomic hyperactivity; emerging evidence suggests a link with vascular dis-
ease. While obstructive sleep apnea (OSA) may be associated with white matter hyperintensi-
ties (WMH), the relationship between PLMs and WMH is unclear. Methods: We prospectively
recruited high-risk TIA or minor stroke patients who presented within two weeks of their acute
cerebrovascular events. Patients underwent polysomnography as well as magnetic resonance
imaging (MRI) or computed tomography (CT) of the brain. Polysomnography was scored accord-
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
ARWMC and age, gender, infarction volume, vascular risk factors (VRFs), prior vascular events,
polysomnography parameters, cognition and neurological status. Significant variables were en-
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
with stroke. VRFs included: hypertension (50%), hyperlipidemia (51%), diabetes (23%), and prior
stroke (20%). The mean ARWMC score was 6.95 (range 0-22). ARWMC score correlated with
PLM index (r=0.377, p=0.016) and presentation with acute stroke (rho=0.418, p=0.007), but
not age, VRFs, infarction volume, apnea-hypopnea index or other variables. Linear regression
analysis revealed that PLM index (β=0.377, R^2=0.142, p=0.016) had the strongest associa-
tion with the ARWMC. Conclusions: PLM index was positively associated with the extent of
white matter hyperintensities. Whether PLMs are implicated in the pathogenesis of WMHs or are
simply a marker of vascular disease remains uncertain. Future studies should explore causal-
ity with vascular disease, and whether treatment of PLMs reduces incident vascular disease.
O1.6
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2007 (p=0,002). Les analyses ajustées pour les caractéristiques et la gravidité des patients montrent
un majeur suivi du dépistage de la dysphagie parmi les cas admis en neurologie (OR : 5,28, IC 95%,
1,35 à 20,6) et/ou dans les centres de plus de 300 admissions/année par AVC (OR : 4,31, IC 95%,
1,04 à 17,8) ainsi que de l’éducation au patient/famille quand le patient est admis en fin de semaine
(OR : 1,62 IC 95%, 1,03 à 2,54). Discussion : L’évolution dans le suivi des recommandations montre
que la qualité des soins infirmières aux personnes ayant subi un AVC s’améliore progressivement en
Catalogne. Toutefois, une amélioration de certaines recommandations est possible. Ainsi, il s’avère
nécessaire de renforcer et promouvoir des interventions plus ciblées et spécifiques.
O2.1
Improved Methods for Longitudinal Motor Mapping After Stroke in Mice:
Automated Movement Tracking with Accelerometers, and Chronic EEG
Recording in a Bilateral Cranial Window Preparation
Silasi, G; Harrison, T; Boyd, J; LeDue, J; Murphy, TH; University of British Columbia,
Vancouver, BC
Longitudinal motor mapping through optogenetic stimulation of the mouse cortex can be used to
reveal cortical reorganization following stroke. Here we present a refined set of procedures for
repeated light-based motor mapping in ChR2-expressing mice implanted with a bilateral cranial
window and a chronic EEG electrode. Light stimulation was delivered sequentially to over 400
points across both cortical hemispheres, and evoked movements were quantified on-line with a
3-axis accelerometer attached to each forelimb. Bilateral maps of forelimb movement amplitude
and movement direction were generated at weekly intervals before and after photothrombosis
targeted to the centre of the forelimb motor cortex. During baseline mapping, light pulses of ~2
mW produced well-defined maps that were centered approximately 0.7 mm anterior and 1.6

Interprovincial Collaboration for Creating Stroke Units in Western Canada
Kamal, N1 Suddes, M2 Collier, T3 Hill, MD2 Dawson, A4 Calder, J3 Harris, D1 LoChang, J1 Newton,
D5 Foster, D6 Harrison, K4 Seeley, L7 Arsenault, S8 Hennessy, B9 Aikman, P1; 1. Stroke Services
BC, Vancouver, BC; 2. Calgary Stroke Program, Calgary, AB; 3. Royal Inland Hospital, Kamloops,
BC; 4. Fraser Health Authority, Surrey, BC; 5. Saskatoon Health Region, Saskatoon, SK; 6.
Vancouver Island Health Authority, Victoria, BC; 7. Interior Health Authority, Kamloops, BC; 8. Van-
couver Coastal Health Authority, Vancouver, BC; 9. Northern Health Authority, Prince George, BC
Background: Stroke Unit (SU) care holds the strongest evidence for reduced mortality and dis-
ability due to stroke. However, according to the 2011 Canadian Stroke Network’s National Stroke
Audit, 23% of stroke patients in Canada were admitted to a SU with BC falling far behind the
national average at only 4%. Method: Using the Improvement Collaborative methodology, a SU
Collaborative was launched by Stroke Services BC, a program of the Provincial Health Services
Authority. Faculty members were recruited from BC and the Calgary Stroke Program. The goal of
the Collaborative is for teams to work towards the creation of new SUs or to improve SU care where
SUs exist. The Collaborative has 4 Learning Sessions, a closing workshop, and bi-weekly webinars.
Teams follow a structured 7-step framework: understanding current volumes; securing space;
establishing the team; ensuring clinical best practice; creating processes for team communica-
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
polling during the Learning Sessions. Teams submit outcome and process data and report on their
progress. Results: Ten teams have enrolled representing the entire province of BC and Saskatoon.
Teams are either working at the hospital or health authority level. Thus far, plans are under way for
the creation of 64 new SU beds in BC, and 12 beds recommended for Saskatoon Health Region.
Results will be presented demonstrating the progress made with respect to change in self-report
of best practice, teams’ progress, and the impact on process and outcome measures. Conclusion:
The creation of new SUs is possible through an interprovincial collaborative approach with partici-
pation from BC, the Calgary Stroke Program, and the Saskatoon Health Region. This is possible
by utilizing the Collaborative approach and through a structured framework for creating new SUs.
mm lateral from bregma. Map borders were defined by sites where light stimulation evoked
EEG deflections, but not movements. Following stroke injury, which destroyed the majority of
the forelimb representations in one hemisphere, we did not see the emergence of new cortical
sites in the injured hemisphere. Instead, movements of the impaired forelimb could be evoked
by stimulation of the ipsilateral (uninjured) hemisphere. Smaller strokes targeted to a portion
of the forelimb motor map did not decrease the total area of forelimb motor representation but
produced more disorganized maps as measured by the local spatial correlation of each map
point. We demonstrate that our method may be used to chronically assess evoked motor output
and post-stroke reorganization. In addition to providing a more complete assessment of forelimb
function, our bilateral preparation affords a within-subject control for anesthetic levels during
mapping by comparing motor output between the intact and injured hemispheres.
O2.2
The Role of Neurovascular Coupling in Stroke Recovery
Lake, EM1 Stanisz, G1, 2 Stefanovic, B1, 2; 1. Sunnybrook Health Science Centre, Toronto, ON;
2. University of Toronto, Toronto, ON
Background: This work combines MRI with behavioral testing to assess the effect of well-
timed, low-dose alpha5-subunit-GABA R antagonism (using L-655,708) on recovery in a
well established model of focal ischemia . By administering a selective GABA-antagonist, we
attempt to support the restoration of normal neuronal activity by ameliorating hypo-excitability
in the chronic stage of recovery. Methods: 6 adult male Sprague Dawleys received intracortical
injections of endothelin-1. MRI was performed prior to stroke and at weekly intervals following
ischemia for 3 weeks. Beginning 7 days following stroke, and continuing for 14 days, animals
received subcutaneous pills containing 1.5mg L-655,708 in 58.5mg of HPMV, NTreated=3,
or 60mg of HPMV, NControl=3. Results: The pronounced deficit in reaching ability seen 1
week following ischemic insult improved significantly more (p=0.0097) in the treated group.

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

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 ≥
90 days since event (n=11, beta=4.48, P=0.01), after adjustment as described above. Conclu-
sion: These results suggest that CEC is inversely associated with severity of carotid stenosis
and that CEC increases with increasing time since symptomatic event. This may be related to
remodeling of HDL during the acute phase reaction after a recent ischemic event.
O2.4
Multi-modality Neuroimaging in a Porcine Model of Endothelin-1 Induced
Cerebral Ischemia: Defining the Acute Infarct Core
d’Esterre, C1 Aviv, R1 Fainardi, E3 Lee, T4; 1. University of Calgary, Calgary, AB; 2. Sunnybrook
Health Sciences Centre, Toronto, ON; 3. Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy;
4. University of Western Ontario, Robarts Research Institute, Lawson Health Research , London, ON
Background: CT perfusion (CTP)-derived parameters and MR-diffusion weighted imaging
(DWI) are currently used to delineate infarct volume; however, reversibility of such defects
has been demonstrated for both modalities. Methods: Ten domestic pigs had a CTP scan prior
to intracranial injection of endothelin-1 (ET-1;0.01mL/kg) into the left striatum. CTP scans
at 30min, 1hr, 1.5hrs were done to monitor ischemic progression. A second dose of ET-1
(0.01mL/kg) was injected at 2hrs from the first injection. Twenty minutes after the second ET-1
injection, 18F-FDG was injected(300-380MBq). The animal was moved to a 1.5T MRI scanner
where DWI was performed. The animal was then moved back to the CT scanner for a final
CTP/PET acquisition within 10 minutes of the DWI. The brain was quickly removed and stained
with tetrazolium-chloride (TTC). The infarct volume defined by low intensity TTC stain, low CBF
(<9.3ml•min^-1•100g^-1), low CBV (<1.07ml•100g^-1), DWI hyper-intensity and low 18F-
FDG uptake were determined. Linear regression was used to correlate the infarct volume 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.
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-
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
overestimated the TTC-infarct core in 66% and 58% of cases, while CTP-CBV, CBFxCBV and
FDG-PET all underestimated the final infarct volume in 100% of animals. The CBF/CBV mis-
match was observed within 4/12 DWI lesions, and 3/12 TTC defined infarcts(Figure). The CBF/
CBV mismatch may not represent penumbra during the acute stroke setting.
O2.5
Quantitative CBF Measurement with CT Perfusion: Is it Correct to Correct the
Partial Volume Averaged Arterial Input curve with Venous Output Curve
Lee, TY1, 2 Menon, BK2 Eesa, M2 Goyal, M2 Demchuk, A2 Frayne, R3; 1. Lawson Health Research
Institute, London, ON; 2. Foothills Medical Centre, Calgary, AB; 3. Seaman Family MR Research
Centre, Calgary, AB
Introduction: To accurately measure cerebral blood flow (CBF) with CT Perfusion, the partial
volume averaged arterial input curve (AIF) is corrected by the ratio of the areas of the AIF and
venous output curve (VOC). This correction method assumes that the VOC is dispersed (widened)
with respect to the AIF but the areas underneath each are the same if the AIF is not partial vol-
ume averaged. We investigated the validity of this assumption in acute stroke patients. Method:
Twelve CT Perfusion studies from stroke patients admitted from March to April 2013 in which
the intracranial internal carotid artery or the basilar artery at level of the pons was visible in
one or more slices were chosen. As the diameters of both artery segments (3.6 and 3.2 mm
respectively) are larger than the limiting resolution (< 1 mm) of the scanner, AIF measured in
them would be minimally affected by partial volume averaging and hence can be used to test the
above assumption. A circular region of interest (ROI) of diameter 1.4 mm was placed in either
the intracranial ICAs or the basilar artery to generate time density curves. The curve with the
highest peak was accepted as the AIF. A similar sized circular ROI was placed at the posterior
portion of the superior sagittal sinus in all slices. The venous curve with the highest peak was
accepted as the VOC. The areas under the AIF and VOC were calculated. Results: The ratios of
the AIF and VOC areas among the twelve CT Perfusion studies were significantly greater than 1.0
(P<0.01; mean ± SD: 1.8 ± 0.7) leading to CBF values that were 1.8 times smaller on average.
Conclusions: Retrograde flow from collaterals likely causes breakdown of the VOC based partial
volume correction method resulting in significant underestimation of CBF.
O2.6
Intracerebral Hemorrhage in Rat Causes Edema and Raised Intracranial Pressure
Hiploylee, C; Colbourne, F; University of Alberta, Edmonton, AB
Background: Intracerebral hemorrhage (ICH) sometimes leads to life-threatening elevations in
intracranial pressure (ICP) that arise from the hematoma mass effect and edema. Whereas not
all patients experience large changes in ICP, it remains a significant concern and predictor of
mortality. Animal studies commonly rely upon edema as a primary endpoint. However, the role
of edema in affecting ICP and the importance of these variables are not clear in the common
rodent ICH models. Methods: Radiotelemetry was used to measure ICP in freely moving, awake
rats (Silasi, MacLellan and Colbourne, 2009). The widely used collagenase model was used
to create a severe ICH that destroys much of the striatum. ICP readings were collected in the
epidural space or in the center of the hematoma for 3 days. This comparison was to discern the
optimal monitoring location. Additional studies, in progress, are evaluating changes in cerebral
perfusion pressure in this setting, and the effects of hematoma size and model on ICP. Results:
Severe ICH resulted in much higher water content (86.05% ± 1.12 SD, p<0.001) and ICP (10.92
mmHg ± 2.93 SD, p<0.001) than shams (77.85% ± 0.73 SD; 4.33 mmHg ± 2.43 SD) with no
difference between epidural and intraparenchymal monitoring. Overall mortality is low but it 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
lead to new biomarkers of recovery after stroke. We aimed to characterize the relationship
between measures of white and gray matter structure within the primary cortical motor out-
put system and paretic arm function in chronic stroke. Twenty-seven individuals with chronic
(>6months) stroke (mean age:65±9.7 years,6F) underwent a single magnetic resonance imag-
ing scan and completed an assessment of upper extremity motor function (Wolf Motor Func-
tion Test or WMFT). A high-resolution T1 and a 60-orientation high angular resolution diffusion
imaging scan were acquired and processed using the Freesurfer image analysis suite and Ex-
ploreDTI software package. Bilateral precentral gyral thickness and mean fractional anisotropy
(FA) of the corticospinal tract were extracted for analysis. Fiber tractography was performed
using a tensor-free fiber orientation algorithm. The WMFT consisted of fifteen timed movement
tasks. A rate score was calculated for each task and averaged across all tasks bilaterally. Paired
samples t-tests and multiple regression analyses were performed to examine hemispheric dif-
ferences and evaluate the association between brain structure and arm function. Significant
hemispheric differences in corticospinal tract FA and precentral gyral thickness were observed
(both p<0.0005). WMFT scores also differed between paretic and non-paretic arms (p=0.003).
Ipsilesional tract FA explained a significant amount of variance in paretic WMFT scores after
accounting for age and post-stroke duration (R2=0.44, p=0.013). Cortical thickness did not ex-
plain an additional significant amount of variance in motor function. Hemispheric differences in
measures of gray and white matter structural status were observed. Only ipsilesional descend-
ing motor output tract status was positively associated with paretic arm function in chronic
stroke. These imaging techniques may be used in future work to predict and evaluate response
to rehabilitation.

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
identify dysfunctional cortex. Results: Compared to controls, stroke patients exhibited signifi-
cant decreases in MF and MSE in tissue surrounding the core lesion. MSE was a more specific
indicator of perilesional abnormalities, as MF was also affected by general changes seen in
aging. Furthermore, reduced complexity of resting signals in perilesional cortex was correlated
with reduced responsiveness in a language comprehension task.
Conclusions: Perilesional “slowing” can be accurately mapped and quantified using MEG.
This technique offers a new way to assess “functional lesions” in stroke and also progressive
disease.
O3.3
Telehealth for Speech-Language-Swallowing Post Stroke: 500 Camera Hours
Baird, AJ1 Smook, C2; 1. SpeechWorks Inc, Winnipeg, MB; 2. Northern Regional Health
Authority, Thompson, MB
At 324,000 square kilometres, covering 52 percent of the province, the Northern Regional Health
Authority (NRHA) is the largest geographical health region in Manitoba. Until 2008, there were
no adult speech-language pathology services for the region and those requiring assessment
and treatment post stroke were flown to Winnipeg for their rehabilitation services. In 2008, the
region added 3 days of adult speech-language services per month, where the speech patholo-
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-
toba Patient Access Network provided the opportunity to investigate the impact of assessment
and weekly treatment provided using telehealth services. The purpose of this presentation is
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to report the outcomes of those assessments and subsequent therapies. Participants for the
program were selected from an existing caseload or were referred from health care providers
both in either the acute or chronic phase. All participants with communication disorders were
assessed using standardized tools, scheduled for weekly therapy sessions and given an iPad to
complete homework activities. The NRHA staff was trained to screen for swallowing disorders
and refer as indicated to speech-language services for recommendations. Of 31 participants,
11 were treated for aphasia, 8 were treated for dysarthria, 8 were treated for cognitive linguistic
deficits, and 8 were treated for swallowing disorders post stroke. For those with aphasia, all
post testing results trended upwards. Subjective improvements were reported with all those
with dysarthria. There were no reports of pneumonias in participants assessed for swallowing
disorders. Conclusions: Speech and language treatment provided once a week using telehealth
produces positive outcomes in people post stroke in all stages of recovery. Providing these
services by telehealth is an acceptable and cost effective solution for stroke treatment provided
by speech-language pathologists.
O3.4
Imaging Correlates of rTMS Treatment for Post-Stroke Aphasia: a Randomized
Controlled Study
Thiel, A1 Anglade, C2 Hartmann, A3 Heiss, W4, 5; 1. Jewish General Hospital, Montreal, QC;
2. Universite de Montreal, Montreal, QC; 3. Rehanova, Cologne, Germany; 4. Max-Planck
Institute for neurological researc h , Cologne, Germany; 5. McGill University, Montreal, QC
Background: Single case reports and small case series suggest that the effect of conventional
speech and language therapy (SLT) for recovery of language from post-stroke aphasia may
be augmented through modulation of activity in language networks by repetitive transcranial
magnetic stimulation (rTMS). Here we report the results of a first randomized and controlled
study in subacute post-stroke aphasia and the effect of rTMS on reorganization of language
networks during the recovery process. Methods: We studied 24 right-handed patients with sub-
acute post-stroke aphasia. Within 4-8 weeks after stroke, patients were randomized to a 10 day
protocol of 20 minutes inhibitory 1Hz rTMS over the right posterior inferior frontal gyrus (pIFG)
or sham stimulation followed by 45 minutes of deficit specific SLT. Language network activity
was measured with O-15-water Positron Emission Tomography during verb generation before
and after treatment. Total left and right hemisphere network activity was quantified by activation
volume indices (AVI) with positive indices indicating larger networks in the left-hemisphere and
negative indices larger volumes in the right hemisphere. Language performance was assessed
using the Aachen Aphasia Test battery (AAT). Results: Global AAT score change, was signifi-
cantly higher in the rTMS group (t-test, P=0.003). The rTMS effect was strongest for the subtest
naming (2 factor RM-ANOVA, P=0.002) but a trend was also observed for comprehension, to-
ken-test and writing (P<0.1). Patients in the rTMS group activated proportionally more voxels in
the left-hemisphere (positive AVI) after treatment than before compared to sham treated patients
(2 factor RM-ANOVA, P=0.027 within group, P=0.045 between groups).There was a moderate
but significant linear relationship between post-treatment AVI and global AAT score change
(r2 = 0.19, P=0.04). Conclusions: Inhibitory rTMS over the right pIFG in combination with SLT
favors the recruitment of left hemispheric language networks and significantly improves lan-
guage recovery in subacute ischemic stroke.
O3.5
Functional Electrical Stimulation Therapy for Upper-Limb Motor Recovery in
Pediatric Stroke Patients with Severe Long-Term Impairment
Kapadia, NM1 Popovic, MR1, 2; 1. Toronto Rehabilitation Institute, Toronto, ON; 2. University of
Toronto, Toronto, ON
Background: The average annual incidence of stroke in children is 2.7 in 100 000, many
of which result in permanent residual cognitive and/or physical impairments. Success-
ful clinical trials of adults have shown that functional electrical stimulation (FES) therapy
can restore voluntary arm and hand function in people with severe stroke; however, the
literature failed to identify trials in which FES was used in a paediatrics stroke popula-
tion. As such, this study was designed to examine functional changes in the upper limb
of severe chronic paediatrics stroke patients following intensive FES therapy, consist-
ing of task-specific upper-limb movements with a combination of preprogrammed FES
and manual assisted motion. Methods: Four severe chronic paediatric stroke participants
were ­assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality
of Upper Extremity Skills Test, Paediatric Evaluation of Disability Inventory, and Assisting
Hand Assessment. FES therapy was administered for 1 hour three times per for 16 weeks,
for a total of 48 treatment sessions. Results: All participants improved on all measures.
Subjects demonstrated an average increase on Rehabilitation Engineering Laboratory Hand
Function Test components of 14.5 for object manipulation (P = .042), 0.78 Nm for instru-
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).
Conclusion: FES therapy with upper-limb training may be an efficacious intervention for pae-
diatric patients with severe stroke.
O3.6
A Longitudinal View of Emotional Vitality of Caregivers of Stroke Survivors
Barbic, SP; Bartlett, SJ; Rodriguez, A; Mayo, NE; McGill University, Montreal, QC
Background: Caregiver emotional vitality (EV) may be an important modifiable target for
intervention by rehabilitation professionals to improve health outcomes of both caregivers
themselves and the individual who experienced a stroke. Objectives: The overall aim was
to contribute to the understanding of the stroke caregiving experience by taking a longitudi-
nal view of EV. The specific objectives were to estimate the extent to which (i) caregiver EV
changes in the first caregiving year; and (ii) estimate the extent to which caregiver charac-
teristics and the functional profile of the care recipient impacts a caregiver’s EV in the first
year. Methods: Data came from an inception cohort of caregivers (n=409) that was followed
over the first post-stroke year. Group-based trajectory modelling (GBTM) was used to identify
distinctive groups of individuals with similar trajectories. Time-specific EV was plotted from the
first time of assessment (one month post-stroke) to 12 months. Dual trajectories were used to
estimate concordance between trajectories of EV and baseline health-related characteristics
of the caregiver and the care recipient. Results: Five trajectories of EV were identified. Four
trajectories maintained their baseline low EV level, and one showed deterioration over time.
Given the s­ coring range of the EV measure was 0-44 (with higher scores indicating higher
EV), all trajectories had baseline means that fell below a total score of 30, with 78% of the
sample having baseline scores of less than 18. Caregiver personal mastery was identified as
a significant predictor of EV. Conclusion: EV in caregivers was on average very low in the first
caregiving year. Personal mastery was identified as a component cause of EV for this sample,
lending preliminary support for the need to incorporate regular assessment of caregiver EV and
personal mastery throughout the caregiving experience.
O3.7
Communication and Mobility After Locked-In Syndrome: a Review of Twenty-Five
Cases
Beaudoin, N1 De Serres, L1 Martel, N1 Poissant, L1 Rochette, A2 Robert, G1 Nicolaidis, A1;
1. Institut de réadaptation Gingras-Lindsay de Montréal , Montréal, QC; 2. Ecole de
réadaptation Université de Montréal, Montral, QC
Background: Persons afflicted with Locked-In Syndrome (LIS) present with the most severe
level of disability that can occur following a stroke. Few Canadian data have documented the
functional outcome of these patients. In this study, communication and mobility has been spe-
cifically addressed. Methods: Twenty-five patients presenting LIS had been followed by the re-
habilitation team at the Montreal Gingras-Lindsay Rehabilitation Institute. The majority received
specific training to access and use technology for optimal independence. We documented their
neurologic and functional evolution over a period up to twenty years. Result: In spite of con-
siderable motor disabilities, many patients achieved a high level of autonomy to communicate
and to control a motorized wheelchair. Patients with incomplete LIS who had recuperated motor
function of one hand were more likely to use a manual joystick. Classic LIS patients may recu-
perate minor movement of head and of one finger or one toe. Some of them succeed using a
cephalic control to drive a wheelchair (40%) and a head mouse emulator to access a computer
(25%). Others presenting even more limited movement need a more sophisticated interface. We
will present a short video of two patients using computerized interfaces to activate a scanning
system permitting combined computer-supported communication and safe wheelchair control.
Conclusions: Advances in technology can improve autonomy for LIS patients. Considering
the strong will to live expressed by those patients and their involvement in social and familial
endeavors, access to rehabilitation for independent communication and mobility are strongly
recommended for all LIS patients.
O4.1
Accreditation Canada’s Stroke Distinction Program: a Quality Improvement
Strategy
Martin, C1 MacIsaac, L2 Martin, G3 Bowman, D1 Basile, VS2 Chapman, S1 McCumber, T2 Jewitt,
R1 Murray, J2 Jin, A1 Reinholdt, F2 Murphy, C1; 1. Stroke Network of Southeastern Ontario,
Kingston General Hospital, Kingston, ON; 2. MacKenzie Health, Richmond Hill, ON;
3. Accreditation Canada, Ottawa, ON
 e6  Stroke  December 2013
Background: Accreditation Canada’s Stroke Services Distinction Program recognizes centres
that demonstrate clinical excellence and outstanding commitment to leadership in stroke care
and prevention in relation to Canadian Best Practice Recommendations for Stroke Care. Kingston
General Hospital (KGH) and Mackenzie Health (MH), recently received Stroke Distinction Awards.
Method: The Distinction program requires: 1) Achievement of evidence-based standards; 2)
Achievement of performance indicator thresholds; 3) Implementation of current stroke protocols;
4) Completion of an innovative project; 5) Evidence of client and family education. Achievement
of the award was a corporate priority with senior management support. Staff and leaders were
engaged in the development of improvement plans and communication strategies to meet the
rigorous requirements. Datasets were used to plan and monitor targeted improvements includ-
ing attention to data quality through independent chart audit. Common quality improvement (QI)
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
stroke unit utilization and dysphagia screening rates with decreased in-hospital stroke mortality
and 30-day readmission rates. Sub-analysis of complication rates by age and stroke type pro-
vided information on those at most risk of complications, providing the basis for continuing QI.
MH enhanced integration of best practice stroke care across the organization through policy
implementation and staff engagement. Both centres realized data quality improvements (e.g.
dysphagia screening). Heightened awareness of Best Practices and increased interprofessional
team collaboration were observed. Collaboration with Accreditation Canada resulted in a quality
improvement cycle for the process itself. The ongoing requirement to submit performance indi-
cators semi-annually drives sustained QI. Conclusion: Pursuit of Stroke Distinction is a catalyst
for driving change and improving stroke care delivery processes and outcomes. Participation in
this program provides an effective means to prepare Ontario centres for 2013-14 Quality Based
Procedures for stroke care.
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O4.2
Stroke Competency Framework: a Quality Improvement Approach to Healthcare
Provider Education
Cole-Haskayne, A1 Garnier, S2 Grant, M1 Suddes, M1; 1. Calgary Stroke Program, Alberta Health
Services, Calgary, AB; 2. St. Paul Healthcare Centre, St Paul, AB
Background: Healthcare provider education was one of seven key improvement themes that
emerged from Alberta Stroke Improvement (ASI), a provincial quality improvement initiative
in 2011-12. The ASI Education Working Group was established to develop a competency-
based healthcare provider education framework and provide recommendations for imple-
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
framework focus on best practice, be inter-professional, link learning resources, identify
core and advanced competencies, be applicable and accessible to urban and rural sites,
provide direction around certification and facilitate performance management. Existing com-
petency frameworks did not address all criteria. Process mapping was used to direct the
development of a Canadian alternative. Stroke experts, clinicians, educators and managers
from a variety of professional backgrounds and areas were involved in the development and
review process. Results: The completed framework is based on a master competency list for
stroke health care providers across the continuum of care. The master list ensured a stan-
dardized and coordinated approach to developing competency checklists that are specific
to discipline and practice settings. Each competency is linked to key learning resources and
knowledge transfer tools. Electronic learning resources are linked directly where available.
The framework allows staff, educators and managers to select areas of focus and document
progress toward achieving goals for performance accountability. Competencies suggested
for orientation and ongoing professional development are differentiated. Conclusions: This
framework standardizes expectations for competencies in stroke care and fulfills a quality
improvement priority. The competency framework and recommendations for implementation
and sustainability will be provided. The usability will be evaluated through focus groups and
a representative sample will complete pre and post outcome measures to determine change
in competence levels.
O4.3
A Regional Assessment of the Economics of Stroke Care in Ontario
Meyer, MJ1 McClure, A2 O’Callaghan, C1 Kelloway, L1 Hall, R3 Bayley, M4 Teasell, R2; 1. Ontario
Stroke Network, Toronto, ON; 2. Lawson Health Research Institute/ UWO, London, ON;
3. Institute for Clinical Evaluative Sciences, Toronto, ON; 4. Toronto Rehabilitation Institute,
Toronto, ON
Background: In 2012, the Ontario Stroke Network (OSN) released an economic evaluation
of stroke care in Ontario suggesting that better application of best-practices could result in
up to $20M a year made available for re-investment in Ontario’s stroke system. The objec-
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
practices and costs of care. Methods: Data were collected from various sources including
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
LHIN, to track current care pathways, and to infer opportunities to improve the provision of
evidence-based, cost-effective care. Results: Wide variation was noted in many areas of
stroke care across Ontario’s LHINs indicating numerous opportunities for improvement. On
average, acute patients spent 31.5% of their length of stay in alternate level of care waiting
for transfer to post-acute care (range 23% - 41%) and, on average, 18% of acute admissions
were TIAs (range 12.6 – 28.7). The estimated average direct cost of acute care ranged from
$7,709 to $13,403 per patient across LHINs and the mean per diem direct cost of acute
care ranged from $654 to $983. The average LOS in inpatient rehabilitation was 37.1 days
(range 29.5 – 45.5). On average, 7% (range 4-12%) of patients in rehabilitation fell into the
mildest rehabilitation patient group (RPG 1160); costing an estimated total of $2.5M annually.
Conclusion: Regional data confirm previous research suggesting that variation in stroke care
exists between Ontario’s LHINs and that opportunities exist in all regions for better application
of evidence-based, cost-effective care.
O4.5
Impact of Culturally Congruent Evidence-Informed Chronic Disease Management
Program on Hypertension Management in First Nation Communities in Ontario
Tobe, S1 Von Sychowski, S2 Kandukur, K2; 1. Sunnybrook, Toronto, ON; 2. Heart and Stroke
Foundation of Ontario, Toronto, ON
Objectives: The objective of the Aboriginal Hypertension Management Program (AHMP) is to
demonstrate a sustainable, evidence-informed chronic disease management program that
enables knowledge integration into the practices of primary care providers and improve man-
agement of essential hypertension in first nation communities. Design and Methods: The
Studywas conducted in five first nation communities in Ontario. The program was imple-
mented on-reserve in collarboartion with local health care organizations. The chronic disease
management toolkit included culturally congruent tools for both health care providers (flow-
sheet, BpTRU, database repository) and patients (posters, educational video and booklets). All
the tools were developed based on the feedback from clients and health care provider from
the participating communities. We intially piloted the program and tools in two communities
as a pilot and then later expanded to five more communities. Local systems change principles
were then applied in each of the interprofessional team’s implementation of the evidence-
informed AHMP, to adapt to local circumstances. Results: In total, 231 patients were enrolled
in five first nation communities, and of these, 177 had a diagnosis of hypertension. Mean BP
at baseline was 130.8/75.0 mmHg, compared to the end-of-study recorded BP of 132.0/74.7
mmHg. Although there was no statistically significant change in mean BP over all, a sub-
analysis showed statistically significant change in mean BP among those whose SBP was
140-159 at baseline (n=20) with a mean change of SBP of 15.3 mmHg. There was also a
mean change of SBP of 27.75 mmHg among those with SBP >160 mmHg at baseline (n=4).
Conclusion: There was a significant blood pressure lowering among those with elevated
systolic blood pressure at baseline after introducing an evidence-informed, interprofessional
culturally congruent, chronic disease management program for hypertension in first nation
communities.
O4.6
A Geoinformatic Analysis of the Impact of Telestroke on Access to Stroke
Thrombolysis in Ontario
Jewett, L2, 3, 1 Connolly, BJ1 Sahlas, DJ1; 1. McMaster University, Hamilton, ON; 2. Population
Health Research Institute, Hamilton, ON; 3. Hamilton Health Sciences, Hamilton, ON
Background: Ontario is Canada’s most populous province, with 13,366,300 people in the 2011
census. The Ontario Stroke System is comprised of 11 regional stroke centres and 17 district
stroke centres and is further augmented by Telestroke linkages between many of these centres
as well as 10 additional Telestroke sites. We undertook a geoinformatic analysis of access to
stroke thrombolysis, in order to evaluate the impact of the Ontario Telemedicine Network’s
Telestroke program. Methods: Population data by dissemination area was used (Statistics
Canada, 2011) to overlay polygons created by Service Area Analysis using ArcGIS 10.1 (ESRI,
2012). The service areas are based on the Ontario Roads Network (DMTI, 2012) and Ontario Car-
tographic Boundaries (Statistics Canada, 2012). The established geographic regions are within
predefined driving times, towards stroke centres. Service areas with and without the impact of
the Telestroke program were compared. Results: Availability of stroke thrombolysis in desig-
nated stroke centres covers 96.03% of the province, leaving approximately 530,308 people in
remote locations without access. 78.18% of the population are within 30 minutes of a regional
or district stroke centre, increasing to 87.22% with Telestroke, an additional 1,208,786 people.
1.48% of the population have access only through the extended time window (between 3 to
4.5 hours), increasing to 2.16% with Telestroke, for an additional 91,313 people. Conclusion:
The vast majority of people in Ontario have access to stroke thrombolysis, which is significantly
augmented by Telestroke. The Ontario Telemedicine Network’s Telestroke program increases
the overall number of people with access to stroke thrombolysis as well as provides more rapid
access to hyperacute stroke treatment for over a million people, with direct benefits impacting
approximately 1 in 10 people in the province.
O4.7
Vancouver Island Health Authority’s (VIHA) Strategic Plan to Ensure All Patients
Receive Care in Stroke Units
Foster, D1 Crisp, R1 Kamal, N2; 1. Vancouver Island Health Authority, Victoria, BC; 2. Stroke
Services BC, Vancouver, BC
Background: VIHA serves 768,000 people and faces significant population growth of people
over 75 years by as much as 17% by 2020. Further issues facing VIHA include a large rural area
with islands and large water inlets. There are 2 tertiary hospitals, 1 regional hospital, 5 com-
munity hospitals, and 5 rural/remote hospitals. A strategic approach is needed for acute stroke
care in order to plan appropriately for the population growth and VIHA’s diverse geography.
Methods: VIHA’s strategic approach plans for three stroke units to serve the entire population.
Victoria General Hospital will be a comprehensive level 1 stroke centre with both a stroke unit
and a rehabilitation unit. It will co-locate stroke patients from South Vancouver Island. Nanaimo
 Abstracts From the 4th Canadian Stroke Congress, 2013  e7
Regional General Hospital will provide intermediate stroke services for the Central Island with
an acute stroke cluster and a rehabilitation unit. Campbell River and District Hospital will also
provide intermediate stroke services with an integrated stroke cluster serving the North Island
and Comox valley. These changes will be supported through participation in a Stroke Unit Collab-
orative organized by Stroke Services BC with participation from across BC and Saskatchewan.
Collaborative Faculty are from BC and Calgary. Results: There have been tremendous strides
made towards the creation of stroke units. To date, beds have been committed at three sites
with teams working towards best practice. These sites have had strong participation in the
Stroke Unit Collaborative with over 25 stroke champions traveling to Vancouver to attend the
face-to-face Learning Sessions, and attendance at the bi-weekly webinars. Conclusions: The
creation of stroke units within a health region is possible through internal and external enablers.
The internal enablers include executive support, hospital buy-in, stroke champion teams at each
site, and education initiatives. The external enablers include interprovincial Stroke Unit Collab-
orative, Canadian Best Practice Recommendations, and research grants.
PL2.1
An in-vivo, MRI-Integrated Real-Time Model of Active Contrast Extravasation in
Acute ICH
Aviv, RI1 Huynh, T2 Ramsay, D3 Huang, Y4 Liu, R2 Hynynen, K4; 1. Sunnybrook Health Sciences
Center, Thornhill, ON; 2. Sunnybrook Health Sciences Center, Toronto, ON; 3. London Health
Sciences, London, ON; 4. Sunnybrook Research institute, Toronto, ON
Purpose: The spot sign or contrast extravasation (CE) within an intracranial hemorrhage (ICH)
is strongly associated with hematoma formation and growth. CE is emerging as the single
most important contributor to morbidity and mortality in ICH but represents a spectrum of
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contrast leakage. An animal model of CE is important to test existing and novel therapeutic
interventions to inform present and future clinical studies. The purpose of this study was to
create the first animal model of CE in acute ICH. Materials and Methods: Animal experiments
were performed in accordance with institutional guidelines and approved by the Research
Institute Animal Care Committee. Each hemisphere of 18 Yorkshire male swine was insonated
with an MR-guided focused ultrasound system after infusion with 0.08ml/kg of Perflutren
lipid microspheres without and with mean arterial pressure elevation using 15mcg/kg/min
phenylephrine infusion. Following insonation dynamic contrast enhanced (DCE) MRI quanti-
fied the rate of contrast leakage. Animals were sacrificed after 2 hours and brains subjected
to histopathological examination. Results: Two distinct patterns of CE were created. Active
CE demonstrated brisk contrast leak with well delineated margins, visible early on DCE. Post
contrast leakage (PCL) demonstrated slower accumulation of CE becoming more confluent
on a delayed post contrast T1. Median (IQR) CE KPS was significantly elevated compared to
PCL (11.3; 6.3-23.2 vs 3.8; 1.1-3.1ml/min/100g; p<0.001). CE demonstrated a median (IQR)
DCE contrast volume of 0.4; 0.1-1.3cm3 compared to PCL (0.04; 0.02-0.1cm3; p=0.01). The
median (IQR) final hemorrhage volume was significantly higher for CE compared to PCL (0.7;
0.4-1.6 vs 0.4; 0.06-0.7cm3; p= 0.02). Significant correlation was seen between increasing
burst length and rate of contrast leak (KPS) (ρ=0.5 (95% CI 0.08-0.8); p=0.02). Conclusion:
We describe a novel MRI-integrated real-time swine ICH model of acute hematoma growth
and contrast extravasation.
PL2.2
Implementation of the Revised Provincial Acute Stroke Redirect Protocol in Urban
and Rural Settings
Stiell, IG1 Smaggus, K2 Clement, CM3 Sharma, M4 Socha, D5 Silvilotti, M6 Jin, A6 Perry, JJ1
Lumsden, J7 Martin, C8 Froats, M1 Dionne, R2, 1 Trickett, J9; 1. University of Ottawa, Ottawa, ON;
2. Regional Paramedic Program for Eastern Ontario, Ottawa, ON; 3. Ottawa Hospital Research
Institute, Ottawa, ON; 4. McMaster University , Hamilton, ON; 5. Hastings-Quinte EMS, Bellville,
ON; 6. Queen’s University, Kingston, ON; 7. Champlain Regional Stroke Network, Ottawa, ON;
8. Stroke Network of Southeastern Ontario, Kingston, ON; 9. The Ottawa Hospital, Ottawa, ON
Background: The Ontario Stroke Redirect Protocol was recently revised to allow EMS to by-
pass to designated stroke centers if total transport time would be <2 hours and total time
from ­symptom onset <3.5 hours. We sought to evaluate the impact, effectiveness, and safety
of the revised Protocol. Methods: We conducted a 12-month multicentre, prospective cohort
study involving all pre-hospital patients presenting <6 hours with possible stroke symptoms.
Participating were 1,000 BLS and 300 ALS paramedics of 9 land EMS services, operating in
a catchment area of 10 rural counties and 5 cities. Paramedics completed a record form for
each case and, initially, a second paramedic independently completed the form. Outcomes and
data analyses included redirect sensitivity and specificity, patient outcomes, adverse events,
and interrater reliability with the kappa statistic. Results: We enrolled 1,277 eligible patients
with 99% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect
criteria and had these characteristics: mean age 72.0 (range 16-101), male 51.1%, mean time
scene-to-hospital 16.7 min (range 0-92) with 15.1% >30 mins. The prehospital adverse event
rate was 14.7% (23.0% for those with transport time >30 mins) with the most common events
being hemodynamic instability and drop in GCS. At the hospital, the 755 patients had a mean NIH
Stroke Scale score 8.7, 23.8% received thrombolysis, 69.3% were admitted, 87.3% survived
to discharge, and had a mean modified Rankin Score 2.3. Paramedics showed 97.9% accuracy
in interpreting the criteria and excellent interrater agreement with kappa values ranging from
0.56 to 0.90 for redirect criteria and 0.94 for need to transport to a stroke centre. Conclusions:
In a large urban-rural area with 9 EMS services, we demonstrated accurate, safe, and effective
implementation of the revised provincial Stroke Redirect Protocol. These revisions will allow
more stroke patients to benefit from early treatment.
PL2.3
Predictors of Stroke Recurrence in Patients with Recent Lacunar Stroke: Second-
ary Prevention of Small Subcortical Strokes (SPS3) Trial
Bakheet, MF1 Hart, RG2 Pearce, LA3 Benavente, O4; 1. Hamilton General Hospital, Hamilton, ON;
2. McMaster University, Hamilton, ON; 3. Biostatistics Consultant, Minot, ND, USA; 4. University
of British Columbia, Vancouver, BC
Background: Among participants in the Secondary Prevention of Small Subcortical Strokes
randomized trial, we sought to identify patients with high vs. low rates of recurrent ischemic
stroke. Methods: Multivariable analyses of 3020 participants with recent MRI-defined lacunar
strokes followed for a mean of 3.7 years with 243 recurrent ischemic strokes. Results: Prior
symptomatic lacunar stroke or TIA (HR 2.2, 95%ci 1.6,2.9), diabetes (HR 2.0, 95%ci 1.5,2.5),
black race (HR 1.7, 95%ci 1.3,2.3) and male sex (HR 1.5, 95%ci 1.1,1.9) were each indepen-
dently predictive of recurrent ischemic stroke. Recurrent ischemic stroke occurred at a rate of
4.3%/yr (95% CI 3.3, 5.5) in patients with prior symptomatic lacunar stroke or TIA (15% of the
cohort), 3.1%/yr (95%CI 2.6, 3.9) in those with >1 of the other 3 risk factors (27% of the cohort),
and 1.3%/yr (95%CI 1.0,1.7) in those with 0 to 1 risk factors (58% of the cohort). There were
no significant interactions between treatment effects and stroke risk status. Conclusion: In
this large, carefully followed cohort of patients with recent lacunar stroke and aggressive blood
pressure management, prior symptomatic lacunar ischemia, diabetes, Black race and male sex
independently predicted ischemic stroke recurrence..
PL2.4
Cardiopulmonary Fitness is Associated with Regional Cerebral Grey Matter Perfu-
sion and Density in Adults with Coronary Artery Disease
Swardfager, W1, 2, 3 MacIntosh, BJ1, 2 Herrmann, N1, 2 Crane, DE1, 2 Saleem, M1 Ranepura, N1 Oh,
PI1, 2, 3 Lanctôt, KL1, 2, 3; 1. Sunnybrook Research Institute, Toronto, ON; 2. Heart & Stroke Founda-
tion Centre for Stroke Recovery, Toronto, ON; 3. Toronto Rehabilitation Institute, Toronto, ON
Purpose: Cardiopulmonary fitness is associated with reduced risk of stroke, and it can confer
neuroprotective and cerebrovascular benefits. Patients with coronary artery disease (CAD) 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
(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-
tiple grey matter regions were associated with fitness at baseline and with greater fitness gains
due to exercise. This study identifies new neurobiological correlates of fitness in older patients
with cardiovascular disease. The possibility to identify novel mediators of the relationship be-
tween fitness and reduced stroke risk is suggested.
PL2.5
Prediction of Hematoma Expansion and Poor Clinical Outcome in Acute Intracere-
bral Hemorrhage: the PREDICT Hematoma Expansion Score
Huynh, TJ1 Demchuk, AM2 Dowlatshahi, D3 Gladstone, DJ1 Laupacis, A1 Kiss, A1 Hill, MD2
Molina, CA4 Rodriguez-Luna, D4 Silva, Y5 Czlonkowska, A6 Lum, C3 Boulanger, J7 Gubitz, G8
Bhatia, R9 Padma, V10 Roy, J10 Case, CS11 Jakubovic, R1 Symons, SP1 Aviv, RI1; 1. University of
Toronto, Toronto, ON; 2. University of Calgary, Calgary, AB; 3. University of Ottawa, Ottawa,
ON; 4. Hospital Universitari Vall d’Hebron, Barcelona, Spain; 5. Dr Josep Trueta University
Hospital, Girona, Spain; 6. Institute of Psychiatry and Neurology of Warsaw, Warsaw, Poland;
7. University of Sherbrooke, Montreal, QC; 8. Dalhousie University, Halifax, NS; 9. All India
Institute of Medical Sciences, New Delhi, DL, India; 10. AMRI Hospital Kolkata, Kolkata, WB,
India; 11. Boston Medical Center, Boston, MA, USA
 e8  Stroke  December 2013
Objective: Predictive models of hematoma expansion in intracerebral hemorrhage (ICH)
are important for risk stratification and guiding potential interventions. The spot sign is
recently shown to potently predict ICH expansion and poor outcome however incorporation
of other clinical variables may improve prediction. We sought to identify clinical and radio-
graphic predictors of hematoma expansion and to develop a practical integrated clinical
score for expansion prediction. We secondarily evaluated the prognostic significance of
the score for 3-month poor clinical outcome prediction. Methods: 219 ICH patients ≤6
hours post-ictus were enrolled in the PREDICT study, a multicenter prospective ICH cohort
study. Patients underwent baseline non-contrast CT, CT angiography (CTA), and 24-hour
CT. 169 patients had 3-month modified Rankin Scale (mRS) measured. Multivariable lo-
gistic regression identified independent clinical, laboratory, and radiographic predictors
of hematoma expansion (>6ml or >33%) and a clinical scoring system was developed
from regression coefficients. Optimism adjusted c-statistic was examined using bootstrap
internal validation. Prognostic significance of the score for predicting 3-month poor clini-
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-
HSS, and time from ictus-to-baseline CT provided the greatest model fit and discrimina-
tion for hematoma expansion prediction (c-statistic: 0.803) and were incorporated in to a
clinical prediction score. Observed probability of expansion ranged from low (7% - 12%)
to high probability (76 - 100%) based on score strata. Bootstrap internal validation dem-
onstrated an adjusted c-statistic of 0.755. The score independently predicted 3-month
poor clinical outcome (OR 1.17, 95% CI 1.05 – 1.31; p=0.021) after adjusting for age,
baseline Glasgow Come Scale, ICH volume, intraventricular hemorrhage presence, and
INR. Conclusions: The PREDICT Hematoma Expansion Score strongly predicts hematoma
expansion and poor clinical outcome in ICH and appears promising as a risk stratification
tool for future potential interventions.
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P.3
Vitamin K Antagonists versus Antiplatelet Monotherapy and Risk of Subdural
Hematoma: Meta-analysis of Randomized Clinical Trials
Connolly, BJ1 Pearce, LA2 Hart, RG1; 1. McMaster University, Hamilton, ON; 2. Biostatistics
Consultant, Minot, ND, USA
Background: Subdural hematomas (“the other intracranial hemorrhage”) are an impor-
tant bleeding complication of anticoagulation with oral vitamin K antagonists (VKAs),
but the risk associated with VKAs has not been defined. Purpose: To determine the
risk of subdural hematoma associated with VKAs vs. antiplatelet agents. Data Sources:
Randomized trials were identified by systematic review of the Cochrane Central Register
of Controlled Trials and other published systematic reviews. Study Selection: Random-
ized trials published since 1980 comparing VKAs with antiplatelet monotherapy were
included. Data extraction: Two reviewers independently extracted data on study design
and subdural hematomas, with differences resolved by joint review and consensus. Re-
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
unpublished data from 5 trials. Trial participants included patients with atrial fibrillation
(4 trials), noncardioembolic stroke (2 trials), and heart failure/reduced left ventricular
ejection fraction (2 trials). Mean participant age was 65 (range 61 to 82) years. The mean
achieved INRs ranged from 2.1 to 3.2. Antiplatelet therapy was aspirin (dose range 75 to
1300 mg/d) except one trial each that tested trifusal 600 mg/d and clopidogrel 75 mg/d.
There were 18 subdural hematomas in those assigned VKAs vs. 7 among those assigned
antiplatelet monotherapy (hazard ratio 2.9, 95%CI 1.4-6.2, p< 0.05). The absolute rates
of subdural hematoma during VKA therapy ranged from 1.2 to 3.5 per 1000 patient-
years of observation. Conclusions: VKA use significantly increases the risk of subdural
hematoma compared with antiplatelet monotherapy. The absolute increase with VKAs
averaged 1.5 per 1000 patient-years.
P.5
Results from the Ontario Stroke Registry’s Audit of Secondary
Stroke Prevention Clinics
Hall, R1 Khan, F1 Zhou, L1 Kelloway, L2 Sahlas, DJ3, 4 Silver, F7, 6, 5 Kapral, M7, 6, 5 Hall, R7, 2, 5;
1. ICES, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. Hamilton Health Sciences,
Hamilton, ON; 4. McMaster University, Hamilton, ON; 5. University of Toronto, Toronto, ON;
6. University Health Network, Toronto, ON; 7. Institute for Clinical Evaluative Sciences,
Toronto, ON
Background: Secondary Prevention Clinics (SPCs) were established in Ontario in 2001 to ex-
pedite access to diagnostics, treatment, and risk factor education programs for patients at risk
of stroke or recurrent stroke. There are currently 43 SPCs in the province. In 2012, the Ontario
Stroke Registry conducted an audit of the care provided at Ontario SPCs. Methods: Informa-
tion was collected on every patient that visited one of 40 SPCs between April 1, 2011 and
March 31, 2012. The Case Record Form was developed through an inter-professional advisory
committee, and data was collected through a web-based application. Sixteen best practice
performance indicators were analyzed using the SPC data and administrative databases.
Results: Of the 28,626 ED visits for suspected or confirmed stroke/TIA in Ontario, 21.3%
were subsequently seen in an SPC. The audit sample included 16,167 patients with 16,487
initial visits and 7,126 follow-up visits. The median time from referral to the first visit was
14 days. Common risk factors were hypertension (62.4%), hyperlipidemia (52.4%), smoking
(22.2%), and diabetes (20.5%). Ninety-four percent of patients had neuroimaging and 83.9%
had vascular imaging completed prior to or at the SPC. The median time from the initial visit to
carotid endarterectomy or stent was 28 days. Medication prescription rates, where indicated,
were: antiplatelet therapy (94.4%); anticoagulant therapy (80.1%); antihypertensive therapy
(68.0%); lipid-lowering agents (65.7%); smoking cessation programs/medication (20.0%).
Approximately 10% of initial visits included cognitive screening. Readmission rates among
ischemic stroke/TIA patients seen at SPCs were 1.8% within 30 days and 2.9% within 90
days of the SPC referral. Conclusion: The results show high rates of investigations and good
outcomes compared to the expected course of a TIA/stroke following an ED visit. There are
significant opportunities for improvement, particularly with respect to timeliness of access to
SPCs, carotid interventions, smoking cessation, and cognitive screening.
R.1
People After Mild Stroke or Transient Ischemic Attack – An Overlooked
Population from a Rehabilitation Perspective
MacKay-Lyons, M; Dalhousie University, Halifax, NS
Purpose: Although non‐disabling stroke (NDS) and transient ischemic attack (TIA) are con-
sidered relatively benign conditions, they can actually signal further vascular events or death.
Understanding the clinical presentation of NDS/TIA is important in identifying effective sec-
ondary prevention strategies. The purpose was to describe the baseline profile of participants
enrolled in the Program of Rehabilitative Exercises and Education to avert Vascular Events
after NDS and TIA (PREVENT) Trial. Methods: Prior to randomization (PREVENT program/usual
care), 148 people early post‐NDS/TIA underwent assessment of comorbidities, vascular risks,
exercise capacity, and walking endurance. Results: Participants were 65+/-10 years of age,
66% male, body mass index of 30+/-6. Most prevalent co‐morbidities were arthritis (39%),
diabetes (21%), coronary artery disease (13%), and atrial fibrillation (12%). Resting systolic
blood pressure was 132+/-18 mmHg. 2‐year risk of second stroke or death was high in 11%
and moderate in 34%. 23% scored <26 on Montreal Cognitive Assessment and 35% scored
>10 on Hospital Anxiety and Depression Scale. Although all participants were described as
‘non-disabled’, 9% had low physical function and 13% moderate physical function (Short
Physical Performance Battery). 28% were classified as inactive and 43% as moderately active
(International Physical Activity Index), 39% had excessive fatigue (Fatigue Assessment Scale),
and 58% were ‘poor sleepers’ (Pittsburgh Sleep Quality Assessment). On stress testing 8%
were positive for ischemia. High variability was found in peak oxygen consumption (19.5+/-
5.9 ml/kg/min, 36% to 147% of predicted) and 6‐minute walk distance (males: 491+/-101
m, 86+/-14% of predicted; females: 406+/-92 m, 81+/-12% of predicted). Conclusions:
A substantial proportion of this cohort demonstrated vascular comorbidities, hypertension,
cognitive impairment, cardiac ischemia, and risk of second stroke. Clinical correlates included
reductions in physical activity, activity tolerance, sleep quality, aerobic capacity and walking
endurance - all potentially modifiable through exercise interventions.
R.2
Can we identify family caregivers in need of support from the health care
system?
Cameron, JI1 Czerwonka, A1 Naglie, G2 Gignac, M3 Green, T4 Warner, G6 Bayley, M7 Silver, F5
Cheung, A5 Phillips, S8 Huijbregts, M2, 9; 1. University of Toronto, Toronto, ON; 2. Baycrest
Centre for Geriatric Care, Toronto, ON; 3. Toronto Western Research Institute, Toronto, ON;
4. University of Calgary, Calgary, AB; 5. University Health Network, Toronto, ON; 6. Dalhousie
University, Halifax, NS; 7. Toronto Rehabilitation Institute - University Health Network, Toronto,
ON; 8. Capital District Health Authority, Halifax, NS; 9. Family Service Toronto, Toronto, ON
Background: Family caregivers play a central role in stroke survivors’ recovery, rehabilita-
tion, and return to community living. Best practice guidelines recommend the provision of
timely education and support for caregivers. The aim of this paper is to identify caregivers at
risk for depression during the acute stroke phase and, therefore, in need of support from the
health care system. The primary hypothesis is that caregivers will report more depression
symptoms if they are caring for stroke survivors with more severe stroke and more stroke-
related disability and the caregiver is female, younger, caring for a spouse, has less knowl-
edge about stroke, less mastery, less social support, more fatigue, and caregiving has more
of an impact on their daily life. Methods: Participants included caregivers who consented
to participate in an ongoing trial. They were caring for survivors of their first stroke and had
to be able to speak and read English. The baseline assessment, completed during the acute
stroke phase, included: 1) indicators of stroke severity (e.g., Canadian Neurological Scale,
Barthel Index); 2) demographic characteristics; and 3) standardized measures (e.g., Mastery,
Stroke Knowledge, Caregiving Impact and Assistance, and Depression). Linear regression
was used to test the study hypothesis. Results: Caregivers (n=299) were 74% female with a
mean age of 58 years. They reported more depression symptoms when they had less mas-
tery, experienced more fatigue, caregiving negatively impacts their life, and were younger
and caring for a spouse (F (13,296) = 22.58, p<.001; adjusted R2=.48). Caregivers’ knowl-
edge of stroke, level of assistance provided to the patient, patient illness severity and dis-
ability were not significantly related to caregiver depression. Conclusions: Young, spousal
caregivers with less mastery, who are fatigued, and are not able to participate in everyday
activities are more likely to report depression and need support from the health care system.
R.4
Evaluating the Impact of Stroke Survivor & Caregiver Support Groups on
Successful Community Reintegration
Brown, G1 Belanger, A2 Martin, C1 Pratt, K2 Langstaff, C1 Brouillard, D2; 1. Stroke Network of
Southeast Ontario , Kingston, ON; 2. Seniors Association - Kingston Region, Kingston, ON
Background: The human cost of stroke is universally understood to have significant and ongo-
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
health system costs related to emergency room visits, hospital admissions and re-admissions.
The Canadian Best Practice Recommendations for Stroke Care highlight the impact of “refer-
rals to community agencies, such as stroke survivor groups…” on individuals and the health
system. This project evaluated the impact of ongoing, professionally facilitated community
stroke survivor and caregiver support groups. Methods: Pre-post comparative evaluation over
a seven month period encompassed quantitative and qualitative domains including caregiver
burden, caregiver well-being, stroke survivor well-being and overall satisfaction with the ser-
vices offered. Evaluation tools included the Stroke Impact Scale, the Montgomery Borgatta
Caregiver Burden Assessment tool, a participant questionnaire as well as individual and focus
group interviews conducted by an objective third party. Results: Referral and activity rates
increased with provision of system navigation and individual support. Positive effects of group
participation were observed on self-reported dimensions of well-being, coping with anxiety,
nervousness, depression and stressors for both caregivers and stroke survivors. Post-test
scores improved on the Stroke Impact Scale in the areas of communication, memory and
thinking and overall perceived recovery. A notable decrease was measured in both objective
and subjective caregiver burden. Strong participant satisfaction and highly informative qualita-
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
of professional psychosocial facilitation within a supportive community infrastructure. Con-
clusions: Results support that professionally facilitated stroke survivor and caregiver stroke
support groups may be significant contributors to perceived recovery, improved psychosocial
outcomes and successful community reintegration for both caregivers and stroke survivors.
R.6
MRI-based Neuroanatomical Predictors of Dysphagia, Dysarthria, and Aphasia in
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
Patients with a First Acute Ischemic Stroke
Flowers, HL1 AlHarbi, M2 Silver, FL3 Mikulis, D2 Chakravarty, MM4 Fang, J5 Martino, R1;
1. Department of Speech-Language Pathology, University of Toronto, Toronto, ON; 2. University
Health Network, Toronto Western Hospital, Toronto, ON; 3. Toronto Western Hospital, Toronto,
ON; 4. Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, ON;
5. Institute for Clinical and Evaluative Sciences, Toronto, ON
Background: Dysphagia, dysarthria and aphasia occur frequently after stroke. We
sought to identify MRI-based neuroanatomical predictors of these impairments early
after ischemic stroke onset. Methods: We randomly selected 250 patients from a con-
secutive cohort of ischemic stroke patients with MRI scans (N=716) from the Registry of
the Canadian Stroke Network’s database (2003–2008) in one stroke centre. We exclud-
ed patients with dementia, brain tumour, neurosurgical interventions, or contusions. We
documented the presence of the acute lesion in 12 neuroanatomical regions of interest
and extracted lesion volumes. We also identified concomitant neurological compromise,
including brain atrophy, white matter disease, and prior covert stroke. Two raters in-
dependently extracted all data, resolving discrepancies by consensus. We computed
logistic regression analyses to identify predictors for each impairment. Results: 160
patients met our eligibility criteria. Predictors of dysphagia included increasing lesion
volume (OR 1.3, 95% CI 1.03–1.7), increasing age (OR 1.4, 95% CI 1.1–1.8), and lesions
to the medulla (OR 6.3, 95% CI 1.5–26.6), pons (OR 4.5, 95% CI 1.5–13.3), insula (OR
4.2, 95% CI 1.6–11.5), and internal capsule (OR 3.5, 95% CI 1.5–8.5). Predictors of
dysarthria included lesions to the pons (OR 7.9, 95% CI 2.7–22.9), internal capsule (OR
3.1, 95% CI 1.5–6.5), and insula (OR 2.6, 95% CI 1.2–5.8). Predictors of left-hemisphere
aphasia included increasing lesion volume (OR 1.5, 95% CI 1.1–2.1) and lesions to the
thalamus (OR 5.0, 95% CI 1.2–20.7), insula (OR 21.7, 95% CI 2.5–190.8), and super-
ficial MCA territory (OR 3.3, 95% CI 1.04–10.5). Conclusions: We modeled neuroana-
tomical predictors of dysphagia throughout the brain and extended previous findings for
dysarthria and aphasia in a large homogeneous sample of patients. Next, we will identify
more discrete neuroanatomical regions using voxel-based lesion symptom mapping.
VC.1
International Harmonization and Pilot Testing of the English Language Screening
Test (LAST)
Flowers, HL1 Flamand-Roze, C2 Denier, C2 Roze, E3 Silver, FL4 Rochon, E1 Skoretz, SA1
Baumwol, K5 Burton, L6 Brookes, K5 McGovern, A6 Harris, G5 Tyson, S7 Langdon, C8 Major, K5
Shaw, S1 Martino, R1; 1. Department of Speech-Language Pathology, University of Toronto,
Toronto, ON; 2. Service de neurologie, CHU Bicêtre, Assistance publique-Hôpitaux de Paris,
Le Kremlin-Bicêtre, France; 3. Département de neurologie, CHU Pitié-Salpêtrière, Assistance
publique-Hôpitaux de Paris, Paris, France; 4. Toronto Western Hospital, Toronto, ON; 5. Sir
Charles Gairdner Hospital, Nedlands, WA, Australia; 6. Greater Manchester and Cheshire
Cardiac & Stroke Network, Stockport, United Kingdom; 7. Stroke & Vascular Research Centre,
University of Manchester, Manchester, United Kingdom; 8. Health Department of Western
Australia, Perth, WA, Australia
Background: The LAST is a unique bedside tool, designed to rapidly and reliably evaluate apha-
sia during the acute phase of stroke. It may also complement stroke severity scales in the initial
evaluation of stroke patients. The LAST was developed and validated in French and subse-
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-
ation, we collectively reviewed problematic items, selecting alternatives by expert consensus
in four English speaking countries and in collaboration with the tool developers. 1. Experts in
Australia, Canada, England, and the USA independently reviewed all 29 items for cultural ac-
ceptability and naturalness of language in multiple linguistic domains: phonology, semantics,
morphology, and syntax. Each country proposed alternatives for unacceptable or unnatural
items. 2. The harmonized version underwent pilot testing in healthy older native speakers in all
four countries, with documentation of expected or deviant responses to each item. 3. Revised
items underwent repeat testing in healthy older native speakers in all four countries, to achieve
a final version. Results: 1. Of the original 29 items, we revised 10 following international expert
review. 2. Pilot testing involved 76 participants (34 male; mean age 60 years, range 23-92; 51
with postsecondary education) and resulted in revisions to three items. 3. Repeat testing of the
three revised items involved 36 participants (15 male; mean age 56 years, range 32-84; 30 with
postsecondary education) and resulted in no further modification. Conclusion: We achieved
international harmonization of the English LAST, ensuring linguistic naturalness and cultural
appropriateness. We confirmed its linguistic validity in healthy older native speakers. Once vali-
dated in stroke patients, the English LAST will provide a much needed screening tool for aphasia.
VC.4
Imaging and Baseline Predictors of Cognitive Performance in Minor Stroke and
TIA Patients at 90 Days
Mandzia, JL1, 2 Smith, EE1, 2, 3 Horton, M1, 2 Hanly, P4 Barber, PA1, 2, 3 Godzwon, C1 Donaldson,
E1 Asdaghi, N5 Patel, S1 Aram, H1 Coutts, SB1, 2, 3; 1. Calgary Stroke Program, Calgary, AB;
2. Department of Clinical Neurosciences, University of Calgary, Calgary, AB; 3. Hotchkiss Brain
Institute, Calgary, AB; 4. Division of Respirology, Department of medicine,University of Calgary,
Calgary, AB; 5. BC Centre for Stroke and Cerebrovascular Disease, Vancouver, BC
Background: Few studies have examined predictors of cognitive impairment following minor
stroke and TIA. We examined clinical and imaging features associated with poor cognitive
outcome at 90 days. Methods: TIA or minor stroke (NIHSS<4) patients underwent cognitive
testing 90 days post event. DWI and white matter lesion volumes (WML) were measured on
baseline MRI. Patients with pre-event mRS>1 or dementia were excluded. Z-scores were
calculated for cognitive tests based on normative data; tests were analyzed as domains of
memory (CVLT long delay free recall), executive function (EF; average of COWAS test FAS and
Trails B) and psychomotor speed (PS; average of Trails B and Digit Symbol Coding). Depression
was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). Presence
of obstructive Sleep Apnea (OSA) was assessed using a Snoresat. Analyses were performed
on the whole data set and then dichotomized based on cognitive score <1 SD below normal.
A p-value of ≤0.016 was chosen for statistical significance, correcting for testing of 3 sepa-
rate cognitive domains. Results: 86 patients were included, 74% male, 55% TIA, mean age
65.2+12.2 and 14.2+3.3 years of education. 62% were DWI positive. 27.9% had moderate to
severe OSA. Median Z-scores were: memory 0, EF -0.12 and PS +0.2. Mean CES-D was 7.9+8.
Cognitive scores were not significantly different based on diagnosis, cause and risk factors of
stroke, OSA, DWI or WML volumes. EF scores correlated with baseline NIHSS (p=0.005) and
90-day CES-D (p=0.004), and were lower in patients with 90-day mRS >0 (p=.017). EF <1
SD was associated with baseline NIHSS (p=0.016) and 90-day CES-D (p=0.002). PS scores
correlated with baseline NIHSS (p=0.01) and CES-D (p=0.001), and were lower in patients with
90-day mRS >0 (p=0.004). Conclusion: Stroke severity, disability and depression predict poor
psychomotor and executive, but not memory test performance at 90 days.
VC.6
Incidental Small Acute Brain Infarcts Are Rare in Neurologically Asymptomatic
Community-Dwelling Older Adults
Batool, S1 O’Donnell, M2 Teo, K2 Dagenais, G3 Poirier, P3 Lear, S4 Wielgosz, A5 Sharma, M2
Stotts, G5 McCreary, CR1 Frayne, R1 Rangarajan, S2 Islam, S2 Yusuf, S2 Smith, EE1; 1. University
of Calgary, Calgary, AB; 2. McMaster University, Hamilton, ON; 3. Laval University, Quebec, QC;
4. Simon Fraser University, Vancouver, BC; 5. University of Ottawa, Ottawa, ON
Introduction: Cerebral microinfarcts are tiny (<2 mm) infarcts seen in autopsied older persons.
Emerging evidence suggests that MRI diffusion weighted imaging (DWI) can detect larger mi-
croinfarcts in their acute stage—prior studies report that 1-5% of cognitively impaired and 15%
of cerebral amyloid angiopathy patients have small incidental DWI positive lesions, suggesting
recent acute infarcts in the last 10-14 days. However, the prevalence of clinically silent acute
infarction has not previously been reported from population-based studies. Methods: In the
PURE-MIND study 803 stroke- and dementia-free participants age 40-79 were recruited from 4
Canadian sites. Participants were selected from population-based sampling within pre-defined
postal code regions. A radiologist reviewed MRI DWI, ADC, FLAIR and T1-weighted sequences
for evidence of DWI hyperintensity consistent with acute infarction, with hypointensity on ADC as
a supporting criterion. A second reader reviewed any questionable scans, with final diagnosis by
consensus. DWI and ADC were missing in 10/803 (1.3%). Results: There were 793 participants
with MRI DWI: mean age 58.4±8.0 years; 260 (33%) were 60-69 years and 74 (9%) ≥70 years;
326 were men (41%); 145 had hypertension (18%), 48 had diabetes (6%) and 57 were smokers
(7%). No definite DWI lesions were detected (0%; 95% CI 0% to 0.5%). Questionable faint DWI
hyperintensities were seen in only 2/803 participants (0.3%; 95% CI 0% to 0.9%); however, in
both cases the faint hyperintensity corresponded to a chronic-appearing T2-hypintense lesion
without ADC hypointensity–a chronic small cavitated infarct, and a white matter T2-hyperinten-
sity. Conclusion: In an unselected community population, incidental acute infarcts are rare on
MRI DWI. Future research on incidental acute small infarcts should focus on at-risk populations.
HS.2
Improving Patient Outcome in Hyper-Acute Practices through
Real Time Audits
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
for stroke. The data is reviewed monthly by the Stroke Quality Committee to monitor MH’s per-
formance against provincial benchmarks. The percentage of patients receiving tPA within 60
minutes dropped to 7.7% in Q3 2011-2012, with an increase in median door to needle times to
70 minutes. The Committee recommended chart audits on every patient receiving tPA to identify
barriers and facilitators to meeting the benchmark. Methods: The Clinical Educator and Clinical
Nurse Specialist collaborated to build ED staff capacity. Their participation in protocols facili-tated
real time education, support and feedback. Relevant research findings were provided by the CNS to
promote understanding and generate buy-in. As a stroke expert, she was able to support patients
and families and provide education. Chart audits were conducted and results shared with ED staff
within 48 hours of thrombolysis. PDSA cycles were initiated to address barriers identi-fied in the
audits. Results: Care of patients with acute stroke was optimized through staff en-gagement and
uptake of best practices. Organizational awareness of stroke and benchmarks was heightened as
the team involved various departments in PDSA cycles. Engaged ED staff demon-strated leader-
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
minutes. Conclusions: Engagement of ED staff facilitated uptake of best practices in hyper–acute
stroke. Notable was the transition from passive participation in the PDSA cycles to active leadership
in the QI process. Staff demonstrated initiative and motivation in developing tools, fact sheets and
a flow sheet to improve compliance and decrease barriers to best practice. This process enhanced
team and inter-departmental collaboration benefitting pa-tients with stroke and their families.
HS.6
Assessment of Delays in Presentation to Stroke Prevention Clinics After TIA or
Minor Stroke: a Preliminary Analysis
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tained (PA) if the goals were attained only at some of the follow up visits, not attained (NA) if the
goals were never attained. Results: A total of 319 patients, qualified for the study. The average
age was 69 and 55% were male. The table summarizes the results of the analysis. We defined
optimal therapy as the control of all or some of the following three goals: hypertension, dyslipid-
emia and compliance with anti-thrombotic treatment.The control of individual risk factors, espe-
cially hypertension was good. However, optimal therapy was only achieved in 22% of patients.
Completely Attained (CA), Partly Attained (PA), Not Attained (NA) Conclusions: Our study
showed that that there was reasonable attainment of therapeutic goals for stroke prevention in
the McGill SPC over an average follow up of 15 months. Greater efforts will be needed in order
to achieve optimal therapy.
P1.002
Octogenarians Should Not Be Excluded From Acute Stroke Intervention Trials as
Major Clinical Responses Common with Reperfusion
Nambiar, V; Almekhlafi, MA; Mishra, S; Desai, J; Eesa, M; Volny, O; Menon, BK; Demchuk, AM;
Goyal, M; Morrish, W; University of Calgary, Calgary, AB
Background: Octogenarians were excluded from many intra-arterial acute ischemic stroke
trials. This was based on the expected delays in achieving recanalization due to tortuous vas-
cular anatomy and a perceived poor potential for recovery especially in those with existing
disability. We sought to assess the safety of the stentrievers technology in this patient popula-
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

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
median age was 64 years with a median NIHSS score of 18(iqr 9). The onset to IV needle time
was 130 minutes (iqr 111). All patients were treated via endovascular therapy with a median
and mean times of IV needle to arterial puncture times of 46 and 49.7 minutes, respectively.
Of all treated with IV tPA, 39 patients (60.9%) had the arterial puncture within 60 minutes of
the IV bolus time. Endovascular recanalization was achieved in 78.1% resulting in a median
24-hour NIHSS score of 6 (iqr 11). Significant improvement in the 24-hour NIHSS scores (drop
of 50% or more from baseline to 24 hours) was noted in 70.3%. Conclusion: An IV needle to
arterial puncture time under 60 minutes was feasible in about 60% of patients treated with IV
tPA and endovascular therapy in our cohort. Potential delays of this time interval in randomized
trials may include the time needed to obtain consent for enrolment into the trial and the time
to activate the endovascular team. Future trials should still aim to achieve a fast IV needle to
arterial puncture time given the potential for significant clinical improvement when these times
are shortened.
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P1.004
The Endocannabinoid Antagonist AM251 as a Method of Protection Prior to
Global Cerebral Ischemia: Implication for Dopamine Function, Neuronal Survival
and Behavior
Dunbar, MR; Azogu, I; de la Tremblaye, PB; Richardson, L; Plamondon, H; University of Ottawa,
Ottawa, ON
Background: Implications for the endocannabinoid system in global cerebral ischemia has not
been clearly defined. Ischemia produces an excitotoxic environment that is severely damag-
ing to neurons, causing degradation of cell membrane and ultimately cell death. Contradictory
research suggests both the benefits and adverse effects of endocannabinoid on neurological in-
jury. Due to the excitotoxic nature of ischemic injury, and the mechanisms at play with endocan-
nabinoid agonists, such as increased transmission of dopamine and glutamate, it is suspected
that CB-1 endocannabinoid antagonists, such as AM251, may provide cell protection. Methods:
40 male Wistar rats were separated into 4 groups (n=10/group). The first group of rats were
administered AM251 (2 mg/kg, i.p) 30 minutes prior to global cerebral ischemia (four vessel oc-
clusion), while the second group were given AM251, 30 minutes prior to sham surgery. Finally
the last two groups were given saline instead of AM251 and given either ischemia or the sham
surgery. Behavioural testing included the open field test and elevated plus maze, which took
place after a five day recovery period following ischemia. Immunohistochemical analyses were
performed with tyrosine hydroxylase (TH) and dopamine receptor 1(DRD1) to compare dopamine
function amongst groups. Thionin staining was used to evaluate post ischemic neuronal death.
Results: Ischemia induced a significant reduction in dopamine within the mesolimbic circuit,
including the ventral tegmental area, nucleus accumbens, CA3 & CA1 of the hippocampus, and
basolateral amygdala. These reductions in dopamine transmission by global ischemia were par-
tially or fully reversed by AM251 pretreatment. Furthermore, cell survival was increased in the
CA1 from treatment with AM251. Behavioural results indicate that AM251 reversed emotional
alterations associated with ischemia insult. Conclusion: The CB1 endocannabinoid antagonist
AM251 facilitated recovery of deficits in dopamine function in the mesolimbic pathway, at-
tenuated ischemic CA1 cell death and regulated emotionality when given prior global cerebral
ischemia.
P1.005
Carotid Artery Distensibility Evaluation with Dynamic MR Imaging
Boesen, ME1, 3 Frayne, R1, 3, 4 Yerly, J1, 3 Lebel, RM2, 3; 1. University of Calgary, Calgary, AB;
2. Applied Sciences Laboratory, GE Healthcare, Calgary, AB; 3. Seaman Family MR Research
Centre, Calgary, AB; 4. Hotchkiss Brain Institute, Calgary, AB
Background: Carotid wall motion can provide insight into stroke risk. Detection of de-
creased arterial distensibility could potentially guide early intervention. We have imple-
mented a retrospectively-gated black-blood MR acquisition to provide carotid wall images
over the cardiac cycle to evaluate distensibility measures. Methods: Eight axial slices were
prescribed over the carotid bifurcation in five volunteers. A standard black-blood MR ac-
quisition was altered to retrospectively associate data acquired with different phases of
the cardiac cycle. One image of the common carotid artery was reconstructed for each
of sixteen phases. Left carotid artery cross-sectional areas were manually traced three
times over on each image. Distensibility coefficients were calculated as: DC=2(Ds-Dd)/DdΔP
where Ds and Dd are systolic and diastolic diameters and ΔP is pulse pressure. Results:
Carotid pulsation over the cardiac cycle was clearly demonstrated (see Figure of carotid
cross-sectional diameters over time). Maximum and minimum cross-sectional areas were
used to derive Ds and Dd. Mean DC was found to be 31.9±10.8MPa-1. This finding falls
within the range reported by Harloff et al. as 41.6±9MPa-1 using a different MR-based
method (Eur Radiol, 2009; 19:1470).
Conclusion: Our proposed technique provides wall contrast and can demonstrate ar-
terial dynamics over the cardiac cycle. Tested in five normal subjects, DC fall within
the expected range. Our technique could also image the dynamics of carotid artery
wall components to provide detailed investigations of distensibility and its relation to
stroke risk.
P1.006
Atrial Fibrillation Screening Using a Handheld ECG Device: Results from the Heart
and Stroke Foundation (HSF) “Be Pulse Aware” Campaign
Boyle, KO1 Morra, D1 Dorian, P1 McCrorie, A2 Haddad, P1 Taylor, L2 Grima, E3 Newman, D1
Langer, A1 Chow, C1 Gladstone, D1; 1. University of Toronto, Toronto, ON; 2. Heart and Stroke
Foundation, Toronto, ON; 3. Canadian Heart Research Centre, Toronto, ON
Background: Early detection and treatment of atrial fibrillation (AF) could prevent many
strokes. New technology devices enable simple, rapid, inexpensive AF screening without
requiring standard 12-lead ECG or medical personnel. We tested the feasibility and yield
of a handheld ECG compared to manual pulse check at public screening events. Meth-
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
radial pulse palpation was performed by volunteer nurses/nursing students followed by
a 30 second single lead ECG rhythm strip by trained personnel (Heart Check™; Cardio-
Comm Solutions, Inc.). The primary endpoint was AF detection by pulse check compared
to ECG with central blinded cardiologist adjudication. Results: Of 1334 participants
(mean age 63 +/-13 years; history of hypertension in 20%), AF was detected by ECG
in 28/1334 (2.1%): 10/1334 (0.7%) newly-detected AF and 18/1334 (1.3%) previously-
known AF. The prevalence of new AF increased from 6/747 (0.8%) in those aged ≥65
years to 3/197 (1.5%) in those ≥75 years and 2/75 (2.7%) in those ≥80 years. Of the
new AF cases detected, 6/10 were potential anticoagulant candidates (CHADS2 score
≥1). Of ECG positive patients with previously known AF and CHADS2 ≥1, 4/11 were not
anticoagulated. Manual pulse check had low sensitivity (43%) and poor positive predic-
tive value (16%) for AF detection. An abnormal pulse was appreciated in only 12/28
ECG-confirmed AF cases (including only 1 of the 10 new AF cases). Conclusions: In
a community screening setting, identification of AF with a handheld ECG device was
feasible and superior to pulse check. AF screening programs have potential to identify
guideline-based AF treatment candidates (both new AF cases and previously-diagnosed
but untreated patients), with greatest yield in the elderly. Community AF screening
should not rely on pulse checks alone.
P1.007
A Novel Day-Unit Care Model for TIA and Minor Stroke Patients Improves Rapid
Access to Care and Satisfaction with Care
Cayley, A2 Iyngarathasan, A2 Abraham, J2 Kalman, L2 Jaigobin, C2 del Campo, M2 Silver, F2
Casaubon, L1; 1. University of Toronto, Toronto, ON; 2. University Health Network, Toronto, ON
Background: About one in four ischemic strokes are preceded by a TIA; 43% of TIAs
occur within one week before stroke. Patients with a TIA require urgent assessment
and preventative treatment but often cannot access a Stroke Prevention Clinic in a
timely fashion. Therefore, patients are often admitted to hospital for evaluation but
it is unclear if inpatient evaluation is optimal or necessary for this patient population.
Methods: We developed a high-risk TIA and Minor Stroke (TAMS) Unit to provide rapid
access to patient assessment, investigations, initiation of prevention strategies, and
stroke prevention education. The TAMS Unit patient assessments were based on a
collaborative model led by stroke Nurse Practitioners and attending stroke Neurolo-
gists. We evaluated the feasibility of this care model and assessed patient satisfaction
through a survey questionnaire. Results: Between Sept. 6, 2011 and Mar. 31, 2013,
265 patients were seen in the TAMS Unit. Median time from emergency department
visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 35% of pa-
tients and minor stroke (NIHSS < 4) in 30% of patients. For the satisfaction survey, 137
questionnaires were mailed out to patients seen in the first year after the unit opened,
with 60 (44%) returned – 52 (38%) were complete and included in the analysis. Overall,
73% of patients strongly agreed and 27% agreed that they were satisfied with their
over-all visit. Sixty percent of patients strongly agreed and 36% agreed that they were
provided with information about their condition. Over-all, patients were satisfied with
their consultations with the stroke NPs and neurologists. Conclusion: Our novel TAMS
Unit is a feasible care model that provides rapid access to assessment and treatment of
high-risk TIA and minor stroke patients. Overall, patients expressed strong satisfaction
with the care they received.
 e12  Stroke  December 2013
P1.008
Perfusion computed tomography for selection of patients with suspected acute
ischemic stroke for thrombolytic therapy—a systematic review and meta-
analysis
Burton, KR1 Dhanoa, D2 Aviv, R1 Moody, A1 Kapral, M1 Murray, K1 Laupacis, A1; 1. University of
Toronto, Toronto, ON; 2. Fraser Health Authority, Surrey, BC
Background: perfusion CT (CTP) imaging is increasingly being used for the diagnosis of acute
ischemic stroke (AIS) as it is cheaper and faster than magnetic resonance imaging (MRI).
While data from systematic reviews of UCT and MRI have been used to populate AIS imag-
ing cost-effectiveness studies, none currently exist that provide estimates of outcomes for
patients selected by CTP imaging. Objectives: to determine the rates of outcomes (mortality,
morbidity and symptomatic intracranial hemorrhage (SICH)) of AIS patients who are selected
for thrombolytic therapy using CTP imaging. Methods: we performed electronic searches in
MEDLINE, EMBASE, the Cochrane Library, PubMed, and Google Scholar up to August 2012,
unrestricted by language of publication and study methodology. We also performed manual
searches of included studies, bibliographies of relevant review articles and we searched the
gray literature for unpublished studies, which included theses, patents, health technology
reviews and conference proceedings. Two independent reviewers extracted study data and
independently assessed risk of bias for each selected study. Results: fourteen studies met
our inclusion criteria for a total of 479 patients. Mortality of CTP-selected AIS patients who
were treated within 3 hours was 17.6% (95% CI, 12.2-23.6%). Mortality of all CTP-selected
patients treated was 7.1% (95% CI, 1.8-15.5%). Favourable outcome (mRS score ≤ 2) for
patients treated within 3 hours and beyond 3 hours was 30.7% (95% CI, 8.4%-59.4%) and
44.5% (95% CI, 0.6-29.5%), respectively. Rates of SICH for patients treated within 3 hours
and beyond 3 hours were 5.4% (95% CI, 3.2-8.2%) and 4.7% (95% CI, 2.0-8.4%) respective-
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
ly. Conclusions: the outcomes of CTP-selected AIS patients can be used in future studies of
CTP imaging cost-effectiveness relative to other neuroimaging modalities within AIS patients.
P1.009
Towards Patient-Tailored Perfusion Thresholds for Prediction of Stroke Outcome
Eilaghi, A1 d’Esterre, C2 Lee, T3 Jakubovic, R1 Brooks, J1 Liu, RT1 Zhang, L1 Swartz, RH1 Aviv,
R1; 1. Sunnybrook Health Sciences Centre, Toronto , ON; 2. Robarts Research Institute, London,
ON; 3. Robarts Research Institute, University of Western Ontario, London, ON
Background and Purpose: Multiple patient-specific clinical and radiological parameters impact
upon traditional perfusion thresholds used to classify/determine tissue outcome. We sought to de-
termine whether modified baseline perfusion thresholds calculated by integrating baseline perfu-
sion and clinical factors better predicts tissue fate and clinical outcome. Methods: Computed to-
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
computed tomography perfusion parameters and follow-up FLAIR images. Optimal thresholds
transformed by clinical and radiological variables for grey matter and white matter tissue were de-
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-
tion Criterion and logistic regression. Reproducibility of models was checked using bootstrapping.
Results: Transformation of perfusion thresholds by clinical and radiological baseline param-
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
blood flow: 91%, 86%, absolute Tmax: 88%, 84%, relative mean transit time: 85%, 78% and
relative cerebral blood volume: 74%, 73%. Transformed thresholds enhanced the clinical 90-day
outcome prediction for cerebral blood flow, Tmax and mean transit time CTP maps. Conclusions:
Transformation of baseline perfusion parameters by patient-specific clinical and radiological pa-
rameters significantly improves the accuracy of tissue fate and clinical outcome prediction.
P1.010
Oxford County Blood Pressure Education Program
Gardner, LA1 Winter, J2; 1. Chief Nursing Executive, Alexandra Hospital, Ingersoll, ON;
2. Oxford County Cardiac Rehabilitation and Secondary Prevention Program, Alexandra
Hospital, Ingersoll, ON
Program Summary: The Oxford Blood Pressure Education Program was developed to test
the feasibility and effectiveness of an education and counselling intervention to improve
blood pressure control among hypertensive individuals diagnosed within three months prior
to recruitment, with no recent cardiovascular or cerebral vascular event, including those who
were already taking antihypertensive medication. The program initially targeted Oxford county
residents who did not have a family physician and sought treatment at a local emergency de-
partment. Each participant was encouraged to bring a support person or family member. The
demands placed on family physicians in the community, coupled with the physician shortage,
means that this educational component may be neglected or incomplete when a diagnosis of
hypertension is made. The program was developed and implemented by the Oxford Stroke
Strategy Working Group, and was piloted for 15 months in 2005 – 2006. Continued funding to
2007 – 2008 was received and the program was expanded to include any community member
with hypertension and their family members, as well as any community member who has an
interest in learning more about hypertension and management strategies. Again funded in
2011-12 through Ministry of Leisure and Recreation. Conclusion: The Oxford Blood Pressure
Education Program is a feasible, community-oriented program compatible with chronic dis-
ease self-management, which was associated with reductions in blood pressure and other risk
factors. These changes were significant statistically, clinically, and potentially, economically.
P1.011
Frequent Atrial Premature Beats Predict Occult Paroxysmal Atrial Fibrillation in
Patients with Cryptogenic Stroke: Results From the Embrace Multicentre Trial
Gladstone, DJ1 Spring, M2 Dorian, P3 Thorpe, K3 Panzov, V3 Hall, J3 Vaid, H1 O’Donnell, M4
Laupacis, A3 Côté, R5 Sharma, M7 Blakely, J1 Shuaib, A8 Hachinski, V9 Coutts, SB10 Sahlas, DJ11
Yip, S12 Teal, P12 Spence, J9 Buck, B8 Verreault, S13 Casaubon, L1 Penn, A14 Selchen, D1 Jin, A15
Howse, D16 Mehdiratta, M2 Mamdani, MM3 for the EMBRACE Steering Committee and Investi-
gators17; 1. University of Toronto, Toronto, ON; 2. Trillium Health Centre, Mississauga, ON; 3.
St. Michael’s Hospital, Toronto, ON; 4. McMaster University, Hamilton, ON; 5. McGill - Montreal
General Hospital, Montreal, QC; 6. University of Ottawa, Ottawa, ON; 7. Ottawa Hospital, Uni-
versity of Ottawa, Ottawa, ON; 8. University of Alberta, Edmonton, AB; 9. University of Western
Ontario, London, ON; 10. University of Calgary, Calgary, AB; 11. Hamilton Health Sciences,
Hamilton, ON; 12. University of British Columbia, Vancouver, BC; 13. Université Laval, Quebec
City, QC; 14. Vancouver Island Health Research Centre, Victoria, BC; 15. Kingston General Hos-
pital, Kingston, ON; 16. Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON; 17.
Sunnybrook Research Institute and Li Ka Shing Knowledge Inst. of St. Michael’s, Toronto, ON
Background: Many ischemic stroke/TIA events are labeled ‘cryptogenic’ but may be due
to undetected paroxysmal atrial fibrillation (PAF). To predict those most likely to have oc-
cult PAF, we investigated the association between atrial ectopic activity on Holter monitor
and subsequent detection of PAF. Methods: We analyzed data from cryptogenic stroke/TIA
patients without known AF enrolled in the 30-day cardiac monitoring arm of the EMBRACE
trial. Participants had baseline Holter monitoring that did not reveal PAF, followed by am-
bulatory cardiac monitoring for up to 30 days to detect PAF. In a preplanned multivariable
logistic regression analysis, we assessed the association between the following Holter and
clinical variables on the outcome of PAF detection: #atrial premature beats (APBs)/24h,
#runs of atrial tachycardia <30 seconds/24h, age, and #prior strokes. Results: Among
cryptogenic stroke/TIA patients (mean age 73±9 years), the median #APBs/24h on 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
entire group, 45/287 (16%), PAF was found in 16/181 (9%) patients with infrequent APBs
(<500/24h) and 20/52 (38%) patients with frequent APBs (>500/24h). PAF was found in
20/187 (11%) patients with 0-2 brief runs of atrial tachycardia and 21/70 (30%) patients
with >2 runs. In the regression model, #APBs was the only statistically significant predic-
tor of PAF (p=0.0016). The probability of PAF increased steadily with increasing #APBs
(for every 100 APBs/24h the OR was 1.4 ) up to 900, above which there was no further
discrimination. Conclusions: Elderly cryptogenic stroke/TIA patients with frequent APBs
have a high probability of occult PAF and may be particularly ideal candidates for pro-
longed cardiac monitoring for PAF detection. Among those with >500 APBs/24h, 1 in 3 had
PAF detected on 30-day monitoring.
P1.012
The University of Alberta Hospital Door-to-Needle (DTN) Process Improvement
Initiative; Significant changes Achieved Through Interdepartmental Collaboration
Halabi, M1 Ghrooda, E2 Taralson, C1 Khan, K2 Amlani, S1 Shuaib, A2 Jeerakathil, T2; 1. Stroke
Program Edmonton Zone, Edmonton, AB; 2. Division of Neurology, University of Alberta
Hospital, Edmonton, AB
Background: Shortening door to needle times (DTN) for ischemic stroke thrombolysis re-
mains a challenge. The literature demonstrates that feedback on performance to multi-
disciplinary stroke stakeholders can reduce DTN times. For 17 years our centre has failed to
lower DTN times to sub 60 minutes. A new multifaceted process improvement initiative was
implemented to streamline the DTN process Methods: April of 2012 marks the inception of
the DTN initiative. Stakeholders from the Emergency Department (ED), Stroke Service, and
Diagnostic Imaging (DI) were engaged and participated in this effort. Detailed process map-
ping was done collaboratively. Problem areas were identified. Specific solutions were de-
vised, trialed, modified, and then re-trialed. Regular meetings were held with educators and
managers to receive and provide feedback. In addition, a “Time in Motion Study” in the ED
was undertaken with “In Real Time” chart reviews completed for all thrombolysed patients.
Cases were discussed on a weekly basis within the stroke team and DTN data was regularly
shared with stakeholders. Education sessions regarding this initiative were provided by the
stroke team to ED and DI staff. Statistical analysis involved linear regression and calcula-
tion of DTNs and confidence intervals for 4 time periods spanning 13 months. Results:
The DTN initiative has rolled out an increasing number of components over 4 time periods.
Bottlenecks in the DTN process were identified then jointly and systematically managed
resulting in a statistically significant declining trend in DTN (R = -2.43; p = 0.0006 for each
subsequent month). DTN decreased significantly from 77 min (65,89) in April-July 2012 to
57 min (49, 65) in February-April 2013. Conclusion: The process improvement initiative
enabled the development of a leaner process. This collaborative effort has aligned previ-
ously siloed departments allowing them to work towards a common goal. Future efforts will
include engaging additional stakeholders such laboratory services.
P1.013
Does Hospital Ischemic Stroke volume relate to Clinical Outcomes in the Ontario
Stroke System?
Hall, R1, 2 Fang, J1 Hodwitz, K1 Saposnik, G3, 1 Bayley, M4; 1. Institute for Clinical Evaluative
Sciences, Toronto, ON; 2. Ontario Stroke Network, Toronto, ON; 3. St. Michael’s Hospital,
Toronto, ON; 4. Toronto Rehabilitation Institute, Toronto, ON
 Abstracts From the 4th Canadian Stroke Congress, 2013  e13
Better outcomes have been found among hospitals that treat high volumes of patients for
specific surgical and medical conditions. We examined whether hospital ischemic stroke
(IS) volume was associated with 30-day mortality to inform regionalization plans. Using FY
2005/06 to 2011/12 CIHI DAD we calculated the average annual IS patient volumes among
Ontario acute hospitals admitting fifteen or more IS patients per year (N = 128). Hospitals
were ranked based on average annual IS volume and stratified into terciles with approxi-
mately one third of patients in each tercile. Hospitals were classified as small (<130), me-
dium (130 – 202) and large (>202). Multivariable hierarchical logistic regression was used
to account for patient clustering within hospitals. Overall, 70,895 patients were hospital-
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
high volume hospitals. Higher volume hospitals admitted younger patients, mean (+/- SD)
age 73.0 (13.9) years compared to 74.0 years (13.3) and 75.3 (12.6) years for medium and
small volume hospitals respectively (p <0.0001). Patients at small volume hospitals dem-
onstrated similar prevalence of comorbid conditions with exception of, diabetes, cardiac
dysrhythmias, renal disease where small volume hospitals patients had lower prevalence
(p < 0.0001). Overall 30-day risk-adjusted ischemic stroke mortality was 15.1%. Mortal-
ity was 1.38 times greater (OR 1.38, 95% CI 1.21, 1.57) for patients cared for in small
hospitals compared to patients cared for in high volume hospitals. There appears to be
an association between acute hospital IS volume and 30-day mortality in Ontario. Patients
admitted to hospitals with annual IS volumes greater than 15 but less than 130 per year
are 38% more likely to die within 30-days than patients admitted to hospitals that see on
average 300 IS patients per year.
P1.014
Developing a Regional Model for Acute Stroke Unit Care - Submitted on Behalf of
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
the Fraser Health Stroke Strategy
Harrison, KJ1 Crozier, T2 Veldhoen, R2 Still, C2; 1. Fraser Health Authority, Langley, BC; 2. Fraser
Health Stroke Strategy, Surrey, BC
Background: In Fraser Health, one of Canada’s largest and fastest growing health regions,
stroke accounts for approximately 2100 hospital admissions annually—a figure that is an-
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
Steering Committee (FHSSC). Since its inception in 2005, the FHSSC has been focused on the
implementation of Acute Stroke Units (ASU) across the region that provide best care practices
and improved patient outcomes by ensuring adequate front-line staffing of all professions,
ongoing quality improvement, and reduction in acute length of stay. On June 26, 2012 the
start of this regional vision was realised with the opening of 12 acute stroke beds at Surrey
Memorial Hospital (SMH) which will increase to 22 beds by June 1, 2014 when the ASU moves
into the new 36 bed Neurology Unit in the SMH Critical Care Tower. Methods: Fraser Health
created a robust ASU with staff empowered to use quality improvement methodology to estab-
lish a model of care that will be replicated across the region. Results: Through employing the
Plan-Do-Study-Act (PDSA) methodology, front-line staff incorporated Canadian Best Practice
Recommendations to develop an acute care stroke model that has resulted in the standardiza-
tion of the following components:
1. patient/family and staff education sessions
2. measurement and evaluation framework
3. clinical decision tools (e.g. depression screen)
4. staffing mix
Conclusion: This pilot project of the SMH ASU has allowed the FHSSC to develop a regional
model for acute stroke care that can be implemented in other regional hospitals to ensure con-
sistent, measurable and improved patient outcomes.
P1.015
Effect of Onset Time of Contralesional Cortex Inhibition Following an Ischemic
Lesion in Rats
Jean-Charles, L1 Mansoori, B1 Touvykine, B1 Morse, l2 Quessy, S1 Dancause, N1, 3; 1. Université
de Montréal, Département de Physiologie, Montréal, QC; 2. Université de Montréal, Montréal,
QC; 3. Groupe de Recherche sur le Système Nerveux Central, Montréal, QC
Following stroke, human imaging studies have shown that there is an early increase of activity
in the contralesional hemisphere that progressively diminishes with time and recovery. Inhibitory
neuromodulatory protocols have been applied to the contralesional hemisphere of stroke pa-
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
highest. Thus, our aim was to investigate the effect of onset time, the time between the lesion
and the beginning of the contralesional inhibition, on motor recovery after cortical lesions. We
used a rat model of cortical lesion with micro-injections of a vasoconstrictor, endothelin-1. In
the same surgical procedure a cannula was implanted in the contralesional cortex. An osmotic
pump filled with muscimol, a GABA-A agonist, was connected to the cannula immediately (Group
0D), 3 days (Group 3D) or 7 days (Group 7D) after the lesion in 3 different groups. The pump
continuously delivered muscimol for 14 days in all groups. Controls spontaneously recovered
from lesions of similar size. The performance of both forelimbs was assessed with the Mon-
toya staircase test. In all experimental groups, there was decrease of grasping function with
the non-paretic hand during the inhibition, confirming the effectiveness of muscimol. For the
paretic forelimb, there was an initial decrease of function after the lesion that progressively
recovered with time. Group 0D recovered significantly better than controls by post-lesion day 28
but Groups 3D and 7D recovered only to the level of controls. These preliminary results suggest
that contralesional inhibition initiated within hours after a cortical lesion is more beneficial to
recovery of the paretic forelimb than the same inhibition protocol initiated 3 or 7 days following
the lesion.
P1.016
Visualization of Nestin Signals Following Ischemic Injury and in
Neuroinflammatory Conditions
Krishnasamy, S1, 2 Weng, YC2, 1 Kriz, J2, 1; 1. University Laval, Quebec, QC; 2. Centre de recher-
che du CHUL, Quebec, QC
Introduction: Neruoinflammation is a process in which the brain responds to infections, dis-
eases and injuries, it occurs due to hypoxia and ischemia to a number of bacterial and viral
infections. The inflammatory process in the neurogenic regions of the brain greatly alters the
microenvironment of the neural stem cells and thereby influences the fate of these Neural
Progenitor Cells (NPGs). The mechanism, function and significance of the modulation of neu-
rogenesis during inflammatory processes remain to be elucidated. To address these ques-
tions we generated a transgenic mouse model in which we can visualize the process of adult
neurogenesis from the brain of live animals using bio photonic/bioluminescence imaging and
high resolution CCD camera. Methods: Nestin-luc-GFP mice were subjected to 90 minutes
of MCAO followed by a reperfusion period of 3 days, 7days and 14 days. To elucidate the
chronic neruoinflammation Lipopolysaccharide (LPS) 5mg/kg body weight was injected to mice
by intraperitoneally for every 3 days until 14 days. Results: In the acute CNS injury model
we observed the up regulation of nestin bioluminescent signal at 24hrs, 3 days and 7 days,
and signal was observed up to a month following the surgery. Chronic administration of LPS
produce an up regulation of nestin signal at 24 hrs and gradually start declines after 72hrs and
reached the baseline level at 14 days. Histological analysis of the brain sections 72 hrs and
7 days after stroke shows an increase of nestin and the nestin-driven GFP transgene expres-
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
advantage of Nestin-luc/GFP transgenic mice to study the ischemic injury induced gliogenesis
and neurogenesis.
P1.017
Enhanced Dynamic Contrast Enhanced (DCE) MR for Brain Perfusion Imaging
Lee, E1, 2 MacDonald, M1, 2 Frayne, R1, 2, 3; 1. Biomedical Engineering, Hotchkiss Brain Institute,
University of Calgary, Calgary, AB; 2. Seaman Family MR Centre, Foothills Medical Centre,
Calgary, AB; 3. Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB
Background: MR perfusion measurements allow for derivation of tissue-level hemodynamic
parameters (eg., cerebral blood flow) that are useful for diagnosis of cerebral ischemia. DCE ap-
proaches typically use fast T1-weighted MR imaging methods that exhibit, over a range, a near
linear relationship between signal intensity and contrast agent concentration. This observation
suggests the potential for more robust estimations of perfusion-derived parameters compared
to other existing MR approaches, leading to better stroke detection and localization. Low blood
volume in brain tissue (WM ~2% blood), however, poses a limitation to this approach. We pro-
pose a technique for maximizing observed signal changes (ΔS=Scontrast-Sbaseline) during the
contrast agent bolus passage in less vascularized white matter tissues while preserving both
spatial and temporal resolution. Methods: A DCE signal model was implemented that allowed
the effects of three key parameters (contrast concentration, repetition time (TR) and flip angle
(FA)) to be understood and modified to optimize ΔS. Imaging performed on a 3-T scanner con-
firmed predictions from the model using phantoms and stroke patients. Patients were scanned
using the DCE method with two TR/FA combinations during a single contrast injection. Results:
As expected, ΔS increases with increasing concentration, and was maximized for a specific (TR,
FA) combination. In phantom and stroke patient studies, the longer TR acquisitions yielded a
larger ΔS, consistent with predictions made by our model. Increase in ΔS by ~47% was readily
observed in images for both the phantoms and stroke patients. Conclusions: Signal difference
in DCE perfusion imaging in WM can be increased by careful selection of TR and FA. More robust
changes in WM improve the precession of perfusion measures with DCE in acute stroke. In order
to provide sufficient temporal sampling rates, however, longer TR DCE techniques will need to
be implemented with accelerated imaging approaches.
P1.018
Screening for High-Risk Comorbidities (Depression, Obstructive Sleep Apnea
and Cognitive Impairment) in the Stroke Clinic: The Need, the Challenges and a
Possible Solution (The Doc Screen)
Lien, K1 Sicard, MN1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook
Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing
Knowledge Institute, Toronto , ON
Background: Treatable comorbidities such as depression, obstructive sleep apnea, and cogni-
tive impairment (DOC) each affect up to 50% of patients post-stroke. Though these DOC condi-
tions worsen outcomes and quality of life, the associations amongst them are understudied.
Routine screening is recommended, but is onerous and cannot be applied in all cases. There is
a need for brief, valid tests to screen for these three comorbidities during the clinical encounter.
The objective of this research study is to develop a 1-page integrated screening assessment to
identify high-risk patients for each of the DOC conditions in large-volume urgent TIA/stroke clin-
ics. Methods: A literature review was conducted for screening tools of DOC comorbidities. More
than 50 tests were identified but few met inclusion criteria of brevity and utility for broad clinical
 e14  Stroke  December 2013
application. Results: The DOC screen is a novel screening tool that combines depression, apnea
and cognitive screening tests (PHQ-2, STOP, and mini-MoCA, respectively). The screen has been
designed such that less contributory cognitive tasks (distracters) have been replaced with mood
and apnea questions to maintain validity of the delayed recall task. Additionally, it employs more
sensitive executive function tasks (clock and abstraction). Scores for each disease can be as-
sessed separately, and the total (out of 20) provides an overall “brain risk” score. Conclusion:
Simple, reliable, evidence-based screening of DOC disorders is necessary and the novel screen
may facilitate this. While brief screens have been studied individually, it remains to be seen if
the integrated measures prove to be feasible and valid.
P1.019
National Survey of Neurologists for TIA Risk Stratification Consensus and
Appropriate Treatment for a Given Level of Risk
Perry, JJ1 Losier, J1 Sutherland, J2 Stiell, IG1 Sharma, M3; 1. University of Ottawa, Ottawa, ON;
2. Ottawa Hospital Research Institute, Ottawa, ON; 3. McMaster University , Hamilton, ON
Background: 5% of transient ischemic attack (TIA) patients have a subsequent stroke ≤7 days.
The Canadian TIA Score uses clinical findings of TIA patients to calculate subsequent stroke risk
≤7 days. Our objectives assessed: 1) anticipated use; 2) component face validity; 3) risk strata
for stroke ≤7 days; 4) actions required, for the Canadian TIA Score. Methods: We conducted
a mail survey of 222 Canadian Neurologists listed in Scott’s Canadian Medical Directory via a
modified Dillman technique. We used pre-notification, up to 3 survey attempts by letter mail
(first with a $10 gift card) and a 4th by registered mail. We asked 41 questions including:
demographics, face validity of the Score’s components (4-point scale), if physicians will use
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the Score (4-point scale), cutoffs (open percents) for minimal, low, high and critical-risk, and
suggested actions for each risk stratum (4-point scale). We calculated descriptive statistics.
Results: Response rate was 53.1%, predominately males (79.3%) with mean age 53.0 years.
Components rated as “very important” or “important” were: first TIA (73.5%), ≥10 minutes
duration (90.1%), history carotid stenosis (92.6%), antiplatelet therapy (52.1%), gait disturbance
(40.5%), unilateral weakness (95.9%), vertigo (negative predictor) (23.2%), speech disturbance
(94.2%), diastolic BP ≥110 (76.0%), atrial fibrillation (99.2%), infarction on CT (92.5%), platelets
≥400x109/L (39.7%), and glucose ≥15mmol/L (63.6%). 86.8% would use the Canadian TIA
Score after validation. Using the 25th percentile (i.e. 75% of physicians would accept this degree
of risk or more) defined: minimal-risk <1%, low-risk 1-5%, high-risk 5.1-15%, and critical-risk
>15% for subsequent stroke ≤7 days. Suggested actions include minimal-risk: ECG, optimize
blood pressure; low-risk: CT head, outpatient carotid imaging, echocardiogram; high-risk: im-
mediate carotid imaging, hospital admission, and critical-risk: echocardiogram on same day.
Conclusions: Neurologists will likely use a validated Canadian TIA Score. Most components
have high face validity. Risk strata are definable with prescribed actions.
P1.021
Community Exercise Partnership: Heart Wise Exercise for TIA and Minor
Non-Disabling Stroke
Morris, MR1 Bourgoin, A1 Gocan, S1 Harris, J2 Woermke, H3 Dyks, T1; 1. Champlain Regional
Stroke Network, Ottawa, ON; 2. The Ottawa Heart Institute-Heart Wise Exercise, Ottawa, ON;
3. Pembroke Regional Hospital, Pembroke, ON
Background: Physical activity (PA) is an important modifiable lifestyle factor in secondary pre-
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-
cular conditions. Methods: An innovative model was employed at Champlain Regional Stroke
Prevention Clinics (SPC) to increase engagement in PA among patients with Transient Ischemic
Attack (TIA) and minor non-disabling stroke (MNDS). This included fitness leader training, sys-
tematic PA prescription and referral to Heart Wise Exercise (HWE) community programs for
patients seeking support with PA. University of Ottawa Heart Institute and Champlain Regional
Stroke Network built on the HWE network of community exercise leaders to increase capacity
and knowledge about stroke best practices. Results: Across the region, 157 exercise leaders
at 24 HWE sites (11 rural, 13 urban) participated in targeted training for exercise after TIA/
MNDS. Health care providers at all four SPC’s in Champlain implemented standardized exercise
prescription pads which included Canadian Best Practice recommendations for PA and identified
regional HWE programs. Fitness leaders who received training reported increased confidence
in providing safe and suitable exercise routines. Successes seen in the stroke program have
been replicated among regional diabetes programs. Challenges for program evaluation have
included access to volumes of referrals and tracking program uptake. Conclusions: PA is an
independent risk factor for stroke and other vascular conditions. As such, the systematic deliv-
ery of counselling, education and support for physical activity is an important vascular health
prevention strategy. Research is needed to assess the impact of partnerships which couple
standardized, patient-focused interventions with structured community programs supported by
trained fitness leaders.
P1.022
CTA Collaterals Can Be Used for Patient Selection in Proximal Anterior Circulation
Occlusions Receiving IA Therapy
Nambiar, VK1 Sohn, S2 Quazi, E1 Mishra, S1 Quazi, A1 Kosior, J1 Demchuk, AM1 Hill, MD1
Goyal, M1 Menon, BK1; 1. University of Calgary, Calgary, AB; 2. Keim Yong University,
Keimyong, Korea
Introduction: The presence of leptomeningeal collaterals are associated with improved
outcome among patients with acute ischemic stroke. We sought to identify if the associa-
tion between recanalization after endovascular acute stroke therapy and favorable clinical
response is modified by the presence of good collateral flow assessed on baseline CT
angiography (CTA). Methods: Data are from the Keimyung Stroke Registry, a prospec-
tively collected dataset of patients with acute ischemic stroke from Daegu, South Korea.
Patients with M1 segment middle cerebral artery (MCA) +/- intracranial internal carotid
artery (ICA) occlusions on baseline CTA from May 2004 to July 2009 who had baseline
MRI were included. Two readers blinded to all clinical information assessed baseline and
follow-up imaging. Leptomeningeal collaterals on baseline CTA was assesed by consensus
using the regional leptomeningeal score (rLMC). Results: Among 84 patients (mean age
65.2±13.2 years, median NIHSS 14; IQR 8.5), median time from stroke onset to initial
MRI was 164 minutes. TIMI 2-3 recanalization was achieved in 39.3% patients and mRS
0-2 at 90 days in 35.8% patients. In a multivariable model, the interaction between col-
lateral status and recanalization was relevant (p=0.048). Only patients with intermediate
or good collaterals who recanalize show a statistically significant association with good
clinical outcome. (Rate Ratio=3.7, 95% CI 1.2-11.5). Patients with good and intermediate
collaterals who do not achieve recanalization and patients with poor collaterals even if
they achieve recanalization do not do well. Conclusion: Results from our study suggest
that a randomized controlled trial focused on achieving fast and effective recanalization
using latest generation mechanical devices (stentrievers) among patients with good and
intermediate collaterals assessed on CTA at baseline could provide confirmatory evidence
for IAT in acute ischemic stroke.
P1.023
Apixaban Versus Aspirin in Atrial Fibrillation Patients ≥ 75 Years Old: an Analysis
From the AVERROES Trial
Ng, K; Shestakovska, OO; Eikelboom, JW; Connolly, SJ; Yusuf, S; Hart, RG;
McMaster University, Hamilton, ON
Background: The AVERROES trial (mean participant age 70 years) compared aspirin with
apixaban, a novel oral Xa inhibitor, in patients at moderate-to-high risk of stroke due to atrial
fibrillation (AF) but were unsuitable for vitamin K antagonists (VKA). Most AF patients in the
community are ≥ 75 years-old, and this age group has higher risks of both stroke and bleed-
ing during antithrombotic therapy than younger AF patients. In these exploratory analyses,
we characterize further the effects of aspirin and apixaban in elderly patients. Methods: The
AVERROES trial (n=5599) included 1898 patients ≥ 75 years with AF. We compared baseline
characteristics and evaluated the effect of apixaban compared with aspirin on stroke and major
bleeding in patients ≥ 75 years versus patients < 75 years. Results: The absolute risk 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-
tive risk reduction 33%; P-value for age interaction = 0.04). Patients ≥ 75 years had higher
CHADS2 score and lower mean GFR compared with patients < 75 years. Whilst the risk of ma-
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),
there was no significant interaction with age. Summary: Patients ≥ 75 years who are unsuit-
able for VKA treatment have substantially greater benefit from apixaban than aspirin compared
with younger patients. Apixaban was not associated with a disproportionately greater risk of
bleeding in patients ≥ 75 compared with younger patients despite the greater absolute risk of
major bleeding and worse renal function.
P1.024
The Effectiveness of Stroke/TIA Education Upon Discharge From the Stroke Unit
at the Grey Nuns Community Hospital
Pfeiffer, TL1 Avoledo, S1 Morrison, L2; 1. Grey Nuns community Hospital, Edmonton, AB;
2. Stroke Program, Edmonton Zone, Edmonton, AB
Background: The Canadian Best Practice Recommendations for stroke care indicates “educa-
tion is an integral part of stroke care that must be addressed at all stages across the continuum
…” As part of the Alberta Stroke Initiative (ASI), a gap analysis completed in 2012 at the Grey
Nuns Community Hospital (GNCH) Stroke Unit identified a lack of stroke education to patients
upon discharge. As a result, the GNCH Stroke Unit created a discharge process for the stan-
dardized Stroke/TIA Information Package developed by the Stroke Program, Edmonton Zone.
A pilot project evaluating the effectiveness of this process is currently underway. Methods:
The new discharge process from the GNCH Stroke Unit consists of the bedside nurse providing
education by reviewing the content within the Stroke/TIA Information Package with all Stroke/
TIA patients. A checklist, secured to the front of the package, is completed by the bedside
nurse and signed off by the patient. Patients are encouraged to review the information package
and bring it to subsequent Stroke Prevention Clinic (SPC) appointments. The SPC clinic nurse
reviews the information a second time with the patient and provides additional resources, as
necessary. An anonymous questionnaire is provided to the patient during the SPC appointment
to confirm education was provided and beneficial. Results: This Stroke/TIA discharge process is
currently a pilot project at the GNCH Stroke Unit. Results have yet to be collected and analyzed,
but patient questionnaires received to date report satisfaction with the education provided. The
process has standardized Stroke/TIA information being provided onsite and has strengthened
relationships between the acute unit and SPC. Conclusion: The GNCH Stroke Unit implemented
Best Practice Recommendations by providing standardized discharge education to all Stroke/TIA
patients. Evidence of similar activities suggests that this process will contribute to a safer and
more informed discharge.
 Abstracts From the 4th Canadian Stroke Congress, 2013  e15
P1.025
Acute Ischemic Stroke Care Path and Pre-Printed Orders Education
Ram-Ditta, D; Fraser Health Stroke Strategy, Surrey, BC
An InterProfessional team in Fraser Health developed an Acute Ischemic Stroke Care Path that
utilized elements of 48/6 (Mandated by the BC Ministry of Health to assess 6 components in
48 hours). In addition, the carepath incorporated best practice standards from the Stroke Best
Practice Guidelines 2010. The carepath presently is for nursing. It is being trialled at our only
stroke unit and four cohort units in acute care for a period of 3 months. It will be revised and
will be available for use in our medicine program. The education session has been designed to
be interactive, fun, and meaningful. The intent of the sessions are to foster the nurses ability
to critically think about why certain elements are important to assess and treat in the stroke
patient. Even though there is a core curriculum, each cohort site’s needs have been assessed,
and the education tailored to address the learning needs. A lesson plan has been developed for
each session and is interprofessional in nature. The education is Interprofessional in nature and
includes education from Physiotherapy, Occupational Therapy, Pharmacy, Speech Language Pa-
thology, Pharmacy, Nursing and the Regional Stroke Coordinator. Even though the education is
in progress, the evaluations has been very positive. The education is based on the needs of each
cohort site, and incorporates members of the interprofessional team such as physiotherapy,
occupational therapy, speech language pathology and pharmacy when the need has been iden-
tified by the manager and educator. The care path and pre-printed orders are also discussed.
P1.026
Targeting the Rgma/Neogenin Pathway to Promote Neuronal Regeneration
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Following Stroke
Shabanzadeh, AP; University of Toronto, Toronto, ON
Membrane proteins play critical roles in many biological processes. Here we developed a series
of peptides to alter the role of the extracellular ligand Repulsive Guidance Molecule RGMa and
its receptor (Neogenin) on diseased neurons. To assess the role of these peptides in Stroke, we
have used several in-vivo stroke models, including a thromboembolic stroke model in rats which
utilizes a distal internal carotid artery occlusion with a clot, and a model of retinal artery stroke.
To get insight into the cellular mechanisms involved after addition of our peptides, we developed
in-vitro stroke models (Oxygen and Glucose Deprivation model). Here, we show that providing
RGMa, to neurons promoted cellular survival in retinal and cerebral stroke models. Because we
have showed that RGMa requires activation by the enzyme SKI-1, we also tested whether or not
a specific inhibitor for this enzyme can promote functional recovery following Stoke (see im-
ages 1 and 2 ) . Interestingly, animals treated with this inhibitor significantly neurological deficit
improvement following MCAO. This was accompanied by a reduction of the infract volume and
brain edema size. Together our results reveal that targeting the RGMa/Neogenin pathway may
provide therapeutic opportunities for the treatment of Stroke.
P1.027
Frequency of Atrial Arrhythmias in Stroke: Prolonged Monitoring of Cardiac
Rhythm for Detection of Atrial Fibrillation After a Cerebral Ischemic Event
(PEAACE) Study
Shuaib, A1 Ghrooda, E1 Yaseen, I1 Mohammad, A1 Dobrowolski, P1 Hasan, M1 Hussain, G2
Ahmad, A1; 1. University of Alberta, Department of Medicine, Division of Neurology, Edmonton,
AB; 2. University of Alberta, Department of Medicine, Division of Cardiology, Edmonton, AB
Background: Recent studies suggest that prolonged cardiac monitoring may identify paroxysmal
atrial fibrillation (PAF) in up to 18% of patients with cryptogenic stroke. PAF can also be a potential
etiology where another potential mechanism is present. We prospectively monitored patients pre-
senting with a TIA or stroke where preliminary investigations (including a Holter) did not show atrial
fibrillation. Methods: Prospective non-randomized study of patients with TIA and acute stroke
between July 2012 and May 2013 where Spider Flash-t™ Monitors (Sorin Group, Italy) were at-
tached to the patients for prolonged monitoring. Clinical events were evaluated with a specifically
designed ‘arrhythmia score’ and the recordings were initially reviewed by the study team and then
by the study cardiologist. The duration and frequency of PAF was recorded and the results were
conveyed to the referring stroke neurologist. Results: In 54 patients (duration of monitoring 10 (±4)
days), there were 17 patients (31%) with PAF (AF >30 seconds 5 patients, AF >3 sec and <30 sec
12 patients). Paroxysmal atrial tachycardia was detected in additional four patients and atrial flut-
ter in an extra two patients. In three PAF, was evident with concomitant symptomatic large vessel
carotid disease. The diagnosis of PAF leads to initiation of anticoagulant treatment in 12 patients.
Conclusions: Prolonged cardiac monitoring for detection of atrial arrhythmias increases the yield
for PAF. Previous studies have focused on patients with cryptogenic stroke. Our study shows that
PAF and other arrhythmias are present with similar frequency in patients where additional mecha-
nisms may account for the etiology and often results in changes in treatment.
P1.028
The “Doc” Screen: Rapid, Routine Screening for Depression, Obstructive Sleep
Apnea and Cognitive Impairment is Feasible in Stroke/TIA Clinics
Sicard, MN1 Lien, K1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook
Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing
Knowledge Institute, Toronto, ON
Background: Depression, obstructive sleep apnea and cognitive impairment (DOC) each affect
30-50% of patients post-stroke. They all impede recovery, increase morbidity and mortality, and
worsen outcomes and quality of life. Best practice guidelines recommend routine screening; yet, all
three are widely under-assessed, under-diagnosed, and under-treated. Detailed screening is too
time-consuming, and cannot be used for everyone. A panel sponsored by the National Institute of
Neurological Disorders and Stroke (NINDS) and Canadian Stroke Network (CSN) has emphasized
the need to develop cognitive screening tools that can be applied in a 5-minute assessment. The
objective of this study is to determine the feasibility of implementing a simple, evidence-based,
clinical screening tool (DOC screen) to identify individuals at high-risk of depression, obstructive
sleep apnea, and cognitive impairments in large-volume stroke/TIA clinics. The primary goal of this
project is to determine whether 85% of eligible patients can complete the DOC screening assess-
ment in ≤ 5minutes. Methods: All consecutive new referrals to the Sunnybrook Stroke Prevention
Clinic who were English-speaking and non-aphasic were eligible to be screened. The clinical care
team were trained in administering the screen and given a stopwatch. The total number of patients,
number screened and the time for completion were logged. Results: Over eleven months, 934
new referral patients were seen at the Sunnybrook Stroke Prevention Clinic. 205 patients declined,
were missed or were ineligible at first screen. Data from 729 screens have been collected; 86
patients were excluded (30 were untimed, 55 non-English-speaking and/or aphasic), and 643 pa-
tients were included. Feasibility analysis showed 89% (95% CI: 86.1%-91.0%) of eligible patients
completed the screen in ≤ 5minutes (range 1.8-11.5 minutes, average 4.2 minutes, S.D. =1.45).
Conclusion: Systematic screening of depression, obstructive sleep apnea, and cognitive impair-
ment in ≤ 5minutes is feasible in a high volume stroke/TIA clinic using the DOC screen.
P1.029
One-Year Experience of a Carotid Intervention Quality Assurance Initiative using
a Carotid Revascularization Performance Feedback Letter
Somji, M1 Gould, L2 MacRae, L2 Carlino, K2 Murty, N1, 2 Szalay, D1, 2 Wells, J1, 2 Sahlas, DJ1;
1. McMaster University, Hamilton, ON; 2. Hamilton Health Sciences, Hamilton, ON
Background: Carotid revascularization, usually carotid endarterectomy (CEA) is a highly effec-
tive strategy for secondary prevention of stroke in patients presenting with symptomatic carotid
artery stenosis. However, the absolute risk reduction is extremely dependent upon timing of
surgery, with maximum benefit if CEA is performed within two weeks of symptoms. Data from
the Registry of the Canadian Stroke Network indicates that median time to surgery in Ontario is
25 days, with only one-third of patients receiving CEA within 2 weeks. Methods: A quality assur-
ance initiative including the development of a carotid revascularization performance feedback
letter was designed in order to foster self surveillance of elements related to achieving target
times. Data obtained through use of the feedback letter was analyzed in order to compare the
duration of key time intervals between the index clinical event and subsequent carotid interven-
tion. Results: Forty-three patients underwent carotid revascularization for symptomatic disease
over a period of one year. Twenty-four patients were initially referred to a Stroke Prevention
Clinic (SPC), whereas 19 patients were instead referred directly to either a vascular surgeon or a
neurosurgeon. Mean time from index clinical event to surgery was 28 days for patients referred
to a SPC compared to 53 days for those referred to a surgeon (p=0.005). Much of this delay
was related to obtaining carotid imaging after initial presentation to a health care provider (6 vs.
17 days; p=0.02). Conclusions: Implementation of a carotid revascularization feedback letter
revealed two distinct clinical pathways for patients presenting with symptomatic carotid artery
disease. The clinical pathway involving referral to a SPC was associated with more efficiencies
in achieving target times for best practice. This validates and emphasizes the importance of
SPCs in managing this population at a high risk of stroke recurrence.
P1.030
Dedicated Stroke Care Reduces Stroke Mortality Rates
Tebbutt, TD; Grand River Hospital, Kitchener, ON
Background: Grand River Hospital (GRH) has been a District Stroke Centre serving Waterloo/
Wellington since 2003 and has been administering tPA since 2004. We implemented a 12 bed
acute stroke unit in 2004. The 30 day stroke mortality rates at GRH have been higher than the
provincial benchmark. This prompted quality improvement initiatives to decrease our stroke
mortality rates. Methods: Chart audits were completed which indicated there was opportunity
for improvement in our coding. A dedicated stroke coder was implemented and targeted educa-
tion was provided to our hospitalists who care for patients on our acute stroke unit. Interdisci-
plinary staff training was implemented focusing on the Canadian Neurological Scale, dysphagia
screening, early mobilization, DVT prophylaxis, falls assessments and safe transfers. Results:
Results demonstrate a trend towards decreased mortality rates, decreased hospital acquired
pneumonia and decreased readmission rates. GRH is now below the provincial benchmark for
stroke mortality. Conclusion: Grand River Hospital was successful in significantly decreasing
stroke mortality rates utilizing a multi-faceted approach. A designated stroke unit with dedi-
cated interdisciplinary staff promotes stroke expertise and facilitates targeted stroke education.
A dedicated stroke coder promoted improved quality of stroke data.
P1.031
The Study of Hyperintense Flair Vessel (HVS) Sign Reversal On FLAIR MRI In
Acute Strokes with Proximal Vessel Occlusions, Does It Make Us Any Wise?
Adatia, S1 Almekhlafi, M1 Nambiar, V1 Trivedi, A1 Sohn, S2 Menon, B1; 1. Foothills Medical
Hospital, Calgary , AB; 2. Keimyong University , Daegu, Korea
Background and Purpose: Hyperintense vessels (HV) have been observed in fluid- attenuated
inversion recovery imaging (FLAIR) MRI sequence in patients with acute ischemic strokes in
 e16  Stroke  December 2013
r­egion of diffusion positivity .They have been linked to slow flow in collateral arterial circulation
and proximal arterial occlusions. We aim to study the reversal of HVS on 24 hours MRI and its
relation to successful recanalization. Methods: We reviewed 148 patients from prospectively
collected acute ischemic strokes with proximal occlusions on CTA. The HV sign was defined :
presence of flair bright vessels on MRI in region of diffusion restriction. Two independent/blinded
clinicians identified it. Its reversal was identified on 24 hours MRI. The recanalization grading
(TIMI) was done on angiograms offered for therapy. Results: 98 patients had HVS sign.35 patients
showed reversal. Interrator agreement was accepatble. (Kappa 0.92) Baseline characteristics like
age, sex, NIHSS, diabetes and smoking was comparable. The patients were offered intravenous
tpa, intra arterial therapy (lytic/ mechanical thrombectomy) or both based on case basis. 30/35
reversal group underwent IV wtih IA, all had successful recanalization (TIMI 2/3 on angiogram
). In the non reversal group, 38/63 patients had IV with IA. 16 showed complete recanalization
(42%). (p<0.005) The initial infarct volume, infarct growth (24 hours) and mRS at 3 months was
comparable in both. In the multivariate analysis model for prediction of reversal of this sign, suc-
cessful recanalization emerged as the prime factor. (p=0.006 ;OR6.21) No effect of age, time to
MRI, time to treatment was seen. Conclusion: The reversal of HVS after successful recanalization
does indicate that these vessels represent sluggish flow due to proximal large vessel occlusions.
This sign can be used as a surrogate marker for presence of large vessel occlusions. To our best
knowledge, our group is the first ever to describe its reversal with recanalization.
P1.032
Cerebral Microbleeds Causing Acute Focal Deficits: Evidence From a CADASIL
Patient
Vitali, P; Boghen, D; Daneault, N; Guillon-Letourneau, L; Poppe, AY; Notre-Dame Hospital,
Montreal, QC
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
Background: Cerebral microbleeds, thought to reflect minor leakage from fragile arterial mi-
crovessels, visualized on gradient-echo MRI sequences, are classically considered as clinically
silent. However, some recent case reports provide evidence that microbleeds can cause fo-
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
no vascular risk factors presenting with sudden onset of severe headache, vertigo, nausea,
photophobia and horizontal diplopia. His past medical history was remarkable for migraine with
aura and some transient stroke-like episodes. Interestingly, his mother died in her early fifties
after suffering from a number of strokes. Neuro-ophthalmological examination early post-onset
revealed left hypertropia, clockwise torsion of the eyes, right head tilt and counter-clockwise
rotary nystagmus and upbeat nystagmus in primary position. This was interpreted prior to the
MRI as consistent with an ocular tilt reaction possibly due to a lesion nearby the left Interstitial
Nucleus of Cajal (INC). An extensive investigation of a posterior circulation stroke was carried
out. Results: CT angiography and serological investigations for stroke in the young adult were
normal. However, brain MRI showed classical radiological findings of CADASIL disease with
extensive leucoencephalopathy involving both temporal poles and several old lacunar strokes.
Notch3 mutation analysis is pending. Surprisingly, no acute ischemic lesion was observed on
DWI sequences, in particular in the brainstem, excluding an acute ischemic stroke. However,
gradient-echo sequences showed a pattern of multiple subcortical microbleeds. In particular,
one microbleed was strategically located in the rostral midbrain, in a region next to the left puta-
tive INC. Conclusions: The observations in this single case support the view that microbleeds
may be associated with acute focal neurological deficits and suggest a possible novel patho-
physiological mechanism underlying the clinical spectrum of CADASIL disease.
P1.033
Development of a Walk-in Code Stroke Protocol for Community Hospital
Emergency Departments in Toronto
Willems, J2 Linkewich, E1 Sharp, S3 Tahair, N4 Olynyk, C5 Swartz, R1; 1. North & East GTA
Stroke Network, Toronto, ON; 2. South East Toronto Stroke Network, Toronto, ON; 3. Toronto
West Stroke Network, Toronto, ON; 4. Toronto Stroke Networks, Toronto, ON; 5. Toronto
Emergency Medical Services, Toronto, ON
Background: Since 2005, the Memorandum of Understanding for Medical Redirect and Repa-
triation of Acute Stroke Patients within Toronto Area (MOU) ensures that acute stroke patients
accessing Toronto Emergency Medical Services (TEMS) are screened for potential eligibility for
hyperacute intervention and transported directly to a Regional Stroke Centre (RSC). The MOU sup-
ports coordinated access to time-sensitive stroke services not available at community hospitals.
Not all patients activate EMS and instead use their own transportation to arrive at a community
hospital emergency department (ED). For patients assessed by community ED physicians who re-
quire RSC services, the lack of a formal process for expedited transfer to a RSC has limited access
to best care. Methodology: The Toronto Stroke Flow Initiative established the Toronto ED/EMS
Working Group to develop a coordinated process to ensure equitable access to RSC services from
community hospitals. Working with physician and staff from community hospital EDs, RSCs, To-
ronto EMS, and Toronto Stroke Networks, a new Walk-in Code Stroke Protocol (WCSP) was devel-
oped. The protocol, implemented on December 3, 2012 includes standardized screening criteria
and communication protocols, clear target timelines and a system failure reporting mechanism
to support quality improvement. Results: From December 2012 to March 2013, 50 patients were
transferred from 12 community hospital EDs to RSCs under the new WCSP, representing 14% of
acute stroke EMS transports. 90% of EMS pick-ups occurred within the 9-minute target time and
9 process-related issues were reported. Ongoing evaluation of the WCSP will monitor 1) system
performance to ensure compliance and identify opportunities for improvement and 2) impact on
patient outcomes including t-PA administration rates. Conclusions: An improved standardized
system of coordinated and equitable access to hyperacute stroke services for patients who arrive
at non-RSC hospitals has been achieved across Toronto. Tools and resources developed may be
transferable to other hub-and-spoke stroke care settings.
P1.034
Optogenetic activation of mouse cortical inhibitory interneurons is sufficient to
increase local blood flow
Anenberg, E; LeDue, J; Murphy, TH; University of British Columbia, Vancouver, BC
Interplay between various cell types in the brain orchestrates the recruitment of blood flow in
accordance with local activity. Coupling alterations in blood flow, and presumably oxygen deliv-
ery, with levels of neuronal activity is essential for normal brain function; however, the underly-
ing mechanisms involved in this regulation are unclear. Studies suggest a role for astrocytes,
pericyctes, pyramidal neurons and interneurons in controlling cerebral blood flow. Here we use
optogenetic techniques, cell type selective excitation, to investigate whether direct activation of
inhibitory interneurons can alter blood flow. By imaging through a polished reinforced thinned
skull window, we have observed that direct photostimulation of inhibitory cells in vivo in VGAT-
mhChR2-YFP BAC transgenic mice alters levels of cortical blood flow and activity. With 3.3 mW
of 473nm light, 100ms of 100Hz 5ms stimulation led to a 9.15±1.08% increase in the laser
speckle signal within 1.9 s (n=3). Similar increases in blood flow assessed by laser speckle
(10.04±0.03%) were achieved with 4 s of sensory stimulation (n=2). Intrinsic optical signals were
used to confirm that stimulation led to brain activation. The initial dip of the intrinsic signal, an
indirect measure of activity composed largely of the deoxygenation of hemoglobin (Hb) (Frostig
et al. 1990) , reached its minimum of -0.021±0.018 ∆R/R% within 1.2 s (n=5). Signal overshoot,
which is proposed to consist largely of HbO2 increase and deoxyHb decrease (Malonek and Grin-
vald, 1996) reached a maximum of 0.205±0.032 ∆R/R% within 3.2 s (n=5). Sensory stimulation
led to an initial dip of similar amplitude to direct optogenetic stimulation (-0.020±0.004 ∆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-
gest that the activation of interneurons is sufficient to mediate elevations in cortical blood flow.
P1.035
Characterization of the Regenerative Response of Endogenous NPCs Following
an ET-1 Induced Focal Ischemic Injury in the Adult Mouse Cortex
Bartlett, RF; Roome, RB; Xiong, J; Vanderluit, J; Memorial University of Newfoundland,
St. John’s, NL
Background: The neural precursor cell (NPC) population of the subventricular zone (SVZ) in
the adult mammalian brain has been the subject of great interest, specifically for their potential
to aid neural regeneration. NPCs have the ability to differentiate into the 3 cells of the central
nervous system – neurons, astrocytes and oligodendrocytes. However, although NPCs migrate
to the site of injury after an ischemic insult as differentiating neuroblasts, the majority of them
undergo apoptosis and fail to contribute towards regeneration. Methods: To test if enhanced
survival of these neuroblasts can assist in the repair of an infarct, we propose to selectively
manipulate the expression of the anti-apoptotic gene, Mcl-1. Our lab has recently developed a
reproducible focal ischemic injury model in the adult mouse forelimb motor cortex. Using this
model, I am investigating the acute peak proliferative response of NPCs when they differentiate
to neuroblasts and begin to migrate towards the focal ischemic injury. This can be achieved
through the use of BrdU, a proliferation marker, and doublecortin, a marker for neuroblasts, im-
munohistochemistry. Additionally, I have further characterized the progression of the injury, this
includes assaying the neuronal, glial and vascular health post injury. Results: I have shown how
NPCs in the SVZ react to an ischemic insult during the first week post injury, this gives greater
resolution than previously investigated NPC activity post ischemia. This is in conjunction with
the cellular and vascular health assays to aid in understanding the response of neuronal and
glial populations over the first week post injury. Conclusions: Characterizing this optimum time
window for manipulation is crucial to determine when to transfect NPCs with Mcl-1 and assess
the extent of neuroblast survival and possible regeneration. This will help identify a role for NPCs
to promote neural repair in the adult brain following ischemic injury.
P1.036
Functional Neuroimaging markers of Cerebral Small Vessel Disease effects
on cognition
Dey, AK2, 4, 5 Turner, G2, 1 Black, SE3, 6, 7 Levine, B5, 6, 8; 1. Department of Occupational and Reha-
bilitation Sciences, University of Toronto, Toronto, ON; 2. Heart and Stroke Foundation Centre
for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, ON; 3. Centre for Stroke
Recovery at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON;
. Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON;
5. Rotman Research Institute, Baycrest Centre, Toronto, ON; 6. Department of Medicine
(Neurology), University of Toronto, Toronto, ON; 7. LC Campbell Cognitive Neurology Research
Unit, Toronto, ON; 8. Department of Psychology, University of Toronto, Toronto, ON
Background: Cerebral small vessel disease (CSVD), characterized by distributed ischemic white
matter damage, is associated with cognitive dysfunction and contributes to dementia risk. While
most research investigating CSVD effects has focused on the relationship between structural im-
aging measures and cognitive decline, there has been relatively little research investigating the
effects of CSVD on functional brain imaging measures in correlation with behaviour. Method:
Here we present a systematic review of papers since 1990 that have studied the mechanism
by which CSVD may affect cognition using functional neuroimaging techniques (8 fMRI, 6 EEG
studies). Results: Converging evidence from fMRI studies suggest that relative to healthy con-
trols, CSVD patients demonstrate impaired deactivation of the posterior cingulate cortex (PCC)/
precuneus - a critical mode in the default mode network (DMN) - as well as decreased func-
tional connectivity in several networks associated with attention, working memory and auditory
and language processing. In contrast, enhanced connectivity to the PCC, mainly through the
temporal-parietal cortex, has been reported and hypothesized to reflect a compensatory adap-
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-
relation between white matter damage and widespread slowing of EEG rhythmicity. Specifically,
severity of ischemic white matter damage has been associated with increased delta power,
decreased alpha2 power and a relative increase in theta/alpha1 band power ratio. Among event-
related potentials (ERPs), N2 and P3 are of particular interest with prior research showing de-
layed latency in those with white matter damage. Conclusion: Building on the aforementioned
results as well as studies of top-down attention regulation, future investigations should utilize a
multimodal approach that combines the strengths of fMRI and EEG techniques and pair it with
multivariate analytical tools that are more powerful than traditional univariate tests.
P1.037
Total Plasma Adiponectin Concentrations and AdipoR1 and AdipoR2 Gene
Expression are Associated with Features of Plaque Instability in Patients with
Carotid Atherosclerosis
Gasbarrino, K1 Doonan, R1 Mantzoros, C2 Lai, C3 Veinot, J3 Daskalopoulou, S1;
1. McGill University, Montreal, QC; 2. Beth Israel Deaconess Medical Center, Boston, MA, USA;
3. University of Ottawa Heart Institute, Ottawa, ON
Background: With the increasing burden of atherosclerosis and stroke on society it is criti-
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,
are associated with coronary artery disease and carotid-intima media thickness. The current
study investigated the association between circulating adiponectin and its receptors (AdipoR1/
AdipoR2) and features of plaque instability. Methods: Patients scheduled for carotid endar-
terectomy were recruited from the Royal Victoria Hospital, Montreal, Quebec. Blood samples
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
maximum stenosis of each carotid plaque obtained was stained with hematoxylin and eosin
and immunostained for the detection of CD68 (macrophages/foam cells), and von Willebrand
Factor (vWF, neovascularization). Two vascular pathologists blindly categorized the plaques ac-
cording to AHA classifications and semi-quantitative scales. Total RNA was extracted from the
tissues and AdipoR1/AdipoR2 mRNA expression was analyzed via qRT-PCR. Results: Patients
(n=190) with less infiltration of foam cells in their plaques had higher levels of total circulating
adiponectin (12.26 ± 6.74 μg/ml) when compared to patients with greater infiltration (8.99 ±
6.97 μg/ml; p=0.010). AdipoR1 expression was significantly lower in plaques with neovascu-
larization (p=0.023). AdipoR2 expression was found to be progressively lower in plaques with
greater instability, with a significant difference between Grade 1 (most stable) and Grade 4
(most unstable) plaques (p=0.044). In addition, plaques that had an intact cap and no presence
of thrombus had significantly higher expression of AdipoR2 than plaques with ruptured caps
and presence of large thrombi (p=0.010). Conclusion: Patients whose plaques were character-
ized as unstable were found to have lower plasma levels of total adiponectin, and lower mRNA
expression of AdipoR1 and AdipoR2. These results suggest a potential role for adiponectin and
its receptors in the development of plaque instability.
P1.038
Acidosis Overrides Oxygen Deprivation to Maintain Mitochondrial Function
Khacho, M; Tarabay, M; Khacho, P; Patten, D; MacLaurin, J; Park, D; Bergeron, R; Harper, M;
Slack, R; University of Ottawa, Ottawa, ON
Mitochondria are dynamic organelles that undergo cycles of fission and fusion, in which the
balance is critical for mitochondrial integrity and normal cellular function. Fission/fragmentation
of mitochondria is an early event in injuries relevant to stroke and is believed to be a key con-
tributor in the demise of neurons following an ischemic insult. Furthermore, studies have shown
that promoting fusion restores neuronal viability during ischemia. Thus identification of strate-
gies to promote mitochondrial fusion would provide invaluable therapeutic potential. Here we
show that acidification of the extracellular milieu, a physiological consequence of hypoxia within
the ischemic penumbra, triggers the rapid elongation of mitochondria in neurons. Acidosis-
mediated mitochondrial elongation protects neurons from death in an in vitro model that mimics
the ischemic penumbra. Elongation of mitochondria, in neurons allowed to undergo the natural
course of acidification during hypoxia, is achieved through the activation of a dual program that
both inhibits fission and promotes fusion. Preventing the pH-dependent elongation of mitochon-
dria by inhibiting the fusion machinery results in mitochondrial fragmentation and a significant
increase in neuronal death. Interestingly, mild acidosis is known to provide neuroprotection
during ischemia, however the mechanism was not completely understood. We now propose
that extracellular pH is a neuroprotective agent that acts as a physiological trigger to rewire the
dynamics of mitochondria and promote survival.
P1.039
Predicting Hemorrhagic Transformation in Acute Ischemic Stroke Patients: FLAIR
vs. Quantitative Permeability Coefficient (KPS)
Gao, M1 Waa, S2 Leung, J3 Alharbi, M2 Mikulis, D3 Silver, F4 Kassner, A3, 5; 1. University of
Toronto, Toronto, ON; 2. Department of Medical Imaging, University Health Network, Toronto,
ON; 3. Department of Medical Imaging, University of Toronto, Toronto, ON; 4. Department of
Neurology, University of Toronto, Toronto, ON; 5. Hospital for Sick Children, Toronto, ON
Background: Recombinant tissue plasminogen activator (rtPA) decreases mortality and im-
proves functional outcomes in patients with acute ischemic stroke (AIS) but is also associated
with a higher risk of hemorrhagic transformation (HT). Both FLAIR hyperintensity and quanti-
tative permeability (KPS) MR imaging have been proposed to help identify patients at higher
risk of HT. The purpose of this study is to compare the utility of FLAIR hyperintensity and KPS
in predicting HT in patients with AIS treated with and without rtPA. Methods: Thirty patients
with AIS were examined within a mean time of 3.6 hours of documented symptom onset. Both
FLAIR and KPS MR imaging were performed. Two raters (blind to HT) independently identified
FLAIR hyperintensity with reference to the DWI lesion. KPS coefficients in the stroke lesion
were estimated for all patients, and the sensitivity and specificity for both FLAIR hyperintensity
and KPS value in predicting HT were calculated. Results: FLAIR hyperintensity was identified
in 12 patients (40%, 3HT, 9 non-HT). There was no statistical significant difference in HT oc-
currence between FLAIR positive and negative patients. The sensitivity and specificity of FLAIR
hyperintensity in predicting HT were 0.3 and 0.55 respectively. Assessment of KPS in the lesions
revealed a statistical significant difference between those who hemorrhaged and those who did
not (P < .0001). ROC analysis produced a KPS threshold of 0.482 with a sensitivity of 1.00 (CI,
0.72-1.0) and a specificity of 0.80 (CI, 0.584-0.919). Conclusions: The results of this study
suggest that FLAIR hyperintensites are frequent findings in AIS patients and are not associated
with a higher HT risk with or without thrombolytic treatment. KPS, on the other hand, shows
excellent potential as clinical adjunct in identifying patients at high risk of HT when considering
them for thrombolytic therapy.
P1.040
The Effect of β-Amyloid on the Severity and Prognosis of Hemorrhagic Stroke
Patients
Nakase, T; Sasaki, M; Suzuki, A; Research Institute for Brain & Blood Vessels, Akita, Japan
Background: It has been investigated that β-amyloid (Aβ) might affect on the neurological
severity of Alzheimer disease. Moreover, Aβ was reported to relate to the vulnerability of brain
arteries. However, the influence of Aβ on the severity and outcome of acute stroke patients has
not been fully understand. This study was aimed to explore the effects of Aβ on the neurological
severity and the prognosis of acute intracranial hemorrhagic stroke (ICH) patients. Methods:
Acute ICH patients were consecutively asked to participate in this study between June 2011 and
September 2012. Then, consented patients were enrolled (n=52, average age 66.9 year-old).
ICH lesion was confirmed by brain computed tomography on admission. Aβ40 and Aβ42 were
measured from blood samples acquired on admission. Neurological severity was assessed by
NIH stroke scale on admission and at one month. Results: The amount of Aβ40 was distributed
between 2.7 and 96.6 pmol/L (mean±SD: 22.0±20.2 pmol/L). If all cases were classified into
low and high amount of Aβ40 (Low40 group: less than 20 pmol/L and High40 group: higher than
20 pmol/L, respectively), the percentage of deep cerebral hemorrhage was significantly abun-
dant in High40 group compared with Low40 group (p=0.021: 87.5% and 54.3%, respectively).
The amount of Aβ42 was not detected in 67.3% of all patients (Low42 group). The average
amount of Aβ42 in remaining 17 cases was 5.2 pmol/L (High42 group). The mortality was higher
in High42 group compared with Low42 group (p=0.059: 23.5% and 5.7%, respectively). There
was no significant relation between the amount of Aβ and the neurological severity. Conclu-
sion: Aβ40 could affect on the fragility of deep brain arteries, and Aβ42 might influence on the
vulnerability of neurons in the hemorrhagic stroke patients.
P1.041
Spreading Depolarization After Stroke is Supported by the Alpha1 Isoform of
Na/K-ATPase
Petrin, DA; Ventura, NM; Peterson, NT; Tse, MY; Andrew, R; Pang, SC; Jin, A;
Queen’s University, Kingston, ON
Background: The mechanisms which promote spreading depolarization (SD) in the post-stroke
brain remain unclear. We examined the role of Na/K-ATPase isoforms in supporting SD after
stroke. Methods: Following focal cerebral ischemia in male C57BL/6J mice, 350 µm live brain
slices were incubated in artificial CSF (aCSF) at 34 oC and then exposed for 20 minutes to either
control solution (aCSF) or ouabain at 1 µM (to selectively block alpha2 and alpha3 isoforms of
Na/K-ATPase) prior to SD induction by oxygen glucose deprivation (OGD). The propensity of the
tissue to undergo SD was assessed by observing changes in SD onset latency and wavefront
velocity as reflected in tissue light transmittance in the ipsi- and contralateral hemispheres.
This was compared to SD induced by exposure to 100 µM of ouabain, in this case, blocking the
alpha1,2 and 3 isoforms of Na/K-ATPase. The mRNA expression of the Na/K-ATPase isoforms
ATP1a1 (alpha1), ATP1a3 (alpha3) and ATP1b1 (beta1) in the post-stroke brain was examined
by real-time quantitative PCR. Results: Following stroke, OGD-induced SD was delayed by 33%
(p < 0.001) and SD wavefront velocity was decreased by 42% (p = 0.016) in the peri-infarct
tissue compared to the contralateral hemisphere. Blockade of all Na/K-ATPase isoforms with
100 µM ouabain abrogated these differences in SD onset and wavefront velocity but preferential
blockade of the alpha2 and 3 isoforms with 1 µM ouabain did not alter SD characteristics 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-
sions: Peri-infarct tissue has a decreased susceptibility to spreading depolarization. Blockade
of the alpha1 but not alpha2/3 isoforms of Na/K-ATPase promotes SD in the post-stroke brain,
and decreased expression of the alpha1 and beta1 isoforms may contribute to endogenous SD
resistance in peri-infarct tissue.
P1.042
Endothelin-1 Mediated Ischemic Injury in the Mouse Forelimb Motor Cortex is
Associated with Specific and Measurable Behavioural Deficits
Roome, RB1, 2 Bartlett, RF1, 2 Jeffers, M1, 2, 3 Xiong, J1, 2 Corbett, D1, 2, 3 Vanderluit, J1, 2;
1. BioMedical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St John’s,
NL; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Ottawa, ON; 3. Dept. Cellular &
Molecular Medicine, University of Ottawa, Ottawa, ON
 e18  Stroke  December 2013
Background: Currently, there is excitement in manipulating neural precursor cells, as they mi-
grate toward cortical infarcts and differentiate into neurons and glia. To assess functional recov-
ery by neural regeneration after an ischemic injury, a reproducible focal injury model is required.
Here, the ability of Endothelin-1 (ET-1), a vasoconstrictive peptide, was assessed in producing
behavioural deficits post-ischemia. Though mice develop smaller infarcts than rats in response
to ET-1, a wealth of transgenic mouse strains exist which can be used to study a variety of
therapeutic interventions post-ischemia, making a focal ischemic injury model in mice attrac-
tive. Methods: A focal ischemic lesion was produced by intra-cortical injections of ET-1 into
the forelimb motor cortex (FMC). Mice were tested on the mouse staircase and cylinder tasks at
time-points post-surgery and euthanized at 2 or 4 weeks. Histology was performed to analyze the
volume, shape and depth of the injury site. Doublecortin (Dcx) and BrdU immunohistochemistry
was performed to label migrating NPCs. Results: Focal ischemic cortical injury is associated with
behavioural deficits. Reaching deficits in the mouse staircase test correlated specifically with
damage to the anterior FMC, highlighting functional subdivisions within the FMC. A sensitive novel
analysis of the cylinder test, “paw-dragging”, predicted ischemic injury in the FMC as well. These
deficits are linked to the number of ET-1 injections given and whether or not the injections dam-
age the anterior forelimb motor cortex. BrdU and Dcx double-positive cells within the injury site
indicated that NPCs had migrated successfully from the SVZ. Conclusion: Here, I have developed
a reproducible model of focal ischemia with measureable behavioural deficits which lends itself to
a variety of experimental regenerative therapies for the treatment of ischemic stroke. Deficits are
pronounced acutely post-ischemia but persist over time with larger ischemic injuries.
P1.043
What Strokes Tell Us About Consciousness
Shamy, MC; Glannon, W; University of Calgary, Calgary, AB
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
Background: Explaining what consciousness is, and how it may arise from the brain, has been a
subject of human study for thousands of years. Given the localized loss of neurological function that
is the hallmark of ischemic stroke, it is possible that lessons from the clinical study of stroke may
help to explain both the nature of consciousness and its relationship to neuroanatomy. Methods:
We address a series of questions around whether, and how, strokes affect consciousness. We relate
the findings of clinical stroke medicine to the theoretical frameworks within which consciousness is
currently analyzed: substance dualism (the brain and mind are causally non-interacting), property
dualism (the mind is a product of the brain, but cannot be explained by brain processes), epiphe-
nomenalism (the mind is a product of the brain but cannot interact with the brain), and physicalism
(the mind is equivalent to physical properties of the brain). Results: We argue that the clinical neu-
roanatomy of ischemic stroke provides the basis for understanding consciousness as a function of
the brain and as a function of brain functions. This theory unites physicalism and property dualism,
and rejects structural dualism and epiphenomenalism. Conclusion: We propose a new theory of
consciousness based on experience from stroke neurology. Moreover, we seek to bridge the meth-
odological and linguistic gap that has for too long divided philosophy from clinical neuroscience.
P1.045
Subunit-Specific Modulation of NMDAR Trafficking by Glycine in Central Neurons
Soares, CA1 Khacho, P1 Lee, KF1 Geddes, SD1 Bergeron, R1, 2 Béïque, J1; 1. University of Ottawa,
Ottawa, ON; 2. Ottawa Hospital Reasearch Institute, Ottawa, ON; 3. Heart and Stroke Founda-
tion Centre for Stroke Recovery, Ottawa, ON
NMDA type glutamate receptors are present at excitatory synapses and are composed of tet-
ramers of GluN1 and GluN2 subunits (primarily GluN2A and GluN2B in hippocampus). These
receptors are gated by the coincident binding of two agonists: glutamate and glycine. During
neuronal ischemia, extracellular concentrations of these agonists rise dramatically, leading to
sustained NMDAR activation and excitotoxicity. As NMDAR-dependent excitotoxicity is sug-
gested to depend on subunit composition and subcellular localization of receptors, we sought
to determine how the trafficking of distinct NMDAR subtypes is altered by sustained NMDAR
activation. A treatment with a high concentration of glycine alone transiently depressed evoked
NMDAR-mediated currents from CA1 pyramidal neurons. To identify potential subunit-specific
rules of this behaviour, we developed a live-cell imaging assay to quantify surface NMDARs
expressing phluorin-tagged NMDAR subunits. With this approach, we observed that glycine in-
duced a preferential internalization of GluN2A-containing NMDARs. Intriguingly, evidence from
both imaging and electrophysiological experiments suggests that the high glycine treatment
induced a transient internalization of synaptic receptors, but a persistent internalization of extra-
synaptic NMDARs. At present, it is unclear whether these trafficking behaviours represent natu-
ral neuroprotective strategies employed by neurons or rather whether they contribute to toxicity.
The development of a mechanistic and molecular framework of these cellular phenomena will
allow us to distinguish between these possibilities.
P1.046
Pharmacological Inhibition of VEGFR-2 Has Differential Effects on Behavioral
Recovery and Cortical Remapping Dependent on Presence or Absence of
Diabetes During Stroke
Tennant, KA; Thompson, K; Lockhart, K; Brown, CE; University of Victoria, Victoria, BC
Diabetes is associated with a higher risk of stroke and a poor prognosis for recovery. Previ-
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-
sentations onto intact peri-infarct areas. We have recently used longitudinal in vivo two-photon
imaging to show that the brain’s vascular response to stroke (increased blood flow velocity and
dilation of vessels) takes weeks to normalize in diabetics, while the non-diabetic vascular re-
sponse normalizes within days. Based on these data and our pilot studies showing abnormal
expression of vascular endothelial growth factor (VEGF) and its receptors in the ischemic diabetic
brain, we hypothesized that pharmacological inhibition of VEGF signaling at a clinically-relevant
time point after stroke would lead to greater behavioral recovery and increased cortical remap-
ping in diabetic mice. Diabetic and non-diabetic mice underwent behavioral testing for 10 weeks
following photothrombotic stroke. Subcutaneous injections of SU5416, a selective inhibitor of
VEGF receptor 2 (VEGFR-2), or vehicle were given every 3 days, beginning 3 days after stroke, for
a total of 8 weeks. 14 weeks after stroke, voltage-sensitive dye imaging was conducted to resolve
the extent of remapping of the forelimb sensory representations. SU5416 treatment of diabetic
mice after stroke improved short and long-term behavioral recovery compared to vehicle-treated
diabetics. This was associated with a trend towards improved cortical responsiveness to forelimb
touch. In contrast, SU5416 treatment of non-diabetic mice after stroke caused a worsening of
behavioral deficits and cortical responsiveness. In summary, these results suggest that inhibition
of VEGFR-2 after stroke may be an effective treatment for diabetics. The fact that this treatment
appeared to worsen both behavioral recovery and cortical rewiring in non-diabetics highlights the
need to develop more specialized treatments for a heterogeneous clinical population.
P1.047
Pharmacological Blockade of Volume-Regulated Anion Channels (VRAC) by
DCPIB Provides Protection Against Hypoxic-Ischemic Neuronal Injury In vivo and
in vitro
Turlova, E1 Zhao, L2 Alibrahim, A1 Wang, G2 Sun, H1; 1. University of Toronto, Toronto, ON;
2. Sun Yat-sen University, Guangzhou, China
Perinatal and neonatal hypoxic-ischemic brain injury often leads to acute mortality and chronic
neurological morbidity in infants and children. Swelling-induced mediation of volume-regulated
chloride channels (VRACs) is thought to be one of the non-glutamate mechanisms in cerebral
ischemia, and CIC3 channel has been proposed as one of the candidates for VRACs. This study
evaluates the importance of VRAC channels in neonatal hypoxic-ischemic injury model using a
specific VRAC antagonist DCPIB as a pharmacological blocker.The cerebral hypoxic-ischemic
injury was induced in P7 (postnatal, day 7) mouse pups. The Rice-Vannucci neonatal adaptation
of Levine procedure with minor modifications was used to induce cerebral hypoxic-ischemic
injury in neonatal mice. Twenty minutes prior to onset of ischemia, DCPIB was administered
intraperitoneally to the animals. The mice, treated with DCPIB, showed a significantly reduced
mean percentage of right hemispheric corrected infarct volume compared to the vehicle-treated
mice. The treatment with DCPIB also improved functional recovery, as was evident by increased
activity of blocker-treated group compared with vehicle-treated group. Additionally, this study
provided supportive evidence of the ability of DCPIB to significantly block VRAC mediated cell
death in vitro in PC12 cell line under oxygen-glucose depravation conditions, as determined
by comparing intracellular chloride ion concentrations in cells treated with DCPIB and control
group. These experiments demonstrate the pathophysiological role of VRACs in ischemic brain
injury, and suggest the blocker as a potential, easily administrable therapeutic drug targeting
VRACs in the context of perinatal and neonatal hypoxic-ischemic brain injury.
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-
peutics is lacking. Here, I will discuss our work evaluating the efficacy of two novel approaches
to blood flow augmentation during ischemic stroke to increase collateral circulation. Using
high-resolution laser speckle contrast imaging (LSCI) and quantitative in vivo two-photon laser
scanning micrsocopy (TPLSM) during middle cerebral artery occlusion (MCAo), we are able to
optically record blood flow in leptomeningeal collaterals in clinically relevant animal models of
ischemic stroke. We demonstrate that transiently diverting blood flow from peripheral circulation
towards the brain via intra-aortic catheter and balloon induces persistent increases in blood flow
through anastomoses between the anterior and middle cerebral arteries during thromboem-
bolic MCAo. Increased collateral flow restores blood flow in distal MCA segments to baseline
levels during aortic occlusion and persists for over one hour after removal of the aortic balloon.
Similarly, intra-arterial (intra-carotid) administration of the nitric oxide donor sodium nitroprus-
side induces significant vasodilation and improves leptomeningeal collateral circulation without
effecting systemic blood pressure. Given the importance of collateral circulation in predicting
stroke outcome and response to treatment, and the potential of collateral flow augmentation as
an adjuvant or stand alone therapy for acute ischemic stroke, this data provides support for fur-
ther development and translation of collateral therapeutics including transient aortic occlusion.
P1.049
Lifetime Stress Cumulatively Programs Brain Transcriptome to Impede Stroke
Recovery and Is Ameliorated by Tactile Stimulation
Zucchi, FC1, 2 Yao, Y1 Ilnytskyy, Y1 Robbins, JC1 Soltanpour, N1 Kovalchuk, I1 Kovalchuk, O1
Metz, GA1; 1. University of Lethbridge, Lethbridge, AB; 2. University of Mato Grosso State,
Caceres, MT, Brazil
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Prenatal stress is a critical variable affecting lifetime health, including stroke risk and out-
come in adulthood. Beneficial experiences may offset the influence of adverse early experi-
ence and programming of health outcomes by stress. Here we investigated if tactile stimu-
lation attenuates the effects of early life stress on behaviour and recovery from ischemic
lesion in a rat model. Prenatally stressed adult male rats underwent focal ischemic motor
cortex lesion while being tested in skilled reaching and skilled walking. One group of rats
experienced cumulative postnatal stress by restraint in adulthood. Tactile stimulation, as
an analogue to human massage therapy was applied to attenuate adverse early influences
and promote post-lesion motor recovery. Animals that experienced both prenatal stress and
stress in adulthood displayed the most severe motor disabilities after the lesion. Additionally,
tactile stimulation offset cumulative prenatal and postnatal stress by promoting recovery
from ischemic lesion and reducing activity of the hypothalamic-pituitary-adrenal axis 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
diversity of pathways. Ischemic lesion mainly up-regulated gene expression patterns, while
these were mainly down-regulated by tactile stimulation. Our results suggest that the sec-
ond half of pregnancy in the rat represents a critical phase of fetal sensorimotor system
development. Cumulative effects of adverse and beneficial lifespan experiences interact with
disease outcomes and brain plasticity. These findings show that beneficial experience later
in life can reverse programming by early adverse experience to modulate physiology, be-
haviour, transcriptome and cerebrovascular health. Acknowledgements: This research was
supported by Alberta Innovates - Health Solutions (AI-HS; FZ and GM), Preterm Birth and
Healthy Outcomes funded by the AHFMR/AI-HS Interdisciplinary Team Grant #200700595
(GM), Hotchkiss Brain Institute (FZ), Norlien Foundation (FZ), and the Canadian Institutes of
Health Research (GM).
P1.050
Fostering community participation for persons with aphasia and their family
members: What we are doing, what we can do better in rehabilitation
Alary Gauvreau, C1 Anglade, C2, 3 Massicotte, J2 Perreault, C2 Kehayia, E4, 3 Michallet, B5, 3 Le
Dorze, G2, 3; 1. Jewish Rehabilitation Hospital, Laval, QC; 2. University of Montreal, Montreal,
QC; 3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, QC;
4. McGill University, Montreal, QC; 5. Université du Québec à Trois-Rivières, Trois-Rivières, QC
Background: Aphasia affects approximately 30% of stroke victims. Client-centered rehabili-
tation is offered for optimizing recovery and independence. However, after discharge, people
with aphasia report not being ready to participate in their community. Their relatives also
mention not knowing how to care and help their loved one. The aim was to understand how
rehabilitation could improve outcomes for people with aphasia and their family members with
respect to social participation. Methods: Eight persons with aphasia and eight of their 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
and available for viewing while the discussion went on. Later, all of statements were analyzed
qualitatively. Results: Most participants expressed the need to easily access the physical
environment and to communicate effectively for satisfying participation in shopping malls.
Participants formulated few suggestions about improving rehabilitation in spite of minor dis-
satisfaction with their experience. However, a new vision of rehabilitation using shopping
malls emerged throughout the analyses. For instance, assessment could include the personal
experience of the person with aphasia in shopping malls. Goals could be set by patients ac-
cording to their need for independence. Therapeutic activities could be held in malls, thus
real-life settings. Speech-language therapists could evaluate the effects of therapy in authen-
tic communication settings. Conclusions: If patients and their families do not feel adequately
prepared for community participation, rehabilitation centers should consider an approach
that is centered on the patient’s and family’s priorities and needs. In this perspective, the
shopping mall could be used as a rehabilitation setting. In doing so, interdisciplinary stroke
rehabilitation expertise could better serve people with communication limitations in real-life
environments.
P1.051
A Comparison of Rural versus Urban Stroke Survivors Treated with a Home-
based, Specialized Stroke Rehabilitation Program
Allen, L1 Richardson, M1 McClure, A1 Meyer, M1, 2 Ure, D3 Jankowski, S3 Teasell, R4, 1;
1. Lawson Health Research Institute, ARGC , London, ON; 2. Western University, Department of
Epidemiology and Biostatistic, London, ON; 3. St. Joseph’s Health Care, London, ON;
4. St.Joseph’s Health Care, Department of Physical Medicine and Rehabilitation, Parkwood
Hospital, London, ON
Background: Rural living has been demonstrated to have an effect on a person’s overall health
status, and rural residing individuals often have decreased access to health and specialized
rehabilitation services. The aim of this study was to determine if there are differences in 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
of 919 stroke survivors receiving care from three Community Stroke Rehabilitation Teams be-
tween January 2009 and December 2012 was analyzed. This program delivers stroke rehabili-
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
linear regression analyses were performed to determine if rural vs. urban status was a signifi-
cant predictor of discharge and 6-month health outcomes, controlling for scores at baseline.
Results: The mean age of the cohort was 69.3(±13.1) years (55% male). Three hundred eighty-
five (41.9%) individuals were classified as living in a rural area using the Rurality Index for
Ontario. No significant difference on the Functional Independence Measure (FIM), the Stroke
Impact Scale (SIS) Physical, Memory, Communication, and Social Participation domains, the
Caregiver Assistance and Confidence Scale (CACS), or the Bakas Caregiver Outcomes Scale
(BCOS) were noted at either discharge or follow up. Rural residence was a significant predictor
of outcome for the HADS Anxiety (p=0.001) and Depression (p=0.039) subscales at discharge,
with urban residents making slightly greater improvements. Rurality was also a significant pre-
dictor of outcome on the Emotion domain of the Stroke Impact Scale at both discharge (p=0.040)
and follow up (p=0.0002), with rural residing individuals experiencing greater positive gains.
Conclusions: When provided with access to a home-based, specialized stroke rehabilitation
program, rural dwelling stroke survivors make and maintain functional gains comparable to
their urban-living counterparts.
P1.052
Perceptual Influences of Visuospatial Neglect During Negotiation of Obstacles
Aravind, G; Lamontagne, A; McGill University, Montreal, QC
Rationale: In our previous study1, we observed that individuals with visuospatial neglect
(VSN) collided with moving obstacles while walking. Whether these collisions occurred due to
perceptual deficits of VSN or locomotor deficits attributed to stroke, was unclear. In this study,
we evaluated the ability of individuals with VSN to avoid moving obstacles during a joystick
task uninfluenced by locomotor capacity. Methods: Twelve participants previously diagnosed
with VSN post-stroke were assessed on the Bells test. They were also tested in a virtual
environment with a target and 3 obstacles, one of which randomly approached from head-on,
or 30° left/right. Participants were seated and pressed a joystick-button on perception of
a moving obstacle (perceptuo-motor task) and proceeded towards the target while avoid-
ing the obstacle using a joystick with their unaffected hand (joystick task). Detection times
(perceptuo-motor task), collision rates and onsets of strategy (joystick task) were examined.
Results: Based on number of omissions on the Bells test, participants were classified as
VSN+ (Omission≥6,n=4), Inattention+ (6<omissions>3,n=4) and VSN- (Omissions<3,n=4).
On average, detection times, delays in onset of strategies and collision rates were larger for
contralesional and head-on obstacles compared to ipsilesional obstacles. A trend was ob-
served where the VSN+ groups showed largest detection times, onset of avoidance strategies
and rates of collisions, followed by the Inattention+ and VSN- groups. Conclusion: Along with
persons with frank VSN, individuals with a history of neglect who test negative on the Bells
test (Inattention + and VSN-) can show difficulties detecting and avoiding obstacles approach-
ing from their neglected side and head-on. This suggests that the Bells test is not sensitive
in detecting perceptual deficits involved during functional tasks such as obstacle-negotiation.
Moreover, presence of collisions in a joystick-driven avoidance task not influenced by lo-
comotor capacity, suggesting perceptual deficits do contribute to poor obstacle-avoidance
abilities in post-stroke VSN.
P1.055
Traduction et validation de l’Overt Behaviour Scale (OBS) en français : l’Échelle
des comportements observables
Godbout, D; Gagnon, J; Ouellette, M; Drolet, J; Kelly, G; Simpson, G; Centre de réadaptation
Lucie-Bruneau, Montréal, QC
Contexte : Les qualités psychométriques de l’échelle OBS sont reconnues. Elle est utilisée dans
les études anglo-saxonnes évaluant les troubles du comportement de la clientèle cérébrolésée.
La traduction et la validation de l’OBS s’imposait car il existe peu d’outils disponibles en français
pour évaluer ces dimensions comportementales post atteintes cérébrales. Méthodologie :
Phase 1 : Comité d’expert par méthode du consensus pour assurer la rigueur de la traduction/
adaptation de l’instrument OBS nommé l’ÉCO (Échelle des comportements observables). Les
 e20  Stroke  December 2013
deux versions (OBS/ÉCO) soumises (avec inversion des énoncés) aux cliniciens évaluant les
clients présentant un trouble du comportement au moins léger.
Phase 2 : les cliniciens complètent également une batterie de questionnaires et tests pour es-
timer la validité divergente et convergente de l’ÉCO.
Échantillon :
•• 29 participants (21H; 8F), âgés de 20 à 70 ans
•• Ayant subi une lésion cérébrale datant de 5 mois à 44 ans
•• suivis en 6 centres de réadaptation (et 1 association de TCC) à Montréal.
Outils d’évaluation
•• Instruments pour mesurer des concepts divergents) : le NRS; l’Inventaire du fardeau; le
questionnaire sur la qualité de vie
•• Instruments pour mesurer des concepts se rapprochant des troubles du comportements :
le MPA I-4 et le SATCé
Résultats préliminaires : Les résultats aux indices de l’OBS sont fortement corrélés (r>.9)
avec ceux obtenus à l’ÉCO. On ne détecte pas de relations significatives entre les résultats à
l’ÉCO et le fonctionnement cognitif, affectif et moteur (NRS), le fardeau (IDF) ainsi qu’avec la
qualité de vie (QPSQV) et les capacités (sous-échelle du MPAI-4). Des corrélations modérées
sont relevées entre les données à l’ÉCO, celles à 4 des dimensions du SATC et aux mesures
d’adaptation psychologique et de participation sociale incluant des énoncés comportementaux
(du MPAI-4). Conclusions : Les résultats indiquent que l’ÉCO est une traduction valide de
l’OBS. Les faibles corrélations entre les résultats à l’ÉCO et ceux obtenus aux mesures du
fonctionnement suite au TCC vont dans le sens de sa validité divergente. Les corrélations plus
fortes entre les résultats et les mesures d’adaptation psychosociale donnent des indices de sa
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validité convergente.
P1.056
Perturbation Motor Corrections Correlate with Features of Reaching and
Proprioception Impairments Post-Stroke
Bourke, TC; Queen’s University, Kingston, ON
Limb afferent feedback is used for perception of our limb geometry and for motor control. Stroke
can damage sensory and motor regions of the brain leading to impairments of upper limb func-
tion. Our previous work found that deficits in position sense were independent of deficits in
reaching performance. This independence is surprising given that limb afferent feedback plays
an important role in voluntary motor action. The objective of the present study was to explore
in more detail the relationship between sensory and motor impairments in subjects with stroke
using three distinct behavioural tasks. Subjects with subacute stroke (n=18) and non-disabled
controls (n=79) were assessed in a KINARM exoskeleton robot. A postural perturbation task
measured how quickly subjects can respond to a perturbation and accurately return to their start
target (no vision of hand following perturbation). A limb matching task assessed the perception
of limb position by measuring the mismatch between one arm moved by the robot and the
subject’s mirror matched limb configuration with their other arm (no vision throughout task).
A visual-guided reaching task assessed the use of vision and proprioception to reach quickly
and accurately to a target. Both arms were assessed in each task and a number of parameters
captured the spatial and/or temporal aspects of task behaviour. In agreement with our previous
results, reaching and position matching deficits were largely independent in this sample. Most
impairments in reaching parameters were significantly correlated with impairments in perturba-
tion corrections. In contrast, the majority of impairments in limb matching parameters were
significantly independent of impairments in perturbation corrective parameters. One exception
was that perturbation response endpoint error was significantly correlated with limb matching
variability (r=0.43, p<8.8x10-4).
Overall these results suggest impairments in integrating feedback into motor corrections being
related to motor impairments and independent of proprioceptive impairments.
P1.057
Comprehensive Assessment of Disability Following Stroke: Initial Validation of
the miFunction Scale
Burley, T; Green, T; University of Calgary, Calgary, AB
Background: Advances in thrombolytic therapy, endovascular intervention and specialized unit
care for stroke have significantly reduced its mortality and morbidity delivering nearly eighty per-
cent of survivors back to their homes and communities. Current established assessment tools
are not sensitive enough to accurately identify differences in disability in the stroke population.
Guided by the World Health Organization (WHO)’s International Classification of Functioning (ICF),
researchers at the University of Calgary developed a functional outcome scale (miFunction) to
assist with the comprehensive evaluation of disability following stroke, based on activity limita-
tions. Methods: This is a pilot study, utilizing a cross-sectional validation and reliability design to
assess the usefulness of the miFunction scale. The cross-sectional validation and reliability de-
sign involves sampling a target population of stroke survivors at a minimum of 60 days following
their event. Two clinicians evaluate participants using the miFunction scale as an assessment
of inter-observer reliability (Cohen’s Weighted Kappa). Further, the clinicians assign participants
with a score on a previously validated instrument for assessment of stroke disability (Modified
Rankin Scale) as an assessment of convergent validation (Pearson’s Correlation Coefficient).
Results: Initial inter-observer reliability and convergent validation results will be presented. Im-
plications for the incorporation of miFunction into a larger study for further evaluation will be
explored. Conclusions: As science and technology for stroke management progress so too must
the ability to assess short and long-term sequelae of this disease process and associated in-
terventions. miFunction is a scale that approaches the evaluation of disability comprehensively,
and in accordance with current, internationally accepted understandings of stroke.
P1.058
Screening for the Blues: Implementing a Depression Screening Tool in the Acute
Stroke Population
Cheung, T; Cayley, A; University Health Network, Toronto, ON
Purpose: As a Regional Stroke Centre of Ontario, we are committed to evidence-based practice
and the promotion of nursing excellence through the implementation of RNAO’s Best Practice
Guidelines. Depression is recognized as one of those best practice guidelines. Depression is
known to have a debilitating effect on many areas of one’s quality of life. In the stroke popula-
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
indicates identification of depression is most critical in the acute phase of a stroke as it has been
directly linked with post-stroke recovery. Approach: The approach utilized for this initiative was
to implement two validated depression screening tools in the stroke in-patient population. The
Patient Health Questionnaire (PHQ-9) was used for non-aphasic patients, and the Stroke Aphasic
Depression Questionnaire (SADQ-10) was used for those with aphasia. Results: All nurses who
worked on the in-patient unit received educational sessions on the two tools and implemented
its use on all admitted stroke patients after day 3 of stroke onset. The results of this initiative
include: increased nursing awareness of post-stroke depression prevalence; early detection and
treatment of post-stroke depression; and improved inter-professional collaboration within the
stroke team. Implications: Knowledge gained from this initiative resulted in a standardized,
evidence-based approach to depression screening and assessment of stroke patients. 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
from acute care to the community; improving one’s capacity for rehabilitation; and decreasing
length of hospital stay.
P1.059
Talk Isn’t Cheap: Reviewing the Amount of Therapy Provided to Stroke Patients
with Communication Disorders
Churchward, K1 Hill, MD2 Knox, D1 Lindland, K3; 1. none, Calgary, AB; 2. University of Calgary,
Calgary, AB; 3. Alberta Health Services, Calgary, AB
Background: There is a threshold effect or a minimum “dose” of treatment required to dem-
onstrate significant gains as measured by standardized tests of language impairment. Lim-
ited research exists regarding which patients (i.e. type and severity of communication deficits,
time post stroke,) would benefit the most from high “dose” treatment. We investigated current
speech-language treatment (SLT) received and outcomes achieved locally by stroke patients
with communication deficits. Methods: A convenience sample of 70 English-speaking patients
with first-ever stroke resulting in aphasia, apraxia of speech and/or dysarthria was recruited in
the sub-acute stage (ie. 3-14 days post stroke). A speech-language assessment battery which
included scoring of the AusTOMS for speech and language, the Western Aphasia Battery (where
appropriate) and the ASHA Communication Quality of Life Scale was administered within 7 days
of study enrolment and was repeated 12-14 weeks later. Severity was measured using the Aus-
TOMs speech and/or language impairment scales. Speech-language pathologists and therapy
assistants reported minutes of direct 1-1 SLT provided to study patients across the continuum
of care (i.e. acute in-patient, tertiary in-patient, and community/outpatient programs) during
the study period. Results: Patients in the greater severity group (n=8) received 29 min (15.2)
of therapy per day compared to patients in the milder group (n=16) who received 9 min (7.8)
of therapy per day. Overall, most (92 %) patients received less than 45 min of treatment per
working day during the study period. Conclusions: The “dose” of therapy received by patients
with communication disorders is related to the initial severity of their impairments. Patients with
more severe communication impairment received more treatment than those with mild impair-
ment. Overall, the dose of SLT received by the majority of patients is below the minimum amount
of treatment recommended in the literature for aphasia.
P1.060
Characteristics of Recovery After Stroke: a Focus on Cognitive,
Mood and Physical Function
Cohen, EJ1 Danells, CJ1, 3 Moreno, HA2 McIlroy, WE2, 1; 1. Centre for Stroke Recovery, Toronto,
ON; 2. University of Waterloo, Waterloo, ON; 3. Sunnybrook, Toronto, ON
Background: Most stroke recovery has been limited to individual domains of recovery. The
changes across domains and interaction between these aspects of recovery, are likely important
to gain a complete understanding of determinants of recovery post stroke. The objective of this
work was to establish the association between different domains of recovery after stroke. Meth-
ods: Patients were selected from the Centre for Stroke Recovery Rehabilitation Affiliates Longi-
tudinal Stroke database based on completion of assessments and time post stroke. At baseline
(0-45 days post) there were 141 participants. The following assessments were selected: 2
minute walk (2mw), Berg Balance Scale(BBS), CES-D, FIM and MoCA. Determination of impair-
ment was concluded by using measure specific cut-off scores. Results: At baseline, there was
significant frequency of impairment in all measures (MoCA-83%, 2MW - 79%, BBS - 77%, FIM
- 64%, CES-D - 33%). More than 45% of the individuals were impaired in 4 or more measures
and 9% were impaired in only one domain. By 1 year after stroke the prevalence of impairments
by domain decreased (MoCa-60%, 2MW - 39%, BBS - 26%, FIM - 7.7%, CES-D - 29%). Only
 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
relationships remained approximately the same after 2 years following stroke. Conclusions:
Findings from this work emphasize the importance of multiple domains of recovery after stroke.
The prevalence of individuals with impairment in multiple domains is important as such profiles
may influence recovery. The work reinforces the need to understand the impact that changes in
one domain may have on others. Knowledge of the multivariate nature of recovery may help to
influence both assessments and interventions after stroke.
P1.061
The Development and Integration of a Comprehensive Spasticity Management
Clinic – Benefits to Patients, Physicians, Health Professionals, and Management
Czajka, T; Hammer, A; Hamilton Health Sciences-Regional Rehabilitation Centre, Hamilton, ON
The Comprehensive Spasticity Management (CSM) clinic located at the Hamilton Health Sci-
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-
sional resources, within ambulatory activity that occurs at the Rehabilitation Centre. This pre-
sentation will outline how we developed the CSM clinic, and integrated it into existing patient
care activity. It will describe the rationale and processes used to develop the clinic and promote
the interdisciplinary approach between the Allied Health and Physician professionals . This
includes the development of service delivery “teams”, common data collection systems, and
common measurement systems that address the measurement of progress and incorporate
patient goals. Preliminary results indicate that in a relatively short time, the clinic has suc-
cessfully developed into a comprehensive approach towards the management of spasticity.
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Our data demonstrates continued gains in client progress and improvements in our attention
to client centred goals. Initial results from our satisfaction questionnaire demonstrates that
patients prefer a team approach and feel that it meets their clinical needs better. Our refer-
ral data demonstrates an increase in referrals, and stroke survivors represent the majority of
new referrals. In addition this clinic has demonstrated benefits in other areas. These include
improvements in the following: job satisfaction , professional growth, opportunity for inter-
professional communication, patient care outside of the CSM clinic, transitions from inpatient
to ambulatory therapy, and referrals to other ambulatory services. Plans for future activities
have been initiated and will be described.
P1.062
Recommendation for using dance as an adjunct therapy in stroke rehabilitation
Demers, M1, 2, 3 McKinley, P1, 2, 3; 1. McGill University, Montreal, QC; 2. Jewish Rehabilitation
Hospital, Laval, QC; 3. Centre for Interdisciplinary Research in Rehabilitation of the Greater
Montreal, Montreal, QC
Background: Dance can be use as an adjunct therapy in rehabilitation to target balance, func-
tional mobility, mood, self-consciousness; a modified dance intervention was shown to be feasi-
ble and realistic in the context of functional intensive rehabilitation for individuals with sub-acute
stroke. Despite the benefits attributed to dance for people with stroke, dance is not widely used
in rehabilitation, because of the lack of clear criteria and guidelines in research on implementa-
tion of dance classes in clinical practice. The objective of this study is to provide evidence-
based guidelines for implementing dance classes in a rehabilitation setting. Methodology: This
presentation is part of a larger research study targeting the dissemination of knowledge about
the therapeutic use of dance in post-stroke rehabilitation. Based on the Canadian Stroke Recom-
mendations and the scientific literature on dance for individuals with disabilities, a dance inter-
vention has been developed for individuals with sub-acute stroke, and specific guidelines have
been identified that will serve to illustrate how a dance intervention might be constructed for
people post-stroke. Results: When implementing a dance intervention designed for people with
sub-acute stroke, the following specific elements must be taken into consideration: participant
safety, choice of music and dance movements, inclusion of a learned two-minute choreography,
and gradation of the exercise in order to include participants with poor sitting or standing bal-
ance, cognitive and/or language deficits, as well as hemiparesis. Conclusion: Based on the
experience acquired by the development of a dance class for individuals with sub-acute stroke,
a few recommendations are presented to ensure the safety and provide the right challenge for
each participant. Those recommendations can facilitate the implementation of a dance class
on a stroke unit.
P1.063
The Use of Goal Attainment Scaling for Setting, Monitoring and Upgrading
Language Goals in the Treatment of Chronic Aphasia
Duke, W1 Bains, R1, 2, 3 Ferdinandi, A1 Tittley, L1; 1. Columbia Speech and Language Services,
Vancouver, BC; 2. Provedence Health Care, Vancouver, BC; 3. University of British Columbia,
Vancouver, BC
Background: Speech-Language Pathologists have long struggled with translating results of
standardized aphasia assessment batteries into specific, measureable, achievable, realistic
and time-bound (SMART) goals. Most assessment batteries focus on categorizing aphasia type
(BDAE-3 and WAB-R), outlining functional difficulties (CADL-2) or identifying affected psycho-
linguistic processes (PALPA). None of these, however, provide a systematic framework to help
clinicians set specific functional goals and monitor progress. Such assessments may also not
have the sensitivity to measure the ongoing “subtle-but-important changes” (Schlosser, 2004)
in functional communication that may occur many months or even years post-stroke for people
in the chronic stage of aphasia. Goal Attainment Scaling (GAS) provides just such a clinical tool.
Originally used in other clinical disciplines such as physiotherapy, geriatrics and mental health,
it has been adapted for use with various communication disorders (Schlosser, 2004). Using
a five point scale, GAS allows the clinician to set graduated, personalized target outcomes
predicated upon the client’s observed baseline. Method: The authors have trialed the use of
GAS for people with chronic aphasia within both a life-participation-focused group program
and a recovery-focused intensive treatment program. Goals were established taking into ac-
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
systematically increasing the challenge presented to clients with aphasia. Examples will be
shared. Conclusions: GAS can help clinicians to set functional and measurable language goals
for individuals with chronic aphasia, and can be a sensitive marker of change in functional
communication.
Disclosure: All four authors receive income from Columbia Speech and Language Services, Inc.,
the agency at which the work described in this poster was completed.
P1.064
Recovery From Action Naming Anomia in Chronic Aphasia: Study on Therapy
Induced Neuroplasticity with 3 Participants
Durand, E1 Marcotte, K2 Ansaldo, A1, 2; 1. CRIUGM, Montreal, QC; 2. Universite de Montreal,
Montreal, QC
Context: Approximately 30% of stroke survivors are left with persistent language impairments.
Aphasia is a language deficit that results in communication disabilities; reduced social par-
ticipation secondary to language loss may in turn lead to isolation, and depression. Anomia is
the most frequent and pervasive aphasic symptom across aphasia types. Recovery from apha-
sia depends upon the brain’s potential to regain function. Aphasia therapy may contribute to
triggering this potential; however, our understanding of the links between neuroplasticity and
aphasia therapy remain limited. In our recent fMRI study , a group of participants with aphasia
(PWA) recovered the ability to name nouns following Massed-Semantic Feature Analysis therapy
(M-SFA); the recovery was correlated with neurofunctional changes reflecting therapy-induced
neuroplasticity. The present study, reports the results of M-SFA with actions verbs and it unveils
the neural substrates sustaining improved naming performance in a group of PWA and verb
anomia. Methodology: A multiple single-case with repeated measures before and after therapy
was used. Three participants with Broca’s aphasia received three weekly individual sessions of
M-SFA, until 80% of improvement with treated action verbs was attained. Event-related fMRI
and behavioral measures were collected at each point time. Results: All three participants have
benefited from M-SFA therapy with a significant action naming improvement. No generalization
was found with untreated verbs. However, participants’ families felt an improvement in every-
day communication. Action naming improvement was associated with significant activation of
semantic processing areas, areas involved in executive and mnemonic functions and areas of
motor programming. Conclusion: This study provides evidence about the potential of a therapy
to trigger brain plasticity and improve the ability to naming verbs in the case of chronic Broca’s
aphasia. Moreover, neurofunctional data suggest that the recruitment of specific viable network
is connected to the nature of the therapy.
P1.065
Effects of a Dual Task on AFO-Supported Gait in Individuals with Poststroke
Hemiplegia
Parker, K1 Clifton, K2 Adderson, J1 Mountain, A2 Eskes, GA2; 1. Capital District Health Authority,
Halifax, NS; 2. Dalhousie University, Halifax, NS
Background: Individuals with post stroke hemiplegia are often prescribed an ankle-foot orthosis
(AFO) to help maintain dorsiflexion during walking. Walking is an attentionally demanding task
and the impact of wearing an AFO has not been evaluated under dual task conditions. The pur-
pose of this study was to evaluate the effect of wearing an AFO on walking while under dual task
conditions. Methods: Eighteen individuals (M(SD) age = 61.2 (14.2) yrs, 12 males) with post
stroke hemiplegia and AFO use for at least 6 weeks were tested while walking with and without
an AFO, with and without a secondary working memory task (auditory 2-back). Order of the 4
walking conditions was randomized. Mean and variability of gait temporal-spatial parameters
were quantified with 2-4 walks per condition over an electronic walkway, GAITRiteTM. Results:
Data were analyzed via a 2 (no AFO vs AFO while walking) x 2 (single vs dual task walking)
mixed-factor ANOVA. Wearing an AFO improved velocity (54.4 vs 44.1 cm/s, p<.002) and step
length (paretic side: 45.4 vs 41.1 cm, p<.01; non-paretic side: 41.6 vs 35.0 cm, p<.001). Per-
forming the n-back task while walking reduced both velocity (51.6 vs 46.9 cm/s, p<.001) and
step length (paretic: 44.6 vs 41.9 cm, p<.001; nonparetic: 39.7 vs 36.8 cm, p<.001), with equal
interference seen in both no AFO and AFO conditions. Auditory 2-back performance (reaction
time, accuracy) was equivalent across conditions. Conclusions: Wearing an AFO provides ben-
efits to walking as measured by velocity and step length. Cognitive-motor interference (CMI) was
evident during dual-task walking, confirming the attentional demands of walking. AFO use does
not appear to increase nor decrease these attentional demands in practiced users, however,
as seen by equivalent CMI across AFO conditions. Interventions aimed at reducing CMI during
walking may be of benefit to optimize mobility in AFO users.
P1.066
Hemiplegic Shoulder Pain Following Stroke: Risk Factors for the Different
Etiologies and Their Outcomes
Fox, MA; Mountain, A; McDonald, A; Phillips, S; Dalhousie University, Halifax, NS
 e22  Stroke  December 2013
Background: Hemiplegic shoulder pain (HSP) has been estimated to occur in 48% to 84% of
people with stroke. The etiology of HSP can broadly be described as neuropathic (HSP-Np) or
musculoskeletal (HSP-Msk) in origin. This study is a retrospective chart review that seeks to
identify risk factors and differences in outcomes for the different etiologies of HSP. Methods:
Charts of 177 patients admitted to an inpatient tertiary stroke rehabilitation service during a three
year period were reviewed. Stroke patients with HSP were identified and classified according
to etiology (HSP-Msk or HSP-Np). Univariate statistical analysis was used to see if there were
any identifiable differences in risk factors and outcomes for the goups with HSP and without.
Results: Of the 177 charts reviewed (M:F 102:75) 62 patients (35%) had HSP. Of these 62 patients,
27 (44%) had HSP-Msk and 35 (56%) HSP-Np. In univariate analysis Chedoke McMaster stage
of recovery of the hand and arm <4 (stratified verses > 4) at admission or discharge (p<0.0001)
and the use of a mechanical lift at any time during admission (p=0.003) was associated with HSP.
Sex, presence of diabetes, stroke etiology (hemorrhagic or ischemic), presence of neglect and
discharge home were not different between the group with HSP and without. When the groups with
HSP-Msk and HSP-Np were compared individually against the group without HSP the Chedoke
McMaster stage of recovery at admission and discharge remained significant for both while use of
mechanical lift remained significant only for HSP-Np (p=0.009). Conclusion: Hemiplegic shoulder
pain is a common complication following stroke. In our retrospective chart review only Chedoke
McMaster Stage of recovery at admission and discharge (HSP-Msk and -Np) and use of mechani-
cal lift during admission (HSP-Np) were associated with hemiplegic shoulder pain.
P1.067
Measurement of Functional Outcomes Using the Goal Attainment Scale in a
Comprehensive Spasticity Management Clinic
Gallagher, S; Sasaki, A; Ismail, F; Boulias, C; West Park Healthcare Centre, Toronto, ON
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
Context: Spasticity is a component of the Upper Motor Neuron Syndrome which significantly
impacts active or passive function. Focal spasticity can be treated effectively with chemode-
nervation; however, reduction of spasticity does not automatically imply treatment success.
Evaluation of treatment outcomes should involve functional changes and goal attainment as
opposed to measures of impairment and symptoms alone. One way of quantifying achieve-
ment of goals is through the Goal Attainment Scale (GAS). The GAS is a tool which scores
the extent to which a patient’s goals are achieved in the course of their intervention. Both
tasks and scores are individually set around one’s current and expected levels of perfor-
mance. GAS allows measure of functional outcome, vs. traditional impairment level scales.
The comprehensive spasticity management clinic at West Park Healthcare Centre (WPHC)
began implementing the GAS with all patients in the fall of 2012. Findings: The GAS has been
completed with 210 patients in the spasticity clinic at WPHC. The GAS is completed in the first
clinic visit for new patients and at treatment visits for returning patients. 83% of our patients
had achieved their goals at follow-up. Goals were scored as achieved if patients scored 0 or
above on the GAS. 16% of patients could not complete the GAS due to cognitive or language
deficits. 54% of the goals are classified as passive goals, and 46% as active goals. Clinical
Relevance/Conclusion: GAS encourages communication and collaboration between multi-
disciplinary team members; and patient involvement. Goals are more likely to be achieved if
patients are setting them.
P1.068
Post-stroke Aphasia Therapy in Bilingual Speakers: Cross-Linguistic Transfer
Effects
Ghazi Saidi, L; Ansaldo, A; CRIUGM, University of Montreal, Montreal, QC
Background: Among the most devastating consequences of stroke, aphasia is character-
ized by impaired language production and comprehension. In multilingual contemporary
society, bilingual aphasia is becoming more and more frequent. Little is known about the
most efficient procedures for triggering language recovery of bilinguals with aphasia. The
question of which language to treat is a longstanding issue in the aphasiology domain.
This issue is particularly relevant given that language therapy in a second language is not
always available. There is evidence that language therapy effects can sometimes transfer
across languages; however, the mechanisms favoring cross-linguistic transfer are poorly
known. Aim: This paper reviews the evidence on cross-linguistic therapy effects in bilingual
aphasia therapy, with a focus on those factors that can modulate cross-linguistic therapy
(CLT) effects in bilinguals with aphasia. Methods: Collected from the following databases:
Medline, ASHA, Cochrane, Aphasiology Archive, Evidence-Based Medicine Guidelines, NHS
Evidence, PsycBite et Speechbite, with the key words bilingual, aphasia, cross-language,
generalization, cognates, naming treatment, and transfer, fifteen articles (two systematic
reviews and 13 case studies) with details on pre and post therapy bilingual aphasia profiles
in adults suffering from anomia, describing therapy frequency and procedures in sufficient
detail to make them replicable and discussing variables influencing the presence or ab-
sence of cross-linguistic transfer effects were analyzed. Results and Conclusion: Effects
of word similarity, structural language overlap, therapy approach, language of therapy (L1
VS L2), cognitive control, and pre and post therapy proficiency factors are discussed, and
a series of cues to develop intervention procedures favoring cross-linguistic transfer of
therapy effects are proposed.
P1.069
L’expérience de la réadaptation de l’AVC avec aphasie telle que vécue par les
proches
Hallé, M1, 2, 3 Le Dorze, G1, 2, 3; 1. École d’orthophonie et d’audiologie, Faculté de médecine, Uni-
versité de Montréal , Montréal, QC; 2. Centre de recherche interdisciplinaire en réadaptation du
Montréal métropolitain (CRIR)- Centre de réadaptation Lucie-Bruneau, Montréal, QC; 3. Réseau
provincial de recherche en adaptation-réadaptation (REPAR), Montréal, QC
Contexte : Les services de réadaptation doivent inclure les proches de personnes ayant subi un
AVC comme le stipulent les “Recommandations canadiennes pour les pratiques optimales de
soins de l’AVC”. Il est difficile de déterminer si de telles recommandations sont appliquées, entre
autres pour les proches de personnes ayant subi un AVC avec aphasie. En effet, ces derniers
présentent davantage de symptômes dépressifs que les proches de personnes ayant subi un AVC
sans aphasie, bien que l’expérience clinique suggère qu’au congé de la réadaptation, ils sont
satisfaits des services reçus. Une meilleure compréhension de leur expérience de la réadaptation
favoriserait une offre de services adaptée à leur situation. Le projet visait donc à identifier les élé-
ments déterminants dans l’expérience vécue par les proches de personnes aphasiques pendant
la réadaptation. Méthodologie : 12 proches de personnes devenues aphasiques à la suite d’un
AVC ont été individuellement interviewés moins de 3 mois après le congé d’une des phases de la
réadaptation. Ces entrevues ont été analysées qualitativement. Résultats : La condition néces-
saire à la satisfaction des proches envers la réadaptation est que les services doivent répondre à
leurs besoins en tant qu’aidant, c’est-à-dire avoir ce qu’il leur faut pour prendre soin du survivant
de l’AVC. Parallèlement, les proches ont d’autres besoins liés à leur bien-être personnel, tel que
du support, et relationnel, tel qu’avoir une bonne communication avec la personne aphasique. Or,
ils n’associent pas ces besoins à la réadaptation. Conséquemment, certains proches ressentent à
la fois de la satisfaction envers les services de réadaptation et des difficultés d’ajustement à l’AVC
avec aphasie. Conclusion : Les services de réadaptation devraient rendre explicite les différents
rôles que peuvent prendre les proches afin qu’une offre de services visant aussi à répondre à
leurs besoins personnels et relationnels paraissent légitime aux proches.
P1.070
A Comparison of Stroke and Acquired Brain Injury Rehabilitation Randomized
Controlled Trials
McIntyre, A; Kwok, C; Aubut, J; Janzen, S; Richardson, M; Hussein, N; Teasell, R; Lawson
Health Research Institute, London, ON
Objective: The rehabilitative needs for acquired brain injury (ABI) and stroke survivors may have
commonalities. Therefore, the objective was to compare the proportion of intervention-based ran-
domized controlled trials (RCTs), their sample size, and methodological quality between the stroke
and ABI rehabilitation literature. Methods: The Evidence-Based Review of Acquired Brain Injury
(ERABI) and the Evidence Based Review for Stroke Rehabilitation (EBRSR) databases were used
to identify all published RCTs in each corresponding field. RCTs were categorized, when possible,
into motor, cognitive, medical complications, or psychosocial intervention groups. The number,
sample size, and Physiotherapy Evidence Database (PEDro) score for each RCT was collected.
Results: A total of 148 ABI and 965 stroke rehabilitation RCTs were identified. Of the RCTs for
stroke, 625 were categorized as motor, 133 as cognitive, 108 as medical complications, and 99
as psychosocial intervention RCTs. Comparatively within ABI, 24 motor, 65 cognitive, 26 medical
complications, and 33 psychosocial RCTs were found. While the emphasis within stroke literature
is placed on motor studies (64.8%), the greatest concentration of ABI RCTs was within cognitive
interventions (43.9%). Compared to ABI RCTs, stroke studies had both a higher mean sample size
(P < 0.0001) and mean PEDro score (P = 0.0001). Conclusions: This study identified a potential
for existing stroke literature to be used to supplement poorly studied areas in ABI and vice versa.
P1.071
The Methodological Quality of Randomized Controlled Trials in Stroke Rehabilita-
tion Literature
McIntyre, A; Janzen, S; Richardson, M; McClure, A; Hussein, N; Teasell, R; Lawson Health
Research Institute, London, ON
Objective: To evaluate the methodological quality of intervention-based, randomized controlled tri-
als (RCTs) published in the stroke rehabilitation literature using the Physiotherapy Evidence Data-
base (PEDro) tool. Methods: All RCTs published from 1973 to 2012 from the stroke rehabilitation lit-
erature were reviewed and included. RCTs that could be appropriately categorized as either a motor,
cognitive, medical complications or psychosocial were grouped. Each study was evaluated using the
PEDro tool; scores for each of the 10 quality ratings (e.g., yes=1 or no=0) and the cumulative score
(maximum10) were recorded to allow for individual item analysis. Results: A total of 1063 RCTs
were included with an overall mean PEDro score of 6.2 ± 1.5. 62.5% of the total sample was rated
as “good” quality (scores 6-8). Among all RCTs combined, the criteria least likely to be satisfied
on the PEDro included: blinding therapists (9.8%), blinding participants (25.5%), intention to treat
analysis (27.6%), and concealed allocation (34.9%). Conversely, baseline comparability (91.7%) and
between-group results comparisons (94.7%) were the most frequently satisfied criteria. Of the 965
intervention-based studies (motor n=625, cognitive n=133, medical n=108, psychosocial n=99),
psychosocial RCTs had the greatest mean PEDro score (6.6 ± 1.4). Medical complication interven-
tion RCTs had the greatest proportion of “excellent” (14.8%; scores 9-10) and “poor” quality studies
(6.5%; scores <4). Conclusions: The results indicate that certain quality criteria are often not satis-
fied and may introduce greater bias. Since the evidence provided from RCTs is used to guide clinical
practices, the methodological quality of studies should be considered when interpreting results.
P1.072
Anatomical Correlates of Proprioceptive Deficits Following Stroke in Humans: a
Case Series
Kenzie, JM1 Semrau, JA1 Findlater, SE1 Herter, TM2 Scott, SH3 Dukelow, SP1; 1. The University
of Calgary, Calgary, AB; 2. University of South Carolina, Columbia, SC, USA; 3. Queen’s
University, Kingston, ON
 Abstracts From the 4th Canadian Stroke Congress, 2013  e23
Background: Proprioception refers to the ability to detect the relative position and move-
ment of our body in space. After stroke, individuals with significantly impaired proprioception
tend to have poor functional outcomes. Newer robotic techniques for measuring propriocep-
tion now provide more reliable and accurate quantification of proprioception than traditional
clinical techniques. We are conducting a large prospective longitudinal study measuring pro-
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
a preliminary case series from our larger ongoing study displaying the types of propriocep-
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
the internal capsule, primary somatosensory cortex and parietal association areas. Meth-
ods: Neuroimaging was performed on 10 subjects 2-10 days post-stroke. Assessment of
proprioception and visually guided reaching in the upper extremities was completed using a
KINARM robotic exoskeleton within the same time frame. Lesion location was compared with
robotic task performance. Results: Subjects with thalamic damage demonstrated significant
proprioceptive deficits with mild to moderate deficits in visually guided reaching. Damage
to the posterior limb of the internal capsule resulted in varying degrees of proprioceptive
and/or reaching deficits. Subjects with damage to primary somatosensory cortex (S1) and
parietal cortex showed the most severe deficits in both proprioception and reaching tasks.
Conclusions: Proprioceptive deficits were consistently observed following lesions of brain
structures classically thought to be involved in proprioception. However, damage to similar
areas in different patients did not necessarily result in identical deficits. In this sample,
damage to S1 and posterior parietal cortex most significantly impacted performance on all
robotic tasks.
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
P1.073
Improving Rehabilitation Intensity - A Common Sense Approach
Lawhead, KE; Windsor Regional Hospital - Tayfour Campus, Windsor , ON
Background: Stroke patients should receive a minimum of 3 hours of direct task-specific
therapy by an interprofessional stroke team a minimum of 5 days per week. Stroke patients
on the Inpatient Rehabilitation Unit at Windsor Regional Hospital, were receiving 2-3 hours
of therapy per day and the transfer of skills to their daily routine was sub optimal. Staff was
frustrated as they often competed to see patients during peak times in the day, despite
nursing reporting that there are times in the day and on weekends when patients are not
engaged in activity. This has led to changes in our care delivery model to improve access to
care and therapy intensity. Methods: A multidisciplinary working group undertook a LEAN
approach to reduce inefficiencies and improve access to therapy. We reviewed a day in
the life of a patient. We engaged Nursing, Physiotherapy, Occupational Therapy, Speech
Language Pathology, Social Work, Psychology, Recreational Therapy and Dietary staff to
create, pilot, and implement a variety of functionally based classes to address the gaps in
service provision. Results: The access to treatment has increased from 2-3 hours/day to
5-6 hours per day for the majority of patients. The delivery of care model has become more
efficient and interprofessional. Patients are engaged in their recovery and participating in
activities outside of traditional therapy hours. Evening and weekend programs continue to
expand as the Program develops. Conclusion: By implementing inpatient home exercise
programs and group classes to supplement on on one therapy sessions, patients have in-
creased access to care, education and have taken personal accountability for their recovery.
Staff has increased the transfer of functional skills into daily routines. Interprofessional care
has broadened throughout the Unit, and therapists use their time with patients to teach and
practice the new and more complex skills.
P1.074
The Frontal Lobes and Autobiographical Memory: A Focal Lesion Study
Levine, B5, 3 Khuu, W5 Black, SE3, 2 Schwartz, ML3, 2 Alexander, MP7; 1. Rotman Research
Institute, Toronto, ON; 2. Sunnybrook Health Sciences Centre, Toronto, ON; 3. University of
Toronto, Toronto, ON; 4. Department of Medicine (Neurology), University of Toronto, Toronto,
ON; 5. Rotman Research Institute, Baycrest, Toronto, ON; 6. Harvard Medical School and Beth
Israel Deaconess Medical Centre (Neurology), Boston, MA, USA; 7. Harvard Medical School and
Beth Israel Deaconess Medical Centre (Neurology), Boston, MA, USA
Most research on the functional neuroanatomy of autobiographical memory has entailed
functional neuroimaging, which is unable to distinguish regions that are activated in associa-
tion with autobiographical memory tasks from those that are necessary for autobiographi-
cal memory task performance. In this respect, patients with focal lesions provide crucial
information. We assessed the effects of focal frontal lesions due to strokes and tumors
in distinct functional-anatomical sectors on autobiographical memory using the Autobio-
graphical Interview (AI), which reliably separates categories of episodic and non-episodic
autobiographical memory. Twenty-three focal lesion patients in the stable phase of recovery
were included. Lesions were visualized and defined on computerized images. Patients were
divided into medial polar (MP; N = 12) and right dorsolateral frontal (RDLF; N = 11) groups,
according to dissociations based on prior studies of the effects of frontal lesions on cogni-
tion (left lateral patients were excluded due to the speech demands of the AI). Episodic and
non-episodic (internal and external) detail scores were derived from text-based analysis of
the transcribed protocols. MP patients generated significantly more details that were not
pertinent to the specified event (external details) compared to control participants. Patients
with RDLF lesions were only marginally significantly impaired for internal details. Lesion
overlap of patients with an excess of external details indicated a focus in the left anterome-
dial prefrontal cortex. Production of external details was correlated with non-perseverative
errors on the Wisconsin Card Sorting Test (WCST). In conclusion, focal frontal damage does
not cause a significant decline in episodic autobiographical memory retrieval per se. Rather,
MP lesions cause a deficit in the control and direction of retrieval and discourse lapses
in global coherence. The maximal overlap in the anteromedial left prefrontal cortex cor-
responds with this region’s involvement in switching attention between internal (self) and
external (environmental) stimuli.
P1.075
Validation of a Novel Computerized Test Battery for Automated Testing
Levine, B1, 2, 3 Bacopulos, A1 Anderson, ND1, 4, 3 Black, SE2, 5 Davidson, PS6 Fitneva, SA7 McAn-
drews, M3, 9 Spaniol, J10 Jeyakumar, N1 Abdi, H11 Beaton, D11 Owen, AM8 Hampshire, A8;
1. Rotman Research Institute, Baycrest, Toronto, ON; 2. Department of Medicine (Neurol-
ogy), University of Toronto, Toronto, ON; 3. Department of Psychology, University of Toronto,
Toronto, ON; 4. Department of Medicine (Psychiatry), University of Toronto, Toronto, ON;
5. Sunnybrook Health Sciences Centre, Toronto, ON; 6. School of Psychology, University of
Ottawa, Ottawa, ON; 7. Department of Psychology, Queen’s University, Kingston, ON;
8. Department of Psychology, University of Western Ontario, London, ON; 9. Toronto Western
Research Institute, Toronto, ON; 10. Department of Psychology, Ryerson University, Toronto,
ON; 11. School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
Computerized tests offer an adjunct to standardized neuropsychological tests, especially for
speeded information processing, attention, executive functioning, and memory, which are of pri-
mary importance in many brain diseases. We assessed the validity of computerized tasks of these
capacities as compared to neuropsychological tasks. 134 healthy participants (mean age: 47.17;
SD: 24.49; range 18–90) completed computerized and traditional neuropsychological batteries
in a counterbalanced fashion. Partial Least Squares – Correlation (PLS-C, Krishnan et al., 2011)
analysis resulted in one significant latent variable accounting for 93% (p<.001) of the cross-block
co-variance (78% after accounting for age). Computerized tests contributing to the latent variable
included visuospatial working memory, inhibition, fluid reasoning, and visuospatial planning from
the Cambridge Brain Sciences battery (CBS; Hampshire et al., 2012), speed and working memory
measures from the CogState battery (Maruff et al., 2009), and a face-name task (Troyer et al.,
2012). Standardized tests that significantly contributed included WASI Block Design and Matrix
Reasoning, the Rey Auditory Verbal Learning Test, Trail Making A and B, and the Symbol Digit Mo-
dalities Test. Based on this analysis, a reduced computerized battery (less than 30 min in duration)
composed of the CBS and face-name tests was identified, which accounted for 61% of the vari-
ance in the full 2-3 hr neuropsychological test battery. Using PLS-Regression, we found that this
reduced computerized battery was comparable to the full neuropsychological battery at predicting
age (r’s = .78 and .75 for the neuropsychological and computerized batteries, respectively). In con-
clusion, an automated, 30-min computerized battery of tests of attention, memory, and executive
functioning is comparable to a 2-3 hr battery of paper-and-pencil tests in terms of its latent struc-
ture and relation to age. Such a battery could be applied in large-scale testing or as a repeatable
screening battery for assessing cognition where access to neuropsychological services is limited.
P1.076
Using a Triage Tool to Facilitate Access to Rehabilitation for Persons with Stroke
Linkewich, E1 Sharp, S2 Willems, J3 Levy, C4 Tahair, N5 Bayley, M6; 1. North & East GTA Stroke
Network, Toronto, ON; 2. Toronto West Stroke Network, Toronto, ON; 3. South East Toronto
Stroke Network, Toronto , ON; 4. GTA Rehab Network, Toronto, ON; 5. Toronto Stroke Net-
works, Toronto, ON; 6. University Health Network - Toronto Rehab, Toronto, ON
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-
cated 60% of inpatient rehab admissions in Toronto were moderate, 17% mild and 22% severe.
With a goal of improving access to timely and appropriate rehab, Stroke Flow established inpatient
admission targets of 12% mild, 53% moderate and 35% severe. The triage tool emerged to sup-
port clinical decision making for early referral to appropriate rehab. Methods: Acute and rehab
leaders considered the provincial expert panel recommendations and existing referral frameworks
(Ottawa and Hamilton) in collaboratively developing the triage tool. Understanding that broader
system changes are required for a full transition to the new model of rehab, initial implementation
focused on patients with an early AlphaFIM® of 60-80. Communication and education to support
this practice change facilitated the February 2013 implementation. Results: Baseline data (Janu-
ary - August 2012) for patients referred with an early AlphaFIM® of 60-80 indicated only 66%
were accepted to rehab, 15% were declined and 8.5% had a decision pending. It is expected that
transition barriers for this group should be minimal unless special needs are identified. Reasons for
decline included: special needs that could not be met (10%); more appropriate for slow stream re-
hab (29%), and limited sitting tolerance and balance (14%). Monitoring of decline rates and reason
for decline will be ongoing. Further evaluation will be conducted at 6 months post-implementation.
Conclusion: The triage tool supports a standard of practice across organizations. A common stan-
dard of practice for rehab referral and management of patients with AlphaFIM® 60-80 have been
established between referrers and rehab providers. This tool is transferable to other geographies.
P1.077
Assessing Depressive Symptoms in Subarachnoid Hemorrhage and Treated and
Untreated Unruptured Aneurysm Patients
Maher, ME1 Macdonald, R2, 1 Schweizer, TA2, 1; 1. University of Toronto, Toronto, ON;
2. St. Michael’s Hospital, Toronto, ON
Background: The CES-D and the HADS-D are two brief self-report scales that are valid and
reliable for assessing depressive symptoms in many populations, including stroke. The goal of
 e24  Stroke  December 2013
this study was twofold: 1) to determine the presence of depressive symptoms in aneurysmal
subarachnoid hemorrhage (aSAH) compared to unruptured intracranial aneurysm (UIA treat-
ed and untreated) patients and 2) to determine which scale is best to use in these groups.
Methods: 117 outpatients were recruited from the Neurovascular Clinic at St. Michael’s Hospital
to complete both the CES-D and the HADS. We assessed 3 groups: aSAH (n=47), UIA treated
(n=30) and UIA untreated (n=40). Cutoff scores of 16 (CES-D) and 8 (HADS-D) were used.
Results: Proportions of patients scoring above cutoffs were: 42.6% (CES-D) and 19% (HADS-D)
of aSAH, 40% (CES-D) and 23.3% (HADS-D) of UIA treated and 22.5% (CES-D) and 15% (HADS-
D) of UIA untreated patients. aSAH patients scoring above the CES-D cutoff had average HADS-D
scores below cutoff (average score= 7.30); UIA treated and UIA untreated patients above the
CES-D cutoff had average HADS-D scores of 8.69 and 8.33 – only slightly above the cutoff
point. Conclusions: Based on these results, the HADS scale may be preferential to use in aSAH
and UIA (treated and untreated) patients. It requires less time to complete than the CES-D and
measures symptoms of depression and also anxiety – which is highly prevalent in stroke popula-
tions. Previous research has shown that the CES-D is influenced by anxiety symptoms in addi-
tion to producing a high number of false positives in the general population. These factors may
be reflected in the high number of patients in this study that fell at or above the CES-D cutoff.
P1.078
Analysis of Fmri Neurofeedback of the Primary Motor Cortex as a Function of
Time During Kinesthetic Motor Imagery
Mansur, A1 Chiew, M2 Tam, F3 Schweizer, TA1 Graham, SJ3; 1. Li Ka Shing Knowledge Institute,
St. Michael’s, Toronto, ON; 2. FMRIB, Nuffield Department of Clinical Neurosciences, Oxford,
United Kingdom; 3. Sunnybrook Research Institute, Sunnybrook Health Sciences Centre,
Toronto, ON
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Background: Functional MRI neurofeedback (fMRI-NF) is a novel tool that can enable self-reg-
ulation of brain activity. By depicting brain activation patterns during performance of imagined
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
with kinesthetic MI in 13 right-handed healthy subjects and 5 controls. Subjects were instructed
to mentally simulate a unilateral finger-tapping task while receiving NF from the primary motor
cortices to increase a lateralization metric of brain activity. Only 6 out of 13 subjects were good
responders, who showed increased activity in the task positive network that correlated with
task performance. Here we focus on the differences in temporal evolution of brain networks
recruited in the good and poor responders in left and right hand imagery tasks. Methods: Pre-
processed data were subjected to a general linear model (GLM) to create parametric maps for
both region-by-region analyses and whole-brain ANOVA analyses. Results: For right hand tasks,
poor responders had minimal motor activation that was stagnant over the four runs of fMRI-NF.
Conversely, good responders had high visual-spatial and motor activation from the first run
with increasing involvement of the inferior frontal gyrus and thalamus over time. For left hand
tasks, poor responders showed more activation than good responders. Conclusion: This work
supports that good candidates for fMRI-NF involving imagery must possess strong visual-spatial
and focused attention skills. Hemispheric differences in brain activity during fMRI-NF may have
implications for use of fMRI-NF with MI therapy in populations with focal deficits. More research
is required with a larger sample of left-handed and right-handed individuals, as part of assess-
ing the role of fMRI-NF applied to MI and stroke.
P1.079
Are the Randomized Controlled Trials in Stroke Rehabilitation Underpowered?
McIntyre, A; McClure, A; Richardson, M; Janzen, S; Hussein, N; Teasell, R; Lawson Health
Research Institute, London, ON
Objective: Many stroke rehabilitation interventions produce small to moderately sized treatment
effects. Randomized controlled trials (RCTs) that enroll a small number of participants may be
unable to detect such effects and result in false, non-reproducible conclusions. Therefore, the
objective was to determine the proportion of RCTs in the stroke rehabilitation literature that
was sufficiently powered to detect a moderate treatment effect. Methods: Stroke rehabilitation
RCTs published between 1973 and 2012 were included for review. Sample sizes from all RCTs
were recorded. Where possible, RCTs were grouped based on intervention type (i.e., motor,
cognitive, medical complications, psychosocial). To detect a moderate treatment effect of 0.5
with the significance level (alpha) set at 0.05 and power (1-beta) set at 0.8, a total sample size
of 128 individuals (64 per group) is required. Results: 1063 RCTs met inclusion criteria with a
mean sample size of 176.4±1002. 17.2% of all RCTs included a sample size of at least 128
individuals. 965 RCTs could be further classified as motor (n=625), cognitive (n=133), medical
complications (=108), and psychosocial (n=99) interventions. The mean sample sizes among
the groups varied considerably: motor –x = 87.4±574.4; cognitive –x = 329.1±1042.2; medical
complications –x = 227.8±547.5; and psychosocial –x = 126.9±117.9. The proportion of RCTs
that included a sample size of at least 128 individuals was 6.9% for motor, 19.9% for cognitive,
26.9% for medical complications, and 33.3% for psychosocial intervention RCTs. Conclusions:
It appears as though a substantial portion of the stroke rehabilitation literature is underpowered.
Larger trials, particularly for motor interventions, are necessary.
P1.080
The Evolution of Stroke Rehabilitation Research
McIntyre, A1 Richardson, M1 Janzen, S1 McClure, A1 Hussein, N1, 3 Teasell, R1, 2, 3; 1. Lawson
Health Research Institute, London, ON; 2. University of Western Ontario, London, ON; 3. St.
Joseph’s Healthcare, London, ON
Objective: To examine the evolution of stroke rehabilitation literature with respect to num-
ber, sample size, and quality of randomized controlled trials (RCTs) over the last four de-
cades (1973-2012). Methods: The Evidence-Based Review of Stroke Rehabilitation (EBRSR;
http://www.ebrsr.com) is a review of RCTs in stroke rehabilitation. RCTs were categorized
into one of five groups based on intervention type: motor, cognitive, medical complica-
tions, psychosocial, and “other”. Data on author(s), year of publication, sample size, and
Physiotherapy Evidence Database (PEDro) score were compiled. Statistical analyses were
conducted using GraphPad Prism (V6.01). Results: 1063 RCTs met inclusion criteria (mo-
tor n=625; cognitive n=133; medical complications n=108, psychosocial n=99, other
=98) with motor intervention RCTs accounting for 58.8% of the total. The number of RCTs
published each year grew between 1973 and 2012, with 35.9% all RCTs published in the
last five years. Overall, motor studies had the smallest median sample size (median =
32; P < 0.017). Between two five-year time brackets, 1973-1977 and 2008-2012, there
was no statistically significant increase in median sample sizes among all RCTs combined
(P = .8427). Overall, psychosocial studies had higher mean PEDro scores when com-
pared to motor (P = .002) and cognitive (P = .036), but not medical complication studies
(P = .5913). Over time, PEDro scores for all RCTs increased from 5.2 ± 0.7 in 1973-1977 to
6.5 ± 1.5 in 2008-2012 (P = .008). Conclusions: The number of RCTs in stroke rehabilita-
tion has increased significantly over the past four decades, with an associated increase in
quality. Future reviews should more closely evaluate changes in number, sample size, and
PEDro scores of specific interventions over time and assess the impact of study quality on
reported outcomes.
P1.081
’Training the Trainers’ - the Process of Effectively Moving Evidence-Based Func-
tional Electrical Stimulation (FES) Into the Clinical Realm
Miller, S1 Gollega, A2 Dukelow, S2; 1. Alberta Health Services - Peter Lougheed Centre, Calgary,
AB; 2. Alberta Health Services, Calgary, AB
Background: In March, 2012, an FES Work Group was formed with ‘champions’ from acute,
tertiary and outpatient sites in the Calgary Zone of Alberta Health Services to develop practical
skills in using functional electrical stimulation (FES) with stroke patients. The FES Work Group
consisted of occupational therapists, physiotherapists and physiatrists with expertise in stroke
rehabilitation. Methods: An initial meeting was held to determine timelines for knowledge
transfer and establish the primary goal of the group which was to build a ‘critical mass’ of
clinicians with practical experience using FES across the Calgary Zone. In house in-servicing
was done to establish a baseline of theoretical and practical knowledge for the FES Work
Group, capitalizing on existing knowledge and clinical experience of group members. Similar
FES equipment was acquired across different sites to ensure consistent use in the Calgary Zone
across inpatient and outpatient centres. A 2 day course was developed in-house with an exter-
nal speaker with advanced training in the use of FES. FES Work Group members helped facili-
tate the course and assisted in the practical workshops. A survey was done of all participants
to look at ways of improving the FES course. Following this, a 1 day course was developed,
with in-house teaching by the FES Work Group. Results: The time from formation of the group
to the development of an in-house course and consistent training of ~ 50 therapists across
the Calgary Zone was ~ 1 year. Based on surveys of participants post 1 day course, > 90 %
rated the course as excellent. The use of therapists as facilitators with the course was rated as
a strength. Conclusion: The ‘train the trainers’ approach proved to be an acceptable method
of practical knowledge transfer. This is a technique that could be applied in other geographic
regions for evidence-based care.
P1.082
Self-Identified Goals: Investigating Areas of Unmet Need for Individuals with
Stroke Using the ICF
Nalder, EJ1 Bottari, C2 Damianakis, T4 Hunt, A3 Dawson, D1, 3; 1. Rotman Research Institute,
Baycrest Hospital, Toronto, ON; 2. Université de Montréal, Montreal, QC; 3. University of
Toronto, Toronto, ON; 4. University of Windsor, Windsor, ON
Background: Despite evidence for the efficacy of stroke rehabilitation in the chronic phase
of recovery, many survivors report unmet service and psychosocial needs. A clear knowledge
of the self-identified goals of stroke survivors is critical to ensure service planning is congru-
ent with the priorities of service users. The International Classification of Functioning (ICF)
core data set for stroke was developed to provide a common framework for describing health
related experiences post-stroke. However, this framework has not been validated in terms
of how it aligns with self-identified goals of stroke-survivors. This paper aims to 1) describe
self-identified goals of stroke survivors and 2) determine the extent to which individuals’ goals
link to the ICF. Methods: Data were collected from 24 participants with stroke on average 3.5
years post-event, as part of a larger randomised controlled trial. The Canadian Occupational
Performance Measure (COPM) was used to elicit stroke-survivor’s goal statements. Qualitative
content analysis was used to thematically analyse goals and map content to the ICF framework.
Results: Twenty-four stroke-survivors identified 125 rehabilitation goals even many years
post-event. All goals were readily classified using the ICF and indicated a need for supports
to facilitate activity participation and manage residual impairments. Activity and participation
goals were most common, particularly in the areas of community, social and civic life (n=19
goals) and mobility (n = 17 goals). Sixteen stroke-survivors also identified recovery goals re-
lated to impaired body functions; most common were neuromusculoskeletal and movement
related functions, and mental functions each with 9 goals. Conclusions: Stroke survivors have
complex and varied goals for rehabilitation which extend beyond the period of acute recovery.
The ICF framework is a useful tool to illustrate the broad rehabilitation needs of individuals
with stroke and may inform service planning and evaluation towards addressing the long-term
needs of stroke survivors.
 Abstracts From the 4th Canadian Stroke Congress, 2013  e25
P1.084
The HNHB Community Stroke Rehabilitation Model - a Component of an
Integrated Stroke Recovery System that Crosses the Continuum From Acute to
Community
Pagliuso, SA; MacRae, L; The HNHB Community Stroke Rehabilitation Working Group; Hamilton
Health Sciences, Hamilton, ON
Background: A gap identified in the HNHB LHIN was the lack of access to community stroke re-
habilitation, especially in rural areas. Therefore a working group(WG) was assembled to develop
a Community Stroke Rehabilitation Service Model(CSRM) as a component of a stroke recovery
system that crosses the continuum. The service model will be aligned with the Canadian Best
Practices for stroke care and the Stroke Reference Group, provide improved access and be
transferable to other LHIN communities. The goals of the model are achieving improved access
to evidence based community outpatient stroke rehabilitation, improved client outcomes, reduc-
tion of hospital lengths of stay and integration of outpatient stroke services. Methods: In order
to develop this model the WG engaged in the following process:
- Defining the ‘eligible’ population and identifying the number of individuals that would be
eligible.
- Identifying client streams and best practice guidelines for each.
- Completing an environmental scan which revealed 8 models for review.
- Application of the HNHB LHIN’s Decision Making Framework (DMF) to evaluate the models.
- Rating each criterion in the DMF as to how they related to the LHIN and provincial priorities
in the context of a CSRM and each criterion was weighted using Expert Choice software.
Results: The WG have developed a model that incorporates the strengths of all the models
reviewed. Which includes the following:
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- Strong link with District and/or Regional Stroke Center, an ISU and with primary care
- Dedicated care coordination
- Time to first visit within 72 hours
- Consistency of Stroke Team Members
- Assessment for CSR within 24-48 hours
- Care Pathway based on Best Practice Recommendations that incorporate opportunities for
reassessment
- Stroke Expertise
- Equitable Access
- Strong link with CCAC
- Standardized reporting requirements
Conclusions/Next Steps:
Implementation of a pilot project and development of an evaluation framework.
P1.085
“Normal” Functional Balance Does Not Necessarily Imply Recovered Standing
Balance Control, as Measured with Posturography in Individuals with Stroke
Patterson, KK1, 2 Mansfield, A2, 1 Inness, E2, 1 McIlroy, WE3, 2, 1; 1. University of Toronto, Toronto,
ON; 2. Toronto Rehab - University Health Network, Toronto, ON; 3. University of Waterloo,
Waterloo, ON
Background: The Berg Balance Scale (BBS) is a functional balance measure commonly used
during stroke rehabilitation1. However, BBS scores can improve without concomitant improve-
ment in physiological postural control measures2. The purpose of this study was to compare
forceplate measures of standing balance between individuals post-stroke scoring above and
below a ‘normal’ BBS score. Methods: Demographic variables, BBS scores, Chedoke McMaster
Stroke Assessment (CMSA) leg and foot scores and forceplate measures of quiet standing bal-
ance (percentage of body weight on the paretic limb and root mean square of centre-of-pressure
for antero-posterior and medio-lateral displacement) were extracted from 168 inpatient rehabili-
tation charts. Individuals were divided into two groups: BBS score above or below a normative
value (lower 95% CI for healthy adults3) and also categorized as within or outside the 95% CI
for healthy adults for each forceplate measure4,5. BBS groups were compared with one-way
ANOVAs and Fisher’s tests. Results: Forty-two (25%) individuals had BBS > normative value.
These individuals had higher CMSA leg (5.6±0.9 vs 4.6±1.1, p<0.001) and foot scores (5.1±0.8
vs 4.2±1.2, p<0.001) and shorter length of stay (31 ± 11 days vs 40±15 days, p<0.001 ) than
individuals with BBS < normative value. The two groups did not differ in age, days post stroke
or the proportion of individuals scoring within the normative CIs for forceplate measures. Dis-
cussion: Individuals post-stroke achieving “normal” BBS scores are not more likely to exhibit
recovered standing balance control as measured by posturography with respect to healthy CI
values. These individuals may employ compensatory strategies that allow superior BBS perfor-
mance which belies continued underlying balance impairment.
References: Blum L et al. Phys Ther. 2008;88:559-566. Garland SJ et al. Arch Phys Med Rehabil.
2003;84:1753-1759. Steffen TM et al. Phys Ther. 2002;82:128-137. Prieto TE et al. Biomedical
Engineering. 1996;43(9):956-966. Mansfield A et al. Clin Biomech. 2011;26:312-317.
P1.086
Influence of Knowledge of Perturbation on Standing Balance Post-Stroke
Pollock, C1 Vieira, T2 Gallina, A2 Ivanova, T1 Cantor, Z1 Garland, S1; 1. University of British
Columbia, Vancouver, BC; 2. Laboratory for Engineering of the Neuromuscular System (LISiN),
Politecnico di Torino, Torino, Italy
Background: The neuromuscular control of standing balance is known to be impaired after
stroke. The purpose of this study was to explore the role of anticipatory reactions in responding
to external perturbations. Methods: Subjects post-stroke, and age-matched controls, stood with
each foot on a separate force platform. Subjects explored their anterior limits of stability (LOS)
by leaning as far forward as possible about the ankles without lifting the heels. External loads
of 2% of body weight were applied at the level of the hips to perturb the subject anteriorly. Ten
loads were applied either by the investigator or were triggered by the subject. High-density
surface electromyography of the calf muscles (multi-channel arrays covering soleus, medial and
lateral gastrocnemius), center of pressure (CP) measurements, and electrodermal activity (EDA;
measurement of physiological arousal) were taken. Results: Subjects post-stroke have lower
LOS in the paretic leg compared to the non-paretic leg and healthy controls. During investigator-
triggered external load drops, the CP excursion in people with stroke moved anteriorly similar to
controls (~80% LOS), although the peak CP excursion was reached quicker in controls. In the
subject-triggered condition, healthy subjects showed a reduction in the CP excursion; however,
this was not demonstrated post-stroke. The relative activity of soleus compared to medial and
lateral gastrocnemius was lower in the paretic muscle than in the non-paretic leg or controls.
Both triggered conditions elicited an increase in EDA in stroke compared to controls. Conclu-
sions: Subjects post-stroke had higher physiological arousal during the external perturbations in
both types of triggered conditions. Whereas healthy subjects changed their motor performance
when the perturbation was self-triggered, the subjects post-stroke did not. The soleus muscle
appeared to be more compromised than the gastrocnemius heads. Together these findings
further illustrate the impairments of neuromuscular control of standing balance.
P1.087
Effect of Intensive Functional Electrical Stimulation Therapy on the Upper Limb
Motor Recovery After Stroke: Single Case Study of a Chronic Stroke Patient
Kawashima, N1, 3, 2 Popovic, MR3, 2 Zivanovic, V3, 2; 1. Research Institute of National Rehabilita-
tion Center for Persons with Disability, Saitama, Japan; 2. University of Toronto, Toronto, ON;
3. Toronto Rehabilitation Institute, Toronto, ON
Purpose: Previous successful randomized controlled trials show that functional electrical stimu-
lation (FES) therapy can restore voluntary arm and hand function in people with severe stroke.
The purpose of this study was to examine neuromuscular changes occurring in the upper limb of
people with severe stroke following intensive FES therapy, consisting of task-specific upper-limb
movements with a combination of preprogrammed FES and manual assisted motion. Methods:
The patient was a 22-year-old woman who had suffered a haemorrhagic stroke 2 years earlier.
FES therapy was administered for 1 hour twice daily for 12 weeks, for a total of 108 treatment
sessions. Results: While maximal voluntary contraction level of the upper-limb muscles did not
show significant improvement, the ability to initiate and stop the muscle contraction voluntarily was
regained in several upper-limb muscles (approx. 5%–15% of the maximum voluntary contraction
of the same muscle in the less-affected arm). A reduction in arm spasticity was also observed, as
indicated by the reduction of H-reflex in the wrist flexor muscle (82.1% to 45.0% in Hmax/Mmax)
and decreased Modified Ashworth Scale scores (from 3 to 2 for the hand and 4 to 3 for the arm).
Coordination between shoulder and elbow joints during the circle-drawing test improved consider-
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
observed in people with severe stroke following intensive FES therapy can be attributed to (a)
regained ability to voluntarily contract muscles of the affected arm, (b) reduced spasticity and
improved muscle tone in the same muscles, and (c) increased range of motion of all joints.
P1.088
Change in Rehabilitation Clinicians’ Practices Related to Upper Limb Manage-
ment Post-Stroke Over the Past Year: Do Changes Align with Best Practice
Guidelines?
Purohit Jadav, R1, 2 Korner-Bitensky, N1, 2 Menon, A1; 1. McGill University, Montréal, QC; 2.
Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR),
Montreal, QC
Background: Upper limb motor impairments are prevalent after stroke. Although there is a re-
cent version of Canadian Best Practice Guideline 2010 (CBPG-2010) integrating precise and up-
dated information about upper limb assessment and management post-stroke, it is unknown if
occupational therapists (OTs) and physical therapists (PTs) have introduced any changes to their
management of upper limb dysfunction. Thus, the aim of this study is to explore change (or lack
thereof) in upper limb management post-stroke by OTs and PTs in a 12 month period in 2012,
as well as facilitators and barriers related to change using a standardized tool, the Professional
Evaluation & Reflection on Change Tool (PERFECT tool). (available online at www.strokengine.
ca/) Methods: A convenience sample of 25 PTs and 25 OTs, working in inpatient stroke rehabili-
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
changes in clinical practice over a 12 month period according to four components of patient
management as measured using the PERFECT: problem identification, assessment, treatment
and referral. Descriptive analyses identified the key facilitators of change; and whether changes
were “evidence-based” or not. Results: The prevalence of change in all four areas of practices
(problem identification, assessment, treatment practices and referral practices) related to upper
limb management post-stroke will be presented. Additionally, key facilitators of evidence-based
change are described. Conclusion/expected contribution: Millions of dollars have been spent
in an effort to identify effective management of the upper limb post-stroke. This study contrib-
utes to our understanding of the uptake of the evidence specific to upper limb management
post-stroke and assists in planning knowledge translation (KT) interventions that promote the
implementation of evidence into practice.
 e26  Stroke  December 2013
P1.089
Clinical-Research Platforms as a Model of Knowledge Translation to Promote
Best Practices in Stroke Rehabilitation
Richards, CL1 Nadeau, S2 Fung, J3 Rossignol, S4 Doyon, J4; 1. Université Laval and CIRRIS
Research Center, Quebec, QC; 2. Université de Montréal, Montreal, QC; 3. McGill Universityand
CRIR Research Center, Montreal, QC; 4. Université de Montréal, Montreal, QC
Background: The Canadian Institutes of Health Research-funded Sensorimotor Rehabilitation
Research Team unites researchers from Université de Montréal, Université Laval and McGill
University, 3 Research Centers and the stroke units of 3 Rehabilitation Centers (RC) in Quebec.
Led by 5 Principal Investigators (PIs), it includes 25 researchers (neuroscientists and clinical 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-
timize rehabilitation and to develop and evaluate innovative therapeutic approaches. Methods:
First, researchers and clinicians in all 3 RCs agreed to use common clinical outcome measures
to document patient profiles and their progression in stroke rehabilitation. Then, to determine
the gaps between current practice and best practices, clinicians responded to a questionnaire
on the SurveyMonkey web-platform and patient charts were audited. Information on intensity
and categories of therapy patients received was collected for each discipline over a 5-day week.
Researchers agreed on standardised laboratory evaluation protocols and outcome measures of
gait and balance analysis, evaluation of pain, and imagery. Results: In each RC, a baseline on
the type and intensity of interventions has been documented. The gap analysis has identified
areas for improvement with the help of the clinical researchers. More importantly, CRPs are
being implemented as all the RCs are now collecting information on the patients using similar
outcome measures, and patient evaluations in the laboratories have commenced to inform the
clinicians. Conclusions: The CRPs, in addition to informing clinical practice, and creating a data
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bank of standardized outcomes, are now ready to embark in clinical research projects whereby
the clinicians will carry out innovative interventions inspired by interactions among the team
members. The challenge in upcoming years will be to demonstrate the benefits of these CRPs
on rehabilitation outcomes.
P1.090
The Proposed Quebec Rehabilitation Stroke Strategy: a Patient-Centered
Approach From Onset to Community Integration
Richards, CL1 Clément, L2 Expert Committee2; 1. Université Laval and CIRRIS Research Center,
Quebec, QC; 2. Quebec Ministry of Health and Social Services (MSSS), Quebec, QC
Background: As part of the development of the Quebec Stroke Strategy a Committee that
brought together experts in different aspects of the rehabilitation continuum, from acute care to
community integration, was given the mandate by the MSSS to propose optimal rehabilitation
trajectories based on best practices. Methods: Members of the committee met 12 times, mostly
by visio-conference and also worked in sub-committees between February 2012 and January
2013. In addition to reading previous reports and key publications, the committee invited experts
to give presentations on subjects such as: stroke units, prevention, community integration, ge-
riatric trajectories, and telerehabilitation. Perceptions of patients and caregivers as well as clini-
cians of the present rehabilitation continuum were obtained by focus groups and a web-based
questionnaire, respectively. Results: The findings revealed numerous areas for improvement:
communication, trajectories, evaluations, therapeutic approaches, length of stay in acute care
and in-patient rehabilitation and outpatient rehabilitation services. The Committee proposes a
patient-centered model inspired by the Canadian Stroke Strategy adapted to the Quebec system.
Key elements include: well defined outcome measures, uniform best practices and trajecto-
ries, standardisation of the care and services offered, services to support persons post stroke
and their caregivers living in the community. Structural elements are: stroke units, prevention
clinics, a rehabilitation triage system, an early supported discharge system, a patient-support
coordination system, systematic follow-ups and community integration programs with strong
links to primary care services. Guiding principles include: patient empowerment and shared
decision-making, caregiver participation, accessibility of services for all with a rehabilitation
potential, continuity in evaluations, therapy and services, and long-term follow-up of patients to
promote maintenance of gains. Conclusions: The committee report was submitted May 1st to
the MSSS. Implementation of the recommendations will provide Quebec with a patient-oriented
rehabilitation continuum based on best practices that promotes the community reintegration of
persons post stroke.
P1.091
Moderate Aerobic Exercise Acutely Increases Cerebral Blood Flow to the Insula
and Hippocampus in Chronic Stroke
Robertson, AD1 Crane, DE1 Shirzadi, Z1 Rajab, S1 Marzolini, S2 Middleton, LE1 MacIntosh, BJ1; 1.
HSF Centre for Stroke Recovery, Toronto, ON; 2. Toronto Rehabilitation, Toronto, ON
Background: Aerobic exercise, as a tool in stroke rehabilitation, improves peak aerobic fit-
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-
trasted to offer insight into post-stroke exercise prescription. Methods: Six participants (56 ± 15
years of age; 2 women) were recruited at the chronic stage of stroke recovery (14 ± 3 months)
and participated in three exercise sessions. The first session involved a symptom-limited cardio-
pulmonary assessment of peak fitness. Subsequent sessions involved 20-minute exercise bouts
on a semi-recumbent cycle ergometer, randomized between 50 % (light) or 70 % (moderate)
of peak work rate. Magnetic resonance imaging was performed using a pseudo-continuous
arterial spin labeling protocol to quantify cerebral blood flow (CBF) prior to, and at two time
points (~ 30 and 55 min) following, exercise. In this preliminary analysis, 7 brain regions were
examined for changes in CBF over time, after a total grey matter normalization to remove global
CBF effects. Results: In repeated-measures analyses, there was a significant time x intensity
interaction in the hippocampi (P = 0.011, unadjusted), with elevated CBF following moderate-
intensity cycling. In addition, the insula showed a trend towards the main effects of time and
exercise intensity (P = 0.098, P = 0.069, respectively), with higher CBF being observed following
the cycling bout, and in the moderate-intensity trial. No effect was noted in the middle frontal,
precentral, or postcentral gyri; caudate nucleus; or precuneus regions. Conclusions: Prelimi-
nary results suggest that the insular and hippocampal brain regions have relative increases in
CBF following cycling, which appear to last at least one hour post-exercise. Moderate exercise
intensity may be necessary to achieve this increased perfusion. Funding: HSF Centre for Stroke
Recovery Hakim Innovative Stroke Research Award.
P1.092
Challenges in Opening the Black Box of Rehabilitation Services in Quebec
Poissant, L1 Rochette, A1 Ahmed, S2 David, I3 Lebrun, L3 Lindsay, P4 Swaine, B1; 1. Université
de Montréal, Montréal, QC; 2. McGill University, Montreal, QC; 3. Centre de recherche interdis-
ciplinaire en réadaptation, Montreal, QC; 4. Canadian Stroke Network, Toronto, QC
Background: The contribution of rehabilitation to reduce disability, limitations and restrictions
of persons with stroke and facilitate the resumption of meaningful roles is well documented.
While there is agreement that rehabilitation makes a difference, little is known on the type of
services provided by the different rehabilitation providers across the continuum of care. Through
partnership with the Quebec Ministry of Health and Social Services (MSSS), our team proposes
to: i) capture gaps between current rehabilitation practice and the Canadian recommendations,
and, ii) characterize rehabilitation services (who, when, what and how). Methods: An audit
tool and a questionnaire were developed using various sources of information (experts, Stroke
guidelines, INESS reports, etc). The audit tool will be pilot tested in six organizations (two acute
care hospitals, two rehabilitation hospitals and two out-patient rehabilitation centres). The
questionnaire will also be tested and sent to stroke managers of these organisations. Results:
These pilot data will inform on the availability and quality of information required to assess
rehabilitation services across the continuum in the rehabilitation process. It will also inform
on the challenges in documenting potential gaps and variability to known stroke guidelines.
Conclusions: This pilot project is a first step towards a provincial audit of rehabilitation services
to be conducted in the fall to determine the portray of stroke rehabilitation pre-implementation
of the stroke care continuum.
P1.093
The influence of a single bout of aerobic exercise on speed of processing and
muscle activity in stroke
Sage, MD1 Roy, E2 Brooks, D1 Beyer, KB2 McIlroy, W2; 1. University of Toronto, Graduate
Department of Rehabilitation Science, Toronto, ON; 2. University of Waterloo, Kinesiology
Department, Waterloo, ON
Background: Research in healthy individuals suggests that aerobic exercise may prime the
central nervous system (CNS) and if delivered to stroke patients prior to neurorehabilitation
may facilitate neurological recovery by augmenting the state of the CNS at the time of active
rehabilitation. The objective was to provide an understanding of the influence of a single ses-
sion of lower-limb aerobic exercise on upper-limb reaction time (RT) and amplitude of muscle
activity within a stroke population. Methods: Fourteen stroke participants (mean age=54.9,
median 56 days post-stroke) performed 20 minutes of lower-limb aerobic exercise (mean heart
rate=54.4% of age-calculated max). Upper-limb simple and choice RT was evaluated pre-, dur-
ing and immediately post-exercise using both limbs. Participants either extended their wrist
or flexed their biceps (depending on functional ability) in response to a target arrow which
pointed left or right (only one direction for simple RT). RT was measured using electromyog-
raphy (EMG) onset. EMG activity was also used to evaluate amplitude of contraction. Results:
During exercise, the non-statistically significant trend was for slower RT and maintenance of
EMG amplitude. After exercise, mean simple RT was 21 and 15ms faster for the affected and
non-affected arms respectively; however, across the group this was not statistically significant.
Within-subject analysis revealed 3 individuals with significantly faster RT (≥19%) after exercise
and 6 others with moderately faster RT (>3.5%). The threshold of 3.5% was considered sig-
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
appears to be impacting the ability to detect statistically significant group differences despite
seemingly large RT changes. There is a need to reveal the individuals or task-related determi-
nants that may account for the exercise effects after stroke.
P1.094
Predicting Language Recovery after Stroke Using Variability of Performance and
Complexity of Functional Connectivity
Schmah, T1 Duncan, ES2 Yourganov, G3 Zemel, RS4 Small, SL5 Strother, SC3; 1. University
of Toronto, Toronto, ON; 2. Departments of Cognitive Science and Neurology, University of
California, Irvine, CA, USA; 3. Rotman Research Institute, Baycrest, and Institute of Medical
Science, University of Toronto, Toronto, ON; 4. Department of Computer Science, University of
Toronto, Toronto, ON; 5. Departments of Neurology, Neurobiology and Behavior, and Cognitive
Sciences, University of California, Irvine, Irvine, CA, USA
Background: A fifth of people with stroke have persistent aphasia. In a longitudinal study of
aphasia treatment, we hypothesized that language improvement would be predicted by intra-
 Abstracts From the 4th Canadian Stroke Congress, 2013  e27
individual variability (IIV) of performance and complexity of brain functional connectivity. Meth-
ods: 15 individuals with aphasia due to stroke completed 6 weeks of intensive therapy in which
they repeated words and phrases presented audiovisually. Repetition accuracy was tested im-
mediately before and after the treatment. All words were scored on a 5-point scale, with IIV
measured by standard deviation. Immediately before treatment, we acquired whole-brain BOLD
functional MR images, incorporating one “imitation” run, in which subjects viewed and repeated
4 audiovisually-presented syllables, and two “rest” runs. Metrics of complexity of functional
connectivity included two estimates of intrinsic dimension of the voxel covariance matrix imple-
mented in FSL Melodic (Beckmann & Smith): Laplace approximation to Bayesian evidence (LAP)
and Minimum description length (MDL) . Pretreatment performance mean and IIV, pretreatment
fMRI metrics evaluated on task and rest runs separately, and age and time since stroke onset
were evaluated for their power to predict improvement in mean repetition accuracy over the
course of treatment. Results: Ordinary least squares regression, using fMRI metrics evaluated
on imitation runs (only) together with the behavioral variables, explained 44% of the variance in
improvement, in independent prediction of recovery using leave-one-out cross-validation. The
significantly predictive variables were: mean and IIV of performance, and LAP (evaluated on
imitation runs). Lower mean performance,higher IIV and higher LAP predicted greater improve-
ment. None of the metrics of resting state fMRI were predictive of improvement. Conclusions:
Aphasia treatment outcome can be predicted from pretreatment performance mean and IIV and
pretreatment task-based fMRI, with higher IIV and higher complexity of functional connectivity
associated with greater improvement.
Reference:
Beckmann, C.F., Smith, S.M. IEEE Transactions on Medical Imaging, 2004
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
P1.095
Influence of Cognitive Deficits on the Ability to Use Feedback for Arm Motor
Recovery in Chronic Stroke
Subramanian, SK; School of PT and OT, McGill University, Montreal, QC
Background: Feedback provision during training is an essential component of motor learning
that improves upper limb motor recovery in individuals post-stroke. Along with sensorimotor im-
pairments, stroke survivors have cognitive impairments (depression, memory, attention, men-
tal flexibility, problem‐solving, visuoperception) which can influence motor learning. However,
whether cognitive impairments limit the ability to use feedback for motor recovery remains un-
clear. We evaluated whether and to what extent cognitive deficits are associated with the ability
to use feedback for upper limb motor learning and recovery. Methods: Participants (61.2±10yrs)
practiced pointing movements in a random sequence 72times/session to 6 targets (12trials/
target; 3sessions/wk; 4wks) either in a physical (PE;n=12) or virtual environment (VE;n=12).
Terminal auditory feedback was provided about movement speed (knowledge of results) and
trunk displacement (knowledge of performance). Changes in movement kinematics (movement
speed, elbow extension (ElbExt), shoulder horizontal adduction (ShHor), shoulder flexion (ShFl)
and trunk displacement) were assessed before, immediately after (POST) and 3mos (RET) af-
ter task practice. Depression and cognitive functioning were assessed with a comprehensive
neuropsychological examination. Repeated-measures ANOVAs analyzed changes in kinematic
outcomes. Multiple regression analyses estimated the strength of the association between ki-
nematic changes (dependant variables) and cognitive scores (predictors). Results: Participants
training in the VE tended to make faster movements and had greater improvements in kinematic
measures (increased ElbExt, ShHor and ShFl ranges and less trunk displacement) compared
to the PE group. Individuals who had fewer deficits in memory, cognitive flexibility and lower
depression levels made greater improvements in kinematics immediately after training (POST).
Kinematic improvements were retained (RET) better in those who had higher memory scores,
visuoperception ability and lower depression levels. Conclusions: Cognitive ability was associ-
ated with the capacity to use feedback for upper limb motor learning and recovery. Information
about cognitive deficits can help clinicians select the most appropriate interventions to maximize
arm motor recovery post‐stroke.
P1.096
The Sensitivity and Specificity of the MoCA and MMSE as Compared to the Cogni-
stat in a Stroke Rehabilitation Population
Friedman, L2 McClure, A2, 3 Speechley, M4 Teasell, R1; 1. Department of Physical Medicine and
Rehabilitation, Schulich School of Medicine and Dentistry, UWO, London, ON; 2. Lawson Health
Research Institute, ARGC, London, ON; 3. St. Joseph’s Health Care, London, ON; 4. Western
University, Department of Epidemiology and Biostatistics, London, ON
Objective: To identify the better of two commonly used screening tools for detecting probable
cognitive impairment in stroke rehabilitation patients using Cognistat as the “gold standard”.
Methods: Stroke patients admitted to an inpatient rehabilitation unit from August 2011 to March
2012 were screened for inclusion eligibility. At the time of admission, the Mini Mental State Ex-
amination (MMSE) and Montreal Cognitive Assessment (MoCA) were administrated by an occu-
pational therapist, whereas the Cognistat was administered by a student investigator. Published
cutoff scores of 24 for MMSE and 26 for MoCA were used to establish the presence of cognitive
impairment. Results: 76 of 144 consecutive admissions (53%) met inclusion criteria and com-
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).
The mean age of the study sample was 67.6 (SD 15.1) years. Mean MMSE and MoCA scores
were 26.5 (SD 3.4) and 20.9 (SD 5.3), respectively. The mean Cognistat composite score (sum
score of all domains) was 62.9 (SD 10.1) out of a possible 82 points. When cognitive impairment
was diagnosed as impaired in one domain of the Cognistat, MMSE sensitivity and specificity was
35.7% and 100%, respectively, while MoCA sensitivity and specificity was 90% and 33.3%, re-
spectively. When diagnosis of cognitive impairment was defined as impairment in two domains
of the Cognistat, MMSE sensitivity and specificity was 43.6% and 95.2%, respectively, while
MoCA sensitivity and specificity was 90.1% and 19.1%, respectively. Discussion: MMSE had
poor sensitivity and good specificity while MoCA had good sensitivity but poor specificity when
compared to Cognistat as the gold standard. Based on these results, the MoCA appears to be
the superior screening tool based on greater sensitivity.
P1.097
Default-Mode Network’s Implication in Language and Therapy-Induced Recovery
in Chronic Aphasia
Tremblay, FB1 Marcotte, K1 Durand, E1, 2 Ansaldo, A1, 2; 1. Université de Montréal, Montreal, QC;
2. Institut Universitaire Gériatrique de Montréal, Montréal, QC
The alteration of large-scale neural networks not primarily known to be implicated in language
may explain the pervasive disorders occurring after stroke’s localised lesions, namely aphasia.
It is observed that the default-mode network (DMN) is engaged in semantic processing and
that the disruption of its functional connectivity is associated with cognitive and semantic dis-
orders in different neuropathologies. Even though its implication in language production is still
unclear, the DMN exhibits neuroplastic changes in conjunction with language recovery induced
by therapy in chronic aphasia.
Nine subjects (5 men and 4 women) who have chronic aphasia secondary to a left-hemisphere
stroke (between 4 and 25 years post-stroke) are matched with ten control participants (4 men
and 6 women). All participants are right-handed native French-speakers. Subjects of the patient
group engage in an intensive naming therapy targeting noun and verb production, the Semantic
Feature Analysis (SFA). The groups undergo two fMRI sessions, prior- and post-treatment, dur-
ing picture naming. Functional connectivity data is then processed using spatial Independent
Component Analysis (sICA) in Nedica, a program designed to compute integration values in
networks of interest: the DMN and the Language Network (LN). A disruption between the anterior
and posterior subnetworks of the DMN is salient in the patients’ group. They all show significant
improvement in object and action naming after SFA. While no significant concurrent change is
observed in the LN, the DMN’s functional connectivity increases in conjunction with the behav-
ioral improvement, and it is predictive of therapy benefits. Still, the integration values of the
DMN and the LN are highly correlated during picture naming. Moreover, noun and verb naming
exhibit distinctive functional connectivity within the DMN. Functional connectivity measures of
the DMN unveil its contribution to semantic processing and its implication in language recovery
after aphasia therapy.
P1.098
Implementing a Formal Procedure for Team Decision-Making Based on an Algo-
rithm for Screening Driving Ability and the Need for On-Road Assessment
Gauthier, J3, 1 Tremblay, L1 Couve, M1 Hazel, M2 Rioux, M2 Higgins, J3, 4 Beaudoin, N2, 3 Crabb,
S2 Lachance, K2 Leclaire, H2 Gagnon, A2 Guerrera, R2 Patenaude, C4; 1. Institut de réadaptation
Gingras-Lindsay-de-Montréal, Montréal, QC; 2. IRGLM, Montréal, QC; 3. Centre de recherche
interdisciplinaire en réadaptation du Montréal métropolitain site IRGLM, Montréal, QC; 4.
Université de Montréal, Montréal, QC
Background: According to a survey among rehabilitation professionals from the neurology pro-
gramme at Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM), screening for driving
ability and the need for on-road assessment is difficult and informing a client they should not be
driving is a delicate matter and should not be the burden of one person. Since stroke typically
causes an array of deficits that can affect driving ability, all rehabilitation professionals should be
involved in the evaluation, in the decision making as well as in informing the client and their fam-
ily. Methods: A variety of different tests routinely used by the team and validated in the literature
to predict on-road driving performance were identified through a chart review and included
in a decision-making algorithm. Only the most informative items from each of the tests were
included based on Rasch analyses. Elements of this algorithm were integrated into a grid. Re-
sults: An algorithm detailing important aspects to be assessed for driving ability was developed
and integrated into an interdisciplinary grid. A formal procedure comprising the systematic filling
of the grid by all the members of the team was created. The procedure includes the systematic
use of the algorithm for screening driving ability of the client thereby ensuring interdisciplinary
assessments and identification of all possible deficits that could lead to an inability to drive and a
team decision. Conclusion: A procedure for screening driving ability by the systematic use of an
interdisciplinary grid that includes validated test items and based on a decision algorithm is now
implemented. Decision-making is shared equally by all professionals involved in the client’s care
thereby increasing the confidence of professionals in the decision making process and creating
a united front for announcing a decision to a client.
P1.099
Who benefits from intensive aphasia programs: Preliminary Outcomes from the
InteRACT program
Wozniak, LA; Kostopoulos, EJ; Dalhousie University, Halifax, NS
Aphasia is a communication disorder affecting expressive language, auditory comprehension,
reading and/or writing following brain injury. It has been reported that up to 35% of adults have
symptoms of aphasia following stroke.
Intensive therapy for individuals with aphasia has been supported in the literature. However, little
is known about the characteristics of individuals who attend these programs and what factors
 e28  Stroke  December 2013
may predict who makes clinically significant changes when attending such a program. Since
2002, Dalhousie University has run the Intensive Residential Aphasia Communication Therapy
(InteRACT) program. The 4.5 week program offers 100+ hours of speech and language therapy
which facilitates community re-integration and promotes quality of life for individuals with apha-
sia and their communication partners. The program is structured with an interprofessional focus,
providing physiotherapy and recreation therapy in addition to communication treatment. Individu-
als with aphasia must attend with a communication partner from home (family member or friend)
to support carry-over of strategies and techniques when the individual returns home. Pre and
post outcome data was analyzed for 71 patients who attended the program from 2002-2012.
Results showed that individuals who attend the program tend to be middle age and predominantly
male. Three outcome measures which assess the impairment, activity and participation levels of
communication were analyzed; The Western Aphasia Battery (AQ), Communicative Activities of
Daily Living and the Communicative Effectiveness Index, respectively. Clinical outcomes were
analyzed for both statistical significance pre and post treatment as well as clinical significance.
It was found that age, gender and time post onset of aphasia were not significant predictors of
improved outcome on measures of language ability or functional communication. The results
demonstrate that adults with aphasia in either the acute or chronic phase of recovery and of all
ages can continue to show positive improvements in language ability with intensive treatment.
P1.100
Pharmacists as Care Providers for Stroke Patients: a Systematic Review
Basaraba, J; George-Phillips, K; Mysak, T; Alberta Health Services, Edmonton, AB
Background: The role of the pharmacist has expanded to a more clinically oriented practice in
a variety of healthcare settings. Although evidence supporting their role in the care of patients
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
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-
marize the evidence evaluating the impact of pharmacist interventions on stroke patient out-
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/
TIA were identified. A meta-analysis was not performed. Results: Twenty-six abstracts and
full-text studies were included. The included studies provided evidence supporting pharmacist
interventions in multiple settings including: emergency departments, inpatient, outpatient, com-
munity pharmacy, and long-term care settings. In the majority of the studies, pharmacist care
was collaborative with other healthcare professionals. Some of the pharmacist interventions
included participation in a stroke response team, assessment for thrombolytic use, medication
reconciliation, participation in patient rounds, identification and resolution of drug therapy prob-
lems, risk factor reduction, and patient education. Examples of outcomes include a reduction in
time to thrombolytic administration, increased medication adherence, patient satisfaction, and
blood pressure and/or lipid control. Conclusions: The available evidence suggests that a variety
of pharmacist interventions can have a positive impact on stroke patient outcomes. Further
research should be conducted to add to the current body of literature.
P1.101
Delivering Cme Accredited Provincial Stroke Rounds in Ontario: How OREG Has
Made it Work From 2008 - Present
Bursey, SJ1 Beal, J2 Edwards, EK3 Thornton, M4; 1. NEO Stroke Network, Sudbury, ON; 2.
Southwestern Ontario Stroke Network, London, ON; 3. TBRHSC, Thunder Bay, ON; 4. Cham-
plain Regional Stroke Network, Ottawa, ON
Background: In 2008, Ontario Regional Education Group (OREG) launched a stroke education
series called Provincial Stroke Rounds delivered via videoconference. In its infancy, Rounds
focused on acute care with Ontario’s stroke neurologists serving as expert presenters with the
target audience being physicians. The initiative has evolved to attract full representation of an
interprofessional stroke healthcare team. Both presenters and attendees have varied clinical/
academic backgrounds and represent the stroke care continuum. Methods: Provincial Stroke
Rounds occurs 6 times per year, as one hour didactic presentations. 11 Ontario Stroke Re-
gions share hosting duties and collaborate with Ontario Telemedicine Network (OTN) to support
registration; videoconference platforms; archiving; and technical aspects. The Northern Ontario
School of Medicine (NOSM) provides accreditation with 1 Mainpro-M1 credit and 1 hour Ac-
credited Group Learning Activity. Host regions follow a standardized step-by-step guide focused
on consistent organization; promotion and delivery of the program. A promotional poster is cre-
ated and disseminated and participant handouts are provided. Evaluation forms, consisting of
short answer and likert scale questions, are scanned/collated at NOSM for summary report
generation. Provincial education needs assessments have been conducted to determine learn-
ing needs. Results: 36 live Rounds have been offered since 2008, with 40-60 provincial sites
joining each event. In 2012, approximately 1000 participants attended live events with 120 more
accessing archived webcasts at a later date. The topics chosen are timely, relevant, evidence-
informed and span the stroke continuum. Technological difficulties using videoconference are
rare and mitigated quickly. Participants state overall satisfaction with the learning opportunity.
Conclusions: Provincial Stroke Rounds enables a wide reach to both urban and rural communi-
ties in Ontario. By reducing professional isolation, and delivering timely and relevant stroke care
topics, Rounds enjoys a loyal following. Next steps include enhancing the knowledge transla-
tional value of the evaluation questions to include “Intent to Change Practice”.
P1.102
Patient and Family Passport for Stroke: Information about Your Care, Treatment
and Recovery
Cole-Haskayne, AL; Beaver, L; Suddes, M; Darren, K; Foothills Medical Centre, Calgary, AB
Background: Stroke patients were given educational information throughout hospitalization.
Duplicate and inconsistent information was provided. Expectations of information and topics
to be covered were not set. Patient experience data showed opportunities for improving pa-
tient education and support. Stroke survivors felt they were not prepared for discharge and
did not have the right information. Methods: A multidisciplinary improvement team across the
continuum was established and based on feedback from patients the “Patient and Family Pass-
port for Stroke” was created. The goal was to provide consistent information, improve patient
centred care throughout the continuum and patient safety. The Passport follows Canadian Best
Practice Recommendations, and Accreditation Canada standards for excellence in stroke care.
Staff documentation expectations outlined the information to be covered throughout the stay.
Results: 1500 Passports have been issued since May 2012. The Passport saves staff time by
providing a complete package of education materials which can be individualized. It assists pa-
tients with recovery and provides needed resources throughout transitions. Passports have been
well received by patients, and staff. Surveys were conducted to assess patient experience and
satisfaction. A statistically significant increase in positive patient experience and higher rates of
positive experience were shown compared to other Provincial zones. Patient experience ratings
show positive results 71-93%, regarding: understanding the stroke information and resources,
having needs and wishes acknowledged, participation, and being able to deal with life events.
Conclusion: Numerous requests have been received for the passport which is now available
electronically. Readmission rates for stroke related causes remains low and has not changed
significantly in the last two years, but there has been a statistically significant reduction in the
average length of stay on the acute stroke unit. The introduction and use of the Passport may
have contributed to this by improving patient and family education and support.
P1.103
Regional Acute Stroke Care in British Columbia’s Lower Mainland
Curry, M1, 2 Emes, D1 Hastings, R1; 1. Fraser Health Stroke Strategy, Vancouver, BC; 2. Univer-
sity of British Columbia, Vancouver, BC
Background: Fraser Health is British Columbia’s most-populated regional health authority serv-
ing over 1.6 million residents extending from the Vancouver suburb of Delta on the Pacific
coast up the Fraser Valley to rural Boston Bar. Twelve hospitals operate in the region with all
sites receiving cerebrovascular cases and with tertiary neurologic and neurosurgical care being
provided at the Royal Columbian Hospital in New Westminster. Timely assessment and manage-
ment of cerebrovascular disease has been shown to affect outcomes. Methods: All cases identi-
fied as possible acute strokes at the time of Emergency Department triage in Fraser Health were
tracked starting in January 2013. The timing of initial symptom onset, emergency department
arrival, triage assessment, emergency physician assessment, computed tomography and, if ap-
plicable, time of angiography and intravenous thrombolysis administration were tracked across
all sites. Other markers of quality acute stroke care were also tracked including whether pa-
tients’ blood glucose levels were measured and recorded, whether a baseline electrocardiogram
was recorded, whether antiplatelet therapy was initiated and whether a swallowing screen was
performed. Results: To date 177 patients have been tracked. There was substantial variability
in the time of various stages of assessment of acute strokes both amongst patients and across
the various hospitals in Fraser Health. Recorded compliance with markers of quality acute stroke
care was suboptimal. Conclusions: In a large health region substantial variability in the time to
assessment of acute strokes exists. Areas for improvement in clinical care have been identified.
P1.104
Knowing Each Other’s Work Across the Stroke Care System: Development of
Essential Professional Conversations for Seamless Care
Darling, S1 Quant, S2, 5 Avinoam, G1 Fortin, J2 Skrabka, K8 Richardson, D3, 7, 4 Linkewich,
B2, 6 Willems, J8 Sharp, S1, 5; 1. Toronto West Stroke Network, Toronto Western Hospital,
University Health Network, Toronto, ON; 2. North & East GTA Stroke Network, Sunnybrook
Health Sciences Centre, Toronto, ON; 3. Toronto Rehabilitation Institute, UHN, Toronto, ON; 4.
Royal College of Physicians and Surgeons of Canada, Toronto, ON; 5. Department of Physical
Therapy, Faculty of Medicine, University of Toronto, Toronto, ON; 6. Northern Ontario School of
Medicine, Thunder Bay, ON; 7. Division of Physiatry, Faculty of Medicine, University of Toronto,
Toronto, ON; 8. South East Toronto Stroke Network, St. Michael’s Hospital, Toronto, ON
Background: People with stroke (PWS) experience fragmented care since multiple health care
providers (HCPs) are involved. System stakeholders also identified the time of patient transi-
tions as an opportunity to significantly impact their quality of care. Specifically, verbal exchange
between HCPs has been considered important for successful patient transitions by enabling
exchange and clarification of unique patient information; familiarity with other practice environ-
ments; relationship development and collaboration. Hence, to develop a system-wide initiative
to improve patient transitions, the Toronto Stroke Networks further explored HCP perceptions of
the impact of conversations on the care that they provide and transition experiences for PWS.
Methods: Using an Appreciative Inquiry approach, 20 HCPs from across the Toronto stroke
system were interviewed regarding their conversations with other HCPs at the time of patient
transitions. Interviews were analyzed for themes to inform the development of a system-wide
initiative. Results: Themes identified included value in conversations, challenge of engaging
in conversations in a complex stroke care system, and the need to enable and enhance con-
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
were developed to enable and enhance conversations, effect positive change within the system,
and improve transitions for PWS. Conclusions: The need to enable and enhance conversations
amongst HCPs has been identified as a key component for optimizing transition experiences for
PWS. This work has led to the development and implementation of EPC within Toronto. Antici-
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
efficiency/effectiveness of patient care, more individualized care using hopeful language, and
increased comfort at the next stage of the care journey for PWS.
P1.105
Value Creation from Interprofessional Collaboration Among Stroke Healthcare
Providers Using Social Media Technology
Fortin, JE1 Skrabka, K2 Avinoam, G3 Willems, J2 Sharp, S3 Linkewich, E1; 1. North&East GTA
Stroke Network / Sunnybrook Health Sciences Centre, Toronto, ON; 2. South East Toronto
Stroke Network / St. Michael’s Hospital, Toronto, ON; 3. Toronto West Stroke Network / Univer-
sity Health Network -TWH, Toronto, ON
Background: The Toronto Stroke Networks (TSNs) Virtual Community of Practice (VCoP) utilizes a
secure social media technology platform. It was built to support the interprofessional collaboration
(IPC) goals of the TSNs Education and Knowledge Translation (KT) plan. This interactive KT model
requires a dynamic and meaningful evaluation of value creation: “…learning enabled by commu-
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
VCoP. Methods: An evaluation framework was developed to assess the efficacy of the VCoP as
a contributor to meaningful IPC of stroke healthcare providers across the TSNs. This framework
integrates key developmental evaluation and knowledge translation principles. Values were as-
signed to participants’ descriptions of how specific aspects and experiences have influenced
knowledge transfer and changes in practice. The VCoP was launched and advertised locally as
a foundation for implementation of best practices. A screening process is used to ensure new
members fit the target population of healthcare providers. Training sessions and activities were
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
initiated across Toronto to build virtual competence and to prompt interprofessional networking
and collaboration on the VCoP. Results: Preliminary results show increases in membership and
feedback on the VCoP. Emerging themes emerged from initial feedback include: functionality, ac-
cessibility, and resources. Further results (quantitative and qualitative) will be captured to review
6 month outcomes . The cumulative effect of a set of narratives and value stories that inform
further development of the VCoP and /or support effective collaboration on the VCoP will be the
marker of efficacy of this tool. Conclusion: With increasing membership, preliminary results have
concurrently informed the further development of the VCoP. The cumulative data at 6 months
will provide a response to the hypothesis that the VCoP is an efficacious KT tool to support IPC.
P1.106
Influencing System Change within North Simcoe Muskoka LHIN: Collaborating to
Design a Model for Stroke Rehabilitation and Transition
Sooley, D; Tee, A; Central East Stroke Network - Royal Victoria Regional Health Centre, Barrie, ON
Background: Opportunities to advance stroke care were identified in North Simcoe Muskoka
(NSM) Local Health Integration Network (LHIN) through development of a business case (NSM
LHIN Stroke Rehabilitation Case for Change). In particular, the need for interprofessional stroke
units, earlier access to rehabilitation, increased intensity of rehabilitation and increased 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
address the fourth priority of community rehabilitation, Central East Stroke Network (CESN) has
collaboratively developed a NSM LHIN Stroke Rehabilitation and Transition Model. Methods: The
strategic approach focused on designing an integrated system that supports effective transitions
of stroke patients with an emphasis on linking care to appropriately resourced community re-
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
patient stories. The future state map was then refined ensuring strategic alignment, considering
local geography, demographics and resources, and was informed by leading practices from
other jurisdictions. A community engagement strategy validated the draft model. Results: A
NSM LHIN Stroke Rehabilitation and Transition Model was developed with input from healthcare
leaders, front-line providers, persons with lived experience, their caregivers, community orga-
nizations and the general public. This preliminary model will now be used to guide planning of
community rehabilitation services. It positions the LHIN well for future planning with regard to
Health System Funding Reform which is expected to include community rehabilitation in future
phases of Quality Based Procedures. Conclusions: The NSM LHIN Stroke Rehabilitation and
Transition Model provides a framework to achieve best practice community rehabilitation and
reintegration for stroke survivors. The methodology used in its development demonstrates the
value of engagement and collaboration to design health system solutions.
P1.107
The Benefits of Interprofessional Education (IPE) to Enhance Acute Stroke Car
Gill, S; Christie, L; Alves, M; Ellis, M; Kelly, J; Leone, A; Skinner, J; Skrabka, K; Willems, J;
St.Michael’s Hospital, Toronto, ON
Background: A key feature indicated for successful organized stroke care is “specialized in-
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-
sional stroke education day. The education was driven by identified needs of front line stroke
staff to help build on their current knowledge and expertise in stroke care. Methods: The Stroke
Assessment and Treatment Team (SATT) delivered concurrent, rotational, interactive small
group education sessions led by the: Clinical Nurse Specialist, Speech Language Pathologist,
Registered Dietitians, Physiotherapist, and Occupational Therapist. RN’s and CA’s were split
into separate groups to address different learning needs. At the end of the session, participants
completed written evaluations that used a survey format with a five point Likert scale with op-
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%
response rate). Of those evaluations completed, 97.5% rated the sessions and the components
as either excellent or very good. Written feedback was very positive with identified themes
including applicability, new learning and desire for further education. Conclusions: Overall the
Interprofessional Education (IPE) sessions were very well received by all staff. These sessions
have created a positive momentum amongst clinicians caring for stroke patients. Partnering
with front line staff in developing education that fits their needs is imperative to successful
learning. The sessions were relevant, practical and included active participation which, are key
principles in staff engagement and motivational learning.
P1.108
A Tool to Assess Language Barriers to Stroke Services: the Communicative
Access Measures for Stroke
Kagan, A1 Simmons-Mackie, N2 Victor, JC3 Mok, A1 Sharp, S4 Linkewich, B5 Willems, J6
Conklin, J7; 1. Aphasia Institute, Toronto, ON; 2. Southeastern Louisiana University, Hammond,
LA, USA; 3. Institute for Clinical Evaluative Sciences, Toronto, ON; 4. Toronto West Regional
Stroke Network, Toronto, ON; 5. North East GTA Stroke Network, Toronto, ON; 6. South East
Toronto Stroke Network, Toronto, ON; 7. Concordia University, Montreal, QC
Background: Research and outcome evaluation targeting systems level change related to com-
municative access to information and decision making for patients with stroke and aphasia is
limited by lack of an appropriate tool to quantitatively capture change. We developed and evalu-
ated a set of web-based Communicative Access Measures for Stroke (CAMS). CAMS comprises
three quantitative surveys for health care facilities from the perspectives of 1) policy makers, 2)
frontline health care providers, and 3) people with aphasia (using a communicatively accessible
pictographic version). Methods: CAMS development included extensive input from multiple fo-
cus groups with experts from the field of stroke, aphasia, and communicative access. All ques-
tions were trialed at a geriatric and long-term care rehabilitation hospital. The web platform for
CAMS is comprised of forms specifically designed to minimize completion times using skip logic
and range minimums and maximums. Usability of the web-tool was trialed at several health care
facilities. Questions are answered using Likert-type scales and yes/no responses. To assess
reliability, three groups of participants from health care facilities (six administrators/manag-
ers, 33 frontline staff and 25 participants with aphasia) completed the questionnaires on two
occasions. Data were analyzed using kappa statistics and intraclass correlations for each item
score on all questionnaires. Results: Examples of the content for each of the three measures,
and online CAMS access link will be included. Reliability for items on the administrator and staff
surveys was moderate to high (Kappa/ICCs ranging from 0.54 to 1.00). Although reliability was
expectedly lower for the PWA survey, with a couple of items with test-retest ICCs < 0.15, most
items had ICCs between 0.4 and 0.6. Conclusion: Preliminary findings suggest that CAMS has
relevance for health care facilities with an interest in quality care improvements for patients with
stroke and aphasia and others who ‘know more than they can say’.
P1.109
Peer support for stroke survivors: A pilot evaluation
Kessler, D1 Egan, M1, 2 Kubina, L1; 1. Bruyere Research Institute, Ottawa, ON; 2. University of
Ottawa, Ottawa, ON
Introduction: Peer support is a potentially cost effective way to enhance well-being and com-
munity reintegration of both recent stroke survivors and their peer supporters. Objectives: In-
depth examination of a peer support program that provides acute care visits and telephone
follow-up post-discharge. We examined a) type of support provided, b) benefits for the stroke
survivor and their care partners, c) potential harms to the stroke survivors, d) impact of providing
support on the peer supporter, and e) processes and resources required. Methods: Instrumental
case study. Semi-structured interviews were carried out with 16 stroke survivors and 8 care
partners immediately following hospital discharge and at 6-months post stroke to explore the
type of support provided, perceived impact of the program, aspects of the program found to
be particularly helpful, and areas for development. As well, interviews were carried out with
6 peer supporters, 3 program co-ordinators and 4 health professionals to gather feedback on
the perceived impact of the program on the peer supporters, and the strengths and weak-
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
perceived as providing encouragement, motivation, validation and decreased feelings of being
alone. However, the visits were not perceived as beneficial by all store survivors. The impact on
the peer supporters included increased social connections, personal growth, enjoyment and the
feeling that they had been able to make a difference in the lives of others. Involvement of the
health care team and a skilled coordinator were crucial to the success the program. Program
costs will be presented. Conclusion: Peer support is a valued service for some recent stroke
survivors and a meaningful activity to longer term survivors.
P1.110
Organized Stroke Care in Ontario: Impact on Hospitalization and Mortality
Lumsden, JE1 Hall, R2 O’Callaghan, C3 Meyer, M3 Khan, F2; 1. The Ottawa Hospital, Ottawa, ON;
2. Institute for Clinical Evaluative Sciences, Toronto, ON; 3. Ontario Stroke Network,
Toronto, ON
 e30  Stroke  December 2013
Background: In 2000, the Ontario Ministry of Health and Long-Term Care implemented a
system of stroke care consisting of 11 Regional Stroke Networks. The goal was to improve
outcomes by reorganizing care to provide equitable access to evidence-based prevention
and care. Using data from the Ontario Stroke Network’s Stroke Evaluation Program we
sought to quantify the impact of Ontario’s Regional Stroke Networks on acute hospitaliza-
tion and in-hospital mortality. Methods: Age and sex risk-adjusted annual admission and
in-hospital mortality rates reported in the Ontario Stroke Evaluation Report were compared
between 2003/04FY and 2010/11FY to estimate the number of stroke and transient isch-
emic attack (TIA) hospital admissions and in-hospital deaths avoided during the 8-year
period. The BURden of ischemic STroke (BURST) Study data was used to estimate the cost
impact associated with changes in stroke/TIA inpatient admissions. Cost estimates from
hospitalization to 3 months were retrospectively estimated using BURST cost data and
were indexed to the year of the stroke event using the Ontario Consumer Price Index for
health and personal care. Results: Stroke/TIA inpatient admission rates decreased from
1.7 per 1,000 population in 2003/04FY to 1.3 per 1,000 population in 2010/11FY. This
is equivalent to an estimated 3,779 fewer stroke/TIA hospital admissions in 2010/11FY
and 16,061 total since 2003/04FY. Risk-adjusted in-hospital mortality rates declined from
14.3% to 11.4% resulting in an estimated 461 fewer deaths in 2010/11FY and 1,555 total
since 2003/04FY. The societal economic impact of reducing stroke/TIA hospitalizations is
an estimated $144 million in 2010/11FY and $581 million since 2003/04FY. Conclusions:
During this 8-year period there were 16,000 fewer hospitalizations and 1,500 fewer in-
hospital deaths observed than was expected for the Ontario population. Improvements in
patient outcomes and health system sustainability have coincided with the development
of Regional Stroke Networks to implement evidence-based stroke prevention and care
across Ontario.
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P1.111
A Collaborative Regional Approach to Supporting Primary Care Providers in
Improving Vascular Health
Murphy, C1 Steacie, A8 Gordon, J2 Kerr, J3 Langley, H4 Martin, C1 McIntyre, M5 Moore, K6
O’Leary, M7; 1. Stroke Network of Southeastern Ontario, Kingston General Hospital, Kingston,
ON; 2. Ontario Renal Network, Kingston, ON; 3. Belleville Queen’s Family Health Organization/
Family Health Team, Belleville, ON; 4. Southeast Regional Cancer Centre, Kingston General
Hospital, Kingston, ON; 5. South East Local Health Integration Network, Belleville, ON; 6.
Kingston Frontenac Lennox and Addington Public Health, Kingston, ON; 7. Self-Management
Program of Southeastern Ontario, Kingston Community Health Centre, Kingston, ON; 8. Upper
Canada Family Health Team, Brockville, ON
Background: Southeastern Ontario (SEO) has higher than provincial rates for vascular dis-
ease risk factors. Members of a SEO Health Collaborative began innovative work in 2011 to
support quality improvements in vascular health within primary care. The needs of primary
care providers in relation to improving vascular health were assessed and key priorities
for action were identified. Opportunities to connect with new initiatives such as Ontario’s
Health Links were pursued. Method: An environmental scan (ES) and Think Tanks were
conducted across SEO targeting primary health care organizations in rural and urban ar-
eas. The findings were compiled into a report: “Vascular Health in Southeastern Ontario:
A Focus on Primary Care”. The SEO Health Collaborative reviewed the findings and ranked
the vascular health needs using a priority matrix. An action plan was developed to collab-
oratively begin to address key priorities. This plan included connecting with local Ontario
Health Links. Results: The ES and Think Tanks identified local primary care organizations
with well-functioning vascular health programs or services that could be shared. Common
priority needs surfaced that informed the collaborative action plan. These included the need
for an integrated vascular health program within primary care, a common methodology for
continuous quality improvement, a mechanism to share successes across primary care or-
ganizations and navigation tools to assist in linking to healthy living programs. Improved
use of the Electronic Medical Record was a mechanism frequently identified to help address
these needs. Conclusion: The ES and Think Tanks provided direction for the development
of a collaborative regional vascular health action plan with clear priorities. This provides the
SEO Health Collaborative and primary care organizations a framework for leading change
across SEO. Mechanisms and opportunities to further improve vascular health continue to
arise in relation to ongoing collaboration with Health Links and the Ontario Integrated Vas-
cular Health Coalition.
P1.112
From Project to Program: The Central LHIN Stroke Prevention Strategy
Murray, J; Mackenzie Health, Richmond Hill, ON
Background: Mackenzie Health is a District Stroke Centre providing cross-continuum stroke
services to York Region in Ontario A Stroke Prevention Clinic (SPC) was established in 2006,
reducing the Transient Ischemic Attack (TIA) admission rate from 30% to 15%. In 2009,
Mackenzie Health submitted a proposal to the Central Local Health Integration Network for
funding under Aging at Home to support The Stroke Prevention Strategy: An Interdisciplin-
ary and Community Approach to Emergency Diversion Through Stroke Prevention and Health
Promotion. The purpose was to increase access to SPCs in the Central LHIN, reduce TIA
admission rate as well as promote risk reduction and secondary stroke prevention. Method:
Aligned with the Ontario Framework for Chronic Disease Prevention and Management, the
model of care provides rapid triage, assessment and interventions for patients referred to
the SPC based on the immediate period of high risk for progression to stroke and the high
recurrence rate for stroke. Once stabilized, SPC patients are referred to local Cardiovascular
Rehabilitation Programs (CVRP). Research demonstrates commonality in the risk factors for
stroke patients and cardiac patients as well as comparable outcomes . A Community Liaison
facilitates uptake of CVR programming, forming a bridge between clinic and community. Pa-
tients are further referred to community services as needed. Results: The three year project
established:
•• a network of five hospital-based, NP-led SPCs;
•• three new community based CVRPs;
•• increased capacity for clinician and patient education in chronic disease self-management
and
•• community-based blood pressure screening clinics for high risk populations.
A 4% reduction in TIA admission rate was realized. Conclusion: This project received base fund-
ing as of April 2012 becoming the Central LHIN Stroke Prevention Strategy.
P1.113
A Large Community Hospital’s Multi-Disciplinary Approach to “Code Stroke”
Pawlowski, E; Hobbs, D; Halton Healthcare Services, Oakville, ON
Background: In the absence of a dedicated stroke response team, a large community hospital
in Oakville, Ontario identified the need to develop a process to expedite identification and treat-
ment to improve outcomes in admitted patients suspected of experiencing an acute stroke.
Early identification and provision of therapies, where efficacy is clearly time dependent, can
be achieved with a standardized process to elicit a coordinated team response. Methods: The
development of a very specific algorithm that highlights the roles and responsibilities of the
multi-disciplinary team is essential in ensuring efficient and timely diagnosis, and safe delivery
of thrombolytics (tPA) to acute inpatients suffering a stroke.
Results/Discussion: The experiences of the development, implementation and sustainment
of a “code stroke” policy in this large community hospital will be discussed. Specific chal-
lenges and solutions related to nursing recognition of stroke, timely access to diagnostic testing,
physician response time and delivery of tPA will be highlighted. Conclusion: A “Code Stroke”
systemic approach to assessing, diagnosing and initiating care assists in eliminating the logisti-
cal and human barriers that can affect the ability to deliver tPA in the absence of a dedicated
stroke response team.
P1.114
Evidence-Informed Knowledge to Practice: Implementation of Stroke Best
Practices
Richardson, D1 Fortin, J2 Avinoam, G3 Skrabka, K4 Willems, J4 Sharp, S3 Linkewich, B2; 1.
Toronto Stroke Network, University Health Network, Toronto, ON; 2. North and East GTA Stroke
Network, Toronto, ON; 3. Toronto West Stroke Network, Toronto, ON; 4. Southeast Toronto
Stroke Network, Toronto, ON
Background: The three Toronto Stroke Networks (TSNs) are comprised of 17 organizations and
therefore an uncountable number of healthcare professionals across the stroke care continuum.
The ‘Stroke Flow’ initiative provided a re-design of the stroke system, based on best practices.
Collaboration to enable the advancement of stroke care is a priority of the Greater Toronto Stroke
Coordinating Committee (GTSCC), which provides overarching coordination and stewardship for
the combined Toronto networks. Methods: Guided by the Graham’s Knowledge to Action Cycle
(KTA), armed with the results of the Stroke Flow project and a multipronged needs assessment
from practitioners in the networks, an Education and KT Implementation plan was developed to
promote improved quality of care and outcomes for people with stroke. A key strategic action
towards implementation of Stroke Care Best Practice was the creation of an Education & Knowl-
edge Translation (KT) Advisory. This team of invited experts in Education, Evaluation, KT and
Health Quality was tasked with enhancing systems collaboration and ensuring well-matched
approaches in KT and QI. A cross system implementation committee (CSIC), comprised of invited
stroke champions from each organization provided grounding to their local context. Results:
The Education and KT advisory committee approved the Education and KT Implementation plan
with strategic feedback to ensure evidence informed implementation. Key directives included
sectioned roll out, iterative feedback and “member checking”, and engagement of front line
providers. Monitoring of the roll out with flexibility was recommended to ensure realistic 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
checking has provided insight on the initial roll out of the TSNs Education and KT Implementation
plan. A structured evaluation will provide depth and direction on the actual value of the education
and KT implementation.
P1.115
L’aquisition des connaissances après le suivi d’une formation spécialisée en
soins infirmiers aux personnes ayant subi un AVC, en Catalonge
Salvat-Plana, M1 Suñer, R3, 4, 2 Abilleira, S2 Gallofré, M2; 1. Pla Director Malaltia Vascular Cere-
bral. Catalan Stroke Programme, Barcelonne, Spain; 2. Stroke Programme, Health Department
of Catalonia (Plan Directeur des Maladies Cérébrovasculaires. Département de Santé de Cata-
logne), Barcelonne, Spain; 3. Faculté Sciences Infirmières. Université de Girona. Catalogne,
Girona, Spain; 4. Hospital Universitari Dr. Josep Trueta de Girona, Girona, Spain
Contexte : Depuis 2009, le groupe consultatif d’infirmières du Plan Directeur de Maladies céré-
brovasculaires (PDMVC), en Catalogne, développe des stratégies pour améliorer la qualité des
soins et services relatifs à l’accident vasculaire cérébral (AVC), comme la formation continue
aux infirmières. Le but de cette étude est de connaître l’effet d’un programme de formation
 Abstracts From the 4th Canadian Stroke Congress, 2013  e31
portant sur les soins aux personnes ayant subi un AVC sur les connaissances des infirmières.
Méthodologie : Un devis avant-après avec un seul groupe a été utilisé. Les infirmières ont suivi
un cours de 36 heures de formation sur les soins à donner aux personnes ayant subi un AVC.
Les connaissances ont été évaluées avant et après à l’aide d’un questionnaire développé par les
chercheurs (15 items, score 0-15 points). Les scores globaux entre les deux évaluations ont été
comparés à l’aide des T-test et des chi-carré. Résultats : Une augmentation significative des
connaissances des 35 (100%) participantes (p=0,000) a été observée entre l’évaluation initiale
(9,1±1,95) et l’évaluation finale (11,6±1,35). Avant le cours, les infirmières travaillant dans une
unité de l’AVC possédaient des connaissances supérieures (p=0,007) par rapport aux connais-
sances de celles travaillant dans des unités conventionnelles de neurologie et de médecine
interne (moyenne: 10,2±1,2 vs 8,4±2,01). Les connaissances finales étaient similaires (p=0,1)
dans les deux groupes (12,1±1,1 vs 11,3±1,4). Intra groupe, les connaissances des infirmières
qui travaillent dans une unité de l’AVC ont augmenté de 1,8 (IC 95%: 1,2-2,5) points et les
résultats du groupe qui ne travaille pas dans ces unités ont augmenté de 2,9 (1,7-4) points.
Aucune différence n’a été notée en ce qui concerne les années d’expérience. Conclusions : Une
augmentation significative des connaissances a été observée à la suite d’une formation spéci-
fique en soins de l’AVC. L’acquisition des connaissances est plus élevée chez les infirmières
travaillant dans les services moins spécialisés.
P1.116
Engaging Rehab Providers in a discussion about Stroke Best Practices: The
Edmonton Zone Rehab Summit 2012
Taralson, CL; Alberta Health Services Stroke Program Edmonton Zone, Edmonton, AB
Background: The Alberta Provincial Stroke Strategy (APSS) was mandated to advance stroke
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prevention and care in Alberta. In December of 2010, APSS released an interim report, revealing
areas of success and opportunities for improvement. The APSS Provincial Rehabilitation Coordi-
nator proposed a series of rehabilitation summits throughout the province, to encourage rehab
providers to evaluate their practice in light of stroke best practices. Alberta Health Services (AHS)
Edmonton Zone embarked on a day of review of Best Practice Recommendations. Participants
from all stroke rehabilitation service delivery sites/programs across the care continuum were
invited to discuss opportunities for improving practice. Although coming from different practice
experiences and settings, participants identified common challenges. Methods: An invitation to
the Summit was disseminated throughout the zone, with particular focus on programs providing
stroke services. Over 60 participants from a variety of professions and settings participated.
Keypad polling technology was used to allow participants to anonymously respond to how well
their program/facility met each recommendation. Participants then identified and prioritized
projects to improve zone delivery of stroke rehabilitation. A final report summarizing the Summit
findings was generated by the facilitation team. Results: Polling results showed participants
believed 13 of the 20 recommendations were regularly or consistently met in their area of
practice. The remaining 7 were predominantly “don’t meet” or “seldom meet”. Six projects
were developed with the aim of improving care. The connecting theme within these projects was
“improve communication regarding stroke support programs throughout the zone, and provide
referral processes/criteria to access these programs”. Conclusions: Engaging care providers
in a face-to-face discussion increased awareness of available services and varying methods
of service delivery across the zone. Common themes and purposes were revealed, as was a
willingness to collaborate to enhance stroke patient care in the Edmonton Zone. On-going events
of this kind are being considered.
P1.117
Rehabilitation Early Supported Discharge (REDi) - Improving the Rehabilitation
Service Model with Comprehensive and Coordinated Outpatient Services
Parsons, J; Vance, S; Ng, V; Just, E; Doull, K; Dawson, A; Strategy, F; Fraser Health, Surrey, BC
Background: Access to rehabilitation services after stroke is a key component of promoting
functional recovery. Best practice indicates a continuum of care is most appropriate, including
inpatient, early supported discharge and outpatient services designed to meet care needs in
the least restrictive setting and promote optimal functional recovery. Fraser Health staff identi-
fied that stroke survivors utilized inpatient rehabilitation services longer than necessary due to
limited availability, delayed access, and lack of coordinated outpatient services. Methods: The
REDi pilot aimed to shift the rehabilitation care delivery model to support early discharge and
functional recovery across the continuum. Using a logic model to design service delivery, the
REDi pilot was implemented in June 2011 and included:
1. A screening and referral process to promote early identification of inpatients that were
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
a multidisciplinary team of Allied Health staff. Results: Evaluation of the service delivery
revealed that all intended outcomes identified in the logic model were achieved.
Client benefits included:
•• Equal or greater functional improvements
•• More timely access to Rehabilitation Services
•• Improved access to frequent, intensive, interdisciplinary outpatient therapy
•• Reduced length of stay in an inpatient rehabilitation setting
•• Reduction of impairment and prevention of disability, including the need for future care
and system resources.
•• System benefits include:
•• Increasing capacity in the Rehabilitation Program through improving access and flow
•• Reducing the cost of Rehabilitation services Conclusions: Efficient use of inpatient re-
habilitation resources after stroke is supported by the availability of comprehensive and
coordinated outpatient rehabilitation. REDi is an effective model to facilitate early discharge
to the community, increase access to rehabilitation, improve the efficiency of inpatient
rehabilitation, and support functional recoveryof appropriate stroke patients in an ambula-
tory setting.
VP.01
Stroke Units in Ontario: The 2013 Ontario Stroke UNit (OSUN) Survey
Fan, I1 Ieraci, L1 Hall, R2 Kelloway, L3 van der Velde, G1 Rac, V1 Kapral, M4, 2 Bayley, M4 Krahn,
M1; 1. THETACollaboroative, Toronto, ON; 2. ICES, Toronto , ON; 3. Ontario Stroke Network,
Toronto , ON; 4. UHN, Toronto , ON
Patient admission to stroke units (SUs) is associated with lower morbidity and mortality. How-
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-
ment. The Ontario Stroke UNit (OSUN) questionnaire was administered as a telephone inter-
view with SU staff based on FY 2013. The survey determined Ontario SU characteristics, which
will assist future analysis of (cost-) effectiveness and associations with improved patient- and
system-level outcomes. Once completed, the survey will represent a census of all 32 SUs in
Ontario as identified in January 2013. Questionnaire responses were not always consistent with
the definition of SU care. SU managers were able to identify the type of SU, however, examina-
tion of the dedicated beds reported implied a different SU definition; some locations had no
dedicated beds reported. FTE information for stroke team resources was difficult to obtain.
Managers tended to include non-hospital staff (e.g. CCAC, district stroke coordinators, etc.) as
“stroke team” resources creating discrepancies with the stroke team Canadian Stroke Strategy
(CSS) criteria. Diagnostic equipment was often reported as being available irrespective of the
corresponding location (i.e. equipment was on-site, or off-site). Meetings and staff education
were difficult to document as meetings with patients varied case-by-case, or meetings were
held as hallway conversations (i.e. informal meetings). Education included both conferences and
in-house talks, the frequency of which was difficult to determine. Ontario SUs have implemented
standard components of stroke care to varying degrees. Some SUs self-identify as a SU, how-
ever, the characteristics of the stroke team and dedicated resources are different from the CSS’s
criteria for establishing a SU. Greater standardization of necessary SU components is required.
VP.02
The Use of an Audit-Feedback Loop to Address Adherence to Stroke Best Prac-
tice Recommendations for Hypertension Management
Allen, L1 Janzen, SE1 Mehta, S1 Britt, E2 Meyer, M1 Teasell, R2; 1. Lawson Health Research
Institute, Parkwood Hospital, London, ON; 2. St.Josephs Healthcare, Parkwood Hospital,
London, ON
Objective: This study aimed to improve blood pressure (BP) monitoring and the management
of hypertension on a stroke rehabilitation unit in accordance with the Canadian Best Practice
Stroke Recommendations. Methods: Baseline data was collected through a retrospective chart
audit of consecutive admissions from October 2010 to March 2011. An evidence-practice gap
was identified regarding the monitoring and management of hypertension. Guided by published
knowledge translation principles, the research and rehabilitation teams collaborated on the de-
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-
sions from May to November 2012. Abstracted information included: BP readings, leaves of
absence, and anti-hypertensive medications administered. Results: 120 charts were initially
reviewed, and 124 in the evaluation audit. Overall, the mean number of days without BP be-
ing taken/ recorded decreased significantly (p=0.0128) from the initial audit (M=4.9; 1-38,
SD=4.74) to the second audit (M=1.27; 1-2, SD=0.47). The proportion of patients, for the initial
and evaluation audits, experiencing ≥1 hypertensive day was 73.3% and 87.15%, respectively.
Of those who had at least one hypertensive day, 52.3% in the initial audit had ≥1 untreated day,
and 44.4% of patients in the follow-up. However, there was no significant difference (p=0.0708)
in the mean number of untreated days between baseline (M=4.43, SD=3.83) and post-imple-
mentation (M=6.83; SD=8.07). Conclusion: Through the identification of an evidence-practice
gap, and the development and implementation of a hypertension strategy, adherence to best
practice guidelines regarding the monitoring of BP improved. Overall this study has assisted in
establishing the value of, and expectation to, provide evidence-based care on the stroke unit.
P2.001
Dynamic Characterization of CT Angiographic ‘Spot Sign’ in Intracerebral Hemor-
rhage
Chakraborty, S1 Alhazzaa, M1 Wasserman, J1 Stotts, G1 Demchuk, A2 Aviv, RI3 Dowlatshahi,
D1; 1. Universitty of Ottawa, Ottawa, ON; 2. University of Calgary, Calgary, AB; 3. University of
Toronto, Toronto, ON
Background and purpose: Static CT angiography is usually used to identify the intracerebral
hemorrhage (ICH) spot sign. We used dynamic CT-angiography to describe spot sign character-
istics and measurement parameters over 60-seconds of image acquisition. Methods: We pro-
spectively collected consecutive patients with acute ICH presenting within 6 hours of symptom
onset who underwent whole brain dynamic CT-angiography (dCTA). Spot parameters (earliest
appearance, duration, Maximum Hounsfield unit (HU), time to maximum HU, time to spot 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
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the efficacy and outcomes in a subgroup of acute stroke patients treated with stent retrievers for
Carotid-T occlusions. Methods: A retrospective chart review was performed in 60 consecutive
patients who underwent intra-arterial therapy for acute stroke in our center between 2010 and
2012. We dichotomized the patients into two groups based on intervention as: stent-retriever
(group 1) and non-stent-retriever (group 2). Demographic and radiological characteristics and
clinical outcome were presented. A good outcome was defined as a 30-day modified Rankin
score < 2 or 10-point decrease in NIHSS. Symptomatic intracranial hemorrhage (ECASS-III defi-
nition) and 30 days mortality were reported. Result: Twenty-three patients treated with stent-
retrievers were compared to 37 cases received other modalities (Penumbra, MERCI, angioplasty,
or intra-arterial tPA;either alone or in combination). There was a higher baseline median NIHSS
score in the stent-retriever group (18 versus 16, p = 0.034). Overall, there were higher re-
canalization rates in group 1 (87% vs. 51% in group 2, p = 0.005). Use of stent-retriever was
associated with good 30 days mRS (78% vs. 43%, p = 0.008), lower mortality (4% vs. 32%,
p=0.011) and no symptomatic hemorrhages. Among patients with carotid “T” occlusions (52%
in group 1 vs. 30% in group 2), stent retriever demonstrated higher recanalization rates (83%
vs. 38%, p=0.0123), favorable clinical outcomes (67% vs. 22%, p=0.036) and shorter time to
recanalization (69 vs. 191 minutes, p=0.0023). Conclusion: In this small cohort, using stent-
retriever offered better recanalization rate and clinical outcome with remarkable safety profile in
acute carotid “T” occlusions when compared to previous multimodal therapy.
Background: Stentrievers can establish immediate by-pass effect by delivering blood to the isch-
emic tissue once the stent is deployed. A potential factor that may introduce delays in achieving a
short imaging to first stentriever deployment time is the timing of the intervention. Method: This
is a longitudinal cohort of acute ischemic stroke patients treated with endovascular therapy in our
center between Jan 2011 to Dec 212. The imaging to first stentriever deployment time was defined
as the time from the completion of CT angiogram to the first angiographic run that shows that
the stentriever has been deployed in the target occluded artery. This time interval was compared
between patients treated during the daytime hours (0700-1800 hours) vs. outside these hours.
Results: 99 patients were analysed. The median imaging to first stentriever deployment time was
86 minutes (80.5 minutes during the daytime vs. 97 minutes outside these hours; U-test p value
0.038). The proportion of patients treated during daytime hours with imaging to first stentriever
deployment time < 120 minutes was 86% compared to 65.8% outside these hours (Chi-square p
0.02). The proportion of patients with successful reperfusion (TICI 2b or 3) treated during the daytime
was 76.7% compared to 76.9% outside daytime hours. The proportion with a favourable discharge
modified Rankin Scale (mRS <3) in those with an imaging to first stentriever deployment time < 120
minutes was 68% vs. 44% in those who did not meet that time (Chi-square p 0.018). Conclusions:
An imaging to first endovascular stentriever deployment time < 120 minutes is feasible and was
achieved more consistently during daytime hours. It was associated with better functional outcome.

P2.003
Not All Successful Reperfusion PatiNot All Successful Reperfusion Patients Are
Equal: The Need for a TICI2c Scoreents Are Equal: The Need for a TICI2c Score
Almekhlafi, MA1, 2 Mishra, S1 Desai, J1 Nambiar, V1 Eesa, M1 Volny, O1 Menon, BK1 Demchuk,
AM1 Goyal, M1; 1. University of Calgary, Calgary, AB; 2. King Abdulaziz University, Jeddah,
Saudi Arabia
Objective: Many recent endovascular studies have used the TICI grading system for evaluating
angiographic outcomes and have used TICI 2B and 3 for successful recanalization as long as
the final perfusion defect was < 50% of the MCA territory. We propose a new scoring system
that separates successful but incomplete reperfusion into 2 categories taking into account
the size of the reperfusion defect. Methods: This is a longitudinal cohort including of anterior
circulation stroke patients treated using intra-arterial stentrievers in our center between Jan
2011 to Dec 2012. Failed reperfusion was defined as per the standard TICI score (TICI 0-2a).
Successful reperfusion was defined as 2b: substantial perfusion with distal branch filling of ≥
50% of territory visualized, 2c: near complete perfusion except for slow flow in a few distal
cortical vessels, or presence of small distal cortical emboli, 3: complete perfusion with nor-
mal filling of all distal branches. Angiograms were scored by a single reviewer blinded of the
patients’ outcomes. Results: In a cohort of 101 patients, 78 achieved successful reperfusion
(77.2%). The results of patients with successful reperfusion is presented according to the
reperfusion score (Table). The proportion of patients who had significant improvement of their
clinical deficits in 24 hours (24-hour NIHSS score drop by 75%) was significantly higher with
TICI2c reperfusion than those with TICI2b (50% vs. 24%, Fisher’s exact p 0.04). Conclusions:
Categorizing successful but incomplete reperfusion into 2 different classes according to the
area of perfusion defect has merits. In this cohort, there was evidence toward different short-
term clinical and imaging outcomes in patients with TICI2b vs. TICI2c scores. These findings
need to be validated in larger cohorts.
P2.005
A ‘Reduce-To-Quit’ Pilot Program for Smokers with Cerebrovascular Disease:
Transitioning Smokers to Set a Quit Date
Armstrong, A1 Reid, R1 Sharma, M2 Stotts, G2 Aitken, D1 Mullen, K1 Papadakis, S1 Gocan, S2
Bourgoin, A2 Laplante, M2 Houbraken, D2 Pipe, AL1; 1. University of Ottawa Heart Institute,
Ottawa, ON; 2. The Ottawa Hospital, Ottawa, ON
Background: Smoking cessation is a life-saving intervention for patients with cerebrovascular
disease, however, only 35% of smokers with TIA or stroke are ready to make a quit attempt after
their event. The aim of this review was to assess whether reducing daily cigarette consumption
leads to a quit attempt in those smokers who are not ready to quit. Methods: The Stroke Preven-
tion Clinic (SPC) ‘reduce-to-quit’ (RTQ) pilot program offers smokers who have experienced a
stroke or TIA, and who are not ready to quit, a 4-week supply of nicotine replacement therapy
(NRT) patch. Since December 2009, 181 smokers with stroke or TIA attending the SPC were
not willing to set a quit date; 49 (27%) were willing to participate in the RTQ program. Results:
Forty-nine individuals participating in the RTQ program were included in the current review (48%
male, mean age = 59.5 +/- 10.6). The average number of cigarettes smoked per day was 23.5
+/-11.9. Eight-two percent of smokers in the program reduced the number of cigarettes they
were smoking per day, the average smoker in the program reduced daily consumption by 13.2
cigarettes (SD +/- 9.7). Overall, 15 smokers (30%) in the RTQ program set a quit date at one
month follow up, with those who had reduced cigarette consumption becoming “ready-to-quit”
at a higher rate (33%) then those smokers who did not reduce their cigarette consumption
(22%). Of those RTQ patients who set a quit date, the abstinence rates (bio-chemically con-
firmed) for those reached at follow-up were 25% and 38% at 6 and 12 months respectively.
Conclusions: The results from the RTQ pilot program suggest that offering treatment to smok-
ers who are not ready to quit can lead to an increase in quit attempts as well as 6 and 12 month
cessation success in this population.

P2.004
Imaging-to- Stent deployment Time Interval Is Shorter during Daytime Hours’ Vs.
Evening Times in Endovascular Therapy for Acute Ischemic Stroke
Almekhlafi, MA; Desai, J; Nambiar, V; Mishra, S; Volny, O; Eesa, M; Demchuk, AM; Menon, BK;
Goyal, M; University of Calgary, Calgary, AB
P2.006
Protocole d’interventions visant le dépistage et la prise en charge de
l’incontinence urinaire auprès de la clientèle ayant subi un AVC
Balg, C1 Mathieu, S1 Rousseau, G1 Dallaire, M1 Dallaire, C2; 1. CHU de Québec - Hôpital Enfant-
Jésus, Québec, QC; 2. Faculté des sciences infirmières - Université Laval, Québec, QC
 Abstracts From the 4th Canadian Stroke Congress, 2013  e33
Problématique : Une proportion importante des patients ayant subi un AVC présente de
l’incontinence urinaire (40-60%) et près de 25% d’entre eux le seront encore lors du congé
de l’hôpital (Barrett, 2001, Cochrane, 2009). Le temps d’attente afin de recevoir l’aide requise
et la crainte de ne pas pouvoir se retenir motivent certains patients à demander d’avoir une
culotte d’incontinence alors que ce n’est pas requis (Pilcher & McArthur, 2012). Les recom-
mandations pour les pratiques optimales des soins de l’AVC (2010) préconisent par ailleurs le
dépistage et la prise en charge de l’incontinence (incluant la rétention urinaire) afin de prévenir
les complications et diminuer la morbidité chez cette clientèle. Méthode : La démarche vise à
documenter les pratiques actuelles à l’aide d’un questionnaire, d’une rencontre des équipes (in-
firmières, infirmières-auxiliaires, préposés aux bénéficiaires), d’une entrevue de patients ayant
subi un AVC et vécu une expérience d’incontinence urinaire. Également, une revue succincte
de la littérature sera effectuée. Un devis de recherche d’interventions sera utilisé (Sidani et al.,
2012). Résultats : L’expérience tacite du personnel, les besoins de la clientèle et la revue de
littérature ont permis d’établir un protocole d’interventions applicable au contexte de pratique.
Les résultats seront présentés de façon préliminaire. Conclusion : Cette démarche a un effet
mobilisateur auprès du personnel soignant, et améliore la qualité des soins.
P2.007
Secular Trends in Ischemic Stroke Subtypes
Bogiatzi, C1 Hackam, DG1 McLeod, I2 Spence, JD1; 1. Robarts Research Institute, Stroke
Prevention and Atherosclerosis Research Center (SPARC), London, ON; 2. Western University,
Department of Statistical and Actuarial Sciences, London, ON
Background: With the aging of the population, and with increasing prevalence of therapy for
hypertension and hyperlipidemia, it might be expected that stroke subtypes would be changing
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.
Methods: Patients referred to Urgent TIA Clinic, in London, Ontario from 2002 to 2012 were
included. Secular trends were analyzed using Poisson regression analysis. Ischemic stroke
subtype classification was validated. Results: 3445 consecutive patients with mean age+SD
of 64.76+14.9 were included; 51% were women, 81% had hypertension; 18% had diabetes;
9% had atrial fibrillation; 14% had open patent foramen ovale; 20% were current smokers.
Cardioembolic strokes increased significantly from 21% in 2002 to 56% in 2012, whereas all
other ischemic stroke subtypes decreased (p<0.01). Additional analyses showed a decrease in
blood pressure, LDL and pack years of smoking, and an increase in medications used to treat
hyperlipidemia (p<0.05). Conclusions: The decrease in atherosclerotic risk factors resulted in
fewer strokes caused by large artery atherosclerosis and small vessel disease. Cardioembolic
strokes have increased significantly as a proportion of first-ever ischemic strokes. This has
important implications for more intensive investigation and treatment to reduce the risk of recur-
rent embolic stroke.
P2.009
[18F]-fluorodeoxyglucose, but not C-reactive Protein, is Related to Intraplaque
Inflammatory Burden in Human Carotid Plaque: A Sub-study of the Canadian
Atherosclerosis Imaging Network (CAIN)
Cocker, MS1 Mc Ardle, B1 Hammond, R2 deKemp, R1 Lum, C3 Youssef, G1 Yerofeyeva, Y4
Karavardanyan, T4 Adeeko, A4 Hill, A3 Stotts, G3 Nagpal, S3 Renaud, J1 Kelly, C1 Brennan, J1
Garrard, L1 Alturkustani, M2 Hammond, L2 DaSilva, J3 Tardif, J5 Beanlands, R1 Spence, J6;
1. University of Ottawa Heart Institute, Ottawa, ON; 2. Western University, London, ON;
3. The Ottawa Hospital, Ottawa, ON; 4. Sunnybrook Research Institute , Toronto, ON;
5. Montreal Heart Institute, Montreal, QC; 6. Robarts Research Institute, London, ON
Background: Inflammation underlies the development and progression of atherosclerotic
plaque. An actively inflamed plaque is considered to be a ‘vulnerable’ high-risk, rupture-prone
lesion. It is imperative to develop surrogate biomarkers that enable for the early detection of dis-
ease. C-reactive protein (CRP) is a marker of systemic inflammation and a risk factor associated
with cardiovascular events. Alternatively, radiolabelled glucose or -fluorodeoxyglucose (18FDG)
imaged with hybrid positron emission tomography (PET) and computed tomography (CT) may
serve as an imaging-derived biomarker of inflammatory burden within plaque. In this investi-
gation, we directly compared systemic CRP and 18FDG carotid uptake to intraplaque inflam-
matory burden using CD68 immunohistology. Methods: Thirty-four patients (67±10 years, 27
male) scheduled for carotid endarterectomy were prospectively recruited. Patients underwent
FDG-PET and CT angiography of carotids. Prior to imaging, blood was collected for the assess-
ment of CRP. Maximum 18FDG uptake at the left and right internal carotids was quantified
and normalized to blood, resulting in a tissue to blood ratio (TBR). Following endarterectomy,
excised plaque was fixed, sectioned and immunostained for CD68. CD68 expression was quan-
tified semi-automatically. Results: Carotid endarterectomy was performed in 34 patients; one
patient received a 2nd carotid endarterectomy due to bilateral disease. Immunohistology was
performed in 23 excised plaques. The extent of inflammation, as quantified with CD68 immu-
nohistology, was related to maximum 18FDG uptake (r=0.636, p=0.001). However, there was
no association between CD68 expression and CRP (r=0.190, p=0.42). Furthermore, CRP was
not associated with maximum 18FDG uptake of the endarterectomy lesions (r=0.179, p=0.34).
Conclusion: As opposed to systemic CRP, 18FDG uptake is strongly related to the extent of in-
flammatory burden within high-risk carotid plaque. However, CRP may not be useful for detect-
ing vulnerable carotid plaque (based on histopathology and 18FDG uptake). Large prospective
outcomes-based studies are required. 18FDG may serve as a robust and direct biomarker of
carotid plaque vulnerability.
P2.010
The Predictive Ability of the CTA Spot for Hematoma Enlargement is Dependent
on Time Since ICH Onset: a Systematic Review and Patient-Level Meta-Analysis
Dowlatshahi, D1 Brouwers, B2 Demchuk, A3 Hill, M3 Aviv, R4 Ufholz, L1 Wintermark, M5 Hemphil
III, J6 Murai, Y7 Wang, Y8 Zhao, X8 Wang, Y8 Li, N8 Greenberg, S2 Romero, J2 Rosand, J2
Goldstein, J2 Sharma, M9; 1. University of Ottawa & Ottawa Hospital Research Institute, Ottawa,
ON; 2. Massachusetts General Hospital, Boston, MA, USA; 3. University of Calgary, Calgary,
AB; 4. University of Toronto, Toronto, ON; 5. University of Virginia, Virgina, USA; 6. UCSF, San
Francisco, CA, USA; 7. Nippon Medical School, Tokyo, Japan; 8. Capital Medical University,
Beijing, China; 9. Population Health Research Institute, Hamilton, ON
Background: Hematoma expansion (HE) occurs in up to 40% of patients with intracerebral
hemorrhage (ICH), and predicts poor outcome. Contrast extravasation following CT-angiography
(CTA), termed “spot-sign”, identifies patients at risk of HE. However, the prevalence and predic-
tive values of the spot sign varies across studies, possibly due to differences in onset-to-CTA
time. We performed a patient-level meta-analysis to define the relationship between onset-to-
CTA time and the predictive performance of spot-sign. Methods: We searched the Cochrane
Central Register, the Cochrane Library Database, MEDLINE and EMBASE for studies of spot sign.
We pooled data on the prevalence and predictive values for significant HE (6mL or 33% growth)
for patients with ICH stratified by onset-to-CTA time: <3hours, 3-6 hours, >6hours. We used
chi-square analysis and two-way ANOVA to compare within and across time strata. Results: Of
1240 studies reviewed, 9 met criteria for analysis: we have received patient-level ICH spot-sign
data from 8 countries and 16 centers (n=705). Prevalence of spot-sign decreased with increas-
ing onset-to-CTA time (p<0.001). The subset with follow-up scans used for HE analysis (n=582)
revealed spot-sign performance was best in early time strata, whereas specificity and NPV were
highest in late time strata. Spot-positive patients had greatest absolute HE in the earlier CTA
time strata (p<0.001). Conclusion: Prevalence, predictive values and magnitude of effect of the
spot-sign are dependent on onset-to-CTA timing.
ICH
onset Mean
to CTA Spot HE (mL)
time N prevalence N Sensitivity Specificity PPV NPV spot +
<3 268 41.8% 236 60% 73% 61% 72% 23.5
hours
3-6 219 19.6% 172 43% 90% 52% 86% 16.6
hours
>6 218 13.8% 174 44% 93% 52% 91% 9.5
hours
P2.011
Hypertensive Disorders in Pregnancy and Future Risk of Stroke: A Systematic
Review
Ganesh, A; Sarna, N; Mehta, R; Smith, E; University of Calgary, Calgary, AB
Background: Many risk factors are currently targeted in the primary prevention of stroke; how-
ever, the role hypertensive disorders in pregnancy in predicting future stroke risk has yet to be
elucidated. Currently women are monitored throughout pregnancy for changes in blood pres-
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-
sess whether women with a history of hypertension in pregnancy are more likely to experience
stroke in later life compared to women with normotensive pregnancies. Methods: The electronic
databases Medline and Pubmed were searched combining the MeSH terms “hypertension,
pregnancy-induced”, “pre-eclampsia”,”eclampsia”, “HELLP syndrome”, or “toxemia” with the
terms “Stroke” or “stroke, lacunar” using the AND modifier, with all terms auto-exploded, while
clinical trials registries and conference proceedings were similarly searched for unpublished
studies. This generated a total of 90 results in Medline and 172 results in Pubmed, of which 9
studies (2 prospective cohort, 4 retrospective cohort, 3 case-control) met inclusion criteria of
involving women with hypertensive disorders in pregnancy; involving a prospective follow-up,
retrospective review of records, or a case-control design; and reporting stroke as a clinical
outcome. Results: There is consistent case-control and retrospective cohort evidence, both
international and multi-racial, of an increased risk of stroke and of mortality from stroke in
women with hypertensive disorders of pregnancy, in particular for those with pre-eclampsia/
eclampsia, as demonstrated by both prospective cohort studies. There is weaker evidence of
an increased incidence of stroke in later life with gestational hypertension alone. Conclusions:
Hypertension in pregnancy likely carries an increased risk for stroke in later life, but the risk is
much more significant for gestational hypertension associated with pre-eclampsia/eclampsia.
There may be benefit in targeting these women for close risk-factor monitoring and control
beyond the post-partum period.
P2.012
Effect of Chronic Resveratrol Pretreatment on Astroglial GFAP/GLT-1 Expression
Following Global Cerebral Ischemia
Girbovan, C; Pitre d’Iorio, M; Plamondon, H; University of Ottawa, Ottawa, ON
Background: Perisynaptic astrocytes express important glutamate transporters, especially
GLT-1 to regulate extracellular glutamate levels and modulate synaptic activation. Evidence is
now accumulating that astrocytes play an active role in the pathophysiology of cerebral ischemia
 e34  Stroke  December 2013
and that down-regulation of astroglial GLT-1 expression in the CA1 subfield of the hippocampus
may contribute to neurotoxic levels of glutamate post ischemia. Resveratrol (RSV), a naturally
occurring polyphenol phytoalexin mainly found in grapes, has been shown to protect the brain
against ischemic injury. While a number of mechanisms of action of RSV in preventing neuronal
damage have been proposed, it remains to be determined if the polyphenol affects astroglial
GLT-1 expression following an ischemic insult. The present study examined the effects of 21-
day RSV pre-treatment (1 or 10mg/kg dose; i.p.) on GFAP and GLT-1 expression in the DG, CA1
and CA3 layers of the hippocampus 7 days following 10 min global ischemia. Methods: Male
Wistar rats were divided into five groups; sham/saline, ischemia/saline, ischemia /1 mg/kg RSV,
ischemia/10 mg/kg RSV and sham/10 mg/kg RSV. 7 days post surgery, brains were perfused
and GFAP and GLT-1 immunohistochemical assessment performed. Results: Our findings indi-
cated significant increase in GFAP expression in ischemic compared to sham-operated animals
and a reduction in GFAP activation by RSV-treated rats in the CA1. Accordingly, ischemic rats
showed a downregulation of GLT-1 expression compared to sham-operated rats in the CA1,
while RSV significantly increased GLT-1 expression in ischemic animals compared to saline-
treated ischemic rats. Conclusion: The higher expression of GLT-1 in the CA1 of RSV-treated
ischemic rats may contribute to this group’s inherent resistance to neuronal cell loss following
cerebral ischemia.
P2.013
Underuse of Cardiac Rhythm Monitoring After Ischemic Stroke and TIA: Missed
Opportunities for Detection and Treatment of Atrial Fibrillation
Gladstone, DJ1 Fang, J2 Dorian, P3 Hachinski, V4 Mamdani, MM3 Laupacis, A3 Lindsay, M5
E­ dwards, JD1 Spring, M6 Saposnik, G1 Silver, FL1 Kapral, M7 On behalf of the Investigators of
the Registry of the Canadian Stroke Network; 1. University of Toronto, Toronto, ON;
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;
4. University of Western Ontario, London, ON; 5. Heart and Stroke Foundation, Ottawa, ON;
6. Institutional Affiliation: Trillium Health Centre, Mississauga, ON; 7. University Health Network
and Institute for Clinical Evaluative Sciences, Toronto, ON
Background: Detection and treatment of atrial fibrillation (AF) is a major goal in secondary
stroke prevention, but it is unclear how intensively ischemic stroke/TIA patients are screened for
paroxysmal AF in practice. Guidelines recommend cardiac monitoring post-stroke, and current
evidence indicates that monitoring for substantially longer than 24h is often necessary to detect
paroxysmal AF. This provincial audit evaluated the type and duration of monitoring provided
post-stroke/TIA as a quality indicator for secondary stroke prevention. Methods: We analyzed
data from Ontario stroke centres in the Registry of the Canadian Stroke Network (07/2003-
03/2009). We included consecutive patients presenting to hospital with a first acute arterial
ischemic stroke or TIA in sinus rhythm who were candidates for AF screening: no history of AF,
no AF documented in hospital, no pacemaker, survival to discharge home or inpatient rehabilita-
tion (discharges to nursing homes/palliative care excluded). Cardiac monitoring was captured
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
hospital; median LOS 3d ), 3213/11,153 (29%) received Holter monitoring within 90 days post-
stroke/TIA: 2403/11,153 (22%) had 24h monitoring only, 611/11,153 (5%) had 48h monitoring,
and 199/11,153 (2%) had >60h monitoring (includes multiple monitors). An event loop recorder
was prescribed in 64/11,153 (0.6%). Subgroup results for TIA patients and elderly (aged >75
years) were consistent with overall findings. Conclusions: A large proportion of patients do not
receive any Holter monitoring within 90 days following ischemic stroke/TIA. Most monitoring
performed was limited to 24h, with very few patients undergoing prolonged monitoring. These
results may contribute to an overdiagnosis of stroke events as ‘cryptogenic’, an underdiagnosis
of AF, and missed anticoagulant treatment opportunities for secondary stroke prevention.
P2.014
The Brain in Motion Study: Progress Report
Tyndall, AV1, 2 Davenport, MH1 Wilson, BJ1 Burek, GM1, 2 Haley, E1, 2 Eskes, GA4 Friedenreich,
CM5, 6, 7 Hill, MD2, 2 Hogan, DB9, 8, 2 Longman, R10, 2 Anderson, TJ11 Leigh, R1, 3, 12 Smith, EE8, 13, 2
Poulin, MJ1, 7, 2; 1. Department of Physiology & Pharmacology, Faculty of Medicine, University of
Calgary, Calgary, AB; 2. Hotchkiss Brain Institute, University of Calgary, Calgary, AB; 3. Depart-
ment of Medicine, University of Calgary, Calgary, AB; 4. Departments of Psychiatry, Medicine
(Neurology), and Psychology, Dalhousie University, Halifax, NS; 5. Department of Popula-
tion Health Research, Alberta Health Services-Cancer Care, Calgary, AB; 6. Departments of
Oncology and Community Health Services, Faculty of Medicine, University of Calgary, Calgary,
AB; 7. Faculty of Kinesiology, Calgary, AB; 8. Department of Clinical Neurosciences, Faculty
of Medicine, University of Calgary, Calgary, AB; 9. Professor and Brenda Stafford Founda-
tion Chair in Geriatric Medicine, Faculty of medicine, University of Calgary, Calgary, AB; 10.
Psychology, Alberta Health Services, Foothills Hospital, Calgary, AB; 11. Libin Cardiovascular
Institute of Alberta, Department of Cardiac Sciences, Calgary, AB; 12. Airway Inflammation
Research Group, Snyder Institute for Chronic Diseases, Faculty of Medicine, University of Cal-
gary, Calgary, AB; 13. Departments of Radiology and Community Health Sciences, University of
Calgary, Calgary, AB
Background: It is estimated that 60% of older adults lead sedentary lifestyles and consequently
do not to achieve the favorable health benefits from regular aerobic fitness. Physical inactivity is
a well-accepted modifiable risk factor for cerebrovascular disease and the decline in cognitive
functions seen in older adults. Preliminary data from our laboratory suggest that the association
between physical fitness and cognitive function may be mediated in part, by improvements in
cerebrovascular function. Methods: 250 men and women aged 55 years and older are being
recruited through poster, newspaper and media advertisements. The 18 month study consists
of three 6-month phases: 1) baseline control; 2) aerobic exercise intervention; and 3) post-
intervention follow-up. Testing measures include: 1) anthropometric characteristics; 2) cardiore-
spiratory fitness test (VO2max); 3) fasting blood sample; 4) neuropsychological test battery; and
5) assessment of cerebrovascular reserve using transcranial Doppler ultrasound. All tests are
conducted upon entry of the study (Phase 1A), 6-months following the first measurements for
second baseline measurements (Phase 1B), at the midpoint (3 months) and end of the aerobic
exercise intervention, and finally 6-months following the completion of the aerobic exercise
intervention for the follow-up assessment. Results: Currently 162 participants are actively en-
rolled in the study. Of these participants, 52 are in the baseline control phase, 55 are in the
aerobic exercise intervention, and 55 are in the follow-up phase or have completed the study.
Conclusion: To our knowledge, this is the first study to investigate the effects of a six-month
aerobic exercise intervention on cerebrovascular and cognitive function in a healthy older popu-
lation. The results of this study will provide physiologic mechanisms whereby exercise promotes
benefits to cognitive function. In addition, the study may also promote the development of ad-
junct therapies to reduce the cognitive decline accompanied by normal brain aging.
P2.015
Rapid Referral Program of the Niagara Health System - District Stroke Centre
McCallum, C; Hammond, L; Rusnak, M; Chew, DL; Niagara Health System, Niagara Falls, ON
Early therapeutic intervention post TIA (pharmacological, diagnostic, surgical) has been proven
to decrease risk for future strokes/TIAs . Niagara’s District Stroke Team has developed a Rapid
Referral strategy to ensure timely access to stroke expertise providing thorough assessment and
intervention by a stroke team member within 24 hours post TIA symptoms. This new program
will result in improved patient outcomes and decreased readmission to hospital. The new clinic
protocol, devised in April 2010 resulted from a review of the Canadian Best Practice Recom-
mendations for Stroke Prevention by the Stroke Team (District Stroke Coordinator, Neurologist,
Acute Care Stroke NP and Stroke Prevention NP). The Stroke Team reviewed “Time from Referral
to Initial Consult” and wait times averaged 14 days. With Canadian Best Practice Recommenda-
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
referred to the Rapid Referral Program. Three key criteria must be met to be considered for
Rapid Referral: speech disturbance, unilateral weakness and symptoms occurring in the last 24
hours. Since the implementation of the Rapid Referral, 76.6% of urgent and emergent patients
are seen within the recommended guidelines of 24 hrs and 72 hours respectively (1). Practice
change based on Canadian Best Practice Recommendations for Stroke Prevention has allowed
the Niagara Health System to become a leader in preventative stroke care. As evidenced by
the Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention and Care
released in June 2013, Niagara Health System’s District Stroke Prevention Clinic is the high
performer for proportion of emergent and urgent SPC visits where the patient was seen within
recommended guidelines. The concept of the Rapid Referral is a proven strategy to reduce wait
times thereby improving quality of care.
P2.017
Accuracy of ICD-10-CA Codes to Identify Paediatric Stroke
Maclagan, L1 Khan, F1 Pontigon, A1 Kapral, M2 Hall, R2 deVeber, G1; 1. Hospital for Sick
­Children, Toronto, ON; 2. Institute for Clinical Evaluative Sciences, Toronto, ON
Background: The 2012 Ontario Stroke Evaluation Report estimates a paediatric stroke inci-
dence of 5.9 per 100,000 population under the age of 18 in Ontario. Using the results of the
2010/11 OSA as the gold standard we determined the accuracy and yield of ICD-10-CA codes
for paediatric stroke to characterize the process for identifying paediatric strokes using 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
Update and additional codes identified by a paediatric stroke neurologist. Cases were identified
if any of the ICD-10-CA codes were found in any of the diagnostic code fields in FY2010/11
CIHI-DAD and National Ambulatory Care Reporting System (NACRS) databases. Trained abstrac-
tors reviewed the medical charts of the cases and determined if it was a true stroke/TIA based
on information in the medical chart. The overall and individual ICD-10-CA codes accuracy was
defined as the proportion of cases that were a true stroke upon chart review among all cases
selected for inclusion into the OSA. We calculated a yield for each ICD-10-CA code and yield
was defined as the percentage of total true strokes captured by a specific code. Results: In
FY2010/11, 479 potential paediatric stroke/TIA cases were identified in CIHI-DAD or NACRS and
136 (28%) were considered to be true strokes/TIAs. Accuracy rates of stroke-specific codes
ranged from 6.7 - 76.6% and yield ranged from 1.8% - 29.5%; highest accuracy and yield was
achieved using I63. Non-specific codes ranged widely from 0-66.7% accuracy and 0-10.2%
yield. Conclusion: The accuracy and yield of ICD-10-CA codes in paediatric stroke is low and
underlines the need for prospective data collection. Further work will explore other ICD-10-CA
codes or processes that may improve the identification of paediatric stroke using administrative
databases.
P2.018
Stroke in Saskatchewan: A Regional Sample
Kwiatkowski, BM1 Bharadwaj, L2; 1. Royal University Hospital, Saskatoon, SK; 2. University of
Saskatchewan, Saskatoon, SK
The latest evidence indicates that 50,000 Canadians will experience a stroke in 2013. The asso-
ciated hospital, rehabilitation, and long term care of stroke patients place a significant burden on
our health care system. National statistics have been utilized in the development of guidelines to
improve care and reduce the impact of stroke. Small less populated regions, such as Saskatch-
 Abstracts From the 4th Canadian Stroke Congress, 2013  e35
ewan, may be underrepresented in national data utilized in the development of stroke prevention
and treatment strategies. A retrospective descriptive chart review was conducted to provide a
profile of stroke and transient ischemic attack cases admitted to Royal University Hospital, re-
gional stroke centre for central and northern Saskatchewan, to determine similarity or difference
to national statistics and to assess the acute management of these cases as defined in the Cana-
dian Best Practice Recommendations for Stroke Care (Canadian Stroke Network and Heart and
Stroke Foundation of Canada, 2011). A randomized sample of 200 cases was selected for review
of adult stroke case records on personal demographics and healthcare performance through the
use of the measures provided in the guidelines. Similarities in the study results and national
information on the type of stroke, risk factors, gender, and age were found. Other findings
included rural inequality in access to treatment and an apparent underutilization of medications
for the treatment of risk factors. There were no cases from remote regions that arrived within the
window for thrombolytic therapy. Hospital adherence to national guidelines comparing selected
indicators was met in most areas and exceeded in some. The remaining indicators provide an
opportunity for improvement and possibly more research. This regional information supplements
the available Canadian information and could be used to guide planning and care strategically
targeting Saskatchewan residents and increasing their potential for success.
P2.019
I Saw the Sign: Improving Stroke Awareness in Canada
LeGrand, C; Arango, M; Joiner, I; Heart and Stroke Foundation of Canada, Ottawa, ON
Background: Stroke is a leading cause of death and disability in Canada. About 50,000 strokes
occur each year and over 315,000 Canadians are living with the effects of stroke. Early identifi-
cation of stroke signs and action to obtain immediate medical attention are critical to achieving
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the best possible outcomes for those experiencing stroke. The Heart and Stroke Foundation
(HSF) has led the development and implementation of stroke public awareness campaigns
in Canada. Despite efforts, research indicates that public knowledge of stroke signs remains
sub-optimal and that Canada lags behind other countries. While there are many contributing
elements to successful recall and recognition, messaging is critical to an effective awareness
campaign. Methods: A one-day meeting was convened to provide feedback to existing stroke
signs campaigns. Meeting participants represented a broad cross-section of HSF staff, clini-
cians/neurologists, cognitive, behavioural, communications and marketing experts from across
Canada. Participants evaluated three stroke signs campaigns - ‘Suddens’ (Canada), Give Me 5
for Stroke (US) and F.A.S.T. (UK and Australia) - through a series of table exercises and large
group dialogue. Results: Research and clinical data indicate that motor and speech signs are
the most frequently reported stroke signs. Marketing best practices, emotional connection with
the audience and a compelling ‘call to action’ are key elements for success. Current HSF mes-
saging contains too many elements. Evidence from the F.A.S.T campaign should be considered
when developing future campaign messages. Conclusions: Improvements to HSF signs of
stroke campaign messages are advised. Shortening the number of signs and ensuring inclusion
of speech, motor and Act Now/call 9-1-1 elements are recommended to improve recall and
recognition. The Foundation will use the feedback from the one-day meeting to inform develop-
ment of future signs of stroke multimedia public awareness campaign.
P2.020
Emergency Department Transient Ischemic Attack Clinical Pathway: Improving
Quality of Care and Patient Safety Using Etiology-based Triage
Treasurywala, K; Fung, W; Wang, A; Kolesnik, J; Cheung, J; Sahlas, D; Lin, D; McMaster
University, Hamilton, ON
Background: Recent evidence suggests tools such as the ABCD2 score can fail to identify
patients at high risk for recurrent stroke, including those in whom evidence-based interventions
for time-sensitive stroke mechanisms exist, such as carotid artery stenosis (CAS) or atrial fibril-
lation. Methods: A novel clinical pathway was devised based upon potential etiologic mecha-
nisms, in order to better integrate Emergency Department (ED) management of patients diag-
nosed with Transient Ischemic Attack (TIA) with subsequent outpatient Stroke Prevention Clinic
(SPC) follow-up, with an emphasis on identifying symptomatic moderate to high-grade CAS. All
adult patients diagnosed with TIA in our ED and who were referred to our SPC from November
5, 2012 to February 28, 2013 were prospectively identified and their clinical outcomes followed
for one month. A historical cohort of patients diagnosed with TIA in the ED prior to the protocol
was reviewed from January 1 to December 31, 2011. Results: Prior to the protocol, the median
time to carotid ultrasound for ED patients referred to the SPC in whom it was subsequently
ordered (49/94) was 6 days. After the protocol, the median time to carotid ultrasound dropped to
1 day, (p<0.001) despite more carotid ultrasounds being requested (77/81) Moreover, 96.3% of
those diagnosed with TIA in the ED had brain imaging compared to 86.2% prior to the protocol
(p=0.03). There was no change in rate of the ordering of EKGs 93.6% before and 92.6% after
(p=1.00). Of the patients without atrial fibrillation, 96.1% were discharged with an antiplatelet
agent compared to 46.2% prior to the protocol (p<0.001). Conclusions: Our clinical pathway
for ED patients evaluated for TIA is based upon potential vascular etiology of TIA and resulted in
an increase in patients undergoing brain imaging, expedited carotid imaging, and an increase in
prescription of antiplatelets, all prior to their SPC appointment .
P2.022
Should Patients with First Cryptogenic Stroke Undergo Routine Tumor Screening?
Maynard, S; Thiel, A; Jewish General Hospital, Montreal, QC
Background: Occult malignancy presenting with stroke (OMPS) is predominantly thought to
be caused by chronic disseminated intravascular coagulation (DIC), non-bacterial thrombotic
endocarditis (NBTE) and putatively arterial embolic disease (AED). The incidence of stroke as
the first presentation of occult malignancy is exceedingly rare, ranging from 0.4-3.0% (ischemic
stroke population). We present three such cases from our stroke unit that we have encountered
within the past 12 months and discuss possible consequences for diagnostic procedures. Meth-
ods: A retrospective chart review was performed for all three cases that were diagnosed with
solid tumor, occult malignancies in the setting of first acute embolic CVA. These cases were
then compared and contrasted to the available literature both on this specific subject and on
the subject of stroke and malignancy in general. Results: According to the literature regarding
OMPS, the most common solid tumor primary site is pulmonary (30%) followed by colorectal
(15%), with adenocarcinoma being the most frequent histopathology. Equally, the most common
etiology of OMPS is NBTE followed by DIC; AED has not been clearly reported. Reported median
survival was 4.5 months. Two of our cases had confirmed adenocarcinoma of the lung (one did
not undergo biopsy), one patient presented with NBTE whereas the other two had neither NBTE
nor DIC and were presumed to represent AED. Two of the patients died within 6 weeks of diag-
nosis and had recurrent embolic events on antiplatelets/unfractionated heparin. One patient who
survived beyond median survival time, responded to single antiplatelet therapy. Conclusions:
Our case series is representative of the literature with respect to primary site and histopathology,
but most common etiologies (NBTE and DIC) were underrepresented. Our and other such cases
underline the need for general criteria from a prognostic approach, and raise questions as to the
efficacy of antiplatelet and anticoagulation therapy in this population.
P2.023
Degree of Ischemic Vasculopathy in Lateral Cholinergic Projections is Associated
with Set-Shifting Executive Dysfunction in Post-Stroke Cognitive Impairment
Muir, RT3, 2, 1 Honjo, K1, 2 Lam, B4, 2, 3 Gao, F1, 2, 3 McNeely, AA1, 2, 3 Harry, RD1, 2, 3 Ganda, A1, 2,
3
Scott, CJ1, 2, 3 Zhao, J1, 2, 3 Ramirez, J2, 1, 3 Graham, SJ2 Rangwala, N5 Marola, J5 Stebbins,
GT6 Gibson, E1, 2 Lobaugh, NJ2 Stuss, DT1, 7 Nyenhuis, DL5 Kang, Y9, 8 Black, SE4, 3, 2; 1. Brain
Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto,
ON; 2. Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences
Centre, University of Toronto, Toronto, ON; 3. L.C. Campbell Cognitive Neurology Research
Unit, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON; 4. Department of
Medicine, Division of Neurology, University of Toronto , Toronto, ON; 5. Hauenstein Neurosci-
ence Centre, Saint Mary’s Health Care, Grand Rapids, MI, USA; 6. Rush University Medical Cen-
tre, Chicago, IL, USA; 7. Rotman Research Institute, Baycrest, University of Toronto, Toronto,
ON; 8. Department of Psychology, Hallym University, Seoul, Korea; 9. Department of Neurology,
Hallym University Sacred Heart Hospital, Seoul, Korea
Background: Post-stroke cognitive impairment is typified by decreased processing speed and
executive dysfunction. The potentially distinct influences of territorial stroke and subcortical
ischemic vasculopathy (SIV) on these executive subcomponents are not well understood. Here
we use the Trail-Making-Test (TMT), which assesses processing speed (TMT-A) and set-shifting
executive function (TMT-B, and TMT-B-minus-A-time), to define these relationships. Methods:
Neuropsychological testing and volumetric MRI from two independent stroke samples were
studied: patients with an Acute/Sub-Acute Ischemic Stroke (ASIS) (South Korea; n=50) and
Chronic Ischemic Stroke (CIS) (North America; n=66). Trail Making Tests (TMT), which assess
processing speed (TMT-A) and set-shifting (TMT-B and TMT-B-minus-A-time) were adminis-
tered. MRIs were processed using a semi-automated imaging pipeline, including stroke tracings
and quantification of global white matter hyperintensities (WMH) volume. Cholinergic WMH were
assessed using the Cholinergic Pathways HyperIntensities Scale (CHIPS). Results: Linear re-
gression analysis of infarct volume, global WMH volume, and CHIPS, as predictors of TMT-A and
TMT-B-minus-A-time, was performed, controlling for age, sex, education, global atrophy and
stroke location in the executive network. For ASIS patients, infarct volume (β=0.700, p=0.0001,
r2=0.44) and global WMH (β=0.207, p=0.002, r2= 0.06) were associated with TMT-A, while
only CHIPS was associated with TMT-B-minus-A-time (β=0.386, p=0.001, r2= 0.11). Similarly,
for CIS patients, infarction volume (β=0.267, p=0.015, r2=0.07) and global WMH (β=0.360,
p=0.003, r2=0.11) were associated with TMT-A, and only CHIPS was associated with TMT-B-
minus-A-time (β=0.413, p=0.001, r2= 0.15). Conclusion: Here we report, and replicate the
differential associations of processing speed and set shifting with cortical/subcortical lesion
measures in two stroke cohorts. The degree of SIV within cholinergic projections was associated
with impaired set-shifting ability, while global SIV and infarction volumes were associated with
reduced processing speed. This suggests that the cholinergic system could be a substrate for
set-shifting executive function deficits and a target of cognitive neurorehabilitation and cholin-
ergic pharmacotherapy.
P2.024
Cerebral Vasospasm and Delayed Cerebral Ischemia in Subarachnoid
Hemorrhage: a Contemporary Case Series
Ng, KH2, 1, 3 Algird, A1, 3 Martin, C3 Jichici, D1, 3 Sahlas, DJ1; 1. McMaster University, Hamilton,
ON; 2. Population Health Research Institute, Hamilton, ON; 3. Hamilton Health Sciences,
Hamilton, ON
Background: Focal or diffuse cerebral vasospasm can occur in up to 30% of patients with
aneurysmal subarachnoid haemorrhage (SAH). 20% to 40% of patients develop neurological
symptoms or secondary ischaemic stroke due to vasospasm despite therapy. Delayed cere-
bral ischaemia (DCI) is defined as symptomatic vasospasm or infarction on CT attributed to
vasospasm. Transcranial Doppler (TCD) monitoring enables identification of patients at risk of
developing DCI and triggers aggressive early medical treatment. Whilst TCD parameters for
proximal middle cerebral artery (MCA) vasospasm are well established, the parameters for the
anterior (ACA) and posterior cerebral artery (PCA) are less well defined. Methods: This is a ret-
rospective consecutive case series of patients with SAH and subsequent DCI (22/98) admitted
between April 2010 to March 2012 at the Hamilton General Hospital. Serial TCDs of the major
 e36  Stroke  December 2013
intracranial vessels were performed and parameters including mean blood flow velocity (mBFV)
were recorded for every patient. Results: 50% of intracranial aneurysms in this case series were
anterior communicating artery aneurysms. 34 DCI events were confirmed on brain imaging,
with 31 events involving the anterior circulation. Those patients with MCA DCI had average and
median mBFV of 186 cm/s and 197 cm/s respectively (range 62 cm/s to 337 cm/s). In patients
with ACA DCI, the average and median mBFV were 115 cm/s and 114 cm/s respectively (range
64 cm/s to 175 cm/s). In patients with PCA DCI, the average and median mBFV were 102 cm/s
and 54 cm/s respectively (range 50 cm/s to 201 cm/s). Conclusions: TCD is a simple bedside
test that can guide the management of patients following SAH at risk of DCI due to vasospasm.
Our case series involving contemporary intensive care management reports mBFV parameters
in patients with DCI following SAH in each of the major arterial territories.
P2.025
Meta-analysis of Albumin in Acute Stroke (ALIAS) Parts 1 and 2 Trials
Palesch, YY1 Martin, RH1 Hill, MD2 Tamariz, D3 Jauch, EC1 Weng, Y1 Speiser, JL1 Woolson, RF1
Barsan, WG4 Moy, CS5 Ginsberg, MD3; 1. Medical University of South Carolina, Charleston, SC,
USA; 2. University of Calgary, Calgary, AB; 3. University of Miami, Miami, FL, USA; 4. University
of Michigan, Ann Arbor, MI, USA; 5. National Institute of Neurological Disorders and Stroke,
Bethesda, MD, USA
Background: The international multicenter (including several Canadian sites) Albumin in Acute
Stroke (ALIAS) Parts 1 and 2 Trials randomized patients with acute ischemic stroke (NIHSS ≥
6) within 5 hours from symptom onset to treatment with 25% human albumin (ALB) at 2 g/kg
infused intravenously over 2 hours or to equivolemic normal saline similarly infused. The Part
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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
the safety data, some of the eligibility criteria were modified with a few minor changes to the
protocol, and the trial was re-started as a new study, i.e., as Part 2. After 841 of the anticipated
1,100 subjects were enrolled in Part 2, the DSMB recommended stopping the study because the
pre-specified futility boundary was crossed. Methods: The primary outcome for both trials was
the favorable outcome defined as mRS 0-1 and/or NIHSS score 0-1 at 90 days from randomiza-
tion. Because the two trials were conducted under a similar protocol at mostly the same clini-
cal sites and coordinated by the same group of investigators, we conducted one-stage meta-
analysis using the participant level data from both trials. As a sensitivity analysis, two-stage
meta-analysis, where the summary measures from each trial are combined, was performed.
Results: In general, the baseline characteristics were similar between the trials overall as well
as between the treatment groups within each trial. These characteristics will be presented by
trial and in aggregate along with the primary outcome analysis results from each trial and from
the meta-analyses. Conclusion: TBA since the results from the Part 2 Trial, and consequently,
from the meta-analysis cannot be disclosed at this time.
P2.026
Late Life Migraine Accompaniments Presenting to the Stroke Clinic: How Much
Investigation is Necessary?
Pim, H; Aube, M; Cote, R; Vieira, L; McGill University, Montreal, QC
Background: Transient ischemic attacks (TIA) can be associated with a 10% risk of stroke in
90 days and urgent investigation and treatment is recommended (1). Fisher described patients
in the stroke age bracket with transient neurological symptoms, late-life migraine accompani-
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
investigations. The decision as to what investigations are necessary, in these individuals, re-
mains a common clinical problem. Methods: Our study will be nested within a larger retrospec-
tive review of the files of all patients referred to the McGill University Stroke Prevention clinic
with a diagnosis of TIA from 2008 to 2012. The clinic sees between 2500 and 3000 patients
with per year. Patients with LMA will be identified by using a modification of the original Fischer
criteria for the diagnosis of LMA (2). Other symptoms that may help to support the diagnosis of
LMA will be documented. We will evaluate the clinical symptomatology, vascular risk factors,
migraine history (where available), investigations carried out and their results. We will document
the incidence of vascular events and the treatment decisions made in these patients. Expected
Results: The study is ongoing and the final results will be presented at the Canadian stroke
congress. We expect to be able to demonstrate a correlation between certain clinical presenta-
tions and the risk of cerebrovascular events. Conclusions: We expect to demonstrate that a
careful history and follow up may obviate the need for extensive cerebrovascular investigations
in many patients with LMA.
1. Johnston, S.C., et al., JAMA, 2000. 284: 2901-2906
2. Fisher CM. Can J Neurol Sci 1980;7:9-17
3. Wijman et al., Stroke. 1998;29:1539-1543
P2.027
Unilateral Surgical Revascularization Improves Cerebrovascular Reactivity of
the Non-intervened Hemisphere in Patients with Bilateral Steno-occlusive and
Moyamoya Disease
Sam, K1 Poublanc, J2 Crawley, AP2 Fisher, JA1 Mikulis, DJ2; 1. University of Toronto, Depart-
ment of Physiology, Toronto, ON; 2. Toronto Western Research Institute, Department of
Medical Imaging, Toronto, ON
Background: Unilateral hemodynamically significant large-vessel intracranial stenosis may be
associated with reduced BOLD cerebrovascular reactivity (CVR), an indicator of autoregulatory
reserve. Reduced CVR has, in turn, been associated with ipsilateral cortical thinning and loss in
cognitive function. These signs and clinical effects have been shown to be reversible following
revascularization. Our aim was to study the effects of unilateral revascularization on CVR in
both hemispheres in the presence of bilateral steno-occlusive or moyamoya disease. Meth-
ods: In this exploratory observational study, 20 patients with either moyamoya disease (n=14)
or bilateral severe stenosis of the ICA (n=6) underwent BOLD CVR MRI at 3T (GE Healthcare,
Milwaukee), and using RespirAct™ (TRI, Toronto, Canada) to control the PCO2 stimulus, before
and after unilateral revascularization (extracranial-intracranial bypass, carotid endarterectomy,
or encephaloduroarteriosynangiosis). Pre- and post-revascularizaion CVR was assessed in both
hemispheres. Results: As expected, the CVR improved in the intervened hemisphere (0.098 ±
0.018 to 0.201± 0.010, P<0.01). There was also a significant post-revascularization improve-
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
via the circle of Willis and other collateral blood vessels. It makes sense that resupply of one
hemisphere reduces the draw of blood flow from the other, improving its autoregulatory reserve,
as reflected in the CVR. Conclusion: Unilateral revascularization can improve vascular reserve
in the non-intervened hemisphere. Bilateral revascularization may not be necessary for restoring
global hemodynamic function.
P2.028
Fallibility, History and Endovascular Stroke Trials: A New Perspective
on Equipoise
Shamy, MC; Stahnisch, FW; Hill, MD; University of Calgary, Calgary, AB
Background: Equipoise is an ethical principle that justifies the enrollment of patients into ran-
domized clinical trials (RCTs) on the basis of conflicted medical opinion, either on the part of
individual physicians or of the community. In light of the results of recent stroke trials that have
contradicted the prevailing opinions of the community, we question the relevance of equipoise
to clinical trial enrollment, particularly in stroke. Methods: We apply examples from stroke
medicine to demonstrate the limitations of equipoise that arise due to its reliance on medical
opinion. We discuss the complex development and instability of medical opinion, in general and
in relation to clinical trials. We review the justifications for RCT enrollment that are not related
to opinion, and seek a more ethically and epistemically robust alternative. Results: We propose
the “fallibility principle” as a new approach to ethical decision-making about RCTs that acknowl-
edges the fallibility of every opinion and that contextualizes recent questions about the ethics
of clinical experimentation within a broader perspective informed by the history of medicine.
Through the lens of fallibility, the dual ethical and epistemic imperative of medicine – providing
best care from best evidence – is conceived as a continuous challenge navigated through a
combination of humility, skepticism and caring. Conclusions: We propose a revision of 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
a novel way.
P2.029
Atrial Fibrillation Prediction Score in Cerebrovascular Disease
Shuaib, A1 Yaseen, I1 Ghrooda, E1 Mohammad, A1 Dobrowolski, P1 Hasan, M1 Hussain, G2
Ahmad, A1; 1. University of Alberta, Department of Medicine, Division of Neurology , Edmonton,
AB; 2. University of Alberta, Department of Medicine, Division of Cardiology, Edmonton, AB
Introduction: Paroxysmal Atrial Fibrillation (PAF) is an important cause of preventable embolic
stroke. Recent studies have shown that PAF is much more likely to be diagnosed with prolonged
cardiac monitoring. We designed a PAF prediction score (including: Recurrent stroke, Pattern of
infarction on imaging, Etiology ,Premature atrial beats and Palpitations) and tested in patients
with TIAs and acute stroke. Methods: Patients seen at University of Alberta stroke program in
whom Holter monitoring was negative for PAF were prospectively enrolled in a study to monitor
for PAF between July 2012 and May 2013. A PAF prediction score (low, medium and high) was
tested to determine the risk for the arrhythmia. Results: 54 patients had 10 (±4) days of moni-
toring (SpiderFlash-t™ monitor, Sorin, Italy). PAF was seen in no patients with low score (0/5),
30% of patients with medium score (3/10) and 36% of patients with high score (14/39). In ad-
dition, atrial flutter was seen in two patients with high score (embolic risk in 41% patients). The
diagnosis resulted in initiation of anticoagulation in 13 patients. Conclusions: The risk of poten-
tial PAF can be calculated with a clinical score. This may allow for the selection of patients where
more focused prolonged cardiac monitoring arrhythmias and change in prevention therapies.
P2.030
Sensitivities and Specificities of the Doc Screen for Depression, Obstructive Sleep
Apnea and Cognitive Impairment on Gold Standard Testing
Sicard, MN1 Lien, K1 Lanctot, K1 Murray, B1 Herrmann, N1 Thorpe, K2 Swartz, R1; 1. Sunnybrook
Health Sciences Centre, Toronto, ON; 2. Applied Health Research Centre of the Li Ka Shing
Knowledge Institute, Toronto , ON
Background: 30-50% of patients post-stroke are affected by each of the following comor-
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.
The primary objective of this study is to assess the validity of the DOC screen for identifying
individuals at high-risk of DOC conditions in a large-volume stroke/TIA clinic. Methods: The
sensitivity and specificity of individual DOC sub-screens (PHQ-2 for depression, STOP for OSA
 Abstracts From the 4th Canadian Stroke Congress, 2013  e37
and Mini-MoCA for cognitive impairment) were assessed compared to gold standard research
assessments in consenting patients at the Sunnybrook Stroke Prevention Clinic. Results: Over
eleven months, 205 patients consented to gold standard testing; not all patients completed
every assessment. The PHQ-2 sub-screen was both specific (88%) and sensitive (72%) com-
pared to the Structured Clinical Interview for the DSM-IV Depression Module (n=193). The mini-
MoCA was equivalent to the full MoCA in predicting cognitive impairment of ≥1 domain on the
neuropsychological test protocol (mini-MoCA, 52% specificity and 80% sensitivity; MoCA, 60%
specificity and 81% sensitivity, n=170). Only 26% of enrolled patients consented to polysom-
nography. Compared to polysomnography (n=47), the STOP sub-screen was sensitive (86%),
but lacked specificity (30%). Conclusion: The PHQ-2 and mini-MOCA results are valid compared
to gold standard assessments. They may be useful in the clinical setting for identifying those at
high-risk for depression and cognitive impairment. The low specificity of STOP, along with low
enrollment in polysomnographys highlights the need for additional simple OSA screening tools.
The sensitivity for detecting OSA was adequate, and sensitivity is preferred for a screening tool.
The DOC screen is a sensitive and valid tool to screen for depression, OSA, and cognitive impair-
ment in the stroke population.
P2.031
tPA Door to Needle Reduction: The Impact of Nurse Stroke Specialists
Tebbutt, TD; Hammond, L; Grand River Hospital, Kitchener, ON
Background: The Central South Stroke Region consists of one Regional Stroke Centre and
three District Stroke Centres (DSCs). Improving door to needle times for tPA was identified as
a Central South Stroke regional priority in 2011/2012 and 2012/2013. The Greater Niagara
General Site (GNG) of the Niagara Health System is a DSC in Central South. The Stroke Team
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at GNG have consistently exceeded the provincial benchmark with door to needle times for
tPA through a unique “Nurse Stroke Specialist” model of care; 39 minutes for the last three
years. Waterloo/Wellington District Stroke Centre collaborated with the Niagara Health System
to determine if this model of care could be applied with success in another district that has
a different medical model. Methods: A site visit was organized to Niagara Health System for
Waterloo/Wellington Stroke Team. This resulted in implementation of the GNG Nurse Stroke
Specialist model which includes several strategies: tPA feedback letters for internal stroke team
members and Emergency Services Network (EMS) staff identifying door to needle times and
patient outcomes, pre-alert by EMS, EMS transporting patient straight to CT, and offering ad-
ditional training for Emergency Department (ED) nurses utilizing Hemispheres which is an eight
module online stroke training program. Results: Grand River Hospital has reduced median door
to needle times from 72 minutes to 58 minutes since April 2011-December 2012. In addition,
we have 33 ED nurses who have signed up for the online Hemispheres Stroke Education series.
Conclusions: The Nurse Stroke Specialist model of care was successfully applied in Waterloo/
Wellington and has facilitated more efficient and timely provision of tPA. This suggests that this
model of care is transferable and could be effective at other sites.
P2.032
FLAIR Hyperintense Vessel Sign on MRI brain (HVS) Does Not Predict Any
Intracranial Hemorrhage or Symptomatic Hemorrhage(sICH) in Acute Strokes
with Proximal Vessel Occlusions Treated with Intravenous or Intra-Arterial Lytic/
Mechanical Therapy
Adatia, S1 Almekhlafi, M1 Nambiar, V1 Trivedi, A1 Sohn, S2 Menon, B1 Al-sereya, A1; 1. Foothills
Medical Hospital, Calgary , AB; 2. Keimyong University , Korea, Korea
Background and Purpose: Hyperintense vessels (HV) have been observed in fluid- attenuated
inversion recovery imaging (FLAIR) MRI sequence in patients with acute ischemic strokes in
region of diffusion positivity .They have been linked to slow flow in collateral arterial circulation
and proximal arterial occlusions. We aim to study its correlation with intracranial hemorrhage.
Methods: We retrospectively reviewed 95 patients from prospectively collected acute ischemic
strokes with proximal occlusions on CTA. The HV sign was defined by presence of flair bright
vessels on MRI in the region of diffusion restriction. Two independent/blinded clinicians iden-
tified it. sICH was defined by SITS-MOST criteria. Results: 59 patients had HVS and 36 did
not. Interrator agreement was good. (Kappa 0.92). Proportion of age, sex, NIHSS, diabetes and
smoking was comparable in both. The patients were offered IV tpa , intra arterial therapy (lytic/
mechanical thrombectomy) or both based on judgment of treating team. In the HVS group, 14
received IV tpa and 44 underwent IA with IV therapy. In the non HVS group, 19/36 had IV tpa, 14
had IA alone and 2 received both. (1 missing). The groups were comparable for rates of recanali-
zation (TIMI 2/3). 8/36 patients in the non HVS group had any ICH and 1 had sICH. 22/59 had any
ICH and 5 sICH in the HVS group. (p=0.2785) In the multivariate regression analysis model for
prediction of sICH, high glucose levels, age and NIHSS emerged as significant predictors. For any
ICH, glucose and initial NIHSS were significant. Conclusion: Presence of HVS is not uncommon
in patients with proximal vessel occlusions. In present study, its presence was not significant for
prediction of intracranial hemorrhage. Glucose levels , age and NIHSS were significant predic-
tors of sICH. Larger sample with pretreatment MRI needs to be studied for correlation of HVS
and intracranial hemorrhage.
P2.033
Spontaneous or Traumatic Cervical Artery Dissection: a Distinction with
Therapeutic Impact?
Tsai, JP1 Swartz, RH1, 2; 1. Division of Neurology, Department of Medicine, University of
Toronto, Toronto, ON; 2. Division of Neurology, Department of Medicine, Sunnybrook Health
Sciences Center, Toronto, ON
Background: The literature classifies cervical artery dissection (CAD) into two etiological
categories: spontaneous or traumatic. This distinction is primarily based on presenting his-
tory, but recent studies and reports suggest that these groups share many similarities. Best
evidence-based management for both spontaneous and traumatic CAD remains unclear, as
on-going randomized controlled trials are challenged by difficulties meeting sufficient power
for conclusive results. We hypothesize that spontaneous and traumatic CAD are mainly dif-
ferentiated by their respective risks for ischemic and hemorrhagic complications, and that
determination of this risk profile is key in devising a rationalized approach to management.
Method: We reviewed the medical literature through MEDLINE and PubMed from 2003 to
2013, with review of references. The search was limited to “English language” and “Hu-
man”, with exclusion of articles solely pertaining to intracranial dissections. Through articles
identified, we compared and contrasted key characteristics between spontaneous and trau-
matic CAD. Results: A total of 246 articles pertaining to spontaneous carotid or vertebral
artery dissection, and 117 articles on traumatic ones, were identified. Review of reported
characteristics showed overlaps between spontaneous and traumatic CAD, including incit-
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-
ences and many similarities exist between spontaneous and traumatic CAD. Major distin-
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.
This principle is likely key in devising a common rationalized approach to therapy for all
cervical artery dissections.
P2.034
Integrated Vascular Management Clinic (IVMC) – A Comprehensive Approach to
Vascular Management
Shipley, C2 White, JL1 Hill, C1; 1. Peterborough Regional Health Centre, Peterborough, ON;
2. Peterborough Regional Vascular Health Network, Peterborough, ON
Background: In 2006, Haliburton Kawartha Pine Ridge (HKPR) was facing the future: a
rapidly aging, medically complex vascular patient population and limited resources in terms
of the availability of specialists to provide comprehensive assessment and treatment. The
IVMC model was established in 2006 to streamline vascular referrals through a coordinated
intake process. The goal of the clinic was to increase accessibility for patients in order to
improve the detection, management and treatment of vascular disease while improving
resource utilization through a collaborative, patient-centred approach. Method: IVMC is a
community-based, nurse led and physician supervised clinic designed to be responsive to
the needs of patients in the HKPR District presenting with a manifestation of any type of
vascular disease. Clinics included under the IVMC umbrella are: TIA Clinic, Chest Pain Fast
Track Clinic, Heart Function, Rapid Access Clinic and Vascular Risk Optimization Clinic.
Patients are referred directly from the Emergency Departments (ED), specialists’ offices,
and family practice organizations across HKPR. Result: Efficient and successful naviga-
tion of patients through the vascular care continuum using standardized, evidence-based
protocols. In 2012/2013, over 3000 patients across the HKPR District were referred to IVMC
Clinics for the detection, management and treatment of vascular disease. Partnerships
have been established between a variety of care providers to ensure effective integra-
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
has been effective in developing and deploying unique and highly efficient services within
the HKPR District. The model aligns with broader provincial targets for the management of
vascular disease; providing rapid access to vascular diagnostic tests, investigations, and
intervention. The efficiencies achieved have resulted in improved coordination of care for
patients requiring multiple vascular investigations, ultimately improving patient outcomes
and reducing health care resource utilization.
P2.035
Chinese or South Asian Ethnicity is not Independently Associated with Delayed
Treatment in Acute Stroke: Observations from the Vancouver Stroke Program
Wilson, L; Mann, S; Murray, K; Yip, S; University of British Columbia, Vancouver, BC
Background: Various pre-hospital and hospital factors have been implicated in delaying time
to treatment with tissue plasminogen activator (tPA) in acute ischemic stroke. However, in a
multicultural city such as Vancouver, it is unclear if ethnicity is a predictor of a prolonged door
to needle time (DTN). Methods: A retrospective chart review was performed of all patients
(n=250) treated with tPA consecutively at Vancouver General Hospital (VGH) from January
2009 to March 2011. Demographic features along with times of symptom onset, arrival, CT
scan and treatment with tPA were recorded for Chinese, South Asians and all other ethnic
groups (“Others”). As the 2013 AHA guidelines recommend a DTN of <60 minutes, multi-
variate logistic regression analysis was used to determine independent variables associated
with a DTN ≥60 minutes. Results: The final study population included 203 patients with
20% Chinese (n=40) and 14% South Asian (n=29) patients. The mean DTN for Chinese and
South Asians was not significantly different from Others (77 and 60 vs. 70 minutes, p=0.26
and p=0.12 respectively). Multivariate logistic regression identified only hospital transfer
(p<0.001) as an independent predictor of DTN less than 60 minutes. Ethnicity was not an
independent factor associated with a prolonged DTN (p=0.25). Conclusions: This study did
not identify ethnicity as an independent variable in delay to treatment with tPA for acute isch-
emic stroke at Vancouver General Hospital. However, hospital transfer was shown to be an
independent variable associated with a shorter DTN and this requires further study as it may
alter future local treatment protocols.
 e38  Stroke  December 2013
P2.036
The Effect of Antalarmin on the Expression of Brain Derived Neurotrophic Factor
mRNA in the Hippocampus and Basal and Stessed-Induced CORT Secretion Fol-
lowing Transient Cerebral Ischemia in the Rat
Barra de la Tremblaye, P; University of Ottawa, Ottawa, ON
Background: Recently, we demonstrated persistent changes triggered by forebrain ischemia
in corticotropin releasing hormone (CRH) and CRH type 1 receptor (CRH-R1) immunoreactive
expression in the paraventricular nucleus of hypothalamus, central amygdala and the CA1 sub-
region of the hippocampus. CRH-R1 receptors have been shown to mediate brain plasticity
by acting on brain-derived neurotrophic factor (BDNF) in a region specific manner following
various stressors. The current study investigated whether inhibition of CRHR1 activation alters
basal and stress-induced CORT levels as well as BDNF and TrkB mRNA expression in the hip-
pocampus following global cerebral ischemia. Methods: Male Wistar rats (N = 30) received
intracerebroventricular infusion of either Antalarmin (2µg/2µl) or saline 30 minutes prior to be-
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
stress. Animals were killed 30 days after reperfusion and thymus, adrenal glands and seminal
vesicles weighed. BDNF and TrkB mRNA expression were assessed by RT-PCR in the dorsal
hippocampus. Results: Statistical analysis of the thymus and adrenal gland weight revealed
significant differences between Ischemic and Sham groups. Only the seminal vesicles reduction
was prevented by Antalarmin administration in ischemic rats. However, persistent elevations in
basal CORT levels post ischemia were significantly reduced by Antalarmin at short and longer–
term intervals and after restraint stress. The expression of BDNF and TrkB mRNA was attenuated
in the hippocampus 30 days post ischemia, independent of antalarmin treatment. Conclusions:
Our findings suggest that forebrain ischemia dysregulate the endocrine system with sensitized
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CORT responses at multiple baseline time intervals and following acute restraint. This phe-
nomenon was attenuated by a single Antalarmin administration prior to ischemia. Decreased
hippocampal expression of BDNF and TrkB mRNA may play a role in functional deficits observed
following global ischemia.
P2.037
Identification of a Novel Transcription Regulator that Controls Macrophage
Polarization and Cholesterol Uptake
Chen, H1, 2, 3 Keyhanian, K4, 2, 3 Pandey, NR4, 2 Zhou, X4, 2 Ho, T5, 3 Wen, K4, 2 Lu, M4, 2 Stewart, AF5, 3;
1. Ottawa Hospital Research Institute, Ottawa, ON; 2. Centre for Stroke Recovery, Ottawa, ON;
3. University of Ottawa, Ottawa, ON; 4. Ottawa Hospital Research Institute, Centre for Stroke
Recovery, Ottawa, ON; 5. University of Ottawa Heart Institute, Ottawa, ON
Background: A meta-analysis published in Lancet Neurology (2009) that included more than
165,000 patients showed that for every 39-mg/dL decrease in LDL-cholesterol (LDL-C) levels,
there was a 21% reduction in the relative risk of stroke. Two independent genome-wide as-
sociation studies (GWAS) found that IRF2BP2 polymorphisms affect LDL-C levels. IRF2BP2 is
the co-repressor of interferon regulatory factor 2, a transcription factor that regulates innate im-
mune response and suppresses interferon alpha (IFNα) expression. IFNα primes macrophages
to become polarized to an M1 inflammatory phenotype (producing pro-inflammatory cytokines).
Macrophages can also become polarized to an M2 phenotype (producing anti-inflammatory
cytokines) important for tissue repair, depending on other external stimuli. Macrophages are
important regulators of cholesterol metabolism and emerging evidence indicates that regula-
tion of M1/M2 polarization influences LDL-C uptake. Methods: To address how IRF2BP2 influ-
ences macrophage handling of LDL-C, we generated a mouse model LysMCre/IRF2BP2flox that
specifically ablates IRF2BP2 in macrophages. Results: IRF2BP2 expression is elevated in M2
macrophages and reduced in M1 macrophages. Ablation of IRF2BP2 in macrophages skews
polarization to the M1 phenotype, with elevated expression of TNFα and IL-1β. Quantitative
RT-PCR analysis showed that IRF2BP2 suppresses the expression of scavenger receptors MSR1
and SCARB1 that uptake LDL-C to macrophages. IRF2BP2 deficient macrophages accumulated
significantly higher levels of oxidized LDL-C. Importantly, altered nutrients and stress affected
IRF2BP2 expression in cultured cells and in the brain. Conclusion: IRF2BP2 is important to
control macrophage polarization and LDL-C uptake and is likely to affect susceptibility to stroke
injury.
P2.038
Loss of MAPK Phosphorylation of Connexin43 is Neuroprotective in Stroke
Freitas-Andrade, M1 Bechberger, J1 MacVicar, B2 Lampe, P3 Naus, C1; 1. Department of Cellular
and Physiological Science, Life Sciences Institute, University of British Columbia, Vancouver,
BC; 2. Brain Research Centre, Department of Psychiatry, University of British Columbia,
Vancouver, BC; 3. Fred Hutchinson Cancer Research Center, Seattle, WA, USA
Astrocytic interactions involving gap junction proteins has been reported to be a mechanism
associated with neuronal survival in ischemic conditions. In astrocytes, gap junctions are com-
posed primarily of the channel protein, Connexin43 (Cx43). These channels provide a substrate
for the formation of a functional glial syncytium. While several reports have demonstrated that
Cx43 is an important factor in cerebral ischemia, the molecular mechanisms involved remains
elusive. The transmembrane regions of Cx43 are relatively conserved with other connexins,
however, the cytoplasmic region is divergent and has been shown to be critical for the regulation
of Cx43. Recently, a study showed that in response to atherogenic stimuli and vascular injury,
Cx43 is phosphorylated at its C-terminus mitogen-activated protein kinase (MAPK) residues and
that this is a key regulator of vascular smooth muscle cell (VSMC) proliferation and vascular scar
tissue formation in vivo. In this study, wild-type (WT) mice and mice containing Cx43-MAPK null
phosphorylation (MK4) mutation were subjected to permanent unilateral middle cerebral artery
occlusion (MCAO). After 4 days of recovery, brain sections were histologically evaluated for
infarct volume. Immunofluorescent analysis of astrocyte reactivity, microglial activation, Cx43
expression, vascular elements and apoptosis was also performed. A significant, ~2-fold, de-
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
not exhibit a typical delineation; “islands” of GFAP positive astrocytes, within the infarct region,
were observed in MK4 mice. In the penumbra, an increase in astrocyte reactivity was observed
in MK4 animals, compared with WT mice. Consistent with the infarct volume data, a significant
reduction in cell death in the MK4 group was measured, compared to corresponding controls.
This study suggests that inhibiting MAPK-Cx43 interaction is associated with neuroprotection in
ischemic conditions.
P2.039
The Cognitive Underpinnings of Confabulation Following Anterior Communicating
Artery (ACoA) Aneurysm Rupture
Ghosh, V1, 2 Moscovitch, M1, 2 Gilboa, A1, 2; 1. University of Toronto, Toronto, ON; 2. Rotman
Research Institute, Baycrest, Toronto, ON
Background: Due to high sensitivity of the anterior communicating artery (ACoA) for aneurysm
rupture, and the relatively focal ventromedial prefrontal cortical (vmPFC) damage that ensues,
an associated triad of symptoms have been labeled the “ACoA syndrome” (Alexander & Freed-
man, 1984; Damasio et al., 1985; DeLuca, 1993). Recent evidence of vmPFC’s role in represent-
ing schemas (Kumaran et al., 2009; Tse et al., 2011; Van Kesteren et al., 2010) could account
for the most elusive of the ACoA syndrome symptoms: confabulation. This experiment probed
the impact of vmPFC damage following ACoA rupture on schematic representation, specifically
testing whether vmPFC lesions would differentially impact activation of a relevant schema and
inhibition of an irrelevant one, even when memory was not required for the task. Methods:
Eight ACoA patients, with three demonstrating confabulation, and a group of healthy adults
had to decide quickly whether words were closely related to a schema (visiting a doctor). Ten
minutes later they repeated the task for a new schema (going to bed) with some words related
to the first schema included as lures. Lastly, they rated the degree of association of targets and
lures to the second schema. Results: Non-confabulating ACoA patients performed comparably
to healthy adults: high accuracy overall and longer response latencies to reject lures related to
the irrelevant schema than lures unrelated to both schemas. Patients with confabulation were
less efficient in rejecting irrelevant schema lures. Damage to a vmPFC sub-region—sub-callosal
cingulate cortex—may have in part been responsible for the differing performance of patients
with and without confabulation, as this region was spared in non-confabulating patients. Con-
clusion: The findings support the hypothesis that the sub-callosal cingulate cortex is pertinent
to confabulation (Schnider, 2003; Gilboa, 2004), and suggest that confabulation in these cases
of ACoA syndrome is associated with poor suppression of irrelevant schemas.
P2.040
Sex Differences in Cognitive Rehabilitation Efficacy in a Rat Model of Vascular
Dementia
Langdon, KD1 Granter-Button, S1 Harley, CW1 Moody-Corbett, F1 Peeling, J2 Corbett, D1;
1. Memorial University, St. John’s, NL; 2. University of Manitoba, Winnipeg, MB
Background: Dementia is a major contributor to morbidity throughout western society. To date,
pharmacological interventions have provided modest benefit in treating resultant cognitive im-
pairments. We report the evaluation of a treatment paradigm consisting of a combination of
physical and cognitive activity (PA/CA) in both male and female rats using a well-characterized
model of vascular dementia. Methods: Early middle-aged (~6mo) Sprague-Dawley rats un-
derwent permanent bilateral carotid artery occlusion (2VO) and were exposed to either a com-
bination of PA (voluntary wheel running) and CA (modified Hebb-Williams maze exposure) or
sedentary housing. Female animals were ovariectomized prior to 2VO, controlling for possible
neuroprotective influences of estrogen. Learning and memory abilities were assessed using
the Morris water maze. Results: Male PA/CA rats demonstrated significant cognitive improve-
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
a result of 2VO. Interestingly, there were no differences between PA/CA and sedentary females
in any of the learning and memory assessments, nor histopathological outcomes. Conclusions:
This study describes a cytoarchitectural abnormality of hippocampal CA1 neurons in early mid-
dle-aged male rats subjected to a surgical procedure that induces cognitive decline. A novel
combination of PA and CA promoted cognitive recovery, an area rarely explored in preclinical
studies. Interestingly however, the positive effects were limited to male animals. Females did
not display altered CA1 cell structure nor did they benefit from the rehabilitation paradigm.
Clearly, failure to employ female animals is a potentially important factor contributing to the
‘translational roadblock’ between basic and clinical science outcomes. The present results are
intriguing because the differential response to the intervention may provide a means for identify-
ing critical mechanisms underlying PA/CA rehabilitation efficacy.
P2.041
In Vivo Channelrhodopsin-2 Stimulation and Voltage-Sensitive Dye Imaging in a
Mouse Model of Stroke Reveals Preserved Functional Connections Posterior to
the Lesion
Lim, DH; LeDue, J; Mohajerani, MH; Murphy, TH; University of British Columbia, Vancouver, BC
 Abstracts From the 4th Canadian Stroke Congress, 2013  e39
Background: Understanding the recovery of cortical function following stroke is important to
develop treatment strategies. While it is known that cortical damage may extend beyond the
stroke core to the peri-infarct region, direct functional assessment of this area has been chal-
lenging because most methods have relied on peripheral stimulation, which is limited to sensory
or motor cortex activation, or have used invasive cortical stimulation, which may cause further
damage. Methods: Recently, we have developed a method to map functional connections in
vivo with high spatial and temporal resolution using voltage-sensitive dye (VSD) imaging com-
bined with Channelrhodopsin-2 (ChR2) stimulation in a transgenic mouse line (Lim et al., 2012).
Here, we examine long-term changes in functional connectivity after a stroke by discretely stim-
ulating multiple sites within the peri-infarct. Results: In animals with a stroke targeted to the
forelimb area of the primary somatosensory cortex (FLS1), the peak VSD response after sensory
stimulation was significantly delayed and reduced, as expected from previous studies (Brown et
al., 2009). The homotopic VSD response to photostimulation was reduced in amplitude, however
it was not significantly delayed, suggesting that the cortical and callosal connections activated
by the phostostimulation were still functional. To further examine which areas were most af-
fected by stroke, 25 cortical sites within the peri-infarct were targeted for photostimulation and
the homotopic VSD response was recorded. After stroke, photostimulation of cortical sites 200
μm away from the stroke core resulted in little or no VSD response except for the site posterior
to the stroke core, which resulted in VSD responses similar to sham animals. Conclusion: We
present this method as a useful tool for investigating recovery after stroke. We suggest that after
stroke connections may be spared, and this distribution likely occurs in a non-random order.
P2.042
Do Reduced Leptomeningeal Collaterals in Humans Result in Leukoaraiosis,
Lacunes and Brain Atrophy?
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
Nambiar, VK1 Sohn, S2 Goyal, M1 Demchuk, AM1 Menon, BK1; 1. University of Calgary, Calgary,
AB; 2. Keim Yong University, Keimyong, Korea
Introduction: We seek to identify if reduction in leptomeningeal collaterals results in leuko-
araiosis, lacunar disease and brain atrophy. In addition, we seek to explore an association be-
tween amyloid angiopathy and reduced leptomeningeal collaterals. Methods: Data are from
the Keimyung Stroke Registry. Consecutive patients with M1 segment middle cerebral artery
(MCA) ± intracranial internal carotid artery (ICA) occlusions on baseline CT-angiography (CTA)
from May 2004 to July 2009 were included. Only patients with baseline CTA and MRI (FLAIR, T1
and GRE) were included in the current study. Two raters assessed leptomeningeal collaterals on
baseline CTA by consensus, using a previously validated regional leptomeningeal score (rLMC).
Brain volume=, volume of periventricular hyperintensity on FLAIR (PVH), number of lacunes
(T1) and microbleeds (GRE) were assessed by consensus, blinded to collateral assessment.
Brain volumes were measured using Quantomo and data analyzed using Stata 12.1. Results:
Baseline characteristics (n=120) were: mean age 67.3 years, median baseline NIHSS 14 (IQR
10) and median stroke symptom onset to CTA 118.5 minutes (IQR 117). There was a significant
difference in PVH in those with poor collateral status vs. those without (median volume 7. 5 ml
vs 4.4 ml, p=0.04). No difference was noted in brain volume, number of lacunes or number of
microbleeds by collateral status. (Table 1) Nonetheless, we noted significant correlation be-
tween brain volume, PVH and number of lacunes. Cerebral microbleeds were not associated
with collateral status, PVH, brain atrophy and lacunas. Conclusion: Our results establish an
association between poor collateral status and leukoaraiosis. Correlation between leukoaraiosis,
brain atrophy and number of lacunes points towards a common pathophysiological mechanism
with reduced collateral status potentially being causal. Insert
P2.043
The Effects of Diabetes on Blood Brain Barrier Integrity and Functional Recovery
from Stroke
Reeson, P; Wang, J; Brown, CE; University of Victoria, Victoria, BC
Diabetics are 2-4 times more likely to suffer a stroke and have poorer recovery resulting in
serious long-term disabilities. Recently it was shown that functional rewiring in the peri-infarct
cortex was impaired in the diabetic brain. Our hypothesis was that diabetes causes maladaptive
vascular responses to stroke that severely impair neuronal plasticity and functional recovery. To
understand the vascular response to stroke, we induced a unilateral ischemic photothrombotic
stroke in the forelimb somatosensory (FLS1) cortex of diabetic and non-diabetic mice. Using
Evans blue, a fluorescent dye impermeable to an intact blood-brain-barrier (BBB), we quantified
dye extravasation in the peri-infarct cortex as a marker of BBB dysfunction. At 3 days follow-
ing stroke we found the cerebrovasculature in the diabetic peri-infarct cortex was significantly
more permeable compared to controls. By 7 days there was no difference between groups and
leakage was resolved by 4 weeks. Since most angiogenic signals are transduced by vascular
endothelial growth factor receptor-2 (VEGF-R2), we assessed VEGF-R2 protein expression in
the peri-infarct cortex with immunohistochemistry and western blots. Diabetic mice exhibited
a heightened and abnormally prolonged expression of VEGF-R2 in peri-infarct vasculature. We
then asked whether administration of a VEGF-R2 inhibitor (SU4516) one hour post stroke could
restore BBB integrity. Diabetic mice treated with SU5416 had significantly lower vascular ex-
travasation. Diabetic and non-diabetic mice receiving chronic administration of either SU5416
or vehicle injections were assessed with adhesive tape and horizontal ladder behavioral task
following stroke. Preliminary testing indicates that VEGF-R2 inhibition may improve recovery in
diabetics. These results indicate that excessive post-ischemic loss of BBB integrity in diabetics
is partially mediated by VEGF signaling, which can be ameliorated with inhibitors of VEGF-R2.
Given the deleterious effects of excessive plasma leakage on neuronal health, restoring BBB
integrity offers a promising approach to restore adaptive plasticity in diabetics following stroke.
P2.044
Endothelial Ectosomes and the Progression of Small Vessel Disease
Schock, SC1 Burger, D2 Edrissi, R1 Cadonic, R1 Hakim, AM1 Thompson, C1; 1. OHRI
Neuroscience and the University of Ottawa, Ottawa, ON; 2. Kidney Research Centre, Univerity
of Ottawa, Ottawa, ON
Background: Cerebral small vessel disease (CSVD) is a progressive condition and a major cause of
vascular dementia. An early pathological feature of CSVD is an increase in blood brain barrier (BBB)
permeability. Ectosomes (microparticles) are small, membrane bound vesicles that are released into
the circulation by a variety of cell types and have been found to increase in several cardiovascular dis-
orders. In the present study circulating levels of ectosomes were measured in a rodent model of CSVD
and some of their properties characterized in vitro. Methods: Chronic cerebral hypoperfusion (CCH)
was induced in male Long Evans rats by permanent bilateral common carotid artery occlusion. Cir-
culating ectosomes were examined by flow cytometry and electron microscopy. Purified ectosomes
were added to cultured rat brain microvascular endothelial cells, cell viability assessed by LDH assay
and barrier permeability assessed by measuring electrical resistance (TEER). BBB permeability was
assessed in vivo using the Evans Blue assay. Results: Following the induction of CCH circulating lev-
els of annexin V + and VE-cadherin + ectosomes were significantly elevated. When added to cultured
endothelial cells ectosomes induced caspase 3-dependent cell death. A TNF-α receptor blocker and
a neutralizing antibody against TRAIL significantly reduced apoptosis. When ectosomes were added
to artificial endothelial barriers there was a significant decrease in electrical resistance and when
injected into the circulation of unoperated rats there was an increase in BBB permeability. Conclu-
sions: Cerebral ischemia causes an increase in circulating ectosomes. Purified ectosomes induce
apoptosis in cultured endothelial cells and a reduction in TEER when added to artificial endothelial
barriers. When injected into the circulation of unoperated rats the ectosomes cause a decrease in
BBB permeability. Ectosomes may be involved in the disruption of the BBB that accompanies human
CSVD and a variety of other neurological conditions and may participate in the progression of CSVD.
P2.045
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
knock-out mice compared to wild-type mice upon 3-7 days recovery. Furthermore, deletion
of BNIP3 gene in cortical neurons of knock-out mice activated a robust autophagic response.
This increased autophagic response in BNIP3-null neurons was accompanied by a decreased
apoptotic response, which may coordinately contribute to the neuroprotection in the knock-out
animals. Conclusions: Our results indicate that BNIP3 is an important upstream regulator for
both autophagy and apoptosis processes in delayed neuron damage in stroke.
P2.046
The Influence of Post-Stroke Lower-Limb Spasticity on the Control of Standing
Balance: Short-Time Cross-Correlation and Coherence Between Individual Limb
Centres of Pressure
 e40  Stroke  December 2013
Singer, JC1 Mansfield, A1, 2, 3 Danells, CJ1, 3 McIlroy, WE1, 2, 4 Mochizuki, G1, 2, 3; 1. Heart and
Stroke Foundation Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON;
2. Toronto Rehabilitation Institute, Toronto, ON; 3. Department of Physical Therapy, University
of Toronto, Toronto, ON; 4. Department of Kinesiology, University of Waterloo, Waterloo, ON
Background: Temporal synchronisation of force output from each lower-limb is an important in-
dex of standing balance control post-stroke1, which appears to be altered by post-stroke lower-
limb spasticity (LLS)2. While previous work has focussed on inter-limb temporal synchronisation
(time-domain), this study examines the time-varying fluctuations in inter-limb centre of 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-
sociated with post-stroke LLS. We hypothesized that individuals with LLS would exhibit greater
temporal desynchronisation, which would be associated with periods of reduced high-frequency
coherence, signifying difficulty executing balance corrections with the affected limb. Methods:
A retrospective analysis of 127 stroke survivors (43 with LLS (LLS); 74 without LLS (No-LLS);
10 without spasticity, low impairment (No-LLS-LI)) was performed. Individual-limb and net-COP
displacements in both anteroposterior and mediolateral directions were calculated during 30
seconds of quiet-standing on adjacent force platforms. The time-varying relationship between
individual limb COP displacements in the time- and frequency-domains was assessed using
short-time cross-correlation and magnitude-squared short-time coherence (MS-STC) functions,
respectively. Average MS-STC was calculated within successive 1 Hz frequency bands (0-5 Hz).
Results: The LLS group exhibited desynchronisation over a greater percentage of the trial dura-
tion than the No-LLS or No-LLS-LI groups (52.4%;29.1%;7.1%;p<0.001). Contrary to our hy-
pothesis, time-varying inter-limb temporal synchrony was related to low-frequency (<1Hz) MS-
STC for all groups. There was no relationship between temporal desynchronisation and either
the time-varying weight-bearing symmetry ratio or the net-COP displacement. Conclusions:
Reduced low-frequency, rather than high-frequency, MS-STC suggests that stroke patients with
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
centre-of-mass dynamics3. While the precise mechanisms remain unknown, stroke patients
with LLS appear to experience such challenges more frequently than those without spasticity.
1. Mansfield A, et al. NNR;2012;26:627-635.
2. Singer J, et al. Clin Biomech;2013,submitted.
3. Zatsiorsky V. et al. Motor Control;1999;3:28-38.
P2.047
Dynamic Control of Pannexin 1 Expression Following Stroke
Swayne, L; Wicki-Stordeur, LE; Boyce, AK; University of Victoria, Victoria, BC
Background: In the face of considerable cell death, the brain has a remarkable capacity for
recovery following stroke. Currently, we are largely unable to optimize this innate process in part
due to knowledge gaps in our understanding of the underlying cellular and molecular mecha-
nisms. Pannexin 1 (Panx1) is a large pore ion and metabolite permeable channel that is thought
to play a major role in mediating vulnerability of neurons in ischemia, in part through dysregula-
tion of ion fluxes and by initiating inflammatory responses that contribute to expansion of injury.
In addition to previously reported expression in mature neurons, and astrocytes, recent work
from our lab indicates that Panx1 is also highly expressed in developing neurons and can modu-
late their behaviours. Notably, Panx1 is activated by several stimuli in the post-stroke brain.
Given that activation of ion channels can often trigger changes in their expression levels, we
investigated whether stroke-associated stimuli alter the expression of Panx1, as this could have
important implications for the innate recovery responses of several cell types following stroke.
Methods: To model stroke in mice in vivo, we induced photothrombosis in the sensorimotor
cortex. We also examined the effects of a variety of stroke brain stimuli (elevated extracellular
potassium, adenosine triphosphate and oxygen and glucose deprivation) in several cell culture
models. To determine Panx1 levels in these models, we used a combination of Western blotting
and live and fixed cell confocal immunofluorescence microscopy. Results: Here we provide
evidence that Panx1 levels are dynamically regulated in a cell-type and region-specific way in
the post-stroke brain. These results were recapitulated in vitro. Conclusions: Together our data
indicate that Panx1 levels change over time following stroke and that this dynamic regulation
could play an important role in the innate repair and recovery processes.
P2.048
The Effect of Cortical Lesion Size on the Reorganization of ispi and Contralesional
Motor Representations
Touvykine, B1 Mansoori, BK1 Jean-Charles, L1, 2 Quessy, S1 Dancause, N1, 2; 1. Université de
Montréal, Montréal, QC; 2. GRSNC, Montréal, QC
Following stroke, patients often have abnormal activation in the injured and intact hemispheres.
The influence of lesion size on the reorganization of motor representations in the ipsilesional
cortex has been previously supported. However, no study has yet investigated how lesion size
affects cortical reorganization in both hemispheres. We thus investigated how the size of cortical
lesions influences the reorganization of the caudal and rostral forelimb areas, the rat’s equiva-
lent of the primary motor cortex (M1) and a premotor area respectively, in both the ipsi and con-
tralesional hemispheres. In adult rats, endothelin-1 was used to induce lesions of either small or
large volume in M1. The behavioral performance of the paretic and non-paretic forelimbs was
evaluated with the Montoya Staircase task, twice the first week and then once a week until day
28 after lesion induction. At the end of the recovery period, the cortical organization of M1 and
the premotor cortex was evaluated with intracortical microstimulation techniques. Motor maps
of animals with small and large lesions were compared to each other and to normal, control rats.
Effective lesion size was confirmed with histological reconstruction.
Rats with large lesions had greater behavioral deficits than rats with small lesions. The ip-
silesional M1 was bigger in rats with small lesions than with large lesions. No change was
observed in contralesional M1. Finally, size of the ipsi and contralesional premotor area changed
compared to controls and significantly correlated with the size of the lesion in both groups.
Our results show that larger lesions result in greater reorganization of the premotor areas in
both hemispheres. In the contralesional hemisphere, the reorganization of the premotor cortex
is more sensitive to lesion size than is M1, and this area may play a greater role in postlesion
recovery of the paretic forelimb or compensation with the non-paretic forelimb.
P2.049
Molecular Effects of Salt-Induced Hypertension on the Development of Acute
Ischemic Stroke in Heterozygous ANP Gene-Disrupted (ANP+/−) Mice
Ventura, NM1 Peterson, NT1, 2 Tse, MY1 Wong, PG1 Jin, AY2, 1 Andrew, R1 Pang, SC1; 1. Queen’s
University, Kingston, ON; 2. Kingston General Hospital, Kingston, ON
Background: Hypertension (HT) is one of the leading risk factors for ischemic stroke. Although
previous investigations have shown the role of HT in myocardial infarction (MI), the effect of salt-
sensitive HT on cerebrovascular events during and after stroke is unclear. Thus our objective was
to assess cerebrovascular adaptations occurring in salt-induced hypertensive mice following acute
ischemic stroke. Four major vasoactive systems were targeted for this study - the natriuretic peptide
system (NPS), nitric oxide system (NOS), renin-angiotensin system (RAS) and endothelin system
(ETS), to better understand the role of salt-sensitive HT in the development stroke. Methods: Salt-
sensitive ANP+/− mice were fed a high salt (HS) (8.0% NaCl) or normal salt (NS) (0.8% NaCl) diet for
7 weeks to induce HT. Acute ischemic stroke was surgically induced by 30 min left middle cerebral
artery occlusion (MCAO) via intraluminal filament. Sham operated mice were used for control. Brain
slices (1mm) were obtained 24 hr post reperfusion and stained in 2,3,5-triphenyltetrazolium chloride
(TTC). Infarct volume was measured using ImageJ software by two blinded observers. Systolic blood
pressure (SBP) was measured by non-invasive tail cuff (Kent Scientific) to ensure development of HT
in the HS treatment group. Vasoactive system peptides and peptide specific receptor mRNA were
measured by real-time quantitative PCR in the fourth brain slice. Results: ANP+/− mice treated
with HS developed HT, left ventricular hypertrophy and experienced significantly larger infarcts as
compared to normotensive mice (P=0.0015). Infarct volume inter-observer correlation coefficients
were R=0.9043 in HS and R=0.9920 in NS treatment groups. No significant differences in mRNA
expression of the NPS or RAS were detected. The NOS and ETS both showed higher levels of expres-
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.
P2.050
Hypothermia does not Influence Iron-induced Injury in Rat Models of
I­ ntracerebral Hemorrhage
Wowk, S; Ma, Y; Colbourne, F; University of Alberta, Edmonton, AB
Background: Hypothermia, used to treat cardiac arrest and neonatal hypoxic–ischemic encepha-
lopathy, is undergoing clinical trials for ischemic and hemorrhagic stroke. Animal studies show a
strong hypothermic neuroprotection against ischemia but little benefit for intracerebral hemorrhage
(ICH). This is surprising because hypothermia attenuates several mechanisms of injury common
to both stroke types such as inflammation and edema. This lack of benefit suggests hypothermia
does not treat key secondary mechanisms of injury specific to ICH or results in harmful side effects.
Thus, we are studying whether hypothermia mitigates oxidative damage caused by iron released
from degrading erythrocytes. We evaluated whether hypothermia alters iron release and accumula-
tion (i.e., hemoglobin breakdown), iron-induced cell death, and levels of iron-binding proteins and
antioxidants. Methods: Rats were given a striatal ICH and parenchymal non-heme iron levels were
measured either 3 or 7 days later. Behaviour was tested in those euthanized at 7 days. In all experi-
ments rats received either 72 hours of hypothermia (33°C; starting 12 hours post-ICH or 1 hour after
FeCl2 injection) or normothermia. A simplified model involving striatal injections of FeCl2 was used
to evaluate iron-induced edema 1 and 3 days post-insult, as well as, tissue loss, neuronal degenera-
tion, and behavioural impairment 7 days post-insult. Finally, rats were given a striatal ICH and ferritin
and antioxidant levels were measured at 3 days. Results: Hypothermia did not delay the release
of non-heme iron or improve behavioural impairments after ICH. FeCl2 caused edema, tissue loss,
neuronal degeneration, and behavioural impairment which were not affected by hypothermia. Hy-
pothermia’s influence on ferritin and antioxidant levels is currently being analyzed. Conclusions:
These results suggest that hypothermia is not targeting iron-mediated damage and it is possible that
hypothermia limits endogenous defense mechanisms (in progress). Through the use of combination
therapies, future research will focus on maximizing neuroprotection against ICH.
P2.051
Evaluating the Effectiveness of Southwestern Ontario’s Community Stroke
Rehabilitation Teams
Allen, L1, 4 Richardson, M1 Meyer, M1, 4 Ure, D2 Jankowski, S2 Teasell, R3, 1; 1. Lawson Health
Research Institute, ARGC , London, ON; 2. St. Joseph’s Health Care, London, ON;
3. St.Joseph’s Health Care, Department of Physical Medicine and Rehabilitation, Parkwood
Hospital, London, ON; 4. Western University, Department of Epidemiology and Biostatistic ,
London, ON
Introduction: The Community Stroke Rehabilitation Teams (CSRT) provide a community-based
interdisciplinary approach to stroke rehabilitation. Our objective was to assess the effectiveness
of the teams with respect to functional and psychosocial outcomes experienced by clients served
by these teams. Methods: Functional and psychosocial outcome data was available at intake and
discharge from the program, as well as at six-month follow up. Repeated measures ANCOVA and
 Abstracts From the 4th Canadian Stroke Congress, 2013  e41
paired t-tests were performed as appropriate to assess patient changes between time points for
each outcome measure. Results: Data was available for 919 individuals (55% male) with a mean
age of 69.3 (±13.1) years. Significant improvements were found between intake and discharge
on the Hospital Anxiety and Depression Scale total score (HADS)(p<0.0001), HADS Anxiety sub-
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-
ticipation (p<0.0001), memory (p=0.012), and physical (p<0.0001) domains of the Stroke Impact
Scale (SIS). These improvements were maintained at 6 month follow up. Improvements on the
Reintegration to Normal Living Index were significant between intake and discharge (p=0.037).
Follow up data was not available for this measure. Conclusions: Results indicate that the CSRT’s
were highly effective at improving the functional and psychosocial recovery of patients after stroke.
Importantly, these gains were maintained at 6 month follow-up after discharge from the program.
Additional analyses are planned to further explore the impact of the CSRTs on patient recovery
and the caregiving experience. This study shows the benefit of interdisciplinary outpatient stroke
rehabilitation provided in the patient’s home on functional and psychosocial outcomes.
P2.052
Understanding the Experience of People with Communication Disability After
Stroke Outside Their Home in Transaction Situations
Anglade, C1 Croteau, C2 Le Dorze, G2, 3; 1. Université de Montréal - CRIR - CRLB, Montréal, QC;
2. Faculté de médecine-Orthophonie et audiologie Université de Montréal, Montreal, QC;
3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, QC
Rationale: People with communication disability (PWCD) after stroke show decreased social
participation, including fewer outings (Dalemans, De Witte et al 2010). However, few reports
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concern how PWA communicate outside their home intransactional situations with unfamiliar
people. Since such transactions occur in natural communication contexts (Traverso, 2009),
we anticipate that they will differ from traditional communication assessments undertaken by
speech and language pathologists (SLP). Objectives: 1) Describe how PWCD interact/commu-
nicate when shopping; 2) understand the experience of PWCD when shopping; 3) understand
the experience of shop-keepers when interacting with PWCD; 4) engage SLPs in reflecting on
their practice based on the emerging results. Participants: The project includes three groups of
participants: 10 PWCD post-stroke (aphasia / dysarthria), 20 storekeepers and five SLP working
in rehabilitation. Design: We will undertake multiple qualitative case studies with PWCD. Par-
ticipants WCD will be accompanied individually by the researcher during visits at two shops and
interactions will be recorded as they occur naturally in a shopping outing. The researcher will
employ participant observation for the analysis of the live portion of data collection and conver-
sational analysis for the filmed interactions. After each transaction, a short qualitative interview
will be conducted with shopkeepers to determine his/her views of the interaction with the PWCD.
Before and after each outing, a semi-structured interview will be conducted with participants
with PWCD to understand their experience. As the results emerge, these will be provided to SLP
participants who will be invited to reflect upon them and discuss practice options for such com-
munication interactions. Preliminary results from this Ph.D. research project will be provided.
Scope: This project will help to understand the experience of PWCD in natural communication
situations and influence aphasia/dysarthria rehabilitation.
P2.053
Effect of BMI on Inpatient Rehabilitation Outcomes after Stroke
Armstrong, R; Wang, H; Dessureault, L; Canadian Institute for Health Information, Ottawa, ON
Background: Studies have reported an inverse relationship between body mass index (BMI)
scores and relative improvement of function in inpatient rehabilitation. High BMIs have also been
associated with increased lengths of stay (LOS) and decreased FIM® efficiency. However, a grow-
ing body of clinical data suggests a survival benefit (e.g., decreased mortality rates) for overweight
patients after stroke and, using the Barthel index, greater improvements in functional outcomes
have been reported in obese patients compared to normal-weight patients. Given the variation
in findings, this study sought to examine the impact of BMI on inpatient rehabilitation LOS and
functional outcomes following stroke using a large pan-Canadian dataset. Methods: Using data
from the National Rehabilitation Reporting System (NRS), stroke clients discharged in fiscal years
2010-2011 and 2011-2012 (n=9,380) were divided into 5 BMI groups: underweight (<18.5 kg/
m2), normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), moderate obesity (30 - 39.9 kg/
m2), and severe obesity (≥40 kg/m2). A Poisson regression model was used to analyze the effect
of BMI group on LOS when adjusted for age, sex, stroke type, number of pre-admit comorbidities,
discharge destination, province of residence, socio-economic status, and presence of depression,
hypothyroidism, congestive heart failure, hypertension and diabetes. Results: Patients in this study
sample had a mean age of 69.9 years. After adjusting for multiple covariates, overweight and mod-
erately obese patients demonstrated shorter LOS compared with those in the normal BMI group
(both p<.0001), whereas LOS was significantly longer in underweight (p<.0001) and severely
obese (p<.01) patients compared to normal-weight patients. Moderate and severely obese patients
experienced the greatest increases in FIM® scores from admission to discharge. Conclusions: Fol-
lowing stroke, overweight and moderately obese patients had shorter stays in inpatient rehabilita-
tion with equivalent functional improvements compared to patients with a BMI in the normal range.
P2.054
Residual Motor Deficits Revealed Using a Complex Reaching Task in Individuals
with Good Arm Recovery After Stroke
Baniña, MC3, 4 McFadyen, BJ2, 1 Levin, MF3, 4; 1. Centre Interdisciplinaire de Recherche en
Réadaptation et Intégration Sociale, Québec, QC; 2. Département de réadaptation, Faculté
de médecine, Université Laval, Québec, QC; 3. School of Physical and Occupational Therapy,
Faculty of Medicine, McGill University, Montreal, QC; 4. Feil-Oberfeld Research Centre,
Jewish Rehabilitation Hospital site of Centre for Interdisciplinary Research in Rehabilitation,
Montreal, QC
After stroke, individuals with good clinical recovery of their affected arm may still report
decreased use in ADLs. Decreased use may be associated with undetected deficits identi-
fied when individuals attempt higher-order motor tasks requiring complex coordination.
One higher-order motor task, avoiding obstacles while reaching, commonly occurs in ev-
eryday environments but is not routinely assessed by clinical scales. We hypothesized that
well-recovered people after stroke would be less successful in avoiding an obstacle in the
reaching path compared to healthy controls. Obstacle avoidance ability during reaching
in a virtual environment was compared between groups. The environment simulated a
commercial refrigerator with shelves and sliding doors. Subjects reached as fast as pos-
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-
out hitting the door. Overall success rates, movement performance and quality variables
for unobstructed (T), successful avoidance (Succ), and failed avoidance (Fail) trials were
recorded. In T trials, stroke subjects used less wrist flexion, wrist abduction and shoulder
rotation compared to controls. For obstructed trials, 36% of controls and 12% of stroke
subjects were successful >65% of the time. For both groups, successful door avoidance
was characterized by changes in the trajectory path occurring closer to the starting posi-
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
controls to achieve success. Results suggest that stroke subjects had residual movement
deficits revealed through a challenging motor task. The potential of using challenging
tasks to identify higher order motor control deficits should be considered when assessing
post-stroke motor recovery.
P2.055
“Care” and “Cure”
Barreau, J; Belson, L; Villa medica, Montreal, QC
The aim of the study was to measure patients’ expectations of Villa Medica Rehabilitation
Hospital in terms of humanism: the “care”. The survey was conducted from June to December
2012. Data collection was made possible through questionnaires given to interested patients
and was stored using Excel 2010. Statistical analysis were made using SPSS 16.0 for Win-
dows. Divided in two strata, the questionnaire looked, in the first place, patients’ satisfaction;
while it opened, in the second place, to the patients’ expectations in terms of humanism. Three
indices emerged. The first index is the “active listening”. 80 % of the questioned patients
wanted to put “active listening” at the center of their cure. Indeed, the study shows the urgency
for the patients to put into words their troubles in a humanistic professional listening. The
second index is the “group talk”. 20 % of the patients expressed a desire to share with one (or
more) of their fellow(s) their experienced trauma. Onset or ongoing of the “active listening”?
The third index is the “interiorization”. 37 % of the questioned patients mention their desire to
proceed to a way of interiorization, conscious that it might order or conduct the cure. Via these
three indices, the study highlights the necessity to set up a “care” which not only accompanies
the “cure” but also carries it. Besides, this study raises the question of the feature of interdis-
ciplinarity: is it only controlled by the sharing of expertise or, more exactly, is it unified by the
principle of humanism?
P2.056
Validation de contenu d’un outil d’évaluation de la compréhension syntaxique de
personnes ayant une aphasie
Bergeron, A3 Bourgeois, M3 Fossard, M2 Desmarais, C1 Lepage, C3; 1. Université Laval,
Québec, QC; 2. Université de Neuchâtel, Neuchâtel, Switzerland; 3. Institut de réadaptation en
déficience physique de Québec, Québec, QC
L’aphasie est la perte partielle ou totale du langage qui peut survenir à la suite d’une lésion céré-
brale. Les personnes ayant une aphasie peuvent présenter des difficultés de compréhension
touchant spécifiquement les phrases. La recherche a montré que le processus de compréhen-
sion de phrases se fait en plusieurs étapes, et que les personnes avec une aphasie peuvent
éprouver des difficultés à l’une ou l’autre de ces étapes. Or, en clinique, ces distinctions sont
rarement prises en compte lors de l’élaboration des épreuves d’évaluation. Pour pallier cette
lacune, un nouvel outil a été créé à l’Université Laval : la « Batterie d’évaluation de la com-
préhension syntaxique » (Caron, LeMay & Fossard, 2010). L’objectif de la présente étude a été
de documenter la validité de contenu de la batterie. Pour ce faire, un questionnaire de validation
a été élaboré afin d’évaluer différents aspects de la batterie tels que la clarté des consignes
et des images, la qualité des items-tests et la pertinence clinique. Trois chercheurs et neuf
orthophonistes ont été sollicités pour compléter le questionnaire. Les données recueillies ont
ensuite été soumises à une analyse quantitative et qualitative. Les résultats obtenus ont permis
de démontrer la validité de contenu de la batterie et d’en identifier les éléments à améliorer.
Ceux-ci concernent entre autres l’ambiguité de certaines images, les explications théoriques, le
choix de certains items-test, la formulation des consignes et la configuration des grilles de nota-
tion du test. L’équipe de recherche a effectué les modifications à l’outil initial afin d’en arriver à
une version qui pourra être utilisée par des cliniciens. Cette batterie permettra de mieux cibler
les difficultés de compréhension des personnes ayant une aphasie et de choisir des méthodes
d’intervention plus spécifiques. Des étapes ultérieures de validation et de normalisation sont
également envisagées.
 e42  Stroke  December 2013
P2.058
Common Forms of Vascular Cognitive Impairment in a Canadian Inpatient Stroke
Rehabilitation Sample
Carter, SL1, 2 DeFreitas, VG1; 1. QEII Health Sciences Centre, NS Rehabilitation Centre, Halifax,
NS; 2. Dalhousie University, Halifax, NS
Background: Canadian best practice recommendations for stroke care include screening and
assessment for vascular cognitive impairment (VCI). Specific forms of VCI may be under-identi-
fied in Canadian inpatient rehabilitation units given high screening rates but low comprehensive
assessment rates (McClure et al., 2012). Identifying common forms of VCI in inpatient settings
could improve post-stroke assessment and rehabilitation. Methods: Common forms of VCI were
examined in a convenience sample of 47 stroke patients from an inpatient rehabilitation facility
who completed a brief neuropsychological assessment (NAB Screening Module). Two cases
were excluded due to language barriers. Mean age was 55.4 years, mean education was 12.3
years, 62% were male, 87% were right-handed, and 78% had ischemic strokes (bilateral 22%;
left 42%; right 36%). Frequency of scores < 5th percentile was examined for NAB index and
subtest scores; correlates of low scores were investigated via Pearson-r. Results: Compared
to age and education-corrected norms, impairment rates were highest on indices of attention/
speed (A/S; 51%) and executive functions (EF; 24%), with lowest mean scores on timed can-
cellation subtests. Mean indices of language, memory, and visuospatial skills were average.
34% of the sample scored < 5th percentile on a summary index of global cognitive function.
Speeded attention and mental flexibility was strongly correlated with global cognitive function
(Trails B r=-0.74, p<0.01), A/S (r=-0.52, p <0.01), and EF (r=-0.51, p<0.01) indices. Global
cognitive function was also correlated with simple speeded attention and sequencing (Trails A
r=-0.46, p<0.01). A/S and EF indices correlated modestly with letter fluency (r=0.42 p<0.01
and r=0.36 p<0.05, respectively); only EF correlated with animal fluency (r=0.43, p<0.01).
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
Conclusions: A/S and EF are most frequently affected in a Canadian inpatient stroke rehabilita-
tion sample, consistent with domain-specific classification rates in chronic stroke (Stricker et al,
2010). These findings guide targeted cognitive rehabilitation programming for inpatient stroke
survivors.
P2.059
The Journey to Better Stroke Care at North York General (NYG)
Chin-Curtis, LA; Carley, T; Ramdeyall, S; Villar-Guerrero, E; North York General, Toronto, ON
Background: As part of the Stroke Flow Initiative, North York General (NYG) dedicated funding
for the development and implementation of a Stroke Assessment and Treatment Team (SATT) to
improve outcomes for newly diagnosed stroke patients by aligning with Canadian Best Practice
Recommendations for stroke care. Past practices at NYG had stroke patients being assessed
by Speech-Language Pathology (SLP) within 24-72 hours of admission, an inter-professional
team assessment, as time and resources permitted 5 days/week, completion of the Alpha-FIM
when patients were rehab ready, and inconsistent use of E-Stroke referral system, as the pri-
mary referral system for patients requiring stroke rehab. Methods: As part of the initiative, NYG
now has 10 designated stroke beds allotted within a 32 bed medical unit; the Toronto Bedside
Swallowing Screening Test (TOR-BSST) is completed within 24 hours of admission for newly
diagnosed stroke patients; an assessment by an inter-professional team (SATT) is completed
within 48 hours of admission; the Alpha-FIM is completed on Day 3 of admission; and E-stroke
is exclusively used for all stroke patients requiring rehabilitation. Results: The development of
SATT promotes early inter-professional team involvement, which in turn allows for early mobili-
zation and facilitates expedited discharge to rehab and/or community integration through CCAC
in-home supports. NYG seeks to meet and exceed Stroke Flow Initiative targets by aiming to
send 30 – 40% of stroke patients to rehab by Day 5 for ischemic stroke patients, and Day 7 for
hemorrhagic stroke patients from the time of admission. Conclusions: Currently, NYG is meet-
ing Canadian best practice guidelines for stroke care with the aspiration for better outcomes for
stroke patients. An educational roll-out is planned for the next phase of this initiative. Internal
processes within the organization (i.e. access to diagnostics, bed control processes) are being
evaluated, in order to improve the stroke flow initiative targets/expectations.
P2.060
The Activities Balance Confidence Scale: Longitudinal Changes and Its Relation
to Other Measures Post Stroke
Cohen, EJ1 Danells, CJ1, 2 McIlroy, WE3, 1; 1. Centre for Stroke Recovery , Toronto, ON;
2. Sunnybrook Health Sciences Centre, Toronto , ON; 3. University of Waterloo, Waterloo, ON
Background: The Activities Balance Confidence Scale (ABC) is a valid and reliable tool for the
stroke population. It explores one’s confidence ratings in maintaining balance while complet-
ing various community-based functional tasks. Studies have shown its relation to some physi-
cal measures. There is little data present in the literature about how confidence changes over
time and how it relates to changes that occur in other measures. Methods: Patients (n = 28)
were selected from the Centre for Stroke Recovery Rehabilitation Affiliates Longitudinal Stroke
database. Patients living in the community were asked to complete the ABC. There were 48
completed assessments and 14 patients had completed 2 or more ABC assessments longitu-
dinally. As well assessments of cognition (MoCA), depression (CES-D), balance (Berg Balance
Scale), function (FIM) and walking speed (2 minute walk) were completed. Results: Cross sec-
tional results revealed correlations to walking speed (r=0.59) and Berg (r= 0.69) as previously
indicated in the literature. In contrast there was no association between ABC and time post
stroke (r=0.18), MoCA (r=0.15) or the CES-D (r=-0.07). Those who answered yes to “do you
have a fear of falling” had a lower average confidence score. Longitudinal data revealed a weak
relationship between ABC changes and changes in: gait speed (r =-0.39), Berg (r=0.13), CES-D
(r=-0.30), FIM (r=-0.37) and MoCA (r=0.14). In addition, for the 3 participants who made the
largest improvements in their ABC, there were no related improvements in the other domains.
Conclusions: Confidence is often overlooked in assessments post stroke and may be an in-
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
simply a product of physical ability and is a potentially important and independent characteristic
that may influence stroke recovery.
P2.061
A Randomized Controlled Study Assessing the Effectiveness of Aphasia-Friendly
Schedules on Therapy Attendance
Collins, D1 Marcoux, C1 Modha, G1 Poirier, B1 Silverberg, ND1, 2 Louie, S1; 1. Vancouver Coastal
Health-GF Strong Rehab, Vancouver, BC; 2. Division of Physical Medicine & Rehabilitation,
Faculty of Medicine, University of British Columbia, Vancouver, BC
Background: A person living with aphasia faces language-based barriers, analogous to people
with physical disabilities living in inaccessible environments. Although stroke rehabilitation
centers are physically accessible, clients with aphasia may have difficulty navigating them.
Frequent tardiness or missed therapy appointments may limit rehabilitation gains. The pur-
pose of this study was to compare the ability of clients with aphasia in an inpatient stroke
rehabilitation setting to independently attend therapy appointments when provided with a
picture-based schedule versus a traditional text-based schedule. Methods: A parallel group
open-label design was utilized. Twenty seven participants with post-stroke moderate to severe
aphasia, as indexed by the Boston Diagnostic Aphasia Examination, were randomly assigned to
a control group (text-only schedule; n=15) or an experimental group (picture and text schedule;
n=12). Over the 15-day study period, therapists completed an attendance record for each par-
ticipant. The primary outcome was the proportion of independently attended therapy sessions.
Independent attendance could involve physical assistance by another person if directed by the
participant. Results: The intervention effect was not significant (F=2.02, p=.17), with a trend
favouring the control group. Further analysis demonstrated that participants in both groups with
severe aphasia attended fewer sessions independently (n=12; M=0.66, SD=0.62) than those
with moderate aphasia (n=12; M=0.92, SD=0.12), F=8.25, p=0.009. Conclusions: The results
from this pilot study suggest that the addition of pictures to a text-based therapy schedule may
not be sufficient to improve independent therapy attendance in clients with aphasia after stroke.
Further environmental supports and/or accommodations may be required, particularly for people
with more severe aphasia.
P2.062
Development of a Clinical-Research Platform: Baseline Portrait of the Intensity
of Interventions in the Stroke Unit of the Institut de Réadaptation en Déficience
Physique de Québec (IRDPQ)
D’Amours, L1 Durand, A2 Malouin, F3 Pelletier, F2 Richards, C3; 1. Institut de réadaptation
en déficience physique de Québec, Quebec, QC; 2. IRDPQ, Quebec, QC; 3. Université Laval,
Québec, QC
Background: One of the projects of the (CIHR) Sensorimotor Rehabilitation Research Team
(SMRRT) is the development and implementation of clinical-research platforms to promote in-
teractions between clinicians and researchers to optimize rehabilitation post stroke. To evaluate
the impact of this platform a portrait of clinical practice pre and post project was required.
Methods: On the last week of April 2012 (five days), the intensity of rehabilitation interventions
provided to 18 in-patients with stroke was recorded from 8am to 9pm.The clinicians (OT, PT,
kinesiologist, nursing staff and physical rehabilitation technician (PTT)) recorded the duration
of their interventions (one to one or in groups) on discipline-specific log sheets. The time spent
with a rehabilitation assistant and practice by the patients outside of official therapy time was
also included. Results: The patients received an average of 13 hours of rehabilitation interven-
tions per week (range: 9 to 22 hours). Eleven of the 13 average weekly hours were dedicated to
supervised individual therapy (an average of 9 hour were given by OT, PT, PTT and the assistant
and an average of 2 hours of rehabilitation activities were given by nursing staff). Lower FIM
scores were correlated (r = -.75, p<.000) with more time with the nursing staff. Nine patients
(50%) also participated in group therapy, thus adding an average of 1 hour per week. The 60%
of patients who practiced outside of official therapy time also increased the intensity by an
average of 1 hour per week. Conclusions: This project has allowed us to document the actual
intensity of interventions received by the patients in our stroke unit and has helped us target
gaps for improvement.
P2.063
Walking Activity During Inpatient Stroke Rehabilitation: Exploring the
­Relationship Between Amount of Practice and Recovery of Gait Control
DePaul, VG1 Wong, J2 Patterson, KK3, 2 McIlroy, WE5, 4, 2 Mansfield, A2, 4, 3; 1. McMaster Univer-
sity, Hamilton, ON; 2. Toronto Rehabilitation Institute, University Health Network, Toronto, ON;
3. Department of Physical Therapy, University of Toronto, Toronto, ON; 4. Heart and Stroke
Foundation Centre for Stroke Recovery, Toronto, ON; 5. Department of Kinesiology, University
of Waterloo, Waterloo, ON
Background: Abundant task-specific practice is commonly recommended as an essential in-
gredient of rehabilitation; however, there has been limited research that specifically examines
the relationship between ‘everyday’ walking and improved control of walking after stroke. The
purpose of this study was to explore the association between amount of daily walking activ-
ity and change in temporal-spatial gait parameters following stroke. Methods: This study is a
 Abstracts From the 4th Canadian Stroke Congress, 2013  e43
subgroup analysis from an ongoing rehabilitation trial. Participants were ambulatory individuals
undergoing inpatient stroke rehabilitation. Amount of walking was recorded using bilateral ac-
celerometers over an average of 10 days per individual. Temporal-spatial gait parameters were
assessed at study enrolment and rehabilitation discharge using the GAITRite walkway. Spear-
man correlation was conducted to explore associations between amount of walking activity and
change scores in gait pace, symmetry, and variability. Results: Initial analysis revealed that the
first 19 participants took an average of 4553 steps (SD 2292; MAX 11891; MIN 2367) and spent
55.18 minutes (SD 20.27; MAX 100; MIN 27) walking per day. Over the study period, participants
changed velocity (mean +40%), cadence (+10%), step length (+13%), and variability of step
length (-17%), step width (+19%), and step time (-6%). Gait symmetry ratios did not change.
While there was evidence of possible relationships between measures of walking activity and
change in step width variability (r=-0.41, p=0.09) and step time variability (r=0.41, p= 0.08),
associations between measures of amount of walking activity and change in indicators of gait
control were not statistically significant. Conclusions: In this study, amount of daily walking
activity was quite variable across individuals in inpatient stroke rehabilitation. Importantly, the
amount of daily walking activity was not significantly associated with improvements measured
in temporal-spatial gait outcomes. Further research is needed to explore the relationship be-
tween both the amount and quality of practice and recovery of walking after stroke.
P2.064
Development of a Clinical-Research Platform: Baseline Portrait of the Clinical
­Approach and Outcomes Measures in the Stroke Unit of the Institut de
Réadaptation en Déficience Physique De Québec (IRDPQ)
Durand, A1, 2 D’Amours, L1 Malouin, F2, 3 Pelletier, F1, 2 Richards, CL2, 3; 1. Institut de
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­réadaptation en déficience physique de Québec, Québec, QC; 2. Centre interdisciplinaire de
recherche en réadaptation et intégration sociale , Québec, QC; 3. Université Laval, Québec, QC
Background: Clinicians from stroke units in 3 Rehabilitation Centers of Quebec have collabo-
rated with the CIHR SensoriMotor Rehabilitation Research Team (SMRRT) to create clinical-re-
search platforms (CRP) to promote best practices. To evaluate the impact of the CRPs, a portrait
of clinical practice before their creation was required. This presentation describes the baseline
clinical portrait at IRDPQ. Methods: Baseline clinical practice was documented by 1) therapy
intensity, 2) a chart audit and 3) clinicians’ perceptions of their practice. Findings from the chart
audit and clinicians’ perceptions are reported. Twenty of 74 charts were audited with a stan-
dardized assessment grid. Selected charts were representative of stroke severity based on FIM
scores of patients admitted to the stroke unit April 1st, 2011 to March 31st, 2012. To document
practice perception, 12 clinicians (7 OT and 5 PT) were administered a questionnaire (based on
Canadian best practice recommendations) on the SurveyMonkey web-platform. Results: Gener-
ally, clinicians applied recommended best practice modalities (100% of patients were engaged
in task-oriented gait training and 85% in task-specific training of the upper extremity). Based
on the chart audit, the most frequently used outcomes measures were the FIM (100%), the
Chedoke activities inventory (100%), the Berg Balance Scale (100%) and walking speed (70%).
Conversely, the CAHAI was never used. Although clinicians perceived that modalities such as
constraint-incuded movement therapy, mental practice, functional electrical stimulation or body
weight supported treadmill walking were applicable with 8 to 26 % of their patients, they used
these modalities with only 0 to 12%. Clinicians’ perceptions were corroborated by the chart
audit. Conclusions: In addition to providing a baseline for the evaluation of the effects of the
CRP on clinical practice and patient outcomes, this portrait will serve as a guide for closing the
gaps to tend towards best practices.
P2.065
”Connections”; Peer to Peer support linking acute care to community
reintegration
Elton-Smith, GM1 Palashniuk, E2; 1. Alberta Health Services, Edmonton, AB; 2. Stroke Recovery
Association of Alberta, Red Deer, AB
Background: Post-discharge from hospital care is reported by stroke survivors as a stressful
and challenging time (Canadian Best Practice Guidelines 2010). Peer Support enables survivors
to assist one another in adjusting to new roles and potentially altered functional and cognitive
abilities. (Clarke Institute 1997). The Stroke Program Edmonton Zone (SPEZ) developed a Peer
Support Program within Edmonton area hospitals to address post-discharge needs of stroke
survivors by connecting survivors and their caregivers to the on-going support of the Stroke
Recovery Association of Edmonton (SRAE). Methods: Phase 1 of the program occurred from Au-
gust 2011-May 2012 and involved developing and implementing the Volunteer Training Program
using support and funding from the Stroke Recovery Association of Alberta (SRAA). A curriculum
for the training program was developed based on the SRA Support Group Handbook, Ottawa’s
Peer-to-Peer Training Manual, Calgary’s Inspires Educational PowerPoint, and in consultation
with SRAE members. Peer Volunteers were recruited from the SRAE and screened by SPEZ and
the Hospital Volunteer Departments. Referral procedures and processes for hospital visits were
created in consultation with each Stroke Team. Phase 2 occurred from September 2012-May
2013 and involved orienting Volunteers to the units, and implementing hospital visits of stroke
patients. Results: Six volunteers were recruited and trained to visit patients at 3 acute care
hospitals. 179 patients received visits and were provided with emotional support and community
resources. 149 of these requested follow-up by phone upon discharge, and more information
regarding SRAE. Conclusions: Peer Support volunteers provide a vital link to support groups
in the community, assisting with community reintegration. Uptake of the Program has been
successful with implementation in all sites containing stroke units. In Phase 3, we will evaluate
patient satisfaction with visits as well as the effectiveness of using Peer Support to connect
stroke patients with community support.
P2.066
Acute post-stroke aphasia management: Multiple perspectives on a single
patient journey
Foster, AM1, 2 Worrall, LE3, 2 Rose, ML4, 2 O’Halloran, R4, 2; 1. The University of Queensland,
Brisbane, QLD, Australia; 2. NHMRC Centre for Clinical Research Excellence in Aphasia
Rehabilitation, Brisbane, QLD, Australia; 3. The Univerisity of Queensland / NHMRC Centre for
Clinical Research Excellence in Aphasia Rehabilitation, Brisbane, QLD, Australia;
4. La Trobe University / NHMRC Centre for Clinical Research Excellence in Aphasia
Rehabilitaiton, Melbourne, VIC, Australia
Background: While previously the focus of acute speech pathologists was the management of
communication disorders, their primary role is now in dysphagia. This shift has prompted grow-
ing interest and an increasing body of evidence about aphasia management in the acute post-
stroke phase. Little is known about the factors influencing speech pathologists’ clinical practice
in acute post-stroke aphasia management, or about how people with aphasia and their close-
others perceive speech pathology during this time. Methods: A purposive sampling approach
was utilised to recruit speech pathologists working in acute post-stroke aphasia within Australia.
Following this, a convenience sampling method was used to recruit, from the caseload of the
speech pathologist, patients with acute post-stroke aphasia and their close-other. A focussed
ethnographic approach was implemented, using a variety of qualitative data collection methods.
Observation took place throughout the person with aphasia’s acute inpatient journey, with con-
current recording of a reflective diary by the speech pathologist. Afterwards, semi-structured
interviews explored the perceptions of this admission with each participant. The collected data
were thematically analysed. Results: Results from a single triad – a speech pathologist, per-
son with aphasia, and their close-other – will be presented, exploring the perceptions of acute
aphasia management from multiple perspectives. Themes will be discussed, with reference to
the literature, to describe the perceptions of acute post-stroke aphasia management. Thematic
commonality and divergence between the different participant groups will be discussed. Con-
clusions: This study provides preliminary, in-depth information regarding the perceptions of
the speech pathology management of acute post-stroke aphasia from multiple perspectives.
By exploring the experiences of healthcare service providers and consumers, this study aims to
contribute to the understanding of how to effect change in acute aphasia management, allowing
for the creation of person-centred approaches to care and decreasing the sense of an evidence-
practice gap for clinicians in this setting.
P2.067
Quantitative Evaluation of Dynamic Balance After Stroke: Development of a Novel
Balance Assessment Toolkit
Fraser, JE1, 2 Jones, SA2 Mansfield, A2, 3, 1 Inness, EL1, 2 Wong, J2 McIlroy, WE4, 2, 1; 1. University
of Toronto, Toronto, ON; 2. Toronto Rehabilitation Institute, Toronto, ON; 3. Heart and Stroke
Foundation Centre for Stroke Recovery, Toronto, ON; 4. University of Waterloo, Waterloo, ON
Background: Current clinical assessments of fall risk and balance control post-stroke rely
largely on observational rating scales, which offer a general overview of balance ability but
provide little insight into underlying control that may help inform clinical decisions. Recent de-
velopments of sensitive, yet low-cost technology, such as the Nintendo® Wii Balance Board
(NWBB), have made it possible to quantitatively assess specific kinetic features of static balance
control within clinical settings. The aim of the current work is to develop and evaluate a novel
toolkit and protocol using multiple NWBBs, to assess dynamic balance control for clinical use
post-stroke. Methods: Outcome measures of reactive balance control (i.e. center of pressure
excursion and temporal components of movement) were captured and extracted in a sample of
healthy and post-stroke adults. The protocol included a specific set of tasks ranging from static
standing conditions to more challenging, dynamic transitions and rapid stepping tests. Results:
Initial results exploring the measurement properties in healthy adults (n=15) reveal good within-
and between-trial consistency across task conditions. For example, rapid step test performance
resulted in a mean step time duration of 0.47 ± 0.018 sec, with consistent variability between-
individuals (mean step time duration variability = 0.043 ± 0.018 sec). Conclusion: Preliminary
findings from this study suggest that the toolkit and protocol provide consistent performance
outcomes of both static and dynamic balance control in a healthy adult population. Ongoing
work is focused on validating the protocol in a sample of sub-acute stroke inpatients by compar-
ing the outcome measures of the toolkit to a ‘gold standard’ assessment of balance control using
research-grade force plates. Ultimately, this work will lead to a more comprehensive clinical
assessment of fall risk and the underlying control systems involved.
P2.068
Is the FIM® a Sufficient Measure of Communication Change in Stroke?
Barr, LG; Ansley, B; Kubilius, B; Whiteman, R; Hamilton Health Sciences, Hamilton, ON
Background: In Ontario, the Functional Independence Measure (FIM®) and supplemen-
tary Canadian Institute for Health Information (CIHI) scales are mandated for use to mea-
sure for change in stroke patients upon admission into and discharge from rehabilitation
programs. In this study we sought to learn whether the FIM® and CIHI cognitive and com-
munication items are sensitive enough to capture the actual communication gains made
in inpatient rehabilitation or whether implementation of an adjunct Speech-Language
Pathology outcome measurement is required. Methods: We completed a retrospective
analysis of 1252 stroke patients who were discharged alive between 2006 and 2011.
The purpose of the analysis was to determine whether statistically significant National
Rehabilitation Reporting System (NRS)- FIM® comprehension/expression and CIHI com-
munication scores changes could be found between admission and discharge. Results:
Statistically, significant increases in all total matched FIM® scores (M= 72.68 to M=
 e44  Stroke  December 2013
96.39 , p < 0.000) and for each expression (M= 4.61 to M=5.35 p< 0.000) and com-
prehension (M= 4.69 to M= 5.33 p < 0.000) subscales. Conclusions: Clinicians must
determine how FIM® and the supplementary CIHI data inform their practice. Although,
the results are statistically significant it remains to be known if the results are clinically
significant. Future analysis will explore whether demographics influence improvements
and whether there exists inter-relationships between the mild, moderate and severe se-
verity groups within the FIM®.
P2.069
Efficacy of Cyclosporin-Rehabilitation Combination Therapy in a Model of
N
­ eonatal Hypoxia-Ischemia
Pedrini Schuch, C2, 3, 4 Jeffers, M3, 4 Nguemeni, C3, 4 Gomez-Smith, M1 Corbett, D3, 4, 5; 1.
University of Ottawa, Ottawa, ON; 2. Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brazil; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Ottawa, ON; 4. Cellular
and Molecular Medicine, University of Ottawa, Ottawa, ON; 5. Faculty of Medicine, Memorial
University, St. John’s, NL
Every year nearly 13 million infants are born prematurely. 10% of survivors subsequently
develop hypoxia-ischemia (HI)-induced cerebral palsy with damage to both white and grey
matter and causing life-long impairments in motor function. It was previously shown that
the immunosuppressant Cyclosporin-A (CsA) promotes proliferation and migration of neu-
ral precursor cells to the site of injury in rodent stroke models. Our intention was to devel-
op a novel treatment paradigm for cerebral palsy by combining CsA with rehabilitation that
could be used in the clinic. At post-natal day (PND) 7, the Levine-Rice model was used to
produce unilateral brain injury by permanently occluding the left carotid artery. 2.5 hours
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later, the rat pups were placed in a hypoxia chamber for 90 minutes (8% O2). On PND 21,
pups were implanted with osmotic pumps delivering CsA (420 mg/mL) and divided into 5
groups: CsA+Rehabilitation; CsA+No Rehabilitation; Vehicle+Rehabilitation; Vehicle+No
Rehabilitation and sham. Animals receiving rehabilitation were housed in an enriched en-
vironment and received reach training for 4h/day, 5 days/week over 4 weeks. During reach
training, animals had access to food rewards that were obtainable using only the impaired
limb (right). Motor function was assessed pre- (PND 17) and post-rehabilitation (PND 49)
using the Montoya Staircase, cylinder and open field tests. Prior to rehabilitation, all ani-
mals were significantly impaired in cylinder (p<0.001) and open field (p=0.03). Following
four weeks of rehabilitation, all rehabilitation groups had increased activity in the open
field compared to uninjured shams. Non-rehabilitated rats were significantly less active
than both rehab (p=0.038) and sham animals (p=0.015). Similarly, rehabilitated animals
recovered to sham level in the Montoya Staircase while non-rehabilitation animals showed
significant impairments compared to all other groups (p < 0.001).
In conclusion, enriched rehabilitation significantly improved motor function in rats following
hypoxia-ischemia, while Cyclosporin-A did not impact functional recovery.
P2.070
Normal Appearing Tissue Volume is Related to Post-Stroke Cognitive Impairment
Honjo, K7, 3 Nyenhuis, DL2 Gao, F7, 3 Scott, CJ7, 3 Ganda, A1 Lobaugh, NJ3 Graham, SJ3 Zhou, XJ4
Rangwala, N4 Stebbins, GT5 Marola, J4 Gibson, E3 McNeely, AA7, 3 Stuss, DT3, 6 Black, SE7, 3, 6;
1. Sunnybrook Health Sciences Centre , Toronto, ON; 2. Hauenstein Neuroscience Center, Saint
Mary’s Health Care, Grand Rapids, MI, USA; 3. Sunnybrook Research Institute, Sunnybrook
Health Sciences Centre, Toronto, ON; 4. University of Illinois College of Medicine at Chicago,
Chicago, IL, USA; 5. Rush University Medical Center, Chicago, IL, USA; 6. Rotman Research
Institute, Baycrest, Toronto, ON; 7. Heart and Stroke Foundation Centre for Stroke Recovery
(Sunnybrook site), University of Toronto, Toronto, ON
Background: Vascular cognitive impairment (VCI) is common in post-stroke patients, af-
fecting two-thirds of stroke survivors (Hachinski, 2006). Neuropsychological testing in this
population usually shows executive dysfunction. However, relationships between lesion
volume and remaining brain and cognition have been little studied in this population. This
study examined relationships between normal appearing brain tissue and cognitive function
in chronic stroke patients. Methods: Gray matter (GM), White matter (WM), cerebrospinal
fluid, and white matter lesions were delineated by in-house software (Ramirez, 2011). In-
farct volumes were traced on 3D-T1 3T-MRI for 58 patients 6–36 months post-stroke. Brain
parenchymal fraction (BPF) was equated to the normal appearing tissue. Z-scores were
computed for the VCI-60 and 30minute protocols,1 each domain, and MoCA. Multiple linear
regression modeling forced age and education in first, and then assessed brain volumetric
measures. Results: 1) BPF contributed significantly to the regression model predicting
MoCA, 60 min, 30 min, Executive, and Spatial functions (R2=0.163,0.335,0.250,0.354,0.1
68, p<0.05). 2) Normal appearing WM (NAWM) predicted MoCA, 60min, 30min, Executive,
Visuospatial, and Memory functions (R2=0.283,0.450,0.280,0.393,0.262,0.161, p<0.05).
3) Left-NAWM predicted MoCA, 60min, 30min, Executive, Spatial, and Language functions
(R2=0.382,0.351,0.206,0.204,0.181, p<0.05). 4) Right-NAWM predicted Spatial function
(R2=0.154, p<0.05), and improved the model significantly over age for 60min, 30min and
Executive function (R2=0.289,0.226,0.274, p<0.05). 5) NAGM improved the model signifi-
cantly over age for Executive function (R2=0.225, p<0.05), and Left-NAGM for 60min and
Executive function (R2=0.238,0.239, p<0.05). 6) Right-NAGM had no contribution. Conclu-
sions: BPF and NAWM showed a strong correlation with the neuropsychological scores,
whereas, NAGM itself did not. Language scores were predicted only by Left-NAWM, and
memory by total NAWM. Right-NAWM only showed contribution to spatial function. Loss of
healthy WM may be an important substrate of VCI. Memory and language functions showed
expected laterality only in WM. Compromise of regional WM connections may be key for
understanding VCI.
P2.071
Where is the Balance in Task-Oriented Circuit Training Interventions?
Inness, EL1, 2 McIlroy, WE1, 2, 3; 1. Toronto Rehabilitation Institute - University Health Network,
Toronto , ON; 2. University of Toronto, Graduate Department of Rehabilitation Science, Toronto,
ON; 3. Heart & Stroke Foundation Centre for Stroke Recovery, Toronto, ON
Background: Balance is an essential feature of safe and independent performance of daily
activities and a key priority in stroke rehabilitation. Therapies are increasingly making use of
task-oriented circuit class training (TO-CCT) as a cost-effective approach to increase practice
opportunity for functional skill acquisition. However, such approaches have failed to demon-
strate superior outcomes or improvement in balance. The purpose of this review is to identify
and describe the treatment elements of TO-CCT that may influence balance outcomes after
stroke. Methods: A scoping review was conducted. A comprehensive search was performed
for randomized controlled (RCT) studies that included the adult stroke population, an interven-
tion of TO-CCT and at least one outcome evaluating balance. Data was extracted using a chart-
ing framework and qualitative content analysis used to identify emerging themes. Results:
Nine studies were included in the review: 1823 studies identified; 45 papers retrieved; 37
excluded; 1 study added from hand-search of reference lists. All studies identified that improv-
ing balance was a central feature of the TO-CCT. The majority of studies referred to balance as
a singular/general construct. There was considerable overlap of tasks across interventions but
no clear consensus or rationale for identified ‘balance’ tasks. Task progression to challenge
balance varied across studies as did the balance outcome measures. The most common tool
was the Berg Balance Scale though some used instrumented measures, self-efficacy ques-
tionnaires or documented falls. Conclusions: Task selection and progression to improve bal-
ance within TO-CCT appears arbitrary. Commonly-used balance measures may demonstrate
changes in functional task performance but not changes in underlying balance control. Further,
such changes may not translate to a broader range of activities of daily life. Both research
and clinical practice would benefit from a unified framework of balance that could support the
development of theoretically-informed treatment elements and corresponding measurement of
therapeutic interventions.
P2.072
Development and Evaluation of a Health Economics Measure for Quality of Life in
Aphasia Post-Stroke
Kagan, A1 Simmons-Mackie, N2 Hoch, J3 Victor, JC4 Mok, A1 Kant, L1 Streiner, D5 Sharp, S6;
1. Aphasia Institute, Toronto, ON; 2. Southeastern Louisiana University, Hammond, LA, USA;
3. St. Michael’s Hospital Keenan Research Centre, Toronto, ON; 4. Institute for Clinical Evalu-
ative Sciences, Toronto, ON; 5. McMaster University, Hamilton, ON; 6. Toronto West Regional
Stroke Network, Toronto, ON
Background: Aphasia, a stroke-related language problem, masks general competence and has
a profound impact on quality of life (QOL). Health economists typically use a numerical index, a
Quality Adjusted Life Year (QALY) to determine the impact of various health conditions on QOL.
There are significant challenges when evaluating cost-effectiveness for aphasia, because of
the language barriers posed in using traditional methods such as the Time Trade Off (TTO) to
establish QALY’s. We therefore developed and evaluated the reliability of a pictographic version
of the TTO method of trading years of life for improved health (picTTO). Methods: An aphasia-
friendly method (picTTO) to depict hypothetical exchange of life years for an aphasia cure was
developed using focus group input from people with aphasia, speech-language pathologists
(SLPs), and volunteers. To establish reliability, a trained SLP administered the picTTO twice to
50 participants with aphasia. Each participant estimated the years s/he would give in exchange
for an aphasia cure at present time and at the time of his/her stroke. QALY utility weights
were calculated and correlated across the two administrations with intraclass correlation coef-
ficients (ICCs) to establish test-retest reliability. Results: ICCs were low for utility weights (0.00
to 0.26, p > 0.05), with low agreement between participants’ willingness to trade-off life years
between administrations (multi-rater kappa: 0.20 and 0.33 respectively). Potential reasons for
low reliability were examined in post-hoc analysis e.g., challenges related to recall, and through
qualitative analysis of participants and SLPs (e.g., holding consistent timeframes in mind at both
administrations, and self-reflection between administrations). However, participants with apha-
sia were able to answer the questions and the direction of change was as expected, showing
increase in QOL post-stroke and after aphasia interventions. Conclusion: The picTTO is worthy
of further investigation; in particular, the methodology used to establish validity and reliability
requires simplification.
P2.073
The Experience of Rehabilitation Professionals as a Source of Information in an
Evidence-Based Reconfiguration of a Poststroke Rehabilitation Continuum
Lamontagne, M1 Richards, CL2 Clément, L2 Azzaria, L3; 1. CIRRIS, Québec, QC; 2. Ministère de
la santé et des services sociaux, Québec, QC; 3. Université Laval, Québec, QC
Background: The Province of Quebec is in the process of reconfiguring its poststroke
rehabilitation continuum. The committee mandated to propose an optimal continuum rec-
ognized the importance of obtaining the perceptions of rehabilitation professionals of the
present system and their suggestions for improvements. Methods: With the support of the
16 regional health agencies, a survey was sent to managers and rehabilitation clinicians
working in acute care, in rehabilitation centers or in the community. It sought participants
insights with regard to 28 items related to accessibility, information, patient implication,
coordination and overall satisfaction with the actual continuum of care and requested sug-
gestions for improvement. Results: A total of 211 rehabilitation professionals with an av-
erage of 12 years experience working with personspost stroke, in the majority ­clinicians
 Abstracts From the 4th Canadian Stroke Congress, 2013  e45
(63%) who working in the community (39%), completed the questionnaire. They rated
accessibility as rather good (mean score (ms): 8/10), continuity (ms: 8/10), information
provided (ms: 8/10), and patient implication (ms: 8/10). Within each dimension, some items
were more and less positively perceived, such as accessibility at non-traditional moments
and accessibility to services for close relatives. Individuals with poor prognoses, complex
or intensive needs, geriatric profiles or with only cognitive / language impairments were
deemed to be less well served. The mean overall satisfaction score was 70%. The differ-
ences were larger between the perceptions of rehabilitation professionals working in the
different phases of the continuum than between those in rural and urban settings. The
participants had many experience-related explanations to justify their scores. Conclusions:
The perceptions and suggestions of the rehabilitation professionals confirmed the need to
improve the accessibility of services for persons poststroke living in the community and
for persons with atypical strokes or more complex needs. These perceptions were taken
into account by the committee in formulating their recommendations for a patient oriented
rehabilitation continuum.
P2.074
A Volunteer-Led Evening and Weekend Activity Program for Clients with Stroke in
Inpatient Rehabilitation
French, EH1 Frowen, A2 Adams, M2; 1. Thunder Bay Regional Health Sciences Centre, Thunder
Bay, ON; 2. St. Joseph’s Care Group, Thunder Bay, ON
Background: Daily activity that is intensive, challenging and meaningful, as well as additional
practice outside of scheduled therapy improves outcomes for people with stroke. Contrary to
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best practices, hospitalized clients with stroke spend most of their waking day inactive and
alone. Evenings and weekends offer a prime opportunity for clients with stroke to practice activi-
ties taught during therapy. Methods: In this program evaluation initiative, clients with stroke on
an inpatient rehabilitation unit were offered opportunities to practice stroke rehabilitation activi-
ties on evenings and weekends. Activities were provided for one-hour, in a small group setting,
and supported by a trained volunteer. Activities included: seated exercises, sit-to-stand practice,
arm ergometer, cognitive, language and recreation tasks. Information was collected during a
six-week pilot phase to determine the feasibility and acceptability of the program. Results: Five
volunteers supported a total of 32 one-hour sessions. Fifteen clients with stroke participated
with an average of four clients attending each session. On average the program operated at
65% capacity. Reasons provided for non-participation included: pain, fatigue, not available and
visitors. The clients described a positive impact of the program on their mood and enjoyed the
social aspect. Both clients and volunteers did suggest incorporating more challenging tasks and
individualized support for activities. Staff indicated that the program did not negatively impact
upon their current responsibilities and were generally satisfied with the program. Conclusions:
Implementation of the program was feasible and acceptable to volunteers, staff and clients on
an inpatient stroke rehabilitation unit. Minor revision to improve client and volunteer satisfaction
with the program, as well as to streamline administrative processes is indicated. The limited
scope of the volunteer, as compared to a rehabilitation staff member, does not meet the needs
of all clients. Resources for a dedicated lead to oversee implementation and evaluation are
essential.
P2.075
Rehabilitation Intensity: Capturing Stroke Patient Improvement One Minute
at a Time
Linkewich, E1, 3 Brien, H2; 1. North & East GTA Stroke Network, Toronto, ON; 2. Ontario Stroke
Network, Toronto, ON; 3. Sunnybrook Health Sciences Centre, Toronto, ON; 4. Northern Ontario
School of Medicine, Thunder Bay, ON
Background: Increased activity and environmental stimulation is important to neurological
recovery after stroke. Stroke best practices recommend at least three hours of therapy per pa-
tient day in inpatient rehabilitation . Rehabilitation intensity (RI) was identified as a key system
driver in the Ontario Stroke Network’s (OSN) Report Cards, yet a mechanism for data collection
is a gap. Initial exploration identified an option to collect this data through workload measure-
ment (WM). Method: A review of rehabilitation WM systems in Ontario was conducted via sur-
vey. Interviews and focus groups were conducted with diverse representation of stakeholders
across the province to inform the definition and feasibility of RI data collection. Using evidence
and stakeholder input, definition and principles were compiled and brought to the provincial
Stroke Reference Group for endorsement. Using the endorsed definition and principles, 2 pi-
lot sites implemented RI collection for 2 one-week periods. Review of technical feasibility to
upload WM into rehab data database (NRS) was initiated. Results: ~66% of organizations
collect WM by patient, 28%, include diagnosis, with a minimum of nine systems (44% using
2 vendors). The RI definition was established and included the time a patient spends in active
individual goal-directed therapy over a 7 day/week period that is monitored and guided by a
therapist. Initial results for RI collection indicated little impact on clinician time and distribu-
tion of RI increasing with stroke severity. Conclusions: Initial results support the feasibility of
RI collection for clinicians in WM. Further work is required to explore technical feasibility to
integrate into NRS.
P2.076
Stroke Rehabilitation in BC: Using Action-Research to Identify Gaps in Care and
Promote Improvements
LoChang, J; Aikman, P; Stroke Services BC, Vancouver, BC
The National Stroke Audit (2008/09) highlighted some important areas for improvement in
care in British Columbia. In terms of rehabilitation, only 8% of patients were admitted to
a rehabilitation facility following acute care, well below the national average of 19%. As a
result, a provincially coordinated gap analysis was conducted to further identify the most
pressing needs for stroke rehabilitation in the BC. The project utilized an observational
action-research methodology to collect quantitative and qualitative information about
stroke rehabilitation in the Province. A tracking tool was developed, to measure clinical
practices against the Canadian Best Practice Guidelines. Questions regarding rehabilita-
tion practices from all phases of the stroke continuum (acute, inpatient rehabilitation,
and community) were included. A total of 238 stroke patients were followed for 6 weeks
during the study period of November 2011 – February 2012. The process used was found
to be valuable not just in terms of documenting gaps in stroke care, but in understanding
the underlying reasons why a gap exists. In addition, the involvement of front line staff
in the methodology was a catalyst for rapid improvements to address issues that were
identified. Key findings:
1. The methodology and analysis identified both province-wide and health authority specific
gaps in availability of services and inconsistencies in practice; on a positive note, leading
practices were also identified that can be shared and expanded upon;
2. The process allowed not only the identification of a gap in practice, but also the contributing
contextual factors;
3. The process engaged care providers as active participants in improving the stroke system
of care;
4. The methodology enabled clinicians at the point of care to see these inconsistencies and
immediately begin formulating actions plans for improvement;
5. The methods used have resulted in positive change at the site, health authority, and Pro-
vincial levels
P2.077
BDNF and COMT Genetic Polymorphism Effects on Motor Function and
Corticospinal Excitability in Chronic Stroke
Mang, CS; Brown, KE; Ross, CJ; Boyd, LA; University of British Columbia, Vancouver, BC
Introduction: The basic neural mechanisms underlying post-stroke motor recovery depend
on the expression of specific genes. There is limited research considering how neuroplastici-
ty-associated gene variants relate to motor recovery after stroke. The present study examines
the impact of the brain-derived neurotrophic factor (BDNF) gene val66met and catechol-O-
methyl transferase (COMT) gene val158met polymorphisms on hemiparetic arm grip strength
and ipsilesional corticospinal excitability in chronic stroke. Methods: To date, 15 individuals
with chronic stroke have been genotyped for the BDNF and COMT polymorphisms from DNA
extracted from saliva samples. Investigators blinded to genotype assessed: 1) grip strength
of the hemiparetic hand (n=15), and 2) ipsilesional corticospinal excitability via transcranial
magnetic stimulation (TMS)-based recruitment curves (RCs) (n=12). For RCs, TMS was ap-
plied over ipsilesional motor cortex at intensities ranging from 90-150% active motor thresh-
old (AMT) in 10% increments. Motor evoked potentials (MEPs) were recorded from the hemi-
paretic wrist extensors. Higher linear slope of the RC plot of stimulus intensity (%AMT) by MEP
amplitude (mV) indicates greater corticospinal excitability. Results: Individuals carrying the
met allele for the BDNF gene (n=3) demonstrated lower grip strength (mean±SD; 12.4±3.5)
and lower recruitment curve slope (5.3±7.5) compared to val/val individuals (grip: 18.8±11.4;
slope: 13.0±20.5). Additionally, those participants that were homozygous val/val COMT geno-
type (n=4) demonstrated lower grip strength (6.3±7.8) and lower recruitment curve slope
(5.3±7.5) than COMT met allele carriers (grip: 21.6±8.3; slope: 17.0±23.7). Conclusion:
Although preliminary, the present findings suggest that common variants of the BDNF and
COMT genes may impact post-stroke motor recovery both functionally and physiologically,
consistent with previous findings of BDNF and COMT genotype effects on neuroplasticity in
healthy individuals. Additional research is underway to enhance power and more fully charac-
terize motor function of participants. Improved understanding of genetic factors that influence
stroke recovery will facilitate the development of novel, personalized post-stroke rehabilita-
tion strategies. Insert
 e46  Stroke  December 2013
P2.078
Outcomes in People Following Stroke Attending an Adapted Cardiac
­Rehabilitation Exercise Program: Does Time from Stroke Make a Difference?
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Marzolini, S4, 3 Tang, A1 McIlroy, W2, 3 Oh, P4, 3 Brooks, D5, 3; 1. School of Rehabilitation Science,
McMaster University, Hamilton, ON; 2. Department of Kinesiology, University of Waterloo, Wa-
terloo, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON; 4. Toronto
Rehabilitation Institute Cardiac Rehabilitation and Secondary Prevention/UHN, Toronto, ON;
5. Department of Physical Therapy, University of Toronto, Toronto, ON
Background: Individuals referred to cardiac rehabilitation programs (CRP) following stroke have
demonstrated post-program improvements in cardiovascular fitness (VO2peak). However, the
effect of CRPs on other outcomes and effect of time-from-stroke have not been investigated.
Purpose: 1) To evaluate effects of a 24-week CRP of resistance and aerobic exercise in 120
participants with motor impairment following stroke; 2) to explore effects of elapsed time-
from-stroke. Methods: Primary outcomes included 6-minute walk distance (6MWD), VO2peak,
timed repeated sit-to-stand performance, and affected-side isometric knee extension strength
(IKES). Secondary measures included gait characteristics (cadence, step lengths, and symme-
try), walking speed, balance (Berg Balance Scale), affected-side range-of-motion, elbow flexion
and grip strength, anaerobic threshold, and perceptions of participation/social re-integration.
Results: After adjusting for multiple comparisons, participants demonstrated significant im-
provements (all p<0.001) in 6MWD (283.2±126.6 to 320.7±141.8 meters), sit-to-stand per-
formance (16.3±9.5 to 13.3±7.1 seconds), affected-side IKES (25.9±10.1 to 30.2±11 kg as %
body mass), and VO2peak (15.2±4.5 to 17.2±4.9 mL∙kg∙min-1). Participants also demonstrated
post-CRP improvements in secondary outcomes: anaerobic threshold, balance, affected-side
hip/shoulder range-of-motion, grip and isometric elbow flexion strength, participation, walking
speed, cadence (all p<0.001) and bilateral step lengths (p<0.04). In a linear regression model,
there was a negative association between change in 6MWD and time-from-stroke (ß=–42.1;
p=0.002) independent of baseline factors. Conclusion: A CRP yields improvements over mul-
tiple domains of recovery; however those who start earlier demonstrate greater improvement in
functional ambulation independent of baseline factors. These data support the use of adapted
CRPs as a standard of care practice following conventional stroke rehabilitation.
P2.079
Virtual Reality Rehabilitation After Stroke Study (Vrrass): an Inpatient Blinded
Randomized Control Trial
McEwen, DW1 Taillon-Hobson, A2 Bilodeau, M2, 1 Sveistrup, H1 Finestone, HM2, 1; 1. University of
Ottawa, Ottawa, ON; 2. Bruyere Research Institute, Ottawa, ON
Background: Exercise training using virtual reality (VR) improves balance in adults with trau-
matic brain injury and adults with chronic hemiparetic stroke. Rigorous randomized studies
regarding its efficacy, safety and applicability are lacking. The objectives of this study were to
determine whether VR therapy, as an adjunct treatment to conventional in-patient stroke reha-
bilitation, 1) is safe and feasible and 2) improves balance and weight bearing on the affected
side. Methods: A blinded randomized controlled trial was implemented in an inpatient stroke
rehabilitation unit. Sixty patients who: 1) had ischemic or hemorrhagic, cortical or subcortical
strokes, 2) had resultant mobility deficits and 3) could stand independently for >1 minute were
randomized into either a control group (seated VR training) or an experimental group (standing
VR training). The seated group performed the various VR exercises without their balance being
challenged. Clinical balance and mobility measures, including the Two-Minute Walk Test, Timed
Up and Go Test and Berg Balance Scale, were recorded before, immediately after and 1 month
after training. Training consisted of 10 to 12, 30 minute sessions of VR exercises which were in
addition to the regular in-patient rehabilitation program. Results: No adverse events occurred
during the study. Preliminary data analyses showed significant improvements in VR gaming
scores and overall measures of motor function, but no significant between-group differences
were noted. Majority of participants reported a positive experience. Conclusions: VR exercise
for stroke rehabilitation inpatients is safe and enjoyable. Since the average total FIM scores on
admission were significantly higher for study participants than for inpatients who did not partici-
pate (93 vs. 75, p < 0.05), the inclusion criterion of standing unaided for > 1 minute limited the
sample selection to high-functioning stroke survivors. Further studies need to include the stroke
rehabilitation inpatient with greater motor impairments.
P2.080
Development of the Community Re-engagement Cue to Action
Trigger Tool (CR CATT)
McKellar, J1 Cheung, D2; 1. Toronto West Stroke Network, Toronto Western Hospital, Toronto,
ON; 2. South East Toronto Stroke Network, St. Micheal’s Hospital, Toronto, ON
Background: The needs and issues faced by persons with stroke are multi-dimensional and
complex. They feel dependent on healthcare providers to guide their care and recovery but often
have difficulty obtaining the support they need. The work presented herein builds on previous re-
search (Cheung and McKellar, 2012) that evaluated the impact of a community re-engagement
(CR) education intervention, which integrated concepts of interprofessional collaborative care
and a CR framework, on healthcare providers’ day-to-day practice. The eight components of
CR were used to create a trigger tool to facilitate discussion between healthcare providers and
persons with stroke across the care continuum. One recommendation from this study was to
develop a patient-mediated trigger tool for persons with stroke, using the same eight compo-
nents of CR, to facilitate a self-management approach to their care. Methods: The trigger tool
was modified for persons with stroke and caregivers and renamed: Community Re-engagement
Cue to Action Trigger Tool (CR CATT). Following a review by the institution’s patient education
department, modifications were made including: larger font, spacious layout with images, health
literacy principles at grade 4-6 level, and wording questions in the first person. The tool was
subsequently reviewed by healthcare providers from various professions in multiple settings and
persons with stroke in the community (n=30) to gauge its usefulness, comprehensiveness and
readability. Results from this enquiry were positive and the tool was perceived to be useful and
comprehensive in anticipating and addressing CR needs. Results: A mixed-methods study was
designed to determine whether exposure to the CR CATT through a patient- mediated interven-
tion, results in self reports of improved anticipation of needs and increased re-engagement in
valued activities post-stroke. Data analysis is ongoing. Conclusions: The CR CATT may provide
an easy to use and implement tool to facilitate persons’ with stroke re-engagement in com-
munity living.
P2.081
Power Mobility Training for Persons with Stroke: a Randomized Control Trial
Mountain, AD1 Kirby, R1 Eskes, GA1 Smith, C2 Thompson, K2; 1. Dalhousie University, Halifax,
NS; 2. QEII Health Sciences Centre, Halifax, NS
Background: Persons with stroke are often overlooked as candidates for power mobility es-
pecially when the person has a co-existent perceptual or cognitive impairment. The purpose of
this study was to examine whether persons with stroke can benefit from power mobility train-
ing and thus be potential candidates for power wheelchair use. Methods: Seventeen partici-
pants (12:5 male:female) from an inpatient stroke rehabilitation program completed baseline
cognitive and perceptual tests and were randomly allocated to the intervention (n=9, 5 with
neglect) or control (n=8, 4 with neglect) groups. They all completed an initial assessment
of their baseline power wheelchair skills using the Wheelchair Skills Test – Power Mobility
version (WST-P #1). The intervention group completed up to five 30-minute power mobility
training sessions. Following completion of all training sessions a second WST-P (WST-P #2)
was done. Control-group participants did not receive any training sessions and completed
WST-P #2 two weeks after WST-P #1. No participants used a power wheelchair nor received
power wheelchair skills training outside of the study. Results: Mean age of participants was
54 yrs (range 25 - 86 yrs). There was no significant difference in the WST-P score between
the control (57%) and intervention groups (56%) at baseline (wilcoxon p value = 0.89). How-
ever, the score on WST-P #2 for the intervention group (75%) was significantly better than
the control group (55%) after training (wilcoxon p value = 0.04). The Wilcoxon Rank Sum test
was used to compare the magnitude of change in WST-P raw scores for participants with and
without neglect and was non-significant (-2.5 for participants with neglect; p value = 0.33).
­Conclusions: Many people with stroke, with or without visuospatial neglect, can improve their
power wheelchair skills with appropriate training.
P2.082
“Until you’re there… you don’t know how you’ll be” The influence of beliefs,
attitudes and experience on patient behaviour
Nelson, ML1 Torchia, M2 Mactavish, J3 Grymonpre, R2; 1. Bridgepoint Health, Toronto, ON;
2. University of Manitoba, Winnipeg, MB; 3. Ryerson University, Toronto, ON
Background: Health care providers and system administrators are driving and experiencing
a paradigm shift; moving from paternalism and toward an egalitarian approach. In order to
practice patient centred care, health care providers must prioritize patient needs; provide
information regarding treatments, while taking patient preferences and expectations into ac-
count. While there is a growing body of literature regarding patient centredness, there is
scant information from the patient perspective about the experience of being a patient and
the subsequent influence on behaviour. Methods: Using phenomenological research methods
and the theory of planned behaviour as a theoretical framework, this study addressed the
questions: a) what is the essence of being a stoke rehabilitation patient, and b) what influence
do beliefs, attitudes, and experience have on people’s behaviour as a patient? Ten stroke
survivors were interviewed on three occasions over the course of inpatient rehabilitation -
admission, mid treatment and prior to discharge. Results: Seven shared elements of being
a rehabilitation patient were identified. The experience of being a rehabilitation patient is
 Abstracts From the 4th Canadian Stroke Congress, 2013  e47
socially oriented, governed and reinforced. Patients’ behaviour was focused on the goal of re-
covery and discharge. Patients described themselves as actively engaged in their treatment;
they did not however approach stroke rehabilitation with a predetermined set of behavioural
beliefs about being a patient. During their rehabilitation patients identified, developed and
adopted strategies to assist in achieving their goal, and evaluated those strategies more posi-
tively. Conclusion: Being a patient was not a single, observable behaviour, but rather a set of
contextually dependent strategies patients’ directed at a situation specific goal. The theory of
planned behaviour was unsuitable for understanding peoples’ beliefs, attitudes and behaviour
about being a patient.
P2.083
Is running induced neurogenesis important for post-stroke recovery?
Nguemeni, C1, 2 Gomez-Smith, M3, 2 Jeffers, M3, 2 Corbett, D3, 2, 4; 1. Heart and Stroke Founda-
tion Centre for Stroke Recovery- University of Ottawa, Ottawa, ON; 2. Cellular and Molecular
Medicine, University of Ottawa, Ottawa, ON; 3. Heart and Stroke Foundation Centre for Stroke
Recovery- Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON; 4. Memorial
University of Newfoundland, St John’s, NL
Background: Rehabilitation offers the greatest hope for stroke patients to regain function.
Recent evidence suggests that aerobic exercise can enhance brain health and improve post-
stroke recovery by a number of mechanisms including neurogenesis. For example,voluntary
wheel running increases neurogenesis in the hippocampal dentate gyrus (DG). Unfortunately,
most preclinical exercise studies provide animals with unlimited access to running wheels and
rodents often run at excessive levels (6-16 km/day). Such a paradigm is not easily translated to
stroke patients who are typically older and have physical limitations. We designed a moderate
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
exercise paradigm where animals would run in bouts totalling ~ 20 minutes or 30-60 minutes
(in 4hr or 8 hr access)/day that allow us to investigate dose-response effects of exercise on
neurogenesis. Methods: Male Sprague Dawley rats were assigned to 5 groups: Sedentary
(Sed) rats, 4 hr (4HR), 8 hr (8HR) and 24 hr alternate day runners (AR) that had access to the
running wheel every other day and 24 hr runners (UR) that had unlimited access to the wheel
every day. During the first week, we labelled newborn cells with bromodeoxyuridine (BrdU,
50mg/kg/day, i.p.). Then, we used the immature neuronal marker doublecortin (DCX) to char-
acterize new cells in the DG after two weeks of running. Results: The AR and UR groups ran
significantly more than any other group. We found a significant increase in BrdU+ cells in the
DG of AR and UR groups. Surprisingly, there was no difference in the percentage of BrdU/DCX+
cells across all the groups. Notably the moderate runners (i.e. 4 & 8hr access) did not show
altered neurogenesis even though moderate exercise levels such as these improve post-stroke
recovery in animal and human studies. Conclusion: These data suggest that the increased
neurogenesis induced by intensive unlimited running wheel access may not be contributing
to post-stroke recovery.
P2.084
Brain Stimulation Combined with Rehabilitation in Acute Stage Improves Upper
Limb Function
Paquette, C1 Reigel, M1 Anglade, C2 Fung, J1 Thiel, A3; 1. McGill University - CRIR, Montreal,
QC; 2. Université de Montréal, Montreal, QC; 3. McGill University/Jewish General Hospital-LDI,
Montreal, QC
Activity in the contralesional primary motor cortex (M1) in acute stage of stroke is increased
due to a reduction of transcallosal inhibition from the affected hemisphere. Brain imaging stud-
ies suggest that this persisting contralesional activity in M1 may limit the functional recovery.
Thus, down regulation of contralesional M1 activity might benefit motor recovery by facilitating
recruitment of motor networks within the affected hemisphere. Two types of non-invasive brain
stimulation: repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current
stimulation (tDCS) can be used to down regulate activity. Our aims were to 1) determine whether
modulation of contralesional M1 activity in acute stage can improve motor function and 2) de-
termine if rTMS and tDCS have comparable effects on motor function recovery. Stroke subjects
were randomized to receive rTMS, tDCS or sham stimulation (Figure1). Subjects received up to
10 days (mean 8 days ) of double-blind inhibitory stimulation over unaffected M1, combined with
physiotherapy (PT). Treatment began on average 12 days after stroke. On each treatment day,
subjects first received 15 minutes of real or sham rTMS immediately followed by real or sham
tDCS during the 40-60 minutes PT session. Motor function was assessed with the Chedoke
Arm and Hand Activity Inventory (CAHAI). CAHAI scores were similar at recruitment (p=0.994)
but were significantly higher after treatment (p<0.05) for subjects in the rTMS group (19 ) than
for subjects receiving tDCS (11 ) or sham stimulation (6 ), as shown in Figure 2. There was no
difference at 3 and 6 months post treatment (p=0.330). Inhibitory rTMS over unaffected M1 sig-
nificantly improved upper limb motor recovery when given early after stroke. These preliminary
results suggest that rTMS in acute stroke may increase rehabilitation potential and possibly
shorten length of stay in rehabilitation clinics.
P2.085
The Effects of Verbal or Manual Cues on Gait Parameters During the
­Rehabilitation Phase of Stroke: a Randomized Cross-Over Trial
Ploughman, M1 Shears, J2 Quinton, S2 Flight, C2 O’Brien, M2 Peacock, M2 Byrne, JM1; 1. Memo-
rial University of Newfoundland, St. John’s, NL; 2. Eastern Health Authority, St. John’s, NL
Background: When retraining walking after stroke, therapists can use a variety of forms of
feedback (e.g. manual cues, verbal instruction or vicarious performance) to guide movement
and activate hemiplegic muscles. Like many therapeutic interventions, feedback choice is based
primarily on clinical experience. This research aimed to compare two therapeutic techniques
(verbal vs. manual cues) to determine their effects on hemiplegic muscle recruitment and gait.
Methods: Nine individuals (6 females; average age 61 years), within 9 months post-stroke
(average 121 days post), visited the laboratory twice (separated by at least 7 days). In each
session subjects performed a total of 16 walking trials. An experienced physiotherapist either
delivered verbal or manual treatment during 4 of these walking trials. The remaining trials in-
cluded four trials each prior to, immediately following and 20 minutes following the intervention.
The treatment delivered in each session was randomized. During all trials lower limb kinematics
were captured using a Vicon system. Electromyography (EMG) was used to record activity of
gastrocnemius, tibialis anterior, vastus lateralis, medial hamstrings, gluteus medius and gluteus
maximus (hemiplegic side only). Kinematic data was used to quantify joint angles at key gait
cycle points. EMG magnitude during stance phase was quantified using root mean square (RMS)
activation. RMS values during post and retention trials were expressed as percentage change
relative to pre-intervention values. Results: Preliminary analysis indicated that verbal instruction
increased lower limb stance phase EMG activity by 4.2 to 23% (p=.05-.58). Manual cues were
less facilitative (-16% to 8%) and in some cases reduced EMG activity. Verbal instruction also
increased ankle plantarflexion range at toe-off on the hemiplegic side (p<.04). Conclusions:
Early results suggest that verbal instruction by experienced physiotherapists improves muscle
recruitment and gait kinematics during the rehabilitative phase of stroke. This finding could be
important in optimizing gait symmetry after stroke.
P2.086
Effects of a Free Water Protocol on Inpatients in a Neurological
Rehabilitation Setting
Pooyania, S1 Galimova, L1 Buchel, C2 Daun, R3 Lenton, L3; 1. Faculty of Medicine, University of
Manitoba, Winnipeg, MB; 2. Private Speech Therpist, Winnipeg, MB; 3. WRHA, Winnipeg, MB
Dysphagia, or difficulty swallowing, is common among stroke and acquired brain injury (ABI)
patients and may result in aspiration. Aspiration has, in turn, been associated with aspiration
pneumonia and a number of subsequent health effects. To reduce the risk of thin liquid aspira-
tion, patients are often restricted to thickened fluids. However, this type of restriction may also
result in complications including dehydration, decreased compliance with swallowing guide-
lines, an increased risk of pneumonia when aspiration takes place, and decreased quality of
life (QOL). Certain research suggests that aspiration pneumonia requires not only aspiration,
but also that aspirated material contain a respiratory pathogen and that the pathogen then over-
whelms the immune system. Some clinicians have, therefore, argued for controlled thin water
intake combined with aggressive oral care. Though increasingly common in clinical practice,
 e48  Stroke  December 2013
limited evidence exists on the ability of such free water protocols to address the complications
of thin fluid restriction while maintaining patient safety. A controlled pilot study of a free water
protocol was undertaken at Riverview Health Centre, in Winnipeg, Manitoba. The study exam-
ined 17 individuals with stroke or ABI who were randomly assigned to either a control group on
thickened fluids or a treatment group that followed a free water protocol. The study compared
instances of complications including aspiration pneumonia, fluid intake, swallowing related QOL
and QOL related to care received from participants’ swallowing clinicians. Although unable to
identify statistically significant differences between the two groups, the results identified signifi-
cant improvements in swallowing related QOL among the treatment group and improvements
in swallowing related care from their swallowing clinician among both. Neither group developed
aspiration pneumonia during the study.
Given these promising results, the pilot study suggests the need for larger scale work in order to
more accurately identify the effects of free water protocols.
P2.087
Functional Electrical Stimulation Therapy Compared with Conventional OT/PT
Therapy for the Restoration of Reaching and Grasping Function in Acute Severe
Hemiplegic Patients: a Randomized Controlled Trial
Thrasher, T1 Zivanovic, V2, 3 McIlroy, W4, 2, 3 Popovic, MR2, 3; 1. University of Houston, Houston,
TX, USA; 2. Toronto Rehabilitation Institute, Toronto, ON; 3. University of Toronto, Toronto, ON;
4. Sunnybrook Health Sciences Centre, Toronto, ON
Background: The purpose of this study was to establish the efficacy of a therapeutic interven-
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
tion based on functional electrical stimulation (FES) therapy to improve reaching and grasping
function after severe hemiplegia due to stroke. The therapy consisted of task-specific upper-
limb movements with a combination of pre-programmed FES and manual assisted motion.
Methods: A total of 21 subjects with acute stroke were randomized into 2 groups, FES plus
conventional occupational therapy and physiotherapy (FES group) or only conventional therapy
(control group) 5 days a week for 12 to 16 weeks. Pre–post training changes were compared.
FES was applied to proximal and then distal muscle groups during specific motor tasks involving
reaching and grasping. At baseline and at the end of treatment, function was assessed us-
ing the Rehabilitation Engineering Laboratory Hand Function Test, the Functional Independence
Measure (FIM), and the Fugl–Meyer Assessment (FMA), along with more standard measures of
rehabilitation outcome. Results: The FES group improved significantly more than the control
group in terms of object manipulation, palmar grip torque, pinch grip pulling force, Barthel Index,
Upper Extremity Fugl–Meyer scores, and Upper Extremity Chedoke–McMaster Stages of Motor
Recovery, as well as the Self Care subset of the FIM. Overall FIM scores were trending towards
a significant improvement in the test group. Conclusions: FES therapy with upper extremity
training may be an efficacious intervention in the rehabilitation of reaching and grasping function
during acute stroke rehabilitation.
P2.088
2012-2013 Post Stroke Complications During Inpatient Rehabilitation – The
Experience in Calgary
Reimer, EA1 Dukelow, S4, 3 Kashyap, D2 Suddes, M4 Knox, J5; 1. Carewest, Calgary, AB;
2. Calgary Stroke Program, Calgary, AB; 3. University of Calgary, Calgary, AB; 4. Calgary Stroke
Program, U of C, Calgary, AB; 5. Alberta Health Services, Calgary Stroke Program, Calgary, AB
Background: Complications following stroke have been summarized in the Canadian Best
Practice Recommendations, Fourth Edition, 2010. McLean (2004) reports that depression
(26%), patient falls (20%), shoulder pain (24%) and urinary tract infections (15%) are the
most common complications observed in hospital. Canadian Best Practice Recommendations
related to post stroke complications exist for acute stroke. To gain an understanding of the
rate of complications experienced by the local stroke patient population, the Calgary Stroke
Program and partners, including the Neuro-Rehabilitation Unit at Carewest Dr. Vernon Fanning
Centre, have worked collaboratively to document the incidence of post stroke complications
both in an acute inpatient setting, and during inpatient rehabilitation. Methods: Post stroke
complications including: recurrent stroke, hemiplegic shoulder pain, falls, pressure ulcers,
spasticity, urinary tract infection, urinary retention, urinary incontinence, depression, deep
vein thrombosis, pulmonary embolism, dysphagia and pneumonia were selected as com-
plications to be documented in each client file. This data was entered into a database, with
results being shared across the continuum, and compared to current literature. Complica-
tion outcomes are also useful to inform process change and staff education with the goal of
minimizing post stroke complications. Results: Preliminary data indicates that the top five
post stroke complications in inpatient rehabilitation include falls, dysphagia, urinary inconti-
nence, depression and urinary tract infection. Results of the data related to all documented
complications in 2012-2013, and analysis of the available data will be shared. Conclusion:
Documentation and analysis of the incidence of post stroke complications and the relation-
ships between complications is valuable to establish standards, understand trends, and de-
velop best practice recommendations to minimize all post stroke complications across the
continuum of stroke care.
P2.089
The Sensorimotor Rehabilitation Research Team of the Canadian Institutes of
Health Research (CIHR): a Model for Knowledge Translation and Evidence-Based
Rehabilitation of Persons After Stroke
Richards, CL1 Rossignol, S2, 3 Nadeau, S2, 3 Fung, J4, 3 Doyon, J2; 1. Université Laval and CIRRIS
Research Center, Quebec, QC; 2. Université de Montréal, Montreal, QC; 3. CRIR Research
Center, Montreal, QC; 4. McGill University, Montreal, QC
Background: This CIHR Emerging Team regroups researchers from Université de Montréal,
Université Laval and McGill University, and Research Centers (RCs: CRIUGM, CRIR and CIR-
RIS), as well as the stroke units of 3 rehabilitation centers (RC: IRGLM, JRH and IRDPQ) and
neuroscientists on campus. The team aims to develop a research-clinical model of knowledge
translation (KT), to promote evidence-based rehabilitation post stroke, to implement clinical-
research platforms in the RCs and to evaluate innovative therapeutic approaches. Methods:
Led by five Principal Investigators (PIs) with Dr Serge Rossignol as the designated PI, the
team includes 25 researchers (neuroscientists and clinical researchers) with expertise in the
recovery of sensorimotor function and imaging of the brain. Clinicians from various disciplines
in the RCs are collaborators. Graduate students and post-doctoral fellows are competitively
funded. The PIs hold monthly meetings by Skype and to date have organized four day-long
meetings and planned an International symposium in 2014. Results: The team is well-es-
tablished halfway into its funding cycle. The clinical research platforms are functional and
clinicians are using a common set of outcome measures to document the clinical profile and
to evaluate change over time. Clinical evaluations are complemented by research laboratory
evaluations and imaging to characterize the patient`s pathophysiological and biomechani-
cal deficits and lesions. The findings help identify appropriate interventions and stimulate
ongoing research protocols. Innovative approaches under development include multisensory
stimulation, strengthening specific muscle groups during walking, pain relief, and the integra-
tion of mental practice into usual clinical practice. The implementation of routine magnetic
imaging and transcranial magnetic stimulation techniques, as well as parallel experiments
in animal stroke models are being investigated. Conclusions: Basic and clinical research-
ers have developed innovative and complementary research to optimize stroke rehabilitation.
The challenge now is to demonstrate that such a KT model promotes improved rehabilitation
outcomes.
P2.090
Caregiver Outcomes in a Community-Based Stroke Rehabilitation Setting:
Results and Tool Selection
Richardson, M1 Allen, L1, 2 Meyer, M1, 2 Ure, D3 Jankowski, S3 Teasell, R1, 3, 4; 1. Lawson Health
Research Institute, London, ON; 2. Department of Epidemiology and Biostatistics, Western
University, London, ON; 3. St. Joseph’s Health Care London, Parkwood Hospital, London, ON;
4. Department of Physical Medicine and Rehabilitation, Western University, London, ON
Background: The caregiving experience has implications for both carer and patient health
following stroke. There is currently no consensus regarding the best tool to evaluate the ex-
perience of caring for a stroke survivor. This study reviewed the use of two caregiver outcome
measurement tools in a community-based rehabilitation setting post stroke. Methods: Data
was derived from a population of 919 patients receiving care from the Community Stroke
Rehabilitation Teams (CSRT) in Ontario. Caregiver outcomes were assessed between February
2009 and December 2012, at baseline, discharge from the program, and 6-month follow-up.
In September 2010, the Bakas Caregiving Outcomes Scale (BCOS) replaced the Caregiver
Assistance and Confidence Scale (CACS) to evaluate caregiver outcomes. Repeated measures
ANCOVA were performed to assess changes in scores. Reasons for switching outcome mea-
surement tools were also addressed. Results: 67 patients had a completed CACS at all three
time points; 17 for the BCOS. The level of assistance required of caregivers decreased sig-
nificantly from admission to discharge (P=0.001), with maintenance at follow-up (P=0.645).
There were no statistically significant changes in a caregiver’s confidence in providing care
from admission to discharge (P=0.724), or discharge to follow-up (P=0.904). The BCOS re-
vealed that caregivers experienced a significantly greater degree of positive change as a re-
sult of caregiving from admission to discharge (P=0.019) from the program. These gains were
not maintained at follow-up (P=0.048) but remained higher than admission scores (P=0.098).
Clinical usefulness and client-friendliness were the reasons given for the transition from the
CACS to the BCOS. Conclusions: Home-based stroke rehabilitation has a significant effect
on the level of assistance provided by caregivers and their overall caregiving experience.
Reasons for the relatively low response rate have yet to be explored. Transition to the BCOS
was supported by the psychometric properties of the scale and feedback from clinicians.
P2.091
Best Practices when Facing Daily Challenges After a First Mild Stroke: You Call
or We Call?
Rochette, A1, 3 Korner-Bitensky, N2, 3 Bishop, D4 Teasell, R5 White, C6 Bravo, G7, 8 Côté, R2
Green, T9 Lebrun, L1 Lanthier, S1 Kapral, M10 Bayley, M10, 11 Wood-Dauphinee, S2; 1. Université
de Montréal, Montréal, QC; 2. McGill University, Montreal, QC; 3. Centre for Interdisciplinary
Research in Rehabilitation of Greater Montreal, Montreal, QC; 4. St-Lukes Hospital, , RI, USA;
5. University of Western Ontario, London, ON; 6. University of Texas, San Antonio, TX, USA;
7. Université de Sherbrooke, Sherbrooke, QC; 8. Research Center on Ageing, Sherbrooke,
QC; 9. University of Calgary, Calgary, AB; 10. University of Toronto, Toronto, ON; 11. Toronto
Rehabilitation Institute, Toronto, ON
Background: In most circumstances, individuals with a “mild” stroke are discharged home
directly from acute care without referral for rehabilitation. The purpose was to compare a mul-
timodal intervention WE CALL (phone support/information provision) with a passive interven-
tion YOU CALL (resource person) in individuals with first mild stroke. Methods: Single-blinded
RCT where primary outcomes were unplanned use of health services (participant diaries) for
adverse events and quality of life (Euroquol-EQ5D, Quality of Life Index). Secondary outcomes
included planned use of health services (diaries), mood (Beck Depression Inventory II) and
 Abstracts From the 4th Canadian Stroke Congress, 2013  e49
participation (Assessment of Life-Habits (LIFE-H). Blind assessments were done at baseline,
6 and 12 months. A mixed model approach for statistical analysis on an intention-to-treat
basis was used where the group factor was intervention type and occasion factor time, with a
significance level of 0.01. Results: We enrolled 186 patients (WE = 92; YOU = 94) with a mean
age 62.5 ± 12.5 and 42.5% female. The majority (98.8%) of participants visited a physician in
the first six months (i.e. during active intervention) but fewer than 20% received rehabilitation
services. No significant differences were seen between groups at six months for any outcomes
with both groups improving from baseline on all measures (effect sizes ranged from 0.25 to
0.7). The only significant change for both groups from 6 months to one year (n=139) was in the
social domains of the LIFE-H (increment in score=0.4/9±1.3 ; ES=0.3). Qualitatively, the WE
CALL intervention was perceived as reassuring, increased insight and problem solving while
decreasing anxiety. Only 6/94 (6.4%) of YOU CALL participants availed themselves of the inter-
vention. Conclusion: While the two groups improved equally over time, WE CALL intervention
was perceived as helpful whereas the passive YOU CALL intervention was not utilized.
Clinical Trial Registration: http://www.controlled-trials.com unique identifier: ISRCTN95662526
Funding: Canadian Stroke Network/CIHR
P2.092
Extending PCA Aphasia Treatment to an Individual with Bilateral Lesions:
A Pilot Study
Rochon, E1 Marcotte, K3, 2 Laird, L1 Simic, T1 Grady, C4, 1 Meltzer, J4, 1 Leonard, C5, 1;
1. University of Toronto, Toronto, ON; 2. Toronto Rehabilitation Institute, Toronto, ON;
3. Universite de Montreal, Montreal, QC; 4. Rotman Research Institute, Baycrest, Toronto, ON;
Downloaded from http://stroke.ahajournals.org/ by guest on December 25, 2017
5. University of Ottawa, Ottawa, ON
Background: Our phonological components analysis (PCA) treatment approach has been
shown to improve naming performance in patients with chronic nonfluent aphasia after left
hemisphere stroke. Consistent with the literature, improved naming after PCA treatment was
associated with neural activation changes in perilesional left hemisphere areas, and in right
hemisphere areas, to a lesser extent. Most studies have focused on patients with left hemi-
sphere lesions. Here we report behavioural and imaging results for a patient with bilateral
lesions who underwent PCA treatment. We predicted improved naming and bilateral neural
activation changes, with perilesional left hemisphere activation changes for treated words
in particular, after PCA treatment. Methods: In this pilot study, ten days of intensive PCA
treatment was administered to a right-handed, 49 year-old male, five years post-onset. He
suffered a left, then right hemisphere stroke, resulting in a mixed aphasia. An event-related
fMRI session was administered pre- and post-treatment, during which he participated in an
overt naming task. Pre-processing and statistical analysis were performed using AFNI. Neu-
roimaging data analyses were performed only on correct responses. Results: After treatment
the participant demonstrated a significant difference in correct production of treated versus
untreated words. This difference was maintained at four and eight weeks. In comparison to
untreated words, preliminary fMRI findings showed enhanced activation in left hemisphere
perilesional areas as well as left parietal and occipital regions after treatment. Right hemi-
sphere perilesional activation was seen only for untreated words. In addition, after treatment
there was a posterior shift in activation for treated words. Conclusions: In addition to benefits
for patients with left hemisphere lesions, PCA treatment was beneficial for treating anomia in
an individual with bilateral lesions. Neuroimaging data indicate that improved naming perfor-
mance for treated items is associated with increased neural activity in left perilesional cortex
during naming of those items.
P2.093
Speed Determinants of Mobility Post Stroke Revealed by Optical Brain Imaging
Sangani, S; Fung, J; Lamontagne, A; McGill University, Montreal, QC
Background: Mobility problems among stroke survivors have a serious impact on their
functional independence and quality of life. Over the last decade, researchers and clini-
cians have acknowledged the importance of incorporating intensive task-specific practice
in gait retraining paradigms after stroke. Speed-intensive gait training has been shown to
provide beneficial effects, both in terms of improved walking speeds as well as in the overall
kinematics of hemiparetic gait. Recent studies utilizing EEG demonstrate that the motor
cortex and the corticospinal tract contribute directly to muscle activation in lower limbs
observed during steady-state treadmill walking. However, cortical mechanisms underly-
ing the efficacy of incorporating different self-imposed speeds during self-paced treadmill
locomotion remain unclear. Objective: To determine cortical mechanisms underlying the
control of gait speed, near-infrared spectroscopy (NIRS) is used to investigate and character-
ize hemodynamic activity in terms of oxy-hemoglobin (Oxy-Hb) concentrations in both the
frontal and sensorimotor cortices during self-paced treadmill locomotion at three different
gait speeds (slow, comfortable, and as fast as possible). Methods: We have recruited 6
healthy control subjects and will target testing 10 post-stroke and 10 control subjects in all.
NIRS measurement was performed using the Hitachi ETG-4000 system with a custom-built
optode cap (44 channels) covering the frontal and sensorimotor cortices. A custom-built
self-paced treadmill was utilized wherein the speed of the treadmill can be servo-controlled
by the subject’s voluntary acceleration and deceleration via an eletropotentiometer and thus
subjects had full control of their own walking speed. Results: Changes in concentrations of
Oxy-Hb in the sensorimotor and frontal cortex demonstrated increased activation during dif-
ferent phases of fast and slow walking conditions as compared to walking at a comfortable
speed. Conclusion: Minimal cortical activation is required to control steady-state walking at
comfortable speed, but any deviation from the optimal speed requires conscious effort and
hence increased cortical activation.
P2.094
An Interdisciplinary Approach to Activity-Based Stroke Rehabilitation
Siebold, T; ARBI, Calgary, AB
Background: Survivors of Stroke are often told that the majority of recovery will occur in
the first six months. However, plasticity research is confirming what many therapists have
believed and experienced: long term recovery is possible and often significant. This case
report will demonstrate the long-term recovery for a client 2 years post stroke. A poster will
illustrate an interdisciplinary activity- based rehabilitation approach to optimize engagement
in this later stage of recovery. Methods: ET, a 44 year old male, suffered a significant left
MCA stroke causing right hemiparesis and expressive aphasia. He started his rehabilitation
program at the Association for the Rehabilitation of the Brain Injured (ARBI) 20 months after
his stroke, and after receiving traditional inpatient and outpatient therapies. To match his
motivation to return to playing ice hockey, an activity-based interdisciplinary approach was
implemented. Therapists used the various component tasks within hockey to address his up-
per extremity, lower extremity, balance, and coordination impairments. The activity analysis
provided opportunities for ET to improve his communication and social skills. Results: On
admission, ET demonstrated a lack of motivation and social participation. With the introduc-
tion of hockey activities, he became engaged with the program, his attendance improved
and he initiated social interactions. Outcome measures included the Canadian Occupational
Performance Measure, Community Balance and Mobility Scale, Action Research Arm Test,
Arm Function Test, Boston Diagnostic Aphasia Examination, and the Leisure Competency
Measure. These quantified his many improvements, including highlighting his return to skat-
ing. Conclusions: The interdisciplinary activity-based approach, ET’s age, and motivation
to return to sport, all contributed to his long-term functional recovery. The rehabilitation
community should remain optimistic about recovery potential even two years post stroke.
Therapy will be most effective when the intervention ideas and strategies are imbedded
within the client’s activity goals.
P2.095
The Effect of Interventions on Balance Self-Efficacy in the Stroke Population:
a Systematic Review and Meta-analysis
Tang, A2 Tao, A1 Soh, M1 Tam, C1 Tan, H1 Thompson, J1 Eng, JJ1; 1. University of British
Columbia, Vancouver, BC; 2. McMaster University, Hamilton, ON
Background: Impairments in balance and mobility are common after stroke, and fall rates are
two-times higher than age- and gender-matched counterparts. Decreased balance self-efficacy
after stroke may be a more important predictor of falls than balance or mobility performance.
This study was a systematic review and meta-analysis of the effectiveness of various interven-
tions on balance self-efficacy among individuals with stroke. Methods: Searches of MEDLINE
(1948-present), CINAHL (1982-present), EMBASE (1980-present) and PsycINFO (1987-present)
were completed in January 2013. Reference lists of selected papers were hand-searched to
identify further relevant studies. Controlled intervention trials in adult stroke populations with
balance self-efficacy as a primary or secondary outcome measure were included. Two indepen-
dent reviewers performed data extraction and assessed the methodological quality of the stud-
ies using the Physical Therapy Evidence Database scale. The weighted effect size of multiple
studies was calculated with RevMan 5.0 using random effects models. Results: Thirteen studies
involving 513 participants met the eligibility criteria for inclusion. Of these, 11 had interventions
involving physical activity and 2 used motor imagery training. Study quality ranged from fair
(n=4) to good (n=9). All studies used balance self-efficacy as a secondary outcome. The Falls
Efficacy Scale-International was used in 1 study; all others used the Activities-specific Balance
Confidence Scale. A medium standardized mean difference (SMD) for the 13 studies was found
(SMD 0.61 95% CI 0.16-1.05, P=0.008). In secondary analyses, motor imagery interventions (2
studies, 63 participants) were not effective (SMD 1.16, 95% CI -1.26-3.58, P=0.35), but with
studies using physical activity interventions (11 studies, 450 participants), the medium effect
size was maintained (SMD 0.52, 95% CI 0.07-0.97, P=0.02). Conclusions: Physical activity
interventions appear to be effective in improving balance self-efficacy after stroke. Random-
ized controlled trials using larger sample sizes and with a primary goal of improving balance
self-efficacy are needed.
P2.096
Kinematic Upper Limb Stroke Assessment Using the Kinect Sensor
Tran, J1 Danells, CJ2 McIlroy, WE1, 2; 1. Univeristy of Waterloo, Waterloo , ON; 2. Heart and
Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences Centre,
Toronto, ON
Introduction: Control of the upper limb is often impaired post-stroke and significantly affects an
individual’s independence and quality of life. Thus there is considerable interest in improving as-
sessment and treatment techniques post-stroke. Kinematic motion analysis has been suggested
to be a more revealing and sensitive technique for identifying impairments in the upper limb.
However the implementation of kinematics in clinical settings is often limited by financial and
time barriers. Advancements in low-cost sensor technology (Microsoft Kinect) have led to re-
newed interest in the incorporation of kinematics as part of clinical assessment. Validity studies
have suggested clinical utility for capturing motion for the upper limb end-point, and trunk. The
purpose of this study was to determine the feasibility of using the Kinect to assess upper limb ki-
nematics as part of a clinical stroke assessment. Methods: Four stroke patients (CMSA: 3, 3, 5,
6) were recruited for this study. Patients performed two tasks with the affected and non-affected
arm. 1) Reach-to-touch a centrally located target and 2) drawing a large circle in the transverse
plane. Tasks were selected to examine upper limb coordination and effective work-reach area.
Main measures were displacement, velocity, and area (drawing task). Results: Reach-to-touch:
 e50  Stroke  December 2013
Slow movement velocities and lower displacement for the affected versus non-affected limb.
Trunk displacement and velocity was increased with non-affected limb use. Across patients,
lower CMSA scores showed decreased limb movement and increased trunk movement quan-
titatively. Circle-drawing: Decreased hand area and increased trunk displacement was shown
with affected-limb use. Conclusion: Preliminary results demonstrate the ability of the Kinect to
detect differences between affected and non-affected limbs in stroke patients of varying impair-
ment levels. Kinect data provides an objective metric of movement quality and quantifies the use
of compensatory strategies. Future studies should investigate the ability of the Kinect to detect
performance changes over time.
P2.097
A Systematic Review of Alternative Mind-Body Approaches to
Stroke Rehabilitation
Wadden, KP1 Short, M2 Boyd, LA1 Mazmanian, D2; 1. University of British Columbia, Vancouver,
BC; 2. Lakehead University , Thunder Bay, ON
Background: There is an increasing focus on integrating complementary and alternative thera-
pies during the stroke recovery process. More specifically, mind-body interventions (e.g., mind-
fulness, yoga) are growing in popularity in rehabilitative centers across Canada. Daily functions
demand both cognitive and motor resources, thus therapeutic interventions that strengthen the
mind-body connections are proving to be a valuable rehabilitative approach. This review exam-
ines the efficacy of commonly used mind-body interventions in stroke rehabilitation. Methods:
A systematic review of the literature on mind-body approaches to stroke rehabilitation was con-
ducted. Randomized controlled trials (RCTs) and controlled clinical trials were included. Results
were not statistically pooled due to vast heterogeneity between study designs (e.g., varying
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outcome measures). Results: A total of 12 studies were included in the review. Mind-body
interventions included mindfulness, relaxation, yoga, and tai chi. Overall, there is evidence of
efficacy for mind-body interventions in stroke rehabilitation, particularly for improving mental
fatigue, physical functioning, and overall quality of life. Conclusions: Although alternative mind-
body approaches are highly integrated into the recovery from pathologies such as depression,
chronic pain, and cancer, to date there is minimal research examining these approaches to
stroke rehabilitation. The considerable evidence presented in the few studies that currently exist
is promising. Findings from this review may help guide the future direction of studies examining
complementary and alternative approaches to stroke rehabilitation.
P2.098
Impaired Control of Balance and Gait Predict Fall Risk Post-Discharge From In-
Patient Stroke Rehabilitation
Wong, J1 Inness, EL1, 2 Biasin, L1, 2 Brunton, K1, 2 Fraser, J1, 2 Bayley, M1, 2 McIlroy, WE4, 3, 2
Mansfield, A1, 2, 3; 1. Toronto Rehabilitation Institute - UHN, Toronto, ON; 2. University of
Toronto, Toronto, ON; 3. Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON;
4. University of Waterloo, Waterloo, ON
Background: Nearly 75% of individuals discharged home after stroke will fall1, which can lead
to injury, fear of falling and activity restriction. While the causes of falls are often multifactorial,
falls ultimately occur due to impaired balance control. Individuals with stroke have difficulty
executing stepping reactions to prevent a fall following a loss of balance2. The purpose of this
study is to identify measures of balance and gait that predict falls after discharge from stroke
rehabilitation. Methods: Participants (n=93; age: 62.7±13.5 years) completed balance and gait
assessment immediately before discharge from in‐patient stroke rehabilitation. Assessment
included: Berg Balance Scale (BBS), static standing and perturbation-evoked reactive balance
measured using forceplates and spatio-temporal features of walking using a pressure-sensitive
mat. Subjects reported falls and activity levels up to six-months post‐discharge. Poisson regres-
sion was used to identify risk factors related to increased fall rates. Results: Thirty-five partici-
pants experienced 65 falls; 12 fell more than once. Lower balance scores (BBS; p=0.045), de-
creased gait velocity (p=0.044), and decreased step width variability (p=0.031) were related to
increased fall rates. Participants were more likely to fall if the non-paretic limb had an increased
contribution during quiet standing than the paretic limb (p=0.0087). For responses to postural
perturbations, increased fall risk was related to increased need for external assistance or up-
per extremity reactions (p=0.026), faster foot-contact time (p=0.044), and increased attempts
to step with a blocked limb (p=0.031). Fallers spent less time walking in the community than
non-fallers (p=0.045). Conclusions: Impaired balance and gait control is related to increased
fall risk post-discharge from stroke rehabilitation. These results suggest that training to improve
both control of the paretic limb and responses to postural perturbations could reduce falls in
community-dwelling stroke survivors.
REFERENCES:
1. Forster, Young. Br Med J. 1995;311:83‐86
2. Inness et al. Phys Ther. 2013
P2.099
Socioeconomic Characteristics of Toronto Neighbourhoods with High Prevalence
of Stroke Survivors
Thom, R2 Bayley, M1, 2 Yaroslavtseva, O1; 1. Toronto Rehabilitation Institute, Toronto, ON; 2.
University of Toronto, Toronto, ON
Background: Previous research suggests the possibility that the socioeconomic character-
istics of the neighbourhood environment in which people live, may contribute to stroke risk.
Further investigation of the sociodemographic characteristics of areas with high stroke preva-
lence could aid in directing city planning approaches in order to mitigate some of these risks
and effectively deliver rehabilitation services. Knowledge of which Toronto neighbourhoods
are at particularly high need for targeted community stroke rehabilitation programs may aid in
stroke program planning which may decrease stroke risk and increase quality of life for stroke
survivors. Objectives: This study is a needs assessment project that seeks to describe the so-
cioeconomic characteristics of the Greater Toronto Area neighbourhoods with high prevalence
of stroke survivors. The socioeconomic characteristics studied include: age, sex, income, level
of education, ethnicity, immigration status, home ownership, and marital status. Methodol-
ogy: The number of stroke survivors discharged from hospitals in the GTA from January 1,
2001 to December 31, 2006 were obtained from the Institute for Clinical Evaluative Sciences
(ICES) Discharge Abstract Database for each of the GTA census tracts. Sociodemographic data
characterizing each census tracts, including age, sex, income, level of education, ethnicity, im-
migration status, home ownership, and marital status, was obtained from the Canadian 2006
Census. ANOVA was used to identify sociodemographic variables characterizing the neighbour-
hoods with high stroke prevalence. Results: The project identified the census tracts within the
GTA that have the highest prevalence of stroke survivors and examined the sociodemographic
characteristics of these areas. Significant relationship has been found for stroke prevalence
and the variables of age, sex, income, marital status, home ownership, education, and citi-
zenship status. Conclusions: The data suggest that socioeconomic characteristics of urban
neighbourhoods may explain and predict the differences in stroke prevalence.
P2.101
Post Stroke Discharge Clinical Follow-up Call
Cole-Haskayne, AL; Gairdner, S; Ryan, L; Suddes, M; Foothills Medical Centre, Calgary, AB
Background: Post discharge calls to the Stroke Prevention Clinic (SPC) increased from pa-
tients requesting further information. Patients seen at their stroke prevention follow-up ap-
pointment had incomplete investigations and medication compliance was an issue. When the
stroke unit was first established, nurse clinicians called patients after discharge. Calls did
not follow a script. Calls were dropped due to time constraints, staffing and other demands.
Calls were felt to be beneficial by nursing staff and client reports. Methods: A literature
review was conducted on discharge clinical calls. Based on learnings from other centers and
staff feedback, a clinical call followup script was developed. A goal of piloting the calls was
to see if the number of calls to the SPC would decrease, followup investigations would be
completed prior to their appointment, and medication compliance would increase. Results:
A Registered Nurse working 0.5 FTE completed 78 one month post discharge calls. Medica-
tions and post discharge plan were reviewed with clients. 13% of patients described having
new or worsened symptoms since discharge. 37% noticed a change in health, 51% had seen
their family Dr, 92% had enough medication till their next appointment, 71% had checked
their BP, 47% said their Physician did not advise what their BP should be, 91% knew 3 of
the 5 signs of stroke and when to call 911, 19% had received our stroke patient passport,
advice from management was sought on 3% of cases, no appointments had to be scheduled
earlier in the SPC, and 3% of patients had questions about driving. Conclusion: Feedback
from nursing staff conducting the calls is that it provided a valuable service and filled a gap.
Medication compliance and followup with family Physicians and other service providers was
encouraged and patients were connected with services when required.
P2.102
Geographic Distribution and Transportation Times for Non-Ambulance Trans-
ported Acute Stroke Patients in the British Columbia Lower Mainland
Harrison, K; Curry, M; Fraser Health Stroke Strategy, Vancouver, BC
Background: Fraser Health services 1.6 million BC residents at twelve hospitals extending
from the Vancouver suburb of Delta on the Pacific coast up over 220km through the Fraser
Valley to rural Boston Bar. Currently all acute stroke patients in Fraser Health either present
on their own or they are transported by ambulance to the closest hospital. Fraser Health is
considering implementing a bypass protocol and centralizing stroke care at a limited number
of sites. Methods: Four-weeks of acute stroke patients (n=40) presenting to Fraser Health
facilities was analyzed. Transportation times were estimated based on usual driving times
gleaned from Google Maps and that transport was from the patient’s residence. Transportation
times were compared between a one-site, two-site, three-site or four-site model sited at the
Royal Columbian Hospital in New Westminster, Surrey Memorial Hospital, Abbotsford Regional
Hospital & Cancer Centre and Chilliwack General Hospital respectively. Results: A one-site
model gave a mean transportation time of 46 minutes and a median of 42 minutes. A two-site
model gave a mean transportation of 44 minutes and a median of 42 minutes. Seven patients
would benefit from a reduced transportation time of, on average, seven minutes. A three-site
model gave a mean transportation time of 30 minutes and a median of 27 minutes compared
with 27 minutes and 25 minutes with a four-site model. On average 26 patients in a three- or
four-site model would experience decreased transport times as compared to a one-site model
and the average time savings would be 23 minutes in a three-site model and 27 minutes in
a four-site model. Conclusions: A one-site centralized model of regional acute stroke care in
Fraser Health leads to increased patient transportation time and delays in acute stroke care
when compared to a multi-site model.
P2.104
A Cross-System Approach to Building Expert Stroke Teams
Fortin, JE1 Skrabka, K2 Avinoam, G3 Linkewich, E1 Willems, J2 Sharp, S3; 1. North&East GTA
Stroke Network / Sunnybrook Health Sciences Centre, Toronto, ON; 2. South East Toronto
 Abstracts From the 4th Canadian Stroke Congress, 2013  e51
Stroke Network / St. Michael’s Hospital, Toronto, ON; 3. Toronto West Stroke Network /
­University Health Network -TWH, Toronto, ON
Background: The Toronto Stroke Networks (TSNs) Education and Knowledge Translation
(KT) Implementation Plan utilizes a systems approach for implementation of Best Prac-
tices and fostering practice change. KT activities were implemented to support dedicated
stroke teams by building expertise in foundational best practices and Interprofessional
Collaborative (IPC) competencies. Methods: The Graham Knowledge to Action (KTA)
cycle informed the structure to address the knowledge gaps and drive positive change.
The Regional Education Coordinators pooled information from a two part collaborative
process assessment that identified cross-system educational needs such as requesting
regular stroke education and developing a team identity. Application of KT education
best practices included using an interprofessional team building approach, completing a
project together, learning in small groups, and sustaining learning through mentorship.
Barriers and facilitators were considered to address the knowledge gaps. Results: A
Cross-System KT Implementation Committee (CSIC) was formed with representation from
the 15 healthcare organizations that provide acute and rehabilitative stroke care within
the TSNs boundaries. The CSIC members act as stroke champions and have engaged in
knowledge exchange and adaptation of the Education and KT plan for local implementa-
tion. An interprofessional collaborative team project included co-creation of posters on
foundational topics (e.g. early mobilization, dysphagia, incontinence, neglect etc.) for
cross-system learning and consistency. To support transfer of knowledge into practice
evidence based small group learning and mentorship guides were developed. Implemen-
tation strategies were launched on the TSNs Virtual Community of Practice for efficient
communication and access, as well as a means of sustainability of the cross-systems
approach. Conclusion: The cross-system approach to build expert teams was developed
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using evidence based KT strategies to fulfill needs of dedicated stroke teams to improve
implementation of best practices. Practice change will be evaluated over the next year
with the anticipation of improved patient outcomes.
P2.105
Improving Timely Administration of Lytic Therapy for Stroke Patients in
Nova Scotia
Gill, N1 White, K1 Swinemar, S4 Goudey, K5 Mooney, M5 Vardy, T6 O’Handley, M7, 8 MacGrath,
M9, 10 MacGillivary, T11 Christian, C3 Simpkin, W3 Phillips, S1, 2, 3; 1. Cardiovascular Health
Nova Scotia, Halifax, NS; 2. Dalhousie University, Halifax, NS; 3. Capital District Health
Authority, Halifax, NS; 4. South Shore District Health Authority, Bridgewater, NS; 5. South
West Nova District Health Authority, Yarmouth, NS; 6. Annapolis Valley District Health
Authority, Kentville, NS; 7. Colchester East Hants Health Authority, Truro, NS; 8. Cumberland
Health Authority, Amherst, NS; 9. Pictou County Health Authority, New Glasgow, NS; 10.
Guysborough Antigonish Strait Health Authority, Antigonish, NS; 11. Cape Breton District
Health Authority, Sydney, NS
Background: Cardiovascular Health Nova Scotia (CVHNS), a program of the Nova Scotia
Department of Health and Wellness, oversees stroke and cardiac care in the province, and
monitors and reports outcomes to the District Health Authorities (DHAs). Significant improve-
ments to stroke care have occurred in the last several years. However, a review of data
in 2011 showed substantial room for improvement in the timeliness of lytic (tPA or tissue
plasminogen activator) administration for ischemic stroke (IS). Methods: Since 2011, CVHNS
and the DHAs have implemented a multifaceted quality improvement (QI) strategy, includ-
ing: provincial stakeholder forums, audit and feedback, and local development of protocols,
algorithms and other decision support tools. Data on selected time points related to all lytic
administration cases (e.g. door to CT and needle) were collected locally, prior to implement-
ing change. Ongoing data collection is being used to monitor change. Results: Additional
results showing change since December 2012 will be available by summer 2013 and in-
cluded in the poster
Conclusion: A provincially coordinated, district driven, QI initiative improved the proportion of
IS patients who were treated with tPA in a timely manner. Improvement was seen within a short
period of time after QI initiatives were undertaken. Ongoing data monitoring and QI strategies,
both at the district and provincial level, are expected to show continued improvement in both
proportions treated in target and median time to treatment.
Pre-Forum (tPA given Post Forum (tPA given
between July 1, 2011 – between Dec 1, 2011 and
Nov 30, 2011; n=52) Aug 30, 2012; n=92)
% in target
Door to CT 17% 43%
(Target = 25 min)
Door to Needle 6% 21%
(Target = 60 min)
Median Time in minutes (with interquartile range)
Door to CT 39 (30-47) 28 (21-42)
Door to Needle 101 (78-125) 79 (63-108)
P2.106
Optimizing the Operational and Economic Impact of a Neurovascular Unit in an
Acute Care Hospital
Hahn-Goldberg, S2 Chow, E2 Appel, E2 Abrams, H1; 1. University Health Network, Toronto, ON;
2. Centre for Innovation in Complex Care, Toronto, ON
Background: There is strong evidence that clinical outcomes are improved for stroke patients
admitted to specialized stroke units. The TCLHIN is creating a stroke strategy to concentrate
stroke care at specific hospitals. The Toronto Western Hospital (TWH) has created a Neurovas-
cular Unit (NVU) using resources from general internal medicine (GIM), neurology, and neurosur-
gery to care for patients with stroke and acute neurovascular injury. Under resource-constrained
conditions, the operational and economic impacts of the NVU were unknown. Methods: Using
patient-level data for NVU-eligible patients from two years prior to the implementation of the NVU
at TWH to a year post-implementation, descriptive analysis and non-parametric testing was con-
ducted to determine differences in cost and LOS pre and post NVU implementation. A discrete
event simulation was created and validated to study changes in patient flow and experiment
with varying levels of patient volumes and resources to determine the ideal number of beds in
the NVU under various conditions. Results: In the first year of operation, the NVU handled 77%
of eligible patient volumes. Only 4% remained as GIM patients, dropping from 24% pre-NVU.
With the introduction of the NVU, average cost per visit and per bed-day decreased by 5% and
12% respectively post-NVU for neurology patients with stroke and acute neurovascular injury.
Acute LOS decreased by up to 16%. Scenario testing showed that the current level of 20 beds is
appropriate for the current demand; however, there is capacity for an increase in demand of up
to 20%. Conclusions: A NVU is possible within an acute care hospital and can be implemented
using existing resources. The NVU at TWH achieved decreased acute LOS and lower total cost
per year for the care of NVU-eligible patients. Ultimately, the created model could be a planning
tool for other hospitals requiring stroke units.
P2.107
Moving Forward on Best Practices for Stroke and Aphasia: a Canadian KTE
Initiative
Kagan, A1 Bayley, M3 Le Dorze, G2 Cook, S1 Garcia, L6 Brenneman Gibson, J1 Hickey, E5 Kel-
loway, L7 Purves, B8 Rochon, E4 Simmons-Mackie, N9 Worrall, L10; 1. Aphasia Institute, Toronto,
ON; 2. Université de Montréal, Montreal, QC; 3. Toronto Rehabilitation Institute, Toronto, ON;
4. University of Toronto, Toronto, ON; 5. Dalhousie University, Halifax, NS; 6. University of
Ottawa, Ottawa, ON; 7. Ontario Stroke Network, Toronto, ON; 8. University of British Colombia,
Vancouver, BC; 9. Southeastern Louisiana University, Hammond, LA, USA; 10. The University of
Queensland, St. Lucia, QLD, Australia
The 2010 Canadian Stroke Strategy guidelines incorporate recommendations for most physical
interventions but have limited reference to aphasia management across the continuum of care
(Worrall et al, in press). Addressing this gap is important because stroke patients with aphasia
have longer lengths of stay, higher costs of care, lower rates of returning home and less favor-
able outcomes overall (Ellis, Simpson, Bonilha, Mauldin & Simpson, 2012). In addition, aphasia
is included in the ten top stroke research priorities (Pollock, St. George, Fenton & Firkins, 2012)
and a large Canadian study identified aphasia as the primary factor that negatively impacts
quality of life for stroke (Lam & Wodchis, 2010). This poster reports on the activities of a team
of stroke and aphasia thought leaders who have started to develop best practice guidelines
for aphasia in Canada, with the long-term goal of integration into the Canadian Stroke Best
Practice Recommendations. The team has a specific interest in Knowledge Translation and Ex-
change (KTE) and successfully obtained a CIHR KTE planning grant to move this agenda forward
(grant#290592, 2013). Key focus areas include:
•• Building reciprocity so that stroke researchers, clinicians and policy makers know about
aphasia and understand the broad “implications” of aphasia intervention
•• Approaching and disseminating research by speech-language pathologists (SLP’s) in a way
that makes sense to the stroke community
•• Evaluating existing evidence in relation to best practice guidelines, and
•• Identifying gaps in evidence
As a first step in ensuring that we are addressing issues that matter to key stakeholders, focus
groups were conducted with individuals with aphasia and family, and Canadian SLPs were sur-
veyed regarding their management of people with aphasia. These data along with a discussion of
the gaps and misalignments between existing best practices guidelines, what SLPs report they are
actually doing, and what people affected by aphasia want, will be the focus of the presentation.
P2.108
Examining Ontario’s Stroke Report Card Indicator Relationships to Understand
the Impact of Best Practice Implementation and Inform System Planning
Linkewich, E1, 4, 5 Khan, F2 Hall, R2, 3; 1. North & East GTA Stroke Network, Toronto, ON; 2.
Ontario Stroke Network, Toronto, ON; 3. Institute for Clinical and Evaluative Sciences, Toronto,
ON; 4. Sunnybrook Health Sciences Centre, Toronto, ON; 5. Northern Ontario School of Medi-
cine, Thunder Bay, ON
Background: In 2011 the Ontario Stroke Evaluation and Quality Committee created Ontario’s
Stroke Report Card, consisting of twenty indicators with potential to influence system performance
and flow of stroke patients across care continuum. Recognizing the anecdotal relationships be-
tween indicators we sought to determine whether there is evidence of statistical relationships
among indicators to inform system planning and development. Methods: Using the FY 2009/10
regional stroke report cards, we performed Pearson correlation analysis, reporting statistical sig-
 e52  Stroke  December 2013
nificance at < 0.05 for clinically relevant associations among indicators. Eight indicators used
FY2008/09 Ontario Stroke Audit data and eight used FY2009/10 Canadian Institute for Health
Information (CIHI) administrative databases and one used the Ontario Home Care Database, FY
2008/09. Results: Of the seventeen indicators, six had statistically significant correlations with
other indicators, specifically: 1) arrival to the emergency department within 3.5 hours of symptom
onset is associated with stroke unit admission (r=0.56, p=0.04) and2) referral to outpatient reha-
bilitation (r=0.55, p=0.04); 3) tPA administration is inversely associated with inpatient admissions
(r=-0.55, p=0.04) and 4) 30-day readmissions (r=-0.56, p=0.04) in the subsequent year; and 5)
access to inpatient rehabilitation is associated with higher FIM efficiency (r=0.53, p=0.05) and
a higher FIM efficiency is associated with shorter time to admission into rehabilitation(r=-0.73,
p=0.003). 6) We also observed an inverse relationship between the proportion of patients admit-
ted into inpatient rehabilitation as well as the proportion of severe stroke patients admitted into
inpatient rehabilitation and the proportion of patients being discharged to long-term care with
(r=-0.57, p=0.03) and (r=-0.59, p=0.03), respectively. Conclusion: Opportunities exist to direct
quality improvement, resource allocation, and system planning toward specific best practices,
such as coordinated stroke care, to improve performance in multiple areas. Although strong cor-
relations were observed between indicator performance, future research will examine change in
indicator performance to assess whether the associations among indicators remain over time.
P2.109
Positioning Primary Care to Improve Transition Experience for Persons with
Stroke and Caregivers
McKellar, J5, 2 Sharp, S5, 2 Li, T1 Xiao, A1 Darling, S2 Linkewich, E4, 3 Willems, J6, 7; 1. University
of Toronto, Toronto, ON; 2. Toronto Western Hospital, UHN, Toronto, ON; 3. Sunnybrook Health
Sciences Centre, Toronto, ON; 4. North and East GTA Stroke Network, Toronto, ON; 5. Toronto
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West Stroke Network, Toronto, ON; 6. South East Toronto Stroke Network, Toronto, ON; 7. St.
Michaels Hospital, Toronto, ON
Background and Objective: Provincial and local priorities in health care are driving change that
focuses on better management of chronic conditions; matching services to patient needs and
enhanced coordination of care across the continuum. Primary care has been identified as a focal
point in this new integrated patient-centred healthcare system(1). The study sought to inform
the iterative development of two new resources designed in Toronto to improve the transition
experience for people with stroke and caregivers by better understanding the opportunities and
requirements from primary care’s role within the recovery journey. These resources include: 1)
Essential Professional Conversations (EPCs): a healthcare provider focused strategy to promote
verbal exchange and learning about how to optimize care coordination and patient-centred care
through transitions; 2) My Stroke Passport (MSP): a patient-mediated communication and navi-
gation tool designed to promote enhanced patient interaction, meaningful care and self-man-
agement. Methods: Private practice, community health centres, and family health teams were
invited to participate. An REB approved qualitative approach was used to collect narrative data
through digitally recorded individual interview(s) or focus groups with primary care providers.
A descriptive thematic approach was utilized to analyze the transcripts. Results: Preliminary
data suggests that primary care plays multiple roles in the coordination of care and manage-
ment of stroke patients. Opportunities identified to support their role and improve continuity
of care include: timely and relevant communication of key information such as patient goals,
medications, test results and further diagnostics. Additionally, tools to promote health literacy/
numeracy and self-management and knowledge of resources are required to address cultural
and psychosocial issues. Conclusion: EPCs and MSP have utility for primary care providers.
Meaningful enhancements will be incorporated to create a comprehensive standard of care for
transition management for stroke care in Toronto.
Reference
1. Drummond Report, Ontario Action Plan for Health, ECFA Act, TCLHIN Strategic Priority 2012
P2.110
Distinction as a Quality Improvement Partnership in a Community Hospital
Reinholdt, F; Murray, J; Mackenzie Health, Richmond Hill, ON
Background: Accreditation Canada and the Canadian Stroke Network developed the Stroke
Services Distinction program in 2010 to bridge the gap between what is known about best
practice stroke care and what is applied. Mackenzie Health, the District Stroke Centre for
York Region in Ontario, chose to participate in the Accreditation Canada Stroke Distinction
program as a Quality Improvement initiative. The intent was to build on existing stroke best
practice, to discover and address gaps in service, and to further our role as a leader in stroke
care. Methods: Achieving Distinction standards across the acute and rehabilitation continuum
was a challenging objective. Strategic engagement of Executive and Clinical Leadership was
a purposeful tactic. A Steering Committee comprised of key clinical and operational leaders
provided overall accountability and oversight for Distinction activities. Based on a gap analysis,
four cross hospital working groups were created to address processes, protocols, and policy
related to Metrics, Acute and Rehab Care Standards, Patient and Family Education and Com-
munity Partnerships. The Steering Committee leveraged learnings from the recently completed
Hospital Accreditation to ensure success. Strategies to engage staff included daily stroke best
practice information (Stroke of Genius), awareness campaigns, targeted education, and mock
tracer sessions conducted by senior administrative and physician leaders. Results: Macken-
zie Health received Distinction status March 19, 2013 achieving 98.3% (174/177) of acute
and rehab standards, 100% of protocols, 100% for patient and family education and 100%
for excellence and innovation. The level of organizational engagement and preparedness was
evident throughout the onsite survey. Conclusions: Through the Distinction journey, Mack-
enzie Health truly became a “stroke aware” hospital. Our success was a result of leadership
engagement, engaged champions, strategic partnerships, and an effective project leadership
and management model.
P2.111
Evaluation of the Perinatal Stroke Parent Support Group
Berscht, S1 Palashniuk, E2 Bemister, TB3; 1. Heart and Stroke Foundation, Calgary, AB; 2.
Stroke Recovery Association of Alberta, Calgary, AB; 3. University of Calgary, Calgary Pediatric
Stroke Program, Calgary, AB
Background: The Perinatal Parent Support Group was created to support parents of chil-
dren living with the effects of perinatal stroke. Perinatal stroke occurs in up to 1 in 2300
live births and is the leading cause of hemiparetic cerebral palsy. Secondary disabilities of
perinatal stroke include epilepsy, behavioral problems, and cognitive deficits. The support
group focuses on empowering affected parents through education and support. In order to
make meaningful changes to the group and plan for sustainability, the organizers/facilitators
initiated a formal evaluation of the group. Methods: An outside evaluator, Objective Research
and Evaluation Inc., was contracted to gather data from current group participants. The evalu-
ator met with representatives from the collaborating institutions in order to create a survey
as well as topics to discuss in a focus group. Objective Research and Evaluation Inc. ran the
focus group independently to ensure participant answers were not influenced by the presence
of the facilitators. Seven parents participated in the focus groups which involved five open
ended questions and completed the survey which consisted of thirteen closed ended ques-
tions. Results: In terms of the logistics of the group, all parents indicated that these details
were either good or excellent. The majority of parents agreed the group has given them the
opportunity to participate in activities they otherwise would not have had the chance to, that
the group has improved their overall health and wellness and that participation in the group
has helped them feel more connected with their community. All parents strongly agreed that
they feel less isolated since joining the group and indicated that they would recommend the
group to other parents in similar situations. Conclusions: The evaluation of the support group
was overwhelmingly positive and suggests an ongoing need to continue and expand on the
Perinatal Parent Support Group.
P2.112
Addressing Aphasia through Interprofessional Stroke Education
Purves, B; Petersen, J; Wood, V; University of British Columbia, Vancouver, BC
Background: Aphasia poses communication challenges for all health professionals work-
ing with people living with this condition. Emerging trends in healthcare training programs,
including interprofessional education, community service learning, and the active involve-
ment of patients as mentors, offer innovative strategies for giving students a range of op-
portunities to learn how to support effective communication with people with aphasia. This
study describes two initiatives designed to integrate such learning into students’ professional
programs. Methods: First, at an annual two-day camp developed through a university-com-
munity partnership, students were organized into interprofessional teams partnered with
people with aphasia to take part together in social-recreational activities. Second, people
with chronic aphasia participated in a program for mentoring speech-language pathology
students. These mentors with aphasia created and led 3 workshops for students from a va-
riety of health professions, describing what it means to live with aphasia and what health
professionals can do to support them. Evaluations of both activities were conducted through
post-activity student surveys. Results: A total of 85 students from 10 health professions have
participated in the aphasia camp over the past three years. Approximately 28 participants
with aphasia have taken part per year. Survey results yielded positive ratings of the camp
both as an interprofessional learning opportunity and as a way to learn about communicating
with people with aphasia. In the 3 mentoring workshops offered to date, a total of 45 students
from 9 health professions have participated. Overall, they rated the workshops as an effective
way to learn how to support people with aphasia in health-care interactions. Conclusions:
Interprofessional education that includes people with aphasia as active partners and offers
opportunities for communication in non-clinical settings provides effective strategies for train-
ing future health care professionals to support the communication of people with aphasia as
a fundamental part of stroke care.
P2.113
A Novel Rotational Advanced Practice Nursing Model to Increase Continuity of
Care and Job Satisfaction
Armesto, A; Bouthillier, C; Runions, S; Linkewich, E; North & East GTA Stroke Network, Sun-
nybrook Health Sciences Centre, Toronto, ON
Background: Within the North and East Greater Toronto Area Stroke Network (NEGTASN) the
Stroke Clinical Nurse Specialist (CNS) roles were set up to support three distinct practice ar-
eas (outpatient, inpatient, program development). As the value of the roles grew so did the
demand to fulfill the associated responsibilities. A collaborative process to identify needs and
possible solutions resulted in a novel 4-month rotational model. Method: The CNSs, along with
the teams, outlined the roles and responsibilities within each area. These role profiles were
further informed by the emerging needs of key organization and system stakeholders. Formal
and informal communication supported the transition to the new rotational model. The model
was implemented in 2010. To sustain the model an orientation period was included at the
beginning of each rotation to support the transition. Weekly meetings were set up with the
CNSs to discuss priorities, changes, challenges, and opportunities. These meetings ensured
consistency within and across practice areas and alignment with best practices and regional
 Abstracts From the 4th Canadian Stroke Congress, 2013  e53
priorities. Results: The CNS profile has risen within the organization and across the region, with
increased recognition and opportunities to lead initiatives. Feedback from physicians, nurses,
the interprofessional team at Sunnybrook and the NEGTASN was positive, identifying themes of
improved collaboration and communication. The CNSs reported: enhanced expertise, stronger
relationships within each area, increased personal satisfaction, and rejuvenation for the work.
This has lead to improved clinical handover and additional quality improvement initiatives. The
communication infrastructure put in place allows for more seamless transition and continuity in
patient care, including coverage for vacation and illness. Conclusion: Overall, the experience of
this model has demonstrated a benefit for the CNS, the patient, and the organization/system. An
iterative process is necessary to ensure responsiveness to emerging needs.
P2.114
Alberta Stroke Improvement Initiative: Collaboration and Quality Improvement
Taralson, CL Burley, T Garnier, S Kashyap, D Fang, S Bohm, V Jeerakathil, T Suddes,
1 1 1 1 2 1 1
M3; 1. Alberta Health Services Stroke Program Edmonton Zone, Edmonton, AB; 2. Alberta
Health Services Cardiovascular Health and Stroke Strategic Clinical Network, Edmonton, AB; 3.
Alberta Health Services Calgary Stroke Program , Calgary, AB
Background: Alberta Stroke Improvement (ASI), a quality improvement (QI) initiative implement-
ed by the Alberta Provincial Stroke Strategy (APSS) was designed to maintain gains made by the
APSS, address and support any further improvement work, and test a model of collaborative QI.
The initiative partnered APSS, The Cardiovascular Health and Stroke Strategic Clinical Network
(SCN) of Alberta Health Services (AHS), and 18 Provincial Stroke Centres. Methods: ASI was
comprised of three phases: Scope, Improve and Sustain, and was coordinated by a multi-pro-
fessional team of individuals with stroke service leadership and QI expertise. In Scope, over 200
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participants representing stroke centres across the province engaged in a site specific review
of their performance against best practice standards. Scope generated a list of improvement
priorities which were themed into 7 major areas of focus, including both clinical and supporting
processes. During Improve, stroke centres selected 1 or 2 areas for improvement resulting in 20
projects provincially. Stroke teams were supported in their QI journey with 3 learning sessions,
educational webinars and coaching calls to introduce QI tools and provide mentorship for the
project work. Results: ASI was successful in building capacity within stroke centre teams and
making measureable improvements in stroke service delivery. The initiative was also successful
in providing transition, strategic direction and practical implementation across stroke centres
as the APSS evolves into the Cardiovascular Health and Stroke Strategic Clinical Network. This
paper/poster will present progress, outcomes from improvement projects and participant expe-
rience data. Two cases studies will be used to reflect the improvement approaches followed by
different centres. Conclusions: Using a systematic, collaborative, provincially scoped approach
to stroke care, ASI supported improvements in the quality of stroke service delivery. Further
partnerships, including cross-provincial approaches, should be explored.
P2.115
Comprehensive Education of Health Care Providers in Long Term Care: Improving
Stroke Care
Thornton, M1 Jelley, W2; 1. Ottawa Hospital, Ottawa, ON; 2. University of Ottawa, Ottawa, ON
Introduction: Integrated Health Networks seek to optimize the care and achieve better outcomes
for stroke survivors. To this end, workshops were implemented to train health care providers
on aspects of ideal management post-stroke. Hypothesis: We hypothesize that participation of
health care providers in comprehensive knowledge transfer workshops that encourage uptake
of best practices would result in improved perception of their ability to manage post-stroke care
effectively. Methods: A seven-hour workshop was offered by the local health network on three
separate occasions, covering various topics related to stroke care. Workshops were taught by
teams of content experts (Nurse Specialist, Occupational Therapist, Physical Therapist, Social
Worker and Speech Language Pathologist). Workshop content included training in safe feeding,
effective communication, handling of the hemiplegic arm, transfer strategies and positioning.
Workshop content was developed by the provincial stroke network and offered to personal sup-
port workers. An 11-point questionnaire was used to gather participants’ perceptions on their
abilities. To increase the sensitivity of the questionnaire, an “ipost-post testî design” was used
after workshop completion, in which participants were asked to reflect on both their current and
prior level of abilities in post-stroke management. Results: A total of 61 health care providers
were trained, primarily personal support workers with a small number of Registered Nurses,
Therapy Assistants and Paramedical Workers from various parts of the care continuum (acute
care, community, long term care and rehabilitation.) The average level of perceived knowledge
in stroke care before the workshop was 3.35/5. This increased to 4.4/5 perceived level of knowl-
edge after the workshop. Overall ratings of the educational experience were excellent (46% of
participants), or very good (48.3%). Conclusions: Participation in a knowledge transfer work-
shop to encourage uptake of best practices resulted in improvement in participants’ confidence,
understanding and perceptions of their knowledge to manage post-stroke care effectively.
P2.116
Evolution of Integrated Outpatient Rehabilitation Service
Parsons, J; Vance, S; Ng, V; Doull, K; Dawson, A; FH Stroke Strategy; Fraser Health, Surrey, BC
Background: Fraser Health piloted two programs for stroke survivors to support transitions
across the rehabilitation continuum. The Rehab Early Discharge (REDi) pilot shifted the service
delivery model from an inpatient care model to a coordinated intensive outpatient service. The
pilot demonstrated measureable positive system impacts with efficiency, LOS and access while
maintaining or improving patient functional outcomes. The second pilot, Stroke Assessment
Rehabilitation and Transitions (Start) included strategic partnerships with Non-Government Or-
ganizations and local municipal programs, to support the delivery of community based services
for stroke survivors that facilitated community transitions and self-management. The Reha-
bilitation Program sought to incorporate the two pilots into a new regional service; Community
REDi. Methods: Regionalization of the service was completed using a developmental evaluation
framework to identify critical elements, guide service design and ensure ongoing monitoring and
enhancement of the service. The logic model is supported by tools such as PDSA (Plan, Study,
Do, Act) cycles, staff and patient surveys and regular operational reporting. Results: Community
REDi is now available in six communities across Fraser Health. Operational benchmarks are be-
ing established and validated against a capacity planning tool and operational utilization reports.
Critical elements of the service include:
•• central intake and regional access
•• coordinated interdisciplinary care
•• clinic supervisor to support client care and program development
•• linkages to primary care physicians
•• community reintegration programming in partnership with NGO’s and muncipalities
•• a business model for community based services that supports ongoing sustainability with
minimal fiscal responsibility for the health authority
•• evaluation framework for development of operational benchmarks Conclusions: Commu-
nity REDi provides coordinated outpatient rehabilitation and community reintegration to
promote early discharge and transition of stroke survivors across a continuum of care.
Through ongoing data collection and anaylsis, evaluation is now embedded into the daily
operations of the program and drives client flow and positive system impacts.
P2.117
Constructing the Meaning of ‘Survivor’
Zwiers, AM; University of Calgary, Calgary , AB
Background: With advances in medicine and technology, patients are experiencing an in-
creased ‘survival’ rate from acute stroke. ‘Survivor’ is a term often used to represent a per-
son with a heroic disposition gained from overcoming adversity. However, the term survivor
used in the context of illness may give patients a false sense of cure. Patients who suffer
 e54  Stroke  December 2013
from acute stroke often experience chronic physical, psychological, social and cognitive
deficits related to type of stroke, location, treatment and available support. Patients are also
at higher risk for stroke recurrence. There is currently little qualitative research describing
how patients adapt to a stroke survivor identity as they recover and rehabilitate within their
communities. Methods: A qualitative grounded theory research design will be used to ex-
amine how adult patients with acute stroke understand the meaning of ‘survivor’, or define
and identify with being a survivor. 15 participants, aged 40 and older, who experienced one
or multiple acute strokes of varying degrees of severity, will be interviewed. Participants will
also submit journal entries outlining their experiences and reasoning used to define, identify
or de-identify with the term ‘survivor’. Results: The findings of this study will generate an
emerging theory around the influences of survivor-ship on recovery among this popula-
tion and what the term ‘survivor’ means for healthcare professionals, caregivers, and other
patients. Conclusions: The language used in healthcare and communities can influence
patient perspectives and outcomes. It is important to examine the terms we use to identify
those who have had an acute stroke experience while providing appropriately contextualized
and individualized care and support.
P2.118
Timing it Right Stroke Family Support Program: Ongoing Randomized
Controlled Trial
Cameron, JI1 Czerwonka, A1 Naglie, G2 Warner, G3 Green, T4 Gignac, M5 Bayley, M6 Huijbregts,
M2 Cheung, A6 Silver, F6 Phillips, S7; 1. University of Toronto, Toronto, ON; 2. Baycrest Centre
for Geriatric Care, Toronto, ON; 3. Dalhousie University, Halifax, NS; 4. University of Calgary,
Calgary, AB; 5. Toronto Western Research Institute, Toronto, ON; 6. Toronto Rehabilitation In-
stitute - University Health Network, Toronto, ON; 7. Capital District Health Authority, Halifax, NS
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Background: Family caregivers play a central role in the recovery, rehabilitation, and commu-
nity re-integration of stroke survivors. We developed the Timing it Right Stroke Family Support
Program (TIRSFSP) to provide stroke families with timely education and support as they care for
stroke survivors transitioning from acute care, through rehabilitation, and back to community
living. The objective of this trial is to determine if receiving the TIRSFSP results in better stroke
knowledge, support, and mental health outcomes for family caregivers. Methods: Family care-
givers of stroke patients have been recruited from 12 acute care hospitals from across Canada
to participate in a mixed methodology RCT. Caregivers are randomized to: 1) standard care, 2)
Self-directed TIRSFSP, or 3) TIRSFSP delivered by a stroke support person for approximately
the first 6 months post stroke. Participants complete standardized measurement instruments
prior to randomization and 3, 6, and 12-months post-stroke. Six participants per research site
are invited to participate in qualitative interviews. Stroke support persons are keeping journals
to document each session with the caregivers. Progress To Date: Recruitment is now com-
plete, with a total of 310 caregivers randomized. One hundred caregivers were randomized to
receive standard care; 106 caregivers were randomized to receive the self-directed TIRSFSP;
and 104 caregivers were randomized to receive the stroke support person delivered TIRSFSP.
Of those randomized, 221 caregivers have completed their 3 month follow-up assessment,
and 211 have completed their 6 month follow-up assessment. Final 12 month post-stroke
follow-up data collection will be completed by October 2013. Implications: This research will
help us determine if the TIRSFSP may benefit family caregivers. If proven effective, it could
be recommended as a model of stroke family education and support that meets the Canadian
Stroke Best Practice Guideline recommendation for providing timely education and support to
families through transitions.
P2.119
‘Spot Sign’ Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy
(SPOTLIGHT): Rationale and Design of a Canadian Image-Guided Randomized
Controlled Trial of Recombinant Factor VIIa
Gladstone, DJ1 Aviv, R1 Demchuk, A2 Hill, MD2 Flaherty, M3 Butcher, K4 Black, SE5 Mamdani,
MM6 Thorpe, K6 Sahlas, DJ7 Spence, J6 De Masi, S6 Hall, J6 SPOTLIGHT Steering Commit-
tee and Investigators, O8; 1. University of Toronto, Toronto, ON; 2. Foothills Medical Centre,
Calgary, AB; 3. University of Cincinnati, Cincinnati, OH, USA; 4. University of Alberta, Edmonton,
AB; 5. Sunnybrook Health Sciences Centre, Toronto, ON; 6. St. Michael’s Hospital, Toronto, ON;
7. Hamilton Health Sciences, Hamilton, ON; 8. and the SPOTLIGHT Steering Committee and
Investigators,
Background: Intracerebral hemorrhage (ICH) is a life-threatening stroke emergency without
any approved hyperacute medical treatment. Some patients deteriorate rapidly after hospital
arrival due to ongoing bleeding and hematoma expansion. Recombinant activated coagulation
factor VII (rFVIIa) is a promising therapy to reduce ICH expansion, but previous trials did not
select patients for treatment based on any markers of active bleeding. Focused trials target-
ing only the active bleeders are needed to develop this therapy further. Using CT angiography
(CTA), it is possible to identify a subgroup at greatest risk for ICH expansion (‘spot sign positive’
patients) to target for hemostatic therapy; ‘spot sign negative’ patients have stopped bleed-
ing and are not expected to respond to such treatment. This trial aims to test the feasibility,
safety and preliminary clinical efficacy of a CTA image-guided emergency treatment protocol
for ICH. Methods: SPOTLIGHT is an investigator-led Canadian phase II double blind multicentre
randomized controlled trial approved by Health Canada. Eligible patients with an acute spon-
taneous spot-sign positive ICH are randomly assigned to receive rFVIIa 80µg/kg or placebo
as quickly as possible within 60 minutes post-CTA and within 6 hours post-onset. Spot sign
negative patients are not enrolled. Because ICH growth is highly time-sensitive and informed
consent cannot always be immediately obtained, a waiver of consent option is proposed to
enable expedited treatment for eligible incapacitated patients without a substitute decision
maker immediately available. The primary endpoint is ICH expansion within 24 hours. Ad-
ditional endpoints are scan-to-needle times, feasibility of recruitment, safety (thromboembolic
SAEs), acute blood pressure protocol, neurological impairment, disability, cognition and de-
pression. Trial recruitment is ongoing. Funded by peer-reviewed grants from Canadian Insti-
tutes of Health Research (CIHR), Ontario Stroke Network, and Ontario Ministry of Research and
Innovation. ClinicalTrials.gov Identifier: NCT01359202
P2.120
The INTERnational Study on Primary Angiitis of the CEntral nervous system
(INTERSPACE): A Call to the World
Lanthier, S1 Calabrese, LH2 Ferro, JM3 Putaala, J4 Strbian, D4 Létourneau-Guillon, L5 Raymond,
J1 Guilbert, F1 Frosch, M6 Chagnon, M7 Singhal, AB8, 6 Poppe, AY1; 1. Centre hospitalier de
l’Université de Montréal, Montreal, QC; 2. Cleveland Clinic, Cleveland, OH, USA; 3. Hospital
Santa-Maria, Lisbon, Portugal; 4. Helsinki University Central Hospital, Helsinki, Finland; 5.
Department of Radiology, Université de Montréal, Montreal, QC; 6. Massachusetts General
Hospital, Boston, MA, USA; 7. Department of Mathematics and Statistics, Université de Mon-
tréal, Montreal, QC; 8. Harvard Medical School, Boston, MA, USA
Primary angiitis of the CNS (PACNS) is a rare and life-threatening form of vasculitis confined to
the CNS. Current knowledge on PACNS mainly derives from single-centre or small-sized se-
ries, implying potential biases. The affected vessel size, appropriate diagnostic process, optimal
treatment, markers of treatment response, and prognosis remain controversial. INTERSPACE is
an ongoing, international, multi-centre, prospective, cohort study, designed to describe clinical
manifestations, investigation results, diagnostic process, misdiagnoses, current treatments, and
outcomes (treatment failures and recurrences) in 200 PACNS patients. Its primary objective is
to identify predictors of death or dependence (modified Rankin Scale: 3-6) following >1 year
of clinical follow-up. Eligibility criteria are age >15 years, acquired neurological dysfunction
consistent with PACNS, imaging study of CNS vessels or CNS histopathology consistent with
PACNS, and exclusion of conditions that may mimic PACNS. Exclusion criteria are immunosup-
pressive therapy initiated before obtaining MRI of the CNS or >30 days before study enrolment,
and study consent not signed. Data on INTERSPACE participants are collected in a web-based
database (accessible at www.youngstrokenetwork.org) at baseline and during clinical follow-
up. Diagnosis of PACNS and outcome events (treatment failure and recurrence) are adjudicated
to maximize validity of INTERSPACE. Multivariate analysis will identify predictors of death or
dependence. Assuming death or dependence at the end of follow-up in 60 participants (30% of
200 participants), as much as 6 predictors may be identified and integrated to the multivariate
model. Since October 2012, 3 study subjects were enrolled from 2 active study sites. In 2013,
5 more sites were activated and 24 are in the process of ethics approval. Fourteen American,
European and Asian countries are represented. Assuming recruitment of 0.5 participant/site/
year, 69 additional sites must join INTERSPACE to complete enrolment and follow-up of 200
adjudicated PACNS patients in 5 years. Please contact sylanthier@gmail.com to submit your
site candidature.
P2.122
The Effect of Combined Upper Limb Rehabilitation and Botulinum Toxin Injections
on Electrophysiological, Clinical, and Behavioural Outcomes in Post-Stroke
Spasticity
Bhatt, H1 Danells, C1 Sharma, S2 Mochizuki, G1; 1. Heart and Stroke Foundation Centre for
Stroke Recovery, Sunnybrook Research Institute, Toronto, ON; 2. Sunnybrook Health Sciences
Centre, Toronto, ON
Background: Approximately 40% of stroke survivors will develop spasticity within the first year after
stroke. Focal injections of Botulinum toxin (BoNT-A) into the affected muscles is a common option
for spasticity management. This approach has been shown to reduce spasticity and pain; however,
the evidence for improved functional outcomes using this management strategy remains equivocal.
Contributing to this may be the type of adjunctive therapy used with the injections or the selection
of outcome measures. The purpose of this study is to compare the effects of a combined BoNT-A/
upper limb movement training approach versus a combined BoNT-A/functional rehabilitation ap-
proach on electrophysiological, clinical and behavioural outcomes in stroke survivors with spasticity
in the upper limb. Methods: In this randomized single-blind crossover design study, participants
are randomized to 10 weeks/3x week of movement training followed by a 12 week washout or 10
weeks/3x week of functional neurorehabilitation followed by a 12 week washout. Participants then
cross over to the alternate therapy. Assessments are done at baseline then at 4, 8 and 10 weeks
after the administration of BoNT-A. Primary electrophysiological outcomes are surface EMG ampli-
tude and timing, EEG amplitude and frequency and single motor unit discharge rate and variability.
Secondary outcomes include clinical (MAS, CMSA) and behavioural (kinetics, kinematics) measures.
Results: To date, 11 participants have been enrolled in the study (mean age = 58.3±15.9 years, 7
male). The median elbow MAS score at intake is 1+ and the median CMSA hand and arm stages
are 2 and 2, respectively. Rate of recruitment is 52.4% and study adherence is 100%. Conclusions:
This clinical trial aims to identify a neurorehabilitation intervention that, when coupled with BoNT-A
injections, enhances recovery in stroke survivors with upper limb spasticity. This will contribute to
the growing body of work probing the capacity for functional recovery in individuals with spasticity
after stroke.
P2.123
Supporting Therapists to Integrate Virtual Reality Systems Within Clinical
Practice: a Knowledge Translation Study
Levac, D1 Glegg, S2 Sveistrup, H1 Finestone, H3 Miller, P4 Brien, M5 Miller, P4 DePaul, V4
Wishart, L4 Harris, J4; 1. University of Ottawa, Ottawa, ON; 2. Sunny Hill Health Centre for
 Abstracts From the 4th Canadian Stroke Congress, 2013  e55
Children, Vancouver, BC; 3. Bruyere Research Institute, Ottawa, ON; 4. McMaster University,
Hamilton, ON; 5. Ottawa Children’s Treatment Center, Ottawa, ON
Virtual reality (VR) systems are promising treatment options for physical therapists (PTs) and oc-
cupational therapists (OTs) in stroke rehabilitation because they incorporate motor learning prin-
ciples of task-oriented, challenging, and motivating practice. However, clinicians face challenges
when integrating VR into clinical practice, including limited availability of training that supports the
implementation of VR-based therapy with a motor learning focus. Untrained therapists may deliver
sub-optimal intervention as they are unprepared to use VR systems effectively. Training support
is required if therapists are to become competent at transferring gains made in VR-based therapy
to better functioning in the real world. This poster describes the methods of an ongoing knowl-
edge translation (KT) study to develop, implement and evaluate a KT strategy to promote motor
learning-based integration of GestureTek’s Interactive Rehabilitation Exercise (IREX) and Gesture
Xtreme (GX) systems into clinical practice in two stroke rehabilitation units. The KT initiative includes
e-learning modules, experiential workshops, and audit and feedback. The 3 e-learning modules
provide foundational knowledge about evidence for VR use in neuro-rehabilitation, neuroplasticity,
motor learning principles, IREX/GX game characteristics, setting SMART goals, and implementing
motor learning strategies. The format includes pre- and post-module confidence logs, interactive
knowledge checks, and video clips. Experiential learning with the GestureTek system occurs in
group and individual formats. Audit and feedback is provided to participants through individual
practice sessions and video stimulated recall sessions. Outcome measures evaluate participant
knowledge and skills and the feasibility of both KT methods and VR implementation. This is the first
study to evaluate a KT strategy focusing on motor learning-based VR interventions. The KT strategy
is generalizable to other VR systems and can be implemented on a wide scale. The goal is to provide
clinicians with skills to utilize VR to yield high quality evidence and enhanced outcomes for stroke
rehabilitation clients.
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P2.124
Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlu-
sion with Emphasis on Minimizing CT to Recanalization Times ESCAPE)
Hill, MD1, 2 Demchuk, AM1, 2 Goyal, M1 Menon, BK1, 2 Eesa, M1 Al-mekhlafi, M1 Desai, J1 Mishra,
S1 Ryckborst, KJ1 The ESCAPE Investigators1; 1. University of Calgary, Calgary, AB; 2. Hotchkiss
Brain Institute, Calgary, AB
Background: There is no convincing, randomized trial evidence that modern endovascular ther-
apy is better than routine care, including routine intravenous thrombolysis, for acute ischemic
stroke. There is nevertheless, strong evidence that endovascular therapy can result in faster,
more complete recanalization (high recanalization rates of about 80%) and that this should result
in better stroke outcomes. Objective: The primary objectives are to show that rapid endovascular
revascularization amongst radiologically selected (small core/proximal anterior circulation occlu-
sion) patients with ischemic stroke results in improved outcome compared to patients treated
in clinical routine. The secondary objectives of this study are to demonstrate the safety and
feasibility of achieving rapid endovascular revascularization in this population of patients (<90
min CT-recanalization; <120 min ESCAPE-center door to recanalization). Design: A Phase3, ran-
domized, open-label with blinded outcome evaluation, controlled design. Population Studied: The
study will test the hypothesis that patients undergoing endovascular revascularization will show a
20% absolute risk benefit (RR = 1.5 relative benefit) over patients receiving clinical routine care.
The assumed rate of good outcome in the control arm is 40% and 60% in the treatment arm.
With 85% power and no interim analyses for efficacy, the sample size consists of 242 evaluable
patients (141 in each group). Sample size is inflated to 250 for crossovers, loss to follow-up
etc. Intervention: Subjects with a small core of infarction, proven large artery anterior circulation
occlusion, good collaterals within a 12-hour window will receive routine guideline-based best
medical care (including IV-tPA as appropriate in a 4.5h window). Control arm subjects will receive
best medical care. Intervention/experimental arm subjects will additionally receive endovascular
thrombectomy or thrombolysis. Outcome measures: Primary efficacy outcomes are NIHSS score
0‐2 OR mRS 0‐2 at 90 days.
ESCAPE- NCT01778335
Trial Status: Active, Recruiting - Email: esctrial@ucalgary.ca
P2.125
Thrombolysis for Minor Ischemic Stroke with Proven Acute Symptomatic Occlu-
sion Using TNK-tPA (TEMPO-1)
Mandzia, JL1 Coutts, SB1, 2, 3 Kenney, C1, 2 Hill, MD1, 2, 3; 1. Calgary Stroke Program, Calgary, AB; 2. Uni-
versity of Calgary, Department of Neuroscience, Calgary, AB; 3. Hotchkiss Brain Institute, Calgary, AB
Background: Minor stroke and TIA are associated with a risk of early major stroke, especially
when a major vessel occlusion is present, seen acutely in 10-30% of these patients. TNK-tPA
(TNKase) compared to alteplase is easier to administer, has a longer half life, higher fibrin
specificity, and a possible lower rate of intracranial hemorrhage. Therefore it may be an ideal
thrombolytic agent in this population. Methods: TEMPO is a multi-centre, prospective cohort,
TNK-tPA dose-escalation, safety and feasibility trial. Patients with TIA or minor stroke with an
NIHSS < 6 and within a 12h treatment window will be enrolled. Patients must have an arterial
occlusion on CTA and not show signs of well-evolved infarction on NCCT. 50 patients will
be enrolled. The first 25 patients will be treated at a dose of 0.1 mg/kg. Assuming safety, a
second cohort of 25 patients will be treated at a dose of 0.25 mg/kg. Primary outcomes will
be rate of symptomatic intracranial and extracranial hemorrhage and feasibility of enrolment
and treatment. Secondary outcomes include complete neurological (NIHSS 0-1) and func-
tional (MRS 0-1) recovery at 90 days, recanalization at 4-8 h and minor bleeding. Results: 16
patients (mean age 69.7, 50% males) have been enrolled at the University of Calgary since
July 2012 with a mean baseline NIHSS of 2.4. Site of intracranial occlusions were: M1 (2), M2
(10), M3 (2), P2 (1) branches and vertebral artery/PICA (1). Recanalization rate between 4-8
h was 25 %. There were no complications. Conclusion: Assuming safety of this approach in
both dose tiers, we will pick the higher of the two doses and proceed with a randomized trial
in this population. An international trial would be required with 500 patients to show a 10%
treatment effect size.
Funding: Heart & Stroke Foundation Alberta, Alberta Innovates Health Solutions.
 Abstracts From the 4th Canadian Stroke Congress, 2013

Stroke. published online November 5, 2013;

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