Regions of homozygosity and a novel variant in Steel syndrome: An added dilemma to diagnosis

Steel syndrome is an autosomal recessive disorder that is caused by mutations in COL27A1 gene. The majority of reported cases have been of Puerto Rican origin, with few reports from India. The present case adds to the repertoire of homozygous recessive disorders from non-consanguineous Indian families. With the present case, a 4-year-old girl, we wish to signify that although mutations in several genes are known to cause skeletal abnormalities, identification of underlying mutations is important as it not only helps with the ascertainment of diagnosis but also aids in determining the role of surgical interventions which is particularly true for Steel syndrome, where the outcome of surgical intervention is usually dismal.

Role of plaque inflammation in symptomatic carotid stenosis

Objective

Prior studies have shown that plaque inflammation on FDG-PET and the symptomatic carotid atheroma inflammation lumen-stenosis (SCAIL) score were associated with recurrent ischemic events, but the findings have thus far not been widely validated. Therefore, we aimed to validate the findings of prior studies.

Methods

A single-center prospective cohort study that recruited patients with (1) recent TIA or ischemic stroke within the past 30 days, (2) ipsilateral carotid artery stenosis of ≥50%, and (3) were not considered for early carotid revascularization. The (1) maximum standardized uptake value (SUVmax) of the symptomatic carotid plaque, (2) the SCAIL score, and (3) stenosis severity of the symptomatic carotid artery were measured for all patients. The outcomes were (1) a 90-day ipsilateral ischemic stroke and (2) a 90-day ipsilateral symptomatic TIA or major adverse cardiovascular event (MACE).

Results

Among the 131 patients included in the study, the commonest cardiovascular risk factor was hypertension (95 patients, 72.5%), followed by diabetes mellitus (77 patients, 58.8%) and being a current smoker (64 patients, 48.9%). The median (IQR) duration between the index cerebral ischemic event and recruitment to the study was 1 (0, 2.5) days. The median (IQR) duration between the index cerebral ischemic event and FDG-PET was 5 (4, 7) days. A total of 14 (10.7%) patients had a 90-day stroke, and 41 (31.3%) patients had a 90-day TIA or MACE. On comparison of the predictive performances of the SCAIL score and SUVmax, SUVmax was found to be superior to the SCAIL score for predicting both 90-day ipsilateral ischemic stroke (AUC: SCAIL = 0.79, SUVmax = 0.92; p < 0.001; 95% CI = 0.072, 0.229) and 90-day TIA or MACE (AUC: SCAIL = 0.76, SUVmax = 0.84; p = 0.009; 95% CI = 0.020, 0.143).

Conclusion

Plaque inflammation as quantified on FDG-PET may serve as a reliable biomarker for risk stratification among patients with ECAD and recent TIA or ischemic stroke. Future studies should evaluate whether patients with significant plaque inflammation as quantified on FDG-PET benefit from carotid revascularization and/or anti-inflammatory therapy.

Internal cerebral vein asymmetry is an independent predictor of poor functional outcome in endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (EVT) in large vessel occlusion (LVO) in anterior circulation acute ischaemic stroke (AIS) results in good functional outcomes in only approximately 60% of the patients. Internal cerebral veins (ICVs) are easily visible, with a consistent midline location, and are linked to stroke outcomes. We hypothesize that ICV asymmetry on multiphasic CT angiogram (mCTA) can be an adjunctive predictor for poor functional outcomes.

METHODS

We studied consecutive AIS patients from 2017 to 2019 with anterior circulation LVO treated with EVT regardless of intravenous thrombolysis. Asymmetrical ICV was defined as the presence of hypodensity (less opacification) on the ipsilateral occlusion side as compared with the contralateral side. The primary outcome was modified Rankin Score (mRS) score at 3 months. Secondary outcomes were good recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3), symptomatic hemorrhage, and mortality.

RESULTS

A total of 185 patients were included with a median age of 70 years (IQR 59-77); 87 patients (47%) were female. 82 patients (44.3%) achieved good functional outcomes (mRS 0-2) at 3 months. On multivariate analysis, National Institutes of Health Stroke Scale (NIHSS) (OR 1.076, 95% CI 1.015 to 1.140; p<0.013), poor collateral score (OR 0.285, 95% CI 0.162 to 0.501; p<0.001), asymmetrical ICV on the peak venous phase (OR 2.47, 95% CI 1.115 to 5.471; p<0.026), and late venous phase of the mCTA (OR 2.642, 95% CI 1.161 to 6.016; p<0.021) were independent risks factors of poor outcomes.

CONCLUSION

ICV asymmetry is a novel radiological sign which is independently associated with poor functional outcomes in EVT, even after correction for collateral circulation. Further studies are needed to validate this finding.

Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: A real-world multicenter experience

Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50 years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90 days, with modified Rankin Scale of 0-2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88-0.96 per point increase, p < 0.001). Successful reperfusion (aOR: 3.22, 95% CI: 1.44-7.21, p = 0.005), higher ASPECTS (aOR: 1.21, 95% CI: 1.01-1.44, p = 0.036), and bridging intravenous thrombolysis (aOR: 2.37, 95% CI: 1.29-4.34, p = 0.005) independently predicted good functional outcomes. Successful reperfusion was inversely associated with in-hospital mortality (aOR: 0.14, 95% CI: 0.03-0.57, p = 0.006). History of hypertension strongly predicted in-hospital mortality (aOR: 4.59, 95% CI: 1.10-19.13, p = 0.036). While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.

Long-term outcomes of ischaemic stroke patients with diabetes in a multi-ethnic cohort in Singapore

ABSTRACT Introduction: Diabetes increases the risk of ischaemic stroke especially among Asians. This study aims to investigate contemporaneous long-term cardiovascular outcomes of ischaemic stroke patients with diabetes in a multi-ethnic Asian cohort. Methods: Consecutive patients with ischaemic stroke were recruited from the National University Hospital, Singapore. Data on age, gender, ethnicity, risk factors (including diabetes status and body mass index [BMI]), stroke severity and mechanisms were collected. These patients were followed up until the day of the first cardiovascular event or July 2016, whichever was earlier. The primary endpoint was the time from enrolment to the first occurrence of a composite of cerebrovascular and coronary artery events. Results: Between July 2011 and December 2013, 720 patients (mean age 60.6 years, 71% men, 43% with diabetes, median National Institute Health Stroke Severity scale 2) were enrolled and followed up. A total of 175 cardiovascular events occurred during a median follow-up of 3.25 years (6.90 events per 1,000 person-month), comprising 163 cerebrovascular and 42 coronary artery events. The adjusted hazard ratio of diabetes was 1.50 (95% CI 1.08–2.10). In a multivariable Cox proportional hazards model, Malay and Indian ethnicities, BMI <23kg/m2 and a prior diagnosis of diabetes were identified as independent predictors of recurrent cardiovascular events. Conclusion: Our study provides quantitative data on the event rates of ischaemic stroke patients with diabetes. These findings provide insights on stroke predictors in a multi-ethnic Asian population, which may have implications in the design of future interventional studies. Keywords: Asian, body mass index, cardiovascular, stroke phenotype

Left ventricular systolic dysfunction is associated with poor functional outcomes after endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (ET) has transformed acute ischemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD, as measured by LV ejection fraction (LVEF), and clinical outcomes in patients with anterior cerebral circulation LVO who underwent ET.

METHODS

This multicenter retrospective cohort study examined anterior circulation LVO AIS patients from six international stroke centers. LVSD was measured by assessment of the echocardiographic LVEF using Simpson's biplane method of discs according to international guidelines. LVSD was defined as LVEF <50%. The primary outcome was defined as a good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3 months.

RESULTS

We included 440 AIS patients with LVO who underwent ET. On multivariate analyses, pre-existing diabetes mellitus (OR 2.05, 95% CI 1.24 to 3.39;p=0.005), unsuccessful reperfusion (Treatment in Cerebral Infarction (TICI) grade 0-2a) status (OR 4.21, 95% CI 2.04 to 8.66; p<0.001) and LVSD (OR 2.08, 95% CI 1.18 to 3.68; p=0.011) were independent predictors of poor functional outcomes at 3 months. On ordinal (shift) analyses, LVSD was associated with an unfavorable shift in the mRS outcomes (OR 2.32, 95% CI 1.52 to 3.53; p<0.001) after adjusting for age and ischemic heart disease.

CONCLUSION

Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to consider cardiac factors for ET, the degree of monitoring and prognostication post-procedure.

Abstract TP408: Uric Acid and the Risk of Recurrent Vascular Events and Mortality in Ischemic Stroke Patients: A 5-year Analysis

Background: Women have generally lower levels of uric acid compared with men, yet their long-term prognostic impact is unclear in ischemic stroke patients. This study aims to investigate the significance of serum uric acid in relation to 5-year recurrent vascular events and mortality in ischemic stroke patients.

Methods: Consecutive patients with acute ischemic stroke were recruited from the National University Hospital, Singapore, between January 2011 and December 2012. Demographic, risk factor, stroke etiology and severity information were compared with the development of vascular events (defined as stroke, myocardial infarction, and vascular-related death) and all-cause mortality. Blood samples were collected during their acute hospitalization; in a subset of patients, repeated samples were collected 3-6 months later. Uric acid was measured in serum using the Cobas c111 analyzer (Roche, Germany). The effects of uric acid on vascular events and death were evaluated by Cox proportional hazard models.

Results: A total of 531 ischemic stroke patients (mean age 59.2 years; 72% men; mean uric acid 357 mmol/l [men], 319 mmol/l [women]) were followed for a mean of 3 years. During this period, 136 vascular events (72% stroke and transient ischemic attack, 18% myocardial infarction and 10% vascular-related death) and 51 deaths were recorded. In women, significant associations were observed between uric acid levels and vascular-related deaths and all-cause deaths (adjusted hazard ratios 1.01 [95% CI 1.00-1.01; p =0.008] and 1.01 [1.00-1.01; p =0.001] respectively); no association was observed with vascular events. By contrast, no significant association was observed between vascular-related events and deaths in men. 176 patients had uric acid levels repeated. Overall, there was an increase in uric acid levels (326 vs 360 mmol/l; p<0.001, paired t-test) approximately 4 months following stroke onset. These changes, however, did not correlate with subsequent development of vascular and death events in men and women.

Conclusions: In women, uric acid levels predict long-term vascular death and all-cause mortality in ischemic stroke patients. The sex-specific differences in the association between uric acid and stroke outcomes warrant further investigations.

Abstract TP186: The Burden of Diabetes Mellitus in Ischemic Stroke Patients and Its Impact on Recurrent Vascular Events and Survival in Singapore

Aims: Few studies have thoroughly examined the long-term prognostic significance of diabetes mellitus (DM) in ischemic stroke patients. We investigated the burden of DM among ischemic stroke patients and its association with recurrent vascular events and survival in Singapore.

Methods: Consecutive patients with acute ischemic stroke were recruited from the National University Hospital, Singapore, between January 2011 and December 2012. Demographic, risk factor, stroke etiology and severity, body mass index (BMI) and medication compliance (Morisky Medication Adherence Scale [MMAS-4]) were collected. Cox proportional hazard models were fitted to examine the relationships between these variables and recurrent vascular events (defined as stroke, myocardial infarction and vascular-related event and death) and all-cause mortality, in DM and non-DM patients. Statistical significance was set at p <0.05.

Results: A total of 720 ischemic stroke patients (mean age 60.6 ± 12.3 years; 71% men) were recruited and followed for a mean of 3.5 ± 1.7 years. DM was present in 308 (43%) patients, of whom, 30% were diagnosed for the first-time. DM patients were generally older, have a higher prevalence of hypertension, hyperlipidemia, ischemic heart disease, peripheral vascular disease and medication non-compliance. During this period, 247 (34%) vascular events (53% stroke and transient ischemic attack, 13% myocardial infarction, 12% vascular-related event and 22% vascular-related death) and 97 (14%) deaths were observed. DM patients were more prone to developing recurrent vascular events (HR 1.63, 95% CI 1.22-2.16), vascular death (1.67, 0.97-2.87) and all-cause mortality (1.58, 1.06-2.36) compared with non-DM patients. In a subgroup analysis, DM patients with normal BMI (<23, Asian criteria) have increased risk of developing recurrent vascular events (HR 1.53, 95% CI 1.00-2.35) and death (2.01, 1.14-3.55).

Conclusions: Ischemic stroke patients with chronic diabetes mellitus are prone to developing recurrent vascular events and have a shorter survival.

Anaplastic lymphoma kinase status in lung cancers: An immunohistochemistry and fluorescence in situ hybridization study from a tertiary cancer center in India

BACKGROUND AND OBJECTIVES

Fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) have shown good concordance for the detection of echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase (ALK) rearrangement. Since studies reporting FISH/IHC concordance, clinicopathological features, and clinical outcomes of ALK-positive patients from India are lacking, this study was undertaken.

MATERIALS AND METHODS

This is a retrospective, observational study of patients with adenocarcinoma of the lung on whom ALK test was performed between March 2013 and December 2015. ALK status was assessed in 341 patients by FISH using Vysis ALK Dual Color Break Apart Rearrangement Probe and IHC using ALK D5F3 clone. Clinicopathological features were noted. Patients were managed as per the standard guidelines. Clinical outcomes - response rate (RR) and progression-free survival (PFS) - were measured.

RESULTS

ALK rearrangement was positive in 37 patients (10.9%). ALK positivity was observed more commonly in younger patients with no predilection for any gender or any specific histological subtype. ALK by IHC was highly sensitive (100%), compared to FISH with concordance rate of 94.4%. Thirty one of thirty seven (31 of 37) patients received therapy of which 3 patients received palliative chemotherapy and 28 patients received tyrosine kinase inhibitors (crizotinib/ceritinib). Overall RR observed was 77.4%, and median PFS had not been reached at a median follow-up of 12.5 months.

INTERPRETATION AND CONCLUSIONS

We report higher frequency of ALK positivity (10.9%) in patients with adenocarcinoma of the lung. ALK by IHC is more sensitive than FISH for ALK detection with high concordance. These patients had good clinical outcome with TKIs targeting ALK fusion protein.

Clinical profile and outcomes of patients with Stage IV adenocarcinoma of lung: A tertiary cancer center experience

BACKGROUND

There is limited Indian data on clinical profile and treatment outcomes for patients with Stage IV adenocarcinoma of lung.

AIM

We aimed to prospectively study the clinical profile and treatment outcomes for patients with Stage IV adenocarcinoma of lung at a tertiary cancer center.

MATERIALS AND METHODS

One hundred and ninetyfour patients with Stage IV adenocarcinoma of lung were prospectively analyzed for demographic and molecular profile (epidermal growth factor receptor [EGFR] and echinodermal microtubuleassociated proteinlike 4anaplastic lymphoma kinase [EML4ALK] mutations). Patients with EGFR and EML4ALK mutations were treated with tyrosine kinase inhibitors. Patients without these mutations were treated with standard chemotherapy regimens. Maintenance chemotherapy was offered to patients as per standard guidelines. Clinical outcomes measured were response rate (RR), progressionfree survival (PFS), and overall survival (OS).

RESULTS

Median age of patients was 56 years (range, 26-82) with a male:female ratio of 2.3:1. EGFR and ALK mutation testing was feasible in 169 (87.1%) and 164 (84.5%), respectively, and detected in 37.9% and 5.5% patients, respectively. Overall RR, PFS and OS of whole cohort were 44.3%, 6.9, and 15.5 months, respectively. PFS and OS of mutated group (EGFR, EML4ALK) were longer than nonmutated group (10.5 vs. 5.4 months, P < 0.0001 and 21.5 vs. 11 months, P = 0.0001, respectively). PFS and OS of patients who received pemetrexed maintenance were longer than those who did not receive maintenance (8.5 vs. 6.5 months, P = 0.1613 and 18.5 vs. 12.5 months, P = 0.0219, respectively).

CONCLUSIONS

Mutation testing at diagnosis is feasible in the vast majority of patients with Stage IV adenocarcinoma of the lung. Patients with EGFR or EML4ALK mutation and those who received pemetrexed maintenance had better clinical outcomes.

Abstract TP300: Re-admissions in Patients With First Onset of Stroke - Looking Beyond Organ Systems

Background: Patients who suffer from a stroke are susceptible to multiple complications, with readmission rates ranging from 20-40% per year, and approximately 25% of readmissions occurring within the first month 1 . Major reasons contributing to readmissions include recurrent stroke (24%), infection (12%), chest pain or myocardial infarction (10%), worsening of stroke symptoms (7%), arrhythmias (7%), and congestive heart failure (3%) 2 . However, additional potentially reversible risk factors have not been extensively studied.

Methods: This retrospective study was conducted at a tertiary hospital in Singapore and included 1283 patients who were admitted for stroke between Jan 2014 and Oct 2015. All patients who had previous history of stroke or died on initial presentation were excluded from the study, leaving 957 patients with first stroke presentation. The dates and diagnoses of readmissions in the first 90 days were collected. Elective admissions or readmissions due to recurrent strokes or coronary syndromes were excluded to focus on readmissions due to infections, medication side effects, falls, or care coordination issues.

Results: Out of 957 patients, 129 (13.4%) were readmitted within 90 days. 98 (10.2%) were readmitted once in 90 days, while 31 (3.2%) were readmitted multiple (2-7) times. The single readmission group showed a bi-modal distribution with 35.7% of readmissions occurring in the first 15 days, 15.3% in 15-30 days, 34.7% in 30-60 days, and 24.5% in 60-90 days after discharge.

In the single readmission group, 36.7% of patients were readmitted for infections (15.3% were urinary tract infections, 21.4% were chest infections), 12.2% were admitted for congestive heart failure symptoms, and 17.3% were admitted for falls or care coordination issues. A majority (59%) of readmitted patients were over the age of 70. 24% of the patients had a middle cerebral artery (MCA) stroke, and 34% had a decrease in function of activities of daily living on discharge.

Conclusion: This study helps to highlight high risk groups for readmissions i.e. patients over the age of 70 years, reduction in function on discharge, and patients with MCA strokes, suitable for targeted interventions in order to reduce rate of readmissions in patients with first stroke.

Good Intracranial Collaterals Trump Poor ASPECTS (Alberta Stroke Program Early CT Score) for Intravenous Thrombolysis in Anterior Circulation Acute Ischemic Stroke

BACKGROUND AND PURPOSE

In acute ischemic stroke, large early infarct size estimated by the Alberta Stroke Program Early CT Score (ASPECTS) is associated with poorer outcomes and is a relative contraindication for recanalization therapies. The state of the intracranial collateral circulation influences the functional outcome and may be a variable to consider before thrombolysis. We evaluated the prognostic effect of the collateral circulation in patients with thrombolyzed acute ischemic stroke who have large early infarct sizes as indicated by low ASPECTS.

MATERIALS AND METHODS

Patients with anterior circulation acute ischemic stroke who received a computed tomographic angiogram and subsequent treatment with intravenous tissue-type plasminogen activator from 2010 to 2013 were studied. Two independent neuroradiologists determined their ASPECTS. We stratified patients using ASPECTS into 2 groups: large volume infarcts (ASPECTS≤7 points) and small volume infarcts (ASPECTS 8-10). In addition, we evaluated a third group with very large volume infarcts (ASPECTS≤5 points). We then analyzed the 3 subgroups using the Maas, Tan, and ASPECTS-collaterals grading systems of the computed tomographic angiogram intracranial collaterals. Good outcomes were defined by modified Rankin Scale score of 0 to 2 at 3 months.

RESULTS

A total of 300 patients were included in the final analysis. For patients with very large volume infarcts (ASPECTS≤5 points), univariable analysis showed that younger age, male sex, lower National Institute of Health Stroke Scale (NIHSS), lower systolic blood pressure, and good collaterals by Maas, Tan, or ASPECTS-collaterals grading were predictors of good outcomes. On multivariate analysis, younger age (odds ratio, 0.93; 95% confidence interval, 0.89-0.97; P=0.002) and good collaterals by ASPECTS-collaterals system (odds ratio, 1.34; 95% confidence interval, 1.15-1.57; P<0.001) were associated with good outcomes.

CONCLUSIONS

In patients with large and very large volume infarcts, good collaterals as measured by the ASPECTS-collaterals system is associated with improved outcomes and can help select patients for intravenous thrombolysis.

Intravenous Thrombolysis for Acute Ischemic Stroke due to Cervical Internal Carotid Artery Occlusion

BACKGROUND

Internal carotid artery (ICA) occlusions are poorly responsive to intravenous thrombolysis with tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). Most study populations have combined intracranial and extracranial ICA occlusions for analysis; few have studied purely cervical ICA occlusions. We evaluated AIS patients with acute cervical ICA occlusion treated with IV-tPA to identify predictors of outcomes.

METHODS

We studied 550 consecutive patients with AIS who received IV-tPA and identified 100 with pure acute cervical ICA occlusion. We evaluated the associations of vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and leptomeningeal collateral vessel status via 3 different grading systems, with functional recovery at 90 days, mortality, recanalization of the primary occlusion, and symptomatic intracranial hemorrhage (SICH). Modified Rankin Scale score 0-1 was defined as an excellent outcome.

RESULTS

The 100 patients had mean age of 67.8 (range 32-96) and median NIHSS score of 19 (range 4-33). Excellent outcomes were observed in 27% of the patients, SICH in 8%, and mortality in 21%. Up to 54% of the patients achieved recanalization at 24 hours. On ordinal regression, good collaterals showed a significant shift in favorable outcomes by Maas, Tan, or ASPECTS collateral grading systems. On multivariate analysis, good collaterals also showed reduced mortality (OR .721, 95% CI .588-.888, P = .002) and a trend to less SICH (OR .81, 95% CI .65-1.007, P = .058). Interestingly, faster treatment was also associated with favorable functional recovery (OR 1.028 per minute, 95% CI 1.010-1.047, P = .001).

CONCLUSIONS

Improved outcomes are seen in patients with early acute cervical ICA occlusion and better collateral circulation. This could be a valuable biomarker for decision making.

Abstract TP54: Topographical Aspects Collateral Score is a Useful Prognostic Factor in Thrombolysed Anterior Circulation Acute Ischemic Stroke Patients

Background: the ASPECTS- collateral score on CT-angiograms was shown to be successful in prognosticating functional outcomes and complications during intravenous thrombolysis in acute ischemic stroke (AIS). We studied predetermined topological information to see if any specific region had more prognostic value.

Methods: consecutive patients from 2010-2014 with intracranial internal carotid artery, M1 or M2 middle carotid artery occlusions treated with intravenous thrombolysis were included. The primary outcome measure was good clinical outcome (3-month modified Rankin Scale score 0-1). We scored each region as 0= no collaterals, 1= poor compared to contralateral and 2= good collaterals. Prognostic value of the 6 cortical ASPECTS-collateral regions in predicting outcomes was determined by multivariable logistic regression.

Results: 310 patients were included (Median age, 66.1±14.5 years; median National Institutes of Health Stroke Scale (NIHSS)- 18 points (range 3-36). Inter-rater reliability for ASPECTS-collaterals was good (κ=0.78). There was no Statistical collinearity among ASPECTS-collateral regions. Using multivariable logistic regression, only the M5 region (odds ratio, 2.72, 95%CI 1.52-4.84, p =0.001), age (OR 0.957 per yr 95%CI 0.936-0.978, p <0.001), Diabetes (OR 0.367, 95%CI 0.193- 0.700, p =0.002) and NIHSSS (OR 0.878 per point, 95%CI 0.836-0.922, p=0.001) were significantly associated with good outcomes. When compared with NIHSS, the receiver operating characteristic curves for NIHSS+M5 (area under the curve, 0.749) correlated well with clinical severity scores. Addition of M5 collateral score showed a statistically significant additive effect to the NIHSS score for predicting good outcomes (Z score: -1.684, p=0.045).

Conclusions: Involvement of the parietal region (M5) regions is a reliable predictor of clinical outcome in anterior circulation large artery occlusion. This simple radiological marker can strengthen the clinical NIHSS score and may be considered during prognostication

How temporal evolution of intracranial collaterals in acute stroke affects clinical outcomes

OBJECTIVE

We compared intracranial collaterals on pretreatment and day 2 brain CT angiograms (CTA) to assess their evolution and relationship with functional outcomes in acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA).

METHODS

Consecutive AIS patients who underwent pretreatment and day 2 CTA and received IV tPA during 2010-2013 were included. Collaterals were evaluated by 2 independent neuroradiologists using 3 predefined criteria: the Miteff system, the Maas system, and 20-point collateral scale by the Alberta Stroke Program Early CT Score methodology. We stratified our cohort by baseline pre-tPA state of their collaterals and by recanalization status of the primary vessel for analysis. Good outcomes at 3 months were defined by a modified Rankin Scale score of 0-1.

RESULTS

This study included 209 patients. Delayed collateral recruitment by any grading system was not associated with good outcomes. All 3 scoring systems showed that collateral recruitment on the follow-up CTA from a baseline poor collateral state was significantly associated with poor outcome and increased bleeding risk. When the primary vessel remained persistently occluded, collateral recruitment was significantly associated with worse outcomes. Interestingly, collateral recruitment was significantly associated with increased mortality in 2 of the 3 grading systems.

CONCLUSIONS

Not all collateral recruitment is beneficial; delayed collateral recruitment may be different from early recruitment and can result in worse outcomes and higher mortality. Prethrombolysis collateral status and recanalization are determinants of how intracranial collateral evolution affects functional outcomes.

Abstract T P39: Serial Alberta Stroke Program Early Ct Score (aspects) Is A Superior Predictor Of Outcomes With Iv Rtpa

Background and purpose: The Alberta stroke program early computed tomography score (ASPECTS) on baseline imaging is known predictor of outcomes for acute ischemic stroke (AIS) patients. We looked at the change in ASPECTS at the baseline CT and 24hr CT in AIS patients treated with IV rTPA to determine if it can help predict 3 month functional outcomes.

Methods: Consecutive AIS patients receiving IV-tPA within 4.5 hours of symptom-onset during 2010-2013 and underwent pre-treatment and day-2 CT were included ASPECTS at the baseline CT and 24hr CT were independently scored in all anterior circulation stroke patients who underwent IV rTPA within 4.5 hours of onset. ASPECTS at baseline, 24hrs and the serial change were analyzed.

Results: 210 consecutive AIS patients were included. ROC curves for ASPECTS on the initial CT scan for MRS 0-1 was AUC 0.613, 95% CI 0.536-0.690, p=0.005, while ROC curves for ASPECTS on the 24hr CT scan for MRS0-1 was AUC 0.763 95% CI 0.699 - 0.828, p <0.001. ASPECTS on the 24hr CT was statistically significantly better able to predict outcomes compared to the initial CT (z= -2.936, p = 0.001). 28 out of 210 patients had an increase in ASPECTS by >3 with a 3-fold risk of worse outcomes (OR 3.572 95%CI 1.393- 9.156, p=0.08).

Conclusion: ASPECT scores on 24hr CT have better prognostic ability compared to the baseline scan. Serial ASPECT scores are a viable surrogate predictor in AIS patients treated with IV rTPA.

Abstract 151: Vascular Events Occur More Frequently In Stroke Patients With Lower Concentrations of Vitamin D: A Prospective Cohort Analysis

Introduction: Vitamin D deficiency has been implicated in vascular dysfunction and the risk of recurrent vascular events. Previous studies, limited by a small sample size and lack of comparisons with long-term events, have yielded discordant results. To assess the hypothesis that low vitamin D levels predict long-term vascular events in patients with ischemic stroke, we conducted a large hospital-based study to compare the association between baseline vitamin D levels and the subsequent risk of vascular events.

Methods: Between January 2010 and July 2011, 590 participants (mean age, 60.7 years; 69% men) diagnosed with ischemic stroke and transient ischemic attack at the National University Hospital, Singapore, were prospectively followed for vascular events (recurrent stroke, myocardial infarction and vascular death). Serum 25-hydroxyvitamin D levels were determined using the Roche Cobas e411 analyzer. Cox proportional hazards models were used to assess the associations between quartiles of serum 25-hydroxyvitamin D and the risk of vascular events, which were adjusted for demographic, stroke severity and subtype, and vascular risk factor covariates.

Results: During a mean follow-up of 3.2 years (1,190 person-year), 116 participants developed a recurrent vascular event (recurrent stroke, n=63; myocardial infarction, n=30; vascular death, n=23). Using Cox proportional hazards models, the multivariate adjusted hazard ratios (95% confidence interval) for recurrent vascular events in participants with lower levels of serum 25-hydroxyvitamin D (<14.9 mmol/l, 14.9-21.4 mmol/l and 21.5-28.9 mmol/l) were 1.43 (0.81-2.55), 1.70 (0.97-2.91) and 2.09 (1.22-3.58) compared to participants with higher concentrations (>28.9 mmol/l). Kaplan-Meier plots for unadjusted rates of vascular events show clear differences in risk by quartiles of serum 25-hydroxyvitamin D after a year of follow-up.

Conclusions: Our results support the association between vitamin D deficiency and increased risk of recurrent vascular events in patients with ischemic stroke. Clinical trials are needed to ascertain whether correcting for this deficiency could indeed reduce the burden of vascular events in these individuals.

Abstract W P36: Timing Of Collateral Circulation In Acute Stroke And Its Effect On Predicting Outcomes

Background: We previously reported that Miteff scoring system on pre-tPA CTA was able to predict good functional outcomes in AIS, conversely substantial collateral recruitment on the 24hr CTA led to worse outcomes. We now aimed to determine if the degree of collateral circulation at a specific timing affects its ability to prognosticate outcomes.

Methods: Patients treated with IV-tPA during 2018-2012 were included. Patients were stratified by onset-to-CTA timing from 0-60, 61-120, 121-180 and >180 minutes. Two independent neuroradiologists evaluated intracranial collaterals using the Miteff’s system, Maas system, and Alberta Stroke Program Early CT score (ASPECTS) 20-point methodology. Good and severely poor outcomes at 3-months were defined by modified Rankin Scale (mRS) score of 0-1 points and 5-6 points, respectively. SICH was intracranial bleed with NIHSS increase of ≥4 points.

Results: 250 Consecutive AAIS patients were included. 52 patients in the 0-60 group, 89 in the 61-120 group, 59 in the 121-180 group and 40 patients in the >180 group. On multivariate analysis from 0-120 minutes, good collaterals by Miteff classification showed a trend to good outcomes (OR 2.460 95%CI 0.985- 9.770, p =0.06) and significantly prevented severely poor outcomes (OR 0.199 95% CI 0.053-0.743, p=0.016) and SICH (OR 0.196 95%CI 0.045-0.862, p=0.03). However the association with prevention of unfavourable outcomes was no longer present in the 121 -180 and > 180 minutes groups.

Conclusions: Good collaterals are associated with better functional outcomes however this benefit may be time dependent.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke

BACKGROUND AND PURPOSE

Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke.

MATERIALS AND METHODS

Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively.

RESULTS

Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes.

CONCLUSIONS

Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Abstract W P35: Assessment of Collaterals on Day-2 CT Angiography Can Predict Functional Outcome in Thrombolyzed Anterior Circulation Acute Ischemic Stroke

Background: Several methods exist that assess the intracranial collaterals on CT-angiography (CTA) of the brain. We compared existing methods for quantification of collaterals on day-2 CTA in thrombolyzed AIS patients to assess their predictive value for functional outcome.

Methods: Consecutive AIS patients treated with intravenous tissue plasminogen activator (IV-tPA) during 2007-2012 were included. Data were collected for demographics, vascular risk factors, NIHSS scores and stroke subtypes. Intracranial collaterals were evaluated by 2 independent neuroradiologists using 4 existing methods- Miteff’s system (grades middle cerebral artery (MCA) collateral branches with respect to sylvian fissure); Maas system (compares collaterals in affected hemisphere against the contralateral side); Modified Tan’s scale (collaterals in 50% or more of MCA territory classified as good); and 20-point collateral grading scale by Alberta Stroke Program Early CT score (ASPECTS) methodology. Good functional outcome at 3-months was determined by modified Rankin scale (mRS) scores of 0-1.

Results: Day-2 CTA was performed in 150 patients with anterior circulation AIS treated with IV-tPA. Median age 66yrs (range 33-92), 47% males, median NIHSS 19 points (range 4-34) and median onset-to-treatment time 165 minutes (range 74-274). Overall, 67 (44.6%) patients achieved good functional outcome at 3-months. On univariable analysis- younger age, lower pre-tPA NIHSS scores, atrial fibrillation, good collaterals according to ASPECTS scoring and good collaterals by Maas methodology were significantly associated with good functional outcome. On multivariable analysis, lower NIHSS (OR 1.155 per NIHSS point; 95% CI 1.066-1.251, p=0.001), younger age (OR 1.052 per year; 95% CI 1.012-1.094, p=0.010), good collaterals by Maas methodology (OR 2.805 95% CI 1.122 -7.011, p =0.002) and good collaterals (score of 9 or more) by ASPECTS methodology (OR 3.769 ; 95%CI: 1.327- 10.708, p= 0.013 ) were found as independent predictors of good outcome.

Conclusion: Of the existing intracranial collaterals scoring systems, only the ASPECTS and Maas methods are reliable predictor of favourable outcome in thrombolyzed anterior circulation AIS patients.

Abstract W P228: Delayed Decompression Hemicraniectomy in Massive Hemispheric Infarction Reduces Mortality but Does Not Improve Functional Outcome

Background: Massive hemispheric infarctions associated with extensive cerebral edema are associated with grave prognosis. Decompressive hemicraniectomy improves outcomes if performed within 48-hours of stroke-onset. In Asia, surgical decompression is often performed late, often after significant clinic-radiological deterioration occurs. We report our experience with decompressive hemicraniectomy when performed after clinical deterioration, radiologolic herniation or pupil dilatation.

Methods: In this retrospective review, we identified acute anterior circulation ischemic stroke patients who underwent ‘delayed’ decompressive hemicraniectomy at our tertiary institution during 2006-2012. We defined ‘delayed’ surgical intervention as the decompressive hemicraniectomy performed after rapid neurological deterioration (drop of 2 or more points on the Glasgow Coma Scale), evidence of cerebral herniation on clinical and/or neuroimaging criteria. Poor functional outcomes were assessed by modified Rankin score 4-6 points at 90 days.

Results: A total of 54 patients (11males, mean age 56 years; range 26-77 years) were included in this study, 36 (67%) male. Mean NIHSS at the time of hospital admission was 21 points (range 12-29). All patient developed clinical deterioration, pupil dilatation and/or radiological signs of cerebral herniation before decompressive surgery. Median time elapsed between stroke onset and surgery was 50.5 hours (range 11-144). Poor functional outcomes were noted in 40 (74%) with mortality in 16 (30%). Univariate analysis revealed higher age, late time to surgery, pupil dilatation and rapid neurological deterioration before surgery associated with poor outcomes. However logistic regression revealed only delayed hemicraniectomy (OR 1.153 per hour increase; 95% confidence interval 1.036-1.283, p=0.009) as the independent predictor of poor functional outcome.

Conclusions: Although delayed decompressive hemicraniectomy in massive hemispheric ischemic stroke reduces mortality, it results in poor functional outcomes. Our results support early surgical intervention, independent of clinical deterioration or radiological herniation for reducing disabilities and the burden on the families.

Abstract W P39: Internal Cerebral Vein Asymmetry on Follow-Up Brain CT after Intravenous Thrombolysis in Acute Anterior Circulation Ischemic Stroke is Associated With Poor Outcome

Background and aim: Identifying early predictors of functional outcome after acute ischemic stroke (AIS) is important for planning rehabilitation strategies. Internal cerebral veins (ICV) drain deep parts of brain, run parallel to each other and consistently seen on CTA. Even minor asymmetry in their filling can be identified. We hypothesized that venous drainage would be impaired in patients with acute occlusion of ICA or MCA. Since systemic thrombolysis can alter the vascular findings, we evaluated the relationship between ICV asymmetry on follow-up CTA and functional outcome.

Methods: Consecutive AIS patients treated with intravenous thrombolysis between 2007 and 2010 were included. ICV asymmetry was assessed by 2 independent blinded stroke neurologists/ neuroradiologists. Functional outcome was assessed by modified Rankin Scale (mRS) at 3-months, dichotomized as good (0-1) and poor (2-6). Data were analyzed for predictors of functional outcome.

Results: Of 2238 patients with AIS, 226 (10.1%) anterior circulation AIS patients received intravenous thrombolysis. Median age 65yrs (range 19-92), 44% males and median National Institute of Health Stroke Scale (NIHSS) 16-points (range 4-32). Hypertension was the commonest risk factor in 173 (76.5%) while 78 (34.5%) had atrial fibrillation. ICV asymmetry on follow-up CTA was assessed in 103 (45.5%) patients. Admission NIHSS score (OR1.07;95%CI 1.079-1.201,p=0.046), change in NIHSS score during first 24 hours (OR 0.737; 95%CI 0.672-0.807,p<0.0001) and ICV asymmetry on follow-up CTA (OR 20.3;95%CI 4.67-52.07,p <0.0001) independently predicted poor outcome at 3-months.

Conclusion: ICV asymmetry on follow-up CTA after intravenous thrombolysis is an early predictor of poor functional outcome.

Abstract T MP29: Impaired Vasodilatory Reserve on Acetazolamide-Challenged 99tc-hmpao-Spect is a Strong Predictor of Stroke Recurrence in Patients With Severe Steno-Occlusive Disease of Intracranial Carotid or Middle Cerebral Artery

Background: Intracranial stenosis carries an increased risk for cerebrovascular ischemia. In severe stenosis, cerebral autoregulation may be impaired due to inadequate cerebral vasodilatory reserve (CVR) & intracranial steal phenomenon (reversed-Robin Hood syndrome-RRHS). Identification of patients with inadequate CVR and RRHS may help in identifying high-risk patients.

Methods: In this prospective study, we included patients with symptomatic and severe stenosis of intracranial carotid (ICA) & middle cerebral artery (MCA). CVR was evaluated with transcranial Doppler (TCD) and breath-holding index (BHI) <0.69 determined inadequate CVR. RRHS was detected as transient velocity reduction in affected artery when flow increased in the reference artery. Patients with RRHS were further evaluated with acetazolamide-challenged 99Tc-HMPAO-SPECT.

Results: 126 patients (80 male, mean age 56yrs; range 23-78yrs) fulfilled our TCD criteria for inadequate CVR. HMPAO-SPECT showed impaired CVR in 84 (67%) patients. RRHS noted on TCD in 38 (45%) patients (median steal magnitude 14%; inter-quartile range, IQR 10) was confirmed by acetazolamide-challenged HMPAO-SPECT (median perfusion deficit 8%; IQR 13%) in 35 (92%) cases (sensitivity 82%, specificity 96% with positive predictive value 96%). A strong relationship between RRHS on TCD and SPECT was noted on ROC curve analysis (area under curve 0.93; 95% confidence interval 0.87-0.98;p<0.00001). Linear relationship was observed between impaired vasodilatory reserve and stroke recurrence during follow up (mean 35months; range 8 to 49months)- 56% in patients with RRHS versus 20% in patients with moderately impaired CVR versus 4% in patients with mildly impaired CVR (chi-square 18.42; df=2; p<0.001 for trend). RRHS on HMPAO-SPECT was an independent predictor of recurrent cerebral ischemic events (RR 1.9, 95%CI 1.2-4.2; p=0.03).

Conclusions: Among patients with severe intracranial stenosis, intracranial steal phenomenon is associated with high risk of cerebral ischemic events. Acetazolamide-challenged HMPAO-SPECT is reliable in the quantification of vasodilatory reserve for selecting a target group of patients for possible revascularization.

Abstract T MP26: Role of 99tc-hmpao Spect in the Assessment of Cerebral Hemodynamic Parameters After Superficial Temporal Artery- Middle Cerebral Artery Bypass in Patients With Severe Steno-Occlusive Disease of Intracranial Carotid and Middle Cerebral Artery

Background and Objective: Although superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery in patients with symptomatic carotid occlusion failed to demonstrate any benefit, its role in symptomatic intracranial steno-occlusive disease has been evaluated scarcely. We evaluated changes in hemodynamic parameters in patients with severe steno-occlusive disease of intracranial internal carotid (ICA) or middle cerebral artery (MCA) who underwent STA-MCA bypass for impaired cerebral vasodilatory reserve (CVR).

Methods: Patients with severe steno-occlusive disease of intracranial ICA or MCA underwent transcranial Doppler (TCD) evaluation and CVR assessment using breath-holding index (BHI). Patients with impaired BHI (<0.69) were further evaluated with acetazolamide-challenged 99Tc-HMPAO-SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. TCD and SPECT were repeated in all patients at 4±1 months and they were followed-up for cerebral ischemic events.

Results: Of the 126 patients (80 male, mean age 56yrs; range 23-78yrs) that fulfilled our inclusion criteria, 84 (67%) showed impaired CVR HMPAO-SPECT. Fifty (60%) of them underwent STA-MCA bypass while 34(40%) received best medical treatment. TCD and acetazolamide-challenged HMPAO-SPECT repeated 4±1 months after surgery showed significant improvement in STA-MCA bypass group. TCD BHI improved from a median (IQR) of -0.05 to 1.1 (p<0.001). Compared to 98% patients with impaired CVR on pre-operative SPECT, only 20% showed abnormal results on post-operative imaging (p<0.001). During follow-up (mean 35 months; range 8 to 49months), only 6/50 (12%) patients in bypass group developed cerebral ischemic events as compared to15/34 (44%) cases on medical therapy (absolute risk reduction 32%, p=0.006).

Conclusion: 99Tc-HMPAO SPECT with acetazolamide challenge is a reliable tool for the assessment of cerebral vasodilatory reserve in patients with severe steno-occlusive disease of intracranial ICA or MCA. STA-MCA bypass surgery in carefully selected patients results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.

Abstract T P61: Patients With Acute Stroke Involving More Than One-Third Middle Cerebral Artery Territory Should Not be Excluded From Intravenous Thrombolysis

Background and aim: Involvement of more than one-third of middle cerebral artery (MCA) territory on initial brain CT is a relative contraindication for IV-tPA and often associated with increased bleeding risk. Involvement of more than 1/3 MCA territory on initial CT is associated with poor functional outcome at 3 months. We present the results of IV-thrombolysis among these patients at our tertiary care centre.

Methods: Data from consecutive acute ischemic stroke (AIS) patients treated with IV-tPA within 4.5 hours between January 2009 to August 2012 were included. The collected data included demographic characteristics, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores, and blood pressure levels before IV-tPA bolus. The presence of early stroke signs involving more than 1/3 of the MCA on the initial CT scan was measured by Alberta Stroke Program Early CT score (ASPECTS ≤7). Outcomes were assessed by modified Rankin Scale (mRS) score at 3 months.

Results: A total of 97 AIS patients with more than one-third MCA involvement received IV-tPA during the study period. Median age was 70 yrs (range 38-89), 55% male, median NIHSS score 20 points (range 3-33) and median onset-to-treatment time 152 minutes (range 55-274). Forty-two (44%) patients achieved good functional outcomes at 3 months (mRS score 0-1). Factors associated with good outcome at 3 months on univariate analysis were younger age, hypertension, non-cardioembolic etiology and lower NIHSS score at presentation. After multivariate analysis, lower age (OR 0.965; 95%CI 0.941-0.989, p=0.005) and lower NIHSS scores at presentation were noted as independent predictor of good outcome at 3 months (OR 0.990; 95%CI 0.869-0,950 p= <0.001 ). The presence of more than1/3 MCA involvement on the ore-thrombolysis CT scan (ASPECTS <8) was not associated with a poor functional outcome at 3 months (OR 1.495 95% CI 0.881-2.540; p=0.136).

Conclusions: Patients with acute stroke involving more than one-third of the MCA on initial brain CT scan, especially if associated with lower NIHSS score, should not be excluded from systemic thrombolysis.

Abstract 2: Extensive Collateral Recruitment after Intravenous Thrombolysis in Acute Ischemic Stroke is Associated with Symptomatic Intracranial Haemorrhage

Background: Various collateral channels are recruited to provide alternative pathways in acute ischemic stroke (AIS), however the relationship with patient outcomes remain unclear. We compared various existing methods of scoring collaterals on the pre-treatment and day-2 computed tomographic angiogram (CTA) of the brain in thrombolyzed AIS patients.

Methods: We included 115 consecutive patients in whom CTA was performed both pre-tPA and on day-2. Intracranial collaterals were evaluated by 2 independent neuroradiologists using 4 existing and one modified method- Miteff’s system (grades middle cerebral artery (MCA) collateral branches with respect to sylvian fissure); Maas system (compares collaterals in affected hemisphere against the contralatral side); Modified Tan’s scale (collaterals in 50% or more of MCA territory classified as good); and 20-point collateral grading scale by Alberta Stroke Program Early CT score (ASPECTS) methodology. For the modified scoring system we adapted ASPECTS methodology into a 14 point score for cortical and internal cerebral veins (ICV) and removing basal ganglia area from scoring. Symptomatic intracranial hemorrhage (SICH) was defined by new bleeding on the CT scan and an increase in NIH stroke scale (NIHSS) by 4 points or more.

Results: On univariate analysis collateral recruitment via the Tan scoring system, ASPECTS method (improvement of ≥6 points), modified scoring system (improvement ≥7 points), hypertension and higher NIHSS score were associated with SICH. On multivariate analysis only collateral recruitment on the Tan scoring system (OR 3.286 95% CI 1.014-11.025, p =0.049), Collateral recruitment on ASPECTS ≥6 points (OR 2.839 95% CI 1.064- 7.576, p = 0.037) and collateral recruitment on the modified scoring system ≥ 7 (OR 4.174 95% CI 1.212-14.372, p = 0.023) were independent predictors of SICH. Interestingly, collateral failure on the day-2 CTA did not show any association with SICH.

Conclusion: Large recruitment of the collateral channels on the day-2 CTA is strongly associated with SICH after thrombolysis . Perhaps, an unregulated cerebral hyperperfusion contributed to SICH and close monitoring along with aggressive blood pressure control might prevent complications.

Abstract W P227: Cerebral Hyperperfusion Syndrome after Intravenous Thrombolysis for Acute Ischemic Stroke

Background: Cerebral hyperperfusion syndrome (CHS) is a recognized complication after surgical revascularization of a chronically atherosclerotic artery. However, this phenomenon is unexpected when an acutely occluded artery is recanalized by IV-TPA for acute ischemic stroke (AIS).In patients with discrepant neuroimaging and clinical findings, our multimodal evaluations revealed CHS in a series of 7 patientsmafter IV- TPA therapy.

Methods: Patients in whom the occluded ICA or MCA in pre-TPA CT-angiogram (CTA) showed recanalization in the day-2 CTA, were observed for any new unexpected neuropsychiatric symptoms/signs. If these were present they underwent multimodal evaluation including serial transcranial Doppler (TCD), quantitative electroencephalography (QEEG) and HMPAO-SPECT. Patients with considerable mismatch between clinical and neuroimaging findings were also included. CHS was deemed to have occurred if the unexpected neuropsychiatric signs corresponded with TCD flow velocity >100% of the contralateral vessel, EEG showed abnormal activity and HMPAO-SPECT scan showed markedly increased cerebral perfusion compared to the contralateral side.

Results: Out of 155 patients treated with IV-TPA, 7 (4.5%) patients fulfilled our definition of CHS. All 7 patients developed the symptoms 2-3 days after IV-TPA. Abnormalities on TCD, QEEG and HMPAO-SPECT were observed in all patients. The unexpected symptoms included generalized headache (4 cases), unexplained persistent drowsiness (3 cases), visual neglect (2 cases), aphasia (2 cases) and severe suicidal thoughts despite complete neurological recovery (1 case). All cases had hypertension prior to the index stroke. Upright posture, fluid restriction and aggressive blood pressure control resulted in rapid resolution of abnormal features in all cases within a week. All patients achieved modified Rankin score 0-1 with no intracranial hemorrhage.

Conclusion: CHS after intravenous thrombolysis in acute ischemic stroke should be suspected in patients that achieve arterial recanalization with unexplained new neuropsychiatric manifestations. Early diagnosis and appropriate management might prevent hemorrhage and achieve good functional outcomes.

Early and continuous neurologic improvements after intravenous thrombolysis are strong predictors of favorable long-term outcomes in acute ischemic stroke

BACKGROUND

Intravenously administered tissue plasminogen activator (IV tPA) remains the only approved therapeutic agent for arterial recanalization in acute ischemic stroke (AIS). Considerable proportion of AIS patients demonstrate changes in their neurologic status within the first 24 hours of intravenous thrombolysis with IV tPA. However, there are little available data on the course of clinical recovery in subacute 2- to 24-hour window and its impact. We evaluated whether neurologic improvement at 2 and 24 hours after IV tPA bolus can predict functional outcomes in AIS patients at 3 months.

METHODS

Data for consecutive AIS patients treated with IV tPA within 4.5 hours of symptom onset during 2007-2011 were prospectively entered in our thrombolyzed registry. National Institutes of Health Stroke Scale (NIHSS) scores were recorded before IV tPA bolus, at 2 and 24 hours. Early neurologic improvement (ENI) at 2 hours was defined as a reduction in NIHSS score by 10 or more points from baseline or an absolute score of 4 or less points at 2 hours. Continuous neurologic improvement (CNI) was defined as a reduction of NIHSS score by 8 or more points between 2 and 24 hours or an absolute score of 4 or less points at 24 hours. Favorable functional outcomes at 3 months were determined by modified Rankin Scale (mRS) score of 0-1.

RESULTS

Of 2460 AIS patients admitted during the study period, 263 (10.7%) received IV tPA within the time window; median age was 64 years (range 19-92), with 63.9% being men, a median NIHSS score of 17 points (range 5-35), and a median onset-to-treatment time of 145 minutes (range 57-270). Overall, 130 (49.4%) thrombolyzed patients achieved an mRS score of 0-1 at 3 months. The female gender, age, and baseline NIHSS score were found to be significantly associated with CNI on univariate analysis. On multivariate analysis, NIHSS score at onset and female gender (odds ratio [OR]: 2.218, 95% confidence interval [CI]: 1.140-4.285; P=.024) were found to be independent predictors of CNI. Factors associated with favorable outcomes at 3 months on univariate analysis were younger age, female gender, hypertension, NIHSS score at onset, recanalization on transcranial Doppler (TCD) monitoring or repeat computed tomography (CT) angiography, ENI at 2 hours, and CNI. On multivariate analysis, NIHSS score at onset (OR per 1-point increase: .835, 95% CI: .751-.929, P<.001), 2-hour TCD recanalization (OR: 3.048, 95% CI: 1.537-6.046; P=.001), 24-hour CT angiographic recanalization (OR: 4.329, 95% CI: 2.382-9.974; P=.001), ENI at 2 hours (OR: 2.536, 95% CI: 1.321-5.102; P=.004), and CNI (OR: 7.253, 95% CI: 3.682-15.115; P<.001) were independent predictors of favorable outcomes at 3 months.

CONCLUSIONS

Women are twice as likely to have CNI from the 2- to 24-hour period after IV tPA. ENI and CNI within the first 24 hours are strong predictors of favorable functional outcomes in thrombolyzed AIS patients.

Vascular contribution to hyperglycaemia-induced hemichorea

Hemichorea, due to contralateral basal ganglia dysfunction, is well described in patients with hyperglycaemia but the underlying mechanism remains poorly understood. We present clinical and radiological data that support ipsilateral vascular compromise to the basal ganglia in such cases. We suggest vascular evaluation in patients with unilateral neurological phenomena secondary to suspected systemic or metabolic disorders.

Identification of a novel mutation in an Indian patient with CAII deficiency syndrome

Carbonic anhydrase II (CAII) deficiency syndrome characterized by osteopetrosis (OP), renal tubular acidosis (RTA), and cerebral calcifications is caused by mutations in the carbonic anhydrase 2 (CA2) gene. Severity of this disorder varies depending on the nature of the mutation and its effect on the protein. We present here, the clinical and radiographic details along with, results of mutational analysis of the CA2 gene in an individual clinically diagnosed with renal tubular acidosis, osteopetrosis and mental retardation and his family members to establish genotype-phenotype correlation. A novel homozygous deletion mutation c.251delT was seen in the patient resulting in a frameshift and a premature stop codon at amino acid position 90 generating a truncated protein leading to a complete loss of function and a consequential deficiency of the enzyme making this a pathogenic mutation. Confirmation of clinical diagnosis by molecular methods is essential as the clinical features of the CAII deficiency syndrome are similar to other forms of OP but the treatment modalities are different. Genetic confirmation of the diagnosis at an early age leads to the timely institution of therapy improving the growth potential, reduces other complications like fractures, and aids in providing prenatal testing and genetic counseling to the parents planning a pregnancy.

A phase II study of once-daily dasatinib for patients with castration-resistant prostate cancer (CRPC) (CA180085)

5147

Background: Dasatinib is a potent oral SRC family kinase inhibitor that also inhibits c-KIT and PDGFR in vitro. The anti-proliferative/anti-metastatic activity as well as osteoclast inhibitory function of dasatinib in pre-clinical models supports its potential as a targeted therapy for prostate cancer. Previously we presented results on BID dosing of dasatinib in the treatment of CRPC (ASCO. 2008 Abstract 5156). A second group of patients (pts) was enrolled to investigate the activity, safety and bone effects of 100 mg once daily dosing. Methods: Male pts with progressive metastatic CRPC, rising PSA, castrate levels of testosterone (< 50 ng/dL) and no prior chemotherapy were enrolled. Dasatinib dose was 100 mg QD. Continuation of bisphosphonates was permitted. Primary endpoint was a composite of: PSA responses, bone scans and disease control by RECIST. Urinary N-telopeptide (uNTX) and bone alkaline phosphatase (BAP) were determined Q 4-weeks as indicators of bone metabolism. Results: 47 pts were treated (median treatment duration was 2.3 months). 11 patients were evaluable by RECIST; of these 64% achieved SD. The composite response rate was (8/47) 17%. Of 22 pts with bone scans, 50% were stable at 12 weeks and 3/9 (33%) were stable at 24 weeks. A prolonged PSA doubling time was observed in 32 of 39 pts (82%), including one pt with a PSA response. Of the pts with evaluable bone markers, including those who continued on bisphosphonate therapy, 20/41 (49%) had a ≥ 35% decrease in uNTX and 21/42 (50%) had a decrease from baseline in BAP. Grade 3/4 adverse events (AEs) were experienced by 13% of pts (diarrhea, asthenia, and pleural effusion [n=1]). Grade 1/2 AEs (≥ 15% of pts) were diarrhea, nausea, headache, fatigue, asthenia, anorexia and dyspnea. Conclusions: Fewer and less severe AEs were observed in all categories for the QD dosing group compared to the previously reported BID dosing cohort. In addition, preliminary clinical activity (tumor and PSA response; decreasing bone turnover [uNTX, BAP]), is now confirmed to be similar in pts treated with 100mg QD and BID dosing. These data support the relevance of further studies of dasatinib in metastatic CRPC.

[Table: see text]

Dasatinib and docetaxel combination treatment for patients with castration-resistant progressive prostate cancer: A phase I/II study (CA180086)

5061

Background: Dasatinib, a potent inhibitor of SRC family kinases, inhibits in vitro prostate cancer cell proliferation and migration. Consistent with those findings are the clinical observations that osteoclast activity and bone turnover are downregulated in patients treated with dasatinib. We report promising preliminary results of dasatinib in combination with docetaxel (D) for treatment of metastatic castration-resistant prostate cancer (CRPC). Methods: Male pts with progressive CRPC and castrate levels of testosterone (≤50 ng/dL) requiring chemotherapy were enrolled. Escalating doses of dasatinib (50–120 mg QD) and D (60–75 mg/m2 Q 21 days) were evaluated (n = 16) followed by enrollment of 30 pts at the phase 2-selected dose (100 mg dasatinib QD + D at 75 mg/m2 Q 21 days). Continuation of bisphosphonates was permitted; anti-androgens were discontinued. Primary endpoint (Ph. 2) was to determine drug-drug interactions. Secondary endpoints were: changes in PSA, bone scans and tumor size, bone metabolism [urinary N-telopeptide (uNTX) and bone alkaline phosphatase (BAP)] and PK. Results: 46 pts were treated with 28 pts still on therapy. Median treatment duration (n = 18, pts off study) was 4.2 months (0.13–9.63). Preliminary analysis showed no interaction between dasatinib and D. PSA response was seen in 13/32 (41%) pts, clinical benefit (PR + SD) for RECIST-evaluable pts was 21/21, [7 PR, 5 uPR and 4 SD (at ≥21 wks) and 5 SD at ≥6 wk)]. Of 31 pts with bone scans, 30 patients had a best response of either improved (32%) or stable (65%) at ≥6 weeks. For pts with measurable bone markers levels, 12/26 (46%) had a ≥35% decrease in uNTX and 17/24 (71%) had a decrease in BAP from baseline. 6 of 42 pts experienced ≥ grade 3 adverse events (AEs), including fatigue, myelosuppression and pleural effusion (n = 1). Most common grade 1/2 AEs were fatigue, dysgeusia, GI, and skin disorders. Conclusions: Dasatinib and D at doses up to 120 mg QD and 75 mg/m2 are safe with manageable toxicities and no drug-drug interactions. These data confirm the antitumor and antiosteoclast activity of dasatinib in combination with D and serve as the basis for the ongoing phase III study of this combination.

[Table: see text]

Difficulties in emotion regulation and impulse control during cocaine abstinence

RATIONALE

Prior research has shown that cocaine dependence is associated with dysfunction of brain systems involved in emotions and motivational states.

OBJECTIVES

To examine whether difficulties in emotion regulation are associated with early cocaine abstinence using the recently validated Difficulties in Emotion Regulation Scale (DERS).

METHOD

Recently abstinent treatment-seeking cocaine patients (n=60) completed the DERS during their first week of inpatient treatment and at discharge (3-4 weeks later), and scores were compared with community controls (n=50).

RESULTS

Compared with controls, cocaine-dependent individuals reported difficulties relating to understanding emotions, managing emotions and impulse control in the first week of abstinence. With continued abstinence, cocaine-dependent individuals showed continued difficulties only in impulse control.

CONCLUSION

Cocaine-dependent individuals report emotion regulation difficulties, particularly during early abstinence. Additionally, protracted distress-related impulse control problems suggest potential relapse vulnerability.

Modulation in the photosensitivity of albumin-bound bilirubin

Exposure of BR-albumin complexes to visible light at pH 8.0 led to a change in the fluorescence intensity at 525 nm, which was found to be different for different serum albumins. Whereas a complex of BR with human serum albumin (HSA) showed a marked increase in fluorescence upon photoirradiation, BR-sheep serum albumin (SSA) complex failed to produce a marked increase. On the other hand, a complex of pig serum albumin (PSA) with BR produced a remarkable decrease in fluorescence upon photoirradiation. Equilibration of these complexes with approximately 20 mM chloroform for 1 h resulted in alteration in the photoinduced fluorescence. These photoinduced fluorescence modulations were found to be concentration dependent. Photoirradiation of BR-HSA complex led to a significant decrease in the positive CDCEs of the bisignate CD spectra in a time dependent manner that can be reconciled, to a significant extent, in the presence of chloroform. Taken together, all these results suggest that chiroptical properties/stability of albumin-bound BR varies with albumin species, protein concentration and the presence of chloroform.