PO-F56

SECOND WORLD CONGRESS OF STROKE, 1992

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S149

THE EPIDDIIOLOGY OF STROKE-RELATED DISABILITY:n'E PERTH CONMUNITY STROKE STUDY

1 22 3 C Anderson* G J~hnson

P Burvill K Jamroz~k E Stewart-Wyn~e FlindersHedical Sentre, SA Psychiatry, UWA Public Health,UWA and Neurology, Royal Perth Hospital, Perth, WA

Previous assessments of the outcome from stroke havebeen largely restricted to selected patients, such asthose admitted to hospital or referred for rehabilit­ation, and have mostly reported only physical funct­ion of the surviving patients •. However, a completeevaluation of the burden of stroke on the communityrequires the inclusion of all cases of stroke and theevaluation of psychological and social function,since physical independence in activities of dailyliving does not necessarily equate with a return tofull health.Data are presented on the follow-up over one year ofpatients registered with the Perth Community StrokeStudy (PCSS). The protocol of this study included:the use of a community-based register of all strokeevents, the application of well standardised instru­ments for measuring physical function and socialactivities at baseline and follow-up assessments; andformal review by a psychiatrist at four months post­stroke.The results show that the cumulative incidence ofdepressive illness in a truly representative seriesof survivors of stroke is lower than that reportedfrom selected cases, that as many patients sufferincapacitating anxiety states as develop depression,and that household and social activities continue tobe regained over the whole of the first year follow­ing a stroke.

WS2

ANGlO & SPECT STUDIES IN THROMBOLYSIS

PROF. P.M. DALAL et al.DEPT. OF NEUROSCIENCES, SIR H.N. HOSPITAL &RESEARCH CENTRE, R.ROY ROAD, BOMBAY 400 004INDIA

In stroke subjects showing acute internalcarotid-middle cerebral occlusion, with MRIevidence of ischaemia, serial angiographicobservations were made during plasminogenactivator (r-tpa)therapy. Here,Tc-99m HMPAOSPECT images were compared before and afteran attempt to induce thrombolysis.

Initial intravenous (i.v.) 10mg bolus ofr-tpa was followed by an infusion of SOmgr-tpa in 60 minutes; remaining 40mg infusedin 0.9% saline over subsequent 60 minutes.

When thrombolysis with r-tpa (80-100mg)byi.v. route was not successful, direct intra­carotid infusion was also not successful.Onthe other hand,spontaneous thrombolysis was"late event" with no improvement in HMPAOimages nor significant clinical recovery.

From similar "in vitro" incubation lysisstudies on the operatively recovered recent& unorganised human carotid thrombi, it issuggested that, among other factors,successor the failure rate of thrombolysis may beinfluenced by plasminogen as well as anti­plasmin content of such thrombi.

SPECT STUDIES OF CBF IN ACUTE STROKE.PROCEDURE AND RESULTS IN ROME.LENZI G.L., DI PIERO V., PANTANO P.

Previous work from our group (Stroke, 1990,21, 895-900) has demonstrated both thefeasibility and clinical relevance of CBF­SPECT evaluation within the first fivehours from the stroke onset.We present here the initial experience withactive trombolysis in "very early stroke".The treatment with r_TPA has to beinitiated within the first three hours tobe sufficiently safe and clinicallyfruitful.The CBF-SPECT evaluatio~ do not add delayto the treatment. With the split-dosemethod it is possible to perform CBF-SPECTby TC-99m HM-PAO twice in the same session.Initial clinical correlation will bediscussed.

WS3

CBF tomography and transcranial Doppler intPA treatment of acute stroke.

Sandra K. Hanson, M.D.,James C. Grotta, M.D., Nabil F. Maklad, M.D.,Ph.D.,Lamk M. Lamki, M.D., Huyen Tran, M.D.,Bruce Barron, M.D. - U.S.A.

The determination of cerebral perfusion statusin the early hours of ischemic stroke is importantfor patient selection and monitoring with thrombo­lytic or cytoprotective therapy. Eleven patientspresenting with acute middle cerebral or internalcarotid artery ischemia and subsequently randomizedinto a thrombolytic or glutamate antagonist trialwere studied with transcranial Doppler (TCD) andTc-99m HM PAO single photon emission computedtomography (SPECT) within six hours of the onset ofsymptoms. Both studies were repeated after 24 hours.

Severity of baseline TCD and SPECT abnormalitycorrelated well with initial clinical presentation.In addition, baseline SPECT and serial TCD and SPECTcorrelated well with clinical course and long termoutcome. In particular, total occlusion by TCDcriteria and recanalization within the first sixhours was associated with substantial earlyimprovement and good long term outcome.

In conclusion, it is feasible to obtainbaseline studies within the time restrictionsrequired for acute drug trials. The combined useof both tests offers important insights into thehemodynamic changes occurring in the early hoursfollowing large vessel occlusion.

S150

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SECOND WORLD CONGRESS OF STROKE, 1992

WS5

rCBF Tomography in tPA treatment of stroke

EA van Royen, M LimburgDepartment of Nuclear Medicine & Dept of NeurologyAcademic Medical Centre, Amsterdam, The Netherlands

We treated five patients with hemispheric ischemicstroke with intravenous recombinant tissue plasmino­gen activator (rtPA), within 3-6 h after strokeonset. Regional cerebral blood-flow was evaluatedwith single photon emission computed tomography(rCBF-SPECT) before and after treatment. One patientwith aphasia and a moderately severe hemiparesis,who had a small flow deficit, was treated 5 h and30 min after the onset of his stroke and had aprompt and complete recovery. The post treatmentrCBF-SPECT showed normal flow. One patient with avery large flow deficit died of transtentorialherniation. In three other patients clinical condi­tion remained unchanged, in one of them despiterestoration of flow, demonstrated by transcranialdoppler examination. In all these patients therCBF-SPECT remained abnormal.- rCBF-SPECT is avaluable tool in the explanatory analysis offibrinolytic treatment in ischemic stroke.

WS6

Serial CBF studies with SPECf in acute ischemic stroke.Diagnose, prognoses and acute treatment evaluation.

B. Sperling, T. S. Olsen, K. Overgaard, H. Jorgensen,O. Henriksen and N. A. Lassen.Bispebjerg Hospital 2400 NV, Copenhagen, Denmark.

The visualization of the CBF changes within a fewhours from the ischemic stroke onset is of importance forevaluation of new therapies as the therapeutic timewindow is estimated to three to six hours. We demon­strate the feasibility of SPECf and that SPECf with theCBF tracer 99mTc-HMPAO does not delay initiation oftreatment in 13 stroke patients studied before and afterr-tPA treatment initiated within 6 hours from onset.

Serial (3 to 6) studies of the development ofspontaneous postischemic reperfusion hyperaemia in 62patients (first CBF <6 hours from onset in 23 pt.s, <24hours in 39 patients) have demonstrated a great variety inreperfusion patterns and in timecourse (both betweenpatients and within patients) of the postischernichyperaemia, leading to yet unanswered questions aboutthe factors involved in reperfusion, e.g. Why is reperfusionhyperaemia not maximal immediately after reperfusion?What inducts this hyperaemia (not lactate)? Is reperfusionalways a result of resolving or migration of the embolus?The prognostic and diagnostic value of the acute CBF willbe discussed.

Superselective fibrinolysis using t-PAfor acute MCAembolism• Usefulness of HM-PAO/SPECffor patientselection-

AkiraTakahashi, MDand Takashi Yoshimoto", MDDiv, of Intravascular Neurosurgery. Kohnan Hospital and Div, of Neurosurgery,Institute of Brain Diseases, Tohoku Univ. School of Medicine", Sendai, Japan

In an attempt to evaluate the feasibility of t·PAon local fibrinolytic therapyforembolicstroke,the experiences and resultswill be presented on the acutemiddlecerebralartery(MCA)occlusion.Twentypatients,admitted within6hours after the onset of stroke (from 1.3 to 5.5 hours, average 2.9 hours),were treated by the infusion of t-PA into or beyond embolus using leakballooncatheteror Tracker-I8 catheter. As a brain protectiveagent, Sendaicocktail(mannitol,vitaminE and Phenytoin)was used as early as possibleafterexclusionof hemorrhagic stroke.Patientswhoshowedanysignsof lowdensityon Cf or thrombotic occlusionwereexcluded. The site of occlusionwereas follows;proximalM1 in 9, distal MI in 7, M2 in 4. Recanalization(complete 13,partial6) wereachievedbetween3.2 to 9.7 hours(average5.4hours)after the onsetat medosageof t-PAranging from 1.2 mg to 9.6 mg.Timerequiredfrom the admission to recanalization was2.5 hoursinaverage.After this therapy, symptoms were improved in II, unchanged in 7,worsened in 2. Whileno hemorrhagic tendencies weredetectedby laboratoryexamination, hemorrhagic infarction includingcorticalarea wasobservedin2 cases.. Pre-therapeutic rCBF evaluation using HM-PAO/SPECT wasperformed in 4 cases in this series. Comparing with other data from acutestroke patients, the patient who showed severe ischemiasuch as less than35%relativerCBF in conical area shouldbe excludedto avoid hemorrhagictransformation after recanalization. Hence,HM·PAO/SPECf is considered asessential for the proper patient selection for this therapy. As a conclusion,supcrselective infusionof t-PAmay play an Important role in the treatmentof acute MCAembolicocclusionif the patientswere selectedcarefullyandtreated withappropriate intravascular neurosurgical techniques.

WS7

CBF tomography in tPA treatment of stroke

Lawrence M. Brass, Pierre B. Fayad, PaulHoffer, and Zachary RattnerUnited States

Thrombolytic therapy is emerging as apromising intervention in patients withacute ischemic stroke. Early reperfusionappears to be associated with improvedoutcome, however, the risks associatedwith this form of therapy are not benign.

The mechanism and size of an area ofischemia both appear to correlate withthe risk for hemorrhage followingthrombolytic therapy. The CT scan and MRare often negative during the first hoursfollowing an ictus. Brain perfusioniffiaging can accurately demonstrate thesize, and give clues to the mechanism ofischemia.

In addition, the degree of the perfusiondeficit may provide clues as to thelikelihood of an improvement ifreperfusion is successful. When combinedwith newer radioligands which bind toneural receptors (e.g., dopamine orbenzodiazipine receptors), SPECT studiesmay help identify those patients mostlikely to have an ongoing perfusiondeficit with viable tissue still present.