Atul T. Patel

Use of Antihypertensive and Antithrombotic Medications after Stroke in Community-Based Care

BACKGROUND: Secondary stroke prevention strategies include pharmacologic approaches to control hypertension and reduce thromboembolic risk. OBJECTIVE: To describe antithrombotic and antihypertensive medication use, and rates of blood pressure control in the Kansas City Stroke Study, a prospective stroke cohort receiving community-based care after primarily mild and moderate stroke. METHODS: Participants from 12 area hospitals provided information about medication use prior to stroke. Study personnel measured blood pressures at enrollment and at one, three, and six months, and collected medication data at six months during in-home assessment. RESULTS: Complete data at six months were available for 355 subjects with ischemic stroke, among whom 13% had atrial fibrillation and 67% had prior hypertension. Prior to stroke, only 45% of the patients were receiving any antithrombotic (anticoagulant and/or antiplatelet) therapy; this figure rose to 77% at six months. Antithrombotic treatment rates among those with atrial fibrillation were 59% before stroke and 83% at six months, including warfarin in 64%. Approximately 70% of subjects had controlled blood pressures one, three, and six months after stroke, defined as systolic blood pressure ≤140 mm Hg and diastolic blood pressure ≤90 mm Hg. Use of multiple antihypertensive agents was common; calcium-channel blockers and angiotensin-converting enzyme inhibitors were used most frequently. However, 19% of subjects with uncontrolled blood pressure were untreated at six months. CONCLUSIONS: Although room for improvement remains, these data suggest improved rates of antithrombotic and antihypertensive medication use after stroke in community-based care in a midwestern metropolitan community, compared with previous reports.

Electromyography and anticoagulation.

Needle electromyography (EMG) is a common and safe diagnostic procedure. Although there are no absolute contraindications to performing an EMG, medically induced coagulopathy represents a relative contraindication. The purpose of this article is to discuss EMG safety for patients taking anticoagulants and antiplatelet agents, and to review the current literature regarding bleeding risks. Safety measures used to avoid serious bleeding complications are also discussed.

OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach

OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established.

Hypothermia-Induced Peripheral Polyneuropathy After an Episode of Drowning

It has been known that cold temperatures can have damaging effects on peripheral nerves. However, there have been very few documented cases in the medical literature of peripheral polyneuropathy as a result of accidental hypothermic exposure from drowning. The first documentation of cold injury to peripheral nerves was recorded in the 11th century [1]. There have also been reports of neuropathy during times of war, in connection with shipwrecks, mountain climbing, and hiking, and in persons under the influence of alcohol or drugs exposed to the cold outdoors [2]. Currently, there has been a large amount of research examining the physiologic effects of hypothermia in animal models. More recently, there has been an interest in hypothermia as a therapeutic agent for various medical conditions such as brain and spinal cord injuries. In this case report, we present a pediatric patient who was presumed to have a hypothermia-induced peripheral polyneuropathy.

Poster 52: Botulinum Toxin A in Upper Limb Spasticity Management: Baseline Data from the Upper Limb International Spasticity (ULIS)-III Study

worst pain, respectively. Between-group differences were significant in actual and least pain (P < .05). Significant treatment effect in favor of ITB was observed in EQ-5D utility score: mean change was 0.09 (0.26) for ITB compared to 0.01 (0.16) for CMM (P < .05). EQ-5D health status score increased by 9.68 (20.42) for ITB versus 4.40 (21.75) for CMM (P >.05). In total 17 (68%) ITB implanted patients reported at least one treatment-related adverse event versus 7 (20%) CMM patients. No patient discontinued ITB therapy due to a treatment-related adverse event. Conclusions: The study demonstrated superiority of ITB therapy versus conventional oral medication in decreasing muscle hypertonia in post-stroke patients with spasticity. This is associated with improvements in pain and quality of life in ITB patients. Level of Evidence: Level I

Poster 69: Safety and Efficacy of High-Dose OnabotulinumtoxinA for Post-Stroke Upper Limb Spasticity: Results of a Double-Blind, Placebo-Controlled Trial

Objective: To test the hypothesis that cerebellar strokes may need an increased length of stay for acute rehabilitation. Design: Retrospective case series. Setting: Acute Rehabilitation Unit at Tertiary care hospital. Participants: 14 patients. Interventions: Not applicable. Main Outcome Measures: FIM efficiency and length of stay. Results: We completed a case review of 5 patients who had been transferred to the CARU following cerebellar strokes. All patients had an initial FIM score between 70-79, four of the five were discharged home andonewasdischarged to subacute rehab. TheFIMefficiency, or change in FIM score divided by the length of stay was calculated to compare cerebellar strokes to our general stroke population. The FIM efficiency for all stroke patients during the 2016 fiscal year was 2.33 in the Jefferson University Hospital CARUwhereas the national averagewas 2.26. Between July 1 and Dec 15, 2016, patients who had an admission diagnosis of stroke with an initial FIM score between 70-79 who were discharged home had an average FIM efficiency of 3.32 (n1⁄49). The FIM efficiency for the 5 patients admitted with cerebellar strokes was 1.61. Conclusions: Posterior cerebral, specifically, PICA cerebellar stroke may represent a subgroup population that have difficult to treat symptoms that may have an impact on length of stay and acute rehabilitation outcomes as seen by a longer length of stay required for a similar progression of FIM efficiency. Level of Evidence: Level III

Poster 361 Impact of Early Intervention with OnabotulinumtoxinA Treatment in Adult Patients with Post-Stroke Lower Limb Spasticity

Disclosures: Atul Patel: Research Grants Allergan, Merz, Ipsen, Speakers bureau Allergan Objective: The objective of this analysis is to evaluate the efficacy of onabotulinumtoxinA in post-stroke lower limb spasticity (PSLLS). Design: Multicenter, phase 3, placebo-controlled study. Setting: 60 global study centers. Participants: Patients with PSLLS (Modified Ashworth Scale [MAS] 3) of the ankle plantar flexors. Interventions: During the 12-week double-blind phase, patients were randomized to receive onabotulinumtoxinA (300U, mandatory muscles [gastrocnemius, soleus, tibialis posterior] and 100U, optional lower limb muscles [flexor digitorum longus, flexor hallucis longus, flexor digitorum brevis, extensor hallucis, rectus femoris]) or placebo. Main Outcome Measures: The primary endpoint was MAS change from baseline average score of weeks 4 and 6. Secondary endpoints included physician-assessed Clinical Global Impression of Change (CGI) average score of weeks 4 and 6 and physicianassessed Goal Attainment Scale (GAS; active and passive at weeks 8 and 12). Results: In the intent-to-treat population (onabotulinumtoxinA, n1⁄4233; placebo, n1⁄4235), significant improvements vs placebo were observed in MAS (e0.81 vs e0.61; P1⁄4.01), CGI (0.86 vs 0.65; P1⁄4.01), and passive GAS scores (week 12, e0.6 vs e0.9; P1⁄4.042). When stratified by time of treatment initiation post-stroke (<24 months, n=153; >24 months, n1⁄4315, posthoc), patients who were treated 24 months since stroke experienced greater improvements (mean difference from baseline vs placebo) in MAS (e0.31 vs e0.17), CGI (0.49 vs 0.12), and passive GAS scores (week 12, 0.37 vs 0.26). Among patients 24 months since stroke, a greater proportion achieved 1 point improvement in active (week 12; P1⁄4.039) and passive (week 8; P1⁄4.023) GAS scores vs placebo. OnabotulinumtoxinA 300e400U was well tolerated with no new safety findings. Conclusions: OnabotulinumtoxinA 300-400U is effective in improving MAS, CGI, and GAS scores in patients with PSLLS with greater benefits among those who initiate treatment 24 months post-stroke. Funding: Allergan plc. Level of Evidence: Level I