Emma Schleiger

Frontal EEG delta/alpha ratio and screening for post-stroke cognitive deficits: The power of four electrodes

This study analysed correlations between post-stroke, quantitative electroencephalographic (QEEG) indices, and cognition-specific, functional outcome measures. Results were compared between QEEG indices calculated from the standard 19 versus 4 frontal (or 4 posterior) electrodes to assess the feasibility and efficacy of employing a reduced electrode montage. Resting-state EEG was recorded at the bedside within 62-101 h after onset of symptoms of middle cerebral artery, ischaemic stroke (confirmed radiologically). Relative power for delta, theta, alpha and beta, delta/alpha ratio (DAR) and pairwise-derived brain symmetry index (pdBSI) were averaged; over all electrodes (global), over F3, F4, F7, F8 (frontal) and P3, P4, T5, T6 (posterior). The functional independence measure and functional assessment measure (FIM-FAM) was administered at mean 105 days post-stroke. Total (30 items) and cognition-specific (5 items) FIM-FAM scores were correlated with QEEG indices using Spearmans coefficient, with a Bonferroni correction. Twenty-five patients were recruited, 4 died within 3 months and 1 was lost to follow-up. Hence 20 cases (10 female; 9 left hemisphere; mean age 68 years, range 38-84) were analysed. Two QEEG indices demonstrated highly-significant correlations with cognitive outcomes: frontal DAR (ρ = -0.664, p ≤ 0.001) and global, relative alpha power (ρ = 0.67, p ≤ 0.001). After correction there were no other significant correlations. Alpha activity - particularly frontally - may index post-stroke attentional capacity, which appears to be a key determinant of functional and cognitive outcomes. Likewise frontal delta pathophysiology influences such outcomes. Pending further studies, DAR from 4 frontal electrodes may inform early screening for post-MCA stroke cognitive deficits, and thereby, clinical decisions.

Improved cerebral pathophysiology immediately following thrombectomy in acute ischaemic stroke: monitoring via quantitative EEG

http://dx.doi.org/10.1016/j.clinph.2016.06.001 1388-2457/ 2016 International Federation of Clinical Neurophysiology. Quantitative EEG (QEEG) has demonstrated value in assessment of cerebral pathophysiology following acute ischaemic stroke (AIS; e.g., Finnigan and van Putten, 2013). Various reports indicate that EEG/QEEG can promptly detect cerebral responses to successful reperfusion therapy, even when this cannot be assessed clinically (Finnigan et al., 2006; de Vos et al., 2008, Finnigan and van Putten, 2013). Additionally QEEG can indicate lack of favourable response to therapy, (e.g. unsuccessful alteplase) and may help expedite decisions regarding intra-arterial interventions (e.g. thrombectomy; Sheikh et al., 2013). We reported marked QEEG changes between preand post-thrombectomy recordings (Sheikh et al., 2013). In EEG acquired from 2 h post-recanalisation the delta/alpha power ratio (DAR) demonstrated significant improvement (3.3) relative to that assessed 4 h prior (10.8; preprocedure), indicating relative normalisation of brain function and successful reperfusion. These changes accurately predicted an excellent outcome, whereas confirmation via post-procedure neurological assessment was not possible until 3 days post-stroke (due to sedation and intubation). Comparisons between AIS and controls indicate that DAR of 3.7 is an accurate criterion value to define abnormally slow EEG in AIS (Finnigan et al., 2016). We now describe a case wherein EEG was recorded throughout a successful thrombectomy procedure. A 56-year-old man, living independently with history of hypertension and type II diabetes, presented approximately 1 h after acute onset of symptoms (‘‘post-stroke”). These included rightsided hemiplegia and facial droop, expressive and receptive dysphasia (NIHSS = 23). CT perfusion (CTP) showed a 115 ml infarct core (estimated using RAPID software; iSchemaView), in the left middle cerebral artery (LMCA) territory, with diffuse penumbra (absolute mismatch difference 109 ml). IV alteplase bolus commenced at 113 min post-ictus. Endovascular treatment was initiated given lack of clinical improvement, large estimated clot size, and the relatively short time since stroke symptom onset. Clot retrieval commenced in the angio suite under conscious sedation (remifentanil) at 155 min post-stroke. Thrombectomy was achieved at 193 min post-stroke with a single pass using a 4 mm 20 mm Trevo stent retriever (Stryker Neurovascular) with immediate return of anterograde LMCA blood flow (TICI 3). By 4 h post-thrombectomy there was return of full power in the right upper and lower limbs. Follow-up MRI at 24 h showed hyperintensity in LMCA territory (frontal and parietal cortical regions and basal ganglia). At 24 and 48 h post-thrombectomy, NIHSS scores were 11 and 9, respectively (severe dysphasia, mild dysarthria, facial droop, partial sensory loss). At two months the patient was independent in motor-based ADL tasks but remained moder-

Informing prognostication of post-stroke cognitive impairment: the accuracy of a pre-sischarge EEG marker

Annual Conference of the Asia Pacific Stroke Organization (APSO) Combined with Stroke Society of Australasia, Brisbane, Qld, Australia, July 14-17, 2016Annual Conference of the Asia Pacific Stroke Organization (APSO) Combined with Stroke Society of Australasia, Brisbane, Qld, Australia, July 14-17, 2016

Early screening for post-stroke cognitive deficits may be informed by degree of EEG alpha slowing

Session 1: ICH/TIA 1100–1230 Management of unruptured intracranial arteriovenous malformations in pediatric patients with stereotactic radiosurgery D Ding, Z Xu, C-P Yen, R M Starke, J P Sheehan University of Virginia, Charlottesville, Virginia, USA Background: Unruptured intracranial arteriovenous malformations (AVM) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs. Therefore, the efficacy of stereotactic radiosurgery (SRS) for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following SRS for unruptured pediatric AVMs. Methods: We evaluated a prospective, institutional AVM SRS database, from 1989 to 2013. Patients with age <18 years at the time of SRS, unruptured nidi, and at least two years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. Results: In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure (53%). The median nidus volume, radiosurgical margin dose, and radiologic follow-up were 3.2 cm, 21.5 Gy, and 45 months, respectively. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29%, 54%, and 72%, respectively. In the multivariate Cox regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55%, 16%, and 2%, respectively. The annual post-radiosurgery hemorrhage rate was 1.3%. Conclusion: Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach. 1. Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 2014; 311:1661–1669. 2. Ding D, Xu Z, Yen CP, Starke RM, Sheehan JP. Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients. Acta Neurochir (Wien) 2014. DOI: 10.1007/s00701-0142305-4. 3. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383:614–621. Subclinical ischemic lesions in patients with intracranial haemorrhage S Singhal, J V Ly, R V Chandra, J Zhou, C Soufan, H Ma, B Clissold, V Srikanth, T G Phan Monash Health, Clayton, VIC, Australia Background and Purpose: Subclinical ischemic lesions on diffusion weighted MR imaging (MRI-DWI) have been recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH). Such lesions are postulated to be part of the amyloid angiopathy spectrum. We hypothesized that the frequency of these MRI-DWI lesions may differ between patients presenting with cSAH, lobar ICH and basal ganglia ICH. Methods: Retrospective study of patients presenting between 2011–2014 with cSAH and/or ICH and subsequent MRI. Patients with an aneurysm, arteriovenous malformation, or hemorrhagic infarct were excluded. ICH topography was classified as lobar or basal ganglia; MRI-DWI lesions were classified as subclinical if there were no associated symptoms; contrast enhanced scans were assessed for leptomeningeal contrast enhancement. Results: Of 115 eligible patients, 56 patients had MRI within 14 days of hemorrhage (mean age 69.4 ± 11.5 years; 48% male). Overall, 21% (n = 12/56) patients with cSAH and/or ICH had subclinical MRI-DWI lesions. MRI-DWI lesions occurred more frequently in patients with cSAH than basal ganglia ICH (n = 5/12 vs 2/30; p = 0.006) and in patients with lobar ICH than basal ganglia ICH (n = 5/18 vs 2/30; p = 0.04). There was no significant difference in MRI-DWI lesions between cSAH and lobar ICH. Patients with MRI-DWI lesions had more frequent adjacent leptomeningeal contrast enhancement (p < 0.001). Conclusion: Subclinical ischemic lesions occur more frequently in patients with cSAH and lobar ICH than basal ganglia ICH. More frequent leptomeningeal contrast enhancement in these patients may point to a common underlying amyloid-related small vessel vasculopathy. Impact of haematoma shape and density on 90-day outcome after intracerebral haemorrhage: The INTERACT2 study C Delcourt, S Zhang, H Arima, S Sato, R A-S Salman, X Wang, C Stapf, T Robinson, P Lavados, J Chalmers, E Heeley, C Anderson Neurology and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia The University of Sydney, Sydney, NSW, Australia Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia University of Edinburgh, NHS Lothian, Edinburg, United Kingdom Université Paris Diderot – Sorbonne Paris, AP-HP Hôpital Lariboisière, Paris, France Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom Departamento de Medicina, Clínica Alemana, Universidad del Desarrollo (P.M.L.), Santiago, Chile The George Institute for Global Health, Sydney, NSW, Australia Background: Irregularity of shape and heterogeneous density suggest multiple bleeding foci and different periods of bleeding, respectively, in acute intracerebral hemorrhage (ICH). These features predict hematoma expansion but with uncertain significance on patient outcome. The aim of this study was to assess the association of shape and density on outcome among participants of INTERACT2, an open-label randomized controlled trial. Method: Shape and density were measured in 2066 patients with baseline CT. The Barras scale was used to categorize the appearance of the ICH, on the largest axial slice, into ‘regular’ (1 to 2) vs ‘irregular’ (3 to 5); density variation into ‘homogeneous’ (1 to 2) vs ‘heterogeneous’ (3 to 5). Logistic regression models were used to assess hematoma parameters on the primary outcome defined as death or major disability (mRS 3–6) at 90 days. Secondary outcomes were death and major disability, separately. Results: Shape irregularity was associated with poor outcome (OR 1.64, 95%CI 1.33–2.03), and separately only on major disability (OR 1.5, 95% CI 1.24–1.83). Density heterogeneity was not associated with poor outcome (OR 1.09, 95%CI 0.87–1.36), or the separate components of death or disability. Abstracts

Prognosticating post-stroke cognitive outcomes: Pre-discharge, frontal EEG markers are informative

Synopsis: Stroke patients with acute occlusions of the large proximal cerebral arteries and high thrombus load do not show an optimal response to i. v. thrombolysis alone. During the recent years mechanical neurointerventional revascularization techniques with clot retrievers and aspiration catheters have been developed in adjunct to systemic therapy. Today interventional thrombectomy is mainly based on a combination with stentretrievers and aspiration. Compared to prior approaches this technique is relatively easy to perform and to standardize and allows for recanalization rates of up to 90 %. Clinical success rates of more than 50 % of patients with mRS 0–2 could be achieved in experienced centers. Drawbacks of catheter based revascularization techniques are logistic demands and the descrepancy between high recanalization rates and lower rates of good clinical outcomes. The problem of futile recanalization was one of the influence factors for the failure of several randomized trials (RCTs) i. v.-lysis vs. thrombectomy. Improper patient selection, inefficient interventional techniques and late time windows were among the reasons why superiority of endovascular treatment could not be demonstrated with high levels of scientific evidence. Neurointerventional hypes and accelerated demands for RCTs at an early stage of development without proof of sufficient efficacy of a new technique led to negative or equivocal results. Hopefully better trials are on the way. To become successful the relationship between neurologists and neurointerventionists should be less competitive to work together with the aim to improve outcome of stroke patients and to keep neurointervenition in the neuro field instead of vascular medicine. Invited Speaker

Pre-discharge EEG markers are informative of post-stroke cognitive outcomes

Background: A rural feedback survey, highlighted need for user friendly, accessible stroke education for generalist staff. Funded by a scholarship from Rural Division of CETI. Developed in partnership by Stroke Care Coordinators within the Hunter New England Area Health Service (HNEAHS), North Coast Area Health Service (NCAHS). Located on the National Stroke Foundation Web Site. Aims: eStroke was designed for clinicians working in Stroke, as well as generalist staff. The primary aim is to provide information to clinicians working within rural facilities. Methods: Built on the evidence-based guidelines and advice from expert multidisciplinary stroke clinicians. E-learning format, easily accessed, at no cost to metropolitan, rural and remote clinicians. Guidance and governance provided by HNEAHS and NCAHS. The Online Package has the ability to collect feedback data on site usage and comments. Results: Consultation with expert clinicians resulted in 10 packages covering pre hospital, acute stroke management, rehabilitation and beyond has been developed. This includes the utilisation of five case studies to demonstrate a practical approach to stroke management. The National Stroke Foundation has collated feedback from the go live date of the rural component of estroke. Conclusion: Provides easily accessible, practical Stroke information for beginner to intermediate in an e learning format. Opportunity to develop and build on existing skill base and develop more specialized skills. To date e Stroke Online package has attracted high volume of users with positive feedback.