Tennille Rowland

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.

Assessments of Upper Limb Ability following Stroke: A Review

The aim of this paper was to review the psychometric properties and clinical utility of assessments of upper limb ability following stroke. Upper limb ability was defined as the use of the arm in meaningful activity. The database searches identified 13 assessments of upper limb ability. The inclusion criteria were (a) an evaluation of upper limb ability post-stroke, (b) a quantitative assessment yielding a numerical score, (c) able to be administered by an occupational therapist and (d) published information building on the results of a review in 2001. The assessments included were reviewed with respect to the ability measured, equipment required, evidence of reliability and validity, and advantages and disadvantages of use. Seven assessments satisfied the inclusion criteria. These assessments have undergone varying degrees of psychometric testing as outcome measures for upper limb recovery and all demonstrate at least adequate levels of reliability and validity. There is variation in the availability of instruction manuals and time commitments for test administration. All test items are generally available and inexpensive, enabling departments to set up the assessments with minimal financial outlay. The assessments described are regularly used in research and all demonstrate psychometric properties that suggest that they could be incorporated into clinical practice. Occupational therapists are encouraged to consider how they may include these assessments into their own clinical practice. An important step in this process may be further research into the clinical utility of these assessments.

Chedoke Arm and Hand Activity Inventory-9 (CAHAI-9): perceived clinical utility within 14 days of stroke.

Abstract Purpose: The Chedoke Arm and Hand Activity Inventory-9 (CAHAI-9) is an activity-based assessment developed to include relevant functional tasks and to be sensitive to clinically important changes in upper limb function. The aim of this study was to explore both therapists’ and clients’ views on the clinical utility of CAHAI-9 within 14 days of stroke. Method: Twenty-one occupational therapists actively working in stroke settings were recruited by convenience sampling from 8 hospitals and participated in semistructured focus groups. Five clients within 14 days of stroke were recruited by consecutive sampling from 1 metropolitan hospital and participated in structured individual interviews. The transcripts were analyzed thematically. Results: Six themes emerged from the focus groups and interviews: collecting information, decisions regarding client suitability, administration and scoring, organizational demands, raising awareness, and clients’ perceptions of CAHAI-9 utility. All therapists agreed CAHAI-9 was suited for the stroke population and assisted identification of client abilities or difficulties within functional contexts. Opinions varied as to whether CAHAI-9 should be routinely administered with clients who had mild and severe upper limb deficits, but therapists agreed it was appropriate for clients with moderate deficits. Therapists made suggestions regarding refinement of the scoring and training to increase utility. All clients with stroke felt that the assessment provided reassurance regarding their recovery. Conclusion: The findings indicate that CAHAI-9 shows promise as an upper limb ability assessment for clients within 14 days of stroke.

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.