The 2001 North American Stroke Meeting

Abstracts

The 2001 North American Stroke Meeting San Diego, CA August 15-18, 2001

190 Constraint-Induced Movement Therapy: Effectiveness in Clients Post CVA with Moderate to Severe Chronic Upper Extremity Motor Deficit N. McNamara, K. Anderson. Denver and Westminster, CO Background: The purpose of this study is to determine the efficacy of constraint induced movement therapy (CIMT) as a treatment intervention for clients with chronic upper extremity residual motor deficits as a result of cerebrovascular accident (CVA). Research has demonstrated the effectiveness of CIMT in increasing the motor ability and amount of use of the involved upper extremity in the upper 20 to 25% (the first quartile) of the chronic CVA population. This study is evaluating the effectiveness of CIMT in the second and third quartiles of this population. Methods: Subjects greater than twelve months poststroke who meet the motor criteria for second or third quartile inclusion wear a restraint on the involved upper extremity for 90% of waking hours for 3 weeks. They participate in 6 hours of training per day to the involved arm, including implementation of task practice and shaping techniques. Motor function and amount of use are tested pre- and postintervention. A sample size of twenty subjects in each group is anticipated. Subject participation began September 2000. Results: Data analysis will be initiated Spring 2001. By July 31, 2001 data will be collected on an estimated 25 subjects. Conclusions: If effective, CIMT could potentially be beneficial for up to 75% of individuals with chronic CVA.

191 Initial Outcomes of a New In-Patient Stroke Education Program D.R. Newman. Santa Fe, NM Background: In November, 2000, an in-patient stroke education program was initiated at St. Vincent Hospital in Santa Fe, NM. Methods: Patients are included in the program based on admitting diagnosis of TIA or stroke. They and their families watch a video about stroke, stroke knowledge is assessed, and an individual risk factor analysis is performed by a stroke educator. Patients are informed about the relationship between their risk factors and stroke risk and asked if they are willing to make lifestyle changes (e.g., taking HTN meds, quitting smoking) to avoid a future event. An information packet is distributed to every patient, and they are asked to give consent for follow-up, four times over a 12 month period, via telephone. Results: To date, 33 patients received in-patient stroke/TIA education. Only 2 patients (6%) were not willing to make lifestyle changes. Of the 16 patients who received at least one follow-up call, 12 (75%) have taken control of their risk factors (i.e., now taking HTN meds as prescribed; stopped smoking; losing weight; exercising; improved diet) and state that their quality of life has improved since the stroke/TIA. Conclusions: Early data suggest that a personalized in-patient stroke education program, presented to patients and their families, may effect positive lifestyle changes that help to reduce future events and improve quality of life in stroke/TIA patients.

Journal of Stroke and Cerebrovascular Diseases, Vol. 10, No. 4 (July-August), 2001: p 191-201

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Utility of the NIH Stroke Scale as a Predictor of Hospital Disposition D. Schlegel, S.J. Kolb, J.M. Luciano, J. Tovar, B.L. Cucchiara, S.E. Kasner. Philadelphia, PA

Glutamate, Homocysteine and Autoantibodies to NMDA Receptor in Patients With TIA and Stroke S. Dambinova, G. Chounteev, I. Zavolokov, A. Iljuchina, A. Scorometz. St. Petersburg, Russia

Background: Early identification of stroke patients in need of rehabilitation (REHAB) or long term nursing home (NH) care may promote more efficient use of resources and improved outcomes. The NIH Stroke Scale (NIHSS) is a simple, reliable rating scale of stroke-related deficit and is an attractive candidate predictor of disposition because it is widely used, easy to learn, and can be performed rapidly upon admission. Methods: Retrospective study of all stroke patients admitted within 24 hours of onset to a university hospital from March to June, 2000. Medical records were reviewed for demographic information, type of stroke, prestroke living arrangement and independence, initial NIHSS, and medical complications during hospitalization. Results: Among 95 patients evaluated during the study period, 58% were discharged home, 29% to REHAB, and 13% to NH. In bivariable analyses, disposition was associated with age, prior independence, and NIHSS, but not with sex, race, stroke type or hemisphere, nor prior living arrangement. In multivariable analyses, disposition was associated only with initial NIHSS. For each one-point increase in NIHSS, the likelihood of going home was significantly reduced (OR⫽0.79, 95% CI: 0.70-0.89, P ⬍ .001). Categorization of NIHSS was also predictive of disposition, with NIHSSⱕ5 being most strongly associated with discharge home, NIHSS 6-13 with REHAB, and NIHSS13 with NH (P ⬍ .001). Although no other baseline characteristics predicted disposition, major medical complications during hospitalization tended to reduce the odds of going home (OR⫽0.30, 95% CI: 0.09-1.0, P ⫽ .055). Conclusion: The NIHSS predicts post-acute care disposition among stroke patients. Predicting disposition on the first day of admission may facilitate and optimize the time-consuming and costly process of securing a bed at a REHAB or NH facility.

Background: The different laboratory blood assays (glutamate, homocysteine contents) independently associated with diagnosis of stroke and autoantibodies to the NMDA receptor as a hallmark of neurotoxicity were studied. Methods: Patients with TIA (n⫽47) and stroke (n⫽137) were subdivided according to severity of symptoms on the basis of detailed interviews, neuroimaging. The plasma glutamate and homocysteine by HPLC were performed. Autoantibodies to NMDA receptor were detected in the blood serum by ELISA using NR2A peptide as an antigen. Results: Glutamate in plasma of patients with TIA (163⫾10 ␮mol/L) was higher than in those with progressive stroke and healthy volunteers (121⫾8 ␮mol/L) and didn’t correlate with neurological deficit. The increased blood homocysteine for patients with TIA and stroke depended on stages of disease. However, approximately 60% of these patients had additional risk factors associated with the atherosclerosis. A high level of NR2A autoantibodies (3.11⫾0.43 ng/mL) in the blood of TIA patients compared to stroke patients (1.98⫾0.20) and healthy volunteers (n⫽50; 1.20⫾0.25 ng/mL) was detected. Conclusion: The laboratory blood assay detecting NR2A autoantibodies correlates more precisely with neurological deficit and neuroimaging of TIA patients.

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Autoantibodies to NMDA Receptor in Chronic Cerebral Ischemia G. Izykenova, O. Granstrem, M. Gappoeva , S. Dambinova. St. Petersburg, Russia

A Randomized, Controlled Pilot Study of Modified Constraint-Induced Therapy in Sub-acute Stroke S.J. Page, S. Sisto, P. Levine, M. Johnston. West Orange, NJ

Background: The ischemia increases NMDA receptor turnover enhancing their degradation and resulting receptor fragments produce an immune response passing into the blood and generating autoantibodies (aAb). Methods: A clear-cut cortex infarction in rats (Wistar, n⫽8) by ligation of the left carotid artery was performed. The infarct area volume and tissue apoptosis were evaluated by TTC staining and in situ hybridization. Western blot of NR2A-D subunits in the infarct area was carried out using commercial antibodies. The blood samples were collected every 4 days during 1 month. Autoantibodies to NMDA receptor were detected in the blood serum by ELISA using NR2A peptide as an antigen. Results: Local damage accompanied with neuronal apoptosis in the infarct area of cortex was demonstrated. Experimental rats exhibited strong NR2A immunoreactivity compared that for NR2C, NR2D and vehicle rats (n⫽6). The increased NR2A aAb level (140%) was revealed in the blood of rats from the 4th day till the end of experiment remained higher than that for controls. Conclusion: The NR2A autoantibodies are hallmark of neurotoxicity and cerebral ischemia.

Background: Although efficacious, research suggests that constraint-induced therapy (CIT) may be difficult to implement, and adherence may be problematic. We compared affected upper limb outcomes of 4 subacute stroke patients receiving modified constraint-induced therapy (mCIT) with 5 patients receiving traditional rehabilitation (TR) and 5 receiving no therapy (CON). Methods: The Fugl-Meyer Motor Recovery Assessment (FuglMeyer) and Action Research Arm Test (ARA) were administered twice prior to intervention, and the Motor Activity Log (MAL) was administered once. mCIT patients participated in 1⁄2-hour, structured therapy sessions, with their less affected limbs restrained 5 days/week during 5-hour times of frequent use. TR patients received therapy administered in identical contact parameters as mCIT. The Fugl-Meyer, ARA, and MAL were again administered after intervention by a blinded rater. Results: Prior to intervention, all scores remained stable. After intervention, nominal changes were displayed by TR and CON patients; Fugl-Meyer and ARA scores improved by ⫹ 11.4 and ⫹ 11.5 points, respectively, for mCIT patients; amount and quality of arm use, measured by the MAL, also improved (⫹ 2.49 and ⫹ .47, respectively). Conclusions: mCIT may be an efficacious and effective method of improving affected arm function and use in patients exhibiting learned nonuse.

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An In-Vitro Comparison of End-Hole Microcatheter and SideHole Microcatheter Delivery of Thrombolytics R.J. Boock, S. Sirivong, C.F. Dowd. Minneapolis, MN, San Francisco, CA

Hemorrhagic Transformation in a Thrombolysis Animal Model J.H. Rha, B.W. Yoon. Inchon and Seoul, Korea

Background and Methods: These studies focus was to determine the efficiency in clot dissolution of a multiple side-hole infusion device compared to an end-hole microcatheter. The lytic response of both urokinase (300,000 units/hr, Abbokinase) and tPA (10 mg/hr, Alteplase) was examined compared to saline controls. The study further refined the optimum positions within clot for both the end-hole microcatheters and the side-hole infusion device. A bench-top system was used utilizing bovine blood with direct comparisons of all test groups. Results: The end-hole microcatheter position yielding the fastest time to reflow was one where the tip was exactly centered within the clot (25.5⫾9.3 min). The best position for the side-hole device was one where the device spanned the clot (12.9⫾8.1 min). The side-hole infusion devices showed a 49% (P ⫽.007) faster dissolution compared to the end-hole microcatheter. There was no statistical difference between lytic agents with microcatheter delivery. However, side-hole delivery showed a dramatic benefit with infusion of tPA showing a 37% decrease in time over urokinase (12.9⫾8.1 min versus 20.4⫾9.4 min, P ⫽ .02). Conclusion: The combinations of a side-hole delivery device with intra-arterial lytic therapies allows for early re-establishment of blood flow to the affected region and thus a potentially more efficacious treatment for acute stroke.

Background: Thrombolytic therapy, the approved treatment of acute ischemic stroke, has major shortcomings of hemorrhagic transformation, still limiting wide clinical application. Appropriate animal model will help to elucidate the mechanism. We thus tried to develop thrombolysis animal model which has similar pathophysiology with human stroke, and also find the condition of hemorrhagic transformation. Methods: In male wistar rats, focal embolic occlusion of proximal middle cerebral artery (MCA) was made by injection of microclot into modified microcatheter. After 1,6, and 24 hours respectively, each group of rats (n⫽15) were infused 10 mg/kg of recombinant tissue plasminogen activator (rTPA) intravenously for 30 minutes. Decapitation and TTC staining was done 24 hours after thrombolysis. Results: Infarct size was smallest in 1 hour rTPA group (4.2⫾3.3% of contralateral hemisphere) indicating successful thrombolytic reperfusion, and largest in 24 hour rTPA group (26.4⫾12.9%). Hemorrhagic transformation was noticed in 2, 2, and 7 rats in 1, 6, and 24 hour group respectively, and the pattern was mostly intracerebral hemorrhage in the caudato-putamen area, rare in the cortex. Conclusions: Our animal model of local embolism and thrombolysis has similar mechanism and characteristics to clinical thrombolytic therapy including hemorrhagic transformation, directly applicable to future thrombolysis research.

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An Analysis of the Pattern and Distribution of Stroke Among Neuroimaging Studies in a Large Urban Hospital Within the “Stroke Belt” C.A. Williams, D. Galbis-Reig, A. Gaskill. South Hill and Richmond, VA

Stroke Prevention Clinic—A Timely Development W. Oczkowski, S. Ireland, S. Nicosia, S. Crocker, N. Pyette, M. Galan. Hamilton, Ontario, Canada

Background: An in depth analysis of the pattern and distribution of stroke in neuroimaging studies within the region known as the “stroke belt” has yet to be described. Methods: Between September 1, 1995 and August 31, 1998, neuroimaging data for 506 patients meeting criteria for stroke as outlined in the National Survey of Stroke were entered into the Central Virginia “Adult Brain Attack Database.” The data were analyzed using descriptive analytical techniques. Results: 50.1% (n⫽133) of noncontrast head CT scans and 75.0% (n⫽6) of contrast head CT scans demonstrated new abnormalities. Abnormalities (old or new) were demonstrated in 49.1% of all MRI studies. The most frequent abnormality among head CT scans was an unspecified hypodensity (45.1%), followed by infarction (32.2%), lacunae (21.1%), and intracranial hemorrhage (15.0%). Among MRI studies infarction (58.2%) was the most frequent abnormality followed by unspecified hyperintensity (16.4%) and lacunae (12.7%). The pattern, proportion, and distribution of abnormalities among both neuroimaging modalities are described and compared. Conclusion: Epidemiological studies using neuroimaging techniques to compare differences in the pattern and distribution of stroke in different areas of the country will aid in determining the causal factors contributing to the increased prevalence of stroke within the stroke belt.

Background: There is a tremendous potential to reduce the toll of stroke through effective, consistent prevention (Ministry of Health and Long-Term Care of Ontario, June 2000). At Hamilton Health Sciences Corporation, a 4-site, Ontario tertiary care centre, 46% of all stroke related Emergency Room admissions are diagnosed as TIA. We have implemented a pilot Stroke Prevention Clinic, sponsored by the Heart and Stroke Foundation of Ontario and funded by Health Canada. Methods: Using an on-line interdisciplinary patient record, a nurse case manager audits time to neurological consultation, test and treatment for outpatients with TIA or minor stroke. Health related quality of life; compliance with medications; change in risk factor behaviours; and patient, family, and physician satisfaction with services are measured. Results: Preliminary results indicate that (1) most referrals to the clinic are appropriate; (2) we have dramatically reduced time to consultation, test and treatment; and (3) we are effective in risk factor reduction. Conclusions: The Stroke Prevention Clinic is an effective strategy to reduce the risk of stroke in high risk patients.

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The Window of Opportunity for Treatment of Focal Cerebral Ischemic Damage with Noninvasive Intranasal Insulin-like Growth Factor-I X.F. Liu, J. R. Fawcett, T. A. DeFor, W. H. Frey II. St. Paul, MN

Young Survivors L. Myers, L. O’Donnell, J. Schlag. Pittsburgh, PA

Background: Insulin-like growth factor-I (IGF-I) does not cross the blood-brain barrier (BBB) efficiently. Intranasal (IN) administration offers a noninvasive method of bypassing the BBB to deliver IGF-I to the brain. This study delineates for the first time the window of opportunity for treatment of focal cerebral ischemic damage using IN IGF-I following middle cerebral artery occlusion (MCAO). Methods: Rats were allowed to survive 7-days following 2h of MCAO. Infarct volume after 7-days and neurologic deficit scores from the postural reflex, adhesive tape and beam balance tests respectively assessing motor, sensory and vestibulomotor functions at 1 to 7-days were used to evaluate the efficacy of IN 150 ␮g IGF-I at different times after the onset of MCAO. Results: IN IGF-I significantly reduces infarct volume when administered at 2h or 4h following the onset of MCAO, improves motor-sensory functions when administered 2h after the onset of MCAO and improves somatosensory function when administered 6 h after the onset of MCAO. Conclusions: Noninvasive intranasal IGF-I provides a broad window of opportunity, up to 6 h after the onset of ischemia, for the treatment of ischemic brain damage. Intranasal administration of IGF-I is a promising treatment for stroke.

Background: UPMC Rehabilitation Hospital’s “Young Survivors” group was begun at the request of a 34 year-old man, who found few common interests with our “older group.” It is the only stroke support group for non-elderly individuals in the Pittsburgh region. Methods: A survey was conducted to determine preference for speaker topics and meeting days. Hospital staff encouraged members to run and maintain the group and its activities. Speakers present information on topics such as driving, recreation, safety, medical care, nutrition, caregiver issues, insurance, and coping strategies. A “buddy program” was developed to link “veterans” with new members. New ideas are being developed such as having members attend stroke awareness events to encourage stroke symptom recognition and prevention. A newsletter serves as a source of support as well as a tool to promote the group. Each young stroke survivor discharged from the hospital receives a copy and an invitation to attend meetings. Results: Increased participation at meetings and social involvement amongst members. Conclusions: Creating a support group for “younger” survivors of stroke has allowed members to begin reaching out to each other in ways that were not possible when they felt they didn’t “fit in” with elderly stroke survivors.

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Appropriate Neurological Evaluation and Multimodality Magnetic Resonance Imaging in Eclampsia M. Hoffmann, J. Keiseb J. Moodley, P. Corr P. Durban, South Africa, Lexington, KY

Differences in Stroke Risk Profile and Stroke Response between Hospitalized Stroke Patients and Community Stroke Screening Participants M. Brethour, P. McDowell. Huntsville, AL

Aim: To determine a sensitive clinical test for the degree and monitoring of neurological deficit in eclampsia. Background: Eclampsia is primarily a vasculopathy of the posterior cerebral circulation and visuospatial impairment such as simultanagnosia is frequent. Methods: Thirty women with eclampsia were quantitatively evaluated with the Canadian Neurological Scale, Glasgow Coma Scale, Mini-Mental State Examination, a validated Cookie Theft Picture Test (CTPT) and MRI (T1/T2), diffusion weighted imaging (DWI) and MRA. Results: The CTPT (simultanagnosia) was 100% sensitive (95% CI: 84.5-100), specificity of 33.3% (95% CI: 1.8-87.5) with positive predictive value of 93.1% (95% CI: 75.8-98.8) and negative predictive value of 100% (95% CI: 5.5-100). The degree of agreement between simultanagnosia as measured by CTPT and DWI was 93.3% (Kappa 0.474; P ⫽ .001). Standard MRI compared to DWI sensitivity was 77.8% (95% CI: 57.3-90.6), specificity of 100% (95% CI: 31-100), positive predictive value 100% (95% CI: 80.8-100) and negative predictive value 33.3% (95% CI: 9-69.1). Conclusions: The CTPT for simultanagnosia was abnormal in the majority of eclamptic patients whilst quantitative neurological scales were normal. MRI and DWI showed excellent correlation with this bedside clinimetric evaluation. The oedema in eclampsia is primarily of vasogenic origin.

Background: To date, the Huntsville Hospital stroke team has screened approximately 2,000 community residents. We have investigated the differences in stroke risk profile and stroke response between community stroke screening participants and patients presenting to the hospital with an acute ischemic stroke. Methods: A convenience sample of 122 patients presenting to Huntsville Hospital from 1997 to 1999 with an acute ischemic stroke were asked to complete the NSA Stroke Risk Appraisal. Their responses were compared with community stroke screening participants randomly matched for age, sex and race. Results: The mean age of the respondents was 65.95 ⫾ 12 years; 79.7% white, and 57.7% male. Patients in the hospital population were more likely to smoke (P ⬍ .001), take HTN medication (P ⬍ .001) and report having undergone CEA (P ⫽ .002). Participants in the community population had higher cholesterol levels (P ⫽ .002); however, they were more likely to exercise (P ⫽ .001). There was no significant population difference in the probability of calling 911 in the event of a stroke. Conclusion: It is important for stroke education and risk factor modification to be tailored to the target population. We feel our preliminary data will enable us to improve educational materials and acute interventions for both hospitalized stroke patients as well as community stroke screening participants.

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Can Ischemic Stroke Clinical Outcome Tools Really Improve Clinical Outcomes? D.S. Book, W.N. Fedder, C. Sunstrom. Milwaukee, WI

Aphasia TeleSupport: Taking Traditional Aphasia Support Groups to the Next Level P.G. Clark, C.L. Scheideman-Miller, P. J. Rentschler. Oklahoma City, OK

Background: Clinical outcome tools for ischemic stroke have been shown to improve administrative outcomes, but clinical measures may not correlate. We present specific clinical outcomes from a set of quality management tools for ischemic stroke to demonstrate both clinical and administrative quality improvements. Methods: A private medical school affiliate hospital multi-disciplinary team developed a set of quality management tools (QMT) for ischemic stroke. The QMT was piloted on a medical/neurological floor and clinical outcome data and LOS were abstracted from the medical records. This data were compared to that of a retrospective control group of consecutive ischemic stroke patients. Results: Mean LOS (⫾SD) for patients during the pilot and control period was 4.1 ⫾3.1 and 6.2 ⫾3.0 days, respectively (P ⬍ .01). Differences between cases and controls will be reported for clinical outcomes including early use of aspirin, deep vein thrombosis prophylaxis, brain imaging, early swallow assessment, anti-thrombotics at discharge, warfarin in atrial fibrillation and documentation of specific stroke mechanism. Conclusions: The results of this pilot study suggest that clinical outcomes improvement can be achieved along with administrative benchmarks by successful implementation of quality management tools.

Background: Many stroke survivors experience decreased quality of life with impaired mobility, diminished levels of activity, language deficits and mood disorders. Caregiver’s stress can be a negative impact on stroke recovery and function. Most stroke survivors and their care givers require community-based education and support to help them cope with the long-term consequences of stroke. Methods: The primary goal of the Aphasia TeleSupport Group is to offer education and social support not only to metro-based stroke survivors and care givers, but to expand education and peer support to rural communities within Oklahoma. Both high and low level telecommunication technologies are utilized to offer services either currently not available, or difficult to access. The aim is to offer services either currently not available, or difficult to access. Results: Seven Aphasia TeleSupport Groups have met with a total of 165 participants. Participants include stroke survivors, care givers, and speech language pathologists from Oklahoma City, Grove, Miami, Ada, and Enid, Oklahoma. Conclusions: Based on preliminary data from the Aphasia TeleSupport Group one-year project, it appears that attendees’ satisfaction and participation have been positive. Their baseline content knowledge of stroke has increased on average of ten points on standardized pre- and post-test measures of modules from NSA’s Putting the Pieces Back Together. [Funds are awarded in part by NSA’s Be Stroke Smart Community Education Award for 2000.]

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Onset and Course of Secondary Conditions Subsequent to SCI and Stroke P.G. Clark, V.L. Phillips, A.E. Moorad, L.R. Post. Oklahoma City, OK, Atlanta, GA

Improvement in Comfortable Walking Speed (CWS) in PostStroke Spastic Hemiplegia following Intrathecal Baclofen (ITB) Therapy G. E. Francisco. Houston, TX

Background: The purpose of this project is to document the patterns of onset and course of secondary conditions for people impaired by SCI and strokes. Understanding when and how secondary conditions, such as depression or pressure sores, develop and the sequelae associated with them are key steps in preventing their occurrence. Methods: Three groups of participants will be recruited for this study. They are: (1) continued follow-up of an existing cohort (n⫽120) of people, newly injured with SCI (SCI I); (2) a second group (n⫽500) to be recruited of those newly injured with SCI (SCI II); and (3) a group (n⫽600) to be recruited of those who recently experienced a stroke. Participants will be interviewed on a monthly to quarterly basis about the presence of secondary conditions including presence of depressive symptoms and levels of fatigue. Data will also be gathered on health care utilization, health behaviors and healthrelated quality of life. Participants will be followed for 6 months to 5 years. Results: The time of onset of secondary condition(s) will be estimated using survival models, while count data models will be used to model the course(s) of secondary condition(s). Preliminary data gathered from this study will be presented. Conclusions: Understanding incidence patterns can form a basis for prevention initiatives. [This project is funded by the Department of Health and Human Services, Center for Disease Control and Prevention.]

Background: ITB therapy in treating poststroke spastic hemiplegia results in significant improvement in muscle tone while preserving muscle strength in the uninvolved contralateral lower limbs. In some, this tone reduction results in improved ambulation. This report presents our experience on the effects of ITB on the CWS of stroke survivors. Methods: Four males (ages 42, 47, 48, 69) and four females (ages 42, 50, 55, 68) underwent ITB pump implantation following inadequate spasticity control with other pharmacologic and physical modalities. Mean strokeonset-to-implantation was 27.8 months (range 14 to 55 months). All were ambulatory prior to implantation. CWS was the mean of three trials, when subjects were asked to walk over a distance of 50 feet at self-selected, comfortable speed. Results: At a mean 9.4 months post-pump implantation, average modified Ashworth Scale (MAS) lower limb muscle scores dropped from 2.22 to 0.54. Normal muscle strength (5/5) was preserved in the uninvolved limbs. Functional Independence Measure (FIM)-mobility in 5 domains (locomotion, sit-to-stand, stand-to-sit, stairs, community ambulation) improved from an average of 17.8 to 22.5. Mean timed ambulation over a distance of 50 feet improved from 132 to 63.6 seconds. Conclusion: ITB therapy improves CWS and certain FIM-mobility domains in individuals with post-stroke spastic hemiplegia.

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Incidence of Sinusitis in Ischemic Stroke Patients M. Schlosser, S. Hazelett, M. Gareri, K. Allen. Akron, OH

Stroke Risk Factors in African Americans: Potential Influence of Religious Affiliation J. Weinhardt, S. Hazelett, K. Wright. Akron, OH

Background: There are numerous reports of the intracranial complications of paranasal sinusitis. Case reports have implied an association between stroke and sinusitis, especially in patients with coexisting stroke risk factors, but no studies have looked at the incidence of sinusitis in stroke patients. Objective: To determine the incidence of sinusitis in all ischemic stroke patients admitted to this acute care hospital over 9 months. Method: Data were obtained by chart review of all patients admitted to this institution’s acute stroke unit from March to November 2000 with a diagnosis of acute ischemic stroke. Sinusitis was confirmed by MRI. Results: Of the 244 patients admitted with ischemic stroke, n⫽29 had a secondary diagnosis of sinusitis (12%). 97% of these also had at least one known stroke risk factor. Use of over-the-counter medications containing phenylpropanolamine was documented for none of the 29, although a history of recent headache, flu, head congestion, or chronic sinus problems was documented for 6. Conclusion: The evidence is consistent with the hypothesis that sinusitis may be a risk factor for ischemic stroke. Whether this association is independent of other risk factors requires further investigation.

Background: African Americans have higher stroke risk. The extent to which cultural factors impact upon this risk is unknown. Purpose: To determine the incidence of uncontrolled stroke risk factors in samples from 2 African American churches which differ in their emphasis on dietary issues. Subjects were participants in a stroke screening conducted in 2 churches. One church encourages vegetarianism (church V, n⫽31), and the other does not emphasize dietary restrictions (church non-V, n⫽18). Method: Blood pressure measurements and cholesterol screens were obtained as part of a comprehensive stroke risk screen. Chi-square was used to calculate differences in proportions and t tests were used to calculate differences in means. Results: Even though the average age of church V,s participants (56.3 yrs) was significantly higher than church non-V (44.7) (95% CI: 1.03,221.17), there was a nonsignificant trend for church V participants to have a diastolic blood pressure ⬍90 mm Hg (P ⫽ .27) and cholesterol levels ⬍200 (P ⫽ .18). The samples were similar with respect to systolic blood pressures ⬍140 mm Hg and cholesterol ⬎240. Conclusion: These results suggest that affiliation with religious organizations that emphasize a vegetarian lifestyle may be associated with lower stroke risk in African Americans. Further studies with larger samples are needed.

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Lessons Learned: Why Educational Interventions May Not Work? E. Miller, J. Spilker. Cincinnati, OH

Dehydroascorbic Acid (DHA) Improves Outcome in Both Reperfused and Nonreperfused Stroke T. Boyd, R. J. Israel, D. Agus, J. Huang, S. Kiss, R. McTaggart; T. Choudhri, L. Kim, W. Fox, D. Pinsky, D. Golde, E. S. Connolly. Tarrytown, NY, Los Angeles, CA, New York, NY

Background: In spite advances in stroke treatment, educating patients/families about how to reduce their stroke risk (i.e., smoking, poor diet, lack of exercise, etc.) remains a central concern of many health care professionals. However, sometimes educational programs do not always produce the anticipated outcomes related to knowledge and behavior change. The purpose of this presentation is to: (1) describe key factors that affected the success of educational interventions to reduce modifiable stroke risk factors in 52 subjects and (2) describe ways to assess these factors thereby permitting more targeted educational interventions. Method: A content analysis of qualitative data from 52 older adults was performed. This qualitative data were gathered in conjunction with quantitative data from an educational intervention study that involved three groups (control, two intervention). Results: From the content analysis, the three most salient factors identified that influenced their learning were: readiness to change, ability to read, and self-efficacy. Conclusions: A variety of assessment tools such as the SMOG, Spache score, and Short Form-Stage of Change exist to assist educators in more effectively target their educational interventions and improve desired outcomes.

Background: Free radicals contribute to neuronal injury following acute ischemic stroke. DHA, a form of ascorbic acid (AA), rapidly enters the brain via GLUT1 transporters, where it is converted to AA, a natural antioxidant. We evaluated DHA therapy in a model of ischemic stroke. Methods: Reperfused or nonreperfused ischemia was created by intraluminal middle cerebral artery occlusion in mice pretreated IV with vehicle, DHA at 40 mg/kg, 250 mg/kg, or 500 mg/kg, or AA 250 mg/kg. Pre- and post-ischemic treatments were tested. Cerebral blood flow, neurological score, infarct volume (% ipsilateral hemisphere), and mortality were compared using Student t test. Results: In either reperfused or nonreperfused settings, DHA pretreatment caused dose-dependent increases in perfusion, with reduced neurological deficit and infarct volume (P ⬍ .05 v vehicle). Mortality was reduced by 50%. Separately, when 250 mg/kg or 500 mg/kg DHA was administered 0.25 or 3 hours after permanent ischemia, neurological deficit was decreased, infarct volume was reduced 6- to 9-fold, and mortality was reduced (P ⬍ .05), suggesting that treatment thresholds longer than 3 hours are feasible with DHA. AA treatment did not improve outcomes. Conclusions: DHA confers potent dosedependent neuroprotection in reperfused and nonreperfused ischemic stroke, even with delayed administration. Additional studies are merited.

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Admission Under Appeal: Giving Denied Stroke Patients a Chance K.S. Williams, R.J. Norwicke, L.M. McLaughlin. Philadelphia, PA

Recovery and Rehabilitation of Arm Use after Stroke C.J. Winstein, D.K. Rose, H.C. Chui, A.N. Yang, W.B. Weiss, S.M. Tan, S.P. Azen. Los Angeles, CA

Background: It has been demonstrated that stroke patients admitted to acute rehabilitation programs are likelier to return to the community and recover more functional skills than patients admitted to subacute programs or nursing homes. However, there is a trend by managed care companies to funnel patients to a lesser level of care in order to save money. Because of this, one acute rehabilitation hospital made a decision to admit patients who had been denied access to acute rehabilitation and then appeal the denial after admission. Method: This presentation will describe an admission under appeal program including the personnel involved, the educational program developed for staff, patients and families, and FIM and financial outcome data. Results: Results indicated that this is a successful program from both a financial and quality outcome perspective. The majority of stroke patients admitted under appeal have been able to return to the community. Conclusions: This program has given us the ability to give stroke patients who had been denied access to acute rehabilitation by their insurance company a chance. It has also allowed us to develop a program to educate stroke survivors and their families how to become advocates for their rights as patients.

Background: Impairments of the upper extremity (UE) are perhaps the most resistant to therapeutic intervention. We report results of a randomized clinical trial pilot study designed to compare the efficacy of 2 specific treatment approaches to that of conventional therapy. Methods: Sixty patients status post unilateral stroke were recruited (M ⫽ 16 days post, M ⫽ 53.6 yrs) and stratified using the Orpington Prognostic Scale into more or less severe levels. Following stratification, subjects were randomized into 1 of 3 UE treatment groups: 1) standard care (SC), (2) SC ⫹ functional training (FT), and (3) SC ⫹ strength training (ST). Results: The difference in performance at the 4-week posttest following intervention was compared to baseline. For the less severe subjects only, the median change in UE Fugl-Meyer motor score of 21 for both FT and ST groups was greater than 6.5 for the SC group (P ⬍ .02). There were no group differences in self-care FIM change. Conclusions: Specificity of training and stroke severity are important factors for recovery and rehabilitation of arm use after stroke.

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Velocity Determinants for the Introduction of Neurofacilitative Arm Swing in Gait Rehabilitation R.J. Allen, M.M. Aguiling. Tacoma, WA

Apolipoprotein E (ApoE) Polymorphism Does Not Predict Functional Recovery Following Non-Hemorrhagic Cerebral Infarction M.H. Rabadi, M.D. Beauvil, B.D. Jordan, A. Blau, B. Volpe, S. Gandy. White Plains and Orangeburg, NY

Background: Numerous neurorehabilitation therapies for stroke attempt facilitation of functional movement by assisting patients to perform patterns of normal movement. Assisted reciprocal arm swing (RAS) is often utilized to facilitate gait retraining. However, stroke patients may initially ambulate at velocities below those normally accompanied by RAS. Induced RAS at low velocities may encourage a counterproductive abnormal pattern and hinder recovery. This study investigated the gait velocity normally initiating neurogenic RAS. Methods: Fifty-seven normal adults (age 21-72), unaffected by pathology influencing gait mechanics, walked uncued on a treadmill from 0.31 to 1.34 m/s. Motion analysis quantified flexion/extension excursion of the glenohumeral joint and this was plotted against gait velocity. Slope analysis of the resulting “S” curve determined initiating velocity for RAS. Results: Passive arm swing appeared at approximately 0.5 m/s, due to trunk counterrotation relative to the pelvis. Neuromuscular initiation of glenohumeral RAS appeared at an average gait velocity of 0.86 m/s. Initiation velocity was negatively correlated with age (r ⫽ ⫺0.52) and customary walking speed (r ⫽ ⫺0.43). Conclusions: Findings revealed a minimum gait velocity for normal neurogenic initiation of RAS, related to age and customary walking speed. Therapists should consider normal initiation velocity when introducing assisted RAS in stroke rehabilitation.

Objective: To determine the influence of Apolipoprotein E (ApoE) genotype on functional recovery following non-hemorrhagic cerebral infarction. Background: Investigators have demonstrated that traumatic brain injury (TBI) patients with the ApoE ⑀4 allele have worse functional outcome than those without the ⑀4 allele. Information about the influence of this allele on functional recovery after stroke in a rehabilitation setting is limited. Method: Fifty-six consecutive patients with their first non-hemorrhagic cerebral infarction were admitted for multidisciplinary rehabilitation, and consented to ApoE ⑀ genotyping. We used the Functional Independence Measure (FIM) scales to assess functional outcome and the Mini Mental State Examination (MMSE) to assess cognition. Results: There were 47 patients with no ApoE ⑀4 alleles (⫺⑀4) and 9 patients with one ApoE ⑀4 allele (⫹⑀4). Demographic variables between the two groups were similar. Although there was a trend for FIM efficiency in favor of the (⫺⑀4) group (0.89 compared to 0.57), there were no differences on the other measures between the 2 groups. Conclusions: In this study, the presence of ApoE ⑀4 genotype had no impact on functional recovery after ischaemic stroke as assessed by FIM scores. The possible role of ApoE genotyping in predicting functional recovery in patients after ischemic stroke should be tested in larger groups.

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Are Stroke Screening Programs Effective? C.D. DeLemos, R.P. Atkinson, S.L. Croopnick, D.A. Wentworth, P.T. Akins. Sacramento, CA

High Titers of CA 125 in Association With Recurrent Cerebral Ischemic Events in Patients with Underlying Malignancy T.G. Jovin, S. Zivkovic, S. Goldstein, L.R. Wechsler, J.M. Gebel. Pittsburgh, PA

Background: Stroke screening events are conducted to educate the public and identify those at risk. The lasting effects of these programs are uncertain. Methods: A stroke screening event was held following the NSA guidelines, with health screening, counseling and education. Health counseling was performed by a physician or registered nurse and emphasized physician follow up for those at risk. Knowledge about stroke was measured by a pre and postevent questionnaire. At 3 months, phone contact was made to attendees identified at risk for stroke to determine their retained knowledge, and any specific actions taken as a result of the screening. Results: Of the 186 attendees, 113 had treatable stroke risk factors. Seventy-eight at risk patients were contacted by phone at 3 months. Symptom recognition was accurate in 59% preevent, 96% postevent and 77% at 3 months. At 3 months, 19% recalled that they were at risk for stroke and 73% reported that had done nothing to change their health practices since the screening. Only 9% followed-up with a doctor and 6% changed their diet. Conclusions: Community stroke screening provides transient improvement but minimal longterm change in knowledge or prevention practices.

Background: Hypercoagulable states are a well-known cause of stroke in patients with cancer. Mucin-producing cancers have been associated with a coagulopathy that causes strokes through deposit of mucinous material in the walls of large and small arteries. We report the association between CA125, a mucin-like glycoprotein, and multiple ischemic strokes in patients with cancer. Methods: We identified four cancer patients, with high levels of CA-125 and recurrent strokes, admitted to our service between 10/1998 and 3/2001. Data were collected through retrospective chart review. CA-125 was prospectively ordered as part of occult malignancy work-up. Results: The median age was 67. All patients had recurrent strokes and despite extensive work-up the cause of stroke could not be detected. The types of cancer were lung cancer (3 patients) and pancreatic cancer (one patient). The median CA-125 level was 903.9 U/mL (normal range 0-35 U/mL). Conclusions: High serum titers of the tumor marker CA-125 were associated with recurrent cerebral ischemic events as an early presenting feature in 4 patients with underlying metastatic malignancy. Whether this observed association reflects a direct hypercoagulable effect of the mucin-like protein CA-125 or is merely an epiphenomenon is unclear. This observed association awaits confirmation by larger prospective studies.

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Stroke Risk Factor Reduction in Primary Care B.K. Dandapani, W.R. Sunter, J. Jambulingam, E. Loesner. Melbourne, FL

Efficacy of Acupressure Versus Botox in the Treatment of Spastic Gait in Stroke Survivors S.A. Sisto, Q. Bond, B. Chen, S. Shiflett, E. Elovic, M.V. Johnston.

Background: Since stroke is largely a preventable disease, our objective was to assess risk factor management before and after cerebral ischemia. Methods: Medical records of 215 stroke patients were reviewed for the prevalence and treatment of risk factors such as hypertension, hyperlipidemia, smoking, alcohol use and obesity before and after stroke. The use of antithrombotic treatment was noted. Results: There were 95 (47%) males and 118 (55%) females). Of the 171 patients with hypertension, 120 (70%) were on treatment prior to stroke and 142 (83%) after stroke. Better control of hypertension after stroke was seen 30% (34/112) (P ⫽ .001). Of the 112 (52%) patients with hyperlipidemia, 41 (36%) were on treatment prior to and 72 (69%) after stroke. Better lipid control was noted in 28% (26/93) after stroke. (P ⫽ .01). There were 85 (40%) patients on aspirin prior to and 125 (58%) (P ⫽ .001) after stroke. No significant change was noted in smoking cessation, alcohol use or weight loss after stroke. Conclusions: Risk factor management improves but at the expense of having suffered a stroke! Primary stroke prevention has considerable room for improvement.

Background: Pathological gait changes due to spasticity affects many stroke survivors. Clinical gait analysis allows for targeted application of Botox to spastic muscle groups that cause gait deviations, while nontraditional modalities such as acupressure allows for a non-invasive treatments for spasticity. Methods: Six subjects were assigned either the Botox, Acupressure, or control group. Gait trials were captured through Vicon Workstation using retroreflective markers and EMG electrodes prior to and 4 weeks post intervention. Subjects in the botox group received up to 400u to muscles targeted by EMG. Subjects received accupressure to 8 muscles on the affected leg twice per week for four weeks. Results: Compared to the control group, the acupressure subjects improved in cadence, velocity, and stride length, and stride times. One Botox subject demonstrated improvements in ROM at the ankle (Stance Mean 2.3°; Swing Mean 2.7°), knee (Stance Mean 5.6°; Swing Mean 9.5°) and hip joints (Stance Mean 1.49°; Swing Mean 27°) whereas the other did not. Conclusion: Acupressure and Botox can be used to improve gait in hemiplegic patients who exhibit lower limb spasticity. Acupressure improves temporal/spatial parameters while Botox improves joint ROM. Further study with a larger sample size is necessary to determine treatment efficacy.

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Microbleeds in Cerebral Amyloid Angiopathy Markedly Reduced on the Side of Carotid Occlusion J. Dominick, J.L. Saver. Los Angeles, CA

The Development of a Computerized Diagnostic Assessment Procedure for Shoulder Pain in Stroke J.E. Matheson, M.A. Klus, E.R. Harrison. Halifax, NS, Canada

Background: Multiple distal microbleeds evident on susceptibility-weighted MRI are characteristic in cerebral amyloid angiopathy, and are usually relatively equally distributed in the hemispheres. We report a case of markedly asymmetric microbleeds, with reduced hemorrhage number ipsilateral to a cervical carotid occlusion. Methods: Case report and literature review. Results: A 77 year-old woman with a longstanding h/o hypertension presented with acute confusional state due to a small right internal capsule and centrum semiovale infarct and dehydration. In addition to the index infarct, initial MRI susceptibility-weighted sequences demonstrated multiple small distal foci of hypointensity consistent with microbleeds, totaling 125 in number. Marked asymmetry was noted, with 98 (78.4%) in the right hemisphere and 27(21.6%) in the left hemisphere. MRA demonstrated occlusion of the cervical internal carotid artery at its origin. Conclusions: Cerebral microbleeds can occur at markedly differential frequencies rates in the left and right hemispheres. We hypothesize that in our patient the internal carotid occlusion relatively protected the left hemisphere from the microbleed precipitating effects of hypertension, and that this case illustrates that proximal vasoocclusive disease can shield brain regions from hypertensive injury.

Background: The purpose of this research is the development of a computer-based diagnostic tool for categorization of shoulder pain for clinical management and treatment studies post stroke. Methods: A review of the stroke and musculoskeletal literature identified 14 “most probable” diagnoses for shoulder pain after stroke. A computerized decision tree algorithm was developed to guide the assessor through data collection. As much differentiating information as possible is gleaned from passive movement because of potential paresis. Stored data within a Filemaker Pro 4.0 database determines the most likely diagnosis(es) through “if-then” statements. Results: Seventy-four stroke patients have been assessed with this procedure. Our experience is described including: (1) advantages - a short time to complete (15 minute), ease of administration, and consistent diagnostic classification, and (2) disadvantages - forced choices of ’pain or no pain’ and reliance on responses to passive movement (the intensity of which may vary between testers) which may limit consistency. Conclusions: This tool provides a systematic approach to assessment of shoulder pain to increase accuracy and consistency of differential diagnosis. Validation and reliability studies are underway.

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Shoulder Pain After Stroke: A Prospective, Interdisciplinary Study of Incidence and Differential Clinical Diagnosis E.R. Harrison, J.E. Matheson, A.M. McDonald, M.A. Madden, M.A. Klus. Halifax, NS, Canada

Cardiovascular Disease (CVD) Risk Factor Status of African American Versus Caucasian Patients Referred to a Stroke Secondary Prevention Program F. Lafranchise, W. Widener, B. Franklin, R. Salmon, C. English, R. Leighton, N. Gordon. Savannah, GA, Royal Oak, MI

Background: Shoulder pain occurs in up to 84% of stroke survivors, frequently limiting upper extremity function and care. The reported frequency of specific diagnoses varies greatly. Effective treatment requires an accurate anatomical-pathological diagnosis. Methods: 74 subjects, with or without shoulder pain, between 2 weeks and 1 year poststroke, receiving ambulatory or inpatient rehabilitation, were examined by 2 physiotherapists (with musculoskeletal and stroke expertise) and 1 physiatrist using a standardized history and physical and previously performed investigations. Probable diagnoses were selected, by consensus, from a list of 14 common diagnoses (developed, prospectively, from the stroke and musculoskeletal literature). Results: Thirty-six subjects (48.6%) had evidence of clinically significant shoulder pain syndromes. The most common pain syndromes were, in descending order, capsulitis/arthropathy (34.5%), muscular pain (12.7%), spasticity (12.7%), subacromial bursitis (10.9%), rotator cuff and medial rotator tendonopathies (7.3% each), anterior subluxation (7.3%) and neural pain (3.6%). Conclusions: Clinically significant hemiplegic shoulder pain was common. The relative frequency of these syndromes and the implications for treatment and further refinement of evaluation of shoulder pain after stroke are presented.

Background: Suboptimal CVD risk factor management contributes to the more than 700,000 strokes that occur annually in the U.S. Recently, we have demonstrated the clinical effectiveness of a physician supervised, nurse case managed stroke secondary prevention program. In this study, we compared the CVD risk factor status of African American versus Caucasian patients referred by physicians to a stroke secondary prevention program. Methods: Multiple CVD risk factors were evaluated in 307 consecutive African American (n⫽77) and Caucasian (n⫽230) patients who previously suffered a stroke or TIA or had carotid artery disease. Results: Although African Americans were younger than Caucasians (63 versus 68 years, P ⬍ .05), African Americans had higher (P ⬍ .05) BMI (difference ⫽ 3 kg/m2), fasting LDL cholesterol (difference ⫽ 19 mg/dL), Lp(a) (difference ⫽ 40 mg/dL), fasting glucose (difference ⫽ 16 mg/dL), and homocysteine (difference ⫽ 3.9 ␮mol/L) levels, and were more likely to smoke cigarettes (15.6 v 13.9%) and be sedentary (74 v 68.3%). Statistically significant differences were not observed for HDL cholesterol, triglycerides, and blood pressure. Conclusions: Multiple CVD risk factors are less well controlled in African American than in Caucasian patients referred to a stroke secondary prevention program.

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Brain Attack Community Education Programs G. McCafferty, P. Kilcullen. Albany, NY

A Controlled Treatment Study for Post Stroke Depression (PSD) P. Kilcullen, G. McCafferty, B. Kligerman, E. Hickling, A. Taylor, B. Davidson. Albany, NY

Background: The incidence of Brain Attack is approximately 600,000 cases per year, with 440,000 survivors. Direct and indirect cost of caring for patients can reach 40 billion dollars (AHA, 1997). Risk factor identification and modification has the potential to reduce the incidence of Brain Attack. Methods: Community programs provide a forum to educate and assess individuals. Screenings include: family and medical history, blood pressure, pulse, height, weight, calculation of ideal body weight, detection for carotid bruits, blood glucose and cholesterol. If indicated, a carotid ultrasound is performed. Participants meet with a health care provider to review findings and discuss an action plan including lifestyle modifications. Dietitians provide counseling. Results: The age range is 23 to 91 with the 67% of the participants over age 60. Findings (N⫽510) are: 44% blood pressure greater than 140/90; 62% cholesterol greater than 200; and 27% weighed more than 120% of their ideal body weight, one person required surgical intervention. Conclusions: The outcomes of this community program are that individuals recognize their risk factors for Brain Attack and take action to correct or control those factors that are modifiable. Additionally, following of the education the participants will recognize the signs and symptoms of Brain Attack and seek appropriate medical attention.

Background: Poststroke depression is well documented. A randomized treatment study to prevent PSD was implemented. Methods: The treatment consisted of psychosocial interventions, addressing cognitive, behavioral, and family factors associated with PSD. Participants were assessed for function (Barthel Index, Motricity Index, Motor-Free Visual Perception Test, Letter Cancellation, and Cognistat), quality of life (Short Form-36, Caregiver Assessment) and mood (Geriatric Depression Scale, Reynolds Depression Screening Inventory [RDSI]), initially, 6 weeks and twelve weeks poststroke. Results: Findings to date (N⫽32) demonstrate that initial comparisons between groups showed no significant differences in age, depression or function. A significant decrease (F ⫽ 8.131, P ⫽ .017) in depression as measured by RDSI was found in the treatment group. The Barthel Index demonstrated significant improvement in function over time in the treatment group only. A negative correlation was found suggesting that lowered physical function is associated with greater depression. A strong positive relationship was found between higher levels of caregiver distress with higher levels of patient depression. Conclusions: These findings support the use of individual psychosocial intervention to help stroke patients cope with depression. Future studies should explore whether a group intervention may be as effective in delivery of a psychosocial intervention to a population that has been identified with poststroke depression.

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Reported Symptoms of Stroke: A Community Base Survey of Stroke Survivors A.B. Jacobs, M. Stenerson, D.C. Tong. Palo Alto, CA

Clinical and Neuroimaging Correlates of “Pusher Phenomenon” Following Stroke M. Golden, M. D’Aquila, M. Reding. White Plains, NY

Background: Despite the availability of tPA for treatment of ischemic stroke, only an estimated 2% of patients in California receive treatment. It remains uncertain whether the low treatment rate is directly related to a failure of people to recognize the symptoms of stroke and call 911. Methods: A written survey was mailed to 215 stroke survivors in Santa Clara and San Mateo Counties in Northern California. Following an approximate 35% return rate, a follow-up phone call was placed to responding participants to confirm and clarify written answers. Results: Despite the prevalence of community education about the warning signs of stroke, very few survey participants described their symptoms as matching to those listed by NSA. Fewer than 5% of participants described their symptoms as having a sudden onset. Often participants failed to act quickly because they failed to recognize their symptoms as stroke. Fewer than 2% of participants had ever heard of tPA. Conclusions: The descriptive symptoms reported by stroke survivors should be included into public education efforts. Anecdotal examples of symptoms should be included in pamphlets and other teaching media. With improved public knowledge of descriptive examples of stroke, more patients may recognize the signs of stroke and benefit from immediate medical treatment.

Objective: To assess the clinical and neuroanatomic correlates of “Pusher Phenomenon” (PP) following stroke. Methods: PP was defined as a score of 1 or greater on a 0 to 17 scale scored by 2 independent physical therapists on 2 consecutive days. Involvement of parietal-insular vestibular cortex (PIVC), temporal operculum (TO), and thalamus, areas previously associated with PP, was recorded. Other variables assessed included leg weakness (Motricity Index), hemianopic visual deficit (confrontation testing), hemihypesthesia (digit localization task). Results: Fifty-five patients were studied a mean of 18 ⫾ 27 SD days post stroke. Pushers did not differ significantly from non-pushers in age or involvement of key neuroimaging areas of interest: PIVC, 12/24 vs 8/31, P ⫽ .06; TO, 8/24 vs 5/31, P ⫽ .14; thalamus, 6/24 vs 3/31, P ⫽ .13. Significantly different variables were: Leg Motricity Index score, 33 ⫾ 31 vs 68 ⫾ 33, P ⫽ .0003; digit localization error, 8 ⫾ 4 vs 4 ⫾ 2 inches, P ⫽ .002; presence of hemianopic visual field deficit, 13/23 vs 5/ 31, P ⫽ .005. Conclusions: Pusher Phenomenon following stroke is associated with motor, somatosensory, and hemianopic visual deficits, but not with involvement of cortical or thalamic vestibular centers.

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Quality and Cost-Improvement Through Development and Implementation of a Stroke Unit J.P. Hanna, A.M. Liskay, N.P. Thakore, M.W. Winkelman. Cleveland, OH

tPA in the Community Hospital D. Jenny, C. Mathiesen. Allentown, PA

Background: Stroke Units are effective in decreasing morbidity and mortality. US healthcare has been reluctant to adapt this model. Concentrating stroke care within a hospital and implementing care pathways will likely improve outcomes while decreasing cost. We assessed whether a modified Stroke Unit model adapted to HCFA guidelines would benefit patient care and reduce healthcare cost. Methods: Medical records were abstracted from 7/01/2000 through 6/30/2001 identifying by ICD-9 codes 433.XX-436.XX. Patients were grouped into preStroke Unit, Stroke Unit implementation phase, and Early Stroke Unit groups. Patient demographics, length of stay, nosocomial complications, prescribed antithrombotic therapy at discharge, discharge disposition, discharge Rankin Disability score, total cost of stay, laboratory costs, radiologic costs, pharmaceutical costs were compared. Results and Conclusions: Review is ongoing and will be available in August 2001.

231 A Community’s Response to Stroke Screening and Education J.M. Simpson, M. Giacoboni. Clearwater, FL Background: Driven by Healthy People 2000, Operation Stroke, and the knowledge that early stroke recognition may result in earlier medical intervention, a local community assessment was performed to determine stroke risk in our community. This assessment revealed a need for a comprehensive stroke screening and education program. Methods: In 2000, screenings were scheduled in zip code levels containing high stroke mortality. A mobile clinic was then taken to the scheduled areas. Screenings consisted of risk factor assessment (blood pressure, body mass index, total cholesterol, HDL, glucose, risky behaviors) and carotid ultrasounds. Education was provided during the event. The process was completed with a follow-up telephone call 24-48 hours later. Results: In January 2001,contact was made with 101 of the 300 participants from 2000. Knowledge retention and medical follow-up were the outcome measures. Results revealed that 80% knew 1 stroke symptom; 64%, 2; and 35%, 3 or more. 87% of people would call 9-1-1 for stroke symptoms, 55% had medical follow-up, and 2 subsequently underwent carotid endarterectomy for ⬎70% stenosis suffering no sequelae. Conclusion: Compared to previous, larger scaled studies results are encouraging. Our screening and education program appears to be having a positive impact on community health.

Background: After a decade using thrombolytics for stroke it was apparent that a process change was needed. Reduction in treatment times can be effectively achieved through redesign. Coordination of care requires a systematic approach to assessment, diagnosis and intervention. Methods: Rapid Response Team(RRT) was developed to organize and improve care, utilizing recommendations from National Stroke Association. A standardized approach was developed and implemented modeling the Trauma Center. After establishing clear internal communication, educational programs were offered to the EMS and community. Data were collected, reported and analyzed. Results: During 1996 to 1999, 20 patients received tPA. The mean door to evaluation, 20 minutes; door to CT scan, 25 minutes; and door to drug, range 47-140 minutes. Since implementation, improvement has been realized: door to evaluation, 7 minutes; door to CT, 20 minutes; and mean door to drug, 92 minutes. Additionally, length of stay has been reduced by 2 days. Conclusions: Outcomes validate the effectiveness of integrating a RRT in the community setting. Critical allocation of resources aimed toward brain recovery enhances ability to intervene. Continued efforts should focus on increasing public awareness on the benefits of early access and continued improvement in management of the acute event.