Introduction: In 2016, the inpatient stroke rehabilitation occupational therapy (OT) team at Hamilton Health Sciences (HHS) initiated the development of a therapeutic group called ‘Breakfast Club’. This program was developed to improve OT rehabilitation intensity goals, while providing functional rehabilitation opportunities. In Canada, rehabilitation intensity is the time that patients are engaged in individualized & task-specific treatment with a therapist. Canadian Stroke Best Practice Recommendations (CSBPR) advises that patients should receive such therapy 3 hours/day, 5 days/week.[i]

Summary: Breakfast Club is a weekly 1.5 hour therapeutic group with an occupational therapist, OTA/PTA, and 2-4 patients. The group occurs in a circuit format that includes chopping vegetables, making coffee, preparing breakfast, cooking at the stove, eating, and washing dishes. The circuit format allows more opportunity for direct therapy & monitoring of patients by a therapist, which increases rehabilitation intensity time. Breakfast Club provides a functional context for patients to work on individualized goals, including upper extremity task-specific training, cognitive remediation, visual scanning, balance & mobility, social interaction & communication, and/or practice using compensatory strategies or equipment. It also addresses CSBPR recommendations for individualized interventions with an aim of resuming participation in desired activities for patients with impaired cognition post-stroke.[ii]

Conclusion: CSBPR states that in stroke rehabilitation, more therapy results in better patient outcomes.[iii] Breakfast Club is an innovative method utilized by the HHS inpatient stroke rehabilitation OT team to increase rehabilitation intensity time.

BREAKFAST CLUB: A FUNCTIONAL APPROACH TO ACHIEVING OCCUPATIONAL THERAPY REHABILITATION INTENSITY GOALS

Background and Aims:
Atherosclerotic carotid plaques are an important cause of ischemic stroke. B-Mode ultrasound imaging is commonly used for detection and measurement of these plaques, yet image interpretation is difficult and subjective due to low contrast, shadows, speckle noise, and ultrasound artefacts. Computer-assisted methods can increase the accuracy and reduce the subjectivity in detection and measurement of carotid plaques.
 Methods:
We propose an automated method using computer vision to detect and measure atherosclerotic plaques in B-Mode vascular ultrasound images. In this method, we first pre-process and normalize the images and track the outer vessel wall automatically. Segmentation algorithms are then used to separate the lumen from the plaque, both in still longitudinal images and in transverse cineclips. In cineclips, the method analyses all image slices automatically and detects atherosclerotic plaques in the entire carotid region, from common carotid artery to bifurcation and internal carotid artery.
Results:
Preliminary results are obtained by analysing carotid ultrasound scans of 58 patients, approximately 2000 images that include longitudinal stills and transverse cineclips. Manual segmentations by an independent blinded expert agree well in comparison with the results of automated segmentation from the proposed method.
Conclusions:
Preliminary results show that the proposed method can improve the accuracy of reporting carotid ultrasound scan in a clinical setting and significantly reduce the reporting time. Additionally, the method provides a platform for scaling of machine learning efforts on quantification of plaque vulnerability. These methods may improve risk stratification and treatment planning of carotid disease.

AUTOMATED DETECTION AND MEASUREMENT OF ATHEROSCLEROTIC CAROTID PLAQUES IN B-MODE ULTRASOUND

AVANT - Stroke-Rehabilitation Education Program in Vietnam
A. Winkler1.
1Klinik Pirawarth, Neurology, Bad Pirawarth, Austria.
Abstract Text
Presentation of the Program
Stroke is major health concern in low-and middle income countries and the leading cause of death in Vietnam. There is considerable lack of structured education of doctors and therapists in stroke rehabilitation. There are no established post-acute rehabilitation facilites, stroke patients are usually demissed from hospitals with no furher support.  
The  AVANT-Program (Austrian Vietnamese Advancement Neurorehabilitation Treatment) is a 3 year cooperative educational program, starting in 2016, to standardize and systemize neurorehabilitation practice in Vietnam. In Association with the Vietnam Medical Association, Ministry of Health,  the Vietnamese Society for Stroke Rehabilitation and funded by an educational grant by EVER-Pharma, important know-how and skills for the rehabilitation of stroke is being brought to as many doctors and therapists as possible. 
AVANT is organized using a “train the trainer” approach. After three years 3000 doctors and therapists and 4000 caregivers will have attended the program across 64 provinces in Vietnam. Vietnamese trainees (A+) attend a 3 week exchange program at Austrian rehabilitation centers (Clinic Pirawarth, Christian Doppler Clinic, Salzburg).Trainers will pass on their knowledge by giving lectures at Vietnamese hospitals to local trainees (A), who will multiply the program goals downstream at A1 and B Levels . The program will be evaluated using an electronically based registry, which should make it possible to detect changes and improvements in stroke-care at the levels of Vietnamese stroke-therapists and caregivers.

AVANT - Stroke-Rehabilitation Education Program in Vietnam

Background and Aims: Effective treatment strategies for post-stroke fatigue and its complications remains elusive. This study determined and compared the effectiveness of individualized therapy and task-oriented circuit training on post-stroke fatigue and sleep-pattern, functional performance and societal re-integration in stroke survivors with post-stroke fatigue. 
Methods: This study involved 20 stroke survivors (10 per group) with post-stroke fatigue (13 males) randomly assigned to circuit task-oriented training and individualized therapy groups, participated in twice-a-week intervention programme for ten weeks and assessed at baseline, 5-week and at 10-week post-intervention. The task-oriented circuit training had 6-stations with various task-oriented exercises in circuit while the individualized therapy also had the same number of tasks but executed individually. Fatigue severity, sleep pattern, functional performance and societal re-integration were assessed using the Fatigue Severity Scale, Insomnia Severity Index, Six minutes’ Walk-Test and Community Integration Questionnaire respectively.
Results: There was significant improvement in post-stroke fatigue and sleep-pattern, functional performance and societal re-integration in stroke survivors with post-stroke fatigue (p<0.05) in both individualized therapy and task-oriented circuit training groups. However, the circuit training group (p<0.05) had better clinical improvements societal re-integration. 
Conclusion: Both task-oriented circuit training and individualized therapy are effective in  ameliorating post-stroke fatigue and improving sleep pattern, functional independent performance and societal re-integration in stroke survivors with post-stroke fatigue but the task-oriented training is more effective in improving societal re-integration in individuals with post-stroke fatigue.

TASK-ORIENTED CIRCUIT TRAINING FOR POST-STROKE FATIGUE, SLEEP-PATTERN, FUNCTIONAL PERFORMANCE AND SOCIETAL RE-INTEGRATION IN STROKE SURVIVORS WITH POST-STROKE FATIGUE: A CLINICAL CONTROLLED STUDY

Background
Diffusion weighted image(DWI) in MRI is the most sensitive tool for detection of ischemic stroke, even in 1hours from first onset. But its sensitivity can not approach to 100%, so the term ‘Diffusion-negative stroke’ was made. Diffusion- negative stroke has been known to be more frequent in posterior circulation ischemia, mainly in brain stem than in anterior circulation. We present a case of diffusion-negative stroke in anterior circulation, which was confirmed as ischemic stroke in F/U DWI-MRI.

Case
A 62 years old women arrived to the emergency department with dysarthria with hemiparesis of right upper and lower extremities. Her neurologic Symptoms emerged about 1 hour and 20minutes before the arrival. And the Symptoms were spontaneously resolved just before arrival. Brain CT was normal findings and MRI was done in series. DWI MRI didn’t show any significant abnormality. (A) T1, T2, SWI and enhanced T1 images, either. MRA was also normal findings. But only perfusion MRI (TTP) showed subtle minimal perfusion deficit in left basal ganglia(globus pallidus) and corona radiata. (A) She was hospitalized for closed observation for neurogic symptom and treated with oral clopidogrel in accordance with TIA. 3hours after admission, she complained of right sided hemiparesis and slurred speech again. MRC grades were 3 in right upper and lower limbs. Her symptoms continued to the next day morning, so we tried follow up DWI-MRI, which was done at 12 hours after the first onset of acute stroke symptoms. But DWI was negative.(B) And soon her symptoms was resolved again. In the next day(HD#3), she showed dysarthria and mild right sided hemiparesis(MRC grade 4). We repeated diffusion & perfusion MRI once more. Finally, DWI showed very subtle high signal intensity in left basal ganglia and corona radiata, which correlated with the perfusion deficit area in previous perfusion MRI. Follow up perfusion MRI showed no significant difference from the previous study, which had showed perfusion deficit in left basal ganglia(globus pallidus) and corona radiata. (C) She was treated with antiplatelet agent under the confirmative diagnosis of lacunar infarction.

Conclusion
Diffusion MRI imaging has been noted with the most sensitve and reliable tool for diagonosis of acute ishemic stroke. But this patient did not showed any abnormal finding in DWI. We propose that the DWI can be the most sensitve tool but, even in negative result in DWI, we can not rule out ischemic stroke perfectly. So close monitoring for the patient’s neurologic symptoms are necessary and we should be always concerned about DWI negative stroke.

A case of a negative DWI MRI within 12 hours of acute ischemic stroke symptoms.

Background:
Stroke is a leading cause of morbidity and mortality in India. A pressing need to develop a national stroke clinical trial network to conduct studies with relevance to Indian population was felt. Indian Council of Medical Research with the help of leading Indian stroke specialists formed INSTRuCT.
Aim:
1. Establish a state of the art stroke clinical trial network in country.
2. Conduct pharmacological and non-pharmacological stroke clinical trials in country.

Methodology

Multiple expert group meetings were conducted by ICMR to understand the scope of the network. Established stroke centers with an annual volume of approximately 200 stroke patients with previous experience of clinical trials done with good clinical practice guidelines were included. Nodal centers for database management, clinical trial monitoring and pharmacological dispensing are assigned.

Results 
Four studies were planned to be initiated in the network in the first phase: 
1. Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) is completed.
2. Secondary Prevention By Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) Trial is ongoing.
3. Ayurveda treatment in the rehabilitation of Ischemic stroke patients in India Trial (RESTORE) is to be initiated. 
4. Early Remote Ischemic Conditioning in Stroke (ERICS) trial is to be initiated.
Conclusion: In the next 5 years, INSTRUCT will develop world-class stroke trials.
Funding: ICMR, New Delhi

ESTABLISHMENT OF THE INDIAN STROKE CLINICAL TRIAL NETWORK (INSTRUCT)

Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. The common risk factors for CVT are prothrombotic conditions, pregnancy, infection, malignancy and drugs. Dutasteride is a 5α-reductase inhibitor and used for benign prostate hypertrophy and androgenetic alopecia. Finasteride, a similar 5α-reductase inhibitor has been reported to induce CVT, but there has been no report of CVT by dutasteride use. 
Case presentation: A 25-year old man presented with headache and diplopia. He had taken 0.5mg dutasteride every other day for nine months to treat alopecia. Headache developed seven months after medication and horizontal diplopia occurred one month after onset of headache. Fundus examination showed bilateral papilledema. Brain magnetic resonance imaging revealed thrombosis in left sigmoid and transverse sinus. There were no prothrombotic, infectious signs and specific drug history to explain CVT other than dutasteride use. Anticoagulation was started and headache and diplopia reduced gradually. 
Conclusions: This case suggested that dutasteride could be a potential cause of CVT. We presume that the increased estrogen level by dutasteride use causes the formation of the thrombus.

A CASE OF CEREBRAL VENOUS THROMBOSIS ASSOCIATED WITH DUTASTERIDE USE

Introduction: Evidence suggests that sedentary behaviour has detrimental effects on health and well-being.  Stroke survivors are particularly sedentary compared to age-matched controls and at risk of associated negative effects including reduced physical function, increased mood problems and mortality. This NIHR(UK)-funded programme aims to develop and evaluate a complex intervention to reduce/break up sedentary behaviour after stroke.
Methods: The programme comprises five work-streams (WS).  WS1 will update quantitative and qualitative evidence relating to sedentary behaviour through systematic reviews.  WS2 is a qualitative study involving observations in two stroke services and interviews with patients, carers and staff, to explore sedentary behaviours and participants’ capability, opportunity and motivation to address them.  WS3 will develop an intervention using co-production principles; WS4 will explore the feasibility of its implementation using a case-study and action research approach.  Finally, WS5 will evaluate clinical and cost-effectiveness using a multicentre cluster Randomised Controlled Trial in 34 stroke services with embedded process evaluation.  
Results: The primary outcome will be health and disability (WHO Disability Assessment Schedule) at 12 months after recruitment (N=1156).  Outcomes will be assessed at baseline, 6, 12 and 24 months and include sedentary behaviour, mood, quality of life, vascular events, CVD risk factors, death and health/social care service use. 
Conclusion: The research will generate an internationally-leading dataset on patterns of sedentary behaviour after stroke, with linked health outcomes, and robustly evaluate a comprehensive intervention protocol. A successful intervention has potential to substantially impact functioning, health and well-being outcomes for stroke survivors at relatively low cost.

The REduCing sedentaRy bEhaviour After sTrokE Study (RECREATE):  Development and evaluation of an intervention to improve outcomes

Background:  Role-play as a component of experiential learning is an effective tool to enhance understanding of basic hemiplegic care; and thus recommended as a teaching strategy to health care providers. Following prior successful series of workshop on basic hemiplegic experiential learning to health care providers, we constructed a continuum session for caregivers to individuals with strokes.

Method: Illustrative report on the use of role-play to improve caregivers’ understanding and awareness on important aspects of hemiplegic care.

Illustrative Report: ‘Stroke for An Hour’ is a role-play session specifically designed for stroke caregivers to improve awareness on how it feels to physically experience stroke with hemiplegia. In addition, the session aim to instil the importance of preventing hemiplegic-related complications and improving independence. Low-cost material were utilized to simulate role-play activities in a ‘hemiplegic’ manner. Sessions with catchy apt names eg ‘Single Magic Hand’, ‘Express Your Need’ and ‘Now You See...Now You Don’t’  highlighted on hemiplegic positioning, mobility, activities of daily living, functional communication and unilateral neglect.

Results: Narrative response showed increased level of basic understanding of hemiplegia. There was positive response in favour of utilizing role -play as an adjunct to structured caregiver training program.
 
Conclusion: Caregivers play an important part in the rehabilitation program of stroke survivors. Role-play is an effective learning tool to promote acquisition of basic knowledge and enhance understanding of basic hemiplegic care. This is recommended as a strategy to improve awareness amongst caregivers of stroke survivors.

‘STROKE FOR AN HOUR’ : USING ROLE - PLAY TO ENHANCE KNOWLEDGE AND AWARENESS AMONG CAREGIVERS OF INDIVIDUALS WITH STROKE

Background:
Intensive rehabilitation is important to optimize recovery in inpatient stroke rehabilitation. In Ontario Canada, rehabilitation intensity (RI) includes active goal directed one-to-one therapy, which is monitored or guided by a therapist. Stroke RI is measured in minutes and collected, monitored and publicly reported. Through stakeholder engagement, a need was identified to develop a provincial resource to support ongoing RI education. 
Methods:
A standard learning module was developed to provide RI education and evaluate clinician knowledge across the province. The draft module was piloted, refined and validated by clinicians and other stakeholders. The final module included an educational slide deck, 12-item quiz and feedback form. The dissemination process began in December 2017 through an existing infrastructure, with dissemination methods varying by region. Quiz results and feedback informed continuous improvement of the module.  
Results:
Within the first three months, 115 clinicians from 18 organizations completed this module. Scores ranged from 62-100% (median: 92%; mean: 91%). Preliminary data indicate that most errors occurred with questions related to recording of therapy assistant time or collaborative treatment. More organizations and clinicians are expected to complete the module as it is implemented across the province. Initial feedback did not necessitate extensive changes to module format or content. 
Conclusion: 
Although data are still being collected, preliminary findings suggest a need for further education related to the measurement of therapy assistant time and collaborative treatment. To support sustainability of RI, results from this work will inform the ongoing development of new RI education or knowledge translation tools.

SUSTAINING STROKE REHABILITATION INTENSITY: EVALUATING CLINICIAN KNOWLEDGE ACROSS ONTARIO

Dural arteriovenous fistula (dAVF) is a rare disease characterized by anomalous communication between dural arteries and venous sinus and/or cortical veins. dAVF is responsible for 10-15% of all intracranial vascular malformations, and affects mainly the group between 50-60 years old. OBJECTIVE: Report and illustrate two clinical cases of dAVF: one “benign” and other “malignant”. METHOD: Case reports. Case1 (benign dAVF): Female, 27yo, with headache for 3 months, and cranial MRI showing a right transverse-sigmoid sinus thrombosis. She was successfully treated with Warfarin 5mg/day. Three months later, started with tinnitus and new MRI showed an early filling of the right dural transverse sinus. In the cerebral digital subtraction angiography (DSA), a dAVF was found between branches of the external carotid artery and the right transverse sinus (BordenI; CognardIIa). After endovascular embolization with Onyx®, she completely improved her symptoms. Case2 (malignant dAVF): Male, 56yo, with headache for 5 days, vomit and dizziness. On physical examination, had ataxia and bilateral papilledema. Cranial MRI showed multiple anomalous vascular structures with tubular enhancement in left cerebellar hemisphere. He underwent cerebral DSA, which confirmed dAVF with venous cortical reflux and venous ectasia (BordenIII; CognardIV). During hospitalization, his headache worsened and cranial CT revealed acute hemorrhage in the left cerebellar hemisphere with compression of the fourth ventricle and hydrocephalus, requiring external ventricular shunt. He underwent dAVF embolization with Onyx® and had complete improvement of symptoms. CONCLUSION: The knowledge of different dAVF presentation (benign and malignant) is of fundamental importance.

BENIGN AND MALIGNANT TYPES OF INTRACRANIAL DURAL ARTERIOVENOUS FISTULA

Background Giant cell arteritis (GCA) affects large extra-cranial supra-aortic arteries. Ischemic stroke is a presenting feature in 5 to 10% and carries a mortality rate of 75%.

Case report A 72-year old woman was admitted with acute dizziness and jaw claudication. Clinical examination showed swollen temporal arteries, cerebellar dysarthria, ataxia of the lower limbs and left hemianopia. Erythrocyte sedimentation rate was elevated (48 mm/h). Brain magnetic resonance imaging (MRI) showed infarction of the right occipital lobe and the cerebellar hemispheres. T1-weighted “black blood” MRI technique showed enhancement and multiple stenoses of the extradural vertebral and carotid arteries as well as the temporal and occipital arteries. Dual antiplatelet therapy and high dose methylprednisolone was started. Temporal artery biopsy confirmed giant cell formation and arterial wall inflammation. 18Fluorodeoxyglucose positron emission tomography (FDG-PET) showed increased tracer uptake in vertebral and subclavian arteries. Despite maximal therapy the patient died three weeks after admission.

Discussion The diagnosis of GCA remains challenging and often requires additional tests like FDG-PET and biopsy. Black blood MRI uses a prepulse for suppression of intraluminal gadolinium to create a high contrast image of the blood vessel wall. This technique is used for detection of vessel wall abnormalities, such as cervical dissection or central nervous system vasculitis. We report the first use of black blood MRI to diagnose GCA. Compared to FDG-PET, Black blood MRI is more readily available. Further studies are needed to investigate concordance between black blood MRI and clinical symptoms, pathology and FDG-PET.

BLACK BLOOD MR IMAGING IN GIANT CELL ARTERITIS

Background: 
Stroke is a leading cause of disability in Canadians, many of whom access rehabilitation care to improve sensory and motor function. While it is widely accepted that motor learning is critical for neurorehabilitation, there is still much to understand about how stroke affects motor learning. Here we examine motor learning patterns in a task that required stroke survivors and healthy adults to adapt their reaching movements to a novel visuomotor rotation.

Methods:
Experiments were performed with a KINARM exoskeleton robot. Subjects (14 stroke survivors; 21 age-matched controls) performed 25 planar reaching movements with normal hand feedback. We then introduced a 30 deg counter-clockwise rotation onto the hand feedback cursor. After 125 movements with rotated hand feedback, subjects again performed 25 movements with normal hand feedback. Angular reaching errors were calculated at the beginning of each trial. Trial-by-trial reaching errors were fit to models to determine learning rates and extents for each participant. These were compared across stroke survivors and healthy adults using Mann-Whitney U tests.

Results:
Our preliminary analysis suggests that although the overall extent of learning was similar (p=0.1361), stroke subjects required more trials to adapt (56.05 ± 7.22 trials) than healthy adults (39.50 ± 5.72 trials; p=0.0392). 

Conclusions:
This suggests stroke survivors can learn to compensate for the rotation but they learn slower and require more trials to adapt than healthy controls.

Adaptations to Novel Visuomotor Rotations After Stroke

Background and Aims

IV rtPA is currently only thrombolytic approved for use in acute ischemic stroke (AIS) within 4.5 hours. Ongoing trials are testing efficacy of IVTenecteplase(TNK). However, TNK has been approved in India for use in AIS within 3 hours (0.2mg/kg-Max 20mg). We describe the initial experience of TNK following approval in 2016.

Objective: To determine outcome and safety of IV TNK(0.2mg/kg) in AIS
Methods: AIS patients admitted in PGIMER Emergency from April 2017 to January 2018 and administered IV TNK were included. Patients fulfilled the standard inclusions and exclusions to thrombolysis. Baseline NIHSS,proportion of patients with improvement of >4points at 24 hours, proportion of patients with modified Rankin Scale (mRS) 0-2 at 3 months was calculated. Safety was assessed from symptomatic intracerebral hemorrhage(SICH) rates asper SITS-MOST definition.Secondary efficacy measure was recanalisation rates at 24 hours of treatment.
Results: 23 patients with AIS were recruited. Mean age was 52 and 65 % were males. Baseline Median NIHSS was13, door to CT time and door to needle times were 13.5 and 50 minutes.Median ASPECT was 8,12 (52.1%) had major intracranial artery occlusion. 36% patients had >4 point NIHSS improvement at 24 hours.2 patients(8.6%) had mRS 0-2 at 1 months whilethe rest had mRS 3 - 5. 4 patients died(17.3%) and 1 patient had a SICH.5(21.7%) had recanalisation.
Conclusion IV TNK at dose of 0.2mg/kg within 3 hours of AIS although is safe but associated with poor outcomes and recanalisation rates in majority patients.Trial results should be awaited before approval of TNK as an economical alternative.

SAFETY AND OUTCOMES OF IV TENECTEPLASE IN ACUTE ISCHEMIC STROKE : INITIAL  POST APPROVAL EXPERIENCE FROM TERTIARY CARE HOSPITAL IN INDIA

Background: About one third of ischemic strokes are caused by cardioembolism. Early determination of stroke etiology is essential for three reasons: 
1. Detection of etiology is more likely to succeed directly after the stroke (‘smoking gun’). For instance, an intracardiac thrombus may vanish after intravenous thrombolysis. 
2. The risk of recurrence is highest early after the initial stroke. 
3. The choice of secondary prevention depends on the etiology. Cardioembolic stroke generally requires treatment with oral anticoagulation.

We hypothesize that a CTA of the heart and entire aortic arch, performed in the acute phase (before reperfusion therapy) in patients with ischemic stroke, is superior to echocardiography in detecting cardio-aortic sources of ischemic stroke.

Methods: International prospective cohort study in two high-volume stroke centers:  Academic Medical Center in Amsterdam and Toronto Western Hospital. Four-hundred and seven consecutive patients with acute ischemic stroke who are eligible for reperfusion therapy (intravenous thrombolysis or intra-arterial thrombectomy) will be included. Patients will undergo an ECG-triggered CTA in the acute setting, including the heart, entire aortic arch, cervical and intracranial arteries. Patients will also receive routine work-up for cardioembolism (ECG, Holter, echocardiography). Predefined relevant sources of embolism from the heart and aortic arch will be systematically scored.   

Results: First enrollment expected in May 2018. Results expected in 2021.

Conclusions: The study will generate the best available evidence regarding the diagnostic yield of heart and aortic arch CTA in the acute phase of ischemic stroke. If CTA is superior to echocardiography, this will likely become the new standard-of-care.

MIND THE HEART: CARDIAC CT-ANGIOGRAPHY IN THE ACUTE PHASE OF ISCHEMIC STROKE

Purpose:
To introduce a new device class “delivery assist catheter” and report first in vivo experience in acute ischemic stroke treatment.
Methods:
Retrospective data collection and analysis of stroke databases of two comprehensive stroke centers focusing on technical and angiographic parameters – primary endpoint defined as reaching the occlusion with a large-bore reperfusion catheter – from patients receiving endovascular stroke treatment using an AXS Offset™ delivery assist catheter (Stryker, Fremont, CA, USA) between May 2017 and November 2017.
Results:
Using the delivery assist catheter, a 6F catheter could be advanced to an intracranial occlusion for direct aspiration thrombectomy in 30 (88.2%) of a total of 34 patients (male: n=14/34 (41.2%), age in years: mean (SD): 75 (11), median baseline NIHSS: 16 (interquartile range (IQR): 12-21)). In 4/34 (11.7%) cases the occlusion could not be reached with the aspiration catheter because of a preceding non-occlusive arteriosclerotic plaque (n=1, 2.9%) or because of severe elongation and tortuosity of the arterial access route (n=3, 8.8%). After aspiration thrombectomy mTICI 2b-3 was reached in 14/30 (46.7%) patients. In 21/34 (61.8%) patients (additional) stent-retriever-maneuvers (median: 1 (IQR: 0-2) were needed. In 28/34 (82.3%) patients final mTICI 2b-3 could be achieved. 
Conclusion:
Delivery assist catheters to support large-bore reperfusion catheters for thromboaspiration in acute ischemic stroke are effective, in particular in case of vessel tortuosity and anatomic obstacles.

Delivery assist catheters: a new device class and initial experience in mechanical thrombectomy in acute ischemic stroke patients

Background and Purpose: Stroke is the leading cause of death and disability in Thailand. Most patients come too late to the hospital. Mobile stroke unit (MSU) enables immediate diagnosis and treatment from any patient location as opposed to prior methods where treatment had to begin at the hospital. This study aims to describe impact of MSU in Thailand.
Methods: The mobile stroke unit responds to 4 hospitals in the Bangkok Dusit Medical Service. It bases on Phyathai1 hospital. Mobile stroke unit team consists of one emergency physician, one nurse, one technician, two emergency medical technician. Suspected stroke patients or their family call 1772#7 for MSU. Patients were examined by emergency physicians and telestroke by neurologists. We reviewed all patients who received IV alteplase on the MSU

Results: A total of fifty two patients since our MSU initiation on December 2015. 26 were acute ischemic stroke, 5 were TIA, 8 were ICH and 13 were stroke mimic. There were 9 patients got IV alteplase, mean age was 64.3 (SD± 14.2) 56% were male. The mean onset to needle time was 171.8 mins. Mean alarm to needle time (ATN) was 71 mins. And mean arrival to needle time was 33.9 mins. At 90 days, the median mRS was 2  

Conclusion: The phyathai1 MSU proved the concept of rapid management of acute stroke. ATN time is very short in the city with the worst traffic in the world

Mobile Stroke Unit: bringing the hospital to the patient in Thailand

Pseudoperipheral nerve palsy has been used to describe sudden isolated focal weakness of a group of limb muscles secondary to stroke. Pseudoradial nerve palsy is a rare presenting feature for acute stroke. Our case 64 years hypertensive male noticed sudden weakness of dorsiflexion of left wrist following a minor road traffic accident. After examination a working diagnosis of traumatic acute left radial nerve palsy or cervical radiculopathy were made. Xray of his left upper limb and cervical spine were normal. Cervical MRI was also noncontributory. NCS of upper limb even after ten days were normal. Then we did MRI of brain which revealed acute ischemic stroke involving right parietal cortex adjuscent to central sulcus as the cause of his wrist drop. He was put on DAP and investigated for cause of stroke. However, after three months power remained grade 3/5. Had the stroke been diagnosed at presentation, patient could have been thrombolysed and he may have recovered completely. We review the literature and discuss the case with probable differential diagnosis at presentation. In conclusion, we emphasize the need for high level of suspicion for diagnosis of acute stroke in patients of stroke-age group with one or multiple risk factors who present with atypical features like pseudmononeuropathy or pseudoradial neuropathy, specially when the etiology is not evident.

PSEUDORADIAL NERVE PALSY: A RARE PRESENTATION OF ACUTE STROKE DEFERRING THE DIAGNOSIS AND DEPRIVING OF THE TREATMENT

Assessment of damage to brain fiber tracts is a promising technique to predict post-stroke deficits. Its transition into clinical practice has been limited by the need to acquire diffusion tensor imaging (DTI) data. Here, we present a technique to obtain this information from routinely collected T1 and/or FLAIR images. The Network Modification (NeMo) tool provides Change in Connectivity (ChaCo) scores as estimates of structural connectivity disruption by superimposing individual infarct masks onto a control DTI tractogram reference set. We demonstrate that NeMo’s ChaCo scores, when entered into stepwise multiple regressions, can predict three initial post-stroke linguistic abilities (picture naming, language comprehension, semantic verbal fluency) of 46 post-stroke aphasia patients (43%female; age:M=63.87,SD=9.21) from ChaCo scores of pre-defined language-related regions, lesion size (M=80.06,SD=59.27cm3) and demographics. For comparison, three basic models based on demographics and lesion size only were constructed. Whereas increasing lesion size (-0.60≤≤-0.31) was identified as a negative predictor in all three basic models (0.059≤R2adjusted≤0.267), its predictive power was outweighed by the ChaCo scores in the extended ChaCo models, not only yielding lower Akaike-Information-Criteria, but also better goodness-of-fit values (0.215≤R2adjusted≤0.395). Especially ChaCo scores of the pars opercularis (0.437≤≤1.532), pars triangularis (-1.914≤≤-0.571) (Broca’s area), and the superior temporal pole (-0.678≤≤-0.645) were consistently predictive for initial post-stroke linguistic abilities. Our data demonstrate that information on connectivity disruption is clinically useful and can be obtained without the need for costly DTI data. Additionally, ChaCo scores may be helpful in predicting initial post-stroke language abilities, and perspectively for prognostication, clinical subject stratification, and rehabilitation development.

USING CLINICAL ROUTINE MRI TO MEASURE LANGUAGE NETWORK DISRUPTION AND PREDICT LANGUAGE DEFICITS IN ACUTE STROKE

Introduction: Patients with transient neurologic symptoms are usually assessed based on physicians’ assumptions; these patients are usually diagnosed with transient ischemic attack (TIA). This study investigated the yield of multimodality magnetic resonance (MRI) for differentiating the TIA from TIA mimics. 
Objective: This retrospective study consecutively identified patients who arrived at the emergency department with transient or rapidly improving symptoms within 12 h of symptom onset between July 2015 and December 2016. They conducted the multimodality MRI composed of diffusion weighted imaging (DWI) and non-contrast and contrast fluid-attenuated inversion recovery (FLAIR) images with gradient-recalled echo imaging, time-of-flight MR angiography, and dynamic susceptibility perfusion-weighted imaging (PWI). The DWI lesion and Hyperintense acute reperfusion marker (HARM) on FLAIR images were determined. The association of final diagnosis confirmed at discharge was analyzed by the DWI lesion and HARM signs.
Results: A total of 174 subjects were enrolled (mean age, 64.0 ± 12.9 years old; male, 54.6%). The DWI lesion was observed in 17.8% whose final diagnosis was TIA. HARM sign was observed in 18 (10%) patients, and their final diagnoses were classified as true TIA (n = 11), seizure (n = 2), posterior reversible encephalopathy (n = 2), reversible cerebral vascular constriction (n = 1) and unclassified encephalopathy (n = 2). The co-incidence of DWI lesion and HAMM signs were observed in 6 subjects who showed the symptomatic steno-occlusive lesions in MCA and ICA. 
Conclusion: The investigation of HARM would be helpful in order to make exact diagnoses in patients suspected of having TIA.

The role of multimodality MR Imaging in patients with transient ischemic attack

Introduction:

There is lack of data on etiology and mechanism of ischemic stroke in rural Western India. The TOAST classification and ASCOD classification are validated to provide strong etiological information on ischemic stroke.

Aims and Objectives:

We aimed to review all admitted stroke patients’ data and classify the stroke etiology/mechanism based on these two classification systems [TOAST and ASCOD] to compare and contrast them.

Materials and Methods:

We retrieved clinical details of consecutive ischemic stroke patients admitted between 1 Jan 2014 to 1 July 2016 from medical records of our hospital and classified them based on the TOAST and ASCOD systems.

Results:

Based on ASCOD classification, A was present in 42% of patients (A1=21% and A2=8%), S in 44% of patients (S1= 9% and S2= 1%), C in 17% of patients (C1= 6% and C2= 4%), O in 5% of patients (O1= 5%), and D in <1% of patients. The TOAST classification showed Large Artery Atherosclerosis (33%), Small Artery Occlusion (29%), Cardioembolism (13%), Other Causes (6%), and Undetermined (18%). On ASCOD classification, there was overlap of disease between Grades 1 and 2 (3%) and when extended to Grade 3 there was overlap in 26%. The ASCOD classification’s inclusion of multiple factors revealed links between different stroke mechanisms while the TOAST classification relied heavily on a single etiological mechanism.

Conclusion: 

Stroke is a complex disease with numerous contributing factors. Considering a single factor for etiology [as in TOAST] is difficult. In comparison, ASCOD could identify significant patients with multiple stroke mechanisms. 

Key words: Stroke, TOAST, classification, ASCOD

Comparing TOAST and ASCOD systems of classification in patients with ischemic strokes in rural western India

Abstact number	WSC18-0893
Abstract title	Construct validity and test-retest reliability of a French version of the International Physical Activity Questionnaire Long Form in stroke patients
	A.S. Honado1, L.G.O. Atigossou2, J.S. Roy3, J.F. Daneault4, C.S. Batcho3.
1Université Laval- CIRRIS, Centre interdisciplinaire de recherche en réadaptation et intégration sociale CIRRIS, Quebec, Canada.
2Université d’Abomey Calavi, École Supérieure de Kinésithérapie- Faculté des Sciences de la Santé, Cotonou, Benin.
3Université Laval- CIRRIS, Department of Rehabilitation, Quebec, Canada.
4Rutgers University, Department of Rehabilitation and Movement Sciences, Newark, USA.
	Abstract Text
Introduction: The International Physical Activity Questionnaire (IPAQ) is a questionnaire frequently used in healthy subjects and different patient groups. However, measurement properties of this questionnaire have not been evaluated in stroke survivors in African francophone countries where there is a lack of context-validated outcome measures. The aim of this study was to evaluate the construct validity and test-retest reliability of a Benin-adapted French version of the IPAQ Long form (IPAQ-Benin) in patients with stroke in Benin.
Subjects and Method: Preliminary analyses were based on 38 stroke patients (27 males; mean age: 55.8±11.6 years old) recruited in Benin, a West-African country. In addition to a 7-day activity monitoring using a wrist-worn device, participants completed the interview-based IPAQ-Benin. They also completed ACTIVLIM-Stroke and ABILOCO-BENIN, two Rasch-built questionnaires previously validated in Benin for stroke-related activity limitations and locomotor ability, respectively. The IPAQ-Benin was completed twice over two days for test-retest reliability that was assessed through intra-class correlation coefficient (ICC). For construct validity, Pearson correlation coefficients (r) were calculated between IPAQ-Benin scores and 7-day steps, ACTIVLIM-Stroke and ABILOCO-BENIN scores.
Results: The IPAQ-Benin showed excellent correlation with daily steps (r=0.94; p <.001) and moderate correlations with ACTIVLIM-Stroke (r=0.53; p <.001) and ABILOCO-Benin (r=0.50; p <.001). IPAQ-Benin demonstrated excellent test-retest reliability (ICC=0.99; CI95%: .98-.99; p <.001).
Conclusion: These preliminary results suggest that IPAQ-Benin is a valid and reliable measure of physical activity in stroke patients. Further investigations on a larger sample are needed to confirm the psychometric properties of this French-version of the questionnaire in African contexts.
Keywords	Stroke
Physical activity
Questionnaire
measurement properties

Construct validity and test-retest reliability of a French version of the International Physical Activity Questionnaire Long Form in stroke patients

Introduction: The latest recommendations by the American Heart / Stroke Association on the use of intravenous thrombolysis for acute ischemic stroke suggest caution in patients with significant burden of cerebral microbleeds (CMBs). We describe such a patient, not previously diagnosed with cerebral amyloid angiopathy, treated with intravenous thrombolysis.

65 year old man with diabetes, hypertension, hyperlipidemia, CAD on low dose aspirin at home, who became confused while playing poker, developing speech changes and perseveration to questions. He was brought to the ER and his initial NIHSS score was 3. CT head did not show hemorrhage. CTA head / neck did not show extra- or intracranial vessel stenoses. He was treated with IV TPA within 3 hours of onset, without worsening of his symptoms. 24-hour head CT showed multiple subcortical hemorrhagic foci in both hemispheres. Brain MRI did not show an acute stroke on DWI. Multiple bilateral acute hemorrhages in each hemisphere were noted, along with innumerable microbleeds in the cerebrum and cerebellum bilaterally. The patient was transferred to acute rehabilitation where he had a generalized seizure.

Conclusion: In patients with multiple microbleeds, suggestive of cerebral amyloid angiopathy (CAA), the use of intravenous thrombolysis can lead to significant hemorrhagic conversion. Unfortunately, the majority of such patients does not have an established diagnosis of CAA or microbleeds previously, and might still be acutely treated with IV tPA.

Intravenous thrombolysis in probable cerebral amyloid angiopathy

Introduction
Ischemic stroke is a leading cause of morbidity worldwide. Reperfusion therapies with intravenous tissue plasminogen activator (IV-tPA) and mechanical thrombectomy (MT) are proven effective in the acute stage. In our country there are difficulties to achieve the implementation of both practices.

Objective
To report the experience of a Stroke Center in the use of MT in acute stroke.

Patients and methods
Retrospective and descriptive analysis of consecutive patients from January 2015 to June 2018, who received reperfusion treatment with MT. We assessed demographic data, treatment times, use of tPA, site of obstruction, recanalization, severity and disability at three months after stroke.

Results
922 patients were admitted with acute stroke during this period, 87 received IV-tPA (9.5%) and 24 were treated with MT (2.6%). In the MT group, the mean age was 66±16 years. Median NIHSS before MT was 20 (range 14-24). 17 (71%) presented occlusion at M1 level. The most frequent etiology was cardioembolism (58%).
Prior to MT, 15 patients (63%) received IV-tPA. Average window-time 184±42 minutes and door-to-needle time for IV-tPA 42±16 minutes. Mean time to onset of symptoms-recanalization 308±147 minutes. In 19 patients (79%) successful recanalization was achieved (TICI 2B/3). At three-month follow-up, the median NIHSS was 5 and mRS 3.

Conclusion
Proper logistics made possible the use of MT in a substantial number of cases. The use of protocols and the training of a multidisciplinary team are fundamental to achieve optimal times. We obtained high recanalization rate and good recovery at three-months. Our results were similar to actual series reported in Latin America.