Oral Abstracts

Getting stroke way out there: the statewide stroke education package

R Peake, K Parrey, M Gill

1Hunter New England Area Health, NSW, Australia, 2North Coast Area Health, NSW, Australia

Background: A rural feedback survey, highlighted need for user friendly, accessible stroke education for generalist staff. Funded by a scholarship from Rural Division of CETI. Developed in partnership by Stroke Care Coordinators within the Hunter New England Area Health Service (HNEAHS), North Coast Area Health Service (NCAHS). Located on the National Stroke Foundation Web Site.

Aims: eStroke was designed for clinicians working in Stroke, as well as generalist staff. The primary aim is to provide information to clinicians working within rural facilities.

Methods: Built on the evidence-based guidelines and advice from expert multidisciplinary stroke clinicians. E-learning format, easily accessed, at no cost to metropolitan, rural and remote clinicians. Guidance and governance provided by HNEAHS and NCAHS. The Online Package has the ability to collect feedback data on site usage and comments.

Results: Consultation with expert clinicians resulted in 10 packages covering pre hospital, acute stroke management, rehabilitation and beyond has been developed. This includes the utilisation of five case studies to demonstrate a practical approach to stroke management. The National Stroke Foundation has collated feedback from the go live date of the rural component of estroke.

Conclusion: Provides easily accessible, practical Stroke information for beginner to intermediate in an e learning format. Opportunity to develop and build on existing skill base and develop more specialized skills. To date e Stroke Online package has attracted high volume of users with positive feedback.

Transcranial Direct Current Stimulation (tDCS): is it effective as a stroke therapy?: a systematic review

J Marquez,1,2 P Van Vliet,1,2 P McElduff,2 J Lagopoulos,3 M Parsons1,2,4

1University of Newcastle, NSW, Australia, 2Hunter Medical Research Institute, NSW, Australia, 3University of Sydney, NSW, Australia, 4Hunter New England Area Health Service, NSW, Australia

Background: Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery.

Aims: To review the evidence in adults with residual impairments as a result of stroke to determine the effectiveness of tDCS in improving task performance and function.

Methods: Two authors independently screened abstracts, extracted data, appraised data for methodological quality and performed meta-analyses of randomized controlled trials. The primary outcome was change in motor function or impairment as a result of transcranial direct current stimulation, using any reported electrode montage, with or without adjunct physical therapy.

Results: The search yielded 15 relevant studies comprising 315 subjects. Compared to sham, cortical stimulation did not produce statistically significant improvements in motor performance when measured immediately after the intervention (anodal stimulation: facilitation of the affected cortex: SMD = 0.05, p = 0.71; cathodal stimulation: inhibition of the non affected cortex: SMD = 0.39, p = 0.08; bihemispheric stimulation: SMD = 0.24, p = 0.39). When the data was analysed according to stroke characteristics statistically significant improvements were evident for those with chronic stroke (SMD = 0.45, p = 0.01) and subjects with mild to moderate stroke impairments (SMD = 0.37, p = 0.02).

Conclusion: Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to stroke patients. Given the range of stimulation variables and heterogeneous nature of stroke, this modality is still experimental and further research is required to determine its clinical merit in stroke rehabilitation.

Where and how do stroke patients spend their time on a stroke unit compared to a geriatric rehabilitation unit?

DM Dennis,1 GJ Hankey,2 L Flicker,3 A Smith,1 K Briffa1

1School of Physiotherapy, Curtin Health Innovation Research Institute, Curtin University of Technology, Departments of 2Neurology and 3Geriatrics, Royal Perth Hospital, Western Australian Centre for Health & Ageing, Centre for Medical Research, University of Western Australia, Perth, WA, Australia

Background and Aim: To observe where and how stroke patients spend their time in a stroke rehabilitation unit (SU), compared with three geriatric rehabilitation units (GRUs) within an Australian State metropolitan area.

Methods: Prospective observational study between 2002 and 2004. The location and behaviour of all inpatients was observed and recorded for 30 minutes on 10 separate occasions over 2 consecutive days every 8 weeks. The specific location and behaviour of up to four inpatients with stroke were also monitored for 15 minutes on eight occasions over 2 days every 8 weeks. Locations (seven categories) and behaviours (15 categories) were classified relating to the unit's physical layout and whether isolated or engaged, and active or inactive.

Results: GRU stroke inpatients were less likely to be located in therapy (OR = 0.11; 95% CI 0.08–0.13) and less likely to be actively engaged in rehabilitation (OR = 0.26; 95% CI 0.23–0.31) than SU patients. They were also more likely to be located in the bed space (OR = 4.01; 95% CI 3.47–4.64) and to be isolated rather than engaged (OR 2.90; 95% CI: 2.52–3.35). Individual mapping data analyses of stroke patients adjusted for potential confounders (age and/or Barthel Index) showed GRU patients spent significantly more time in the bedspace (Incidence Rate Ratio (IRR): 1.41; 95% CI: 1.01–1.98) and isolated (IRR: 1.34; 95% CI: 1.04–1.72), and less time active (IRR: 0.66; 95% CI: 0.45–0.98) than SU patients.

Conclusions: There was a difference in the location and behaviour of patients undergoing rehabilitation in a SU compared to the GRUs.

Dynamic sitting balance control tests in stroke survivors: a study of reliability and validity

W Tsang, S Fong, S Ng

Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China

Background: Stroke survivors may have difficulties to maintain sitting balance due to the impaired control of trunk muscles. However, the temporal and spatial domains of dynamic sitting balance test for stroke survivors are lacking.

Aims: To investigate the reliability and validity of two sitting balance tests, namely limits of stability test (LOS) and sequential weight shifting test (SWS) in stroke survivors.

Methods: Eleven community-dwelling stroke survivors with onset for at least two years (mean time since stroke = 8.0 years [SD 4.0]) and 15 healthy subjects were recruited. Reaction time, maximum excursion, directional control of LOS, and total movement time and directional control of SWS were measured. Modified Function Reach Test (MFRT) and Trunk Impairment Scale (TIS) were also conducted to correlate with LOS and SWS.

Results: Excellent test-retest reliability was demonstrated in reaction time (ICC[3,8] = 0.760) and maximum excursion (ICC[3,8] = 0.929) of LOS and total movement time of SWS (ICC[3,3] = 0.864) in stroke survivors. Known groups validity was only shown in reaction time of LOS (p = 0.039) between the two groups. Reaction time of LOS of stroke subjects was significantly correlated with MFRT (r = –0.684, p = 0.020), while directional control of LOS was significantly correlated with the dynamic sitting balance score (r = 0.846, p = 0.001) and total score (r = 0.817, p = 0.002) of TIS. For SWS, total movement time was significantly correlated with dynamic sitting balance score of TIS (r = –0.654, p = 0.029).

Conclusion: Moderate to excellent test-retest reliability was found in LOS and SWS tests in stroke survivors. The convergence and discrimination perspectives of construct validity were established.

Updating the national stroke foundation stroke clinical guidelines

L Wright, K Hill

National Stroke Foundation, Melbourne, Vic., Australia

Background: Clinical guideline recommendations are developed to assist health professionals to make evidence-based decisions. This is reliant on having the most up-to-date evidence available. The current National Health and Medical Research Council (NHMRC) standards require guidelines to be updated within five years. An online process which provides transparency and enables timely changes/updates, such as the wiki platform developed and used by the Cancer Council of Australia (CCA), would provide a more useful model to update guidelines but is currently not considered within the NHMRC standards.

Aims: To report on an alternative process for updating the national stroke guidelines.

Methods: We reviewed the CCA wiki platform (“wiki”) against the existing NHMRC standards to determine compatibility and identify where changes to the wiki model might be required.

Results: The processes utilising the wiki were methodologically robust and were deemed to comply with 45/50 of the mandatory elements of the NHMRC standards with minor changes needed to comply with the other five elements. Difficulties arise predominantly due to the fact that the NHMRC standards are based on physically published guidelines.

Conclusion: It is important that guideline development is supported by rigorous methodology and that this methodology is able to be responsive as the evidence base changes. Based on the current analysis the NSF believes that the wiki platform is able to accommodate robust methodology to support the development of more responsive guidelines.

National rehabilitation stroke services framework

L Wright, K Hill, R Naylor, E Lalor

National Stroke Foundation, Melbourne, Vic., Australia

Background: The Acute Stroke Services Framework was first developed by the National Stroke Foundation (NSF) in 2002 and subsequently updated in 2008 and 2011. Infrastructure (e.g. access to community rehabilitation) and resources (e.g. staffing) for stroke rehabilitation around Australia varies and there is no agreed definition or description of best practice stroke rehabilitation services.

Aim: To describe the development of a framework for stroke rehabilitation services in Australia.

Methods: A nationally representative advisory group is established and national and international data and literature reviewed prior to drafting the framework. A face-to-face meeting is planned with key health professionals to finalise the draft framework and consensus was gained using a modified Delphi process.

Results: This project is currently being undertaken and description of the process and final framework will be presented.

Conclusion: For the first time there will exist a national framework for stroke rehabilitation services to complement the acute framework. This should assist decision makers to consider issues across the care continuum when making critical decisions about infrastructure and resourcing requirements for stroke services.

Cerebral small vessel disease: cross-ethnic comparison between Chinese and White populations

V Mok,1 VK Srikanth,2 Y Xiong,3 TG Phan,4 C Moran,4 S Chu,5 Q Zhao,6 WWC Chu,4 A Wong,7 Z Hong,6 X Liu,3 LKS Wong,1 D Ding6

1Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China, 2Stroke and Ageing Research Centre, Medicine, Southern Clinical School, Monash Medical Centre, Clayton Victoria, Melbourne, Victoria, Australia, 3Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu Province, China, 4Department of Radiology & Organ Imaging, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China, 5Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China, 6Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China, 7Department of Psychological Studies, The Hong Kong Institute of Education, Taipo, Hong Kong Special Administrative Region

Aim: Ethnic differences have been reported between Asians and Whites in the prevalence of stroke subtypes. However, it is unknown if population differences exist for manifestations of cerebral small vessel disease. We compared the prevalence and risk of white matter hypertensities (WMH), lacunes, and microbleeds between Han Chinese and White Australian individuals randomly selected from their respective populations.

Methods: Magnetic resonance imaging (1.5-Tesla) was performed on participants of the Shanghai Aging Study (n = 321, mean age 69 ± 6 years) and Tasmanian Study of Cognition and Gait (n = 397, mean age 72 ± 7 years). A single expert rater recorded measures of WMH, lacunes, and microbleeds. We also compared lesion prevalence between age- and gender-matched subgroups from the two cohorts. Among all subjects (n = 718), we performed multiple logistic regression, adjusted for putative risk factors, to examine if ethnicity was independently associated with these lesions.

Results: The prevalence rates of confluent WMH, lacunes, and microbleeds among Chinese and Whites were 37% vs. 34% (p = 0.09), 29% vs. 34% (p = 0.24) and 9% vs. 11% (p = 0.59), respectively. Subgroup analysis among age- and gender-matched subjects showed that confluent WMH was significantly more common among Chinese (38.5%) than Whites (28.4%, p = 0.01). In multiple logistic regression, Chinese ethnicity was associated with a higher risk of confluent WMH (odds ratio 1.7, 95% confidence interval 1.1–2.6, p = 0.01). No differences were seen for lacunes and microbleeds.

Conclusions: In this population-based cross-national comparison, Han Chinese had a greater risk of confluent WMH than White Australians, but a similar risk of lacunes and microbleeds.

Blood pressure and outcome in long-term survivors of stroke

J Kim,1 SL Gall,2 MR Nelson,2 JE Sharman,2 AG Thrift1,3

1Stroke and Ageing Research Centre (STARC), Department of Medicine, Southern Clinical School, Monash Medical Centre, Monash University, Melbourne, 3The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic., 2Menzies Research Institute, University of Tasmania, Hobart, Tas., Australia

Introduction: Hypertension increases the risk of cardiovascular mortality, but recent evidence suggests that low blood pressure (BP) may have similar adverse prognostic effects in people with pre-existing disease. For the first time, this study aimed to determine the association between BP and cardiovascular outcomes in long-term stroke survivors.

Methods: Participants of the North East Melbourne Stroke Incidence Study who had survived to 5 years post-stroke were contacted for a follow-up assessment. BP was measured by research nurses according to the British Hypertension Society protocol. Multivariable Cox proportional hazards regression was used to assess the association between BP measurements at 5 years post-stroke and an outcome of death, acute myocardial infarction (AMI) or recurrent stroke to 10 years post-stroke. Adjustment to sociodemographic factors, disability, self-reported risk factors and medications were considered in the final model.

Results: Compared to patients with a systolic blood pressure (SBP) ≤120 mmHg, patients with a SBP of 131–141 mmHg had a 38% lower risk of stroke, AMI or death (p = 0.018). Compared to patients with SBP ≤120 mmHg, there was a trend toward lower risk of stroke, AMI or death in patients with SBP 121–130 mmHg (p = 0.071). Patients with SBP ≤120 mmHg had similar outcomes to patients with SBP ≥142 mmHg (p = 0.180).

Conclusion: There was a non-linear independent association between BP and adverse outcomes in long-term survivors of stroke, with increased risk associated with both low and high BP. Caution should be applied in pursuing low BP targets in stroke survivors.

Rapid blood pressure lowering in acute intracerebral haemorrhage: relationship of time and intensity of treatment on haematoma growth in the INTERACT2 trial

H Arima for the INTERACT2 Investigators

The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia

Background: Based on the pilot phase INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT1), the main phase INTERACT2 was designed to test the effectiveness of early intensive BP lowering in a broad range of adults with ICH, the most serious and least treatable form of stroke.

Methods: INTERACT2 was an academic, international, multicentre, prospective, open, blinded endpoint, randomised controlled trial. Eligible patients with spontaneous ICH within 6 hours of onset and elevated systolic BP (150–220 mmHg) were allocated to receive intensive (to a target systolic level of <140 mmHg within 1 hour using intravenous agents) or guideline-recommended (systolic level <180 mmHg) BP lowering treatment. The primary outcome was a poor outcome, defined as death or major disability (i.e. scores 3–6) on the modified Rankin Scale at 90 days. The key secondary outcome was an ordinal analysis on this scale. Serious adverse events and mortality were also compared. The trial is registered (ACTRN1260800036239, NCT00716079, ISRCTN73916115) and funded by the National Health and Medical Research Council (NHMRC) of Australia.

Results: Between October 2008 and August 2012, a total of 2839 participants (mean age 63.5 years; 62.9% male) were enrolled from 144 hospitals in 21 countries. Data on the primary outcome at 90 days were known in 2794 (98.3%) patients. The main results were presented at the European Stroke Conference in London in May 2013.

Conclusions: For the SSA 2013 annual conference, further data pertaining to the treatment effects on haematoma growth by time and intensity of BP lowering are presented.

Automated mismatch assessment of arterial spin labeling compared to conventional bolus tracking perfusion mismatch

A Bivard,1 P Stanwell,2 V Krishnamurthy,2 CR Levi,2 SM Davis,1 M Parsons2

1Melbourne Brain Centre, Flory Neuroscience Institute, University of Melbourne, Melbourne, Vic., 2Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia

Aim: Arterial Spin Labeling (ASL) is a magnetic resonance perfusion imaging technique that does not require contrast administration and thus may be more practical in hyperacute stroke than susceptibility-weighted bolus-tracking perfusion imaging (PWI). However, ASL requires validation in acute ischemic stroke for measurement of the acute penumbra.

Methods: Fifty-five patients with acute hemispheric ischemic stroke were imaged within 6 hours of symptom onset with MRI including ASL, diffusion weighted MR imaging (DWI) and PWI and perfusion computed tomography (CTP). All patients were also scanned at 24 hours with the same MRI sequences (including ASL).

Results: An ASL-CBF threshold of 40% showed the highest AUC when compared to the 24 hour DWI (AUC 0.74 SD 0.63–0.85), PWI Tmax 6 seconds lesion (AUC 0.72 SD 0.65–0.81) and CTP Tmax 6 seconds lesion (AUC 0.74 SD 0.63–0.84). The ASL derived perfusion lesion CBF 40% overestimated the volume by 17mL/29% (±8mL/13%), typically in hypoperfused white matter. ASL mismatch volume (ratio of 1.2 for DWI: Perfusion lesion) compared to PWI and CTP mismatch showed good sensitivity (0.81) and specificity (0.71) for identifying patients potentially suitable for treatment with thrombolysis.

Discussion: Automated ASL mismatch calculation shows promise in the hyperacute clinical setting.

Spectroscopy of hyperperfused and mildly hypoperfused tissue following ischemic stroke

A Bivard,1 N Yassi,1 P Stanwell,2 V Krishnamurthy,2 CR Levi,2 SM Davis,1 M Parsons2

1Melbourne Brain Centre, Flory Neuroscience Institute, University of Melbourne, Melbourne, Vic., 2Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia

Following reperfusion therapy, there is little evidence on the health of human tissue salvaged from ischemia. Recent studies using a new non-contrast perfusion imaging method, arterial spin labeling (ASL), have identified that patients showing increased perfusion (hyperperfusion) have a better recovery and lower mortality[1]. This study aimed to investigate the potential mechanism of hyperperfusion using magnetic resonance spectroscopy (MRS).

Methods: Ischemic stroke patients who were treated with thrombolysis were recruited into an MRS study. Forty eight hours after thrombolytic treatment patients were scanned with MRS (SVS PRESS TE 30), arterial spin labeling, and diffusion weighted imaging (DWI). Salvaged penumbral tissue was determined following ASL scanning as tissue that showed increased CBF from acute to 48 hours that did not infarct on DWI. An MRS voxel was placed in the reperfused penumbral grey matter. Additionally 10, healthy age matched controls were enrolled and scanned using MRS.

Results: 40 Patients were enrolled in this study, 16 with hyperperfusion and 21 showing persistent hypoperfusion on ASL. Three patients were excluded due to poor quality MRS. Spectroscopy metabolites significantly varied between hyperperfused(hy) and persistently hypoperfused(hp) compared to control tissue(c) for creatine (5.5 hy vs 4 hp vs 5.6 c p < 0.05), glutamate (6.1 hy vs 5.5 hp vs 6.9 c, p < 0.05), myo-inositol (5.2 hy vs 4.8 hp vs 5 c, p < 0.05) and lactate (0.93 hy vs 1.22 hp vs 0.4 c, p < 0.05).

Discussion: This spectroscopic assessment shows that hyperperfused tissue is very similar to normal tissue in terms of metabolite levels. This study has identified that hyperperfusion of salvaged penumbral tissue leads to rapid metabolic recovery.


[1] Bivard A, Stanwell P, Levi CR, Parsons MW. Arterial spin labeling identifies tissue salvage and good clinical recovery after acute ischemic stroke. J Neuroimaging doi: 10.1111/j.1552-6569.2012.00728.x

Rapid blood pressure lowering in acute intracerebral haemorrhage: poor outcome predictors among participants in the INTERACT2 trial

E Heeley for the INTERACT2 Investigators

The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia

Background: Based on the pilot phase INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT1), the main phase INTERACT2 was designed to test the effectiveness of early intensive BP lowering in a broad range of adults with ICH, the most serious and least treatable form of stroke.

Methods: INTERACT2 was an academic, international, multicentre, prospective, open, blinded endpoint, randomised controlled trial. Eligible patients with spontaneous ICH within 6 hours of onset and elevated systolic BP (150–220 mmHg) were allocated to receive intensive (to a target systolic level of <140 mmHg within 1 hour using intravenous agents) or guideline-recommended (systolic level <180 mmHg) BP lowering treatment. The primary outcome was a poor outcome, defined as death or major disability (i.e. scores 3–6) on the modified Rankin Scale at 90 days. The key secondary outcome was an ordinal analysis on this scale. Serious adverse events and mortality were also compared. The trial is registered (ACTRN1260800036239, NCT00716079, ISRCTN73916115) and funded by the National Health and Medical Research Council (NHMRC) of Australia.

Results: Between October 2008 and August 2012, a total of 2839 participants (mean age 63.5 years; 62.9% male) were enrolled from 144 hospitals in 21 countries. Data on the primary outcome at 90 days were known in 2794 (98.3%) patients. The main results were presented at the European Stroke Conference in London in May 2013.

Conclusions: For the SSA 2013 annual conference, data are presented for predictors of poor outcome (death and major disability at 90 days) among participants in the trial.

Referring patients for rehabilitation assessment after acute severe stroke: does current practice reflect best practice guidelines?

S Hakkennes,1 K Hill,2 K Brock,3 J Bernhardt,4 L Churilov4

1Barwon Health, Geelong, 2School of Physiotherapy, Curtin University, Perth, 3St Vincent's Health, Fitzroy, 4Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic., Australia

Background: Clinical practice guidelines recommend that all acute stroke patients (except those for palliative care), should be assessed for suitability for rehabilitation by a specialist rehabilitation team.

Aim: This study aimed to determine the frequency of, and variables associated with, referral for rehabilitation assessment during acute hospitalisation after severe stroke.

Methods: A multi-site prospective cohort study was conducted in five acute public hospitals in Victoria, Australia. Consecutive severe stroke (Mobility Scale for Acute Stroke ≤15) patients admitted to participating hospitals were included. Demographic information and information related to the patient's pre-stroke, social and current health status was collected. Hierachical logistic regression modeling was used to assess the association between the patient related variables and the effect of the hospital unit on the dependent variable, referral for rehabilitation assessment (yes/no).

Results: Of the 103 patients included, one fifth (n = 20) were not referred for a rehabilitation assessment. After adjusting for pre-stroke independence, age (odds ratio (OR) = 0.85, 95% confidence interval (CI) = 0.75–0.96, p = 0.008) and current mobility (OR = 1.5, 95% CI = 1.12–2.01, p = 0.007) were independently associated with referral for rehabilitation assessment. In addition the regression model estimated that hospital unit accounted for 57% of the variation in rehabilitation referral practice (p < 0.001).

Conclusion: After acute severe stroke, younger patients and those patients displaying less impairment in their mobility were more likely to be referred for a rehabilitation assessment. The high proportion of variation in rehabilitation referral accounted for by the hospital unit indicates that organisational processes strongly influence rehabilitation referral practices.

Longitudinal associations of white matter lesions, brain infarcts and brain atrophy on gait decline – a population-based study

ML Callisaya,1,2 R Beare,1 TG Phan,1 L Blizzard,2 AG Thrift,1 J Chen,1 VK Srikanth1,2

1Department of Medicine, Southern Clinical School, Monash University, Melbourne, Vic., 2Menzies Research Institute Tasmania, University of Tasmania, Hobart, Tas., Australia

Background: The interplay between brain infarcts, white matter lesions and brain atrophy in causing gait decline is poorly understood.

Aim: To investigate the longitudinal associations between changes in brain structure and walking performance in a population-based study of older people.

Methods: Participants aged 60–86 years were randomly selected from the electoral roll. At baseline and follow-up, study participants underwent high resolution MRI. Volumes of grey matter, white matter and white matter lesions (WML) were calculated using automated segmentations methods. Brain infarcts were identified by consensus between two experts. Gait variables were measured using a GAITRite computerized walkway. Linear regression was used to estimate the effect of change in each brain variable with change in each gait variable. Time between appointments, age, sex, BMI, education level, total intracranial volume and medical history were used as covariates.

Results: Two hundred twenty-five participants had baseline and follow-up data (mean follow-up 30.6 months). A greater reduction in white matter volume was associated with a decrease in gait speed (p = 0.001), step length (p = 0.005) and cadence (p = 0.001). Greater progression of WML volume was associated with a decline in gait speed (p = 0.04). Greater age amplified the adverse effect of WML progression for step length (p = 0.04). The presence of baseline infarcts amplified the adverse effect of grey matter atrophy on cadence (p = 0.02).

Conclusion: Both vascular lesions and brain atrophy play a role in gait decline in older age, and present potential targets for interventions.

Progression of cerebral white matter hyperintensities increases the risk of multiple falls in older people: a prospective population-based study

ML Callisaya,1,2 R Beare,1 TG Phan,1 L Blizzard,2 AG Thrift,1 J Chen,1 VK Srikanth1,2

1Department of Medicine, Southern Clinical School, Monash University, Melbourne, Vic., 2Menzies Research Institute Tasmania, University of Tasmania, Hobart, Tas., Australia

Background: Cerebral white matter hyperintensities (WMH) measured at one point in time are associated with increased risk of falls. However, evidence is lacking as to whether WMH progression increases falls risk.

Aim: To investigate the association between progression of WMH and risk of falls in a prospective population-based sample of older people.

Methods: Participants aged 60–86 years were randomly selected from the electoral roll. At baseline and follow-up, volumes of WMH were calculated using automated MRI segmentation. Falls were recorded prospectively over 12 months. Participants were classified as multiple or non-multiple fallers. Log binomial regression was used to estimate the relative risk of multiple falls associated with WMH progression adjusted for follow-up time, age, sex and total intracranial volume.

Results: One hundred eighty-four people had baseline (mean age 70.4, SD 6.5) and follow-up MRI and falls data, with a mean follow-up of 2.5 years. Over 12 months, 35 participants (19.0%) reported multiple falls. A greater progression of WMH volume (WMH volume change as a proportion of baseline WMH volume) was associated with an increased risk of multiple falls (adjusted relative risk 1.32, CI 1.01–1.72, p = 0.04).

Conclusions: Greater progression of WMH's increased the risk of multiple falls, suggesting that interventions to slow the progression of WMH may be successful in reducing multiple falls in older people.

The frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies

ML Hackett, K Pickles

Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia

Background: In 2005 we published a systematic review indicating the high frequency of depression after stroke (33%, 95% confidence interval [CI] 29–36%).

Aim: To update our systematic review to determine whether increased awareness of depression and its associated burden has resulted in reductions in the proportion of stroke survivors with depression.

Methods: We updated our systematic review of all published, non-experimental, stroke studies with prospective, consecutive patient recruitment and quantification of depressive symptoms/disorder following stroke. We tightened our inclusion criteria to ensure only the highest quality studies were included.

Results: Data were available from 58 studies conducted between 1977 and 2012. 24 new studies were included and 17 studies from the previous review were excluded (due to age limits, restrictive inclusion criteria etc). Although the frequency of depression continued to vary across stroke studies, the overall pooled estimate was 32% (95% CI 28–35%). The larger number of long term follow-up studies enabled depression frequencies to be determined at 6–9 months (44%, 95% CI 16–71%), 1 year (34%, 95% CI 29–39%), 24 years (27%, 95% CI 21–33%) and 5 years (26%, 95% CI 19–35%) after stroke, and in populations that included people with a history of depression, aphasia or only those with a first-ever stroke.

Conclusion: Depression remains a common problem after stroke with the risk of occurrence being similar up to 5 years after stroke. We continue calls to improve the prevention and management of this disabling condition.

The prevalence of stroke in Aboriginal and non-Aboriginal Western Australians: a study using data linkage

JM Katzenellenbogen,1,2 FM Sanfilippo,2 M Hobbs,2 SC Thompson1

1Combined Universities Centre for Rural Health, 2School of Population Health, University of Western Australia, Perth, WA, Australia

Aim: To compare the prevalence of stroke (2005–2009) and co-morbidities in Aboriginal and non-Aboriginal Western Australians.

Methods: The prevalence of stroke was estimated among all individuals 20–84 years admitted to Western Australia (WA) hospitals for stroke in the previous 20 years and who were still alive at midyear in the index year, using the WA Data Linkage System. Age-standardised rates were calculated using WA population estimates and the WHO World Standard population. History of admission for a range of cardiovascular risk factors and co-morbidities were ascertained by reviewing the hospital records of these prevalent cases using a 20-year look-back period.

Results: Aboriginal cases were significantly younger than non-Aboriginal cases. The male Aboriginal age-standardised prevalence (2,566 per 100,000: 95% CI 2413–2718) was 3.9 times higher and the female age-standardised prevalence (1987 per 100,000: 95% CI 1873–2099) was 4.1 times higher than the corresponding non-Aboriginal prevalence. The age-standardised proportion of Aboriginal patients with a history of risk factors and co-morbidities was significantly higher than for non-Aboriginal patients for hypertension (ratio = 1.2), alcohol/drugs (ratio = 1.9), diabetes (2.5), chronic kidney disease (3.1) and heart failure (2.3). History of atrial fibrillation was significantly lower.

Conclusion: The significantly higher prevalence of stroke in the Aboriginal population reflects the disparity in incidence previously described. The additional co-morbidity and cardiovascular risk factor burden is substantial, adding to the complexity of caring for Aboriginal survivors of stroke. This clinical complexity and the younger age of first stroke need to be incorporated in models for care for Aboriginal stroke patients.

Secondary stroke prevention in general practice: the STAND FIRM study

J Kim,1 DA Cadilhac,1,2,3 MR Nelson,4,5 VK Srikanth,1,4 RP Gerraty,6 SM Fitzgerald,5 LM Sanders,1 AG Thrift1,2

1Stroke and Ageing Research Centre (STARC), Department of Medicine, Southern Clinical School, Monash Medical Centre, 5Department Epidemiology & Preventive Medicine, 6Department of Medicine, Epworth Healthcare, Monash University, 3Department of Medicine, The University of Melbourne, Melbourne, 2The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic., 4Menzies Research Institute, University of Tasmania, Hobart, Tas., Australia

Introduction: Adherence to secondary prevention recommendations vary. Audit and feedback may be used as an effective means of changing clinician behaviour in general practice.

Aim: To investigate the usefulness of audit and feedback to improve secondary stroke prevention in primary care.

Methods: General practitioners (GPs) involved in the intervention arm of the Shared Team Approach between Nurses and Doctors for Improved Risk Factor Management (STAND FIRM) randomised controlled trial were invited to participate in an education activity on stroke. GPs attended a seminar on secondary stroke prevention and then were instructed to identify 20 patients with a history of stroke/TIA in their general practice. The GPs documented stroke risk factors, and the pharmacological and non-pharmacological treatments prescribed to the patients they identified. As an educational reinforcing activity, the participating GPs were instructed to comment on how the management of the audited patients could be improved.

Results: Six of 14 GPs attending the seminar participated in the clinical audit, providing data for 101 patients. Prescription rates in these patients were 83% for antihypertensives, 79% for antithrombotics, and 75% for cholesterol-lowering medications. Two GPs provided comments on how the management of their 40 audited patients might be improved. These GPs indicated that in 9/40 patients, they would consider prescribing a new prevention medication. Other changes suggested by GPs included: checking medication adherence and providing advice on lifestyle changes.

Conclusion: Comprehensive education activities permit reflection on clinical practice. GPs identified many areas of their secondary prevention management that could be improved.

When should physical rehabilitation commence after stroke: a systematic review

E Lynch,1 S Hillier,1 DA Cadilhac2

1University of South Australia, Adelaide, SA, 2Monash University, Melbourne, Vic., Australia

Background: Knowing when to commence physical rehabilitation after stroke is important to ensure optimal clinical benefit for stroke survivors and to maximise the efficiency of health care.

Aims: To determine:

  • (i) How soon after stroke should physical rehabilitation commence in the acute ward?
  • (ii) When stroke survivors are not on a comprehensive stroke unit, how soon after stroke should they be transferred from an acute ward to a rehabilitation service?

Method: A systematic search was undertaken of Medline, Embase, CINAHL, Scopus, Cochrane and PubMed databases from inception to November 2012. Peer-reviewed publications in English comparing outcomes from acute stroke survivors who commenced inpatient physical rehabilitation at different time points were included.

Results: FIve randomised controlled trials (RCTs) and 38 observational studies were included. Meta-analysis was performed with three RCTs investigating mobilisation within 24 hours compared to 48 hours. Commencing mobilisation within 24 hours trended towards higher mortality (P = 0.06), and had no significant effect on rates of complications, performance in activities of daily living or likelihood of good outcome.

Only observational studies provided evidence of the effect of timing of admission to rehabilitation (n = 31) and 26 of these accounted for stroke severity in the analyses. Twenty-one of the 26 studies found in favour of shorter stroke onset to rehabilitation admission intervals in terms of post-stroke function.

Conclusion: Benefits of commencing physical rehabilitation within 24 hours of stroke remain unclear. Longer stroke onset to rehabilitation admission intervals were more often associated with worse functional outcomes, but the research evidence is limited.

Rapid blood pressure lowering in acute intracerebral haemorrhage: clinical implications of the INTERACT2 trial

CS Anderson for the INTERACT2 Investigators

The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia

Background: Based on the pilot phase INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT1), the main phase INTERACT2 was designed to test the effectiveness of early intensive BP lowering in a broad range of adults with ICH, the most serious and least treatable form of stroke.

Methods: INTERACT2 was an academic, international, multicentre, prospective, open, blinded endpoint, randomised controlled trial. Eligible patients with spontaneous ICH within 6 hours of onset and elevated systolic BP (150–220 mmHg) were allocated to receive intensive (to a target systolic level of <140 mmHg within 1 hour using intravenous agents) or guideline-recommended (systolic level <180 mmHg) BP lowering treatment. The primary outcome was a poor outcome, defined as death or major disability (i.e. scores 3–6) on the modified Rankin Scale at 90 days. The key secondary outcome was an ordinal analysis on this scale. Serious adverse events and mortality were also compared. The trial is registered (ACTRN1260800036239, NCT00716079, ISRCTN73916115) and funded by the National Health and Medical Research Council (NHMRC) of Australia.

Results: Between October 2008 and August 2012, a total of 2839 participants (mean age 63.5 years; 62.9% male) were enrolled from 144 hospitals in 21 countries. Data on the primary outcome at 90 days were known in 2794 (98.3%) patients. The main results were presented at the European Stroke Conference in London in May 2013.

Conclusions: For the SSA 2013 annual conference, further data pertaining to the clinical practice implications of the results of the trial are presented.

The West Australian intravenous minocycline and tPA stroke study (WAIMATSS): progress update

DJ Blacker,1,2 D Prentice,3 GJ Hankey,1,3 M Bynevelt,4 E Kohler,3 TR Bates,5 LK Kho,3,5 A Alvaro,6 A Kelly,6 A Claxton3

1Department of Neurology, Sir Charles Gairdner Hospital, 2School of Medicine and Pharmacology, The University of Western Australia, 3Stroke Unit, Royal Perth Hospital, 4Department of Radiology, Sir Charles Gairdner Hospital, Perth, 5Comprehensive Stroke Unit, Swan District Hospital, Midland, 6Neurology Department, Fremantle Hospital, Fremantle, WA, Australia

Background: Haemorrhagic transformation (HT) is a feared complication of thrombolytic therapy for acute stroke. At the SSA meeting in 2012, we presented the details of the WAIMATSS protocol. We now present an update on recruitment, including some illustrative cases.

Aims: To test the hypothesis that patients treated with IV minocyline and tPA have fewer intracranial haemorrhages than those treated with tPA alone.

Methods: Patients treated with IV tPA up to 4.5 hours will be randomised to IV minocycline 200 mg BID for five doses commencing less than 6 hours after symptom onset versus standard post tPA care. An protocol amendment approved by ethics in October 2012, now allows for an assent process to be utilised, in addition to informed consent.

The primary endpoint is “any” ICH identified on CT scan 24 ± 8 hours after treatment. CT scans will be examined by neuroradiologists blinded to treatment. Secondary endpoints include; ICH as defined by the ECASS criteria; day one, two and seven NIHSS, and days 30 and 90 modified Rankin and Barthel Index scores. An MRI substudy will compare ICH seen on MRIs performed between days five to seven post treatment.

Results: At mid-January 2013, 12 subjects had been enrolled. The only serious adverse event has been an episode of orol-lingual angio-oedema in the standard treatment group. Illustrative cases from the main study, and MRI substudy will be shown.

Conclusions: WAIMATSS is progressing as planned, and proving to have a workable protocol, that could be expanded into a phase 3 study.

Trends over time in the risk of stroke after an incident transient ischaemic attack

V Sundararajan,1 TG Phan,1,2 P Choi,1,2 AG Thrift,1,2 B Clissold,1,2 VK Srikanth1,2

1Department of Medicine, Southern Clinical School, 2 Stroke and Ageing Research Centre, Monash University, Melbourne, Vic., Australia

Background: In the setting of suboptimal secondary prevention, transient ischaemic attack (TIA) has been reported to herald the onset of stroke in up to 10% of patients within 90 days. However, the long-term population trends in the early risk of stroke after TIA are unknown.

Aims: Our aim was to study the trends over time in the risk of stroke after an incident TIA. We hypothesised that there was an appreciable decline in the risk of stroke after TIA over the last decade.

Methods: Population-level cohort study from Victoria, Australia (population 5.6 million), using linked hospital and emergency department data between 2001–2011. Logistic regression was used to quantify the 30 and 90-day age and gender adjusted nonfatal and fatal stroke risk following incident TIA.

Results: Of 50,535 incident TIA cases based on a look-back of 2 years, the mean (sd) age was 71.3 years (14.7); 51% were women. Overall 30 and 90-day stroke risks were 2.3% and 3.5%. After adjusting for age and gender, the yearly odds of stroke at 90 days following a TIA decreased by 3% over the study period (OR for the effect of year: 0.97, 95% CI 0.95,0.99). There was no significant yearly trend for the 30-day odds of stroke (OR 0.9, 95% CI 0.97, 1.01).

Conclusion: Over the last 10 years there has been a measurable decline in the 90-day odds of stroke following TIA. The reasons for this will require further investigation, and may reflect improved primary and secondary prevention.

Validation of a finite element model of heat transfer in the stroke-affected brain against data from humans and non-human primates

T Lillicrap,1,2,3 M Tahtali,2 A Neely,2 X Wang,2 CR Levi,3 M Parsons,3 A Bivard,3,4 C Lueck1

1The Canberra Hospital and Australian National University, 2The University of New South Wales @ Canberra, Canberra, ACT, 3John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia,4Brain Institute, Melbourne, Vic., Australia

Background: Therapeutic hypothermia is a promising treatment for acute ischaemic stroke. However, a number of questions remain unanswered, particularly regarding our ability to cool ischaemic brain tissue. Finite element modelling (FEM) is increasingly being used to examine heat exchange in relation to treatments such as cryosurgery and has the potential to inform clinical trials of therapeutic hypothermia.

Aims: To validate a finite element model of heat exchange in the stroke-affected brain against in vivo data.

Methods: The model was used to simulate the circumstances of a previous study in non-human primates [1] which collected data on blood flow and temperature after induction of an ischaemic stroke. The results of the model were compared to the experimental results. The model was also used to compare simulations with data collected using MR thermography from ischaemic stroke patients recruited at John Hunter Hospital and The Canberra Hospital.

Results: The results of the model's simulations were within the limits of experimental error when compared to the results of MR thermography.

Discussion: This study suggests that the finite element model of heat transfer is valid and is therefore potentially useful for clinical application. Further studies are ongoing.

1. Sun, Z., et al., Differential Temporal Evolution Patterns in Brain Temperature in Different Ischemic Tissues in a Monkey Model of Middle Cerebral Artery Occlusion. Journal of Biomedicine and Biotechnology, 2012. 2012: p. 8.

Helsinki model halved stroke thrombolysis door-to-needle times to 25 minutes at the Royal Melbourne Hospital in just 4 months

A Meretoja, L Weir, M Ugalde, N Yassi, B Yan, P Hand, M Truesdale, SM Davis, BC Campbell

Royal Melbourne Hospital, Parkville, Vic., Australia

Background: The Helsinki model of stroke thrombolysis with a median 20 minutes door-to-needle time (DNT) was described in 2012.

Aim: We tested the transferability of the model to an Australian healthcare setting.

Methods: The existing ‘code stroke’ model at the Royal Melbourne Hospital was evaluated and restructured in January–April 2012 to include key components of the Helsinki model: (1) Ambulance pre-notification with patient details alerting the stroke team to meet the patient on arrival; (2) Patients transferred directly from triage onto the CT table on the ambulance stretcher and; (3) tPA delivered in CT immediately after imaging. We analyzed our prospective, consecutive tPA registry for effects of these protocol changes on our DNT following implementation during business hours (8am–5pm Monday–Friday) from May 2012.

Results: There were 62 patients treated with tPA in the 10 months following the protocol change. Compared to 85 patients treated in 2011, the median (IQR) DNT was reduced from 61 (43–75) minutes to 46 (23–80) minutes (p = 0.020). All of the effect came from the change in the in-hours DNT, down from 43 (33–59) to 25 (19–48) minutes (p = 0.002), whilst the out-of-hours delays remained essentially unchanged, 67 (55–82) to 62 (44–104) minutes (p = 0.982).

Conclusion: We demonstrated rapid transferability of an optimized tPA protocol across different healthcare settings. With the cooperation of ambulance, emergency, and stroke teams we succeeded in the absence of a dedicated neurological emergency department or electronic patient records which are features of the Finnish system. The next challenge is providing the same service out-of-hours.

Benefits and challenges of implementing an acute stroke telemedicine program: a qualitative study

N Moloczij,1 DA Cadilhac,2 K Moss,1 I Mosley,2 CF Bladin1 on behalf of the Victorian Stroke Telemedicine Project

1The Florey Institute of Neuroscience & Mental Health, 2Monash University, Melbourne, Vic., Australia

Background: Telemedicine systems can facilitate evidence-based care for patients with stroke, but are rarely used in Australia. The Victorian Stroke Telemedicine (VST) Project included a 4-month pilot phase then, following feedback and modifications, a full-year implementation was conducted with one regional hospital.

Aim: To identify the benefits and challenges before, during and after the VST program from the perspective of hospital staff and on-call neurologists.

Methods: Clinicians who had participated in VST telemedicine consultations during the pilot or 1 year implementation phases were invited to participate. Semi-structured interviews with on-call neurologists, medical and nursing staff were conducted face-to-face or by telephone. Interviews were recorded or notes were taken and transcribed. Thematic analysis was used to identify major themes and sub-themes.

Results: Twenty-five interviews took place (n = 12 after pilot; n = 13 after 1 year phase; 44% with Emergency Department staff; 32% medical staff and 24% neurologists. Three clinicians were interviewed at both time points. Initially reported findings of the VST program included the following benefits: achieving a formalised pathway to access 24 hour stroke advice; having assistance and confidence in clinical decision making; providing a user-friendly system within the Emergency Department; and raising stroke awareness across the hospital. Ongoing challenges included: competing workloads; inconsistent experiences of video-conferencing; infrequency of consultations; and transfer of patients to tertiary hospitals.

Conclusion: The VST stroke telemedicine program was perceived to be beneficial for enhancing the management of stroke in a Victorian regional hospital. These data can be used to address the identified challenges.

Stroke survivors with severe motor disability can make clinically important improvements during inpatient rehabilitation

KS Hayward,1 SS Kuys,2,3 RN Barker,4,5 SG Brauer1

1The University of Queensland, 3The Prince Charles Hospital, Brisbane, 2Griffith University, Gold Coast, 4James Cook University, 5Townsville Mackay Medicare Local, Townsville, Qld, Australia

Background: Stroke survivors with severe motor disability present a rehabilitation challenge.

Aim: Determine if stroke survivors with severe overall and upper limb motor disability can improve and determine how often a minimal clinically important difference (MCID) is achieved.

Methods: A prospective observational study was undertaken in Geriatric and Rehabilitation Units in Queensland, Australia. A total of 618 stroke survivors with a primary diagnosis of stroke receiving physiotherapy were included. The primary outcome measures were the motor subscale of the Functional Independence Measure (motor-FIM) and Motor Assessment Scale Item 6 Upper Arm Function (MAS6). Outcomes were collected on admission to and discharge from inpatient rehabilitation.

Results: All participant groups improved during inpatient rehabilitation. Of those with severe motor disability (≤40 m-FIM score), a significant improvement in the m-FIM was demonstrated (p < 0.0001), which equated to 57%–83% of participants achieving a MCID. Of those with severe upper limb motor disability (≤2 for MAS6), a significant improvement in arm function was demonstrated (p < 0.0001), which equated to 68% of participants achieving a MCID. Stroke survivors who were older (>74 years) and had severe disability were also able to demonstrate a significant improvement (m-FIM: p < 0.0001, MCID achieved by 42%–84%; MAS6: p < 0.0001, MCID achieved by 72%).

Conclusion: This study demonstrates that a statistically significant and clinically meaningful improvement in function is achievable by stroke survivors who have severe motor disability, irrespective of age. This suggests severity of disability alone should not preclude admission to inpatient rehabilitation.

Using magnetoencephalography to measure biological change in the brain after post-stroke Wii-based movement therapy, preliminary data

CT Shiner,1 BW Johnson,2 PA McNulty1

1Neuroscience Research Australia and University of New South Wales, 2Macquarie Centre for Cognitive Science, Macquarie University, Sydney, NSW, Australia

Background: Brain imaging techniques suggest that successful post-stroke rehabilitation is based on cortical reorganisation. Magnetoencephalography (MEG) has better temporal resolution than many more traditional magnetic resonance imaging (MRI) techniques and this should identify shifts in the loci of brain activation during functional tasks after therapy.

Aims: To investigate whether MEG can be used to identify changes in brain activity after stroke. A secondary aim was to quantify cortical reorganisation induced by a 14-day protocol of Wii-based Movement Therapy targeting the more-affected upper-limb.

Methods: Four stroke patients (age 46.8 ± 13.9 years, 16.8 ± 19.1 months post-stroke, mean and SD) were scanned using the KIT-Macquarie MEG160, consisting of 160 coaxial first-order gradiometers with a 50 mm baseline. Patients performed a block design unimanual finger-tapping task, and both sides were investigated. Three patients received the standard, 14-day Wii-based Movement Therapy protocol, before being scanned post-therapy. Functional ability was assessed pre- and post-therapy.

Results: Use of the more-affected hand after stroke was associated with substantially greater bilateral activation of sensorimotor cortices compared to movement of the less-affected hand. The focus of activation shifted from the pre-motor area (Brodmann's Area 6) pre-therapy to the primary motor cortex (Brodmann's area 4) post-therapy. Activation changes were accompanied by improvements in functional movement ability of the more-affected hand.

Conclusion: This preliminary investigation suggests that MEG can be used to detect altered brain activation patterns after stroke. Furthermore, it confirms that measurable biological change in the brain can be induced by a 14-day protocol of Wii-based movement therapy.

A novel scheme to objectively and unambiguously stratify motor-function ability post-stroke

McNulty PA,1,2 Thompson-Butel AG,1,2 Lin GG,1 Shiner CT1,2

1Neuroscience Research Australia and 2University of New South Wales, Sydney, NSW, Australia

Background: The neurological deficits of stroke patients are routinely defined according to motor functional ability when determining treatment, discharge destination, rehabiliation and long-term assistance. Participants in clinical research studies are stratified to avoid sampling bias either between or within groups.

Aims: This study aimed to define a standardised method to stratify post-stroke motor function.

Methods: We studied 67 patients hemiparetic after unilateral stroke, aged 18–83 years (59.8 ± 14.0 years, mean ± SD) and 1–264 months post-stroke (23.6 ± 39.6 months). Functional ability of the more-affected upper-limb was assessed using the Wolf Motor Function Test (WMFT), upper-limb motor subscale of the Fugl Meyer Assessment (FMA), Box and Block Test (BBT), grooved-pegboard test (GPT) and active range-of-motion. An hypothesis-based hierarchical cluster analysis was used to test the strength of our proposed scheme.

Results: Rank-ordered WMFT and FMA scores described an almost continuous distribution with floor and ceiling effects respectively, and did not discriminate functional groups. Range-of-motion did not discriminate between high and moderate function. Patients were reliably classified into three functional ability levels using combined performance on the BBT and GPT. Either WMFT or FMA scores were necessary to identify misclassifications when reducing the data set required for stratification. The derived scheme was congruent with clinical observations.

Conclusions: Two simple tests of gross (BBT) and fine (GPT) manual dexterity discriminated the motor functional ability of stroke patients allowing stratification into high, moderate and low ability. The BBT and GPT are unambiguous objective tests of functional ability that are relatively quick and easy to administer in any location.

Understanding the factors associated with unmet needs in Australian stroke survivors

NE Andrew,1 MF Kilkenny,1,2 R Naylor,3 T Purvis,1 DA Cadilhac1,2 On behalf of the National Stroke Foundation, Australia

1Translational Public Health Unit, Stroke & Ageing Research Centre, Southern Clinical School, Monash University, Clayton, 2Florey Institute of Neurosciences and Mental Health, Heidelberg,3National Stroke Foundation, Melbourne, Vic., Australia

Background: It remains unclear what the factors are that may influence whether or not stroke survivors' needs are met in the long-term.

Aims: To describe factors associated with long-term unmet needs in community dwelling stroke survivors.

Method: Data from the 2012 Australian Stroke Survivor and Carer Needs Survey were used. Adults 12+ months post-stroke and living in the community participated. Survivor unmet needs were assessed over six domains: health; everyday living; work; leisure; social support; and finances. Unmet needs were expressed as a proportion of those reporting unmet or partially met needs over those with needs in that domain. Multivariate negative-binomial and logistic regression were used.

Results: Survey completed by 765 survivors (62% male, median age 68 years). Most (84%) reported ≥1 unmet need. Median number of unmet met needs was 4/20 (Q1, Q3: 1, 9). Health, leisure and work were the most impacted domains. Factors associated with increased numbers of unmet needs were younger age (<65 years), increased disability, and emotional, cognitive, or fatigue problems (all p < 0.001). Increased disability (aOR: 3. 5, 95% CI: 1.8, 6.5) and fatigue (aOR: 2.4, 95% CI: 1.2, 4.8) were associated with unmet health needs. Younger age (aOR: 0.5, 95% CI: 0.3, 0.9) and increased disability (aOR: 4.2, 95% CI: 2.3, 7.5) were associated with unmet leisure needs; and increased disability (aOR: 12.8, 95% CI: 4.0, 41.2) and being 1–2 years post-stroke (aOR: 0.19, 95% CI: 0.07, 0.6) with unmet work needs.

Conclusion: Different factors were associated with long-term unmet needs, in particular younger age and increased disability. This information may be used to address these issues.

Factors associated with negative impacts on carers' lives

NE Andrew,1 MF Kilkenny,1,2 R Naylor,3 T Purvis,1 DA Cadilhac1,2 On behalf of the National Stroke Foundation, Australia

1Translational Public Health Unit, Stroke & Ageing Research Centre, Southern Clinical School, Monash University, Clayton,.2Florey Institute of Neurosciences and Mental Health, Heidelberg,3National Stroke Foundation, Melbourne, Vic., Australia

Background: Carers play a crucial role in supporting the recovery of stroke survivors. However, little is known about the factors that may negatively influence the impact on carers.

Aim: To identify stroke survivor and carer characteristics associated with moderate to extreme impacts on carers' lives.

Method: Data from the Australian Stroke Survivor and Carer Needs Survey were used. Community dwelling adults 12+ months post-stroke and their carers participated. Independent variables included carer and survivor demographics, survivor health problems and disability. Multivariate logistic regression was used.

Results: Surveys were completed by 765 survivors (67% male, median age 71 years); 369 (48%) contained carer responses (26% male, median age 64 years). Factors associated with moderate to extreme changes in the following domains were: leisure, increased survivor disability (aOR: 8.8, 95% CI: 4.6, 17.0), poor survivor mobility (aOR: 3.8, 95% CI: 1.2, 11.9) and survivor with emotional problems (aOR: 2.6, 95% CI: 1.1, 6.0); work, increased survivor disability (aOR: 10.8, 95% CI: 4.2, 27.6) and survivor cognition problems (aOR: 4.5, 95% CI: 1.1, 18.0); family relationships, previous carer experience (aOR: 7.3, 95% CI: 2.9, 18.5) and increased survivor disability (aOR: 6.5, 2.4, 17.5); and social relationships, living with survivor (aOR: 3.0, 95% CI: 1.0, 8.8), being female (aOR: 0.3, 95% CI: 0.1, 0.8) and increased survivor disability (aOR: 4.3, 95% CI: 2.2, 8.5). Needing more support was associated with younger carer age (aOR:0.4, 95%CI:0.2, 0.8), increased survivor disability (aOR: 2.5, 95% CI: 1.1, 5.5), and survivor emotional problems (aOR: 3.7, 95% CI: 1.0, 13.3).

Conclusion: The factors that influence negative impacts on carers are varied and are influenced by a range of survivor and carer characteristics.

Community rehabilitation of stroke survivors and follow-up

DA Cadilhac,1,2,3 T Purvis,1,2 E Ritchie,4 MF Kilkenny,1,2,3 C Price,4 K Hill,4 E Lalor4

1Translational Public Health Unit, Stroke & Ageing Research Centre, Southern Clinical School, Monash University, 2National Stroke Research Institute, Florey Neuroscience Institutes, 3University of Melbourne, 4National Stroke Foundation, Melbourne, Vic., Australia

Background: Rehabilitation for stroke survivors often needs to continue after discharge from in-patient care and there is variable access to community-based rehabilitation services. It remains unclear what access stroke survivors in Australia have to community-based rehabilitation services.

Aims: To describe the access to community rehabilitation and follow up stroke survivors are offered in Australian rehabilitation hospitals in 2012.

Methods: A clinician at each participating hospital completed a self-reported survey regarding organisational aspects of stroke services as part of the National Stroke Foundation (NSF) audit programme. Most hospitals also elected to audit approximately 40 consecutive stroke admissions from the previous calendar year. Standardised training and support in data collection were provided by NSF staff. Descriptive statistics presented.

Results: Most (107/111; 96%) hospitals self-reported access to community rehabilitation, but 5–15% described waiting times longer than 1 month for patients to receive ongoing community therapy, and over one third reported that survivors were not seen within a week by early supported discharge services. Overall, 2821 patients were audited from 101 hospitals. Mean age 73 (SD 14) years, 54% males, 76% ischaemic stroke, 7% had none to slight disability (modified Rankin score 0–2) on admission. Among patients discharged to a private residence (1934, 69%), almost a quarter received no referral for further rehabilitation following discharge. Of those who accessed further rehabilitation, 42% had community-based rehabilitation and 39% had outpatient rehabilitation.

Conclusion: Access to community-based rehabilitation services once a stroke survivor has been discharged from hospital is variable and systems of referral could be improved.

Early mobilization after thrombolysis (rt-PA) in acute stroke: are rt-PA treated patients enrolled in a trial of early mobilization (AVERT) different from those that are not?

L Muhl,1 J Kulin,1 M Dagonnier,2,3 L Churilov,2,3 H Dewey,2,3,4 J Bernhardt,2,3 T Lindén2,5

1Faculty of Medicine, Linköping University of Health, Linkoping, Sweden, 5The Institute of Neuroscience and Physiology, Gothenburg University, Gothenburg, Sweden, 2The Florey Institute of Neuroscience and Mental Health, 3The University of Melbourne, 4Department of Neurology, Austin Health, Melbourne, Vic., Australia

Background: A key treatment for acute ischaemic stroke is thrombolysis with recombinant tissue plasminogen activator (rtPA). However, treatment is not devoid of side effects and patients are carefully selected. A Very Early Rehabilitation Trial (AVERT) tests currently whether starting out of bed activity within 24 hours of stroke onset improves outcome. Patients treated with rtPA can be recruited if the physician allows.

Aim: To identify factors that might influence the inclusion of rtPA treated patients in AVERT.

Methods: Data from all patients thrombolysed at Austin Health between September 2007 and December 2011 were retrospectively extracted from medical records. Factors of interest included: demographic and stroke characteristics, 24-hour clinical response to rtPA treatment, cerebral imaging and process factors (day and time of admission).

Results: Over the study period, 211 patients received rtPA at Austin Health. Fifty (24%) were recruited to AVERT (rtPA-AVERT). Of the 161 patients not recruited, 105 (65%) were eligible according to the inclusion/exclusion criteria, and could potentially have been included (pot-AVERT). There were no significant differences in demographics, Oxfordshire stroke classification or stroke severity on admission between groups. rtPA-AVERT patients showed less change in NIHSS 24 hours after treatment than pot-AVERT patients (median change of 2 points, 95% CI: 0.3; p = 0.03). A higher proportion of them were admitted on weekdays (p = 0.04).

Conclusion: Excluding a possible clinical instability, no significant clinical differences were identified between thrombolysed patients included in AVERT and those who were not. These results increase the generalization of the future AVERT's results to the rt-PA treated stroke population.

Incidence and outcomes of TIA: preliminary findings from the population-based Auckland transient ischemic attack study (ATIAS)

R Krishnamurthi,1 A Jones,1 VL Feigin,1 S Barker-Collo,2 K McPherson,3 PA Barber4 on behalf of the ARCOS IV Programme Group

1National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, 3Person-Centered Rehabilitation Centre, Faculty of Health and Environmental Sciences, Auckland University of Technology, 2Department of Psychology, 4Centre for Brain Research, University of Auckland, Auckland, New Zealand

Background: There is a paucity of reliable data on transient ischemic attack (TIA) incidence and outcomes worldwide and none from Australasia. The Auckland Transient Ischemic Attack Study (ATIAS) was nested within the fourth Auckland Regional Community Stroke Study (ARCOS IV), a population-based, stroke/TIA incidence and outcomes study.

Aim: The aim ATIAS is to measure the incidence and outcomes of TIA at a population level in NZ.

Method: The “hot-pursuit” method of case ascertainment was used to register all first-ever and recurrent (TIA) from 1st March 2011 to 29th February 2012 in people ≥16 years, normally resident within the Greater Auckland Region from multiple overlapping sources, including people not presenting to hospital. All participants are assessed for stroke in the 12 months post-TIA. Participants who consented were followed in more detail at 3 and 12 months.

Results: To date, there were just over 700 incident cases of TIA (49% males, mean age (SD) 74.1 (13.7) years, 65% NZ Europeans, 4% Maori and 8% Pacific Islanders. Ninety-seven percent of TIA cases were identified from hospital admissions, and 3% from GP practices or residential care facilities. To date, 47 cases of recurrent TIA and 9 stroke 12 months post-TIA have been identified. Approximately 44% of participants consented to more detailed follow-up.

Discussion: Recruitment into the ATIAS study is now complete and cross-checking for complete case ascertainment, is underway. Currents indications of TIA incidence rates suggest that case-ascertainment was robust. Final reports of TIA incidence and outcomes will be available in the next 12 months.

Characterising neurobehavioural change following stroke: preliminary findings

R Stolwyk,1 E O'Connell,2 AG Thrift,3 C Redpath,1 E Byrne,1 P New2

1School of Psychology and Psychiatry, Monash University, 2Rehabilitation and Aged Services Program, Kingston Centre, Southern Health, 3Epidemiology and Prevention Unit, Stroke and Ageing Research Centre, Department of Medicine, Monash Medical Centre, Southern Health, Melbourne, Vic., Australia

Background: While numerous investigators have researched challenging behaviour following stroke, relatively few have explored the broader construct of neurobehavioural function. Aims: To (i) characterise the incidence of neurobehavioural change during subacute stroke recovery; (ii) identify demographic and disease variables associated with neurobehavioural changes; and (ii) investigate the impact of neurobehavioural change on nursing burden.

Method: To date, 36 people who suffered ischaemic/haemorrhagic stroke have been consecutively recruited from an inpatient stroke rehabilitation ward. Nursing staff completed the St Andrews – Swansea Neurobehavioural Outcome Scale (SASNOS) in addition to a measure of nursing burden for each patient.

Preliminary results: Nurses reported 41% of stroke patients exhibited behavioural difficulties relating to interpersonal relationships; 47% relating to cognition; 3% with inhibition; 6% with aggression; and 3% with communication. Haemorrhagic stroke was more closely associated with cognitive, inhibition and communication behavioural disturbance compared to ischaemic stroke (Pearson r = –0.540, –0.455, –403 respectively, all p < 0.05). Nursing care burden was significantly associated with inhibition, aggression and communication neurobehavioural change (Pearson r = –0.456, –0.669, –0.639 respectively, all p < 0.05), but not interpersonal relationships or cognition. No significant associations were found between age, gender, lesion location or stroke severity with neurobehavioural change.

Conclusions: We have preliminary evidence that interpersonal and cognitive neurobehavioural difficulties are most common early after stroke but, despite being less common, inhibition, aggression and communication changes are causing more burden for nursing staff. This study is ongoing and will include additional self-report, report from ‘close others’ and longitudinal data.

Comparison of three tools to measure improvements in upper-limb function with post-stroke therapy

AG Thompson-Butel,1,2 GG Lin,1 CT Shiner,1,2 PA McNulty1,2

1Neuroscience Research Australia, 2University New South Wales, Sydney, NSW, Australia

Background: The upper-limb Motor Assessment Scale items 6–8 (MAS) are the most commonly used assessment post-stroke in Australia. Internationally, the upper-limb motor subscale of the Fugl-Meyer Assessment (FMA) is most common, with the Wolf Motor Function Test (WMFT) growing in use.

Aim: To compare these assessment tools of upper-limb motor function in the same post-stroke heterogeneous cohort.

Methods: Forty-one hemiparetic patients (26 male and 15 female), aged 22–83 years (62.4 ± 12.3 years, mean ± SD) and 1 month – 21 years post stroke (24.7 ± 42.1 months) were assessed before and after a 14-day upper-limb rehabilitation program of Wii-based Movement Therapy. Patients were stratified as low-, moderate- or high-motor function according to our novel classification scheme. The MAS was analysed both with and without the hierarchical scoring structure.

Results: Upper-limb function improved significantly for the pooled cohort for the MAS (with and without hierarchical scoring), FMA and WMFT (p < 0.001 for all). Differences became apparent when improvements were analysed for each functional group. Floor and ceiling effects were evident for the MAS, ceiling effects for the FMA and floor effects for the WMFT. Improvements were statistically significant for all motor-function groups with the FMA, for the moderate and high groups with the WMFT, but only the high-function group with the MAS with hierarchical scoring, and the moderate- and high-function groups with the MAS without hierarchical scoring.

Conclusion: These results suggest that if only a single test is used, the FMA is sensitive to change regardless of functional status. The MAS was the least sensitive test.

Suprascapular nerve block reduces shoulder pain post stroke: a randomised controlled trial

Z Adey-Wakeling,1 M Crotty,1 EM Shanahan2

1Flinders University, Department of Rehabilitation and Aged Care, SA, Australia, 2Flinders University, Department of Rheumatology, SA, Australia

Background: Shoulder pain is a common complication post stroke. There is limited evidence to guide management of hemiplegic shoulder pain (HSP). Suprascapular Nerve Block has been shown to be safe and effective in the treatment of shoulder pain in a variety of medical conditions, though its applicability in HSP has not been established.

Aim: To assess the effectiveness of Suprascapular Nerve Block in reducing severity of HSP.

Methods: A randomised controlled trial comparing suprascapular nerve block injection (depo-medrol and bupivocaine) with placebo injection (normal saline) in a population of patients with hemiplegic shoulder pain within 12 months of stroke. Pain was measured using visual analogue scale (VAS) at baseline, then by an assessor masked to allocation at 1, 4 and 12 weeks. An intention to treat analysis was undertaken.

Results: A total of 64 participants were randomised, 32 each to intervention and placebo groups. Study arms were similar for age, gender and stroke type and stroke severity. Baseline mean visual analogue scores (VAS) for pain was comparable (68.9 in the control group, and 61.4 in the intervention group). Non-parametric statistical analysis demonstrated a statistically significant (p < 0.02) reduction in pain scores in the intervention group compared to control group, maintained to 12 weeks. No side-effects were reported.

Discussion: Suprascapular nerve block is a clinically important and effective intervention for the management of HSP.

Npas4 upregulation in the corticolimbic system in stroke: implications for post-stroke depression

WK Leong1, TS Klarić,1 Y Lin,2 SA Koblar,1 MD Lewis1

1University of Adelaide, Adelaide, SA, Australia, and 2Massachusetts Institute of Technology, Boston, MA, USA

Background: The neuronal Per-Arnt-Sim domain protein 4 (Npas4) is an important transcriptional regulator of synaptic plasticity and cognition. Specifically Npas4 contributes to the homeostatic balance of excitation and inhibition, by regulating the number of inhibitory synapses in an activity and calcium dependant manner. Depression is a major clinical problem post-stroke.

Aims: The objective of this study was to characterise the in vivo neuroanatomical expression pattern of the Npas4 protein in a rat model of focal cerebral ischemia.

Methods: Animals were subjected to unilateral middle cerebral artery occlusion (MCAo) for 2 h, after which the spatial and neuronal profiles of Npas4 protein expression were analysed by immunohistochemistry at different time points post-reperfusion.

Results: Focal cerebral ischemia induced an early, transient and robust upregulation of Npas4 in a brain region-dependent manner involving predominantly principal neurons. Interestingly, we observed a unique differential induction of Npas4 protein expression in corticolimbic regions of the rat brain that are critically linked to cognition and emotion.

Discussion: The stroke-induced Npas4 upregulation within the corticolimbic circuitry lead us to ask what possible roles this transcription factor may have in major depression.


[1] Leong WK, Klaric TS, Lin Y, Lewis MD, Koblar SA (2013) Upregulation of the neuronal Per-Arnt-Sim domain protein 4 (Npas4) in the rat corticolimbic system following focal cerebral ischemia. Eur J Neurosci (In press).

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

E Schleiger,1 N Sheikh,1,2,3 T Rowland,4 A Wong,2,3 S Read,2,3 S Finnigan1

1UQ Centre for Clinical Research, 2School of Medicine, The University of Queensland, 3Acute Stroke Unit, Neurology Department, 4Department of Occupational Therapy, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia

Background: Cognitive impairment and vascular dementia are common sequelae of stroke, however their prognostication remains elusive. Quantitative electro-encephalography (QEEG) provides markers of global brain dysfunction which have proven uniquely informative for prognostication of outcomes assessed using routine clinical scales [1]. Markers sensitive to the proportion and amplitude (power) of abnormal, slow EEG activity relative to faster activity are particularly informative in this context.

Aim: To analyse correlations between pre-discharge QEEG markers and cognitive measures at 3 months post-stroke.

Method: Resting-state EEG was recorded at 72 hours post-symptom onset using standard methods. QEEG relative band-power measures for standard EEG frequency bands (delta, theta, alpha, beta) were computed from 3 minutes of artefact-free EEG. Cognitive outcomes were assessed using items of the Functional Assessment Measure (FAM) at 3 months post-stroke. These respectively assess memory, problem solving, orientation, attention and safety judgements. Correlations between QEEG and cognitive outcome scores were investigated using Spearman's coefficient.

Results: Thirty-two ischaemic stroke patients were recruited. Eight were deceased by follow-up and analyses were performed on 24 patients. Both alpha (ρ = 0.632, p = 0.001) and beta (ρ = 0.583, p = 0.003) relative power showed significant positive correlations with cognitive scores. Relative delta power showed a significant negative correlation with cognitive outcomes (ρ = –0.644, p = 0.001).

Discussion: These outcomes indicate that QEEG markers from a standard, pre-discharge EEG may, together with routine observations, inform clinical prognoses and decisions, for example regarding appropriate levels of post-discharge care or rehabilitation strategies. This study is ongoing.


[1] S. Finnigan, M. van Putten, EEG in ischaemic stroke: Quantitative EEG can uniquely inform (sub-)acute prognoses and clinical management. Clinical Neurophysiology (2013) 124:1019.

The impact of CCS and TOAST classification systems on genetic associations with ischaemic stroke

J Thomas,1 O Parsons,2 M Traylor,2 L Li,3 S Bevan,2 C Sudlow,4 P Rothwell,3 H Markus,2 CR Levi,1 L Holliday,1 J Attia1

1Priority Research Centre for Brain and Mental Health, University of Newcastle, Newcastle, NSW, Australia, and 2Stroke and Dementia Research Centre, St. George's University of London, London, 3Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, 4Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK

Background: Recent genome wide association studies (GWAS) identified novel polymorphisms associated with increased risk of ischaemic stroke (IS) and linked these to ischaemic stroke subtypes as defined by TOAST. It has been proposed the recently developed Causative Classification System (CCS) may increase power in GWAS.

Aims: To evaluate CCS by comparing effect sizes for known genetic polymorphisms, when patients were classified both by CCS and TOAST.

Methods: Data on 2674 cases and 6419 controls were obtained from WTCCC2-UK and ASGC IS GWAS. TOAST classified cases were reclassified using the CCS and compared using interrater agreement analysis. Strength of association between 285 large artery atherosclerosis (LAA) and 596 cardioembolic (CE) cases with the novel polymorphisms for LAA (HDAC9, 9p21, 6p21.1, ABO) and CE (PITX2, ZFHX3, ABO) was compared between the TOAST and CCS phenotypes.

Results: Effect sizes calculated between CCS and TOAST differed slightly. For LAA associated SNPs, effect sizes under CCS tended to be slightly larger than under TOAST with HDAC9 showing the largest reduction (28.5%) in required sample size for 80% power under CCS. Conversely, CCS gave smaller effect sizes for CE associated SNPs with ZFHX3 showing the greatest increase (101.7%) in required sample size.

Conclusion: Reclassification under CCS revealed only minor changes in effect sizes with contrasting direction of change for LAA and CE, suggesting it does not lead to increased power. Classification using CCS offers advantages such as recording of clinical information, but reclassification of TOAST classified cases is unlikely to lead to major increases in power.

The Australian public's knowledge of stroke symptoms improves following national education campaigns

JE Bray,1 R Johnson,2 K Trobbiani,2 I Mosley,1 E Lalor,2 DA Cadilhac1 on behalf of the National Stroke Foundation

1Monash University, 2National Stroke Foundation, Melbourne, Vic., Australia

Background: In 2004, the National Stroke Foundation (NSF) of Australia commenced annual national campaigns and surveys to improve and monitor the Australian public's stroke symptom knowledge. The aim of this study is to examine changes and associated factors in the Australian public's knowledge of stroke symptoms since the campaigns commenced.

Methods: An independent national survey was conducted annually between 2003 and 2008 and in 2010 using a computer assisted telephone interview (CATI) program on random state-weighted samples of Australians aged over 40 years. The annual proportions of unprompted stroke symptoms recalled were compared and logistic regression determined factors associated with recalling ≥2 common symptoms, including awareness of stroke campaigns.

Results: A total of 13,442 participants completed the interview (annually ranging between 1003 and 2591). Awareness of the campaigns increased from 36% to 50% between 2004 and 2010 (p < 0.001), advertising and media were cited as common sources. Unprompted identification of stroke symptoms improved each year between 2003 and 2010: ≥1 symptom correct from 68% to 81% (p < 0.001); ≥2 correct from 39% to 63% (p < 0.001); ≥3 correct from 19% to 32% (p < 0.001). Factors associated with recalling ≥2 common symptoms were: surveyed after 2005, previous stroke/TIA (aOR = 1.22, 95% CI: 1.01–1.47), female (aOR = 1.50,95% CI: 1.37–1.64), >year 12 education aOR = 1.27,95% CI: 1.17–1.38), age <68 years (aOR = 1.51,95% CI: 1.35–1.68), aware of stroke advertising (aOR = 1.73,95% CI: 1.59–1.88). Individual risk factors (hypertension, diabetes, hypercholesterolemia, atrial fibrillation) were not significantly associated.

Conclusions: The Australian public's awareness and recall of stroke symptoms has steadily improved since commencement of awareness campaigns by the NSF in 2004, particularly in recent years and in those aware of campaigns.

Temporal changes in management and outcomes of subarachnoid haemorrhage: trends over 30 years

FM Suh,1 R Krishnamurthi,1 P Schweder,2 S Taylor,1 K McPherson,1 S Barker-Collo,1,3 PA Barber,1,2,3 E Mee,2 VL Feigin1

1AUT University, 2Auckland City Hospital, 3University of Auckland, Auckland, New Zealand

Background: Subarachnoid haemorrhage (SAH) accounts for 3–7% of all strokes, and often results in poor outcomes. Population-based studies are the most reliable way to estimate long-term trends in subarachnoid haemorrhage (SAH) incidence and outcomes.

Aims: To (a) measure changes in demographics, management, death and disability outcomes of SAH over a 30-year period, and (b) identify potential predictors of good (modified Rankin Scale; mRS 0–2) and poor (mRS 3–6) outcomes.

Methods: Data from the internationally unique longitudinal population-based stroke study (Auckland Regional Community Outcome Stroke study) was used to identify all new SAH cases(hospitalised and non-hospitalised). Data have been collected over three decades (1981–2012) using similar case finding strategies. Trends in incidence, demographics (age, SAH severity, gender, ethnicity) and management (type of treatment received and time to treatment) were analysed. Primary outcome meaures were death and disability (mRS) at one and 6 months post-SAH.

Results: A total of 313 SAH cases were identified. Incidence rates decreased over the first two decades (14.6 to 11.3 to 10 per 100,000) and analysis of 2012–2013 rates are underway. The proportion of female cases in the 2012–2013 period was approximately 74%, and mean age was 56.4 years, higher than the previous mean ages. Analysis of potential predictors and their change over the three decades are currently underway.

Conclusion: This population-based study has provided an excellent basis for evaluating SAH incidence and outcomes over time. Current trends indicate the incidence of SAH has decreased, and mean age increased over the past 30 years.

The forgotten mood disorder: anxiety is prevalent after stroke

T Cumming,1 I Skoog,2 C Blomstrand,2 T Linden1,2

1Florey Institute of Neuroscience and Mental Health, Melbourne, Vic., Australia, and 2Institute of Neuroscience and Physiology, Gothenburg University, Göteborg, Sweden

Background: Stroke is a threatening event – it raises the possibility of further strokes, loss of independence and ultimately death – and therefore may be a trigger for development of anxiety. While post-stroke depression has been extensively studied, the prevalence and nature of anxiety disorders following stroke has not been well established.

Hypothesis: Anxiety disorders will be significantly more prevalent in stroke survivors than in controls.

Methods: Stroke survivors were followed up at 18 months post-stroke, and their results were compared to a group of age- and sex-matched general population controls. A comprehensive psychiatric interview was undertaken and anxiety disorders were diagnosed according to DSM-III-R criteria.

Results: Mean age of the 149 stroke survivors was 81.0 (SD 5.3) years, while mean age of the 745 controls was 81.3 (SD 5.7). In both groups, 65% were women. Generalised anxiety disorder was identified in 27% of the stroke group but only 8% of controls. The stroke group also had a higher prevalence of phobic disorder (24% versus 8%) and obsessive-compulsive disorder (9% versus 2%). All of these differences were highly significant (p < 0.001). Stroke-control differences were greater in those without depression; when including only those with depression, prevalence of generalised anxiety disorder was 40% in both stroke and controls.

Conclusion: Anxiety disorders, including phobic disorder and obsessive-compulsive disorder, are common after stroke. Higher prevalence of anxiety in stroke cannot be explained by concomitant depression; group differences in anxiety prevalence were greater in those without depression.

Management of impairments in rehabilitation

K Hill,4 T Purvis,1,2 E Ritchie,4 MF Kilkenny,1,2,3 C Price,4 E Lalor,4 DA Cadilhac1,2,3

1Translational Public Health Unit, Stroke & Ageing Research Centre, Southern Clinical School, Monash University, 2National Stroke Research Institute, Florey Neuroscience Institutes, 3University of Melbourne, 4National Stroke Foundation, Melbourne, Vic., Australia

Background: Stroke is a major cause of mortality and disability. Common disabilities following stroke include difficulty with walking and upper limb (UL) function, and requiring assistance with activities of daily living (ADLs). Biennial national audits of Australian stroke inpatient rehabilitation hospitals provide a means to assess the use of recommended management strategies for addressing various impairments following stroke.

Aims: To determine if patients admitted to rehabilitation hospitals during 2012, who experienced difficulty with UL function, walking and ADLs post stroke, where managed according to evidence-based guidelines.

Methods: Clinicians at each participating hospital retrospectively audited up to 40 consecutive stroke admissions from the previous calendar year. Standardized training, a data dictionary and support in use of the online data collection system were provided by National Stroke Foundation staff. Descriptive univariate statistics are presented.

Results: Overall, 2821 patients were audited from 101 hospitals. Mean age 73 (SD 14) years, 54% males, 76% ischaemic stroke. 69% of patients had difficulty with UL function. 823 (50%) of these were not managed according to guideline recommendations. Most (87%) patients had difficulties with ADLs. Of these, 91% received at least one of the recommended guideline management options, while 952 (39%) were managed with therapies not based on guideline recommendations. Likewise, 84% had difficulty walking independently. Although 93% received at least one of the recommended guideline management options, 1275 (54%) were also managed with ‘other therapies’.

Conclusion: Large variation exists in health professional's management of impairments of patients during rehabilitation, not all of which follow guideline recommendations.

Development of a somatosensory screening tool for use in clinical rehabilitation settings with stroke survivors

L Carey,1,2 Y Mak,1,2,3 A-M Tan,1,2 K Rickard,3 T Matyas1,2,4

1Neurorehabilitation and Recovery, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, 2La Trobe University, Bundoora, 3Southern Health, 4The University of Melbourne, Parkville, Melbourne, Vic., Australia

Background: Quantitative, standardised measures of discriminative sensibility that are suitable for use in clinical settings with stroke survivors are not readily available.

Aim: We aimed to develop a sensory screening tool using brief versions of standardised assessments to quantify sensory discrimination capacity in stroke survivors in the rehabilitation phase of recovery.

Methods: The sample comprised data from exisiting cohorts of stroke survivors (n = 50 or n = 63) and age matched healthy controls (n = 50) who had been assessed on quantitative measures of sensory performance. Test scores were re-analysed to determine the ability of brief test versions to detect impairment. Performance scores based on a brief number of trials were compared with those of the more detailed original test version to determine sensitivity and specificity of the brief test. Criteria of abnormality were defined relative to age matched healthy controls to guide interpretation of scores. Sensitivity and specificity were determined for brief versions of the Tactile Discrimination Test, Wrist Position Sense Test and functional Tactile Object Recogntition Test.

Results: High sensitivity and specificity were found for the Tactile Discrimination Test (12 vs 50 trials; sensitivity 85.3%, specificity 93.75%); Wrist Position Sense Test (10 vs 20 trials; sensitivity 93%, specificity 95%) and the functional Tactile Object Recognition Test (7 vs 14 trials; sensitivity 85.7%, specificity 92.9%).

Conclusion: Evidence of high sensitivity and specificity of brief versions of quantitative measures of sensory performance support their use in an evidence-based somatosensory sensory tool. This tool, known as SenScreen, is currently being tested in a clinical setting.

Survival and cost analysis of stroke for the Indigenous and non-Indigenous patients

J You, Y Zhao, C Connors, S Guthridge

Northern Territory Department of Health, Darwin, NT, Australia

Background: Stroke is a leading cause of death and burdens of disease in Australia. The impact of stroke on the Northern Territory (NT) population was unclear. This study estimates the survival rates and lifetime costs for stroke patients in the NT from 1991 to 2010.

Methods: NT hospital morbidity data was used for this study. Age-standardization and Cox-proportional hazard models were applied to estimate the survival rates and lifetime hospital costs for the Indigenous and non-Indigenous patients. Demographic and geographic information including remoteness and Charlson comorbidity were analyzed to identify the links between the risk factors and mortality.

Results: The NT stroke case fatality was estimated at 33%, with much higher figures for hemorrhagic stroke. The average survival was 10.4 years for patients with ischemic stroke, which cost around $91,000, and only 4.4 years for those with hemorrhagic stroke, which cost $56,000.

Conclusions: Understanding the factors contributing to survival and cost for stroke patients is important. This study will provide potentially useful information on the links between risk factors and stroke mortality, assist resource planning and services for patients with stroke and improve survival for stroke patients.

Glenohumeral joint position, motor recovery and shoulder pain in acute post-stroke hemiplegia patients

P Choolun,1,2 SS Kuys,2,3 L Bisset,2,4 P Mills2

1Royal Brisbane and Women's Hospital, 3The Prince Charles Hospital, Brisbane, 2Griffith University, 4Gold Coast Hospital, Gold Coast, Qld, Australia

Background: Longitudinal changes in glenohumeral joint (GHJ) position may contribute to functional recovery and development of shoulder pain following acute post-stroke hemiplegia.

Aims: To assess longitudinal changes in GHJ position in patients with acute post-stroke hemiplegia and investigate its relationship with motor recovery, shoulder pain and muscle stiffness.

Methods: Twenty-seven post-stroke patients (mean age 66.9 years (SD 16.6), 58.6% female, 51.9% left side affected) were assessed within 14 days of acute hospital admission and at 6 weeks follow-up. Outcomes included bilateral GHJ centre of rotation, pressure pain threshold (PPT), motor recovery and muscle stiffness.

Results: By week 6, changes in the anteroposterior position of GHJ centre of rotation were seen bilaterally (hemiplegic anterior 5.4 mm SD 1.35; non-hemiplegic posterior 2.5 mm SD 0.85; p = 0.025). Patients with poor motor recovery had lower PPT on the hemiplegic side (mean 115.0, SD 46.9 kPa) compared to those with good motor recovery (mean 322.5, SD 17.3 kPa; p = 0.059). Patients with shoulder pain had greater baseline variability in GHJ superoinferior movement (p = 0.007). At 6-weeks, patients with increased muscle stiffness had greater variability in hemiplegic anteroposterior movement compared to those with normal muscle tone (p = 0.054).

Conclusion: Bilateral changes in GHJ position were identified in patients with acute post-stroke hemiplegia. Patients with poor motor recovery, altered muscle stiffness or shoulder pain, may exhibit hyperalgesia and greater variability in the GHJ position on the hemiplegic side, providing direction for developing innovative approaches to the management of upper limb recovery and pain post-stroke.

Does a focus on participation and personal goal achievement have an impact on depression in the first year after stroke?

C Graven,1,2 K Brock,2 K Hill,3 D Ames,4 S Cotton,5 L Joubert1

1The University of Melbourne, 2St.Vincent's Hospital Melbourne, 4National Ageing Research Institute, 5Orygen Youth Health Research Centre, Melbourne, Victoria, 3Curtin University, Perth, WA, Australia

Background and Aims: Depression is a common sequelae following stroke. The effectiveness of goal-based interventions on post-stroke depression is largely unknown. The aim of this study was to investigate the effectiveness of a client-centred, integrated approach to facilitating goal achievement in the first year post-stroke on depressed mood.

Methods: This study was a randomised controlled trial that addressed ways to enhance participation in patient-valued activities and screened for adverse stroke sequelae, following discharge home from rehabilitation. The control group received treatment as determined by the treating rehabilitation team. In addition, the intervention group received: collaborative goal setting, review of goal achievement levels, written information provision, and further referral to relevant health services as required. The main outcome measure was depression, measured by the Geriatric Depression Scale (GDS-15 item), with depression defined as GDS ≥ 6 at 12 months post stroke.

Results: One-hundred and ten participants with the primary diagnosis of stroke were recruited. No significant groups differences were identified at baseline on all demographic and clinical variables. There was a significant difference between the two groups with respect to the rates of depression at 12 month post-stroke. The rate of depression in the intervention group (14.6%, n = 7) was significantly lower than the rate of depression in the control group (34.8%, n = 16), χ2(1) = 5.19, p = 0.023.

Conclusions: This model of community-based rehabilitation management proved effective in reducing the incidence of post-stroke depression. An integrated approach that takes into account the patient's expressed valued activities should form a routine part of post-stroke management.

Quality assurance in stroke care: the utility of the Australian Stroke Clinical Quality Registry (AuSCR)

DA Cadilhac,1,2 NA Lannin,3 B Grabsch,2 GA Donnan,2 CS Anderson4

1Florey Institute of Neuroscience and Mental Health, Heidelberg, 2Stroke and Ageing Research Centre, Monash University, Clayton, 3Alfred Clinical School, La Trobe University, Melbourne, Vic., 4The George Institute for Global Health, Camperdown, NSW, Australia

Background: Clinical quality registries are recognised as a credible tool for monitoring, benchmarking, and providing evidence to improve clinical care. In Australia, the Australian Stroke Clinical Registry (AuSCR) provides a unique data set for prospectively assessing the quality of stroke care and outcomes.

Aims: To describe the utility of the AuSCR and its potential for informing quality improvement activities in acute stroke care.

Methods: Eligible patients' data (demographics, acute clinical care and 90 days post-stroke health outcomes and quality of life) are entered into the AuSCR. These data are available to facilitate monitoring of processes of care.

Results: From June 2009 until February 2013, data from 9,149 patients (32 hospitals) have been entered into AuSCR. Complete data sets for all AuSCR registrants at site level has given hospitals the option to use AuSCR as their prime source of data for patients with stroke. Hospital users have also been able to interrogate the data themselves. On-demand live reports have facilitated monitoring and benchmarking with nationwide comparative data, and have been used by hospitals to inform meetings at unit and management level. National annual reports are produced to allow hospitals to conduct an appraisal of their progress in adhering to key clinical indicators compared to other hospitals. Quarterly newsletters provide a tool for communicating with hospitals to ensure that the AuSCR system contains quality data.

Conclusion: Although relatively ‘young’, AuSCR is already being well utilised for its potential to reduce evidence-practice gaps in hospitals.

The importance of understanding community outcome after stroke: using data from the Australian Stroke Clinical Registry

NA Lannin,1,2 DA Cadilhac,3 CS Anderson,4 J Hata,4 J Lim,4 B Grabsch,5 GA Donnan5 and members of the Australian Stroke Clinical Registry Management Committee

1La Trobe University, 2Alfred Health, Melbourne, 3Stroke and Ageing Research Centre, Monash University, Clayton, 5Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic., 4The George Institute for Global Health, Camperdown, NSW, Australia

Background: The Australian Stroke Clinical Registry (AuSCR) includes data on the process of care and outcomes for patients admitted to hospital with acute stroke or transient ischaemic attack (TIA).

Aim: To describe post-discharge living situation, death and recurrent stroke, and health-related quality of life (HRQoL) among AuSCR participants between January and December 2011.

Method: Prospective data from 16 hospitals on patients with acute stroke or TIA followed up at 90+ days after the first episode of care using a modified Dillman protocol. HRQoL was assessed using the EuroQOL (EQ-5D).

Results: A total of 2519 patients contributed data, 1215 (87%) with follow-up data. Their mean age was 75 years, 47% were female and 69% had ischaemic stroke. Most were discharged home (n = 1173; 51%); patients managed in a stroke unit were more likely to attend rehabilitation (odds ratio 1.9, 95% CI 1.4–2.5) when adjusted for predictive factors such as age and gender. Mean EQ5D HRQoL score was 0.63 (normative value 0.76). Most respondents reported limitations in everyday activities as a result of the stroke (60%) and 48% reported experiencing depression/anxiety.

Discussion: Outcomes from AuSCR data suggest that stroke unit care increases the likelihood of receiving post-stroke rehabilitation. Ongoing concerns remain regarding self-reported HRQoL and the likelihood of experiencing reduced participation in meaningful activities after stroke.

Clinical use of telemedicine for acute stroke care in a regional area: findings from the Victorian Stroke Telemedicine (VST) project

CF Bladin,1 DA Cadilhac,2 N Moloczij,1 H Dewey,3 P Hand,4 RP Gerraty,5 D Badcock,6 S Denisenko,1 S Ermel,6 P Disler6 on behalf of the Victorian Stroke Telemedicine project

1The Florey Institute of Neuroscience & Mental Health, 2Monash University, 3Austin Health, 4Royal Melbourne Hospital, 5Epworth Hospital, Melbourne, 6Bendigo Health, Bendigo, Vic., Australia

Background: Telemedicine systems can facilitate evidence-based care for patients with stroke, but are rarely used in rural Australia.

Aim: To describe a novel stroke telemedicine program used in a regional emergency department to increase stroke thrombolysis utilisation.

Methods: The finalised Victorian Stroke Telemedicine (VST) protocol was implemented at one site (Bendigo Health) from October 2011 to October 2012. All patients who presented to the Emergency Department within 4.5 hours of stroke onset, who were aged 18 years or older, and had suspected stroke symptoms, were eligible for a telemedicine consultation. Data collected included: patient data, telemedicine consultation variables and 3-month patient outcomes. Descriptive statistics are presented.

Results: Thirty-one VST consultations were undertaken using the finalised protocol: 61% male, median age 66 years (IQR 55–78 years); 74% ischemic stroke; 3% intracerebral haemorrhage; 10% TIA; 13% non-stroke. Overall, 42% of the VST patients (n = 13) received thrombolysis with a median door-to-needle time of 89 minutes (IQR 72–117). Median length of stay was 2.5 days (IQR 2–5). At discharge, 58% went home, 6% to aged care, and 10% died. One patient who received thrombolysis died. At three months, 61% had little or no disability (mRS 0–2); 29% had moderate to severe disability (mRS 3–5); and there were no further deaths. Prior to the commencement of VST, the thrombolysis rate was 5% for all admitted strokes. This increased to 14% following the use of the VST protocol at this hospital.

Conclusion: The VST program has enhanced thrombolysis delivery in a regional emergency department.

Hospital re-admissions following stroke: AuSCR and Victorian hospital discharge data linkage study

MF Kilkenny,1,2 H Dewey,2,3 NE Andrew,1 NA Lannin,4 CS Anderson,5 GA Donnan,2 DA Cadilhac1,2

1Stroke & Ageing Research Centre, Southern Clinical School, Monash University, Clayton, 2Florey Institute of Neurosciences and Mental Health, 3Austin health, Heidelberg, 4Alfred Clinical School, Faculty of Health Sciences, La Trobe University, Melbourne, Vic., 5The George Institute for Global Health, The University of Sydney, Sydney, NSW, Australia

Background: Overseas studies indicate a 6.5%–24% frequency of hospital re-admissions within 30 days following stroke. Limited data are available on this outcome within Australia with estimates to the same hospital being about 6.5%. No data are available on re-admission up to 1 year after a stroke admission to any hospital.

Aim: To determine the frequency of hospital re-admissions to any hospital within 1 and 6 months, and at 1 year of an admission with acute stroke.

Methods: Australian Stroke Clinical Registry (AuSCR) data from one large hospital in Melbourne, Victoria (Australia) for the period 15 June 2009 and 31 December 2010 were linked to the Victorian government hospital discharge data using stepwise deterministic methods. The frequencies of re-presentations after the AuSCR index event up until February 2011 were calculated for 1 month, 6 months and 1 year.

Results: There were 317 (43%) patients (mean age 73 years, 55% male, 64% ischaemic stroke) with a hospital re-admission: at one month 10% (3% with stroke to any hospital; and 2% with stroke to same hospital ) and by 6 months 34% (6% with stroke to any hospital and 4% with stroke to same hospital). Of those who survived the first episode, 41% were re-admitted for any cause and 6% were re-admitted for stroke to any hospital within 1 year.

Conclusions: Over 40% of patients with a discharge diagnosis of stroke were re-admitted to hospital within one year. There is an urgent need to understand the causes of re-admission after stroke.

Nurse unit managers views of organisational barriers and enablers within New South Wales stroke units liable to influence evidence-based practice

P Drury,1,2 S Middleton,1,2 L McInnes,1,2 S Dale,1,2 J Hardy3

1Nursing Research Institute, St. Vincent's & Mater Health Sydney and Australian Catholic University (ACU), 2National Centre for Clinical Outcomes Research (NaCCOR), ACU, 3University of Sydney, Sydney, NSW, Australia

Background: Efforts to change practice are unlikely to succeed unless barriers are identified and addressed. We investigated organisational barriers and enablers likely to influence change within NSW stroke units prior to the commencement of Quality in Acute Stroke Care (QASC) trial. The QASC trial was designed to foster acceptance of guideline recommendations and evidence-based management of fever, hyperglycaemia and swallowing dysfunction following stroke.

Method: Nurse Unit Managers (NUMs) from 19 stroke units participating in the trial were surveyed to measure their views of: self-leadership ability (measured by the Leadership Practices Inventory [LPI]); organisational learning (measured by the Organisational Learning Survey [OLS]); attitudes towards evidence-based practice; and stroke unit readiness for change.

Results: Surveys were returned from 19 (100%) NUMs. The mean values across all subscales of the LPI were >40 (possible range 6 to 60) indicating high leadership ability. The mean score across all five learning capabilities of the OLS were >4 on the seven-point scale indicating a culture of learning. NUMs estimated 80% of clinical practice to be evidence-based yet NUMs agreed (medium 3, IQR 2–3.5 [1 = strongly disagree to 5 = strongly agree]) using evidence in practice places unreasonable demands on colleagues. NUMs indicated that 95% (n = 18) of stroke units had a staff member responsible for guideline implementation yet 73% (n = 14) indicated this staff member was not allocated sufficient time to fulfill their role.

Discussion: Although barriers to change and the successful uptake of the QASC intervention existed, NUMs indicated that stroke units were accepting of change required to facilitate evidence-based practice.

Slightly more active, just as alone: a comparative observational study of stroke rehabilitation and acute stroke care in Sweden

A Åstrand,1 C Saxin,1 T Cumming,2 M Halvorsen,3 L Churilov,2 J Bernhardt,2,4 T Lindén,1,2

1Institute of Neuroscience and Physiology/Physiotherapy, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, 3Karolinska University Hospital, Stockholm, Sweden, 2Florey Institute of Neurosciene and Mental Health, Melbourne, 4LaTrobe University, Bundoora, Vic., Australia

Background: Augmented exercise has been shown to result in better gait and increased independence after stroke. Currently, research indicates that acute stroke patients are largely inactive and alone, spending >90% of the day in or beside the bed. It is widely assumed that levels of activity are higher in the rehabilitation setting.

Aim: To compare the levels of activity in stroke patients at acute and rehabilitation units.

Methods: This was a multi-site observational study conducted across one acute stroke unit and four rehabilitation units in Sweden. Observations were conducted during 1 day between 8 am and 5 pm. In10-minute intervals physical activity, location and interaction were ascertained and recorded using standardized behavioural mapping forms.

Results: Data were collected from 104 stroke patients in rehabilitation units and 86 stroke patients in acute stroke care. No significant difference was found between the groups in amount of time spent standing or walking (acute median 6% versus rehabilitation median 8%). The acute group spent more of the day lying (median 56%) than sitting (median 19%) whereas the rehabilitation group spent more of the day sitting (38%) than lying (31%). Patients in rehabilitation spent less time in the bedroom than acute patients (p < 0.001) but were just as alone.

Conclusion: After stroke, progression from the acute hospital to a rehabilitation unit does not entail a significant increase in upright physical activity, although patients do typically move from mostly lying to mostly sitting. This highlights the current challenges we face in increasing patient activity across the spectrum to improve health.

Stroke trial participant information is excessively difficult to read

MA Poulson, S Horton, PR Fitzsimmons

Department of Stroke Medicine and Clinical Gerontology, Royal Liverpool University Hospital, Liverpool, UK

Introduction: Poor health literacy is common with the average adult reading at the 8th grade level. Guidelines suggest information intended for patients should be written at or below the 6th grade level. We aimed to asses the readability of stroke trial participant information sheets using two validated readability measures.

Methods: Participant information sheets were requested from all actively recruiting studies in the NIHR stroke portfolio. Body text was extracted using a standardised method and analysed with the Flesch-Kincaid and the Simple Measure of Gobbledygook (SMOG) formulae.

Results: Participant information sheets were received from 42 (41%) of studies.

The mean SMOG grade was 11.9 (95% CI 11.7–12.1), with a mean Flesch-Kincaid grade of 9.84 (95% CI 9.50–10.2). When grouped by SMOG grade, none of the sheets were categorised as being of easy or average reading difficulty (SMOG <10), with 55% categorised as difficult to read (SMOG 10–12) and 45% being very difficult to read (SMOG >12). Flesch-Kincaid and SMOG grades correlated well with Pearson's r = 0.943, however the Flesch-Kincaid formula significantly underestimated reading difficulty, mean underestimation 2.05 grades (95% CI 1.90–2.19), P < 0.0001.

Conclusions: In this sample nearly half of the participant information sheets were written at degree level or higher, with a SMOG grade over 12. None of the sheets would be comprehensible to the average adult, nor did any comply with current readability guidelines. To ensure participant understanding, researchers should routinely assess the readability of written material used as part of the informed consent process, with SMOG being the readability measure of choice.