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London, United Kingdom 2013 Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854 689 Acute stroke: clinical patterns and practice (PO 648 - 708) 648 Acute stroke: clinical patterns and practice Moyamoya Disease Initially Manifesting as Vascular Parkinsonism H.J. Cho1, K.P. Park2 Department of Neurology, Pusan National University Hospital, Busan, SOUTH KOREA1, De-partment of Neurology, Pusan National University Yangsan Hospital, Yangsan, SOUTH KOREA2 Moyamoya disease is a cerebrovascular disorder characterized by progressive stenosis of the distal internal carotid artery, which can attribute to the wide range of clinical presentations. The majority of affected patients present with transient or fixed symptoms of cerebral ischemia such as hemipare-sis, dysarthria and aphasia. However, vascular parkinsonism (VP) has been described as extremely rare clinical manifestation. We report a patient presenting with clinical symptom of VP as the initial manifestation of moyamoya disease. A 55-year-old woman presented with slowly progressive gait disturbance during a period of 2 years. She had no remarkable past history except for hypertension. On neurological examination, brady-kinesia in all extremities, but more prominent on the left side, was noted with no resting tremor and rigidity. She showed small-stepped gait with pivotal turning, initiation failure and postural instabili-ty. Deep tendon reflexes were asymmetrically brisker on the left. T2-weighted and FLAIR images of the brain demonstrated diffuse hyperintensity involving cortical and subcortical areas of the bilateral frontal lobes. MRA and digital subtraction angiography of the brain revealed steno-occlusion at the terminal ends of the bilateral internal carotid arteries with the development of collateral vascular network. To our knowledge, this is the first case presenting with clinical symptoms of VP as the initial mani-festation of moyamoya disease. Our case allows us to supplement clinical symptoms of VP to the initial manifestation of moyamoya disease, resulted from chronic ischemia to cortical and subcortical areas of the brain. 649 Acute stroke: clinical patterns and practice Impact of systems change on stroke thrombolysis in Nova Scotia, Canada S. Phillips1, D. Hunter2, C. Christian3, W. Simpkin4, K. White5, G. Gubitz6, J. Shankar7, S. Swine-mar8, M. Mooney9, T. Vardy10, M. O’Handley11, M. MacGrath12, T. MacGillivary13, N. Gill14 Capital Health and Dalhousie University, Halifax, CANADA1, University of Aberdeen, Aber-deen, UNITED KINGDOM2, Capital Health, Halifax, CANADA3, Capital Health, Halifax, CANA-DA4, Cardiovascular Health Nova Scotia, Halifax, CANADA5, Capital Health and Dalhousie Uni-versity, Halifax, CANADA6, Capital Health and Dalhousie University, Halifax, CANADA7, South Shore Health, Bridgewater, CANADA8, South West Health, Yarmouth, CANADA9, Annapolis Valley Health Authority, Kentville, CANADA10, Colchester East Hants Health Authority, Truro, CANADA11, Guysborough Antigonish Strait Health Authority, Antigonish, CANADA12, Cape Breton District Health Authority, Sydney, CANADA13, Cardiovascular Health Nova Scotia, Halifax, CANADA14 Background: Stroke treatment with intravenous alteplase (IV tPA) remains under-used in many health care jurisdictions. Here we report the impact of systems change in the province of Nova Sco-tia, Canada (population about 980,000). Methods: Cardiovascular Health Nova Scotia (CVHNS), a program of the Nova Scotia Depart-ment of Health and Wellness, led the development of the Nova Scotia Stroke System, comprised of the Capital District Stroke Program (CDSP, serving a population of about 400,000) and 6 smaller District Stroke Programs (DSPs). To increase province-wide utilization of IV tPA, all districts im-plemented ambulance bypass protocols (ABPs) (in CDSP on World Stroke Day 2010) and, in Nov 2011, CVHNS hosted a forum involving key clinical and administrative personnel from all DSPs in order to stimulate the development of policies and procedures for more effective and efficient deliv-ery of IV tPA. CDSP implemented its Acute Stroke Protocol (ASP) on 01 Apr 2012. Pre-systems change data sources were the Registry of the CDSP (RCDSP) and the 2004/05 Nova Scotia Stroke Audit. Post-systems change data sources were the RCDSP and the CVHNS stroke database. Results: In the CDSP: a) 8% (247/3265) of ischemic strokes were treated with IV tPA 30May1996- 31May2009 (P=0.2); b) after extension of the treatment window to 4.5 h in Jun 2009, 12% (50/421) were treated (P=0.002); c) post-ABP (29Oct2010-31Mar2012), 20% (89/366) were treated (P<0.001); d) post-ASP (01Apr-27Sep2012), 23% (49/218) were treated (P=0.6); e) median (in-ter- quartile range) door-to-treatment time (minutes) was 93 (47-139) pre-ASP (Oct2010-Mar2012) and 74 (54-94) post-ASP (Apr-Sep 2012; P<0.001). In the other 6 DSPs, 4% (14/341) were treated in Apr2004-Mar2005 and 15% (58/400) in Jul2011-Mar2012 (P<0.001). Conclusion: Recent systems change in Nova Scotia increased the use of IV tPA. Ambulance bypass increased the proportion of patients treated; an in-hospital protocol improved treatment efficiency.


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