A Simple and Safe Method for Checking the Position of Central Venous Catheters-A New and Reliable Threshold for Right Atrial Swirl Sign in Microbubbles Tests.

Background: Central venous catheters (CVCs) are indispensable tools in intensive care and emergency medicine. CVC malpositions still occur frequently and can cause various complications leading to increased patient mortality. A microbubbles test (MBT) can be used to confirm correct CVC positioning. However, there is serious doubt regarding whether the currently applied threshold of a 2 s push-to-bubbles time (PTB time) for rapid atrial swirl sign (RASS) in an MBT is reliable and accurate. The aim of the present study was to prove the quality of a new threshold: 1 s. Methods: Consecutive patients who were admitted to the intensive care unit (ICU) in a German neurological specialist hospital from 1 March 2021 to 20 July 2022 were enrolled. After ultrasound-guided CVC insertion, an MBT was performed, PTB time was measured, and RASS was interpreted. Additionally, a chest X-ray (CXR) was requested to check CVC position. Results: A total of 102 CVCs (98% jugular and 2% subclavian) were inserted in 102 patients (38% female and 62% male; median age: 66 years). Negative RASS (PTB time > 1 s) was observed in 2 out of 102 patients, resulting in an echocardiographic malposition rate of 2.0%. CXR confirmed the echocardiographic results. After correcting CVC position in the initially malpositioned CVCs, the PTB time was <1 s (positive RASS). The MBT protocol took about 0.5 min on average, while the CXR results were all available within 30 min. Sensitivity, specificity, and positive and negative predictive value were each 100% for the detection of CVC malpositions via an MBT using a threshold of 1 s compared to CXR. Conclusions: A new threshold of a 1 s PTB time for RASS in an MBT could detect CVC malpositions with excellent quality compared to CXR. Since the MBT was fast and safe and could be performed at the bedside, we propose that an MBT with the new and reliable threshold of 1 s should be routinely used in patient care.

Ultrasound assessment of brain supplying arteries (extracranial). / Die Ultraschalluntersuchung der hirnversorgenden Arterien (extrakraniell).

Ultrasonography of the brain-supplying arteries is a non-invasive and highly efficient technique for the assessment of a stenosis or a vessel occlusion in patients with cerebrovascular diseases. This article reviews the examination technique for a standardized ultrasound assessment of the extracranial carotid and vertebral arteries. It further describes the multiparametric grading criteria of internal carotid artery stenosis and it gives recommendations for a standardised documentation of findings. Additionally, it proposes recommendations for intima-media thickness measurement and for classifying atherosclerotic plaques with B-mode ultrasonography. Moreover, criteria for the diagnosis of in-stent stenoses, vertebral artery dissections and subclavian steal syndrome are provided.

Ultrasound assessment of brain supplying arteries (transcranial). / Die Ultraschalluntersuchung der hirnversorgenden Arterien (transkraniell).

Ultrasonography of intracranial arteries is a non-invasive and highly efficient method for the diagnosis and follow-up of patients with cerebrovascular diseases, also in the bedside setting of the critically ill. For reliable assessment and interpretation of sonographic findings, the technique requires - apart from dedicated anatomic and pathophysiological knowledge of cerebral arteries and their hemodynamics - the comprehension of alternative imaging modalities such as CT or MR angiography. This article reviews the transcranial color-coded duplex sonographic (TCCS) examination technique including the transcranial Doppler sonography (TCD) for a standardized ultrasound assessment of the intracranial arteries and typical pathological cases. As a complementary tool, transorbital ultrasound for the assessment of the optic nerve sheath diameter and adjacent structures is also described in this article.

Microembolizations in the Arterial Cerebral Circulation in Patients with Atrial Fibrillation Ablation Using the Cryoballoon Technique-Protocol and Methodology of a Prospective Observational Study.

There is considerable uncertainty regarding the impact of microembolic signals (MESs) on neuropsychological abilities in patients receiving pulmonary vein isolation and beyond using the cryoballoon technique. We conducted the largest prospective observational study on this topic, providing insights into the gradual unmasking of procedure-related MESs and their impacts on neuropsychological outcomes. MESs were continuously detected periprocedurally using transcranial Doppler ultrasonography. Neuropsychological status was evaluated comprehensively using the CERAD Plus test battery, which consists of 11 neuropsychological subtests. Patients with atrial fibrillation were included in the study with an equal distribution (50:50) of paroxysmal or persistent presentations. Of 167 consecutive eligible patients, 100 were included within the study enrollment period from February 2021 to August 2022. The study, including the documentation of all follow-up visits, ended in November 2022. This paper focuses on describing the study protocol and methodology and presenting the baseline data.

Analysis of the effect of cortisone on the QT interval.

BACKGROUND: Cardiac death caused by malignant arrhythmias is very prevalent. Prolongation of the QT interval is a relevant aspect in arrhythmia mechanisms. Prior studies have revealed that the QTc interval could be shortened by cortisone. Moreover, in an animal model of long QT syndrome, cortisone treatment shortens the ventricular action potential duration. The present study investigated the effect of methylprednisolone (MPS) on the QTc interval in cardiovascularly healthy humans. METHODS: Patients who had just been diagnosed with multiple sclerosis receiving MPS therapy were analysed prospectively. Demographic data, laboratory values, anti-arrhythmic medication and baseline and follow-up ECGs were extracted from the patients' medical records. RESULTS: Seventy-eight patients were included. The mean ± standard deviation age was 47 ± 15 years. The values of the electrolytes were normal. All patients were treated with MPS for 3 or 5 days. The heart rate increased at the beginning of MPS therapy and decreased during the subsequent period. ECG measurements showed that the QTc interval was prolonged at the beginning of MPS therapy and shortened over the course of treatment. The longest QTc intervals were obtained by calculation with Bazett's formula. CONCLUSIONS: In humans, cortisone shortens the QTc interval over time. The analysis indicates a cumulative effect of cortisone that lasts longer. The results of our pilot study reveal that cortisone might be added to therapeutic strategies in patients with long QT syndromes. Further clinical studies have to be carried out to analyze potential clinical options.

Poststenotic Distal Caliber Reduction Predicts Very High-Grade Proximal Internal Carotid Artery Stenosis.

BACKGROUND: Angiography relates the residual lumen to the poststenotic distal lumen (NASCET criterion) and expresses the result in percent lumen reduction. This method is not applicable when there is a collapse of the distal lumen, as seen in severe stenosis. The purpose of this study was to evaluate whether the reduced poststenotic caliber could be an additional sonographic criterion for estimation of the degree of stenosis. METHODS: We measured the caliber of the distal lumen of the extracranial internal carotid artery (ICA) in 57 patients with low-grade stenosis <50% (NASCET criterion), and in 57 patients with unilateral stenosis of ≥ 50 %. All were classified following international recommendations. The criteria used included the poststenotic velocity to discriminate moderate to high-grade stenosis (50-70%) from very high-grade (≥ 80 %) stenosis. In addition, we measured the interrater reliability of the ultrasonic measurement of the lumen in the distal ICA. RESULTS: In the group of patients with 50% to 70% stenosis, the distal lumen was 4.3 ± 0.6 mm. In the group with very high-grade stenosis ≥ 80%, the distal lumen was 2.6±0.5mm (p<0.0001). A distal lumen of 3.2 mm or less predicted a very high-grade stenosis with a sensitivity of 0.92 and a specificity of 0.96 (AUC 0.986; 95% CI 0.97-1.00; p=0.0001). CONCLUSION: The distal poststenotic lumen is an additional ultrasonic criterion to discriminate a very high-grade ICA stenosis from a lesser degree of ICA stenosis. It can help avoid misinterpretation due to the high variability of intrastenotic peak systolic velocities (PSV) in very high-grade ICA stenoses.

One decade of oral anticoagulation in stroke patients: Results from a large country-wide hospital-based registry.

Background New evidence regarding stroke prevention in atrial fibrillation has been published. Implementing knowledge into clinical practice remains challenging. Aims To investigate oral anticoagulants in stroke patients documented in a nationwide registry. Methods The database is an obligatory federal-state-wide hospital-based registry that covers more than 95% of all ischemic strokes, transient ischemic attacks and intracerebral hemorrhages in a community of more than six million inhabitants (Hesse/Germany). We analyzed oral anticoagulants prescribed on discharge in patients with stroke or transient ischemic attack during 2006-2015. Results From 2006 to 2015, we annually selected median 20,895 patients. From 2006 to 2015, the proportion of patients treated with oral anticoagulants increased (9.8% to 24%). The annual proportion of patients with atrial fibrillation remained constant (median: 23%). In atrial fibrillation patients treated with oral anticoagulants, the age increased (median 2008/2009: 76.9 years vs. 2014/2015 79.4 years). The percentage of treated individuals in atrial fibrillation increased dramatically (2006: 30.1% to 2015: 74.5%); in 2015, 30.8% of these patients received vitamin K antagonists and 70.2% new oral anticoagulants. Independent factors associated with new oral anticoagulants therapy were a previous medication with new oral anticoagulants and a treatment on stroke unit. Between new oral anticoagulants- and vitamin K antagonists-treated patients (2015), no differences in age were noted (both mean: 79.4 years). Conclusions The new oral anticoagulants availability enhanced a general trend treating more target patients with oral anticoagulants.

Excellent interrater agreement for the differentiation of fasciculations and artefacts - a dynamic myosonography study.

OBJECTIVE: The aim of the study was to confirm the diagnostic performance of dynamic myosonography with regard to its reliability to correctly identify fasciculations and to distinguish them from artefacts. Furthermore, interrater agreement regarding the identification of different muscle movements was investigated. METHODS: A total of 11 observers analysed 25 muscle ultrasound videos acquired using a standardized protocol. The video files illustrated fasciculations and artefacts (voluntary probe movements, voluntary contractions or swallowing and pulsating vessels) in different muscle groups. RESULTS: Fasciculations could be distinguished from artefacts with a sensitivity of 90.9% and specificity of 98.5%. Interrater agreement regarding the presence or absence of fasciculations showed an overall median of 100% (interquartile range, IQR: 96-100%). In every investigated muscle group, the median of the interpreter agreement was found to be 100% (correct ratings of all observers: submental muscles: 43 of 44; biceps muscles: 22 of 22; forearm flexors: 31 of 33; rectus abdominis muscles: 33 of 33; quadriceps muscles: 19 of 22; tibialis anterior muscles: 51 of 55; undefinable muscles: 65 of 66). CONCLUSION: Dynamic myosonography is an extremely reliable tool with excellent interrater agreement to correctly identify fasciculations and to distinguish them from artefacts. SIGNIFICANCE: Myosonography should be further incorporated in clinical routine diagnostic work-up.

Cardiac Troponin I elevation after epileptic seizure.

BACKGROUND: Cardiac troponin-I (cTNI) is highly specific biomarker to prove myocardial damage, e.g. in acute coronary syndrome (ACS). However, it occurs in other conditions as well. We therefore analysed cTNI increase in patients after generalized convulsive seizure. METHODS: Consecutive patients admitted with acute generalized convulsive seizure were included in case of cTNI measurement on admission. Among 898 selected cases, 53 patients were referred secondary to our department; in 845 cases cTNI measurements on admission were available. In case of multiple admissions (81 cases), only the first admission entered our analysis. In 17 patients elevated cTNI was determined due to ACS; in one patient a myocarditis was found. 5 patients suffered of relevant renal insufficiency. Finally 741 patients were included in the analysis. A cTNI cut-off level of ≥ 0.1 ng/ml was considered. Factors associated with a cTNI increase were analysed subsequently. RESULTS: The mean age of the study population (n = 741) was 47.8 years (SD ± 18.6), 40.9% were female. In 50 patients (6.7%) a cTNI elevation of unknown origin was found; no obvious cardiac involvement could be detected in these patients who all remained asymptomatic. A vascular risk profile (including at least hypertension, hypercholesterolemia or diabetes) (OR = 3.62; CI: 1.59 to 8.21; p = 0.001) and elevated creatine kinase on admission (OR = 2.36; CI: 1.26 to 4.39; p = 0.002) were independent factors associated with cTNI release. CONCLUSION: cTNI release occurs in patients with generalized convulsive seizure with predominance in patients with vascular risk profile.

Factors associated with shunt dynamic in patients with cryptogenic stroke and patent foramen ovale: an observational cohort study.

BACKGROUND: As previously reported there is evidence for a reduction in right to left shunt (RLS) in stroke patients with patent foramen ovale (PFO). This occurs predominantly in patients with cryptogenic stroke (CS). We therefore analysed factors associated with a shunt reduction on follow-up in stroke patients suffering of CS. METHODS: On index event PFO and RLS were proven by transesophageal echocardiography and contrast-enhanced transcranial Doppler-sonography (ce-TCD). Silent PE was proved by ventilation perfusion scintigraphy (V/Q) within the stroke work-up on index event; all scans were re-evaluated in a blinded manner by two experts. The RLS was re-assessed on follow-up by ce-TCD. A reduction in shunt volume was defined as a difference of ≥20 microembolic signals (MES) or the lack of evidence of RLS on follow-up. For subsequent analyses patients with CS were considered; parameters such as deep vein thrombosis (DVT) and silent pulmonary embolism (PE) were analysed. RESULTS: In 39 PFO patients suffering of a CS the RLS was re-assessed on follow-up. In all patients (n = 39) with CS a V/Q was performed; the median age was 40 years, 24 (61.5%) patients were female. In 27 patients a reduction in RLS was evident. Silent PE was evident in 18/39 patients (46.2%). Factors such as atrial septum aneurysm, DVT or even silent PE were not associated with RLS dynamics. A greater time delay from index event to follow-up assessment was associated with a decrease in shunt volume (median 12 vs. 6 months, p = 0.013). CONCLUSIONS: In patients with CS a reduction in RLS is not associated with the presence of a venous embolic event such as DVT or silent PE. A greater time delay between the initial and the follow-up investigation increases the likelihood for the detection of a reduction in RLS.

Cerebral vein thrombosis: clinical manifestation and diagnosis.

BACKGROUND: Cerebral venous thrombosis (CVT) is a disease with a wide spectrum of symptoms and severity. In this study we analysed the predictive value of clinical signs and symptoms and the contribution of D-dimer measurements for diagnosis. METHODS: We evaluated consecutive patients admitted with suspected CVT receiving non-invasive imaging. Symptoms and symptom combination as well as D-dimer levels were evaluated regarding their diagnostic value. RESULTS: 239 patients were included in this study, 170 (71%) were females. In 39 patients (16%) a CVT was found. For identifying a CVT patients underwent either a venous CT-angiography or MR-angiography or both. No combination of symptoms either alone or together with the D-dimer measurements had a sensitivity and positive predictive value as well as negative predictive value and specificity high enough to serve as red flag. D-dimer testing produced rates of 9% false positive and of 24% false negative results. For D-dimer values a Receiver Operating Characteristic curve (ROC) and the area under the curve (AUC = 0.921; CI: 0.864-0.977) were calculated. An increase of sensitivity above 0.9 results in a relevant decrease in specificity; a sensitivity of 0.9 matches a specificity value of 0.9. This corresponds to a D-dimer cut-off level of 0.16 µg/ml. CONCLUSION: Imaging as performed by venous CT-angiography or MR-angiography has a 1 to 2 in 10 chance to detect CVT when typical symptoms are present. D-dimer measurements are of limited clinical value because of false positive and negative results.

High frequency of silent pulmonary embolism in patients with cryptogenic stroke and patent foramen ovale.

BACKGROUND AND PURPOSE: Deep vein thrombosis and pulmonary embolism (PE) prove venous embolic activity and enforce the suspicion of paradoxical embolism in patients with stroke with patent foramen ovale. Because it has implications in secondary prevention, we investigated the frequency of silent PE in such a cohort of patients. METHODS: Patients with cryptogenic stroke or transient ischemic attack and patent foramen ovale who underwent a ventilation perfusion scintigraphy were identified from a stroke registry. Blinded from clinical data, ventilation perfusion scintigraphy scans were re-evaluated independently by 2 experts. Patients showing at least a subsegmental defect were considered as having silent PE. Factors potentially associated with PE were analyzed. RESULTS: The evaluation included 151 patients. Median age was 55.2 years and 59.9% were male. In 56 (37%) patients, silent PE was found; a deep vein thrombosis was evident in 11 (7%) patients. Atrial septal aneurysm was identified in 39 patients and hypermobile atrial septum in 37 patients. Atrial septal aneurysm and hypermobile atrial septum were independently associated with PE. In females, intake of oral contraceptives showed certain association with PE (6 of 25 versus 3 of 40; P=0.07). CONCLUSIONS: Silent PE frequently occurs in patients with cryptogenic stroke and patent foramen ovale, particularly when atrial septal aneurysm or hypermobile atrial septum are present.

Embolic lesion pattern in stroke patients with patent foramen ovale compared with patients lacking an embolic source.

BACKGROUND AND PURPOSE: Multiple acute ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI-MRI) are thought to be of embolic origin. However, in several patients with multiple ischemic lesions on DWI-MRI, no embolic source was detected, despite a thorough clinical work-up. Stroke etiology in such cases is then classified as cryptogenic. In other patients, a potential embolic source is limited to a patent foramen ovale (PFO) that may act as an embolic source of unsure relevance. We therefore examined the prevalence of the multiple-lesion pattern in patients with cryptogenic stroke compared with patients with PFO. METHODS: We screened 650 stroke patients by DWI-MRI. For the subsequent evaluation, we excluded patients with a cardiac embolic source other than PFO, symptomatic carotid artery disease, and other apparent stroke causes, such as dissection or vasculitis, and patients whose diagnostic work-up was incomplete. For the remaining 106 patients, we found DWI lesions in 73, who were subjected to further evaluation. RESULTS: There were no differences in the occurrence of the multiple-lesion pattern in patients with cryptogenic stroke compared with patients with PFO, either for the entire group or for the subgroup of young stroke patients who were <50 years old. Patients with PFO showed a significantly higher incidence of multiple lesions in the posterior circulation. CONCLUSIONS: The multiple-lesion pattern on DWI-MRI is not uncommon, even when extensive testing does not reveal any embolic source. Therefore, it is not possible to discriminate between cryptogenic stroke and stroke from an assumed paradoxical embolism.