Long-term outcome of a pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack: study protocol.

BACKGROUND: Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of incident cardiovascular events and recurrent stroke. Despite compelling evidence about the efficacy of secondary prevention, a substantial gap exists between risk factor management in real life and that recommended by international guidelines. We conducted the STROKE-CARD trial (NCT02156778), a multifaceted pragmatic disease management program between 2014 and 2018 with follow-up until 2019. This program successfully reduced cardiovascular risk and improved health-related quality of life and functional outcome in patients with acute ischaemic stroke or TIA within 12 months after the index event. To investigate potential long-term effects of STROKE-CARD care compared to standard care, an extension of follow-up is warranted. METHODS: We aim to include all patients from the STROKE-CARD trial (n = 2149) for long-term follow-up between 2019 and 2021 with the study visit scheduled 3-6 years after the stroke/TIA event. The co-primary endpoint is the composite of major recurrent cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, and vascular death) from hospital discharge until the long-term follow-up visit and health-related quality of life measured with the European Quality of Life-5 Dimensions (EQ-5D-3L) at the final visit. Secondary endpoints include overall mortality, long-term functional outcome, and target-level achievement in risk factor management. DISCUSSION: This long-term follow-up will provide evidence on whether the pragmatic post-stroke/TIA intervention program STROKE-CARD is capable of preventing recurrent cardiovascular events and improving quality-of-life in the long run. Trial registration clinicaltrials.gov: NCT04205006 on 19 December 2019.

Successful treatment of refractory cerebral oedema in ecstasy/cocaine-induced fulminant hepatic failure using a new high-efficacy liver detoxification device (FPSA-Prometheus).

Ecstasy-induced fulminant hepatic failure is associated with high mortality. If complicated by cerebral oedema, orthotopic liver transplantation is the only established treatment. We report a case of combined ecstasy/cocaine-induced fulminant hepatic failure presenting with severe rhabdomyolysis, myocardial infarction and multiorgan failure. Transplantation was declined by the transplant surgeons because of a history of intravenous drug abuse. As excessive hyperammonaemia (318 mumol/l) and refractory transtentorial herniation developed, treatment with a new liver detoxification device combining high-flux haemodialysis and adsorption (FPSA-Prometheus) was initiated. Within a few hours of treatment, ammonia levels normalised. Cerebral oedema was greatly reduced by day 4 and hepatic function gradually recovered. Following neurologic rehabilitation for ischaemic sequelae of herniation, the patient was discharged from hospital with only minimal deficits. In conclusion, efficient extracorporeal detoxification may be an option for reversal of hyperammonaemia and refractory cerebral oedema in ecstasy/cocaine-induced acute liver failure.

Clinical features of unilateral headaches beyond migraine and cluster headache and their response to indomethacin.

The majority of previous studies on unilateral headaches beyond migraine and cluster headache have focussed on certain disorders such as paroxysmal hemicrania, SUNCT and primary stabbing headache. We assessed headache characteristics, importance of neuroimaging and response to indomethacin in an unselected series of uncommon unilateral headaches. We investigated all consecutive patients presented with unilateral headaches not fulfilling ICHD-II criteria of migraine and cluster headache. Patients underwent cranial magnetic resonance imaging or computed tomography as well as an indo-test, i.e. oral indomethacin 75 mg b.i.d. for 3 days. Among 63 patients we diagnosed primary stabbing headache in 12 patients, (probable) paroxysmal hemicrania in 6 and tension-type headache in 3 patients. One patient each had probable SUNCT, new daily persistent headache and nasociliary neuralgia. Eight patients had a secondary headache and 31 could not be classified according to ICDH-II. Imaging revealed lesions causally related to the headache in 8 patients. Indo-test achieved full remission of headache in 13 of 51 patients. At follow-up 11 ± 3 months after the first visit 29% of the patients were headache-free for ≥3 months. In conclusion, almost half of the patients presented with unilateral headaches beyond migraine and cluster headache cannot be classified according to ICHD-II. Among classifiable headaches primary stabbing headache was the most common. Imaging should be considered to rule out secondary headaches. The course is favourable in one third of the patients.

Facial pain and the second edition of the International Classification of Headache Disorders.

BACKGROUND: Recurrent or chronic facial pain may be a diagnostic challenge. Applying the diagnostic criteria of the second edition of the International Classification of Headache Disorders (ICHD-II) leaves a considerable number of patients unclassifiable. OBJECTIVE: The aim of this study was to establish and evaluate revised criteria of trigeminal neuralgia and persistent idiopathic facial pain. METHODS: Based on the diagnostic value of 12 clinical features of trigeminal neuralgia and 15 features of persistent idiopathic facial in 97 patients referred for facial pain to a neurological tertiary care centre we established revised criteria for persistent idiopathic facial pain and additional criteria for probable trigeminal neuralgia and probable idiopathic facial pain. RESULTS: Applying the newly proposed criteria reduced the number of patients with facial pain not classifiable by more than 50%. The new criteria improved the sensitivity, particularly in idiopathic facial pain and did not cause a relevant decrease in specificity compared to ICHD-II. CONCLUSION: This study suggests that amendments to the ICHD-II criteria improve the diagnostic classification of facial pain.

Eletriptan for the short-term prophylaxis of cluster headache.

BACKGROUND: A beneficial prophylactic effect from eletriptan 40 mg given to a single patient with cluster headache was observed. OBJECTIVE: To further evaluate the efficacy of eletriptan in the short-term prophylaxis of cluster headache. METHODS: We treated 18 patients; mean age, 40.5 years (standard deviation [SD], 9.9). The number of cluster headache attacks was recorded during a baseline period of 6 days, and during 6 days of treatment with eletriptan 40 mg twice daily. The primary outcome measure was the reduction in the number of attacks during the treatment period. RESULTS: In the 16 patients who completed the study (2 patients were lost to follow-up), the mean total number of attacks decreased from 10.9 (SD, 5.6) during baseline to 6.3 (SD, 3.7) during treatment with eletriptan (P=.01) The reduction in the number of attacks exceeded 50% in 6 patients. CONCLUSION: This small open-label study suggests that eletriptan 40 mg twice daily may be useful for the short-term prophylaxis of cluster headache.