Medical nutrition therapy of stroke patients with dysphagia ­ 2021 / A dysphagia táplálásterápiája stroke-betegek esetében - 2021.

Összefoglaló. A neurológiai betegek körében a dysphagia elofordulása gyakori, és több oka van. Az utóbbi évek kutatásai a közvetlen neurológiai kórokok (beleértve a gyakori stroke) szerepét is részletesen feltárták. Felismerték az ún. néma aspiráció jelentoségét: ez gyakran áll az (aspirációs) pneumonia hátterében, amely sokszor halálos szövodmény lehet. Az ún. poststroke pneumonia fogalma gyökeresen más értelmezésbe helyezte a stroke-ot követo tüdogyulladások megítélését, jellegzetessége alapján egyértelmuen a stroke közvetlen cerebralis hatásaként alakul ki. Egyértelmuvé vált a nyelészavar korai felismerésének és ellátásának szükségessége. A stroke-betegek megfelelo tápláltsági állapota az eredményes rehabilitációnak, a szövodményszám csökkentésének, a rövidebb kórházi kezelésnek, az alacsonyabb mortalitásnak a záloga. A dysphagia a betegség kimenetelének független elorejelzoje lehet, különösen az elso három hónapban. A nyelészavar malnutritióval, kiszáradással és a kórházi tartózkodás hosszabb idotartamával jár együtt, emeli a gyógyszerköltségeket. A stroke-beteg ellátásának egyik elso eleme a dysphagia szurése. Táplálásterápiára akkor szorul a stroke-beteg, amikor magas a kóros tápláltsági állapot kialakulásának kockázata, és per os táplálással nem fedezheto biztonságosan a megfelelo energia-, tápanyag- és folyadékbevitel. A táplálásterápia módját, eszközeit, az energia- és tápanyagbeviteli célértékeket az orvos határozza meg, az alapbetegség súlyosságától, a társbetegségektol és a laborértékektol függoen. Az étrend minden esetben individuális és progresszív, azaz alkalmazkodik a beteg állapotához és annak változásához. A dietetikus feladata a megfelelo diéta összeállítása mellett a beteg, a hozzátartozó és a kezeloszemélyzet oktatása, az állapot követése, a beteg tápláltsági állapotának, tápanyagbeviteli értékeinek gyakori elemzése, szükség esetén tápszerek ajánlása. Orv Hetil. 2021; 162(40): 1601-1609. Summary. Among neurological patients, the incidence of dysphagia is common and has several causes. Research in recent years has explored the role of direct neurological pathogens (including frequent strokes). The frequency of 'silent aspiration', which often underlies (aspirational) pneumonia and can be a fatal complication, has been recently discovered. The concept of 'post-stroke pneumonia' has drastically changed the assessment of post-stroke pneumonia. Based on its characteristics, it clearly develops as a direct cerebral effect of stroke. The need for early detection and early care of swallowing disorder has become clear. Adequate nutritional status of stroke patients is the key to successful rehabilitation, reduction of complications, shorter hospitalization, and lower mortality. Dysphagia can be an independent predictor of disease outcome, especially in the first three months. Swallowing disorder is associated with malnutrition, dehydration and longer lengths of hospital stay, increasing drug costs. One of the first elements in the care of a stroke patient is screening for dysphagia. The stroke patient needs nutritional therapy when the risk for abnormal nutritional condition is high or if the condition is already present, or when oral nutrition does not safely cover adequate energy, nutrient and fluid intake. The method and means of nutritional therapy, the goals of energy and nutrient intake are determined by the doctor, depending on the severity of the underlying disease, comorbidities and laboratory values.The diet is individual and progressive in each case. The dietitian's task is not only to compile a proper diet, but also to educate the patients and relatives. The dietitian is responsible for monitoring the patient's nutritional status. Orv Hetil. 2021; 162(40): 1601-1609.

Impact of COVID-19 on ischemic stroke care in Hungary.

Data about the coronavirus disease 2019 (COVID-19) pandemic's collateral damage on ischemic stroke (IS) care during the second epidemic wave in Central Europe are limited. We sought to evaluate the impact of the COVID-19 outbreak on Hungarian IS care during the two epidemic waves. This retrospective observational study was based on a nationwide reimbursement database that encompasses all IS admissions and all reperfusion interventions, i.e., intravenous thrombolysis (IVT) and endovascular therapy (EVT) from 2 January 2017 to 31 December 2020 in Hungary. COVID-19 pandemic's effect on the number of IS admissions and reperfusion interventions were analyzed using different statistics: means, medians, trends, relative rates, and linear relationships. The mean and median values of IS admissions and reperfusion interventions decreased only in some measure during the COVID-periods. However, trend analysis demonstrated a significant decline from the trends. The decline's dynamic and amplitude have differed for each variable. In contrast to IVT, the number of IS admissions and EVTs negatively correlated with the epidemic waves' amplitude. Besides, the decrease in the number of IS admissions was more pronounced than the decrease in the number of reperfusion interventions. Our study demonstrated a significant disruption in IS care during the COVID-19 epidemic in Hungary, in which multiple different factors might play a role. The disproportionate reduction of IS admission numbers could partially be explained by the effect of health emergency operative measures and changes in patients' social behavior. Further studies are needed to evaluate the causes of our observations.

Coronary stent implantation for acute basilar artery occlusion with underlying stenosis.

AIMS: Our aim was to study the effectiveness of coronary stent implantation during the endovascular treatment (EVT) of acute basilar artery occlusion (BAO) with occlusion-underlying intracranial atherosclerotic stenosis (ICAS). METHODS AND RESULTS: We retrospectively analysed 91 consecutive BAO patients who underwent EVT between February 2014 and January 2019 in a single, high-volume neurointerventional centre. We studied the effect of immediate coronary stent implantation on the clinical outcome of BAO with occlusion-underlying stenosis. BAO patients with underlying ICAS (n=41) were characterised by longer symptom-onset-to-reperfusion times (231 min vs 173 min, p=0.0020), lower TICI 2b-3 reperfusion rates (65.85% vs 90.00%, p=0.0084), and higher overall mortality (HR 2.021, p=0.0417) compared to the BAO cases without ICAS (n=50). The patients undergoing stenting (n=18) had lower residual basilar artery (BA) stenosis (14.7% vs 81.0%, p<0.0001), higher chance for functional recovery (OR 7.6, p=0.0250) and higher chance of survival (HR 4.163, p=0.0026) compared to the BAO-ICAS cases treated without coronary stents (n=21). CONCLUSIONS: The immediate treatment of the occlusion-underlying stenosis with coronary stents and dual antiplatelet therapy (DAPT) in BAO was associated with improved overall survival and better functional outcomes.

New hospital structure in the twenty-first century: the position of level III (tertiary) neurological and stroke care in a changing healthcare system.

AIM: The determination of the necessary capacity and number of neurology wards of level III progressivity that can be defined in the system of criteria detailed in this article and which possess optimal operating conditions in Hungarian terms. METHODS: We used the National Health Insurance Company's database to calculate case numbers and capacity for different levels of neurological and stroke care. We also revised the allocation of advanced diagnostic and therapeutic technologies, and proposed changes, based on health insurance data. We also discussed these propositions with clinical experts to test their viability. RESULTS: We determined the adequate number of organisational units capable of providing special neurological healthcare services on the basis of the basic data of the Hungarian healthcare system, specifying this number as 6 instead of the current 11. CONCLUSIONS: In our study, we have identified significant bias in the nationwide level of neurological and stroke care organisation, which needs revised allocation of healthcare resources. Naturally, this can only be carried out through the restructuring of the emergency care system and the expansion of pre-hospital care.

[Thrombolysis in acute ischemic stroke with intravenous recombinant tissue-type plasminogen activator]. / Akut ischaemiás stroke thrombolysise intravénás rekombináns szöveti plazminogén aktivátorral.

INTRODUCTION: The authors summarised their experiences of systemic intravenous thrombolysis using recombinant tissue-type plasminogen activator with 3 hours therapeutic window in acute ischaemic stroke. AIM: The aim of this work was to test the safety and efficacy of systemic thrombolysis in our unselected, community-based patient population. RESULTS: The mean door-to-needle time was 45 minutes, the number of bleeding complications and successful recanalisation was similar to the results of the large international trials. In spite of these facts the functional outcome of our patients turned out to be worse. Compared to the baseline characteristics of the international trials the initial neurological deficit--a well known bad prognostic parameter- and also the comorbidity of our patients was more severe. CONCLUSION: In Hungary only patients with alarming, initial symptoms arrive quickly enough for thrombolysis to the hospital, while in most of the patients with less severe stroke symptoms the delay for hospital admission is more than 3 hours. The authors assume that with more effective patient education it might be possible to solve this problem and make thrombolysis to exert a greater impact on the effectiveness of the acute stroke therapy.

[Thrombolytic therapy in acute ischemic stroke with streptokinase]. / Akut ischaemiás stroke thrombolyticus kezelése sztreptokinázzal.

AIM AND METHODS: In an open, observational study, 40 consecutive ischemic stroke patients eligible for thrombolytic therapy using the combined ECASS/NINDS inclusion criteria have been treated intravenously with 1.5 M units of streptokinase. The therapeutic window was 3 hours or shorter. RESULTS: The safety analysis documented a low rate (5%) of intracerebral hemorrhages, and an additional 13% rate of hemorrhagic transformation of the initial infarction. Two patients died due to intracerebral bleeding. The efficacy of the SK thrombolysis was significant in 53% of the patients (the mean of the improvement on the NIH stroke scale was 15 points), while an other 42% of the patients achieved only the mean of 4 points improvement on their NIHSS score. DISCUSSION: These results are of the same magnitude, as those documented in the NINDS trial with rt-PA. Time window rather than the thrombolytic agent itself seems to be the decisive factor for successful thrombolysis. CONCLUSION: The good safety profile of SK in acute stroke using the ECASS/NINDS criteria, and the cost-effectiveness of the drug underline the necessity of a new SK trial with the recently accepted inclusion and exclusion criteria.

[Effectiveness and safety of intraventricular fibrinolysis in secondary intraventricular hemorrhages (a prospective, randomized study)]. / Az agykamrába töro vérzések lokális fibrinolízisének biztonságossága és hatékonysága (prospektív, randomizált vizsgálat).

BACKGROUND AND PURPOSE: Intraventricular clot secondary to brain hemorrhage has still one of the worst prognosis among all stroke subtypes, regardless of conservative therapy or surgical interventions. The rapid clot resolution with thrombolytic agents could improve the outcome by restoring the impaired cerebrospinal fluid circulation, for this reason, the authors examined the safety and efficacy of Urokinase therapy in a randomized, controlled study. METHODS: They enrolled 27 patients with severe intraventricular hemorrhage between 1998 and 2002. All patients had supratentorial intracerebral hemorrhage caused by hypertension, with IVH, moreover clinically worsening course due to the obstructive hydrocephalus confirmed by CT. Eleven persons were treated with ventriculostomy alone and 16 received adjunctive intraventricular urokinase. The authors examined the early, 30-day and 1-year mortality, furthermore the neurological (Scandinavian Stroke Scale) and functional outcome (Barthel Scale). The mean age was 60 +/- 9.5. The initial Scandinavian Stroke Scale was 7.51 +/- 8.64, Glasgow Coma Scale was 6.85 +/- 2.52, intracerebral hemorrhage volume was 22.44 +/- 18.14 ml. RESULTS: The 1 year survival rate was significant higher in the urokinase treated group (p = 0.014), This tendency in the mortality (31.3% vs. 54.5%) and in the neurological/functional condition (SSS, p = 0.078/Barthel, p = 0.119) at 30th day have been also documented. No hemorrhagic complications due to urokinase were observed. Two meningitis (7.4%) and two intraparenchymal hemorrhages (7.4%) related to drain insertion were detected (p = 0.009). The probability of pulmonary infection was roughly two times higher in the group without clot lysis (RR = 1.870; 95% CI: 1.004-3.482). CONCLUSIONS: In the authors experience, urokinase treatment reveals to be safe in the intraventricular clot lysis. This therapy allows earlier mobilization and rehabilitation, and decreases the number of infections, which are favorable to the long-term survival rate.

[Molecular markers of endothelial dysfunction in acute ischemic stroke]. / A vascularis endothelium károsodásának szignálmolekulái akut ischaemiás stroke-ban.

INTRODUCTION: In spite of all similarities, ischemic stroke cases representing 80% of the acute cerebrovascular accidents, different steps of platelet activation, coagulation and fibrinolytic cascade are involved in the pathomechanism of the different stroke subtypes. The differentiation of the atherothrombotic, cardioembolic and lacunar forms of acute ischemic stroke is based on the comprehensive evaluation of clinical signs, neuroimaging technics, and diagnostic ultrasound, but also a significant effort was made to characterize the specificities of the underlying processes of the coagulation system by signal molecules, in order to clarify their possible role and to support the diagnostic and therapeutic decisions. PATIENTS AND METHODS: The von Willebrand factor was studied as the marker of endothelial injury in 34 acute ischemic stroke patients within 24 hours after the onset of their stroke, and repeatedly 2, 4, and 12 weeks thereafter. To determine the probable source of the von Willebrand factor, usually released not only by endothelial cells, but also by platelets, the authors simultaneously measured the levels of an additional endothelial marker, thrombomodulin, and a platelet activation marker, beta-thromboglobulin. RESULTS: The mean of von Willebrand factor levels measured in stroke patients on the first day was 123%, whereas the mean of the control group 72% (p < 0.05). There was no significant difference according to stroke subtype. Von Willebrand values determined two weeks later showed a further 60% increase in stroke patients, and after a gradual fall their level remained above the concentration of the control group. The beta-thromboglobulin level measured in stroke group was significantly higher, than in control individuals (171 IU/ml vs. 32 IU/ml, p < 0.001). This was characteristic for atherothrombotic and cardioembolic stroke, but not for lacunar infarctions. If measured repeatedly, beta-thromboglobulin levels decreased rapidly in the first two weeks, than somewhat slower. Soluble thrombomodulin was slightly elevated in stroke patients (4.24 ng/ml) compared to healthy subjects (3.81 ng/ml), without statistical significance, and without major differences between subgroups. CONCLUSIONS: While early determination of beta-thromboglobulin can contribute to the differential diagnoses of the subtypes of ischemic stroke, the long-lasting elevation of von Willebrand factor may reflect endothelial dysfunction caused by several factors in the microvasculature of the penumbra.

Regional differences in incidence rates, outcome predictors and survival of stroke.

The aim of our study was to compare subtype-specific incidence rates, case-fatality rates and outcome predictors in different geographical areas, and decide what drives the variations. Analyzing standardized, prospective stroke registers in the Akita Prefecture, Japan, and in Hungary with catchment areas of more than 1.2 and 1.5 million during the same 18 months, we assumed population and ethnic variations in subtype-specific incidence rates, indicating higher risk of ischemic stroke in Hungary and higher risk of hemorrhagic stroke in Japan. The determinants of 28-day case-fatality rates, at least in part, also varied in different populations. However, survival from stroke was mainly influenced by stroke management.