A Network-Wide Stroke Team Program Reduces Time to Treatment for Endovascular Stroke Therapy in a Regional Stroke-Network.

BACKGROUND AND PURPOSE: Driven by the positive results of randomized, controlled trials of endovascular stroke therapies (EVT) in stroke patients with large vessel occlusion, different approaches to speed up the workflow for EVT candidates are currently being implemented worldwide. We aimed to assess the effect of a simple stroke network-wide workflow improvement project, primarily focusing on i.v. thrombolysis, on process times for patients undergoing EVT. METHODS: In 2015, we conducted a network-wide, peer-to-peer acute stroke workflow improvement program for i.v. thrombolysis with the main components of implementing a binding team-based algorithm at every stroke unit of the regional network, educating all stroke teams about non-technical skills and providing a stroke-specific simulation training. Before and after the intervention we recorded periprocedural process times, including patients undergoing EVT at the 3 EVT-capable centers (January - June 2015, n = 80 vs. July 2015 - June 2016, n = 184). RESULTS: In this multi-centric evaluation of 268 patients receiving EVT, we observed a relevant shortening of the median time from symptom onset to EVT specifically in patients requiring secondary transfer by almost an hour (300 min, 25-75% interquartile range [IQR] 231-381 min to 254 min, IQR 215.25-341 min; p = 0.117), including a reduction of the median door-to-groin time at the EVT-capable center in this patient group by 15.5 min (59 min, IQR 35-102 min to 43.5 min, IQR 27.75-81.25 min; p = 0.063). In patients directly admitted to an EVT-capable center, the median door-to-groin interval was reduced by 10.5 min (125 min, IQR 83.5-170.5 min to 114.5 min, IQR 66.5-151 min; p = 0.167), but a considerable heterogeneity between the centers was observed (p < 0.001). CONCLUSIONS: We show that a simple network-wide workflow improvement program primarily directed at fast i.v. thrombolysis also accelerates process times for EVT candidates and is a promising measure to improve the performance of an entire stroke network.

[Comparison of Different Mechanical Insufflator-Exsufflator Systems by Measurement of the Peak Exspiratory Flow (PEF)]. / Vergleich verschiedener mechanischer Hustenhilfen durch Messung der exspiratorischen Spitzenflüsse.

Background The management of pulmonary secretion in patients with respiratory muscle weakness using mechanical insufflator-exsufflator systems (MIE) is an established treatment option. There are significant differences in the efficiency of different devices in practical use. The intention of this study was to evaluate the peak exspiratory flow (PEF) values of different devices with and without use of equipment. Methods PEFs of ten MIE were investigated in vitro using different equipment. Results The efficiency of the devices showed significant differences. The use of two bacterial filters showed a significant reduction of 13 % compared to one filter, the use of a catheter mount revealed a significant reduction of 10 %, with an elbow connector additionally 15 %. With a commonly used equipment (1800 mm tube, one filter, catheter tube with elbow) there was a difference of 58 % between the devices Nippy (2,86 l/s) and Pulsar (1,2 l/s). Conclusion There are significant differences in PEF of different MIE and use of different equipment. That could be of therapeutic relevance. Further studies are needed to investigate the clinical relevance of these findings. Recommendations for the use of devices and equipment are necessary to ensure the efficacy of the elimination of pulmonary mucus.

A novel SOX10 mutation in a patient with PCWH who developed hypoxic-ischemic encephalopathy after E. coli sepsis.

UNLABELLED: We describe a male infant with a novel SOX10 mutation and a severe course of PCWH--a special phenotype of Shah-Waardenburg syndrome involving peripheral demyelinating neuropathy, central dysmyelinating leukodystrophy, Waardenburg syndrome, and Hirschsprung's disease. The patient had severe hypoplastic hypoganglionosis of the small and total colonic intestine together with peripheral and central dysmyelination. The patient was completely dependent on parenteral nutrition. We identified a novel frameshift mutation, p.Asp293GlyfsX10, in the SOX10 gene of this patient. The mutation would encode a protein that lacked the transactivation domain and resulted in the largest duplication described to date. At the age of 20 months, the boy presented with a severe complication with a translocation of Escherichia coli and developed sepsis leading to severe hypoxic-ischemic encephalopathy with persistent vegetative state (PVS). The boy died at the age of 24 months. CONCLUSION: Septic encephalopathy with hypoxic-ischemic encephalopathy can be a serious complication in severe sepsis. It is unknown to what extent the mutant SOX10 protein influenced the degree of brain injury--for example central nervous system susceptibility to hypoxia-during sepsis, which may explain the severe encephalopathy with clinical signs of PVS the boy developed.

In vivo detection of developing vessel occlusion in photothrombotic ischemic brain lesions in the rat by iron particle enhanced MRI.

The aim of our study was to visualize developing vessel occlusion in focal cerebral ischemia in vivo. Cortical photothrombosis (PT) was induced in rats, which in addition received superparamagnetic iron oxide (SPIO) particles intravenously. When SPIO particles were applied simultaneously during illumination of the brain for induction of PT, animals showed a markedly hypointense cortical lesion on T2-weighted (T2-w) magnetic-resonance images (MRI). At 3 h after PT, this hypointense area was surrounded by a small hyperintense rim. At 48 h after PT the hyperintense rim had further extended, whereas the hypointense lesion core did not change in size or signal. On histological sections areas of signal loss on T2-w MRI corresponded to local accumulation of iron particles, which were trapped within vessel thrombi. When SPIO particles were applied at 2 h after PT, the lesion appeared hyperintense on T2-w MRI, but was surrounded by a small hypointense rim indicating ongoing vessel occlusion at its outer margins. In contrast, delayed SPIO application at 24 h after completion of PT produced a merely hyperintense cortical lesion on T2-w MRI. Correspondingly, no iron deposits were seen on tissue sections. In conclusion, early SPIO-enhanced MRI provides a reliable in vivo tool to delineate areas of developing vessel occlusion in experimental cerebral ischemia and identifies vessel thrombosis as one mechanism of secondary infarct growth in the PT paradigm. This new imaging technique may aid to evaluate antithrombotic treatment strategies in the future.

Neurologic complications after particle embolization of intracranial meningiomas.

BACKGROUND AND PURPOSE: Preoperative embolization of meningiomas is frequently used to facilitate surgery and to reduce intraoperative blood loss. The purpose of this study was to evaluate the frequency of procedure-related neurologic complications during and after particle embolization of intracranial meningiomas. METHODS: Between 1996 and 2004, 185 consecutive patients underwent particle embolization of an intracranial meningioma. Devascularization was performed by means of superselective probing of the tumor-feeding vessels and ensuing free-flow embolization with spherical particles. All procedures were performed with systemic heparinization. RESULTS: Six patients (3.2%) had ischemic events with neurologic deficit. Two had amaurosis, and four patients presented with hemiparesis. Hemorrhage occurred in six patients (3.2%). In five of these patients, rapid microsurgical tumor removal resulted in a favorable outcome without persistent neurologic deficit. In one patient, massive intratumoral, subarachnoid, and subdural hemorrhage was lethal. CONCLUSION: Particle embolization of meningiomas is associated with a substantial risk of ischemic and hemorrhagic events. The individual risk-to-benefit ratio of embolization should be thoroughly considered.

Fatal atypical reversible posterior leukoencephalopathy syndrome: a case report.

INTRODUCTION: Reversible posterior leukoencephalopathy syndrome - a reversible subacute global encephalopathy clinically presenting with headache, altered mental status, visual symptoms such as hemianopsia or cortical blindness, motor symptoms, and focal or generalized seizures - is characterized by a subcortical vasogenic edema symmetrically affecting posterior brain regions. Complete reversibility of both clinical signs and magnetic resonance imaging lesions is regarded as a defining feature of reversible posterior leukoencephalopathy syndrome. Reversible posterior leukoencephalopathy syndrome is almost exclusively seen in the setting of a predisposing clinical condition, such as pre-eclampsia, systemic infections, sepsis and shock, certain autoimmune diseases, various malignancies and cytotoxic chemotherapy, transplantation and concomitant immunosuppression (especially with calcineurin inhibitors) as well as episodes of abrupt hypertension. We describe for the first time clinical, radiological and histological findings in a case of reversible posterior leukoencephalopathy syndrome with an irreversible and fatal outcome occurring in the absence of any of the known predisposing clinical conditions except for a hypertensive episode. CASE PRESENTATION: A 58-year-old Caucasian woman presented with a two-week history of subacute and progressive occipital headache, blurred vision and imbalance of gait and with no evidence for raised arterial blood pressure during the two weeks previous to admission. Her past medical history was unremarkable except for controlled arterial hypertension. Cerebral magnetic resonance imaging demonstrated cortical and subcortical lesions with combined vasogenic and cytotoxic edema atypical for both venous congestion and arterial infarction. Routine laboratory and cerebrospinal fluid parameters were normal. The diagnosis of reversible posterior leukoencephalopathy syndrome was established.Within hours after admission the patient showed a rapidly decreasing level of consciousness, extension and flexion synergisms, bilaterally extensor plantar responses and rapid cardiopulmonary decompensation requiring ventilatory and cardiocirculatory support. Follow-up cerebral imaging demonstrated widespread and confluent cytotoxic edematous lesions in different arterial territories, global cerebral swelling, and subsequent upper and lower brainstem herniation. Four days after admission, the patient was declared dead because of brain death. CONCLUSION: This case demonstrates that fulminant and fatal reversible posterior leukoencephalopathy syndrome may occur spontaneously, that is, in the absence of any of the known predisposing systemic conditions.

Proximal stent fixation of fractured coils: technical note.

Coil fracture represents a serious device-related complication during coil embolisation of intracranial aneurysms. If the coil cannot be retrieved completely, the loose end floating in the parent vessel can prolapse into the distal part of the vessel and may cause occlusion and brain infarction. We present a new technique in which the loose end of the fractured coil is fixed with a stent at the proximal parent vessel wall. Herniation of the loose coil end to the distal part of the vessel with potential vessel occlusion is therefore prevented. This procedure was technically feasible in all cases and no clinical complications were encountered. We suggest this new technique as a treatment option in cases of fractured coils.

Assessment of nerve degeneration by gadofluorine M-enhanced magnetic resonance imaging.

Nerve injury represents a major cause of disability. In the peripheral nervous system, nerves have the capacity to regrow but within weeks after injury, it is impossible to clarify whether proper regeneration is under way or is failing. In this experimental study, we report on a novel tool to assess nerve outgrowth in vivo. After systemic application, the novel gadolinium-based magnetic resonance (MR) contrast agent Gadofluorine M (Gf) selectively accumulated and persisted in nerve fibers undergoing Wallerian degeneration causing bright contrast on T1-weighted MR images. Gf enhancement on MR imaging was present already at 48 hours within the entire nerve segments undergoing Wallerian degeneration, and subsequently disappeared from proximal to distal parts in parallel to regrowth of nerve fibers. Most importantly, Gf enhancement persisted in nonregenerating, permanently transected nerves. Our novel Gf-based MR imaging methodology holds promise for clinical use to bridge the diagnostic gap between nerve injury and completed nerve regeneration, and to determine the necessity for neurolysis and engraftment if spontaneous regeneration is not successful.