Fatal intracranial haemorrhage occurring after oral anticoagulant treatment initiation for secondary stroke prevention in patients with atrial fibrillation.

BACKGROUND AND PURPOSE: In this pooled analysis of seven multicentre cohorts potential differences were investigated in the incidence, characteristics and outcomes between intracranial haemorrhages (ICHs) associated with the use of non-vitamin K antagonist oral anticoagulants (NOAC-ICH) or with vitamin K antagonists (VKA-ICH) in ischaemic stroke patients after oral anticoagulant treatment initiation for atrial fibrillation (AF). METHODS: Data from 4912 eligible AF patients who were admitted in a stroke unit with ischaemic stroke or transient ischaemic attack and who were treated with either VKAs or NOACs within 3 months post-stroke were included. Fatal ICH was defined as death occurring during the first 30 days after ICH onset. A meta-analysis of available observational studies reporting 30-day mortality rates from NOAC-ICH or VKA-ICH onset was additionally performed. RESULTS: During 5970 patient-years of follow-up 71 participants had an ICH, of whom 20 were NOAC-ICH and 51 VKA-ICH. Patients in the two groups had comparable baseline characteristics, except for the higher prevalence of kidney disease in VKA-ICH patients. There was a non-significant higher number of fatal ICH in patients with VKAs (11 events per 3385 patient-years) than in those with NOACs (three events per 2623 patient-years; hazard ratio 0.32, 95% confidence interval 0.09-1.14). Three-month functional outcomes were similar (P > 0.2) in the two groups. The meta-analysis showed a lower 30-day mortality risk for patients with NOAC-ICH compared to VKA-ICH (relative risk 0.70, 95% confidence interval 0.51-0.95). CONCLUSIONS: Non-vitamin K oral anticoagulants for intracranial haemorrhages and VKA-ICH occurring during secondary stroke prevention of AF patients have comparable baseline characteristics and outcomes except for the risk of fatal ICH within 30 days, which might be greater in VKA-ICH.

[Endovascular thrombectomy for ischemic stroke]. / Rekanalisierende Therapie bei ischämischem Schlaganfall.

The standard of care for patients with acute stroke of the anterior circulation and large vessel occlusion is the combined treatment with intravenous rt-PA (recombinant tissue-type plasminogen activator) and endovascular thrombectomy. The therapy is highly effective while reducing functional deficits and long-term disability. International guidelines recommend thrombectomy during the first 6 h after symptom onset, but new evidence supports its use in selected patients within a time window of up to 24 h. Eligible patients show a clinical core mismatch, i. e. severe neurologic deficits contrasting to a small core of cerebral infarction. Future research questions regard the treatment of vessel occlusion at the M2 segments as well as the best anesthetic management during the intervention. The infrastructure of stroke care especially in rural areas is based on the drip-and-ship paradigm that implies emergency treatment with the start of intravenous thrombolysis at the nearest hospital followed by transport to an interventional center in case of large vessel occlusion.

[Therapeutic hypothermia in acute brain injury]. / Therapeutische Hypothermie bei akuten Hirnschädigungen.

Induced therapeutic hypothermia (TH) is defined as a controlled reduction of the core body temperature below the physiological range. While TH is neuroprotective in many different models of brain injury, it is only recommended for patients after cardiopulmonary resuscitation and newborns suffering from perinatal hypoxic-ischemic encephalopathy (HIE). Although a strong association exists between elevated body core temperature (fever) and worsening of outcome, TH has so far not been proven to influence outcome after ischemic stroke, intracerebral hemorrhage or subarachnoidal hemorrhage because of insufficient clinical data. This review summarizes the data on TH for different clinical indications and discusses relevant aspects of its use in neurological intensive care units.

[Antipyretic strategies for acute stroke: a nationwide survey among German stroke units]. / Antipyretische Strategien bei akutem Schlaganfall: Eine bundesweite Erhebung auf zertifizierten Stroke-Units.

BACKGROUND: Fever in acute stroke is associated with poor prognosis, but evidence-based recommendations on antipyretic therapy are lacking. METHODS: A nation-wide survey was carried out among all certified stoke units in Germany about principles and organization of antipyretic strategies. RESULTS: In all cases antipyretic treatment is the standard of care. The use of paracetamol is part of the first-line therapy in 94%. In cases of non-response, distinct heterogeneity of therapeutic methods and intensities becomes apparent leading potentially to insufficient antipyretic treatment. CONCLUSION: So far, there is uncertainty about the optimal antipyretic treatment strategy after acute stroke. While current guidelines are not very explicit, efforts should be made to define a standardized, evidence-based antipyretic protocol to improve patient care, outcome on stroke units and comparability of therapeutic strategies.

Enteric co-innervation of striated muscle fibres in human oesophagus.

Oesophageal striated muscle of several mammalian species receives dual innervation from both vagal motor fibres originating in the brain stem and enteric nerve fibres originating in myenteric ganglia. The aim of this study was to investigate this so-called enteric co-innervation in the human oesophagus. Histochemical and immunohistochemical methods combined with confocal laser scanning microscopy were utilized to study innervation of 14 oesophagi obtained from body donors (age range 47-95 years). In addition, the distribution of striated and smooth muscle in longitudinal and circular layers of the tunica muscularis was studied semiquantitatively. The upper half of the oesophagus was built up of both muscle types with a predominance (>50-60%) of striated muscle, whereas the lower half consisted of smooth muscle only. The majority of motor endplates was compact and ovoid. Enteric nerve fibres on approximately 17% of motor endplates stained for neuronal nitric oxide synthase, vasoactive intestinal polypeptide, galanin and neuropeptide Y and were completely separated from vagal cholinergic nerve terminals. There was remarkable variability of co-innervation rates between striated muscle bundles with some reaching almost 50%. Myenteric neurons representing the putative source of enteric co-innervating nerve fibres, stained for all these markers, which were almost completely colocalized with NADPH-diaphorase. Our study provides evidence for enteric co-innervation of striated muscle in human oesophagus. From these and recent functional results in various rodent species, we suggest that this innervation component represents an integral part of an intramural reflex mechanism for local most likely inhibitory modulation of oesophageal motility.

Quantitative evaluation of body surface potential mapping of heart electrical field in ischaemic heart disease.

New possibilities of quantitative evaluation of body surface potential mapping were studied in 78 patients with ischaemic heart disease. Integral maps of the Q wave, QRS and ST-T intervals were plotted and isochronous maps of ventricular activation time and maps of asynchronous potential minima of the Q wave were determined. Minimum and maximum potential values and their time relations were evaluated in the maps. Left ventricular contraction abnormality detected by left ventricular angiography was determined by a point score and expressed as an index of asynergy. The number of coronary artery branches with significant narrowing was assessed and the extent of coronary artery damage was evaluated by an arbitrary defined index. Using quantitative parameters from the maps, multiple stepwise linear regression was performed. The relationship between map parameters and index of asynergy corresponded to multiple correlation coefficient r = 0.69 (p = 0.01) in the whole group of patients. In the group of patients with left ventricular contraction abnormality the relationship between these parameters was found to be r = 0.87 (p = 0.01). The relationship between map parameters and the number of coronary artery branches with significant stenosis was r = 0.60 (p = 0.01) in the group of patients with positive coronary angiography. In the same group of patients the relationship between map parameters and the index evaluating coronary artery damage was equal to r = 0.63 (p = 0.01). The data obtained from body surface integral maps enable to quantify cardiac ischaemic damage.

[The relation of flow velocity in the carotid vessels to age]. / Závislost prutokové rychlosti v karotickém recisti na veku.

Using continual Doppler sonography, the authors measured the highest systolic blood flow rate in the extracranial carotid bloodstream in 3 groups of non-cardiac patients of an average age of 22, 76 and 93 years. In each group, the arteria carotis communis showed, with increasing age, a decrease in the highest systolic rate: 0.692 +/- 0.084 - 0.414 +/- 0.073 - 0.297 +/- 0.031 m/s (p less than 0.01 in all the three groups). Equally, a decrease in the highest systolic rate was found in the arteria carotis interna: 0.506 +/- 0.071 - 0.298 +/- 0.064 - 0.211 +/- 0.10 m/s (p less than 0.01 in all 3 groups). The paper shows a statistically significant decrease in the systolic blood rate in the carotid bloodstream related to aging (p less than 0.01) and discusses causes of this phenomenon.