[Telemedicine in stroke-pertinent to stroke care in Germany]. / Telemedizin in der Schlaganfallversorgung ­ versorgungsrelevant für Deutschland.

BACKGROUND AND OBJECTIVE: Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution. METHODS: The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks. RESULTS: Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states. CONCLUSION: Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

Sex differences in perihemorrhagic edema evolution after spontaneous intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Clinical data on sex differences in perihemorrhagic edema (PHE) after intracerebral hemorrhage (ICH) are lacking. METHODS: Patients with spontaneous supratentorial ICH who had received standard conservative treatment were identified retrospectively. PHE development was assessed over a 14-day period on follow-up CT scans (days 1, 2-4, 5-7, 8-11, and 12-14). ICH and PHE volumes were assessed semiautomatically and compared between men and women. RESULTS: A total of 387 patients (233 men) were included. Starting at days 2-4, women showed lower PHE values (P < 0.05; days 2-4, 8-11) or a trend toward significance (P ≤ 0.1; days 5-7, 12-14). CONCLUSIONS: Female sex may predict lower PHE volumes.

Radiopacity of intracerebral hemorrhage correlates with perihemorrhagic edema.

BACKGROUND: Experimental evidence indicates that iron plays a key role in edema formation after intracerebral hemorrhage (ICH). We investigated the relationship between ICH radiopacity on CT as a marker of hematoma iron content and perihemorrhagic edema (PHE) after ICH. METHODS: We retrospectively investigated patients with spontaneous lobar and ganglionic supratentorial ICH who received follow-up CT scans during the first 7days after symptom onset (d1, d2-4, d5-7). Measurements of ICH and edema volumes were taken using a semiautomatic threshold-based volumetric algorithm. Radiopacity of the blood clot was determined using the mean Hounsfield unit (HU) count of the ICH. RESULTS: A total of 117 patients aged 71.92±11.55years with spontaneous ICH (34.63±32.44ml) were included in the analysis. Mean ICH radiopacity was 59.7±3.4HU. We found significantly larger relative PHE at d2-4 (1.7±0.9 vs. 1.3±0.8; P=0.032) and d5-7 (2.0±1.3 vs. 1.3±0.9; P=0.007) and larger peak relative PHE (2.3±1.6 vs. 1.6±1.1; P=0.006) in patients with ICH radiopacity >60HU (n=59), as compared to patients with ICH radiopacity <60HU (n=58). CONCLUSIONS: Higher ICH radiopacity, reflecting higher in vivo hematoma iron content, is associated with more PHE after ICH.

Single versus bilateral external ventricular drainage for intraventricular fibrinolysis in severe ventricular haemorrhage.

BACKGROUND: Intraventricular fibrinolysis (IVF) through bilateral external ventricular drains (EVD) may provide better access of the thrombolytic agent to the intraventricular clot, potentially influencing clot clearance and outcome. METHODS: Patients with spontaneous ganglionic intracerebral haemorrhage (ICH)<40 cm(3) and intraventricular haemorrhage (IVH) with acute hydrocephalus have been treated with IVF. The decision for placement of one or two EVDs has been left to the discretion of the treating physician. CT volumetry, the effects on cerebrospinal fluid (CSF) circulation and outcome at 3 months have been analysed for patients with one (group I, n = 13) or two EVDs (group II, n = 14). RESULTS: No difference was found in clot resolution between the two groups (clot half life 2.1 (SD 1.2) vs 2.4 (1.3) days). A separate analysis of the third and fourth ventricle clearance was similar (1.6 (0.6) versus 1.8 (0.8) days), indicating no difference in reconstitution of CSF circulation. A trend towards a longer EVD duration and higher infection rate was found in the bilateral EVD group. No difference was found in outcome at 3 months. CONCLUSIONS: Our results do not support the use of bilateral EVDs for IVF in patients with severe IVH.

Comparison of conventional CTA and volume perfusion CTA in evaluation of cerebral arterial vasculature in acute stroke.

BACKGROUND AND PURPOSE: CTA-like datasets can be reconstructed from whole-brain VPCTA. The aim of our study was to compare VPCTA with CTA for detection of intracranial stenosis and occlusion in stroke patients. Omitting CTA from stroke CT could reduce radiation dose. MATERIALS AND METHODS: One hundred sixty-three patients were included in this retrospective analysis. Inclusion criterion was suspected stroke within 4.5 hours after onset of symptoms. All examinations were performed on a 128-section multidetector CT scanner. Axial, coronal, and sagittal maximum intensity projections were reconstructed from CTA and from peak arterial phase of VPCTA. Images were scored for quality and presence of intracranial stenosis >50% or occlusion. For statistical analysis, the Wilcoxon signed-rank test and Fisher exact test were used, with a 2-tailed P value of .05 or less for statistical significance. RESULTS: Average image quality was superior in CTA (P < .05). However, image quality dichotomized for diagnostic significance was without difference between CTA and VPCTA (P > .05). Comparative statistical analysis revealed no significant difference for detection of intracranial stenosis and occlusion between CTA and VPCTA (P > .05). Substitution of intracranial CTA by VPCTA would lower radiation dose by 0.5 mSv. CONCLUSIONS: VPCTA is suited to assess the intracranial vasculature in patients with stroke and might have the potential to decrease radiation dose by substituting for intracranial CTA in stroke CT. Additional studies are necessary to further evaluate potential benefits of the dynamic nature of VPCTA.

Therapeutic hypothermia for space-occupying Herpes simplex virus encephalitis.

Development of space-occupying edema in patients with severe Herpes simplex virus encephalitis is a major factor for high morbidity and mortality. Conventional intracranial pressure-lowering modalities are limited and more aggressive treatment options for such patients have rarely been described. This article reports on a HIV-positive patient with Herpes simplex type 2 encephalitis and elevated intracranial pressure refractory to medical therapy. Induced moderate hypothermia of 33 °C resulted in fast and sustained control of intracranial pressure. After three months, the patient had a fairly good functional outcome with a Glasgow Outcome Scale score of 4.