[Interdisciplinary neurovascular networks: state of the art]. / Interdisziplinäre neurovaskuläre Netzwerke: eine Standortbestimmung.

BACKGROUND: In order to treat the complete spectrum of neurovascular diseases at a high level of quality, which goes beyond the purely acute treatment of stroke, the German Stroke Society (DSG) together with the German Societies for Neurosurgery and Neuroradiology developed a certification procedure for neurovascular networks (NVN). Structurally, a NVN consists of a coordinating center with at least three neurovascular network partners with a certified stroke unit. From 2018 to 2020 a total of 15 NVN have so far been audited and certified according to this new standard. OBJECTIVE: How efficient are the NVN? Are high standards maintained? MATERIAL AND METHODS: The reports of the audits were analyzed. The data were taken from the period 2017-2019. RESULTS: The 15 NVN treated a total of 86,510 stroke patients in the years examined and were networked with a total of 107 partner clinics, which were situated an average of 25 km from the coordinating center and transferred a total of 2726 patients. The coordinating centers performed 2463 thrombectomies and treated 2383 patients with nontraumatic intracerebral bleeding. In 712 patients with acute aneurysmatic subarachnoid hemorrhages endovascular treatment was carried out and clipping in 401. The audit was successful in the majority of the NVN. CONCLUSION: The certification process of NVN has been successfully established and the audits proved to be a useful instrument for quality control and improvement. The 15 NVN are highly efficient and treat more than one quarter of stroke patients in German stroke units.

[Juvenile stroke - what is important?] / Juveniler Schlaganfall ­ was gibt es zu beachten?

Stroke in young adults is a diagnostic and therapeutic challenge for all persons involved. Approximately 15% of ischemic strokes occur in young adults. Lack of awareness of the symptoms in emergency departments often results in delayed diagnosis and access to specific therapeutic options, such as revascularization. The causes are often heterogeneous and necessitate specific investigations. The etiology of juvenile stroke includes drug abuse, vasculitis and arteriopathies, such as reversible vasoconstriction syndrome and posterior reversible encephalopathy syndrome, although the prevalence of classical vascular risk factors is high. The most frequent causes of ischemic stroke in young adults are cardioembolism and microangiopathy; furthermore, dissection of vessels of the neck are more frequent compared to older patients. According to the results of currently available studies reperfusion strategies, such as intravenous fibrinolysis and mechanical thrombectomy are efficacious and safe in young patients.

[Cerebral amyloid angiopathy associated with inflammation]. / Zerebrale Amyloidangiopathie assoziiert mit Inflammation.

Cerebral amyloid angiopathy (CAA) associated with inflammation is a rare form of a potentially reversible encephalopathy in a subgroup of patients with CAA. The cerebral amyloid deposition can in isolated cases induce an inflammation predominantly of the cerebral blood vessels and a multifocal edema of the cerebral white matter. The courses can occur as monophasic, relapsing remitting and primarily progressive forms. We present seven cases with different courses of the disease and give an overview of the pathophysiology, clinical aspects and treatment of the disease with reference to the current literature. The cases presented show a very different and often difficult differential diagnostic clinical picture and all showed a significant improvement under steroid medication without signs of recurrence of the disease during the course. The recognition and early consistent treatment of inflammatory forms of CAA with and without direct inflammatory involvement of vessels can be decisive for successful treatment.

Reliability of the calculated maximal lactate steady state in amateur cyclists.

Complex performance diagnostics in sports medicine should contain maximal aerobic and maximal anaerobic performance. The requirements on appropriate stress protocols are high. To validate a test protocol quality criteria like objectivity and reliability are necessary. Therefore, the present study was performed in intention to analyze the reliability of maximal lactate production rate ([Formula: see text]Lamax) by using a sprint test, maximum oxygen consumption ([Formula: see text]O2max) by using a ramp test and, based on these data, resulting power in calculated maximum lactate-steady-state (PMLSS) especially for amateur cyclists. All subjects (n = 23, age 26 ± 4 years) were leisure cyclists. At three different days they completed first a sprint test to approximate [Formula: see text]Lamax. After 60 min of recreation time a ramp test to assess [Formula: see text]O2max was performed. The results of [Formula: see text]Lamax-test and [Formula: see text]O2max-test and the body weight were used to calculate PMLSS for all subjects. The intra class correlation (ICC) for [Formula: see text]Lamax and [Formula: see text]O2max was 0.904 and 0.987, respectively, coefficient of variation (CV) was 6.3% and 2.1%, respectively. Between the measurements the reliable change index of 0.11 mmol·l (-1)s (-1) for [Formula: see text]Lamax and 3.3 mlkg (-1)min (-1) for [Formula: see text]O2max achieved significance. The mean of the calculated PMLSS was 237 ± 72 W with an RCI of 9 W and reached with ICC = 0.985 a very high reliability. Both metabolic performance tests and the calculated PMLSS are reliable for leisure cyclists.

[Syncope from the viewpoint of a neurologist]. / Synkope aus der Sicht des Neurologen.

Syncope is a pathogenetically diverse syndrome that often requires an interdisciplinary investigation. In addition to cardiovascular reasons of syncope neurological diseases and differential diagnoses have to be considered. In particular, neurodegenerative disorders, such as Parkinson's disease or polyneuropathy may cause orthostatic intolerance and syncope due to a malfunction of autonomic reflexes. Furthermore, important differential diagnoses of syncope, such as epilepsy, drop attacks or circulatory disorders in the territory of the basilar artery are attributed to the neurological field.

[Medical treatment of Parkinson's disease in elderly and multimorbid patients]. / Pharmakotherapie des Morbus Parkinson beim älteren, multimorbiden Patienten.

BACKGROUND: Parkinson's disease is a frequent neurodegenerative disease, which typically occurs in older age. With progression of the disease, therapeutic complications, such as dyskinesias and fluctuations in the response to medication are common. To embed the medication of Parkinson's disease into a complex treatment plan of a patient suffering from multimorbidity can be challenging. OBJECTIVES: Not only the cardinal motor symptoms have to be treated properly but also the non-motor symptoms e.g. depression, dementia, autonomic dysregulations and gastrointestinal disorders. Pharmacological treatment and their risks are presented. CONCLUSION: Especially in older patients the symptoms need to be treated with regard to multimorbidity and the risks of polypharmacotherapy. The therapeutic strategy needs to be carefully planned in order to achieve a high quality of life and social interaction.

[Optimal stroke prevention in the geriatric patient with atrial fibrillation: position paper of an interdisciplinary expert panel]. / Optimale Schlaganfallprävention bei geriatrischen Patienten mit Vorhofflimmern. Konsensbericht eines interdiszipIinären Expertengremiums.

BACKGROUND: The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. METHOD: The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. RESULTS AND CONCLUSIONS: The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment AII patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2 score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric

[Heart or brain? Problem patients at the interface between cardiology and neurology]. / Herz oder Hirn? Problempatienten an der Schnittstelle zwischen Kardiologie und Neurologie.

A large number of patients fall into a category at the interface between heart or brain and are expected to require thorough clinical knowledge from both the cardiological as well as the neurological point of view for further patient-oriented treatment. The current article therefore addresses this important issue and aims to provide important information for clinical decision making for those patients at the interface between heart and brain. Due to the clinical impact, patients with carotid stenosis, a patent foramen ovale or non-valvular atrial fibrillation are described in more detail in this article.

Two-year vascular hospitalisation rates and associated costs in patients at risk of atherothrombosis in France and Germany: highest burden for peripheral arterial disease.

OBJECTIVES: To obtain Western European perspectives on the economic burden of atherothrombosis in patients with multiple risk factors only (MRF), cerebrovascular disease (CVD), coronary artery disease (CAD), and in the under-evaluated group of patients with peripheral arterial disease (PAD), we examined vascular-related hospitalisation rates and associated costs in France and Germany. DESIGN: The prospective REACH Registry enrolled 4693 patients in France, and 5594 patients in Germany (from December 2003 until June 2004). METHODS: For each country, 2-year rates and costs associated with cardiovascular events and vascular-related hospitalisations were examined for patients with MRF, CVD, CAD, and PAD. RESULTS: Two-year hospitalisation costs were highest for patients with PAD (3182.1€ for France; 2724.4€ for Germany) and lowest for the MRF group (749.1€ for France; 503.3€ for Germany). Peripheral revascularizations and amputations were the greatest contributors to costs for all risk groups. Across all PAD subgroups, peripheral procedures constituted approximately half of the 2-year costs. CONCLUSION: Hospitalisation rates and costs associated with atherothrombotic disease in France and Germany are high, especially so for patients with PAD.

[Industry-funded therapy studies: what is in the pipeline?]. / Industriegeförderte Therapiestudien : Was ist in der Pipeline?

Several acute stroke trials are underway or have been recently completed. Among the latter are the ICTUS trial and the IST-3 trial. Several other approaches are being tested for thrombolytic therapy among them modern imaging-based patient selection and new thrombolytic agents, such as desmoteplase and tenecteplase. Other strategies include neuroprotection and neurorestoration, biophysical approaches, such as near infrared laser therapy, hemodynamic augmentation and sphenopalatine ganglion stimulation. Mechanical thrombectomy is practiced in many centers although randomized trials are pending and the IMS-3 trial was stopped. This overview will cover the very recently completed and currently recruiting acute ischemic stroke trials.

[Regional and national stroke units in Germany: amended certification criteria]. / Regionale und überregionale Stroke-Units in Deutschland : Aktualisierte Zertifizierungskriterien.

Stroke units (SU) have been certified for many years by the German Stroke Society (DSG) and the German Stroke Aid Foundation (SDSH). Since 2009 this is now undertaken in the third generation by the LGA InterCert of the Technical Surveillance Society of Rhineland (TÜV Rheinland). This article presents the amended certification criteria which came into effect in 2012. Many criteria and definitions could be further defined and specified and residual grey areas and fields of conflict could be reduced. For the first time a distinction has been made between the minimum requirements relevant for certification and additional recommendations by the SU Commission of the DSG. In this manner the authors are aiming to motivate SU operators not just to align quality assurance measures to the minimum requirements but to deliberately go beyond them. There is a great deal of evidence to indicate that this will not only serve to increase the motivation of personnel and the quality of treatment but simultaneously the economic situation can also be improved.

[Epidemiology, clinical picture and management of atrial fibrillation]. / Epidemiologie, Klinik und Management des Vorhofflimmerns.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affects approximately 1% of adults and prevalence increases with age. Nine per cent of those aged 80 years and older have AF. AF is associated with increased cardiovascular mortality and morbidity, including stroke.Stroke in patients with AF is more severe and more likely to be fatal. Prevention of thromboembolism with oral anticoagulants and rate or rhythm control are the main therapeutic strategies for patients with AF. Vitamin K antagonists reduce the risk of stroke in patients with AF, however are underutilized. Dronedarone is the first antiarrhythmic drug that reduces the stroke rate.

Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease.

OBJECTIVES: Poor blood pressure (BP) control is common amongst patients with symptomatic atherothrombotic disease. It is unclear whether BP control and management differ across atherothrombotic disease subtypes. METHODS: We analysed the baseline data of 44,984 patients with documented coronary artery disease (CAD) only (n = 30,414), cerebrovascular disease (CVD) only (n = 11,359) and peripheral arterial disease (PAD) only (n = 3211) from the international REduction of Atherothrombosis for Continued Health Registry and investigated the impact of atherothrombotic disease subtype on BP control and use of antihypertensive drugs. RESULTS: The proportion of patients with BP controlled (<140/90 mmHg) was higher in CAD (58.1%) than in CVD (44.8%) or PAD (38.9%) patients (P < 0.001). Amongst patients with treated hypertension, CAD patients were more likely to have BP controlled than were CVD patients [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.59-1.75] or PAD (OR = 2.30; 95% CI = 2.10-2.52). These differences were smaller in women than in men and decreased with age. Amongst treated patients, CAD patients were more likely to receive > or =3-drug combination therapies than were CVD (OR = 1.73; 95% CI = 1.64-1.83) or PAD (OR = 1.64; 95% CI = 1.49-1.80) patients. Adjustment for age, gender, waist obesity, diabetes, education level and world region did not alter the results. CONCLUSIONS: Coronary artery disease patients are more likely than CVD or PAD patients to have BP controlled and to receive antihypertensive drugs, particularly combination therapies. Promotion of more effective BP control through combination antihypertensive therapies could improve secondary prevention and therefore prevent complications in CVD and PAD patients.