[FEES in the stroke unit: recommendations for implementation in the clinical routine]. / FEES auf der Stroke-Unit : Empfehlungen zur Umsetzung im klinischen Alltag.

Dysphagia occurs in about 50 % of patients with acute stroke, is strongly related to early complications, such as aspiration pneumonia and is a major cause of increased morbidity and mortality in acute stroke. Flexible endoscopic evaluation of swallowing (FEES) has proven to be an easy to use, non-invasive tool for assessment of dysphagia in acute stroke, significantly adding accuracy to the clinical evaluation of dysphagia. With respect to the growing use of FEES in German stroke units this article summarizes recommendations for implementation and execution.A 3-step process is recommended to acquire the relevant knowledge and skills for carrying out FEES. After a systematic training (first step), swallowing endoscopy should be done under close supervision (second step) which is then followed by independent practice coupled with indirect supervision (third step). In principle, FEES should adopt a team approach involving both neurologists and speech language pathologists (SLP) or alternatively speech therapists. The allocation of responsibilities between these two professions should be kept flexible and should be adjusted to the individual level of education. Reducing the role of the SLP to mere assistance work in particular should be avoided. To enhance interprofessional communication and to allow for a smooth and efficient workflow, endoscopic grading of stroke-related dysphagia should adopt a standardized score that also includes protective and rehabilitative measures as well as nutritional recommendations. A major task for the future is to develop an educational curriculum for FEES that takes the specific needs of stroke unit care into account and is applicable to both physicians and SLPs.

[Near-infrared laser treatment of acute stroke: from bench to bedside]. / Nah-Infrarot-Lasertherapie beim akuten Schlaganfall : From bench to bedside.

Near-infrared laser therapy (NIRLT) as a transcranial laser therapy (TLT) is currently being investigated as a neuroreparatory and neuroprotective treatment for acute ischemic stroke patients in a pivotal phase III trial (NEST-3). In this review we cover the theoretical background, experimental studies, translational research and the clinical trial program.

[Malignant hyperthermia and its differential diagnosis]. / Maligne Hyperthermie und deren Differenzialdiagnosen.

Hyperthermia affects almost all endogenous regulatory systems, where especially cardiovascular and central nervous system interactions can result in life threatening complications. This review illustrates signs and symptoms, pathophysiology and therapeutic options of the three most common hyperthermic syndromes in neurology: malignant hyperthermia, serotonine-syndrom and malignant neuroleptic syndrome. The aim of this contribution is to enable the reader to make the differential diagnosis of these three disease entities. Furthermore the association of other specific myopathies and hyperthermia syndromes is discussed.

[Acute cerebral circulation problems]. / Akute zerebrale Durchblutungsstörung.

Acute stroke is the third most common cause of death and also the most common cause of permanent disability in industrialized countries. Ischemic stroke is caused by occlusion of a cerebral artery leading to a critical reduction in brain perfusion in the respective brain area (penumbra). Most acute stroke treatment strategies are based on the penumbra concept: attaining rapid and persistent reperfusion is followed by the protection of critically ischemic and not yet infarcted (penumbral) tissue by, e.g., neuroprotection. Examination of the acute stroke patient includes a brief history, neurostatus and imaging (CT or MRI) for the exclusion of intracerebral hemorrhage. The diagnostic standard is CT; modern stroke MRI protocols provide an improved selection in later time windows. Intravenous thrombolysis with rt-PA within 3 h of symptom onset is the only approved therapy with a proven significant benefit for the patient. The effect is smaller but still significant if treatment occurs up to 4.5 h, and may still be present in MRI selected patients up to 9 h. More aggressive forms of therapy include interventional reperfusion techniques and therapy of malignant MCA infarction such as hemicraniectomy and hypothermia, which at present, however, are not routine and are only performed in specialized centers.

[The value of platelet inhibitors in the secondary prophylaxis of stroke -- a review]. / Stellenwert von Thrombozyten-Aggregationshemmern in der Sekundärprävention des ischämischen Schlaganfalls.

INTRODUCTION: The goal of secondary prophylaxis following cerebral ischemia is a long lasting inhibition of thrombogenesis to prevent recurrent stroke or other vascular events. Platelet inhibitors (PI) according to meta-analyses lead to a relative risk reduction (RRR) of 22 % for vascular events after stroke. The aim of this article is a summary and critical review of all relevant studies and meta-analyses for secondary prevention of stroke and to give a differentiated therapeutic recommendation. METHODS: We performed a careful and extensive review of the present literature for PI in the secondary prevention of stroke. Next to the classic meta-analyses such as the Antiplatelet Trialists' analysis, the relevant single trials (e. g. CATS, TASS, ESPS 2, CURE, CAPRIE) as well as meta-analyses and post hoc analyses of these studies are summarized and interpreted. Therapeutic recommendations are in consistence with the recommendations and guidelines of national (DGN), European (EUSI) and international (AHA/ASA) Groups/Associations. Also, the present literature was searched for new information with regard to side effects and pharmacological interactions and introduced into the review. CONCLUSIONS: ASA reduces the RR after TIA/stroke by approximately 13 % and has the same efficacy with less side effects in lower dosages (50 - 325 mg/Tag). Ticlopidine is a reserve drug due to its unfavorable side effect profile (neutropenia, TTP). Clopidogrel is better than ASA (RRR 8.7 %) for vascular patients in preventing another vascular event (stroke, MI, vascular death). This effect is pronounced in patients at high risk for atherothrombotic events such as previous MI, cardiac surgery, or diabetes. Dipyridamole+ASA is better than ASA in patients with TIA/stroke (in indirect comparison also than Clopidogrel) for the secondary prevention of recurrent stroke (RRR 23 %), but not for the prevention of other vascular events. Therefore, Clopidogrel should be primarily given to patients with a high vascular risk (one or more cardiovascular risk factors) or to patients with ASA intolerance. Dipyridamole/ASA should be primarily given to TIA/stroke patients with a lower cardiovascular comorbidity. Studies for the combination of Clopidogrel/ASA (MATCH, CHARISMA) and for the comparison of both combinations (PRoFESS) are underway. At present, the combination of clopidogrel and ASA for cerebrovascular prevention should only be given within controlled studies or as an individual treatment with an accordingly acquired informed consent.

Effect and feasibility of controlled rewarming after moderate hypothermia in stroke patients with malignant infarction of the middle cerebral artery.

BACKGROUND AND PURPOSE: Moderate hypothermia has been found to reduce intracranial pressure (ICP) significantly in patients who have severe middle cerebral artery infarction. However, during passive rewarming, ICP continuously rises and some patients suffer transtentorial herniation. METHODS: We investigated the question of whether slower rewarming leads to slower increase in ICP and slower decrease in cerebral perfusion pressure (CPP). Furthermore, we studied feasibility of slow, controlled rewarming. ICP, CPP, and core body temperature were monitored continuously. Achievement of rewarming protocol was assessed by hit rate of temperature target intervals. Side effects of hypothermia were assessed. RESULTS: Rates of change of both ICP and CPP were correlated significantly with increase in temperature (ICP r=0.62, P=0.002; CPP r=-0.50, P=0.017). In feasibility analysis of 13 controlled rewarmed patients, hit rate of temperature target intervals was 63% (median; range 48% to 81%); hit rate within the target interval or below was 79% (median; range 62% to 94%). CONCLUSIONS: Slow, controlled rewarming is feasible and may be used for ICP and CPP control after moderate hypothermia for space-occupying infarction.

[Nocturnal spinal fracture--first manifestation of epilepsy]. / Nächtliche Wirbelfraktur--Erstmanifestation einer Epilepsie.

A 54-year-old patient suffered overnight a double thoracic burst-fracture. One week later during the investigation for a metabolic or endocrinological cause, a witnessed seizure led to an unstable fracture of the humerus and the scapula. The neurological work-up revealed a cerebral astrocytoma as the epileptogenic focus. Forces generated during a tonic-clonic seizure can result in axial skeletal trauma, including thoracic and lumbar burst fractures. Vertebral fractures unrelated to an exogenous trauma are therefore always suspicious of an underlying epileptic disease.

Epstein-Barr virus meningoencephalitis with a lymphoma-like response in an immunocompetent host.

We report the clinical and neuropathological findings in an immunocompetent 19-year-old patient with a fatal acute Epstein-Barr virus (EBV) meningoencephalitis and a lymphoma-like B-lymphocyte response. Our results suggest that an immunotoxic rather than direct viral neuronal invasion mediates brain damage in EBV encephalitis and rule out primary central nervous system lymphoma (PCNSL) in our patient. We discuss immunosuppression as a therapeutic option, because present strategies mainly consist of symptomatic therapy due to unclear pathogenesis and nonavailability of effective antiviral agents.

Diagnostic accuracy of MRI compared to CCT in patients with brain metastases.

OBJECTIVES: In patients with extracranial neoplasms, the occurrence and number of brain metastases (BM) are critical for further diagnostic approaches and therapeutic strategies and the patient's prognosis. Although widely accepted, there is surprisingly little evidence in the literature that MRI is superior to CCT. Therefore, in patients with solitary BM according to diagnostic contrast-enhanced computed tomography (CCT), we investigated, what additional information could be gained by contrast-enhanced magnetic resonance imaging (MRI). METHODS/RESULTS: Among 55 patients with solitary BM according to CCT, 17 had multiple BM on MRI (31%) and 38 had solitary BM in both. Based on a presumed binomial distribution of our data, we calculated a rate of at least 19% of patients with solitary BM on CCT, in which MRI would show multiple lesions (p = 0.05). The two main characteristics for BM missed by CCT were the smaller diameter, which averages 2 cm less than in BM identified with both modalities, and a preferential frontotemporal location. CONCLUSION: MRI is indeed superior to CCT in the diagnosis of BM the essential reasons besides detection of smaller lesions being a better soft tissue contrast, significantly stronger enhancement with paramagnetic contrast agents, the lack of bone artifacts, fewer partial volume effects, and direct imaging in three different planes. Therefore, MRI is indispensable in the diagnostic workup of patients with BM for choosing the optimum therapeutic approach, especially with regard to the decision whether to operate or to primarily irradiate the patient's metastases.