Factors in the acquisition of independent walking in patients with cerebral infarction using decision tree analysis.

OBJECTIVES: Independent walking is considered a rehabilitation factor for patients with stroke. There are no reports examining the predictors of independent walking at approximately one month after stroke onset. We aimed to examine factors related to the degree of independent walking, using a decision tree analysis, in patients with stroke. MATERIALS AND METHODS: This retrospective, observational study was conducted on patients with cerebral infarction. The study period was from May 2017 to October 2021. Patients were categorized into independent (≥ 6; N=88) and dependent (≤ 5; N=98) groups based on the Functional Independence Measure locomotion scale at discharge. A decision tree analysis was performed to identify factors related to independent walking. RESULTS: Overall, 186 participants (mean age, 77.8 ± 9.6 years; 104 men and 82 women) were included. The independent group had higher scores in Functional Assessment for Control of Trunk (14.7 ± 4.6 vs. 7.8 ± 6.0, p <.001), Berg Balance Scale (35.5 ± 15.1 vs. 17.9 ± 15.4, p <.001) and Mini Mental State Examination-Japanese (22.6 ± 5.2 vs. 16.1 ± 7.3, p <.001) on admission than the dependent group. Decision tree analysis identified the Functional Assessment for Control of Trunk score on admission as the best discriminator for independent walking. CONCLUSIONS: The interrelationship between trunk function, cognitive function, and balance function may influence the acquisition of independent walking in patients with stroke.

Nutritional intervention after an early assessment by a flexible endoscopic evaluation of swallowing is associated with a shorter hospital stay for patients with acute cerebral infarction: A retrospective study.

BACKGROUND AND OBJECTIVES: It is important to evaluate the swallowing function of patients with acute cerebral infarction. The effects of nutritional intervention after an early assessment by a flexible endoscopic evaluation of swallowing (FEES) were evaluated. METHODS AND STUDY DESIGN: This retrospective study included 274 patients who were hospitalized for acute cerebral infarction and underwent a FEES between 2016 and 2018. The effects of early nutritional intervention after an assessment by a FEES within 48 h from admission were evaluated. The patients were divided into a shorter hospital stay group (<30 days) and a longer group (≥30 days). A multivariate analysis was performed to identify the predictive factors for a shorter hospital stay. RESULTS: The overall patient characteristics were as follows: 166 men; median age, 81 years old; and median body mass index (BMI), 21.1 kg/m2. No significant differences in the age, sex, or BMI were found between the shorter and longer hospital stay groups. A FEES within 48 h of admission (odds ratio [OR], 2.040; 95% confidence interval [CI], 1.120-3.700; p=0.019), FILS level ≥6 at admission (OR, 2.300; 95% CI, 1.190-4.440; p=0.013), and an administered energy dose of ≥18.5 kcal/kg on hospital day 3 (OR, 2.360; 95% CI, 1.180-4.690; p=0.015) were independently associated with a hospital stay <30 days. CONCLUSIONS: Patients with acute cerebral infarction are more likely to have a shorter hospital stay (<30 days) if they undergo a FEES early after admission and receive optimal nutritional intervention.

Clinical evidence and GRADE assessment for breviscapine injection (DengZhanHuaSu) in patients with acute cerebral infarction.

ETHNOPHARMACOLOGICAL RELEVANCE: Breviscapine injections (DengZhanHuaSu, DZHS) is a famous Chinese patent medicine authorized by China Food and Drug Administration, which is widely used to treat acute cerebral infarction (ACI) in China. AIM OF THE STUDY: In the present study, meta-analysis has been performed in determining the efficacy and safety of DZHS combined with conventional treatment (CT) for ACI and GRADE assessment. MATERIALS AND METHODS: Randomized controlled trials (RCTs) testing the use of DZHS for treating ACI were screened by searching the databases of the Cochrane Library, PubMed, Embase, and Web of Science as well as four Chinese databases. Meta-analysis was carried out with RevMan 5.3 and Stata 16.0 software. The quality of research evidence was assessed by the GRADEprofiler (GRADEpro version: 3.6). RESULTS: Forty-three studies (n = 4618) were included. When compared to the control groups, the total effective rate of the national institutes of health stroke scale (NIHSS) was higher in the experimental group with DZHS (RR = 1.23, 95% CI = 1.19 to 1.28, P < 0.001; RR = 1.29, 95% CI = 1.21 to 1.38, P < 0.001); clinical symptoms and signs were improved in the experimental group with DZHS (RR = 1.17, 95% CI = 1.10 to 1.24, P < 0.001; RR = 1.25, 95% CI = 1.11 to 1.42, P < 0.001); the incidence of adverse reactions was reduced in the experimental group with DZHS (RR = 0.50, 95% CI = 0.26 to 0.98, P = 0.044); and the NIHSS score was decreased in the experimental group with DZHS (WMD = -3.30, 95% CI = -3.86 to -2.73, P < 0.001). CONCLUSIONS: DZHS combined with CT is conditionally recommended to improve the total effective rate of the NIHSS, clinical symptoms, and neurological deficits and reduce the incidence of adverse reactions, and no serious adverse reactions were noted. The GRADE assessment indicates that the overall certainty quality of evidence is low. Further large-scale, well-designed and high-quality RCTs are needed to confirm the positive results. PROSPERO registration No. CRD42019128856.

Value of the Barthel scale in prognostic prediction for patients with cerebral infarction.

BACKGROUND: This study aims to evaluate the ADL(activity of daily living) of patients with acute cerebral infarction through BI scoring, in order to observe its predictive value in the prognosis of these patients. METHODS: According to the inclusion and exclusion criteria, patients with acute anterior circulation cerebral infarction were included in the present study. Then, the BI scoring was analyzed through five grades, in order to further investigate the dose-response relationship between BI scoring and mortality risk in patients with cerebral infarction. The receiver operating characteristic (ROC) curves for BI-scored patients were drawn, and the predictive authenticity of the Barthel scale in prognostic prediction for patients with cerebral infarction was estimated. RESULTS: The difference in BI scores between the survival group and death group were statistically significant (t = 10.029, P < 0.05), in which the score was lower in the death group than in the survival group. According to the linear trend ×2-test, the decrease in BI score indicates an increase in mortality risk in patients with cerebral infarction. The area under the curve (AUC) of the ROC curve was 0.794 with a P-value of < 0.05. CONCLUSION: BI scoring is a highly valuable scoring system for the prognostic prediction of patients with acute cerebral infarction.

Assessment of cerebral infarction after transient cerebral ischemic attack by ABCD2 score combined with the position of intracranial vascular stenosis.

This study aims to investigate the value of the ABCD score combined with the position of the offending vessel stenosis in predicting the risk of transient ischemic attack (TIA) to develop into cerebral infarction.The ABCD score and head magnetic resonance imaging + magnetic resonance angiography (MRA) results of 192 patients with TIA were retrospectively analyzed. With the 7th day as the endpoint time, these patients were divided into 3 groups, according to ABCD scores: low-risk group (n = 105), moderate-risk group (n = 60), and high-risk group (n = 27). Blood vessels were screened using head MRA results, and patients were accordingly divided into 2 groups: proximal vascular stenosis group (n = 71) and nonproximal vascular stenosis group (n = 171). Then, the association of the position of the intracranial vascular stenosis and ABCD score with short-term prognosis was analyzed.Based on the ABCD score, the incidence of cerebral infarction after 1 week was significantly higher in the high-risk group (85.7%) than in the moderate-risk group (16.7%) and low-risk group (1.9%), and the differences were statistically significant (P < .05). When the ABCD score was ≥4 points, the incidence of cerebral infarction after 1 week was significantly higher in the proximal vascular stenosis group (59.1%) than in the nonproximal vascular stenosis group (30.8%), and the difference was statistically significant (P < .05). When the ABCD score was <4 points, the incidence of cerebral infarction after 1 week in the proximal stenosis group (2%) was not significantly different from that in the nonproximal stenosis group (1.9%, P > .05).The ABCD score combined with proximal offending vessel stenosis can improve the short-term prediction of cerebral infarction in patients with TIA.

Total MRI burden of cerebral vessel disease correlates with the progression in patients with acute single small subcortical strokes.

BACKGROUND: The patients of single small subcortical strokes (SS) commonly have neurological worsening with risk factors, and mechanisms remain unclear. Asymptomatic lacunes, white matter lesions, cerebral microbleeds, and enlarged perivascular spaces are MRI markers of cerebral small vessel disease (cSVD). Previous studies mostly explored the association between the neurological deterioration and presence of above markers separately. The relationship between progressive single small SS and the simultaneous presence of multiple markers of cSVD has not been fully identified. We aimed to investigate whether total burden of cSVD detected with MRI was associated with progressive small SS in this study. METHODS: Patients with single small SS (2.0 cm in diameter) were prospectively recruited during January 2016 and May 2018. Progression was defined as worsening by ≥1 point in National Institutes Health Stroke Scale (NIHSS) motor score within 72 hr from onset. The presence and burden of cSVD were determined by brain MRI, producing a score between 0 and 4. Besides, the patients' characteristics, clinical data, medical treatments during hospitalization stay were collected and statistically analyzed. Associations with progression were tested with forward stepwise regression analyses. RESULTS: Fifty-seven (35.6%) patients underwent progression. No significant difference was observed in the distribution of any single vascular risk factor and its related laboratory data among these patients. After adjustment for age, sex, NIHSS score at admission, and time from stroke to MRI in separate models, severe WMHs (OR = 4.892; 95% CI = 2.011-11.904, p = 0.016), moderate- and high-grade basal ganglia EPVS (OR = 2.970; 95% CI = 1.861-6.121, p = 0.009), and total cSVD score (OR = 3.359; 95% CI = 2.016-5.599, p = 0.010) were associated with progression. CONCLUSION: This study demonstrated that total MRI cSVD burden was independently associated with progression after single small subcortical strokes.

Manejo da terapia antitrombótica em pacientes com acidentes vascular cerebral: onde estamos em 2018? / Management of antithrombotic therapy in estroke patients: where do we stand in 2018?

O acidente vascular cerebral (AVC) é a maior causa de incapacidade em todo mundo, e atualmente é também considerado como a segunda maior causa de morte no Brasil. O AVC isquêmico é o subtipo mais comum e pode ser subdividido etiologicamente em car-dioembólico, aterosclerótico de grandes ou pequenas artérias (lacunas), criptogênico ou de outras etiologias. Dependendo da etiologia encontrada, a profilaxia secundária de novos eventos deve ser feita através de medicações antitrombóticas específicas. Portanto, investigar adequadamente a etiologia do evento vascular isquêmico é fundamental para a instituição da profilaxia secundária apropriada. A terapia antitrombótica pós-AVC isquêmico evoluiu consideravelmente na última década. Especificamente para pacientes com AVC e fibrilação atrial, a incorporação de anticoagulantes de ação direta à prática clínica representa um grande avanço, já que tais medicações são mais eficazes e seguras para o tratamento de pacientes de alto risco. No presente artigo, discutiremos o uso de antitrombóticos em pacientes com AVC em diferentes momentos pós-icto vascular e nas distintas etiologias possíveis

Stroke is the leading cause of disability worldwide, and is currently also considered the second leading cause of death in Brazil. Ischemic stroke is the most common subtype and can be subdivided etiologically into cardioembolic, atherosclerotic (large artery atherosclero-sis or small vessel disease-lacunae), cryptogenic or strokes of other etiologies. Depending on the etiology, secondary prophylaxis of new events should be undertaken with specific antithrombotic medications. Therefore, a thorough investigation of ischemic vascular event etiology is essential for the introduction of appropriate secondary prophylaxis. Antithrombotic therapy after ischemic stroke has evolved considerably in the last decade. The incorporation of direct-acting anticoagulants into clinical practice represents a major advance, particularly for stroke and atrial fibrillation patients, since such medications are safer and more effective for the treatment of high-risk patients. In this article, we will discuss the use of antithrombo-tics in stroke patients at different post-stroke stages and in the distinct possible etiologies

Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke.

BACKGROUND AND AIMS: Documentation of atrial fibrillation is required to initiate oral anticoagulation therapy for recurrent stroke prevention. Atrial fibrillation often goes undetected with traditional electrocardiogram monitoring techniques. We evaluated whether atrial fibrillation detection using continuous long-term monitoring with an insertable cardiac monitor is cost-effective for preventing recurrent stroke in patients with cryptogenic stroke, in comparison to the standard of care. METHODS: A lifetime Markov model was developed to estimate the cost-effectiveness of insertable cardiac monitors from a UK National Health Service perspective using data from the randomized CRYSTAL-AF trial and other published literature. We also conducted scenario analyses (CHADS2 score) and probabilistic sensitivity analyses. All costs and benefits were discounted at 3.5%. RESULTS: Monitoring cryptogenic stroke patients with an insertable cardiac monitor was associated with fewer recurrent strokes and increased quality-adjusted life years compared to the standard of care (7.37 vs 7.22). Stroke-related costs were reduced in insertable cardiac monitor patients, but overall costs remained higher than the standard of care (£19,631 vs £17,045). The incremental cost-effectiveness ratio was £17,175 per quality-adjusted life years gained, compared to standard of care in the base-case scenario, which is below established quality-adjusted life years willingness-to-pay thresholds. When warfarin replaced non-vitamin-K oral anticoagulants as the main anticoagulation therapy, the incremental cost-effectiveness ratio was £13,296 per quality-adjusted life years gained. CONCLUSION: Insertable cardiac monitors are a cost-effective diagnostic tool for the prevention of recurrent stroke in patients with cryptogenic stroke. The cost-effectiveness results have relevance for the UK and across value-based healthcare systems that assess costs relative to outcomes.

Assessment of the Diagnostic Value of Plasma Levels, Activities, and Their Ratios of von Willebrand Factor and ADAMTS13 in Patients with Cerebral Infarction.

BACKGROUND AND OBJECTIVES: Raised levels of von Willebrand factor (VWF) and reduced levels of a disintegrin and a metalloproteinase with a thrombospondin type I motif, member 13 (ADAMTS13) activity are associated with thrombosis. We aimed to investigate the relationships between plasma levels of VWF and ADAMTS13, their ratios, and the occurrence of cerebral infarction and to understand the roles of VWF and ADAMTS13 in cerebral infarction. METHODS: Ninety-four patients with cerebral infarction and 103 controls were analyzed. Plasma levels of VWF antigen (VWF: Ag), VWF ristocetin cofactor activity (VWF: Rcof), and VWF collagen binding activity (VWF: CB) were measured by enzyme-linked immunosorbent assay (ELISA). The ADAMTS13 activity (ADAMTS13) was measured with FRETS-VWF73. The relationship between plasma levels and ratios of VWF and ADAMTS13 and the occurrence of cerebral infarction were analyzed. RESULTS: Patients with cerebral infarction displayed higher VWF: Ag and VWF: Rcof levels and lower ADAMTS13, VWF: CB/VWF: Ag, ADAMTS13/VWF: Ag, and ADAMTS13/VWF: Rcof levels compared to controls (P < .01). The highest quartiles of VWF: Ag (odds ratio [OR] = 5.11, 95% confidence interval [CI], 1.49-17.50) and VWF: Rcof (OR = 5.04, 95% CI, 1.62-15.66) and the lowest quartiles of VWF: CB/VWF: Ag (OR = 5.91, 95% CI, 1.95-17.93), ADAMTS13/VWF: Ag (OR = 9.11, 95% CI, 2.49-33.33), and ADAMTS13/VWF: Rcof (OR = 3.73, 95% CI, 1.39-10.03) are associated with cerebral infarction. CONCLUSIONS: An association was found between reduced levels of VWF: CB/VWF: Ag, ADAMTS13/VWF: Ag, and ADAMTS13/VWF: Rcof ratios and cerebral infarction. Our data suggest that increased levels of VWF and reduced levels of ADAMTS13 activity may contribute to the pathogenesis of cerebral infarction.

Impact of Leukoaraiosis Burden on Hemispheric Lateralization of the National Institutes of Health Stroke Scale Deficit in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) awards higher deficit scores for infarcts in the dominant hemisphere when compared with otherwise similar infarcts in the nondominant hemisphere. This has been shown to adversely affect stroke recognition, therapeutic decisions, and outcome. However, factors modifying the association between infarct side and deficit severity are incompletely understood. Thus, we sought to determine whether age and age-related leukoaraiosis alter the relation between NIHSS deficit score and the side and volume of infarction. METHODS: We studied 238 patients with supratentorial, nonlacunar ischemic infarcts prospectively included in our stroke registry between January 2013 and January 2014. NIHSS deficit severity was assessed at the time of presentation. Infarct volumes were assessed by manual planimetry on diffusion-weighted imaging. Leukoaraiosis burden was graded on fluid-attenuated inversion recovery images according to the Fazekas scale and dichotomized to none-to-mild (0-2) versus severe (3-6). Multivariable linear regression with backward elimination was used to identify independent predictors of the admission NIHSS. RESULTS: Left-hemispheric infarction (P<0.001), severe leukoaraiosis (P=0.001), their interaction term (P=0.005), infarct volume (P<0.001), and sex (P=0.013) were independently associated with the NIHSS deficit. Analysis of the individual NIHSS components showed that severe leukoaraiosis was associated with an increase of the lateralizing components of the NIHSS in patients with right-hemispheric infarction (P<0.05). CONCLUSIONS: Severe leukoaraiosis substantially attenuates the classic hemispheric lateralization of the NIHSS deficit by relating to greater NIHSS scores of components that are typically assigned to left hemisphere function.

Assessment of bilateral cerebral peduncular infarction: Magnetic resonance imaging, clinical features, and prognosis.

BACKGROUND: Bilateral cerebral peduncular infarction (BCPI) is an extremely rare neurological disorder, and related literature is scarce. This study investigated the clinical manifestations, magnetic resonance imaging (MRI) features and prognosis of BCPI. METHOD: We retrospectively reviewed the clinical features, MRI and magnetic resonance angiography manifestations, and prognosis of 14 patients with BCPI, confirmed by diffusion-weighted MRI from 5050 cerebral infarction patients at our medical center from January 2007 to June 2013. RESULT: Eleven of the 14 (78.6%) patients had quadriplegia and 9 (64.3%) had decreased consciousness. At the most severe stage, the National Institutes of Health Stroke Scale scores ranged from grades 4 to 26 (mean grade, 18.9). Eleven (78.6%) cases were caused by large artery atherosclerosis. Besides the bilateral cerebral peduncle, the pons (85.7%) and cerebellum (42.9%) were the other infarct locations. Twelve (85.7%) patients had vertebrobasilar artery occlusion or severe stenosis, and 12 (85.7%) did not have collateral patency of the posterior cerebral artery. Thirteen (92.9%) patients had poor prognosis and 9 of them died. OCCLUSION: BCPI is a very rare disorder and associated with severe vertebrobasilar artery stenosis or occlusion without collateral patency of the posterior communicating artery. It has a very poor prognosis.

Negative Word Production in Adults With Right Hemisphere Brain Damage: Effects of Implicit Assessment and Contextual Bias.

PURPOSE: Both theory and evidence suggest that unilateral right hemisphere brain damage (RHD) should impair the processing of negative emotions. Typical metalinguistic assessments, however, may obscure processing strengths. This study investigated whether adults with RHD would produce proportionately fewer negative emotion words than control participants in an implicit assessment task and whether a negatively toned contextual bias would enhance performance. METHODS: Eleven participants with RHD and 10 control participants without brain damage watched a video in 2 parts and described each segment. Between segments, participants evaluated the emotion conveyed by sentences designed to induce the negative bias. RESULTS: The primary outcome measure, percentage of negative emotion words in video descriptions, did not differ between groups. After the contextual bias, this measure significantly increased for both groups, whereas production of motion words, a control variable, remained constant. CONCLUSIONS: Findings are consistent with a view that attributes some deficient RHD performances to the nature and/or demands of explicit metalinguistic assessment tasks. These results call for modulation of prevailing hypotheses that attribute negative emotion processing as an undifferentiated whole solely to the right cerebral hemisphere. The results also further substantiate the rationale of an experimental treatment that exploits contextual bias and priming for individuals with RHD.

Leukoaraiosis Burden Significantly Modulates the Association Between Infarct Volume and National Institutes of Health Stroke Scale in Ischemic Stroke.

BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) provides a reliable, quantitative measure of ischemic stroke severity and is predicted by the infarct size. We sought to determine whether leukoaraiosis severity affects the association between infarct size and NIHSS. METHODS: NIHSS and diffusion-weighted imaging-defined infarct volumes from 312 prospectively enrolled patients with supratentorial, ischemic strokes were analyzed. Leukoaraiosis severity was graded according to the Fazekas scale and conceptually defined as absent (0; n=44), mild (1-2; n=106), moderate (3-4; n=105), and severe (5-6; n=57). ANCOVA was used to describe the effect of leukoaraiosis on the association between infarct volume and NIHSS. Multivariable linear regression models were constructed to assess whether the association of leukoaraiosis and infarct volume on NIHSS was independent of other clinically relevant covariates. RESULTS: Overall, there was a significant correlation between the infarct volume and NIHSS (r=0.591; P<0.001). This correlation significantly attenuated with increasing leukoaraiosis severity from r=0.786 (P<0.001; absent leukoaraiosis) to r=0.498 (P<0.001; severe leukoaraiosis) and as shown by ANCOVA (P<0.001). Leukoaraiosis (coefficient, 0.107; 95% confidence interval, 0.036-0.179; P=0.016) and infarct volume (coefficient, 0.360; 95% confidence interval, 0.305-0.416; P<0.001) were independently associated with a greater NIHSS deficit in the fully adjusted multivariable model. CONCLUSIONS: Leukoaraiosis significantly modulates the association between infarct volume and NIHSS. The clinical implications of these findings need further exploration in prospective studies but may be relevant to mitigate outcome differences in patients with stroke by aiding treatment decisions that rely on the NIHSS.

ANTONIA perfusion and stroke. A software tool for the multi-purpose analysis of MR perfusion-weighted datasets and quantitative ischemic stroke assessment.

OBJECTIVES: The objective of this work is to present the software tool ANTONIA, which has been developed to facilitate a quantitative analysis of perfusion-weighted MRI (PWI) datasets in general as well as the subsequent multi-parametric analysis of additional datasets for the specific purpose of acute ischemic stroke patient dataset evaluation. METHODS: Three different methods for the analysis of DSC or DCE PWI datasets are currently implemented in ANTONIA, which can be case-specifically selected based on the study protocol. These methods comprise a curve fitting method as well as a deconvolution-based and deconvolution-free method integrating a previously defined arterial input function. The perfusion analysis is extended for the purpose of acute ischemic stroke analysis by additional methods that enable an automatic atlas-based selection of the arterial input function, an analysis of the perfusion-diffusion and DWI-FLAIR mismatch as well as segmentation-based volumetric analyses. RESULTS: For reliability evaluation, the described software tool was used by two observers for quantitative analysis of 15 datasets from acute ischemic stroke patients to extract the acute lesion core volume, FLAIR ratio, perfusion-diffusion mismatch volume with manually as well as automatically selected arterial input functions, and follow-up lesion volume. The results of this evaluation revealed that the described software tool leads to highly reproducible results for all parameters if the automatic arterial input function selection method is used. CONCLUSION: Due to the broad selection of processing methods that are available in the software tool, ANTONIA is especially helpful to support image-based perfusion and acute ischemic stroke research projects.

Assessment of macular ganglion cell loss patterns in neurologic lesions that mimic glaucoma.

PURPOSE: To evaluate patterns of macular retinal ganglion cell (RGC) loss measured by spectral domain optical coherence tomography in patients with neurologic lesions mimicking glaucoma. METHODS: We evaluated four patients with neurological lesions who showed characteristic patterns of RGC loss, as determined by ganglion cell thickness (GCT) mapping. RESULTS: Case 1 was a 30-year-old man who had been treated with glaucoma medication. A left homonymous vertical pattern of RGC loss was observed in his GCT map and a past brain magnetic resonance imaging (MRI) revealed a hemorrhagic lesion around the right optic radiation. Case 2 was a 72-year-old man with a pituitary adenoma who had a binasal vertical pattern of RGC loss that corresponded with bitemporal hemianopsia. Case 3 was a 77-year-old man treated for suspected glaucoma. His GCT map showed a right inferior quadratic pattern of loss, indicating a right superior homonymous quadranopsia in his visual field (VF). His brain MRI revealed a left posterior cerebral artery territory infarct. Case 4 was a 38-year-old woman with an unreliable VF who was referred for suspected glaucoma. Her GCT map revealed a left homonymous vertical pattern of RGC loss, which may have been related to a previous head trauma. CONCLUSIONS: Evaluation of the patterns of macular RGC loss may be helpful in the differential diagnosis of RGC-related diseases, including glaucoma and neurologic lesions. When a patient's VF is unavailable, this method may be an effective tool for diagnosing and monitoring transneuronal retrograde degeneration-related structural changes.

[Quality parameters in the treatment of acute stroke: comparison of various regional treatment concepts]. / Qualitätsparameter der akuten Schlaganfallversorgung: Gegenüberstellung unterschiedlicher regionaler Versorgungskonzepte.

BACKGROUND: The long-term prognosis of stroke patients is still dependent in particular on the timing of a correct diagnosis, immediate initiation of a suitable specific therapy and competent treatment in a stroke unit. Therefore, nationwide attempts are being made to establish a comprehensive coverage of the necessary specific competence and infrastructural requirements. Divergent regional circumstances and economic viewpoints determine the characteristics of the various healthcare concepts and the interplay between participating cooperation partners. This article compares the development with respect to three qualitative treatment parameters exemplified by four regional healthcare models during the time period 2008-2011. METHODS: The hospitalization rates for patients with transitory ischemic attacks, ischemic and hemorrhagic stroke, the case numbers for stoke unit treatment and the rates of systemic thrombolysis and mechanical thrombectomy in the regions of Berlin, the Ruhr Area, Ostwestfalen-Lippe and southeast Bayern (TEMPiS) are presented based on the data from the DRG statistical reports for the years 2008 and 2011. RESULTS: The average hospitalization rates for ischemic stroke patients (brain infarct ICD 163) in the time period from 2008 to 2011 were 294 per 100,000 inhabitants for the Ruhr Area, 257 per 100,000 inhabitants for Ostwestfalen-Lippe and 265 per 100,000 inhabitants each for Berlin and southeast Bayern. The complex stroke treatment quota for southeast Bayern in 2008 was 31 % and 47 % in 2011 and the respective quotas for the other regions studied were 42-44 % and 58-59 %. The rate of systemic thrombolysis in 2008 ranged between 4.2 % and 7.4 % and in 2011 the increase in the range for the 4 regions studied was between 41 % and 145 %. In 2011 the thrombectomy quota of 2 % in the Ruhr Area was the only one which was above the national average of 1.3 % of all brain infarcts. DISCUSSION: Stroke is a common disease in the four regions studied. For the established forms of therapy, complex treatment of stroke and systemic thrombolysis, the positive effect of structurally improved approaches in the four different regional treatment concepts could be confirmed during the course of the observational time period selected. Mechanical thrombectomy which is currently still considered to be an individual healing attempt, was used significantly more often in the Ruhr Area in 2011 than in the other three regions studied. A standardized referral procedure had previously been established in the metropolitan regions.

Cost-effectiveness analysis of the neuroprotective agent edaravone for noncardioembolic cerebral infarction.

BACKGROUND: The free radical scavenger edaravone has been reported useful for improvement in activities of daily living and for prevention of recurrent stroke in the edaravone versus sodium ozagrel in acute noncardioembolic ischemic stroke (EDO) trial. The aim of this report was to evaluate the cost-effectiveness of edaravone compared to the intravenous antiplatelet drug ozagrel sodium (ozagrel) for noncardioembolic stroke (non-CES) based on the EDO trial data. METHODS: A cost-effectiveness analysis was performed using the Markov model, which also incorporated the long-term course after the acute stage of non-CES. From the perspective of a health care payer, direct medical costs and nursing care costs were taken into account in the cost analysis. The quality-adjusted life year (QALY) served as an indicator of effectiveness. Simulation at 5 and 10 years after the onset of non-CES was carried out. The study involved 68-year-old patients with non-CES, selected against the EDO trial subject selection criteria. A 14-day treatment with edaravone 60 mg/day or ozagrel 160 mg/day was assumed as acute treatment for non-CES. RESULTS: The use of edaravone was associated with a reduction in total costs (0.51 million yen [$6,374] at 5 years and 0.64 million yen [$8,039]) at 10 years after the onset of non-CES) and improvement in QALYs (0.23 at 5 years and 0.38 at 10 years). Compared to ozagrel therapy, edaravone therapy was a cost-saving strategy for treating non-CES. CONCLUSIONS: Compared to ozagrel therapy, edaravone therapy for non-CES is not only useful from a clinical viewpoint, but also valuable from a socioeconomic perspective.

Assessment of corticospinal tract (CST) damage in acute stroke patients: comparison of tract-specific analysis versus segmentation of a CST template.

PURPOSE: To compare two techniques to assess corticospinal tract (CST) damage in stroke patients: tract-specific analysis by probabilistic tractography and segmentation using a CST template. MATERIALS AND METHODS: We extracted fractional anisotropy (FA) values, the FA ratio, and mean diffusivity (MD) in 18 stroke patients and 21 healthy volunteers matched for age and sex. We compared the two methods in order to determine their ability to detect 1) differences between diffusion tensor imaging (DTI) parameters of healthy volunteers and stroke patients, 2) the correlation between DTI parameters and clinical scores, and 3) the correlation between DTI parameters and blood oxygen level-dependent (BOLD) signals in a fist-closure task. RESULTS: FA values were higher with the tractography approach than with the segmentation method, but differences between the ipsilesional CST and the homologous region in healthy subjects were detected using both methods. In patients, clinical scores were significantly correlated with FA values and FA ratios with both methods. The BOLD signal was positively correlated with FA values for CST with the segmentation but not with the tractography approach. CONCLUSION: CST damage in stroke patients can be assessed by either probabilistic tractography or segmentation of a CST template. Although each method has advantages and limitations, both are sensitive enough to detect differences among stroke patients and identify specific correlations with clinical scores.

Cardiovascular and cerebrovascular diseases in ankylosing spondylitis: current insights.

Patients with ankylosing spondylitis (AS) suffer from an increased cardiovascular (CV) risk. The evidence for increased atherosclerotic disease is nowadays convincing, while the precise contribution of the so-called AS-specific (related) cardiac manifestations toward the increased CV risk still needs to be determined. Such studies should be performed in the near future, since they might have clinical consequences-for example, mandatory echocardiographic screening of AS patients. There appears to be a clear contribution of the "traditional" CV risk factors, as well as the underlying chronic inflammatory process, to the increased atherosclerotic risk in AS. Furthermore, there is accumulating evidence for an etiological role of inflammation in the AS-related cardiac manifestations. Nowadays, CV risk management appears necessary for AS patients, and this should consist of, on the one hand, assessment and treatment, if necessary, of the "traditional" CV risk factors, and, on the other hand, effective suppression of the inflammatory process.