[CLIPPERS syndrome - a disorder with many faces- a case report]. / CLIPPERS-Syndrom: Eine Erkrankung mit vielen Gesichtern ­ ein Fallbericht.

The CLIPPERS syndrome is a chronic, inflammatory disorder of the central nervous system of unknown etiology, which was first described in 2010 by Pittock and colleagues. It is characterized by typical magnetic resonance imaging (MRI) changes with lesions mainly in the brainstem, a perivascular, lymphohistiocytic inflammatory process and significant improvement under glucocorticoid therapy. Here we describe the case of a 40-year-old male who presented initially with typical clinical and radiological signs of CLIPPERS syndrome and who achieved complete remission under immunosuppressive therapy. Two years later, he presented with severe headaches. The MRI showed a reappearance of the lesion in the cerebellum, but now with a confluent character. The first brain biopsy showed lymphoproliferation. A second brain biopsy could finally confirm the suspected diagnosis of a primary CNS lymphoma.

Safety of Endovascular Thrombectomy in Patients Receiving Non-Vitamin K Antagonist Oral Anticoagulants.

BACKGROUND AND PURPOSE: Prospective data on the safety of endovascular thrombectomy in acute stroke patients on non-vitamin K antagonist oral anticoagulants are lacking. METHODS: Prospective multicenter observational study. Patients with ischemic stroke undergoing thrombectomy with or without preceding thrombolysis were enrolled into the Registry of Acute Ischemic Stroke Under New Oral Anticoagulants. Baseline characteristics and functional outcome at 3 months were assessed. Hemorrhagic transformation and symptomatic intracranial hemorrhage were analyzed. Reperfusion was graded using the modified Thrombolysis in Cerebral Infarction score. RESULTS: Of 28 patients treated with thrombectomy, 5 had received also systemic thrombolysis (18%). Intracranial hemorrhage was observed in 46%, but symptomatic intracranial hemorrhage occurred only in 1 patient. Successful reperfusion (Thrombolysis in Cerebral Infarction score, 2b-3) was achieved in 59%. At 3 months, 19% had a modified Rankin Scale score of 0 to 2, and mortality was 26%. CONCLUSIONS: Thrombectomy in non-vitamin K antagonist oral anticoagulant patients seems safe although a comparatively high rate of asymptomatic hemorrhagic transformation was noted. Confirmation in larger prospective controlled cohorts is necessary. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01850797.

Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study.

OBJECTIVE: A study was undertaken to evaluate clinical and procedural factors associated with outcome and recanalization in endovascular stroke treatment (EVT) of basilar artery (BA) occlusion. METHODS: ENDOSTROKE is an investigator-initiated multicenter registry for patients undergoing EVT. This analysis includes 148 consecutive patients with BA occlusion, with 59% having received intravenous thrombolysis prior to EVT. Recanalization (defined as Thrombolysis in Cerebral Infarction [TICI] score 2b-3) and collateral status (using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology collateral grading system) were assessed by a blinded core laboratory. Good (moderate) outcome was defined as a modified Rankin Scale score of 0 to 2 (0-3) assessed after at least 3 months (median time to follow-up = 120 days). RESULTS: Thirty-four percent had good and 42% had moderate clinical outcome; mortality was 35%. TICI 2b-3 recanalization was achieved by 79%. Age, hypertension, National Institutes of Health Stroke Scale scores, collateral status, and the use of magnetic resonance imaging prior to EVT predicted clinical outcome, the latter 3 remaining independent predictors in multivariate analysis. Independent predictors of recanalization were better collateral status and the use of a stent retriever. However, recanalization did not significantly predict clinical outcome. INTERPRETATION: Beside initial stroke severity, the collateral status predicts clinical outcome and recanalization in BA occlusion. Our data suggest that the use of a stent retriever is associated with high recanalization rates, but recanalization on its own does not predict outcome. The role of other modifiable factors, including the choice of pretreatment imaging modality and time issues, warrants further investigation.

Estimating the Quantitative Demand of NOAC Antidote Doses on Stroke Units.

BACKGROUND: The first specific antidote for non-vitamin K antagonist oral anticoagulants (NOAC) has recently been approved. NOAC antidotes will allow specific treatment for 2 hitherto problematic patient groups: patients with oral anticoagulant therapy (OAT)-associated intracerebral hemorrhage (ICH) and maybe also thrombolysis candidates presenting on oral anticoagulation (OAT). We aimed to estimate the frequency of these events and hence the quantitative demand of antidote doses on a stroke unit. METHODS: We extracted data of patients with acute ischemic stroke and ICH (<24 h after symptom onset) in the years 2012-2015 from a state-wide prospective stroke inpatient registry. We selected 8 stroke units and determined the mode of OAT upon admission in 2012-2013. In 2015, the mode of OAT became a mandatory item of the inpatient registry. From the number of anticoagulated patients and the NOAC share, we estimated the current and future demand for NOAC antidote doses on stroke units. RESULTS: Eighteen percent of ICH patients within 6 h of symptom onset or an unknown symptom onset were on OAT. Given a NOAC share at admission of 40%, about 7% of all ICH patients may qualify for NOAC reversal therapy. Thirteen percent of ischemic stroke patients admitted within 4 h presented on anticoagulation. Given the availability of an appropriate antidote, a NOAC share of 50% could lead to a 6.1% increase in thrombolysis rate. CONCLUSIONS: Stroke units serving populations with a comparable demographic structure should prepare to treat up to 1% of all acute ischemic stroke patients and 7% of all acute ICH patients with NOAC antidotes. These numbers may increase with the mounting prevalence of atrial fibrillation and an increasing use of NOAC.

Collateral vessels in proximal middle cerebral artery occlusion: the ENDOSTROKE study.

PURPOSE: To determine the impact of collateral vessel status on clinical and imaging outcomes in patients undergoing endovascular therapy (EVT) for proximal middle cerebral artery (MCA) occlusion. MATERIALS AND METHODS: There were 160 patients with proximal MCA occlusion at six centers in this institutional review board-approved multicenter EVT registry. Angiograms were analyzed at a blinded core laboratory, and collateral vessel status was assessed by using the American Society of Interventional and Therapeutic Neuroradiology (ASITN)/Society of Interventional Radiology (SIR) collateral vessel grading system, while reperfusion was assessed by using the Thrombolysis in Cerebral Infarction (TICI) scale. Good outcome was defined as a modified Rankin Scale score of 0-2 at follow-up. Binary logistic regression analysis was performed by using parameters with P < .2 in univariate analysis. RESULTS: Good clinical outcome was attained in 62 (39%) of the 160 patients, and TICI 2b-3 reperfusion was achieved in 94 (59%) patients. Nineteen patients had ASITN/SIR collateral vessel grades of 0 or 1, 63 patients had a grade of 2, and 78 patients had grades of 3 or 4. Better collateral vessels were associated with higher reperfusion rates (21%, 48%, and 77% for ASITN/SIR grades of 0 or 1, 2, and 3 or 4, respectively; P < .001), a higher proportion of infarcts smaller than one-third of the MCA territory (32%, 48%, and 69% for ASITN/SIR grades of 0 or 1, 2, and 3 or 4, respectively; P < .001), and a higher proportion of good clinical outcome (11%, 35%, and 49% for ASITN/SIR grades of 0 or 1, 2, and 3 or 4, respectively; P = .007). At multivariable analysis, collateral vessel status independently predicted reperfusion, final infarct size, and clinical outcome. Within an onset-to-treatment time (OTT) of 0-3 hours, collateral vessel status predicted final infarct size and reperfusion. Within an OTT of 3-6 hours, it additionally predicted clinical outcome, with 53% of patients with ASITN/SIR grades of 3 or 4 having a good outcome, as compared with 0% of patients with grades of 0 or 1 and 27% of patients with a grade of 2 (P = .008). CONCLUSION: In this patient population, collateral vessel status independently predicted the pivotal outcome parameters of reperfusion, infarct size, and clinical outcome. These data underscore the utility of patient selection for EVT on the basis of collateral vessel status.

Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage.

IMPORTANCE: Although use of oral anticoagulants (OACs) is increasing, there is a substantial lack of data on how to treat OAC-associated intracerebral hemorrhage (ICH). OBJECTIVE: To assess the association of anticoagulation reversal and blood pressure (BP) with hematoma enlargement and the effects of OAC resumption. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at 19 German tertiary care centers (2006-2012) including 1176 individuals for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of OAC resumption. EXPOSURES: Reversal of anticoagulation during acute phase, systolic BP at 4 hours, and reinitiation of OAC for long-term treatment. MAIN OUTCOMES AND MEASURES: Frequency of hematoma enlargement in relation to international normalized ratio (INR) and BP. Incidence analysis of ischemic and hemorrhagic events with or without OAC resumption. Factors associated with favorable (modified Rankin Scale score, 0-3) vs unfavorable functional outcome. RESULTS: Hemorrhage enlargement occurred in 307 of 853 patients (36.0%). Reduced rates of hematoma enlargement were associated with reversal of INR levels <1.3 within 4 hours after admission (43/217 [19.8%]) vs INR of ≥1.3 (264/636 [41.5%]; P < .001) and systolic BP <160 mm Hg at 4 hours (167/504 [33.1%]) vs ≥160 mm Hg (98/187 [52.4%]; P < .001). The combination of INR reversal <1.3 within 4 hours and systolic BP of <160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement (35/193 [18.1%] vs 220/498 [44.2%] not achieving these values; OR, 0.28; 95% CI, 0.19-0.42; P < .001) and lower rates of in-hospital mortality (26/193 [13.5%] vs 103/498 [20.7%]; OR, 0.60; 95% CI, 0.37-0.95; P = .03). OAC was resumed in 172 of 719 survivors (23.9%). OAC resumption showed fewer ischemic complications (OAC: 9/172 [5.2%] vs no OAC: 82/547 [15.0%]; P < .001) and not significantly different hemorrhagic complications (OAC: 14/172 [8.1%] vs no OAC: 36/547 [6.6%]; P = .48). Propensity-matched survival analysis in patients with atrial fibrillation who restarted OAC showed a decreased HR of 0.258 (95% CI, 0.125-0.534; P < .001) for long-term mortality. Functional long-term outcome was unfavorable in 786 of 1083 patients (72.6%). CONCLUSIONS AND RELEVANCE: Among patients with OAC-associated ICH, reversal of INR <1.3 within 4 hours and systolic BP <160 mm Hg at 4 hours were associated with lower rates of hematoma enlargement, and resumption of OAC therapy was associated with lower risk of ischemic events. These findings require replication and assessment in prospective studies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01829581.

[Pharmaceutical care of a patient with oral anticoagulation and renal impairment]. / Pharmazeutische Betreuung eines Patienten mit chronischer Niereninsuffizienz unter oraler Antikoagulation.

Atrial fibrillation is one of the most important indications for oral anticoagulation. Besides vitamin K antagonists, the novel oral anticoagulants dabigatran, apixaban, edoxaban and rivaroxaban are one therapy option in patients with atrial fibrillation. The following case report describes an 83-year-old female patient treated with dabigatran for secondary stroke prevention. Due to different factors, the renal function of the patient decreases significantly (acute on chronic renal failure), resulting in a re-evaluation of the current treatment. This case report is an example of decision-making 'for and against' novel oral anticoagulants versus vitamin K antagonists.

[Novel oral anticoagulants--issues in clinical practice]. / Neue orale Antikoagulanzien.

The novel oral anticoagulants (NOAC) dabigatran, apixaban, edoxaban and rivaroxaban target either thrombin or factor Xa for the prevention and treatment of thrombosis. A short introduction of the main indications for an oral anticoagulation is followed by the pharmacology of each drug, their effectiveness, selected drug-drug interactions and adverse drug events, especially bleeding. The article represents clinical aspects for the perioperative management, the possibilities for monitoring of each drug, the application in patients with renal impairment as well as different advantages and disadvantages.

Dysphagia risk assessment in acute left-hemispheric middle cerebral artery stroke.

BACKGROUND AND PURPOSE: Bedside evaluation of dysphagia may be challenging in left middle cerebral artery (MCA) stroke due to frequently existing aphasia. Here we analyse the predictive value of common bedside screening tests and of two items of cortical dysfunction, aphasia and buccofacial apraxia (BFA), for the detection of dysphagia. METHODS: We prospectively examined 67 consecutive patients with clinical and imaging evidence of acute (<72 h) left MCA stroke. Dysphonia, dysarthria, abnormal volitional cough and abnormal gag reflex were assessed followed by a standardized 50-ml water-swallowing test determining the symptoms cough and voice change after swallow. Aphasia and BFA were assessed according to defined criteria. Fibre-optic endoscopic evaluation of swallowing (FEES) was performed for validation of dysphagia. RESULTS: 41 (61%) patients had FEES-proven dysphagia. Abnormal gag reflex, abnormal volitional cough, cough after swallow, aphasia and BFA were significantly more frequent in dysphagic as compared to non-dysphagic patients, while dysphonia, dysarthria and voice change after swallow were not. Aphasia and BFA had the highest sensitivity (97 and 78%, respectively) and high negative predictive values (89 and 68%, respectively) for dysphagia. Multivariate regression analysis did not identify an independent predictor of dysphagia. CONCLUSIONS: In left MCA stroke, the sensitivity and specificity of common bedside dysphagia screening methods are low. In contrast, aphasia and BFA have a high sensitivity and high negative predictive power, presumably due to the neuro-anatomical overlap between cortical regions involved in swallowing, speech production, imitation and voluntary movement control.

Adherence to hospital discharge medication in patients with ischemic stroke: a prospective, interventional 2-phase study.

BACKGROUND AND PURPOSE: Communication between hospitals and primary care physicians is essential for the continuity of care for patients being transferred from hospital to ambulatory care. Patients are often discharged from hospital on medication regimes different from those used before hospital admission. The aim of the study was to evaluate the adherence to hospital discharge medication in patients with ischemic stroke before and after implementing a systematic approach provided by a clinical pharmacist. METHODS: Patients with transient ischemic attack/ischemic stroke taking ≥ 2 drugs during hospital stay and at discharge were prospectively recruited. In the control group, the neurologist included the medication list in the discharge letter as before. In the intervention group, the clinical pharmacist listed the medication on admission and at discharge next to each other and gave detailed information for all medication changes during hospital stay. RESULTS: Overall, 312 patients were enrolled in the study with 156 patients in each group. Significant differences between the control group and intervention group were ascertained with regard to adherence to both antithrombotic drugs (83.8% control group versus 91.9% intervention group [P=0.033]) and to statin therapy (69.8% control group versus 87.7% intervention group [P<0.001]). CONCLUSIONS: Providing detailed information on medication changes can lead to substantially improved adherence to discharge medication, probably resulting in better secondary stroke prevention.

Lifestyle risk factors for ischemic stroke and transient ischemic attack in young adults in the Stroke in Young Fabry Patients study.

BACKGROUND AND PURPOSE: Although many stroke patients are young or middle-aged, risk factor profiles in these age groups are poorly understood. METHODS: The Stroke in Young Fabry Patients (sifap1) study prospectively recruited a large multinational European cohort of patients with cerebrovascular events aged 18 to 55 years to establish their prevalence of Fabry disease. In a secondary analysis of patients with ischemic stroke or transient ischemic attack, we studied age- and sex-specific prevalences of various risk factors. RESULTS: Among 4467 patients (median age, 47 years; interquartile range, 40-51), the most frequent well-documented and modifiable risk factors were smoking (55.5%), physical inactivity (48.2%), arterial hypertension (46.6%), dyslipidemia (34.9%), and obesity (22.3%). Modifiable less well-documented or potentially modifiable risk factors like high-risk alcohol consumption (33.0%) and short sleep duration (20.6%) were more frequent in men, and migraine (26.5%) was more frequent in women. Women were more often physically inactive, most pronouncedly at ages <35 years (18-24: 38.2%; 25-34: 51.7%), and had high proportions of abdominal obesity at age 25 years or older (74%). Physical inactivity, arterial hypertension, dyslipidemia, obesity, and diabetes mellitus increased with age. CONCLUSIONS: In this large European cohort of young patients with acute ischemic cerebrovascular events, modifiable risk factors were highly prevalent, particularly in men and older patients. These data emphasize the need for vigorous primary and secondary prevention measures already in young populations targeting modifiable lifestyle vascular risk factors.

Age dependency of successful recanalization in anterior circulation stroke: the ENDOSTROKE study.

BACKGROUND: Clinical outcome after endovascular stroke therapy (EVT) for proximal anterior circulation stroke is often disappointing despite high recanalization rates. The ENDOSTROKE study aims to determine predictors of clinical outcome in patients undergoing EVT. Here we focus on the impact of age and recanalization on proximal middle cerebral artery (M1-MCA) or carotid T occlusion. METHODS: ENDOSTROKE is an investigator-initiated, industrially independent multicenter registry launched in January, 2011, for consecutive patients undergoing EVT for large-vessel stroke. This analysis focuses on patients treated in 11 academic and nonacademic stroke centers with angiographically proven M1-MCA (n = 259) or carotid T occlusion (n = 103). Recanalization was defined as Thrombolysis in Myocardial Infarction (TIMI) score 2 or 3, and in patients with available Thrombolysis in Cerebral Ischemia (TICI) data (n = 309) as TICI scores 2b-3. Good outcome was defined as modified Rankin Scale (mRS) score of 0-2 assessed after 3 months or later. RESULTS: The median age was 68 years (25th and 75th percentiles: 56, 76 years), and the median National Institutes of Health Stroke Scale (NIHSS) score at admission was 16 (13, 19); 41% of the patients had a favorable (mRS scores 0-2), and 59% had an unfavorable (mRS scores 3-6) outcome; 83% reached TIMI 2-3 flow. Independent predictors of good outcome were younger age, lower initial NIHSS scores, TIMI 2/3 recanalization and lower serum glucose levels. Outcome was highly dependent on patients' age: 60% of the patients within the lowest age quartile (range: 18-56 years) experienced good clinical outcome, decreasing stepwise over 47% (57-68 years) and 37% (69-76 years) to 17% in the highest age quartile (77-94 years). The proportion of patients with poor clinical outcome despite TIMI 2/3 recanalization ('futile recanalization') increased dramatically from only 29% in the lowest age quartile over 34% and 40% (2nd and 3rd age quartiles) up to 53% in the highest age quartile. Results were similar in patients with available TICI scores, with 'futile recanalization' rates increasing from 24% to 46% (lowest to highest age quartile). CONCLUSIONS: This study emphasizes the dramatic impact of patients' age on outcome in EVT for M1-MCA or carotid T occlusion, even in the presence of recanalization. Reasons for this age-related decrease in clinically successful recanalization rates urgently need clarification and may comprise patient-related factors (age-related increase in cardioembolic strokes, collateral status, comorbidities) as well as periprocedural issues (tortuous vessel anatomy in the elderly, age-dependent negative impact of general anesthesia in EVT).

Periprocedural aspects in mechanical recanalization for acute stroke: data from the ENDOSTROKE registry.

INTRODUCTION: The ENDOSTROKE registry aims to accompany the spreading use of endovascular stroke treatment (EVT) in academic and non-academic hospitals. This analysis focuses on preprocedural imaging, patient handling and referral, as well as on different treatment modalities in mechanical recanalization. METHODS: Data for this study were from observational registry study in 12 stroke centers in Germany and Austria with online assessment of prespecified variables concerning endovascular stroke therapy. RESULTS: Data from 734 patients undergoing EVT were analyzed. Preferred imaging modality prior to EVT was CT (83 %) and CTA (78 %). In 95 %, EVT was performed under general anesthesia. In 55 % of patients, a combination of intravenous (IV) thrombolysis and EVT was used, followed by pure EVT (25 %), intra-arterial (IA) thrombolysis plus EVT (13 %) and IV + IA thrombolysis plus EVT (7 %). Intrahospital time delay until start of EVT was 91 and 99 min in anterior and vertebrobasilar circulation stroke, respectively. Average duration of EVT was 60 min. Overall thrombolysis in myocardial infarction grade 2/3 recanalization rate was 85 %. Stent retrievers were used in 75 %, being associated with higher recanalization rates than non-stent retrievers. Hemorrhagic complications (symptomatic and asymptomatic) occurred in 12 %. Overall vessel occlusion time was approximately 60 min longer in patients being referred from a primary care hospital for EVT. CONCLUSION: This study gives an overview of procedure-related factors in current EVT practice. It gives estimates on preprocedural imaging modalities, periprocedural handling, and treatment combinations used for EVT. Patient referral for EVT from primary care hospitals is associated with longer vessel occlusion times.

T2' imaging within perfusion-restricted tissue in high-grade occlusive carotid disease.

BACKGROUND AND PURPOSE: Quantitative T2' imaging presumably detects regional changes in the relation of oxygenated and deoxygenated hemoglobin. Regional differences in hemoglobin oxygenation might reflect areas with increased oxygen extraction for compensation of reduced perfusion pressure. We investigated quantitative T2' imaging in patients with high-grade stenoses of brain-supplying arteries and hypothesized that T2' values are lower in perfusion-restricted areas as compared with normally perfused tissue. METHODS: Eighteen patients (15 men; mean age±SD, 54±12.8 years) with unilateral symptomatic or asymptomatic high-grade extracranial or intracranial internal carotid artery or proximal middle cerebral artery stenosis/occlusion were included. MR examination included perfusion-weighted imaging and quantitative, motion-corrected mapping of T2' time. Time-to-peak and mean transit time maps were thresholded for different degrees of perfusion delays (eg, >0 seconds, ≥2 seconds) compared with the contralateral hemisphere. Mean T2' values in areas of impaired perfusion were compared with T2' values in corresponding contralateral or ipsilateral, normoperfused areas. RESULTS: Mean size of perfusion-impaired areas in time-to-peak maps (time-to-peak delay>0 seconds) was 10.8 mL (±6.3) and 11.5 mL (±6.4) in mean transit time maps (mean transit time delay>0 seconds). T2' values were significantly (P<0.01) lower in all perfusion-restricted compared with corresponding contralateral brain areas (ipsilateral versus contralateral). For time-to-peak delay >0 seconds, T2' values were 115 ms (±9) versus 125 ms (±12). For mean transit time delay>0 seconds, T2' values were 115 ms (±9) versus 128 ms (±10). Differences in T2' values increased with the severity of the perfusion delay. Ipsilateral T2' values outside the perfusion-disturbed areas did not differ from contralateral T2' values. CONCLUSIONS: Motion-corrected T2' imaging presumably detects areas with increased oxygen extraction within perfusion-restricted tissue in patients with high-grade occlusive vessel disease.

T2'- and PASL-based perfusion mapping at 3 Tesla: influence of oxygen-ventilation on cerebral autoregulation.

PURPOSE: To use T2'-mapping together with Pulsed Arterial Spin Labeling (PASL) providing quantitative information of deoxygenation level and cerebral blood flow (CBF) in the cerebral gray matter to obtain simultaneous information about the cerebral oxygen metabolism and the resulting cerebral vasoreactivity under normoxic and hyperoxic conditions. MATERIALS AND METHODS: Twelve young, healthy volunteers underwent MRI under normoxic and hyperoxic conditions performing PASL and high-resolution, motion-corrected T2* and T2-mapping to calculate T2'values. Regions of interest (ROI) were placed in the frontoparietal cortex and thalamus by manual and automatic segmentation. For each ROI, mean normoxic T2'- and CBF values were extracted and compared with the same parameters assessed under hyperoxic ventilation. RESULTS: A hyperoxic-induced decrease of the CBF could be shown in the frontoparietal cortex (P = 0.009). The T2 values of frontoparietal cortex decreased under hyperoxic inhalation compared with normoxia (P = 0.01), whereas T2' remained unchanged. CONCLUSION: Motion-corrected high-resolution T2'-maps can be used together with PASL to evaluate the DeoxyHb content in relation to CBF in the cerebral gray matter. We could show that cortical CBF decreases under hyperoxic inhalation in healthy young subjects, whereas the T2' values remained constant. These data suggest that hyperoxic-induced vasoconstriction may protect the brain against hyperoxemia.

Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: A prospective multicenter observational study.

OBJECTIVE: Early identification of patients at risk of space-occupying "malignant" middle cerebral artery (MCA) infarction (MMI) is needed to enable timely decision for potentially life-saving treatment such as decompressive hemicraniectomy. We tested the hypothesis that acute stroke magnetic resonance imaging (MRI) predicts MMI within 6 hours of stroke onset. METHODS: In a prospective, multicenter, observational cohort study patients with acute ischemic stroke and MCA main stem occlusion were studied by MRI including diffusion-weighted imaging (DWI), perfusion imaging (PI), and MR-angiography within 6 hours of symptom onset. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI. RESULTS: Of 140 patients included, 27 (19.3%) developed MMI. The following parameters were identified as independent predictors of MMI: larger acute DWI lesion volume (per 1 ml odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.06; p < 0.001), combined MCA + internal carotid artery occlusion (5.38, 1.55-18.68; p = 0.008), and severity of neurological deficit on admission assessed by the National Institutes of Health Stroke Scale score (per 1 point 1.16, 1.00-1.35; p = 0.053). The prespecified threshold of a DWI lesion volume >82 ml predicted MMI with high specificity (0.98, 95% CI 0.94-1.00), negative predictive value (0.90, 0.83-0.94), and positive predictive value (0.88, 0.62-0.98), but sensitivity was low (0.52, 0.32-0.71). INTERPRETATION: Stroke MRI on admission predicts malignant course in severe MCA stroke with high positive and negative predictive value and may help in guiding treatment decisions, such as decompressive surgery. In a subset of patients with small initial DWI lesion volumes, repeated diagnostic tests are required.

Clinical outcome after mechanical recanalization as mono- or adjunctive therapy in acute stroke: importance of time to recanalization.

BACKGROUND: The clinical benefit of mechanical recanalization procedures for acute stroke is still a matter of debate. We report the clinical and imaging results of 34 consecutive patients, focusing on time aspects (i.e. vessel occlusion time and procedure duration). METHODS: During a 3-year period, 34 stroke patients with large-vessel occlusion (anterior circulation, n = 19; posterior circulation, n = 15) were treated with several mechanical recanalization devices with (n = 17) or without prior intravenous thrombolysis. Clinical and imaging data before (NIHSS) and after treatment [(mRS) 3 and 6-30 months] were analyzed. The angiographic outcome (TIMI score), complication rates, and procedural issues (i.e. procedure duration and vessel occlusion time) were assessed. RESULTS: The median NIHSS on admission was 17. Successful recanalization (TIMI 2 and 3) was achieved in 23 (68%) patients. The median time from symptom onset to recanalization was 330 min, and the median time from angiography to recanalization was 101 min. Six (18%) patients had a good clinical outcome (3-month mRS ≤2), and 10 (29%) died. The vessel occlusion time was significantly shorter in patients with a good compared to poor clinical outcome (247 vs. 348 min, p = 0.024). In the subgroup of anterior circulation stroke, successful recanalization, and no symptomatic intracranial hemorrhage (n = 11), there was a strong correlation between vessel occlusion time and clinical outcome (r = 0.711, p = 0.014). CONCLUSIONS: The rate of vessel recanalization with endovascular therapy is promising. Nevertheless, the long-term clinical outcome is still disadvantageous in the majority of patients, presumably due to too long vessel occlusion times. Better strategies for patient selection and optimization of recanalization strategies (i.e. shorter time intervals to vessel patency) are warranted.

Quality assurance data for regional drip-and-ship strategies- gearing up the transfer process.

BACKGROUND: Stroke patients with large vessel occlusion (LVO) require endovascular therapy (EVT) provided by comprehensive stroke centers (CSC). One strategy to achieve fast stroke symptom 'onset to treatment' times (OTT) is the preclinical selection of patients with severe stroke for direct transport to CSC. Another is the optimization of interhospital transfer workflow. Our aim was to investigate the dynamics of the OTT of 'drip-and-ship' patients as well as the current 'door-in-door-out' time (DIDO) and its determinants at representative regional German stroke units. METHODS: We determined the numbers of all EVT treatments, 'drip-and-ship' and 'direct-to-center' patients and their median OTT from the mandatory quality assurance registry of the federal state of Hesse, Germany (2012-2019). Additionally, we captured process time stamps from primary stroke centers (PSC) in a consecutive registry of patients referred for EVT in our regional stroke network over a 3 months period. RESULTS: Along with an increase of the EVT rate, the proportion of drip-and-ship patients grew steadily from 19.4% in 2012 to 31.3% in 2019. The time discrepancy for the median OTT between 'drip-and-ship' and 'direct-to-center' patients continuously declined from 173 to 74 min. The largest share of the DIDO (median 92, IQR 69-110) is spent with the organization of EVT and consecutive patient transfer. CONCLUSIONS: 'Drip-and-ship' patients are an important and growing proportion of stroke patients undergoing EVT. The discrepancy in OTT for EVT between 'drip-and-ship' and 'direct-to-center' patients has been reduced considerably. Further optimization of the DIDO primarily aiming at the processes after the detection of LVO is urgently needed to improve stroke patient care.