Recent silent infarcts do not increase the risk of haemorrhage after intravenous thrombolysis.

BACKGROUND AND PURPOSE: Haemorrhagic transformation (HT) is one of the main risks of intravenous thrombolysis (IVT) for acute ischaemic stroke. Contraindications serve to exclude patients at high risk of HT after IVT. One of these contraindications is a stroke within the preceding 3 months. It is unclear if this contraindication should include recent clinically silent infarcts (RSIs). The aim of this study was to investigate whether RSIs are associated with a higher risk of HT and a worse clinical outcome after IVT for acute ischaemic stroke. METHODS: In a retrospective monocentric cohort study, all patients who received IVT for acute ischaemic stroke based on magnetic resonance imaging were assessed over 5 years. RSIs were defined as lesions with diffusion restriction and positive signal on fluid attenuated inversion recovery sequences. Patients with RSIs (RSI+) were compared to patients without RSIs (RSI-) regarding HT after IVT and clinical outcome. RESULTS: In all, 981 patients who had received IVT for acute ischaemic stroke demonstrated by magnetic resonance imaging were identified. RSIs were detected in 115 patients (11.5%). HT after IVT was observed in 32 (28.3%) RSI+ and 56 (25.8%) RSI- patients (P = 0.624). Symptomatic intracerebral haemorrhage was noted in two (1.8%) RSI+ and five (2.3%) RSI- patients (P = 1.000). No differences in clinical outcome were observed. CONCLUSIONS: The detection of RSIs in patients treated with IVT for acute ischaemic stroke was not associated with a higher risk of HT or a worse clinical outcome. The results of this study argue against considering RSIs as a contraindication for IVT.

[Management of dysphagia in acute stroke : A prospective study for validation of current recommendations]. / Dysphagiemanagement beim akuten Schlaganfall : Eine prospektive Studie zur Überprüfung der geltenden Empfehlungen.

BACKGROUND: The German expert recommendations on the management of dysphagia in patients after acute stroke suggest an algorithm for clinical and technical investigations to identify patients at risk for aspiration and thus reduce the rate of aspiration pneumonia. The effectiveness of this algorithm has, however, not yet been prospectively validated . METHODS: In this study 144 consecutive stroke patients were assessed by a full bedside swallowing assessment including the screening procedures of standardized swallowing assessment (SSA) and 2 out of 6. Flexible endoscopic evaluation of swallowing (FEES) was performed in all patients. RESULTS: Aspiration was diagnosed in 25 patients (17.4%) by FEES. The SSA predicted aspiration with a sensitivity of 76% and a specificity of 55.5% and the 2 out of 6 screening with a sensitivity of 68.0% and a specificity of 61.0%. Of the patients 7 with negative screening for 2 out of 6 and 6 patients with negative SSA showed silent aspiration with the penetration aspiration scale (PAS 8) during FEES (28% of all patients with aspiration). Significant predictors for aspiration were dysarthria, dysphonia, abnormal volitional cough and cough after swallowing water; however, in multivariable analysis only dysarthria and cough after swallowing water were identified as independent predictors for aspiration. The rate of aspiration pneumonia was 2.8%. CONCLUSION: Clinical screening alone is not sufficient to identify patients at risk for aspiration pneumonia. The FEES should be used at a low threshold in cases of severe stroke and minor clinical abnormalities, especially concerning isolated dysarthria and cough after swallowing water; therefore, current recommendations should be correspondingly modified.

[Survey regarding the treatment of malignant middle cerebral artery infarction in German hospitals]. / Umfragestudie zur Behandlung des malignen Mediainfarkts an deutschen Kliniken.

BACKGROUND: There are a variety of intensive care therapies in the treatment of malignant middle cerebral artery infarction (MMI) besides hemicraniectomy (HC), the only treatment with proven efficacy. It is, however, not known how HC and conservative treatments are utilized in German hospitals, Furthermore, data on the care-situation of patients with MMI in Germany is scarce. METHODS: An anonymous questionnaire was sent to 297 neurological and 133 neurosurgical hospitals in Germany. RESULTS: The Response rate was 24,7%. Most respondents indicated personal experience in the treatment of MMI (83,3%). HC is usually performed early on site (83,3%). Indication to HC is confirmed on a high level of hierarchy and profession using clinical and radiological criteria in 78,2% of hospitals. Inherent standardized treatment protocols are established in 70,8% of hospitals. Patients are treated on an intensive care unit in 74,5% of hospitals after DHC and in 42,5% of hospitals under non-surgical treatment. Intracranial pressure monitoring is not performed on a regular basis. Differing opinions were observed concerning diagnosis and treatment of MMI without recognizable consensus. CONCLUSION: Basically, structural requirements for the treatment of MMI exist in the participating hospitals. Heterogeneity in the treatment of MMI is striking. The implementation of treatment protocols and adherence to guidelines are desirable steps to optimize treatment.

Optical coherence tomography-based assessment of retinal vascular pathology in cerebral small vessel disease.

BACKGROUND: Cerebral small vessel disease (CSVD) is a disorder of brain vasculature that causes various structural changes in the brain parenchyma, and is associated with various clinical symptoms such as cognitive impairment and gait disorders. Structural changes of brain arterioles cannot be visualized with routine imaging techniques in vivo. However, optical coherence tomography (OCT) is thought to be a "window to the brain". Thus, retinal vessel parameters may correlate with CSVD characteristic brain lesions and cerebrospinal fluid biomarkers (CSF) of the neuropathological processes in CSVD like endothelial damage, microglial activation and neuroaxonal damage. METHODS: We applied OCT-based assessment of retinal vessels, magnetic resonance imaging (MRI), and CSF biomarker analysis in a monocentric prospective cohort of 24 patients with sporadic CSVD related stroke and cognitive impairment. MRI lesions were defined according to the STandards for ReportIng Vascular changes on nEuroimaging (STRIVE). Biomarkers were assessed using commercially available ELISA kits. Owing to the unavailability of an age-matched control-group lacking MRI-characteristics of CSVD, we compared the retinal vessel parameters in CSVD patients (73.8 ± 8.5 years) with a younger group of healthy controls (51.0 ± 16.0 years) by using an age- and sex-adjusted multiple linear regression analysis model. RESULTS: Among the parameters measured with OCT, the Wall to Lumen Ratio (WLR) but not Mean Wall Thickness (MWT) of the superior branch of the retinal artery correlated significantly with the volume of white matter hyperintensities on MRI (rs = - 0.5) and with CSF-levels of Chitinase 3 like 1 protein (rs = - 0.6), zona occludens 1 protein (rs = - 0.5) and GFAP (rs = - 0.4). MWT and WLR were higher in CSVD than in controls (28.9 µm vs. 23.9 µm, p = 0.001 and 0.32 vs. 0.25, p = 0.001). CONCLUSIONS: In this exploratory study, WLR correlated with the volume of white matter hyperintensities, and markers of vascular integrity, microglial activation, and neuroaxonal damage in CSVD. Further prospective studies should clarify whether retinal vessel parameters and CSF biomarkers may serve to monitor the natural course and treatment effects in clinical studies on CSVD.

MR-imaging pattern is not a predictor of occult atrial fibrillation in patients with cryptogenic stroke.

BACKGROUND: To date, insertable cardiac monitors (ICMs) are the most effective method for the detection of occult atrial fibrillation (AF) in cryptogenic stroke. The overall detection rate after 12 months, however, is low and ranges between 12.4 and 33.3%, even if clinical predictors are considered. Ischemic stroke patients due to cardiogenic embolism present with particular lesion patterns. In patients with cryptogenic stroke, MR-imaging pattern may be a valuable predictor for AF. METHODS: This is an MRI-based, retrospective, observational, comparative, single-center study of 104 patients who underwent ICM implantation after cryptogenic stroke. The findings were compared to a reference group with related stroke etiology, i.e., 166 patients with embolic stroke due to AF detected for the first time by long-term ECG. Lesion patterns were evaluated with regard to affected territories, distribution (cortical, lacunar, scattered), lesion volume, and lesion size (diameter of the lesion size > 20 mm). RESULTS: The MR-imaging analysis of acute ischemic lesions yielded no association between AF and lesion size or volume, arterial vessel distribution, or the number of affected territories. There was no significant difference between the cohorts regarding ischemic patterns (cortical lesions, scattered lesions, and lacunar infarcts). An important clinical inference of our findings is that 10% (2 of 20) of cases in the ICM group in whom AF was detected had a lacunar infarct pattern. Similar results were shown in cases of ischemic stroke patients with AF detected for the first time by long-term ECG, with 10.9% (16 of 147) of them showing lacunar infarcts. The analysis of chronic MRI lesions revealed no differences between the groups in the rate of chronic lesions, arterial vessel distribution, or the number of affected territories. Left atrial size (LA size) and the presence of atrial runs in long-term ECG were independently associated with AF. CONCLUSIONS: In this MRI-based analysis of patients with cryptogenic stroke who had received ICM implantation, the detection rate of AF in patients with ICM was not related to the imaging pattern. In addition, the lacunar infarct pattern should not be an exclusion criterion for ICM insertion in patients with cryptogenic stroke. ICM insertion in patients with cryptogenic stroke should not be evaluated solely on the basis of reference to infarct patterns.

Direct Electrochemical Addressing of Immobilized Alcohol Dehydrogenase for the Heterogeneous Bioelectrocatalytic Reduction of Butyraldehyde to Butanol.

Modified electrodes using immobilized alcohol dehydrogenase enzymes for the efficient electroreduction of butyraldehyde to butanol are presented as an important step for the utilization of CO2-reduction products. Alcohol dehydrogenase was immobilized, embedded in an alginate-silicate hybrid gel, on a carbon felt (CF) electrode. The application of this enzyme to the reduction of an aldehyde to an alcohol with the aid of the coenzyme nicotinamide adenine dinucleotide (NADH), in analogy to the final step in the natural reduction cascade of CO2 to alcohol, has been already reported. However, the use of such enzymatic reductions is limited because of the necessity of providing expensive NADH as a sacrificial electron and proton donor. Immobilization of such dehydrogenase enzymes on electrodes and direct pumping of electrons into the biocatalysts offers an easy and efficient way for the biochemical recycling of CO2 to valuable chemicals or alternative synthetic fuels. We report the direct electrochemical addressing of immobilized alcohol dehydrogenase for the reduction of butyraldehyde to butanol without consumption of NADH. The selective reduction of butyraldehyde to butanol occurs at room temperature, ambient pressure and neutral pH. Production of butanol was detected by using liquid-injection gas chromatography and was estimated to occur with Faradaic efficiencies of around 40 %.

Air trapping from torsion of a congenital cyst of the lung.

Report on a case of congenital cyst of the lung which was attached to the pleura of the right upper lobe and because of torsion of its pedicle produced air trapping and mediastinal shift. Etiology, diagnosis and surgical indications are reviewed from the literature. No similar case has been previously reported.

[The psychosocial status of HIV-positive mothers and their children]. / Die psychosoziale Situation HIV-positiver Mütter und deren Kinder.

We studied the psycho-social circumstances of HIV-positive women and their children, who were born between January 1, 1984 and June 30, 1991 and are being treated at the Department of Pediatrics. We interviewed 19 women out of 21 families using the problem-centered interview technique according to Witzel. 29 out of 30 children were older than 18 months. Four children were HIV-positive and the serology of one patient aged 12 months who had been perinatally exposed was yet unclarified. The study showed massive problems within these families, such as considerable partner problems, drug abuse and social isolation. Furthermore, there was a lack of child care to relieve the mothers. The predominance of drug problems and insufficient experience of social institutions with the problematic nature of HIV-infection in mothers and children require more efficient preventive measures.

Analysis of quasicontinuous radon monitor response.

Continuous radon monitors respond quickly to changes in radon concentration but bear uncertainties due to the fact that the radon concentration in the detector changes within a counting interval. This disadvantage can be overcome by applying quasicontinuous sampling, where the detector chamber is sealed after the sample has been drawn, so that the radon concentration does not change while counting. The chamber is usually kept closed for 15 min or longer and subsequently flushed or evacuated before the new sample is taken. This paper presents a forward-marching algorithm suitable for the analysis of the response of quasicontinuous radon monitors. The method can be used to obtain both 222Rn and 220Rn concentrations in the gas sample.

Measurements of radon concentration and the role of earth tides in a gypsum mine in Walferdange, Luxembourg.

Measurements of the 222Rn and 220Rn concentration in air, the atmospheric pressure, and the air sample temperature were carried out in an abandoned gypsum mine in Walferdange, Luxembourg. The 222Rn concentration shows a negative correlation with the atmospheric pressure and a tentative positive correlation with gravity variations. The results suggest a porous flow of radon bearing gas across the rock-air interface, which is induced by tidal stresses.

A randomized trial of 4-aminopyridine in EA2 and related familial episodic ataxias.

OBJECTIVE: The therapeutic effects of 4-aminopyridine (4AP) were investigated in a randomized, double-blind, crossover trial in 10 subjects with familial episodic ataxia with nystagmus. METHODS: After randomization, placebo or 4AP (5 mg 3 times daily) was administered for 2 3-month-long treatment periods separated by a 1-month-long washout period. The primary outcome measure was the number of ataxia attacks per month; the secondary outcome measures were the attack duration and patient-reported quality of life (Vestibular Disorders Activities of Daily Living Scale [VDADL]). Nonparametric tests and a random-effects model were used for statistical analysis. RESULTS: The diagnosis of episodic ataxia type 2 (EA2) was genetically confirmed in 7 subjects. Patients receiving placebo had a median monthly attack frequency of 6.50, whereas patients taking 4AP had a frequency of 1.65 (p = 0.03). Median monthly attack duration decreased from 13.65 hours with placebo to 4.45 hours with 4AP (p = 0.08). The VDADL score decreased from 6.00 to 1.50 (p = 0.02). 4AP was well-tolerated. CONCLUSIONS: This controlled trial on EA2 and familial episodic ataxia with nystagmus demonstrated that 4AP decreases attack frequency and improves quality of life. LEVEL OF EVIDENCE: This crossover study provides Class II evidence that 4AP decreases attack frequency and improves the patient-reported quality of life in patients with episodic ataxia and related familial ataxias.

[Active scoliosis in a modified Milwaukee brace (author's transl)]. / Aktive Skoliosengymnastik im modifizierten Milwaukee-Korsett.

On the basis of new insights in sport-medicine active exercises in the Milwaukee brace have been developed which enable the patient to straighten out his spine "on command". The first exercises serves the straightening. A skin-stimulus (spearing) makes the patient straighten his spine actively. First the doctor, later the parents, stimulate with a prick near the thoracic bulge. The patients learn to withdraw the gibbus from it. To re-inforce muscular power, an isometric resistance is exerted after correction. The second exercise corresponds to the well-known active extension with the extension-bandage of Krämer, but this effect is achieved with a modification of the brace. The pelvic girdle contains two shallow holes into which grips can be inserted. The lenght of these grips is so arranged that the power of the arms can be used to best effect. This exercise, too, will later be carried out against the resistance of a sandbag weighing 2-4 kg which is put on the patient's head. Both exercises have the great advantage that they seem to make sense to the patient and will be gladly and regularly carried out. They also encourage the young girls to wear the brace with more hope for success.

[Scoliosis, metabolism and growth of the vertebral column (author's transl)]. / Skoliose, Stoffwechsel und Wirbelsäulenwachstum

Modern investigators incline to the opinion, that more biochemical than biomechanical disorders take part in cause of the "idiopathic'' scolioses. It seems, however, that there is not only one cause but more in some subgroups. Idiopathic scolioses, which have symptomes of arachnodactyly, seem to be a big one of these subgroups. These cases allow to state a hypothesis, in which kind a disordered metabolism leads to a deviation of the spine. This hypothesis is basing on the fact, that the enchondral growth in the length and the periostal growth in the width of "long bones'' are not regulated in the same endocrinological kind and that the enchondral growth of the vertebral-bodies-column happens in cranio-caudal direction, the enchondral growth of the vertebral-archies-column, however, in anterior-posterior direction. If the balance between enchondral and periostal growth is disturbed, you can see typical chances on the long bones, which resemble either an "arachnodactyly" or a "chondrodysplasy". The same disturbance will cause a "kyphosis" respectively a "lordosis" (or scoliosis) on the vertebral spine; either the bodies-column or the archies-column will become longer (higher). The results of metabolism research are suitable to these facts. If the balance between enchondral and periostal growth,--basing on a dysbolism,--is disturbed in such a kind, that the vertebral-bodies-column is growing faster than the vertebral-archies-column, the vertebral spine is forced to change into a lordosis respectively into a scoliosis. If you want to cure an idiopathic scoliosis, you first have to remove or to paralyse the dysbolism. The aim of all research has to be to find an effective chemotherapeutical treatment of mindst a part of all idiopathic scolioses.