No Harmful Effect of Endovascular Treatment before Decompressive Surgery-Implications for Handling Patients with Space-Occupying Brain Infarction.

This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann-Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann-Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.

Fluid Balance Variations During the Early Phase of Large Hemispheric Stroke Are Associated With Patients' Functional Outcome.

Background: From the variety of factors underlying the ischemia-associated edema formation in large hemispheric stroke (LHS), an increased brain water content during the early phase seems to have a pivotal role for long-lasting tissue damage. However, the importance of the fluid management during the acute phase of LHS has so far not been adequately studied. Therefore, this study explored the association between the fluid balance and functional outcome in patients suffering from LHS. Methods: We analyzed hospital-based medical records of 39 consecutive patients with LHS and decompressive hemicraniectomy. Over the first 10 days after admission, the volumes of all administered fluids were assessed daily and corrected for daily urinary output and insensible loss. Functional outcome at 3 months was assessed with the modified Rankin Scale (mRS) and dichotomized into an acceptable (mRS ≤ 4) vs. a poor outcome (mRS ≥ 5). Results: Compared to patients with a poor functional outcome (n = 19), those with an acceptable outcome (n = 20) were characterized by a significantly lower cumulative net fluid balance at day 5 (1.6 ± 2.5 vs. 3.4 ± 4.4 l), day 7 (2.0 ± 2.9 vs. 4.6 ± 5.2 l), and day 10 (0 ± 2.5 vs. 5.6 ± 6.2 l). In addition to age, only the cumulative net fluid balance at day 10 served as an independent factor for poor functional outcome in multiple regression analyses. Conclusion: These data provide evidence for a critical role of the early phase net fluid balance with respect to the functional outcome after LHS. This observation leads to the hypothesis that patients with LHS might benefit from a more restrictive volume therapy. However, prospective studies are warranted to establish a causal relationship and recommendations for treatment strategies.

Inter-rater reliability of the ICPC-2 in a German general practice setting.

QUESTIONS: Three- and four-digit International Classification of Diseases (ICD-10) is not a reliable classification system in primary care. The reliability of the International Classification of Primary Care (ICPC-2) as an alternative coding system has not yet been investigated in a German general practice setting. METHODS: Cross-sectional data were collected during a one year period in a general practice setting. PARTICIPANTS: A total of 8,877 patients were randomly selected. MAIN OUTCOME MEASURES: The first of the reasons for encounter was taken into account on new and chronic managed problems. The ICPC-2 coding of each case was performed by two raters to investigate the inter-rater agreement. The degree of agreement between the raters was assessed by using Cohen's kappa (κ ≥ 0.61 meaning high or satisfactory and κ ≤ 0.6 (incl. ≤ 0.000) meaning low or unsatisfactory). RESULTS: The reliability was good to excellent at the chapter level, at the component level the reliability was moderate though good in the components 1-symptoms and 7-diseases. At single code level the agreement was only fair to moderate in both chapters and components. One third to half of the used codes showed good inter-rater agreement. CONCLUSION: The ICPC-2 is an adequate and feasible instrument for routine use in general practice. The fair to moderate reliability on the single code level should be considered when designing studies and interpreting data that are based on the ICPC-2.

Change of strength and rate of rise of tension relate to functional arm recovery after stroke.

OBJECTIVE: To examine the relationship between individual strength parameters and functional motor ability over time during rehabilitation in stroke patients. DESIGN: A multiple-baseline experiment with assessment at inclusion and after 3 and 6 weeks. SETTING: Secondary-care rehabilitation center. PARTICIPANTS: A convenience sample of 16 subacute stroke patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Maximal voluntary force and rate of rise of tension of hand grip, wrist extension, and elbow flexion and extension were recorded at all 3 times. At the same time, functional motor assessments were evaluated by the Action Research Arm Test (ARAT), Box and Block test, and Rivermead Test. RESULTS: We found no correlation between maximal voluntary force increases of various muscle contractions measurements. Neither the increase of grip strength nor that of wrist extension force correlated with improvement in ARAT score. Yet the improvement in the rate of rise of tension of hand grip (Spearman rho=.91) and of wrist extension (Spearman rho=.73) correlated with the improvement of the ARAT score and explained 77% of the variance of the ARAT. CONCLUSIONS: The change in the rate of rise of tension of the hand grip has a better predictive value for the functional recovery compared to the change in maximal voluntary force in patients with moderate arm and hand weakness after stroke. The rate of rise of tension of hand grip seems an adequate quantifiable parameter to detect small improvements during functional recovery.