Translation of the 'time is brain' concept into clinical practice: focus on prehospital stroke management.

Acute stroke is one of the main causes of death and chronic disability. Thrombolysis with recombinant tissue plasminogen activator within the first hours after onset of symptoms is an effective therapeutic option for ischemic stroke. However, fewer than 2% to 7% of patients receive this treatment, primarily because most patients reach the hospital too late for the initiation of successful therapy. Several measures can reduce detrimental delay until treatment. It is of importance to use continual public awareness campaigns to reduce delays in patients' alarm of emergency medical services. Further relevant measures are repetitive education of emergency medical services teams to ensure the systematic use of scales designed for recognition of stroke symptoms and the proper triage of patients to stroke centers. A most important time-saving measure is prenotification of the receiving hospital by the emergency medical services team. In the future, treatment already at the emergency site may allow more than a small minority of patients to benefit from available treatment.

["Time is brain". Optimizing prehospital stroke management]. / "Zeit ist Hirn". Optimierung des prähospitalen Schlaganfallmanagements.

Acute stroke is one of the main causes of death and chronic disability. Thrombolysis, achieved by administering recombinant tissue plasminogen activator within 4.5 h, is an effective therapeutic option for ischemic stroke. However, less than 2-12 % of patients receive this treatment and a major reason is that most patients reach the hospital too late. Several time-saving measures should be implemented. Firstly, optimized and continual public awareness campaigns for patients should be initiated to reduce delays in notifying the emergency medical service. Secondly, emergency medical service personnel should develop protocols for prenotification of the receiving hospital. Other suggested measures involve educating emergency medical service personnel to systematically use scales for recognizing the symptoms of stroke and to triage patients to experienced stroke centers. In the future, administering treatment at the emergency site (mobile stroke unit concept) may allow more than a small minority of patients to benefit from available recanalization treatment options.

Mobile stroke unit for diagnosis-based triage of persons with suspected stroke.

BACKGROUND: In this feasibility study, we tested whether prehospital diagnostic stroke workup enables rational decision-making regarding treatment and the target hospital in persons with suspected stroke. METHODS: A mobile stroke unit that delivers imaging (including multimodal brain imaging with CT angiography and CT perfusion), point-of-care-laboratory analysis, and neurologic expertise directly at the emergency site was analyzed for its use in prehospital diagnosis-based triage of suspected stroke patients. RESULTS: We present 4 complementary cases with suspected stroke who underwent prehospital diagnostic workup that enabled direct diagnosis-based treatment decisions and reliable triage regarding the most appropriate medical facility for that individual, e.g., a primary hospital vs specialized centers of a tertiary hospital. CONCLUSIONS: This preliminary report demonstrates the feasibility of prehospital diagnostic stroke workup for immediate etiology-specific decision-making regarding the necessary time-sensitive stroke treatment and the most appropriate target hospital.

Stent-assisted mechanical recanalization for treatment of acute intracerebral artery occlusions.

BACKGROUND AND PURPOSE: The purpose of this study was to demonstrate a new approach to the use of a self-expanding stent in the treatment of acute ischemic stroke. METHODS: Twenty-two consecutive patients with acute intracerebral artery occlusions were treated with a self-expandable intracranial stent, which was withdrawn in its unfolded state. For this technique, we used the Solitaire AB/FR, which is the only intracranial stent that is fully recoverable. Eight patients had an occlusion of the basilar artery, 12 had a middle cerebral artery occlusion, and 2 had terminal carotid artery occlusions; 6 of these had to be treated first for an acute occlusion originating in the internal carotid artery. Recanalization results were assessed by follow-up angiography immediately after the procedure. Neurologic status was evaluated before and after treatment (90-day follow-up) according to the National Institutes of Health Stroke Scale and modified Rankin scale. RESULTS: Successful revascularization was achieved in 20 of 22 (90.9%) patients (thrombolysis in cerebral infarction [TICI] 2a/b and 3), a TICI 3 state was accomplished in 12 patients, and partial recanalization or slow distal branch filling with filling of more than two-thirds of the vessel territory was achieved in 8 patients (TICI 2b). There was immediate flow restoration in 21 of 22 (95.4%) cases after deployment of the device. The stent was removed in its unfolded state in all patients. The mean time from stroke symptom onset to recanalization was 277 minutes, with a standard deviation of 118 minutes. Mean National Institutes of Health Stroke Scale score on admission was 19.4, with a standard deviation of 5.7. Almost two-thirds of the patients (63.6%) improved by > 10 points on the National Institutes of Health Stroke Scale at discharge, and 50% showed a modified Rankin scale score of ≤ 2 at 90 days (59% with a modified Rankin scale ≤ 3). Mortality was 18.1%. In 1 case, an asymptomatic intracranial hemorrhage was detected on control computed tomography, and 2 patients had a symptomatic intracranial hemorrhage. CONCLUSIONS: Withdrawal of an unfolded, fully recoverable, intracranial stent yielded very promising angiographic and clinical results. It combines the advantages of prompt flow restoration and mechanical thrombectomy.

Revascularization in acute ischaemic stroke using the penumbra system: the first single center experience.

BACKGROUND AND PURPOSE: This is the first single center experience illustrating the effectiveness of the penumbra system (PS) in the treatment of large vessel occlusive disease in the arena of acute ischaemic stroke. The PS is an innovative mechanical thrombectomy device, employed in the revascularization of large cerebral vessel occlusions in patients via the utilization of an aspiration platform. METHODS: This is a prospective, non-randomized controlled trial evaluating the clinical and functional outcome in 29 patients with acute intra-cranial occlusions consequent to mechanical thrombectomy by the PS either as mono-therapy or as an adjunct to current standard of care. Patients were evaluated by a neurologist and treated by our in house interventional neuro-radiologists. Primary end-points were revascularization of the occluded target vessel to TIMI grade 2 or 3 and neurological outcome as measured by an improvement in the NIH Stroke Scale (NIHSS) score after the procedure. RESULTS: Complete revascularization (TIMI 3) was achieved in 21/29 (72.4%) of patients. Partial revascularization (TIMI 2) was established in 4/29 (13.8%) of patients. Revascularization failed in four (13.8%) patients. Nineteen (19) patients (65.5%) had at least a four-point improvement in NIHSS scores. Modified Rankin scale scores of < or =2 were seen in 37.9% of patients. There were no device-related adverse events. Symptomatic intra-cranial hemorrhage occurred in 7% of patients. CONCLUSIONS: The PS has the potential of exercising a significant impact in the interventional treatment of ischaemic stroke in the future.

[Carotid artery stenting for acute stroke]. / Karotisstent beim akuten Schlaganfall.

For patients with acute ischemic stroke due to total occlusion of the internal carotid artery (ICA), an effective intervention to improve neurologic symptoms and clinical outcome has not yet been established. Some authors have reported successful revascularization for patients with acute stroke symptoms secondary to ICA occlusion only in isolated series and case reports. Emergency recanalization and carotid artery stent placement can improve neurologic outcome in selected patients with acute ischemic stroke and total occlusion of the ICA.

Lesion load in unprotected carotid artery stenting.

INTRODUCTION: The purpose of the study was to determine the incidence of new ischemic lesions found on diffusion-weighted MR imaging (DWI) in nonselected patients after unprotected carotid artery stent placement. MATERIALS AND METHODS: We retrospectively reviewed a nonrandomized cohort of 197 patients presenting with carotid occlusive disease who underwent unprotected carotid artery stent placement between 2003 and 2006. Mean degree of stenosis was 86.94% +/- 9.72. In all patients, DWI was obtained before and 24 h after stent placement. New lesions were evaluated according to size and location. RESULTS: In 59 of 197 patients (29.9%), new ischemic lesions were found on DWI in the vessel dependent area. In 23 of 197 patients (11.7%), new ischemic lesions were found in the vessel independent area. Combined stroke/death rate was 3.63%. CONCLUSION: In our series of unprotected carotid angioplasty with stent, we found new DWI lesions in 34% of the patients. Further studies should now show in how far protection devices can reduce these lesions.

Hyperperfusion syndrome after carotid stent angioplasty.

INTRODUCTION: This study assesses the incidence and causes of hyperperfusion syndrome occurring after carotid artery stenting (CAS). MATERIALS AND METHODS: We retrospectively reviewed the clinical database of 417 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or intracranial hemorrhage. Magnetic resonance imaging (MRI) including fluid-attenuated inversion recovery and diffusion-weighted imaging was performed before and after CAS in 269 cases. A Spearman's rho nonparametric correlation was performed to determine whether there was a correlation between the occurrence/development of hyperperfusion syndrome and the patient's age, degree of stenosis on the stented and contralateral side, risk factors such as diabetes, smoking, hypertension, adiposity, gender and fluoroscopy time, and mean area of postprocedural lesions as well as preexisting lesions. Significance was established at p < 0.05. RESULTS: Of the 417 carotid arteries stented and where MRI was also completed, we found hyperperfusion syndrome in 2.4% (ten cases). Patients who had preexisting brain lesions (previous or acute stroke) were at a higher risk of developing hyperperfusion syndrome (p = 0.022; Spearman's rho test). We could not validate any correlation with the other patient characteristics. CONCLUSION: Extensive microvascular disease may be a predictor of hyperperfusion syndrome after carotid stent placement. We believe that further studies are warranted to predict more accurately which patients are at greater risk of developing this often fatal complication.

[Differential diagnosis of non-neoplastic space-occupying lesions of the spinal cord]. / Differenzialdiagnostik der nichtneoplastischen spinalen Raumforderung.

This overview addresses the topic of non-neoplastic intraspinal space-occupying lesions. Knowledge of these entities is essential to distinguish them from tumorous processes. A selection of clinically relevant differential diagnoses is presented which pertain to inflammatory, vascular, and degenerative diseases. In addition, special clinical findings, the radiological procedure, and therapeutic possibilities are outlined.

[Stroke]. / Hirninfarkt.

Today stroke represents a major medical and political problem in Western industrial nations. High demands need to be placed on the initial diagnostic work-up and therapeutic treatment to ensure that the patients benefit from the recent advancements achieved in diagnostic and therapeutic fields. According to the motto "time is brain" the clinical examination and imaging have to be performed within 60 min ("door to needle time") so that potential patients can be quickly treated with systemic or intra-arterial lysis. However, it should be taken into consideration that the selection of diagnostic imaging facilities depends on several factors such as infrastructure, the time remaining in the diagnostic window, and the severity of the clinical symptoms.

[Basics of acute stroke treatment]. / Grundzüge der akuten Schlaganfalltherapie.

Acute stroke presents an emergency that requires immediate referral to a specialized hospital, preferably with a stroke unit. Disability and mortality are reduced by 30% in patients treated in stroke units compared to those treated on regular wards, even if a specialized team is present on the ward. Systolic blood pressure may remain high at 200-220 mmHg in the acute phase and should not be lowered too quickly. Further guidelines for basic care include: optimal O2 delivery, blood sugar levels below 100-150 mg%, and lowering body temperature below 37.5 degrees C using physical means or drugs. Increased intracranial pressure should be treated by raising the upper body of the patient, administration of glycerol, mannitol, and/or sorbitol, artificial respiration, and special monitoring of Tris buffer. Decompressive craniectomy may be considered in cases of "malignant" media stroke and expansive cerebellar infarction. Fibrinolysis is the most effective stroke treatment and is twice as effective in the treatment of stroke than myocardial infarction. Fibrinolysis may be initiated within 3 h of a stroke in the anterior circulation. If a penumbra is detectable by "PWI-DWI mismatch MRI," specialized hospitals may perform fibrinolysis up to 6 h after symptom onset. In cases of stroke in the basilar artery, fibrinolysis may be performed even later after symptom onset. Intra-arterial fibrinolysis is performed in these cases using rt-PA or urokinase. Follow-up treatment of stroke patients should not only address post-stroke depression and neuropsychological deficits, but also include patient education about risk factors such as high blood pressure, diabetes mellitus, and cardiac arrhythmias.

[Quality control in imaging standards for stroke diagnosis]. / Qualitätssicherung in der bildgebenden Schlaganfalldiagnostik.

Hospitals in "Rhineland-Palatinate" and "Saarland" as well as in other German states are using benchmarking in quality control and to improve diagnostic procedures and treatment in stroke. The goal is a continuous learning process in which participants improve their performance by comparing themselves to the highest quality care. CCT/MRI procedures are an important tool in stroke therapy and prophylaxis. Structural quality was good in all 39 participating hospitals. The best evidence-based indicator in quality control of CCT/MRI procedures is the process quality in performing these procedures within 3 h after stroke onset. Process quality was better in hospitals that cared for many stroke patients than in those with fewer cases. The latter hospitals also had less clinical and diagnostic competence. Benchmarking in quality control was successful because over the years improvement in stroke management was obvious in the participating hospitals.

Clinical and neuroimaging features of "idiopathic" syringomyelia.

In some adult patients with cervical syringomyelia, MRI studies do not identify primary disease within the foramen magnum or spinal canal. To identify the etiology of this idiopathic type of syringomyelia, clinical features and posterior fossa (PF) measurements from 17 of these patients, 17 patients with Chiari I-type syringomyelia, and 32 control subjects were compared. Idiopathic syringomyelia and Chiari I-type syringomyelia manifested central cervical myelopathy and a small PF with narrow CSF spaces, suggesting that they develop by the same mechanism.

Presence of Chlamydia pneumoniae DNA in the cerebral spinal fluid is a common phenomenon in a variety of neurological diseases and not restricted to multiple sclerosis.

Chlamydial DNA and viable organisms have been reported in the cerebrospinal fluid (CSF) of multiple sclerosis (MS) patients. We investigated whether this phenomenon is specific for MS and not occurring in patients with other neurological diseases (OND) or in healthy controls and whether it is caused by infected blood monocytes having crossed the blood-brain barrier. Twelve (21%) of fifty-eight MS patients and 20 (43%) of 47 OND patients had Chlamydia pneumoniae DNA in the CSF as determined by nested polymerase chain reaction. Viable organisms were cultured from one OND patient. We failed to detect C. pneumoniae in the CSF of 67 neurologically healthy persons. C. pneumoniae was detected in parallel in the blood monocytes of 2 of 6 CSF-positive MS patients and in 8 of 10 CSF-positive OND patients. Thus, chlamydial presence cannot exclusively be explained as being caused by contaminating infected monocytes that have crossed the blood-brain barrier. In peripheral blood mononuclear cell-negative patients, chlamydia have been cleared from the circulation but persist in the central nervous system (CNS), indicating the establishment of a chronic process. In summary, the presence of C. pneumoniae in patients with neurological diseases is a common phenomenon and is not restricted to MS patients. The pathogenetic relevance of a chronic chlamydial CNS infection for neurological diseases remains unclear, but the hypothesis that susceptible patients may be impaired in their ability to clear chlamydiae from the CNS requires further examination.

[Quality assurance in treatment of stroke: basic module of the German Stroke Registry Study Group]. / Qualitätssicherung in der Schlaganfall-Behandlung: das Basismodul der Arbeitsgemeinschaft Deutscher Schlaganfall-Register (ADSR).

BACKGROUND AND PURPOSE: Comparable, standardised data on the quality and efficiency of stroke care in Germany are lacking. The Arbeitsgemeinschaft Deutscher Schlaganfall-Register (ADSR--German Stroke Registries Study Group) has defined a "Minimum DataSet" for the evaluation of quality indicators of stroke treatment in Germany. METHODS: The ADSR is a voluntary network of current regional stroke registries aiming at a standardisation in the use of stroke terminology and methods of data collection for German stroke databases. Currently six regional stroke registries are cooperating in the ADSR, combining data from about 18,000 stroke patients in 110 hospitals annually. RESULTS: In the design of the ADSR DataSet a modular approach was chosen. The ADSR "Minimum DataSet" was adapted for a wide use in different health care facilities. In addition to the "Minimum DataSet" an "Advanced DataSet" will be developed to document additional items of stroke care in specialised stroke centres. The ADSR DataSet collection will be completed by special "Extended DataSets", designed for answering centre-specific and research questions. CONCLUSION: The ADSR "Minimum DataSet" allows a standardised assessment of stroke care in Germany. It is the first questionnaire that provides valid and reliable comparisons between different clinical settings as well as regional stroke databases. The ADSR "Minimum DataSet" defines core items for a future National German Health Report on stroke care.

The Erve virus: possible mode of transmission and reservoir.

The Erve virus is suspected to cause severe headache in humans, lasting several days (thunderclap headache). Mice are characterized as a probable reservoir for the Erve virus. We tested 396 wild mice for Erve virus using an immunofluorescence test and found Erve virus antibodies in five cases, showing that small mammals form a reservoir for Erve virus. If ticks are the vector for the virus, a coincidence with borreliosis should exist. We were unable to confirm this in a homogeneous cohort of 955 young men, 62 of whom tested positive for borreliosis. This group did not test positive significantly more often in the immunofluorescence test than a gender- and age-matched control group.

Chronic fatigue syndrome in patients with Lyme borreliosis.

Several authors have reported a chronic fatigue-like syndrome in patients that have suffered from Lyme borreliosis in the past. To further investigate this suspicion of an association without sample bias, we carried out a prospective, double-blind study and tested 1, 156 healthy young males for Borrelia antibodies. Seropositive subjects who had never suffered from clinically manifest Lyme borreliosis or neuroborreliosis showed significantly more often chronic fatigue (p = 0.02) and malaise (p = 0.01) than seronegative recruits. Therefore we believe it is worth examining whether an antibiotic therapy should be considered in patients with chronic fatigue syndrome and positive Borrelia serology.

Effects of multiple sclerosis and other inflammatory CNS disorders on tick-borne encephalitis serology.

The goal of the present study was to investigate whether a direct association exists between false-positive recognition of IgG antibodies and inflammatory changes in the central nervous system (CNS) and whether inflammatory diseases of the CNS affect the specificity of the enzyme-linked immunosorbent assay (ELISA) of tick-borne encephalitis (TBE) virus. A group of patients (1,815), treated in the Department of Neurology, University Hospital of the Saarland, Homburg/Saar, Germany, were tested forTBE IgG antibodies by ELISA. Several subgroups of patients with and without inflammatory changes in the CSF as well as patients with and without confirmed multiple sclerosis (MS) were investigated. Overall, 4.5% of all the 1,815 patients and 4.8% of the patients with inflammatory changes in the CSF but without MS had TBE IgG antibodies. In the subgroup with inflammatory changes in the CSF and MS, 4.4% of the patients were TBE IgG-positive. In the subgroup without inflammatory changes in the CSF, 3.8% of the patients without MS were TBE IgG-positive and 4.9% of the patients with MS were TBE IgG-positive. The rate of TBE IgG positivity was not significantly different in the subgroups with and without inflammatory changes in the CSF (P = 0.45). The comparison of the subgroups with and without MS showed no significant difference in the TBE IgG titer (P = 0.83) as well. This indicates that the specificity of the ELISA was affected neither by inflammatory changes in the CSF nor by MS.