New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline.

Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.

Safety of apnea testing for the diagnosis of brain death: a comprehensive study on neuromonitoring data and blood gas analysis.

BACKGROUND AND PURPOSE: Here, we studied the safety of apnea testing (AT) for the determination of brain death with regard to intracranial pressure (ICP), cerebral perfusion and arterial blood gas parameters. We hypothesized that ICP only increases when cerebral perfusion pressure (CPP) remains positive during AT. METHODS: A total of 34 patients who fulfilled brain death criteria were identified by chart review (2009-2017). We analysed ICP, CPP and mean arterial pressure (MAP) prior to AT, during AT and after AT, as well as arterial pH, paCO2 , paO2 and arterial O2 saturation at the start and end of AT. RESULTS: Intracranial pressure was 87.9 ± 17.7 mmHg (mean ± SD) prior to AT, 89.9 ± 17.2 mmHg during AT and 86.4 ± 15.2 mmHg after AT (P = 0.9). CPP was -6.9 ± 12.8 mmHg prior to AT, -7.1 ± 13.7 mmHg during AT and -8.6 ± 13.0 mmHg after AT (P = 0.98), respectively. MAP was 82.9 ± 14.6 mmHg prior to AT, 84.7 ± 13.9 mmHg during AT and 79.7 ± 9.6 mmHg after AT (P = 0.57), respectively. A total of 10 patients had positive CPP (8.6 ± 4.3 mmHg), but ICP did not increase during AT. Arterial pH decreased from 7.43 ± 0.06 to 7.22 ± 0.06 (P < 0.05), paCO2 increased from 38.6 ± 4.2 to 69.6 ± 8.0 mmHg (P < 0.05), paO2 decreased from 416.3 ± 113.4 to 289.2 ± 146.5 mmHg (P < 0.05), and O2 saturation was stable at 99.8 ± 0.4% and 98.2 ± 3.2% (P = 0.39). CONCLUSIONS: Apnea testing had no detrimental effect on ICP, CPP, MAP or oxygenation, regardless of the presence of an initially positive CPP. The lack of further ICP elevations is presumably explained by critical closing pressures above individual CPP levels during AT.

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology.

BACKGROUND AND PURPOSE: Current guidelines on cerebral venous thrombosis (CVT) diagnosis and management were issued by the European Federation of Neurological Societies in 2010. We aimed to update the previous European Federation of Neurological Societies guidelines using a clearer and evidence-based methodology. METHOD: We followed the Grading of Recommendations, Assessment, Development and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews and writing recommendations based on the quality of available scientific evidence. RESULTS: We suggest using magnetic resonance or computed tomographic angiography for confirming the diagnosis of CVT and not routinely screening patients with CVT for thrombophilia or cancer. We recommend parenteral anticoagulation in acute CVT and decompressive surgery to prevent death due to brain herniation. We suggest preferentially using low-molecular-weight heparin in the acute phase and not direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that, in women who have suffered a previous CVT, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular-weight heparin should be considered throughout pregnancy and puerperium. CONCLUSIONS: Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of CVT.

Outcome of heparin-treated patients with acute cerebral venous sinus thrombosis: influence of the temporal pattern of intracerebral haemorrhage.

BACKGROUND AND PURPOSE: The influence of temporal patterns of intracerebral haemorrhage (ICH) on the outcome of heparin-treated patients with cerebral venous sinus thrombosis (CVST) has not been examined systematically. METHODS: Temporal patterns of ICH and their influence on survival without disability (modified Rankin Scale score ≤1 point) at hospital discharge were examined in 141 consecutive hospital-admitted patients with acute CVST who were treated with intravenous unfractionated heparin. RESULTS: Of all 141 patients (median age 40 years; 73% women), 59 (42%) had ICH at the time of diagnosis (early ICH). Of these, seven (12%) subsequently had extension of ICH and 13 (22%) had additional ICHs at other locations (delayed ICH). Of 82 patients without early ICH, nine (11%) later had delayed ICH. After a median hospital stay of 26 days, 107 patients (76%) were discharged without disability. Patients with early ICH were less likely to survive without disability until discharge than those without early ICH [63% vs. 85%; risk ratio (RR) 0.73; P = 0.005]. The association was attenuated after adjusting for age, sex and impaired consciousness on admission (RR 0.83; P = 0.03). Taking temporal patterns of ICH into account, early ICH with subsequent complication (extension or delayed ICH) had a larger influence on survival without disability (RR 0.57; 95% confidence interval 0.35-0.95) than early ICH without complications (RR 0.78; 95% confidence interval 0.67-0.91). CONCLUSIONS: Heparin-treated CVST patients were less likely to survive without disability when ICH was present on admission. This association may largely be driven by subsequent extension of haemorrhage or additionally occurring delayed haemorrhage.

[Ancillary procedures in the diagnostics of brain death. Utilization, results and consequences in northeastern Germany]. / Apparative Verfahren in der Hirntoddiagnostik. Nutzung, Ergebnisse und Auswirkungen in Nordostdeutschland.

BACKGROUND: According to the German Medical Council guidelines, the proof of irreversible brain death can be carried out using clinical investigations alone or can necessitate the use of ancillary tests (ATs), depending on the patient age and type of brain injury. METHODS: Retrospective evaluation of the diagnostics of irreversible brain death, which were carried out using ATs according to the third edition of the guidelines between January 2001 and December 2010 in Berlin, Brandenburg and Mecklenburg-Western Pomerania and were registered at the German National Foundation for Organ Transplantation. RESULTS: In 1401 patients (aged 0-94 years) a total of 1636 ATs were carried out. The most frequently used additional procedure for the first AT was an electroencephalogram (EEG) in 71.7 %. Confirmatory results regarding irreversibility were reported for 93.6 % of the initial ATs. Negative results of ATs were less common with primary supratentorial brain lesions (2.9 %) compared to infratentorial lesions (13.7 %), secondary hypoxic brain damage (8.1 %) and children younger than 2 years old (18.5 %). Regardless of the AT results, a return of clinical brain function was never documented. The timing, type and repetition of ATs were variable. In most cases the diagnostic process was clearly accelerated by the use of ATs but was significantly delayed in 10.1 % compared to a purely clinical proof of irreversible brain death. CONCLUSION: ATs by themselves do not provide evidence of the cessation of all brain functions. Instead, they are used to prove the irreversibility of the clinically defined syndrome. For patients over 2 years old and in the absence of primary brainstem lesions, clinical re-assessment and ATs are considered to be equally accurate in demonstrating irreversibility. A standardization of diagnostic procedures between hospitals would be desirable.

[Access to brain death diagnostics]. / Zugang zur Hirntoddiagnostik.

BACKGROUND AND OBJECTIVES: In Germany the diagnosis of brain death must strictly adhere to the expert guidelines of the German chamber of physicians. For patients with primary supratentorial or hypoxic brain injury aged 2 years or more, repeat clinical examinations or one complete examination combined with an ancillary test are equally accurate. This study aimed to identify factors with potential impact on whether and by which means a formal brain death examination is pursued. MATERIAL AND METHODS: A retrospective analysis was carried out of recorded data of all patients who died in the acute phase after severe brain injury during mechanical ventilation in an intensive care unit and who were registered at the north east regional bureau of the German organ procurement organization (Deutsche Stiftung Organtransplantation) between 2001 and 2010. RESULTS: Of 5988 reported patients, a protocol-specified brain death examination was initiated in 3023, leading to a diagnosis of brain death in 2592. All other patients died due to permanent cardiac arrest. Patients were less likely to undergo brain death examinations in the presence of one or more of the following characteristics: perceived medical contraindication for organ donation, patient age greater than 69 years, hypoxic brain damage, treatment in a hospital without neurological and neurosurgical departments and death on a weekend or public holiday. In 2192 patients (72.5%), neurologists or neurosurgeons participated in the diagnostic procedures and in 926 of these cases members of specialized external diagnostic expert teams were involved. Ancillary tests were rarely used by physicians based at the treating hospitals (31.1%) but on a regular basis by members of the external teams (93.4%). The risk of death due to permanent cardiac arrest before completion of the brain death examination was increased approximately 7-fold when a neurological or neurosurgical consultation with ancillary studies was not performed. DISCUSSION: Access to neurological expertise and to ancillary tests has a significant impact on the provision of guideline-specified diagnostic procedures for suspected brain death. Centralized diagnostic teams offer an effective means to support qualified brain death examinations.

[Primary and secondary prevention of stroke]. / Primär- und Sekundärprävention des Schlaganfalls.

Despite considerable advances in acute stroke therapy, stroke prevention remains the most promising approach for reducing the burden of stroke. A healthy lifestyle and the treatment of cardiometabolic risk factors are the cornerstones of both primary and secondary stroke prevention. Due to a proportionately higher risk of bleeding complications, platelet inhibitors are not recommended for primary stroke prevention. Platelet inhibitors are effective in the secondary prevention of stroke with acetyl salicylic acid (ASS) and clopidogrel showing the most consistent data. New oral anticoagulants are slightly more effective than coumarin and significantly reduce the risk of intracranial hemorrhage. They offer the opportunity to bring more patients with atrial fibrillation at risk for stroke into anticoagulation particularly those on ASS therapy. Surgery for patients with asymptomatic carotid artery stenosis should be viewed critically with respect to an only marginal benefit and improvement in medical therapies. Carotid endarterectomy remains the gold standard for patients with symptomatic carotid stenosis because of an increased procedural stroke risk with carotid stenting. Patients with symptomatic intracranial stenosis or cryptogenic stroke and a patent foramen ovale should receive only medical treatment.

EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients.

BACKGROUND: Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed as a result of the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis and symptomatic therapy including control of seizures and elevated intracranial pressure. METHODS: We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence but consensus was clear we stated our opinion as good practice points. RESULTS AND CONCLUSIONS: Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous LMWH or with dose-adjusted intravenous heparin (level B recommendation). Concomitant intracranial haemorrhage (ICH) related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulant therapy after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with "mild" thrombophilia, such as heterozygous factor V Leiden or prothrombin G20210A mutation and high plasma levels of factor VIII. Indefinite AC should be considered in patients with recurrent episodes of CVST and in those with one episode of CVST and 'severe' thrombophilia, such as antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without large ICH and threatening herniation (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. However, in severe cases with impending herniation craniectomy can be used as a life-saving intervention (good practice point).

320-slice CT neuroimaging: initial clinical experience and image quality evaluation.

The aim of this study was to report initial clinical experience with a 320-slice CT scanner and to perform an image quality evaluation. 26 patients with presumptive cerebrovascular pathology underwent 320-slice CT. Single-rotation CT of the head, incremental CT angiography (three-dimensional (3D) CTA) as well as four-dimensional whole-brain CTA (4D CTA) and whole-brain CT perfusion (CTP) were performed and the resulting images were assessed for quality and compared with those obtained with 64-slice CT protocols. 320-slice CT neuroimaging could be performed in all cases. The image quality of 320-slice CT of the head and 3D CTA was inferior to that of the 64-slice protocols. The image quality of 4D 320-slice CTA was rated as inferior to both 320- and 64-slice 3D CTA. 4D CTA-CTP imaging added information with pivotal clinical implications. 320-slice CT neuroimaging is feasible technique that permits whole-brain 4D imaging and has the potential to identify pathologies with altered haemodynamics. However, image quality is a limitation of this technique at present.

[Reasons for underuse of oral anticoagulation in atrial fibrillation-associated stroke: prospective study of German stroke patients]. / Analyse des "Nichtgebrauchs" der oralen Antikoagulation zur Schlaganfallprävention bei Vorhofflimmern: Eine prospektive Studie.

Oral anticoagulation in atrial fibrillation (AF) is effective in primary and secondary prevention of cardioembolic stroke, but is often underused in practice. The detailed reasons for non-use of oral anticoagulation are less well known. We prospectively analyzed 105 consecutive cases of acute ischemic stroke associated with atrial fibrillation. Patients were investigated by a semi-structured interview. The most frequent reasons for underuse were: unknown AF (43 %). In case of known AF: reluctance of patients (30 %), contraindications (25 %) and compliance problems (20 %). There was good agreement between patients and physicians views about nonuse or aborted use of oral anticoagulation (kappa 0.64 and 0.93, respectively). Unknown atrial fibrillation is the most prevalent cause of underutilization of oral anticoagulation in acute stroke patients. Since atrial fibrillation is easy to detect in most cases, it could be worthwhile to screen elderly patients without contraindications for anticoagulation.

Treatment of cerebral venous and sinus thrombosis.

Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for less than 1% of all strokes. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low molecular weight heparin, the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We reviewed the strength of evidence reported in the literature to support these interventions and provide treatment recommendations based on the best available evidence. Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous low molecular weight heparin or dose-adjusted intravenous heparin. Concomitant intracranial hemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral AC after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with 'mild' hereditary thrombophilia. Indefinite AC should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and 'severe' hereditary thrombophilia. There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial hemorrhage. There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Anti-edema treatment (including hyperventilation, osmotic diuretics, craniectomy) should be used as life-saving interventions.

Comparative evaluation of 2D time-of-flight and 3D elliptic centric contrast-enhanced MR venography in patients with presumptive cerebral venous and sinus thrombosis.

We retrospectively evaluated an elliptic centric ordered 3D (ec 3D) magnetic resonance venography (MRV) technique in comparison to 2D time-of-flight (2D TOF) MRV in patients with presumptive cerebral venous sinus thrombosis (CVST). Twenty-five patients (mean age 40.6 +/- 16.5 years) with presumptive CVST underwent cerebral MRI including 2D TOF and ec 3D MRV. Radiologic findings and clinical outcome were correlated. MRV studies were evaluated by two neuroradiologists in a blinded manner for image quality, assessment of various sinus, internal cerebral veins (ICV), vein of Labbé and Galen (VL/VG) as well as for additional imaging procedures required. Sensitivity/specificity of ec 3D MRV amounted to 85.7%/97.2% as compared with 2D TOF 71.4%/55.6 %. Ec 3D MRV performed superior in terms of image quality as well as assessment of all sinus and veins except for the straight sinus. Additional imaging procedures were less often required in ec 3D MRV studies (28% vs. 66% for 2D TOF MRV; P < 0.001). Interobserver agreement was significantly increased by using ec 3D MRV (93.1% vs. 70.9% of readings). The results of our study provide additional evidence for the superiority of ec 3D compared with 2D TOF MR venography for the diagnosis or exclusion of acute CVST in daily clinical practice.

Risk and predictors of early epileptic seizures in acute cerebral venous and sinus thrombosis.

We assessed the risk and determined predictors of early epileptic seizures (ES) in patients with acute cerebral venous and sinus thrombosis (CVST). A prospective series of 194 consecutive patients with acute CVST admitted to neurological wards in two German university hospitals was analysed for frequency of ES and in-hospital mortality. Demographic, clinical and radiological characteristics during the acute stage were retrospectively analysed for significant association with ES in univariate and multivariate analyses. During the acute stage, 19 patients (9.8%) died. Early symptomatic seizures were found in 86 patients (44.3%). Status epilepticus occurred in 11 patients (12.8%) of whom four died. Amongst patients with epileptic seizures, mortality was three times higher in those with status than in those without (36.4% and 12%, respectively). In multivariate logistic regression analysis, motor deficit [odds ratio (OR) 5.8; 95% CI 2.98-11.42; P < 0.001], intracranial haemorrhage (OR 2.8; 95% CI 1.46-5.56; P = 0.002) and cortical vein thrombosis (OR 2.9; 95% CI 1.43-5.96; P = 0.003) were independent predictors of early epileptic seizures. Status epilepticus was an important source of morbidity and early mortality in patients with CVST in this study. Patients with focal motor deficits, cortical vein thrombosis and intracranial haemorrhage carried the highest risk for ES. Prophylactic antiepileptic treatment may be an option for these patients.

EFNS guideline on the treatment of cerebral venous and sinus thrombosis.

Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed due to the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence, but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation should be treated either with body weight-adjusted subcutaneous LMWH or dose-adjusted intravenous heparin (good practice point). Concomitant intracranial haemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulation after the acute phase is unclear. Oral anticoagulation may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with 'mild' hereditary thrombophilia. Indefinite anticoagulation (AC) should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and 'severe' hereditary thrombophilia (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Antioedema treatment (including hyperventilation, osmotic diuretics and craniectomy) should be used as life saving interventions (good practice point).

[Multislice computed tomographic myelography]. / CT-Myelographie in Mehrschichttechnik.

While magnetic resonance imaging (MRI) is the first line modality in depicting intramedullary spinal lesions, computed tomographic (CT) myelography has gained renewed attention due to the introduction of multislice scanning (MS-CT). Compared with conventional CT, MS-CT permits rapid, high-resolution imaging of various spinal pathologies with extended scan length. Although soft tissue contrast is inferior to that with MRI, MS-CT myelography performs best in detailed assessment of osseous pathologies, 3D imaging of orthopedic and anesthesiologic implants, and showing dural leakage and causes of CSF circulation impairment. Whenever MRI is not available or contraindicated, MS-CT myelography is the method of choice for evaluating spinal lesions.

[Sporadic cerebral amyloid angiopathy with ischemic leukoencephalopathy and microbleeds. Cause for a rapidly progressive dementia syndrome]. / Sporadische zerebrale Amyloidangiopathie mit ischämischer Leukenzephalopathie und Mikroblutungen. Ursache eines rasch progredienten demenziellen Syndroms.

We describe a 72-year-old patient with rapidly progressive dementia and a complex focal seizure. Magnetic resonance (MR) imaging revealed leukoencephalopathy with the involvement of the U-fibers as well as cortical and subcortical microbleeds. Brain biopsy confirmed the diagnosis of cerebral Abeta amyloid angiopathy (CAA). The presented case illustrates the significance of CAA as a cause of rapidly progressive dementia and leukoencephalopathy and points out the importance of T2-weighted MR imaging in the evaluation of dementia.

[Adenocarcinoma-associated nonbacterial thrombotic endocarditis as the cause of recurrent strokes]. / Adenokarzinom-assoziierte nichtbakterielle thrombotische Endokarditis als Ursache rezidivierender Schlaganfälle.

We describe a 60-year-old female patient without vascular risk factors diagnosed with cardioembolic ischemic stroke due to an atrial septal aneurysm with a right-to-left shunt. However, further investigation after recurrent strokes revealed a nonbacterial thrombotic endocarditis (NBTE) caused by a metastatic adenocarcinoma. The presented case illustrates the difficulties in establishing the diagnosis of NBTE premortally and points out the importance of repeated echocardiographic evaluations of cardiac valves and serological examination of tumor markers in patients with recurrent strokes of unknown origin.

A negative personal and family history for venous thrombotic events is not sufficient to exclude thrombophilia in patients with cerebral venous thrombosis.

A hereditary thrombophilia is found in 20-30% of patients with cerebral venous thrombosis (CVT). These patients might have an increased rate of a positive personal or family history of venous thrombotic events. We investigated the diagnostic value of a structured personal and family history for venous thrombotic events in 56 consecutive cases of CVT. Fourteen of 56 patients (25%) had a hereditary thrombophilia, mostly factor V Leiden. Patients with both CVT and hereditary thrombophilia had more frequently a positive family and personal history than patients affected by CVT only but the difference was not strong enough to differ from the 42 CVT patients without thrombophilia (43% vs. 31%; P = 0.52 and 14% vs. 10 %; P = 0.63). We conclude that a negative personal and family history of venous thrombotic events is not sufficient to exclude thrombophilia and patients with CVT should be tested for inherited thrombophilia regardless of the patient's past personal and family history for venous thrombotic events.