Evidence for changes in population-level subjective well-being during the COVID-19 pandemic from 30 waves of representative panel data collected in Austria between March 2020 and March 2022.

OBJECTIVES: This study was conducted to describe how population-level subjective well-being (SWB) evolved throughout the pandemic. STUDY DESIGN: Thirty waves of panel data representative of the Austrian population aged ≥14 years were collected between March 2020 and March 2022. Participants were quota sampled from a pre-existing online panel based on key demographics closely mirroring the Austrian resident population. METHODS: We present wave-specific means of SWB throughout 2 years of the COVID-19 pandemic next to the evolution of the pandemic (cases and deaths) and stringency of lockdown measures in Austria as well as estimate their bivariate correlations. RESULTS: The analysed sample consisted of 3,293 participants contributing to a total of 46,168 observations. All components of SWB - negative affect, positive affect and life satisfaction - showed population-level fluctuation between March 2020 and March 2022. The magnitude of these changes was small. Population-level SWB correlated with the incidence rate of COVID-19 deaths (negative affect: r = 0.69, positive affect: r = -0.70, life satisfaction: r = -0.47), the Stringency Index (negative affect = 0.50, positive affect = -0.47, life satisfaction = -0.47) and less so with the incidence of COVID-19 cases (negative affect = 0.43, positive affect = -0.31, life satisfaction = -0.38). CONCLUSIONS: Population-level SWB fluctuated in accordance with rises and falls in COVID-19 cases and deaths as well as with the stringency of lockdown measures. This connection suggests that incidence of COVID-19 cases and deaths, as well as public health measures to contain the pandemic affect population-level SWB and could thereby impact population health and productivity.

Trajectories of loneliness, depressive symptoms, and anxiety symptoms during the COVID-19 pandemic in Austria.

OBJECTIVE: There is considerable heterogeneity within populations regarding the effects of the COVID-19 pandemic on mental health. This study aimed at identifying latent groups of individuals within the older Austrian population that differ in their mental health trajectories across three phases of the pandemic. STUDY DESIGN: Data were gathered from a longitudinal survey study among a sample of older adults in Austria. The survey was carried out in May 2020 (N1 = 556), March 2021 (N2 = 462), and December 2021 (N3 = 370) via either computer-assisted web or telephone interviewing. METHODS: Latent class growth analysis was conducted to explore different homogenous groups in terms of non-linear trajectories of loneliness, depressive symptoms, and anxiety symptoms as well as potential correlates thereof. RESULTS: We identified four latent classes. The vast majority of individuals belong to two classes that are either resilient (71%) or that have recovered relatively quickly from an initial COVID-19 shock (10.2%). Deterioration in mental health after the first phase of the pandemic (13.4%) or a generally high mental health burden (5.4%) characterizes the other two classes. CONCLUSIONS: About 19% of individuals showed increasing or elevated levels in loneliness, depressive symptoms, and anxiety symptoms across the COVID-19 pandemic. The feeling of being socially supported and in control over one's own life emerged as potentially protective factors.

Longitudinal effects of COVID-19-related loneliness on symptoms of mental distress among older adults in Austria.

OBJECTIVE: COVID-19-related social restrictions resulted in more loneliness, but whether this had further effects on mental health remains unclear. This study aimed at examining the longitudinal effects of COVID-19-related loneliness on mental health among older adults (aged ≥60 years) in Austria. STUDY DESIGN: Survey data were gathered from a longitudinal observational study among a random sample of older Austrian adults. The first survey wave was conducted in May 2020 (N1 = 557), and the second wave was conducted in March 2021 (N2 = 463). METHODS: Data collection was based on either computer-assisted web or telephone interviewing. For statistical analysis, we used a cross-lagged panel analysis. RESULTS: The results showed the perceived COVID-19-related social restrictions to predict loneliness, which in turn predicted depressive and anxiety symptoms 10 months later. CONCLUSIONS: COVID-19-related loneliness emerged as a risk factor for subsequent mental distress among older adults in Austria.

[Attitudes Towards End-of-Life Decisions and Long-Term Care Dependency: Results of a Representative Survey of Austrians Aged 50]. / Einstellungen zu Entscheidungen am Lebensende und Pflegebedürftigkeit: Ergebnisse einer repräsentativen Befragung der österreichischen Bevölkerung (50+).

AIM OF THE STUDY: Existing research on attitudes in the general population regarding end-of-life decisions has included neither old age long-term care dependency nor worries regarding age(ing). The aim of this study is to present first results from a recent survey on this topic. METHODS: A nationally representative cross-sectional survey of the population aged 50+was conducted in Austria (n=968) in 2015. RESULTS: 29.0% of the respondents indicated not wanting to live on as a severely care-dependent older person. In the case of an older care-dependent person, 48.5% approved of forgoing life-sustaining treatment, 41.7% of assisted suicide and 34.1% of euthanasia if requested. Worries about old age and ageing were widespread (53.7-83.0%) and highly worried respondents were more inclined to support assisted suicide and euthanasia compared to those less worried. CONCLUSIONS: Worries and negative stereotypes regarding age(ing) and long-term care dependency should be addressed by information campaigns.

Systemic thrombolysis for cerebral venous and dural sinus thrombosis: a systematic review.

BACKGROUND: The use of thrombolytics is frequently considered in patients with cerebral venous and dural sinus thrombosis (CVT) who deteriorate despite anticoagulant therapy. PURPOSE: To collect all the published information about the use of systemic thrombolysis in CVT in order to assess its efficacy and safety. METHODS: We performed a PubMed search, checked all reference lists of studies found and used data from the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Outcome was classified at the last available follow-up by the modified Rankin Scale (mRS). The cases were stratified according to variables that might influence outcome. RESULTS: A total of 16 reports (26 patients, 2 from the ISCVT and 24 from the systematic review of the literature) were included. No randomized clinical trial was found. Seven patients presented with isolated intracranial hypertension syndrome (26.9%), 17 with encephalopathy (65.4%) and 2 were comatose (7.7%). The superior sagittal sinus was the one most often affected (n = 21; 80.8%), and there was thrombosis of the deep cerebral venous system in 5 patients (19.2%). Urokinase was the thrombolytic agent most frequently administered (n = 19; 73.1%), whereas streptokinase and recombinant tissue plasminogen activator were used in 2 cases each (7.7%). Intracranial hemorrhages occurred in 3 cases (11.5%). Extracranial hemorrhages occurred in 5 cases (19.2%), and overall there were 3 cases of serious bleeding (11.5%), including 2 deaths (7.7%). Partial or complete recanalization was verified in most patients (n = 16; 61.5%). The survival rate was 92.3% (24/26 patients). At the last available follow-up, 22/25 patients regained independency (mRS scores 0-2; 88%), 2/25 died (mRS score 6; 8%) and 1/25 was severely dependent (mRS scores 3-5; 4%). CONCLUSIONS: In all, 88% of the CVT patients treated with systemic thrombolysis regained their independency, but 2 deaths associated with intracranial hemorrhage occurred. The mortality rate and disability at the last available follow-up were similar to those found in 2 previous systematic reviews concerning the use of thrombolytics in CVT. Due to the small sample size and lack of controls, the efficacy of systemic thrombolysis in acute CVT cannot be assessed from the published information. Concerning safety, a nonnegligible proportion of bleedings was reported.

Observational case-control study of the prevalence of chronic cerebrospinal venous insufficiency in multiple sclerosis: results from the CoSMo study.

BACKGROUND: Chronic cerebrospinal venous insufficiency (CCSVI) has been proposed as a possible cause of multiple sclerosis (MS). OBJECTIVES: The CoSMo study evaluated the association between CCSVI and MS. METHODS: The primary end-point of this multicentric, case-control study was to compare the prevalence of CCSVI between patients with MS, patients with other neurodegenerative diseases (ONDs) and healthy controls (HCs). Color-coded duplex sonography was performed by a sonologist and the images were sent to one of three central sonologists for a second reading. Agreement between local and central sonologists or, in case of disagreement, the predominant judgment among the three central readers, was required for a diagnosis of CCSVI. All readings, data collection and analysis were blinded. RESULTS: The study involved 35 MS centers across Italy and included 1874 subjects aged 18-55. 1767 (94%) were evaluable: 1165 MS patients, 226 patients with ONDs and 376 HCs. CCSVI prevalence was 3.26%, 3.10% and 2.13% for the MS, OND and HC groups, respectively. No significant difference in CCSVI prevalence was found amongst the three cohorts (MS versus HC, OR = 1.55, 95%CI = 0.72-3.36, p = 0.30; OND versus HC, OR = 1.47, 95%CI = 0.53-4.11, p = 0.46; MS versus OND, OR = 1.05, 95%CI = 0.47-2.39, p = 0.99). High negative and low positive agreement was found between the local and centralized readers. CONCLUSIONS: CCSVI is not associated with MS.

Paraneoplastic neurological syndromes in patients with carcinoid.

BACKGROUND: Paraneoplastic neurological syndromes (PNS) are mainly associated with small-cell lung cancer, gynaecological tumours and lymphomas. Few studies report the association of neurological syndromes with a carcinoid, the majority being a serotonin-related myopathy. We report four patients with a PNS associated with carcinoid. PATIENTS AND RESULTS: The clinical syndromes were sensory neuropathy, limbic encephalitis, myelopathy and brain stem encephalitis. Two patients had antineuronal autoantibodies (one anti-Hu, one anti-Yo), one patient had antinuclear antibodies, and one patient had no autoantibodies. For two of the carcinoids, expression of HuD in the tumour could be demonstrated. CONCLUSION: This study demonstrates that carcinoids can also be associated with classical antineuronal antibody-associated PNS.

Circulating microemboli in patients with myeloproliferative disorders.

Myeloproliferative disorders (MPD) are associated with an increased risk for thrombembolic events. In this study, we examined the prognostic value of transcranial Doppler (TCD) microemboli detection regarding clinical events and correlated TCD findings with results of blood cell counts and platelet flow cytometry to gain insight into the composition of circulating microemboli in these patients. In a cohort of 42 patients with MPD TCD microemboli detection was performed on a single occasion and correlated with thrombembolic events during a prospective follow up of 29.7 +/- 7.3 month. In all patients, a complete blood count and in 17 patients platelet flow cytometry were performed on the day of the TCD examination. Microembolic signals (MES) were recorded in 15 (35.7%) patients, however, without any correlation with the type of MPD, blood cell counts, or thrombembolic events [9 (21.4%)]. MES positive and negative patients did not differ regarding the levels of activated platelets, platelet microaggregates, or microparticles. We found a strong trend for higher rates of platelet-neutrophil conjugates in MES positive patients (P = 0.09). Detection of MES by TCD on a single occasion in MPD patients has only limited prognostic value. MES do not correlate with the type of MPD, nor blood cell counts. Flow cytometry suggests that MES in MPD may consist of platelet-neutrophil aggregates.

Failed visualization of clot signal in cerebral venous thrombosis on initial MR imaging.

Currently, the combination of T1- and T2-weighted spin echo magnetic resonance imaging (MRI) sequences with MR venography is considered the best diagnostic tool for diagnosing cerebral venous thrombosis (CVT), because they allow positive identification of the thrombotic clot along with the disturbed venous flow signal. We report two patients in whom initial MRI with the mentioned techniques did not show a clot signal. In both patients anticoagulation was started despit lacking proof of CVT by imaging and both patients improved. Only on repeated MRI sinus clot signal could be confirmed.

Contribution of diffusion-weighted imaging in determination of stroke etiology.

INTRODUCTION: Diffusion-weighted (DW) MR imaging enables early identification of ischemic lesions in stroke. Stroke subtype may be related to different lesion patterns. The aim of this study was to analyze the subtype of ischemic lesions as determined by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria by using DW MR imaging. METHODS AND RESULTS: In this study, 510 consecutive patients with ischemic stroke (95%) and transient ischemic attack (5%) aged 65 +/- 12 years were investigated by use of DW MR imaging within 48 hours of the clinical onset of symptoms. Lesions on DW imaging were classified as single, scattered, or multiple lesions in one vascular territory and multiple in more than one vascular territory. We found a significant overall association of DW imaging lesion patterns and classification with stroke subtype by using the TOAST criteria (P < .001). Single corticosubcortical lesions (P < .01) and multiple bilateral lesions in the anterior (AC) and posterior circulation (P < .001) on DW imaging were significantly associated with a cardiac embolic source. Multiple unilateral lesions in the AC were significantly associated with large-artery arteriosclerosis. Because of the 15-mm criterion for small-artery occlusion, cryptogenic stroke was significantly associated with subcortical lesions >/=15 mm. CONCLUSION: We found a strong relationship between stroke subtype and DW imaging lesion pattern. The finding of multiple bilateral lesions was significantly associated with a cardiac embolic source, which may be caused by a specific thrombus texture with a tendency for embolus dissemination.

Experimental stroke: ischaemic lesion volume and oedema formation differ among rat strains (a comparison between Wistar and Sprague-Dawley rats using MRI).

Investigating focal cerebral ischaemia requires animal models that are relevant to human stroke. This study was designed to evaluate the influence of early reperfusion and choice of rat strains on infarct volume and oedema formation. Thirty-six Wistar and Sprague-Dawley rats were subjected to temporary middle cerebral artery occlusion (MCAO) for 90 min (groups I and II) or to permanent MCAO (groups III and IV) using the suture technique. Ischaemic lesion volume and oedema formation were quantified 24 h after MCAO using 7T-magnetic resonance imaging (MRI). Impact of rat strains: Reperfusion led to significant larger ischaemic lesion volumes in Wistar rats as compared to Sprague-Dawley rats (P<0.0005). Oedema formation was similar in both rat strains. Permanent MCAO led to significantly larger ischaemic lesion volumes in Sprague-Dawley rats (P<0.05). Oedema formation, however, was significantly more accentuated in Wistar rats (P<0.005). Impact of reperfusion: Reperfusion did not cause any changes in ischaemic lesion volume in Wistar rats. Oedema formation, however, was significantly reduced (P<0.0005). In Sprague-Dawley rats, reperfusion caused a significant reduction of ischaemic lesion volume (P<0.00005), but did not modify oedema formation. These findings emphasize the critical importance of rat strain differences in experimental stroke research.

Upper cranial nerve palsy resulting from spontaneous carotid dissection.

INTRODUCTION: Upper cranial nerve palsy has a variety of causes such as cerebral and nerve ischemia, diabetes, infectious and non-infectious meningitis, subarachnoid hemorrhage and intracranial aneurysm. CASE 1 : A 45-year-old man suffered from holocephalic headaches and a right-sided neck pain for two weeks. He presented to our emergency department because of a sudden ptosis of the right eye. On admission neurological examination revealed a right sided Horner's syndrome and hypesthesia of the right side of the face. Magnetic resonance angiography identified a circumscribed dissection of the right extracranial internal carotid artery originating from the carotid bifurcation. Conventional angiography 2 weeks later showed a nearly recanalized artery. CASE 2 : A 55-year-old previously healthy man without cardiovascular risk factors developed right sided neck pain when loading a seeder with several sacks of crop. A few hours later he noticed a left-sided weakness. On admission a severe left sided hemiparesis and a mild neglect were present. Duplex sonography revealed a right-sided distal internal carotid artery (ICA) occlusion. The next morning the patient complained of double vision; he had a right-sided pupil-sparing oculomotor palsy. The diagnosis of ICA dissection was confirmed by conventional angiography, at that time showing a partially recanalized ICA without involvement of the cavernous region by the dissection. CONCLUSION: ICA dissection must be included in the differential diagnosis of upper cranial nerve palsy and should be assessed by duplex ultrasound and magnetic resonance imaging. A possible explanation is nerve ischemia due to a transient or permanent interruption of the blood supply by compression of the vasa nervorum originating from the intracranial carotid artery.

Characterization of the mononuclear infiltrate in basal cell carcinoma: a predominantly T cell-mediated immune response with minor participation of Leu-7+ (natural killer) cells and Leu-14+ (B) cells.

We investigated the peritumoral inflammatory infiltrate in 22 basal cell carcinoma (BCC) from 18 patients using a series of monoclonal antibodies. In all the 22 BCC the infiltrate consisted mainly of T cells (55 +/- 15%) and only in three cases an invasion of the tumor nests by these cells was observed. The T helper (TH) subset predominated over the T suppressor/cytotoxic (TS/C) subset (TH/TS/C ratio of 1.9 +/- 0.8). In 8 of 22 BCC mild infiltrate was observed with 48 +/- 13% T cells and a TH/TS/C ratio of 1.5 +/- 0.6. In 14 of 22 BCC moderate to heavy infiltrate with 59 +/- 15% T cells and a TH/TS/C ratio of 2.0 +/- 1.0 was observed. There was a significant difference in the percentage of T cells in BCC with moderate to heavy infiltrate and that in BCC with mild infiltration. The mean percentage of HLA-DR+ cells was 54 +/- 11%; Langerhans cells (LC) 4 +/- 5%; and Leu-M5+ (monocytes and macrophages) 16 +/- 11%. Less than 2% Leu-14+(B) cells were seen in the infiltrate. The mean percentage of Leu-7+ (natural killer) cells was 4 +/- 4%, and only 1 of 22 BCC Leu-7+ cells invaded tumor nests, contacting with tumor cells. From these results we concluded that T cells play a major role in the defence against BCC proliferation. The main role of Langerhans cells and Leu-M5+ cells may be that of antigen presentation. B cells and NK cells probably play a minor role in the local defence against BCC proliferation.

Anti-Mycobacterium leprae monoclonal antibodies cross-react with human skin: an alternative explanation for the immune responses in leprosy.

A panel of 17 mouse monoclonal antibodies (MoAb) raised against Mycobacterium leprae (M. leprae) antigens was used to detect antigenic determinants in normal human skin. An indirect immunoperoxidase technique was used. Eight of the MoAb detected epidermal antigens similar to patterns well known for human sera. Five of these MoAb detected determinants in the dermis, too. These observations may indicate a certain degree of similarity between the antigenic determinants occurring in M. leprae and in the human host. We propose that such a similarity on the one hand may facilitate the survival of M. leprae in the human host when the antigens are not recognized as "non-self," a situation which seems to occur in lepromatous leprosy, when the patients' tissues are loaded with bacteria virtually without any immune response. On the other hand, M. leprae antigens which mimic host antigens may induce an auto-immune reaction against the host's own antigens, which could explain the immune reaction in tuberculoid leprosy and during a "reversal reaction" when M. leprae is not observed in the host tissues, but extensive granuloma formation occurs.

Sonographic monitoring of midline shift in space-occupying stroke: an early outcome predictor.

BACKGROUND AND PURPOSE: Transcranial color-coded duplex sonography (TCCS) allows bedside imaging of intracranial hemodynamics and parenchymal structures. It provides reliable information regarding midline shift (MLS) in space-occupying hemispheric stroke. We studied the value of MLS measurement to predict fatal outcome at different time points after stroke onset. METHODS: Forty-two patients with acute, severe hemispheric stroke were enrolled. Cranial computed tomography (CCT) and extracranial duplex sonography were performed on admission. TCCS was carried out 8+/-3, 16+/-3, 24+/-3, 32+/-3, and 40+/-3 hours after stroke onset. Lesion size was determined from follow-up CCT. RESULTS: Twelve patients died as the result of cerebral herniation (group 1); 28 survived (group 2). Two patients received decompressive hemicraniectomy and were therefore excluded from further evaluation. MLS was significantly higher in group 1 as early as 16 hours after onset of stroke. Specificity and positive predictive values for death caused by cerebral herniation of MLS >/=2.5, 3.5, 4.0, and 5.0 mm after 16, 24, 32, and 40 hours were 1.0. CONCLUSIONS: TCCS helps to estimate outcome as early as 16 hours after stroke onset and thus facilitates identification of patients who are unlikely to survive without decompressive craniectomy. Because of its noninvasive character and bedside suitability, sonographic monitoring of MLS might be a useful tool in management of critically ill patients who cannot undergo repeated CCT scans.

Neuroprotective effects of MK-801 in different rat stroke models for permanent middle cerebral artery occlusion: adverse effects of hypothalamic damage and strategies for its avoidance.

BACKGROUND AND PURPOSE: Permanent middle cerebral artery occlusion (MCAO) with the use of the suture technique causes hypothalamic damage with subsequent hyperthermia, which can confound neuroprotective drug studies. In the present study the neuroprotective effects of dizocilpine (MK-801) were compared in different permanent MCAO models with and without hypothalamic damage and hyperthermia. METHODS: Sixty Sprague-Dawley rats were treated with MK-801 or placebo, beginning 15 minutes before MCAO, and assigned to the following groups: suture MCAO (group I), macrosphere MCAO without hypothalamic damage (group II), or macrosphere MCAO with intentionally induced hypothalamic infarction (group III). Body temperature was measured at 3, 6, and 24 hours. Lesion size was determined after 24 hours (2,3,5-triphenyltetrazolium chloride staining). RESULTS: Hypothalamic damage was present in animals in group I and was intentionally induced in group III with the use of a modified macrosphere MCAO technique. Body temperature was significantly increased 3, 6, and 24 hours after MCAO in these 2 groups of animals. Hypothalamic damage and subsequent hyperthermia could be avoided effectively by limiting the number of macrospheres (group II). MK-801 provided a highly significant neuroprotective effect in group II but not in groups I and III. CONCLUSIONS: Hypothalamic damage with subsequent hyperthermia masked the neuroprotective effect of MK-801. This side effect can be avoided by using the macrosphere MCAO technique with a limited number of spheres. This model therefore may be more appropriate to study the effects of neuroprotective drugs in permanent focal cerebral ischemia than the suture method.

Noninvasive quantification of brain edema and the space-occupying effect in rat stroke models using magnetic resonance imaging.

BACKGROUND AND PURPOSE: Brain edema is a life-threatening consequence of stroke and leads to an extension of the affected tissue. The space-occupying effect due to brain edema can be quantified in rat stroke models with the use of MRI. The present study was performed to test 2 hypotheses: (1) Can quantification of the space-occupying effect due to brain edema serve as a noninvasive measure for brain water content? (2) Does morphometric assessment of brain swelling allow determination of true infarct size on MRI after correction for the space-occupying effect of edema? METHODS: Thirty rats were subjected to permanent suture middle cerebral artery occlusion. MRI was performed after 6 or 24 hours, and hemispheric swelling was assessed morphometrically. Interobserver and intraobserver agreements were determined for MRI measurements. In study I, the space-occupying effect due to brain edema was correlated with the absolute brain water content by the wet/dry method. In study II, lesion volumes corrected and uncorrected for edema were calculated on MRI and on TTC staining and compared. RESULTS: Interobserver and intraobserver agreements for MRI measurements were excellent (r>or=0.97). Brain water content and hemispheric swelling correlated well after 6 and 24 hours (r>or=0.95). Corrected lesion volumes correlated with r=0.78 between TTC staining and MRI. Without edema correction, lesion volumes were overestimated by 20.3% after 6 hours and by 29.6% after 24 hours of ischemia. CONCLUSIONS: Morphometric assessment of hemispheric swelling on MRI can determine the increase in absolute brain water content noninvasively and can also provide ischemic lesion volumes corrected for brain edema.

DIAS I: duplex-sonographic assessment of the cerebrovascular status in acute stroke. A useful tool for future stroke trials.

BACKGROUND AND PURPOSE: A number of controlled trials have evaluated the benefit of intravenous thrombolysis in acute stroke with inconsistent results. None of these studies assessed the initial vascular status or provided information regarding the recanalization rate after therapy. Further trials need to clarify whether certain subgroups might possibly benefit more than others from intravenous thrombolysis. Therefore, a fast and valid method for assessment of cerebrovascular status is needed. In this multicenter study, we evaluated the potentials and limitations of color-coded duplex sonography (TCCS) for cerebrovascular status assessment in acute stroke patients before and after therapy. Furthermore, we compared the recanalization rate for patients referred to thrombolytic and conservative medical therapy. METHODS: Fifty-eight patients suffering from hemispheric stroke were enrolled consecutively in 8 centers. Duplex sonography was performed on admission, 2 hours after start of therapy, and 24 hours after onset of symptoms. Therapy was started within 6 hours. RESULTS: Intravenous thrombolysis was performed in 18 patients, conservative medical therapy in 39 patients, and early thromboendarterectomy in 1 patient. The middle cerebral artery (MCA) mainstem was patent in 29 patients (53.7%), occluded in 25 (46.3%), and was not assessable in 4 patients. Recanalization of the occluded MCA after 2 and 24 hours was diagnosed in 50% and 78% of the patients treated with rtPA and in 0% and 8% in the conservatively treated patients. CONCLUSIONS: Intravenous thrombolysis is highly effective in restoring blood flow after MCA occlusion. TCCS is suitable for assessment of the cerebrovascular status in acute stroke and therefore might define therapeutically relevant subgroups of patients in future stroke trials on the basis of their vascular pathology.

Sonographic monitoring of midline shift in hemispheric infarctions.

BACKGROUND AND OBJECTIVE: Transcranial color-coded sonography (TS) allows a noninvasive, accurate evaluation of lateral displacement of the third ventricle. The authors studied the prognostic value of TS monitoring of the midline shift (MLS) in acute hemispheric stroke. METHOD: Sixteen patients with acute middle cerebral artery (MCA) occlusion were investigated. On admission, the median modified Scandinavian Stroke Scale (mSSS) score was 6.0 (range, 5 to 8). Five patients died from cerebral herniation (group 1), 10 survived (group 2), and 1 patient (Patient 16) survived after decompressive surgery. TS was performed on days 1 to 4 (10 +/- 3, 32 +/- 4, 57 +/- 5, and 82 +/- 5 hours after onset of symptoms). Distance from the TS probe to the center of the third ventricle was measured both from the symptomatic (A) and asymptomatic (B) sides. MLS was calculated using the formula MLS = (A - B)/2. RESULTS: Ten hours after stroke onset, MLS and mSSS scores were not significantly different between the two groups. At 32, 57, and 82 hours, MLS was higher in group 1 (32 hours, p = 0.001; 57 hours, p = 0.003; 82 hours, p = 0.023) whereas there was no difference in mSSS score after 32 hours. All patients with an MLS < 4 mm at 32 hours survived, whereas patients with an MLS > 4 mm died as a result of cerebral herniation, with the exception of the one patient who underwent decompressive hemicraniectomy. CONCLUSIONS: The study of MLS at 32 hours after stroke onset in patients with severe MCA infarctions may identify patients who are unlikely to survive. The value of MLS in determining the indication of decompressive craniectomy merits further study.