[Show abstract][Hide abstract] ABSTRACT: Large hemispheric infarction (LHI), synonymously called malignant middle cerebral artery (MCA) infarction, is a severe neurological disease with a high mortality and morbidity. Treating physicians as well as relatives are often faced with few and low quality data when attempting to apply optimal treatment to these patients and make decisions. While current stroke treatment guidelines focus on risk factors, prevention and acute management, they include only limited recommendations concerning intensive care management of LHI. The Neurocritical Care Society (NCS) and the German Society for Neurocritical and Emergency Medicine (DGNI) organized an interdisciplinary consensus conference on intensive care management of LHI to meet this demand. European and American experts in neurology, neurocritical care, neurosurgery, neuroradiology and neuroanesthesiology were selected based on their expertise and research focus. Subgroups for several main topics elaborated a number of central clinical questions concerning this topic and evaluated the quality of the currently available data according to the grading of recommendation assessment, development and evaluation (GRADE) guideline system. Subsequently, evidence-based recommendations were compiled after weighing the advantages against the disadvantages of certain management options. This is a commented abridged version of the results of the consensus conference.
Der Nervenarzt 06/2015; 86(8). DOI:10.1007/s00115-015-4361-2 · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mechanical devices for the recanalization of vessel occlusions in severe acute ischemic stroke have been developed for more than a decade. Several devices have been approved for clinical use on the basis of uncontrolled case series. Many neurologists have asked for randomized clinical trials comparing the new devices with standard treatment, e.g. thrombolytic therapy within a 4.5 h time window. The first 3 investigator initiated randomized trials published in 2013 failed to show superiority of mechanical thrombectomy over standard treatment. In the aftermath of these negative results several new trials with changes in design (e.g. shorter time window and only proximal vessel occlusions) and the use of modern devices with proven higher recanalization rates, so called stent retrievers, have been launched. In October 2014 the first of these new trials was presented and showed a clear superiority of thrombectomy. Based on this result interim analyses of five other studies were performed and most were prematurely terminated because of overwhelming efficacy. Only one trial testing another type of recanalization device failed to reach a statistically significant result. Currently five studies have already been published and two more studies have been presented at scientific conferences. This article provides an overview of the study protocols and the results of the individual studies, their common features and the characteristics of patients who benefit from this treatment. Finally, the consequences that these results may have for the treatment of patients with severe stroke caused by proximal vessel occlusion are discussed.
Der Nervenarzt 05/2015; 86(6). DOI:10.1007/s00115-015-4319-4 · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Endovascular recanalization in ischemic stroke is often performed under general anesthesia. Some studies have shown a detrimental effect of general anesthesia. The reasons are unknown.
This was an observational study with retrospective and prospective phases. From 2008 to 2010, 60 patients treated by endovascular recanalization due to proximal vessel occlusion were analyzed with regard to ventilation parameters, blood gas values, blood pressure, and clinical parameters (pre-protocol phase). Subsequently, a protocol with target values for end-tidal CO2 (Petco2) and systolic blood pressure (SBP) was introduced and prospectively analyzed in 64 patients in 2012 (protocol phase).
In the pre-protocol phase, significant hypocapnia (<30 mm Hg), a decrease in SBP after intervention (p<0.001), and an increase in SBP after extubation (p<0.001) were observed. After implementing the protocol in 2012, 63% of Petco2 values and 55% of SBP values (median) of the duration of intervention were within the predefined range. Severe hypocapnia and hypotension (SBP <100 mm Hg) after the intervention were significantly reduced. Longer duration of Petco2 values within 40-45 mm Hg, intracerebral hemorrhage, longer door to needle time, older age, unsuccessful recanalization, longer duration of endovascular treatment, and higher cumulative dose of norepinephrine were associated with an unfavorable outcome (modified Rankin Scale score >2). Intracerebral hemorrhage (OR 0.028, p=0.001), age (OR 0.9, p=0.013), and cumulative dose of norepinephrine (OR 0.142, p=0.003) were independent predictors of an unfavorable outcome.
In patients receiving endovascular stroke treatment under general anesthesia, the cumulative dose of norepinephrine was an independent predictor of an unfavorable outcome. Further studies are needed to evaluate the optimal management of blood pressure in these patients, and whether avoidance of catecholamines could partly explain the improved outcomes for patients treated under conscious sedation in retrospective studies.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Journal of Neurointerventional Surgery 03/2015; DOI:10.1136/neurintsurg-2014-011523 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
In primary and secondary prevention, statins significantly reduce cardiovascular and cerebrovascular events. Pre-interventional statin medication shows a benefit in carotid artery stenosis patients treated with endarterectomy; however, there are few data available for patients treated with stent-angioplasty. The aim of this study was to investigate whether pre-interventional statin therapy is associated with decreased peri-interventional risk of stroke, myocardial infarction, and mortality in patients undergoing stent-angioplasty for internal carotid stenosis.
Data for 344 consecutively documented patients with internal carotid artery stenosis treated with stent-angioplasty in the years 2002–2012 at the same stroke center were collected in a prospectively defined database. Risk factors, medication, and indication for therapy were documented. Univariate and multivariate analysis was performed to investigate independent reduction of peri-interventional stroke, myocardial infarction, or death by statin medication prior to stent-angioplasty.
The median age was 70 years (p25: 63, p75: 76), 75.5% of patients were male, and the median stenosis was 85% according to ECST criteria (p25: 80%, p75: 90%). 20.1% of patients had asymptomatic stenoses, and 60.2% had statin medication before stenting. As per multivariate analysis, pre-interventional statin medication was a predictor for significant peri-interventional risk reduction regarding primary endpoint ischemic stroke, myocardial infarction (MI), or death (odds ratio (OR) 0.31, p = .006). Statins also had a significant protective effect in secondary endpoint ischemic stroke, intracranial bleeding or death (OR 0.39, p = .014), and ischemic stroke or myocardial infarction (OR 0.20; p = .002).
This study shows that pre-interventional statin medication has a protective effect against peri-interventional stroke, MI, or death in patients with internal carotid artery stenosis treated with stent-angioplasty. Accordingly, statins could be considered as a standard pre-interventional medical therapy in carotid stenting.
European Journal of Vascular and Endovascular Surgery 09/2014; 48(6). DOI:10.1016/j.ejvs.2014.08.010 · 2.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In diesem Beitrag wurde die Autorenschaft um folgende Namen ergänzt:G. FraedrichH. MudraU. Mansmannfür das SPACE-2 Steering CommitteeWir bitten, die korrigierte Autorenschaft zu beachten.
Der Nervenarzt 06/2014; 85(6):760-760. DOI:10.1007/s00115-014-4090-y · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: RationaleCooling reduced infarct size and improved neurological outcomes in animal studies modeling ischemic stroke, and also improved outcome in randomized clinical trials in patients with hypoxic-ischemic brain injury after cardiac arrest. Cooling awake patients with ischemic stroke has been shown feasible in phase II clinical trials.Primary aimTo determine whether systemic cooling to a target body temperature between 34·0 and 35·0°C, started within six-hours of symptom onset and maintained for 24 h, improves functional outcome at three-months in patients with acute ischemic stroke.DesignInternational, multicenter, phase III, randomized, open-label clinical trial with blinded outcome assessment in 1500 patients aged 18 years or older with acute ischemic stroke and a National Institutes of Health Stroke Scale score of 6 up to and including 18. In patients randomized to hypothermia, cooling to a target body temperature of 34–35°C will be started within six-hours after symptom onset with rapid intravenous infusion of refrigerated normal saline or a surface cooling technique and maintained for 24 h with a surface or endovascular technique. Patients randomized to hypothermia will receive pethidine and buspirone to prevent shivering and discomfort.Primary outcomeScore on the modified Rankin Scale at 91 days, as analyzed with ordinal logistic regression and expressed as a common odds ratio.DiscussionWith 750 patients per intervention group, this trial has 90% power to detect 7% absolute improvement at the 5% significance level. The full trial protocol is available at http://www.eurohyp1.eu. ClinicalTrials.gov Identifier: NCT01833312.
International Journal of Stroke 06/2014; 9(5):642-645. DOI:10.1111/ijs.12294 · 3.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Asymptomatic carotid artery stenosis may be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS) or with best medical treatment (BMT) only. Definitive and evidence-based treatment recommendations for one of these options are currently not possible. Studies showing an advantage of CEA over BMT alone do not meet current standards from a pharmacological point of view. On the other hand, more recent data point to a further stroke risk reduction using BMT according to current standards. Studies on carotid artery stenting as a third alternative treatment are partially insufficient, especially when comparing CAS with BMT. Initiated in 2009, the randomized, controlled, multicenter SPACE-2 trial is intended to answer the question about the best treatment option of asymptomatic carotid artery stenosis; however, to increase recruitment rates as a condition for the successful completion of this important study, the trial design had to be modified.
Der Nervenarzt 04/2014; 85(4):477. DOI:10.1007/s00115-014-4032-8 · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Zerebrale Sinus- und Venenthrombosen (SVT) stellen weniger als 0,5–1 % aller Schlaganfälle dar und kommen gehäuft bei jungen, weiblichen Erwachsenen vor. Generell gilt die Prognose einer SVT als günstig, trotzdem sterben 3–15 % aller Patienten mit SVT in der Akutphase der Erkrankung, meist aufgrund fulminant raumfordernder Stauungsinfarkte oder -blutungen mit nachfolgender zerebraler Herniation. Intensivmedizinische Behandlungsmethoden in Analogie zur Behandlung schwerer ischämischer Infarkte stellen ein aggressives interdisziplinäres Therapiekonzept dar, das anhand von 5 Fällen vorgestellt werden soll.Alle 5 Patienten waren von einer drohenden oder beginnenden zerebralen Herniation und schwerwiegenden fokal-neurologischen Defiziten betroffen, was zur Entscheidung für eine Thrombektomie, Thrombolyse oder Hemikraniektomie (HK) bzw. deren Kombination führte. Trotz der schwer verlaufenden SVTs und trotz vieler intensivmedizinischer Komplikationen, die zunächst eine schlechte Prognose vermuten ließen, konnten alle 5 Patienten nach Überleben der Akutphase in die Rehabilitation verlegt werden und erreichten ein erstaunlich gutes klinisches Ergebnis.In Anbetracht des lebensbedrohlichen Verlaufs von schweren SVTs kann ein aggressives, interdisziplinäres Management inklusive endovaskulärer Thrombektomie und Hemikraniektomie zu einem kaum erwarteten Behandlungsergebnis ohne schwere Behinderung oder starke Abhängigkeit führen. Diese Behandlung sollte vermutlich frühzeitig bei Patienten mit schweren Pansinusthrombosen und hohem Risiko eines ungünstigen Verlaufs durch Entstehung von zerebralen Ödemen, Infarkten oder Blutungen erfolgen.
Der Nervenarzt 02/2014; 85(2). DOI:10.1007/s00115-013-3959-5 · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thrombosis of cerebral veins or sinuses (CVST) is a rare condition. In a monocentric retrospective cohort study the clinical characteristics, risk factors, radiological findings as well as course and prognosis of patients over the past 15 years were examined.
Between January 1998 and March 2013 all patients who were treated as inpatients for CVST at the department of neurology of the University of Heidelberg were systematically registered in a database. Along with all relevant clinical data the modified Rankin scale (MRS) was used to measure the clinical severity. A follow-up visit was performed at three time points. The odds ratios (OR) were calculated to establish predictors of good outcome (MRS 0-2), mortality at discharge and at follow-up. Significant variables after univariate analysis were tested for independency in a multivariate logistic regression model.
A total of 143 patients were included in the study. The median age was 43 years (range 17-74 years) and 67.4 % of patients were female. The most common symptoms were headache (70.6 %), seizures (50.4 %) and paresis (37.8 %). The most prominent clinical risk factor was oral contraception (40.4 %). The two most common localizations of thrombosis were the transversal sinus with the sigmoid sinus (66.4 %) and the sagittal superior sinus (47.6 %). On admission 42.7 % of patients suffered additionally from intracerebral hemorrhage and 12.6 % from congestive infarction. Of the patients 9.5 % (10 out of 105) showed a pathologically reduced activated protein C (APC) resistance and 8.4 % (6 out of 94) a prothrombin mutation. All patients were initially treated with heparin and 88.7 % were switched to cumarin during the course of the disease. The median duration of anticoagulation was 15.75 months (range 1-121 months). On discharge 77.7 % had a good outcome and the in-hospital mortality was 4.7 %. The median time to follow-up in 108 patients was 36 months (range 3-132 months), 74.1 % of patients had a good outcome (MRS 0-2) and 18.5 % died. Independent predictors of in-hospital mortality were MRS on admission (OR 2.2, 95 % CI 1.03-4.7) and of mortality at follow-up the presence of a malignant disease (OR 50.2, 6-423) and intracerebral hemorrhage on admission (OR 10.3, 1.7-62.6).
The results of this study are in line with previously published data on CVST. The most prominent clinical risk factors for CVST were female gender and oral contraception. At discharge from hospital and 3 years after CVST approximately 75 % of patients achieved a good clinical outcome. A severe clinical syndrome and the presence of an intracerebral hemorrhage on admission were independent predictors of mortality.
Der Nervenarzt 01/2014; 85(2). DOI:10.1007/s00115-013-4000-8 · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cerebral venous and sinus thrombosis (CVST) constitutes less than 0.5-1 % of all strokes and occurs predominantly in young female adults. In general the clinical outcome is favorable but 3-15 % of patients die in the acute phase and in the majority of cases due to cerebral herniation. Intensive care treatment analogous to that of severe ischemic infarct leads to an aggressive interdisciplinary therapy concept that can achieve good clinical outcome. Based on five cases of severe CVST treatment options will be presented.
All five patients were affected by impending or incipient cerebral herniation and severe focal neurological deficits which resulted in the decision to implement thrombectomy, thrombolysis or hemicraniectomy. Despite the severe course and many intensive care complications which suggested a poor prognosis, all five patients could be transferred to rehabilitation after having survived the acute phase and achieved an amazingly good overall clinical outcome.
Considering the life-threatening course of severe CVST, aggressive interdisciplinary management by endovascular thrombectomy and hemicraniectomy can lead to a scarcely expected clinical outcome without disability or severe dependency. This treatment should be performed early and in an escalatory manner in patients with severe CVST who have an increased risk of an unfavorable outcome due to edema, infarction and hemorrhage.
[Show abstract][Hide abstract] ABSTRACT: Die zerebrale Sinus-/Venenthrombose (SVT) ist eine seltene Erkrankung, bei der es zu einem thrombotischen Verschluss zerebraler Venen oder Sinus kommt. Wir untersuchten in einer monozentrischen retrospektiven Kohortenstudie klinische Charakteristika, Risikofaktoren, Bildgebungsbefunde und die Prognose unserer Patienten über einen Zeitraum von 15 Jahren.Im Zeitraum von Januar 1998 bis März 2013 wurden alle Patienten, welche in der Neurologischen Klinik der Universität Heidelberg stationär aufgrund einer SVT behandelt wurden, systematisch erfasst. Neben den klinischen Befunden wurde als Skala zur Beurteilung des klinischen Schweregrades die modified Rankin Scale (mRS) verwendet. Zu drei Zeitpunkten erfolgte eine Follow-up-Visite. Bei der Auswertung der Prädiktoren für ein gutes neurologisches Outcome (mRS 0–2) und für die Mortalität bei Entlassung sowie beim Follow-up wurden Odds Ratios zur Verdeutlichung der Stärke der Assoziation berechnet. Signifikante Variablen in der univariaten Analyse wurden in einem logistischen Regressionsmodell auf ihre Unabhängigkeit überprüft.Es konnten 143 Patienten in die Studie eingeschlossen werden. Das mediane Alter lag bei 43 Jahren (17–84, min–max) und 67,4 % der Patienten waren weiblich. Die häufigsten Symptome waren Kopfschmerzen (70,6 %), epileptische Anfälle (50,4 %) und Lähmungen (37,8 %). Der häufigste klinische Risikofaktor war die Einnahme einer oralen Kontrazeption (40,4 %). Die beiden häufigsten Lokalisationen der Thrombose waren der Sinus transversus mit Übergang in den Sinus sigmoideus (66,4 %) und der Sinus sagittalis superior (47,6 %). 42,7 % der Patienten hatten eine begleitende Hirnblutung und 12,6 % einen Stauungsinfarkt. In 9,5 % (10/105) der Fälle konnte eine pathologisch erniedrigte APC (aktiviertes Protein C) -Resistenz nachgewiesen werden und in 8,4 % (6/94) eine Prothrombinmutation. Alle Patienten wurden initial mit Heparinen behandelt und 88,7 % im Verlauf auf Phenprocoumon eingestellt. Die mediane Dauer der Antikoagulation lag bei 15,75 Monaten (1–121). 77,7 % der Patienten hatten bei Entlassung ein gutes Outcome (mRS 0–2) und die Mortalität während des stationären Aufenthaltes lag bei 4,7 %. Die mediane Dauer des Follow-ups von 108 Patienten lag bei 36 Monaten (3–132) und 74,1 % dieser Patienten erreichten ein gutes Outcome (mRS 0–2). 18,5 % der Patienten waren bis dahin verstorben. Unabhängige Prädiktoren für die Mortalität bei Entlassung waren ein hoher mRS bei Aufnahme (OR 2,2, 95 %-CI 1,03–4,7) und für Mortalität beim Follow-up das Vorhandensein eines Malignoms (OR 50,2, 6–423) und eine Hirnblutung bei Aufnahme 10,3 (1,7–62,6).Unsere Ergebnisse orientieren sich eng an der bisher publizierten Datenlage zur SVT. Die wesentlichen klinischen Risikofaktoren für eine SVT waren das weibliche Geschlecht und die Einnahme oraler Kontrazeptiva. Ungefähr 75 % der Patienten hatten bei Entlassung und beim Follow-up nach durchschnittlich 3 Jahren ein gutes Outcome erreicht. Ein schlechter klinischer Zustand bei Aufnahme und das Vorhandensein einer Hirnblutung waren wesentliche Prädiktoren für die Sterblichkeit.
Der Nervenarzt 01/2014; 85(2). · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We aimed to investigate the feasibility, preliminary safety, and efficacy of prolonged low-dose intravenous thrombolysis in posterior circulation stroke patients with a thrombus lodged in the basilar artery who were ineligible for standard rtPA administration.
We retrospectively analyzed consecutively collected patients in our stroke database who suffered from a basilar artery thrombosis and were treated with prolonged (>1 h), intravenous, low-dose (≤20 mg) rtPA between 01/2005 and 11/2012.
Patients included in this study (n = 14) were 68.5 years (IQR 55.5; 72.75) of age and presented with a median NIHSS of 2 (1; 5.25). Median time from symptom onset to treatment was 63 h (33; 141). A median dose of 5.21 μg/kg h (4.46; 6.25) rtPA was administered over 24 h (min 10; max 48). No patient experienced symptomatic intracerebral hemorrhage, one patient developed a spinal epidural hematoma, and two elderly patients were switched to comfort care and died. In eight patients (57 %) a decrease in thrombus size or no thrombus at all was detected on control imaging. Nine patients (64 %) had a favorable outcome (mRS 0-2) at day 90.
Prolonged low-dose thrombolysis with rtPA may be considered as individual treatment option in selected high-risk patients with basilar artery thrombosis. Presented data may lay the groundwork to further investigate safety and efficacy in a prospective trial.
Neurocritical Care 11/2013; 21(1). DOI:10.1007/s12028-013-9891-5 · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
In 1998 Baden-Wuerttemberg (BW), a federal state in southwest Germany with 10.8 million inhabitants, implemented a structured medical concept for the treatment of acute stroke.
Since 2004 participation in the BW stroke database is mandatory for all hospitals in BW involved in acute stroke care. The stroke database includes all inpatients ≥18 years of age who have suffered an ischemic or hemorrhagic stroke within 7 days before hospitalization. This article presents methodological aspects and first results of the BW stroke database in the time period from 2007 to 2011.
Annual inclusion numbers increased continuously (29,422 vs. 35,724, p < 0.001). Median age of stroke onset was stable over time. The proportion of stroke patients ≥80 years increased from 36.9 to 38.8% (p < 0.001). Rates of patients treated in neurology departments rose from 50.7 to 60.9% (p < 0.001) and numbers of patients treated in stroke units rose from 59.1 to 68.4% (p < 0.001). Admission via emergency medical systems increased from 42.8 to 49.7% (p < 0.001) and arrival within 3 h increased from 29.8 to 34.4% (p < 0.001).
We present results from a large, prospective and consecutive stroke patient database. This first analysis demonstrates a continuous increase of absolute and relative numbers of stroke patients who arrive within 3 h after onset, are hospitalized in neurology departments and treated in stroke units, and are aged ≥80 years.