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ABSTRACT: Septic thrombosis of the cavernous sinus (CST) is a rare and potentially life-threatening condition mostly caused by facial or ear, nose, and throat infections. Anatomic structures in vicinity of the cavernous sinus are thereby susceptible to inflammatory damage. In particular nervous system structures are almost regularly affected; however, only few authors reported severe involvement of the internal carotid artery (ICA).
We present an atypical clinical course of CST in a 61-year-old male diabetic patient caused by a distant focus of inflammation. Septic CST after surgical treatment of an anorectal abscess was complicated by occlusion of the ICA and multiple embolic strokes. The diagnosis was established by magnetic resonance imaging scan, symptoms resolved after antibiotic therapy and heparin anticoagulation.
The presented case and review of literature emphasizes the variability of signs and clinical course of CST, a frequent cause of delayed diagnosis. Especially in immunocompromised patients, the primary source of CST may be a distant inflammatory focus with nonspecific and subacute symptoms. Septic CST can be a rare cause of ischemic stroke when complicated by ICA occlusion because of septic arteritis. Expedited diagnostic workup is necessary and rests upon radiologic investigations.
The Neurologist 09/2012; 18(5):310-2. · 1.26 Impact Factor
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Journal of Neurology 04/2012; 256(6):1019-1019. · 3.47 Impact Factor
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ABSTRACT: Guidelines recommend maintaining the heart rate (HR) of acute stroke patients within physiological limits; data on the frequency and predictors of significant deviations from these limits are scarce.
Demographical data, stroke risk factors, NIH stroke scale score, lesion size and location, and ECG parameters were prospectively assessed in 256 patients with ischemic stroke. Patients were continuously monitored for at least 24 hours on a certified stroke unit. Tachycardia (HR ≥ 120 bpm) and bradycardia (HR <45 bpm) and cardiac rhythm (sinus rhythm or atrial fibrillation) were documented. We investigated the influence of risk factors on HR disturbances and their respective influence on dependence (modified Rankin Scale ≥ 3 after three months) and mortality.
HR ≥ 120 bpm occurred in 39 patients (15%). Stroke severity (larger lesion size/higher NIHSS-score on admission), atrial fibrillation and HR on admission predicted its occurrence. HR <45 bpm occurred in 12 patients (5%) and was predicted by lower HR on admission. Neither HR ≥ 120 nor HR <45 bpm independently predicted poor outcome at three moths. Stroke location had no effect on the occurrence of HR violations. Clinical severity and age remained the only consistent predictors of poor outcome.
Significant tachycardia and bradycardia are frequent phenomena in acute stroke; however they do not independently predict clinical course or outcome. Continuous monitoring allows detecting rhythm disturbances in stroke patients and allows deciding whether urgent medical treatment is necessary.
BMC Neurology 01/2011; 11:47. · 2.17 Impact Factor
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ABSTRACT: In recent years, a considerable number of new sporadic or hereditary small artery diseases of the brain have been detected which preferably occur in younger age, below 45 years. Cerebral microangiopathies constitute an appreciable portion of all strokes. In middle aged patients, hereditary cerebral small vessel diseases have to be separated from sporadic degenerative cerebral microangiopathy which is mainly due to a high vascular risk load. Features of the following disorders and details how to differentiate them, are reviewed here, namely CADASIL, MELAS, AD-RVLC, HEMID, CARASIL, PADMAL, FABRY, COL4A1-related cerebral small vessel diseases and a Portuguese type of autosomal dominant cerebral small vessel disease (SVDB). The symptomatic overlap of the cerebral microangiopathies include also other distinctive non-hereditary diseases like posterior (reversible) encephalopathy and Susac's syndrome which are also described. Some of the microangiopathies described here are not only seen in the young but also in the elderly. The precise diagnosis has direct therapeutic implications in several of these entities. Cerebral microangiopathies cause recurring strokes and diffuse white matter lesions leading to a broad spectrum of gait disturbances and in most of these disorders cognitive impairment or even vascular dementia in the long term. Often, they also involve the eye, the inner ear or the kidney. Several typical imaging findings from illustrative cases are presented. The order in which these diseases are presented here is not dictated by an inner logic principle, because a genetically or pathophysiologically based classification system of all these entities does not exist yet. Some entities are well established and not unusual, whereas others have only been described in a few cases in total.
Journal of the neurological sciences 12/2010; 299(1-2):81-5. · 2.32 Impact Factor
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ABSTRACT: To compare the severity of atherosclerosis in the carotid, coronary and femoral arteries in autopsy findings of stroke patients.
40 patients (age: 75.2 (12.3) years, 21 men, 19 women) were investigated, who died of ischemic stroke. Carotid, femoral and coronary arteries were removed and cut into slices. Atherosclerotic changes were scored and compared. The severity of atherosclerotic changes of the common carotid artery did not correlate with any other arteries. Atherosclerotic parameters of the internal carotid artery correlated with those of the deep femoral and common femoral arteries (r=0.457-0.459; P=0.022-0.028 respectively). We found significant correlations between the deep femoral artery and left anterior descendent coronary arteries (r=0.513; P=0.012). External carotid artery correlated with both the left anterior descendent coronary and deep femoral arteries (r=0.458-0.473 and P=0.028-0.017 respectively).
The severity of atherosclerosis in the external carotid arteries and/or the femoral arteries showed a stronger correlation with the atherosclerosis in the coronaries than that of the common carotid arteries.
Journal of the neurological sciences 09/2009; 287(1-2):241-5. · 2.32 Impact Factor
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ABSTRACT: Fiberoptic endoscopic evaluation of swallowing (FEES) is a suitable method for dysphagia assessment after acute stroke. Recently, we developed the fiberoptic endoscopic dysphagia severity scale (FEDSS) for acute stroke patients, grading dysphagia into 6 severity codes (1 to 6; 1 being best). The purpose of this study was to investigate the impact of the FEDSS as a predictor of outcomes at 3 months and intermediate complications during acute treatment.
A total of 153 consecutive first-ever acute stroke patients were enrolled. Dysphagia was classified according to the FEDSS, assessed within 24 h after admission. Intermediate outcomes were pneumonia and endotracheal intubation. Functional outcome was measured by the modified Rankin Scale (mRS) at 3 months. Multivariate regression analysis was used to identify whether the FEDSS was an independent predictor of outcome and intercurrent complications. Analyses were adjusted for sex, age and National Institutes of Health Stroke Scale (NIH-SS) on admission.
The FEDSS was found to predict the mRS at 3 months as well as but independent from the NIH-SS. For each additional point on the FEDSS, the likelihood of dependency at 3 months (mRS > or = 3) raised by approximately 50%. Each increase of 1 point on the FEDSS conferred a more than 2-fold increased chance of developing pneumonia. The odds for the necessity of endotracheal intubation raised by a factor of nearly 2.5 with each additional point on the FEDSS.
The FEDSS strongly and independently predicts outcome and intercurrent complications after acute stroke. Thus, a baseline FEES examination provides valuable prognostic information for the treatment of acute stroke patients.
Cerebrovascular Diseases 07/2009; 28(3):283-9. · 2.72 Impact Factor
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MMW Fortschritte der Medizin 02/2009; 151(1-2):42-3.
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ABSTRACT: Admission blood pressure (BP) and significant decreases in BP after acute stroke have been correlated with outcome. Few data are available on the impact of extreme values at any time point within the first 24 hours.
BP was measured hourly for 24 hours in 325 consecutive patients with acute ischemic stroke. Predefined endpoints were systolic BP >or=200, diastolic BP >or=110, or systolic BP <100 mm Hg during the first 24 hours, and significant systolic BP decreases by >26 mm Hg within 4 hours after admission. Multiple logistic regression analysis identified independent predictors of each end point and determined the impact on dependency at 3 months defined as modified Rankin scale score >or=3.
Upper threshold violations occurred in 70% of cases during the admission process, and more frequently in patients arriving early after stroke; 30% of cases exhibited such values at a later time point. History of hypertension (P<0.01) and higher NIHSS on admission (P<0.05) were independent predictors. Systolic BP <100 mm Hg occurred at random and was associated with younger age (P<0.05). Night time admission was the strongest independent predictor of systolic BP decreases >26 mm Hg (P<0.0001). Diabetes, NIHSS on admission, and age were associated with adverse outcome at 3 months, whereas threshold violations and decreases were not. There was a trend for administration of antihypertensives being associated with poor outcome (P<0.1).
External stimuli, premorbid risk factors, diurnal BP variations, and disease-immanent mechanisms all influence the course of BP after acute stroke. Monitoring should precede any medical BP treatment.
Stroke 12/2008; 40(2):462-8. · 5.73 Impact Factor
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ABSTRACT: Poor knowledge of stroke symptoms within the general population might be responsible for significant delay between symptom onset and hospital admission in most stroke patients.
We prospectively evaluated whether theoretical knowledge about stroke influenced time to admission among 102 consecutive acute stroke patients using standardized questionnaires. We assessed in multiple logistic regression models the influence of theoretical knowledge (knowledge about stroke symptoms and knowledge about the appropriate actions to be taken in the case of a stroke) on the real actions taken in the acute situation. Predictors of a delayed hospital admission greater than 2 hours after stroke onset were determined. Models were adjusted for age, gender, level of education, stroke severity, previous history of stroke or transient ischemic attack (TIA), and being alone at symptom onset.
Patients arrived significantly later, if the patients themselves were the managers of the emergency situation [odds ratio (OR): 4.7; 95% confidence interval (CI): 1.5-140.8]. Symptom knowledge and action knowledge were not found to be significantly associated with shorter pre-hospital times, whereas the correct diagnosis of stroke by the manager (OR: 0.2; 95% CI: 0.1-0.4) and calling the emergency medical system (OR: 0.3; 95% CI: 0.1-0.7) independently led to a higher likelihood to arrive at a hospital within 2 hours.
Our study underscores that good theoretical knowledge about stroke does not imply appropriate management in the emergency situation. Educational efforts need to incorporate more practical aspects in order to translate theoretical knowledge into concrete action.
Neurological Research 08/2007; 29(5):476-9. · 1.52 Impact Factor
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ABSTRACT: Stroke patients often report that primary care physicians (PCPs) are their first medical contact after onset of symptoms. We studied PCP attitudes and current practice in early management of suspected stroke patients.
A cross-sectional survey was conducted among 714 general practitioners, internists, and neurologists providing acute primary care for stroke patients in 4 different regions in Germany. PCP attitudes and practices were assessed with standardized questionnaires and case vignettes presenting suspected stroke patients contacting PCPs either by phone or in practice. Factors influencing the decision of the PCPs to admit patients with clear stroke symptoms as medical emergency to hospital were assessed using multivariate analysis.
In total, 395 PCPs participated in the study (55.3%). Most PCPs agreed that stroke (94.7%) and transient ischemic attack (84.8%) were medical emergencies. In case vignettes, admission to hospital as medical emergency was preferred management after first contact to patients with clear stroke symptoms by phone or in practice (68.9% and 65.6%, respectively). Outpatient clarification was the preferred option of PCPs in patients with unclear stroke symptoms contacting PCPs by phone or in practice (54.7% and 75.5%, respectively) and in transient ischemic attack patients (50.9%). Working as general practitioner (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6) and practice location outside metropolitan area (P=0.002) independently decreased probability of admitting suspected stroke patients as medical emergency when first contact to PCPs was by phone. PCP agreement that all stroke and transient ischemic attack patients must be admitted to hospital increased probability for early hospitalization of stroke and transient ischemic attack patients when first contact was in practice (odds ratio, 2.0; 95% confidence interval, 1.2 to 3.3, and odds ratio, 1.8; 95% confidence interval, 1.1 to 2.8, respectively).
Stroke and transient ischemic attack were well recognized as medical emergencies by PCPs in our study. However, only two-thirds of PCP would immediately admit stroke suspected patients with clear symptoms to hospital as medical emergency.
Stroke 05/2007; 38(4):1298-303. · 5.73 Impact Factor
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ABSTRACT: Synkinesias secondary to nerve lesions and aberrant re-innervation are well-known phenomena especially after lesions of the facial nerve. Synkinesias can successfully be treated with botulinum toxin A (BTx A). Synkinesias of the cremaster muscle have not been described or treated to date. We present the case of a 62-year-old man who developed synkinesias of both cremaster muscles after extensive laparatomy for esophageal cancer. Treatment of synkinesias with various oral medications had been unsuccessful. Electromyography-guided injections of BTx A in both cremaster muscles (15 MU on the right and 10 on the left) led to significant symptom relief for an average of 8 weeks. We present the case including pre- and posttreatment video clips.
Movement Disorders 11/2006; 21(10):1787-8. · 4.51 Impact Factor
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ABSTRACT: The CARESS (Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic carotid Stenosis) trial proved the effectiveness of the combination of clopidogrel and aspirin compared with aspirin alone in reducing presence and number of microembolic signals (MES) in patients with recently symptomatic carotid stenosis. The present study aimed at installing primary and secondary quality control measures in CARESS because MES evaluation relies on subjective judgment by human experts.
As primary quality control, centers participating in CARESS evaluated a reference digital audio tape (DAT) before the study containing both MES and artifacts. Interobserver agreement of classifying signals as MES was expressed as proportions of specific agreement of positive ratings (ps+/-values). For all DATs included in CARESS (n=300), online number of MES and off-line number of MES read by the central reader were compared using correlation coefficients. As secondary control, a sample of 16 of 300 DATs was cross-validated by another independent reader (post-trial validator).
For the reference tape, the cumulative ps+/-value was 0.894 based on 12 of 14 observers. Two observers with very different results improved after a training procedure. Agreement between post-trial validator and central reader was ps+=0.805, indicating very good agreement. Correlation between online evaluation and off-line evaluation of DATs was very good overall (cumulative rho=0.84; P<0.001).
Multicenter studies using MES as outcome parameter are feasible. However, primary and secondary quality control procedures are important.
Stroke 04/2006; 37(4):1065-9. · 5.73 Impact Factor
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ABSTRACT: To investigate whether acute phase intracranial CT angiography (CTA) independently predicts infarction and functional outcome in ischemic stroke.
Hundred and fifty-one consecutive patients with acute (<12 h) ischemic stroke who received intracranial CTA were investigated. Stroke severity on admission was determined using the National Institute of Health Stroke Scale (NIHSS). Reconstructed CTAs were investigated for relevant pathology. Follow-up imaging was performed 24-48 h after admission. Functional outcome was assessed after 3 months using the modified Rankin scale. Single factor and multiple logistic regression analyses were performed to predict infarction and dependency (modified Rankin scale > or = 3) on follow-up.
Median NIHSS on admission was 10 (IQR 3-14). Out of the 151 patients, 61 (40%) had pathological CTA findings. Infarction was demonstrated in 60/61 patients (98%) with and in 67/90 patients (74%) without vessel pathology. Presence of infarction on follow-up imaging and dependency at 3 months were correlated with pathological CTA findings on admission in single factor analysis (each p < 0.001). After adjustment for age (> or =/<65 years), NIHSS (> or =/<10), sex, therapy, and time to presentation (> or =/<3 h), only NIHSS > or = 10 on admission was predictive of dependency at follow-up (p < 0.001).
Pathological CTA findings in the acute phase of ischemic stroke do not independently predict a poor outcome at 3 months after acute stroke.
Cerebrovascular Diseases 01/2006; 22(5-6):362-7. · 2.72 Impact Factor
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ABSTRACT: Proper assessment of the intracranial arteries by transcranial color-coded duplex sonography (TCCD) is occasionally made difficult by an insufficient temporal bone window, an unfavorable insonation angle, or low flow velocity or volume. In these cases, echocontrast could be helpful to increase the diagnostic confidence or to make the diagnosis at all.
We investigated 67 temporal windows of 47 patients with insufficient native transtemporal insonation conditions before and after the application of the second-generation (gas-filled) microbubble contrast agent Sonovue (in 20 patients out of these 47, both temporal windows were insufficient, in the remaining 27 only one side).
As compared to the precontrast scans, echocontrast allowed for more segments to be evaluated by pulsed Doppler sonography (p < 0.0001) and for longer lumen segments to be displayed on color mode (p < 0.0001). With the help of contrast medium, flow velocity in the middle cerebral artery could be measured through 65 windows as compared to only 26 windows before contrast was applied (p < 0.0001).
In patients with poor precontrast visualization of intracranial arteries, echocontrast-enhanced TCCD is very helpful.
Cerebrovascular Diseases 01/2005; 20(5):332-6. · 2.72 Impact Factor
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ABSTRACT: Platelet activation is involved in the pathogenesis of cerebrovascular ischemia, but the major agonist involved has yet to be identified. To investigate the role of thrombin in platelet activation in patients with acute ischemic stroke, and while thrombin is the most likely candidate for activation of the thrombin receptor PAR-1 in vivo, we assessed its cleavage and internalization using the antibodies SPAN12, binding to uncleaved PAR-1, and WEDE15, recognizing cleaved and uncleaved, but not internalized PAR-1. In contrast to healthy age-matched controls, platelets from stroke patients exhibited significant cleavage and internalization of PAR-1 (P<0.001) and failed to respond to thrombin in vitro. Enhanced surface expression of CD62P, CD63, TSP-1 and less mepacrine uptake showed platelet degranulation during stroke. Platelets from patients with acute cerebral ischemia are exhausted and desensitized to thrombin through cleavage of PAR-1, indicating that high concentrations of thrombin occur with acute cerebrovascular ischemic events in vivo.
Thrombosis and Haemostasis 02/2004; 91(2):334-44. · 5.04 Impact Factor
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Journal of Neurology 11/2003; 250(10):1255-6. · 3.47 Impact Factor
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ABSTRACT: Microembolic signals can be detected by transcranial ultrasound as signals of high intensity and short duration. These signals represent circulating gaseous or solid particles. To optimize the differentiation from artefacts and the background signal and to facilitate the clinical use, several attempts have been made to automatize the detection of microemboli. Microemboli occur spontaneously in various clinical situations but their clinical impact and possible therapeutical implications are still under debate. This article provides a review of the actual literature concerning the current state of technical and clinical aspects of microembolus detection.
European Journal of Ultrasound 12/2002; 16(1-2):21-30.
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ABSTRACT: Carotid bruits are supposed to indicate the presence of high-grade common carotid or extracranial internal carotid artery stenosis in a large proportion of patients. Using a stethoscope, we prospectively auscultated 273 carotid arteries of 145 patients blinded to the results of a complete extracranial and intracranial Doppler investigation including extracranial color-coded duplex ultrasound. Fifty-four arteries showed stenosis of > or = 50%-99%, or occlusion of the extracranial internal or the common carotid artery. In 25 of these arteries, a bruit was present. In 9 out of 16 patients with extracranial stenosis from 70%-99%, a bruit was detected. In one additional patient with a middle-grade external carotid artery stenosis, a bruit was also present. In seven additional patients, a bruit was present in the absence of any carotid artery stenosis, cardiac vitium or goiter. The sensitivity of carotid auscultation for the detection of a 70%-99% stenosis of the common or extracranial internal carotid artery was 56% and specificity was 91%. The positive predictive value of a bruit found during carotid auscultation was 27%, and the negative predictive value of a normal auscultation was 97%. Carotid auscultation is a useful screening procedure in the detection of carotid stenosis or occlusion, but requires confirmation by carotid ultrasound.
Neurological Research 10/2002; 24(7):705-8. · 1.52 Impact Factor
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ABSTRACT: One of the most frequent diagnostic pitfalls in cerebrovascular ultrasound is the evaluation of the vertebrobasilar system in the case of vertebral artery (VA) hypoplasia because the diagnostic findings are sometimes suggestive of significant pathologies, but may be completely normal as well. The Venturi effect is a phenomenon of hydrodynamics which describes a drop in hydrostatic pressure along areas of high flow velocities.
We review the physical background of the Venturi effect and describe how it can explain both physiological and pathological flow phenomena encountered during cerebrovascular ultrasound investigations. We focused on flow phenomena at the vertebrobasilar junction by theoretically calculating conditions with different influx angles and flow velocities on two-dimensional digital subtraction angiography images. In the discussion, we also address other areas of cerebrovascular ultrasound, where the Venturi effect is of particular interest.
The blood flow velocity within the VAs and the angle between a hypoplastic VA and the basilar artery (BA) are important determinants of the intraluminal pressures of these arteries and thus their resistances. In the case of angles below 90 degrees between the distal VA and the BA, abnormal extracranial flow profiles may suggest downstream VA stenosis or occlusion, whereas in the case of angles above 90 degrees, a diagnosis of an AV fistula downstream to the V4 segment may be assumed. Furthermore, various hemodynamic effects at the site of a stenosis of the brain supplying arteries can also be explained by a transstenotic pressure drop created by the Venturi effect, particularly the generation of musical murmurs. The systolic dip ('systolic deceleration') at the origin of the VA due to subclavian artery stenosis is also a consequence of the Venturi effect.
Cerebrovascular Diseases 02/2002; 14(2):98-104. · 2.72 Impact Factor
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ABSTRACT: Primary angiitis of the central nervous system (PACNS) is a rare disease. The definite diagnosis is made upon proof of mononuclear inflammation of the vessel wall on brain biopsy. The diagnosis can also be established on clinical grounds, typical findings on intra-arterial angiography and other investigatory grounds excluding other diseases. Therapy comprises an aggressive immunosuppressive approach. Close monitoring of the patients is mandatory. Transcranial Doppler ultrasound (TCD) has not yet been used to follow up the vasculitic lesions in PACNS.
We report on a 32-year-old female with massive cerebral infarctions secondary to multiple large-vessel stenoses because of probable PACNS. The patient was followed closely by means of TCD. During therapy the cerebral blood flow velocities normalized as displayed by TCD. Clinical improvement followed several days after normalization of cerebral blood flow.
TCD is a valuable noninvasive bedside tool to monitor cerebral blood flow velocities and therapy response in patients with cerebral vasculitis, if large arteries are involved.
Cerebrovascular Diseases 02/2002; 14(2):139-42. · 2.72 Impact Factor
