[Show abstract][Hide abstract] ABSTRACT: Although use of oral anticoagulants (OACs) is increasing, there is a substantial lack of data on how to treat OAC-associated intracerebral hemorrhage (ICH).
To assess the association of anticoagulation reversal and blood pressure (BP) with hematoma enlargement and the effects of OAC resumption.
Retrospective cohort study at 19 German tertiary care centers (2006-2012) including 1176 individuals for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of OAC resumption.
Reversal of anticoagulation during acute phase, systolic BP at 4 hours, and reinitiation of OAC for long-term treatment.
Frequency of hematoma enlargement in relation to international normalized ratio (INR) and BP. Incidence analysis of ischemic and hemorrhagic events with or without OAC resumption. Factors associated with favorable (modified Rankin Scale score, 0-3) vs unfavorable functional outcome.
Hemorrhage enlargement occurred in 307 of 853 patients (36.0%). Reduced rates of hematoma enlargement were associated with reversal of INR levels <1.3 within 4 hours after admission (43/217 [19.8%]) vs INR of ≥1.3 (264/636 [41.5%]; P < .001) and systolic BP <160 mm Hg at 4 hours (167/504 [33.1%]) vs ≥160 mm Hg (98/187 [52.4%]; P < .001). The combination of INR reversal <1.3 within 4 hours and systolic BP of <160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement (35/193 [18.1%] vs 220/498 [44.2%] not achieving these values; OR, 0.28; 95% CI, 0.19-0.42; P < .001) and lower rates of in-hospital mortality (26/193 [13.5%] vs 103/498 [20.7%]; OR, 0.60; 95% CI, 0.37-0.95; P = .03). OAC was resumed in 172 of 719 survivors (23.9%). OAC resumption showed fewer ischemic complications (OAC: 9/172 [5.2%] vs no OAC: 82/547 [15.0%]; P < .001) and not significantly different hemorrhagic complications (OAC: 14/172 [8.1%] vs no OAC: 36/547 [6.6%]; P = .48). Propensity-matched survival analysis in patients with atrial fibrillation who restarted OAC showed a decreased HR of 0.258 (95% CI, 0.125-0.534; P < .001) for long-term mortality. Functional long-term outcome was unfavorable in 786 of 1083 patients (72.6%).
Among patients with OAC-associated ICH, reversal of INR <1.3 within 4 hours and systolic BP <160 mm Hg at 4 hours were associated with lower rates of hematoma enlargement, and resumption of OAC therapy was associated with lower risk of ischemic events. These findings require replication and assessment in prospective studies.
clinicaltrials.gov Identifier: NCT01829581.
JAMA The Journal of the American Medical Association 02/2015; 313(8):824-36. DOI:10.1001/jama.2015.0846 · 35.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Epilepsien sind die häufigsten neurologischen Erkrankungen bei Frauen im reproduktiven Alter. Da eine gute präkonzeptionelle therapeutische Einstellung der Erkrankung und die gezielte Auswahl der dabei verwendeten Medikamente entscheidend für den erfolgreichen Verlauf einer Schwangerschaft sind, kommt der interdisziplinären Zusammenarbeit zwischen Frauenarzt und Neurologen, der rechtzeitigen kritischen Überprüfung der Diagnose und Therapie sowie ggf. deren Anpassung und der möglichst langfristigen Planung einer Schwangerschaft wesentliche Bedeutung zu, damit der Kinderwunsch ohne Ängste realisiert werden kann. Trotz der lange bekannten teratogenen Risiken einiger Antiepileptika hat eine schwangere Epilepsiepatientin eine Chance von über 90% auf ein gesundes Kind. Während die Entbindung in der Klinik obligat ist, besteht kein Grund, Epilepsiepatientinnen eine normale Geburt unter kontinuierlicher Einnahme ihrer Medikamente vorzuenthalten oder vom Stillen abzuraten.
Der Gynäkologe 12/2011; 44(12). DOI:10.1007/s00129-011-2817-4
[Show abstract][Hide abstract] ABSTRACT: Here, we demonstrate a first case of tick-borne encephalitis (TBE) associated with an isolated reversible splenial corpus callosum lesion (IRSL) and highlight the wide range of different clinical entities in which such alterations have been observed. A 42-year-old man showed fever, cephalgia and mild disturbance of coordination and gait. Diagnosis was ascertained by slight CSF-pleiocytosis and positive TBE-IgG as well as by positive intrathekal specific antibody index on follow-up. MRI demonstrated a single ovoid hyperintensity in T2 and DWI with reduction in ADC in the splenium of corpus callosum which was abrogated in follow-up after 6 weeks. Most entities of IRSL presented with excellent prognosis, including our novel case of TBE. We discuss different possible pathomechanisms and the so far unexplained propensity of the splenium for such alterations. Clinicians should be familiar with this phenomenon to avoid unnecessary diagnostic or therapeutic efforts.
[Show abstract][Hide abstract] ABSTRACT: There is increasing evidence for hormone-dependent modification of function and behavior during the menstrual cycle, but little is known about associated short-term structural alterations of the brain. Preliminary studies suggest that a hormone-dependent decline in brain volume occurs in postmenopausal, or women receiving antiestrogens, long term. Advances in serial MR-volumetry have allowed for the accurate detection of small volume changes of the brain. Recently, activity-induced short-term structural plasticity of the brain was demonstrated, challenging the view that the brain is as rigid as formerly believed.
We used MR-volumetry to investigate short-term brain volume changes across the menstrual cycle in women or a parallel 4 week period in men, respectively. We found a significant grey matter volume peak and CSF loss at the time of ovulation in females. This volume peak did not correlate with estradiol or progesterone hormone levels. Men did not show any significant brain volume alterations.
These data give evidence of short-term hormone-dependent structural brain changes during the menstrual cycle, which need to be correlated with functional states and have to be considered in structure-associated functional brain research.
PLoS ONE 02/2011; 6(2):e14655. DOI:10.1371/journal.pone.0014655 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report the case of a patient with idiopathic generalized epilepsy who ten years after the onset of his epilepsy also developed recurring nocturnal paroxysmal episodes reminiscent of his seizure semiology. Video monitoring and polysomnography revealed episodes of nocturnal groaning. Escalation of antiepileptic treatment was avoided.
Epileptic disorders: international epilepsy journal with videotape 06/2010; 12(2):136-7. DOI:10.1684/epd.2010.0317 · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Gait disturbances are frequent in older patients and lead to immobility, falls, and increased mortality. In gerontoneurologic patients a higher prevalence of risk factors for gait disturbances and falls has to be attributed due to neurodegenerative diseases, dementia, delirium, or psychotropic medication. The potential of neurological expertise to contribute to the evaluation and treatment of falls and gait disorders in geriatric patients is still not fully exploited. Sometimes a fall can be an index event to the diagnosis of the underlying disorder. This review, therefore, focuses on the relationship between falls, gait, and neurological diagnosis. It helps to find the correct diagnosis of the underlying disease as one major step in the management of gait disorders and fall prevention. From a pragmatic point of view falls can be classified according to loss or preservation of consciousness. Gait disturbances should be differentiated into gait disorders with and without cognitive impairment. Although gait impairments are influenced by multifactorial parameters, this differentiation may help to find a diagnosis and also to initiate an appropriate, disease-specific therapy. In addition, every fall patient has to be analyzed individually according to his individual risk factors, which all can potentially be influenced to improve mobility and to reduce falls.
[Show abstract][Hide abstract] ABSTRACT: The clinical differentiation between stroke and seizure is usually straightforward but postictal neurological deficits can be mistaken for stroke in case no detailed medical history is available. Up to now, the imaging findings of Todd's paresis are not well described. This case report demonstrates that postictal paresis can be accompanied by a reversible global hemispheric hypoperfusion as measured with perfusion MRI indicating transient but profound cerebrovascular dysfunction in postictal paresis. Extensive postictal perfusion changes must be discriminated from emerging stroke to avoid potentially harmful therapy like thrombolysis. Further investigations are warranted to clarify the role of cerebrovascular dysfunction in the pathophysiology of postictal paresis.
Epilepsy research 03/2010; 89(2-3):355-9. DOI:10.1016/j.eplepsyres.2010.02.009 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Arteriosclerosis related stenosis in the carotid bulb causes autonomic imbalance, likely due to carotid chemoreceptor and baroreceptor dysfunction. The latter are associated with increased cerebrovascular and cardiovascular mortality. Chemoreceptor and baroreceptor dysfunction is also involved in the origin of central sleep apnea syndrome (CSA) in different clinical entities. We hypothesized that CSA is associated with stenosis of the internal carotid artery (ICA). The mechanism of this association is an autonomic imbalance induced by stenosis-mediated chemoreceptor and baroreceptor dysfunction.
Cross-sectional prospective study.
University-based tertiary referral sleep clinic and research center.
Fifty-nine patients with various degrees of asymptomatic extracranial ICA (elCA) (n = 49) and intracranial ICA (ilCA) stenosis (n = 10) were investigated.
Polysomnography to detect CSA and analysis of spontaneous heart rate variability (HRV) to detect autonomic imbalance.
CSA occurred in 39% of the patients with elCA stenosis but was absent in patients with ilCA stenosis. CSA was present in patients with severe elCA stenosis of > or = 70% on one side. Independent predictors for CSA were severity of stenosis, asymmetric distribution of stenosis between both elCA and autonomic imbalance, namely a decrease of parasympathetic tone. The specific constellation of HRV-parameters indicated increased chemoreceptor sensitivity and impaired baroreflex sensitivity.
CSA indicates autonomic dysfunction in patients with asymptomatic elCA stenosis. Detection of CSA may help to identify asymptomatic patients with an increased risk of cerebrovascular or cardiovascular events who particularly benefit from carotid revascularization.
[Show abstract][Hide abstract] ABSTRACT: To assess and visualize gravitational effects on brain morphology and the position of the brain within the skull by magnetic resonance (MR) morphometry in order to identify confounding effects and possible sources of error for accurate planning of neurosurgical interventions.
Three-dimensional MR imaging data sets of 13 healthy adults were acquired in different positions in the scanner. With a morphometric approach, data sets were evaluated by deformation field analysis and the brain boundary shift integral. Distortions of the brain were assessed comparing right versus left and prone versus supine positioning, respectively.
Two effects could be differentiated: 1) greatest brain deformation of up to 1.7 mm predominantly located around central brain structures in the lateral direction and a less pronounced change after position changes in posterior-anterior direction, and 2) the brain boundary shift integral depicted position-dependent brain shift relative to the inner skull.
Position-dependent effects on brain structure may undermine the accuracy of neuronavigational and other neurosurgical procedures. Furthermore, in longitudinal MR volumetric studies, gravitational effects should be kept in mind and the scanning position should be rigidly controlled for.
[Show abstract][Hide abstract] ABSTRACT: Non-convulsive status epilepticus (NCSE) is characterized by continuous or recurrent, generalized or focal epileptiform activity on the electroencephalogram and diverse clinical symptoms with alterations of mental state and vigilance. NCSE is not rare but certainly under diagnosed. There is some debate about how aggressive NCSE should be treated, as high dose anticonvulsants maybe partially responsible for the morbidity and mortality of patients with NCSE. We hypothesized that levetiracetam (LEV) as a well tolerated, highly effective new anticonvulsant, may be a safe treatment option. We retrospectively analyzed all (8) patients with NCSE who received levetiracetam from our database, compared with 11 patients with NCSE treated with conventional intravenous status medication as controls. These eight patients showed a marked clinical improvement with final cessation of ictal EEG-activity and clinical symptoms of NCSE after initiation of LEV within 3 days (mean 1.5 days). The response to conventional treatment was similarly effective but there were severe side effects whereas no relevant side effects in the LEV-treated group were noticed. A long-term follow up (6-36 months from discharge) revealed six patients with a persisting reduction in seizure frequency on medication with LEV. One patient changed the anticonvulsive medication because of inefficacy and one died from other causes than epilepsy 2 months after discharge from hospital. We found no significant differences in hospitalisation time, time in intensive care unit and outcome between the LEV group and the control group. This retrospectively acquired data suggests that LEV may be a well tolerated, effective treatment option in NCSE. This highlights the need for a prospective controlled study to further elucidate the utility of LEV in the treatment of NCSE, particularly as an intravenous formulation is now available.
Epilepsy Research 04/2007; 73(3):238-44. DOI:10.1016/j.eplepsyres.2006.10.011 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Neonatal freeze lesions in newborn rats induce focal malformations of the cerebral cortex mimicking human polymicrogyria which is a common cause of epilepsy and neuropsychological deficits in children and adults. Experimental and clinical studies demonstrated hyperexcitability in the malformation itself and peridysplastic cortex associated with a widespread imbalance of excitatory and inhibitory function and extensive alterations in cortical connectivity. We investigated the integrity of functional cortical inhibition using a paired pulse paradigm in brain slice preparations of adult freeze-lesioned rats. In contrast to previous electrophysiological studies focusing on the dysplastic cortex and the ipsilateral hemisphere, we here mapped both hemispheres. Extracellular field potentials were evoked by application of double pulses at the border of layer VI/white matter and recorded in layer II/III. Evaluation of the ratio of the field potential amplitudes at different recording positions allowed an assessment of regional functional inhibition. Using this approach, we observed a significant reduction of functional inhibition in the somatosensory cortex of the contralateral hemisphere, whereas only slight alterations were detected in the ipsilateral lesion surround. Our results provide evidence that focal cortical malformations not only impair cortical excitability in the ipsilateral hemisphere but also induce a disinhibition of the contralateral cortex.