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Background: Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing autoimmune disease of the central nervous system, affecting mainly optic nerves and spinal cord. NMOSD pathophysiology is associated with anti-aquaporin-4 (AQP4) immunoglobulin G (IgG) autoantibodies. Rapid extracorporeal elimination of autoantibodies with apheresis techniques, such as immunoadsorption (IA), was proven to be an effective treatment of NMOSD attacks. Data on the long-term use of IA to prevent attacks or progression of NMOSD are lacking. Objectives: The aim of this study was to evaluate efficacy and safety of maintenance IA for preventing recurrence of NMOSD attacks in patients refractory to other immunotherapies. Design: Case study. Methods: Retrospective analysis of two female patients with severe NMOSD refractory to conventional immunotherapies was performed. Both patients had responded to tryptophan IA (Tr-IA) as attack therapy and subsequently were treated with biweekly maintenance Tr-IA. Results: Patient 1 (AQP4-IgG seropositive, age 42 years) had 1.38 attacks of optic neuritis per year within 10.1 years before commencing regular Tr-IA. With maintenance Tr-IA for 3.1 years, one mild attack occurred, which was responsive to steroid pulse therapy. Expanded Disability Status Scale (EDSS) was stable at 5.0. Visual function score of the last eye improved from 3 to 1. Patient 2 (AQP4-IgG seronegative, age 43 years) experienced 1.7 attacks per year, mainly acute myelitis and optic neuritis, during the period of 10.0 years before the start of Tr-IA. During regular Tr-IA treatment, no further NMOSD attack occurred. The patient was clinically stable without any additional immunosuppressive treatment for 5.3 years. EDSS improved from 6.0 to 5.0, and the ambulation score from 7 to 1. Tolerability of Tr-IA was good in both patients. No serious adverse events occurred during long-term clinical trajectories. Conclusion: Tr-IA was well tolerated as maintenance treatment and resulted in clinical stabilization of two patients with highly active NMOSD, who were refractory to standard drug therapy.

Background: Widespread quick access to mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is one of the main challenges in stroke care. It is unclear if newly established MT units are required 24 h/7 d. We explored the diurnal admission rate of patients with AIS potentially eligible for MT to provide a basis for discussion of daytime-adapted stroke care concepts.Methods: Data collected from the Baden-Württemberg Stroke Registry in Germany were assessed (2008–2012). We analyzed the admission rate of patients with AIS stratified by the National Institutes of Health Stroke Scale (NIHSS) score at admission in 3-h intervals. An NIHSS score ≥10 was considered a predictor of large vessel occlusion. The average annual admission number of patients with severe AIS were stratified by stroke service level and calculated for a three-shift model and working/non-working hours.Results: Of 91,864, 22,527 (21%) presented with an NIHSS score ≥10. The average admission rates per year for a hospital without Stroke Unit (SU), with a local SU, with a regional SU and a stroke center were 8, 52, 90 and 178, respectively. Approximately 61% were admitted during working hours, 54% in the early shift, 36% in the late shift and 10% in the night shift.Conclusions: A two-shift model, excluding the night shift, would cover 90% of the patients with severe AIS. A model with coverage during working hours would miss ~40% of the patients with severe AIS. To achieve a quick and area-wide MT, it seems preferable for newly implemented MT-units to offer MT in a two-shift model at a minimum.

IntroductionBased on data from the Baden-Wuerttemberg stroke registry, we aimed to explore the diurnal variation of acute ischemic stroke (IS) care delivery.Materials and methods92,530 IS patients were included, of whom 37,471 (40%) presented within an onset-to-door time ≤4.5 h. Daytime was stratified in 3-h time intervals and working vs. non-working hours. Stroke onset and hospital admission time, rate of door-to-neurological examination time ≤30 min, onset-/door-to-imaging time IV thrombolysis (IVT) rates, and onset-/door-to-needle time were determined. Multivariable regression models were used stratified by stroke onset and hospital admission time to assess the relationship between IVT rates, quality performance parameters, and daytime. The time interval 0:00 h to 3:00 h and working hours, respectively, were taken as reference.ResultsThe IVT rate of the whole study population was strongly associated with the sleep–wake cycle. In patients presenting within the 4.5-h time window and potentially eligible for IVT stratification by hospital admission time identified two time intervals with lower IVT rates. First, between 3:01 h and 6:00 h (IVT rate 18%) and likely attributed to in-hospital delays with the lowest diurnal rate of door-to-neurological examination time ≤30 min and the longest door-to-needle time Second, between 6:01 h and 15:00 h (IVT rate 23–25%) compared to the late afternoon and evening hours (IVT rate 27–29%) due to a longer onset-to-imaging time and door-to-imaging time. No evidence for a compromised stroke service during non-working hours was observed.ConclusionThe analysis provides evidence that acute IS care is subject to diurnal variation which may affect stroke outcome. An optimization of IS care aiming at constantly high IVT rates over the course of the day therefore appears desirable.

Acute ischemic lesions of the posterior optic nerve and optic tract can produce a variety of visual field defects. A 71-year-old woman presented with acute hemianopia, which led to rt-PA thrombolysis for suspected posterior cerebral artery ischemia. 3-Tesla cMRI, however, revealed the cause to be an acute posterior ischemic optic neuropathy. Cases like this may be more common than thought and quite regularly overlooked in clinical practice, especially when there is no high-resolution MRI available. This case strengthens the importance of repeat MR imaging in patients with persistent visual field defects.

Background and Purpose: Arterial spin labeling (ASL) MRI provides information on tissue perfusion by consecutive readout of labeled blood captured in arteries or the microvasculature without using contrast agents.Methods: We used a single-shot 3D acquisition and readout technique for ASL with multiple inflow times (TI) to evaluate hemodynamic compromise and dynamics of arterial blood inflow expressed by the bolus arrival time (BAT). Thirty-six patients with ischemic stroke were examined with a standard multimodal MRI protocol including dynamic susceptibility contrast (DSC) and multi-TI ASL perfusion imaging. Time-to-peak maps were used to classify hemodynamic impairment as either hypo- or hyperperfusion.Results: Overall there was a good agreement of ASL perfusion maps with DSC perfusion imaging on visual analysis. Correlations were found between ASL-BAT/(DSC-)Mean transit time (MTT) (r = .416; P < .01) and ASL-CBF/MTT (r = -.489; P < .01). Using ASL, BAT in ischemic territory was delayed by 55% (P = .001) in patients with hypoperfusion (n = 28); CBF was reduced by 39% (P<.001). All patients with hyperperfusion (n = 6) had higher CBF on ASL.Conclusions: The use of ASL with multiple TI allows the contrast-free assessment of hemodynamic impairment in ischemic stroke patients. Quantitative ASL perfusion analysis reliably demonstrates areas of delayed BAT and reduced CBF matching findings of DSC. [ABSTRACT FROM AUTHOR]

Simultaneous ipsilateral patellar tendon (PT) and anterior cruciate ligament (ACL) tear is a rare injury. Associated meniscal and ligamentous injuries are common but frequently initially missed. In contrast, to date, there is no report of associated fractures. We report on a 40-year-old female Caucasian patient presenting with a ski injury resulting in simultaneous ipsilateral patellar tendon and ACL tear combined with a tibia plateau fracture and a medial and lateral meniscus lesion. ORIF of the tibia as well as one-stage primary reconstruction of the PT and ACL and suturing of the menisci was conducted. The final follow-up was 2 years postoperatively. Lower extremity kinematic, kinetic, and muscle activity measurements were conducted. Although the clinical result was excellent, altered joint kinematics went along with large side-to-side difference in hip and knee joint moments during midstance and terminal stance. During weight acceptance, vastus medialis and hamstring muscles showed greater relative activity in the injured than the uninjured side. This case demonstrates the possibility of excellent early and midterm results with a one-stage approach and suitable rehabilitation scheme. Biomechanical measurements could further help evaluate the outcome of the treatments and implications for the development of potential secondary damage.

Grade III valgus deformity (tibiofemoral alignment > 20°) is present in only 0.5% of patients receiving total knee arthroplasty. Furthermore, cases with a valgus deformity exceeding 40° are even rarer. Since they mostly affect elderly, polymorbid patients, successful outcome means a great challenge. We report on a case of a 90-year-old patient with a valgus deformity of 47°. The patient was preoperatively restricted to a wheel chair, unable to walk, and only able to stand for a few seconds. The maximal knee flexion was 100°, and there was an extension deficit of 15°. The WOMAC score was 91; the EQ-5D-5L Index was 0.048. She was treated with a constrained hinged prosthesis. Postoperatively, the axis was 6° valgus. After 3 months of rehabilitation, she was independent using a wheeled walker. The maximal flexion of the knee was 110° and there was no extension deficit. The WOMAC score was 45; the EQ-5D-5L Index was 0.813. This case demonstrates the possibility of a satisfactory result and an improvement in quality of life and mobility with a plausible timetable and with reasonable use of resources even in advanced age and severe valgus deformity.