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Background and purpose Many countries worldwide, including Germany, reported that the first wave of the coronavirus disease 2019 (COVID‐19) pandemic in early 2020 influenced the care of acute ischemic stroke (AIS) patients, but data are lacking for further pandemic wave periods. Methods We conducted a nationwide, retrospective, cross‐sectional study of all hospitalized patients with the main diagnosis of AIS in 2019 and 2020. Primary outcomes were the number of hospitalizations for AIS, the application of stroke unit care, intravenous thrombolysis (IVT), and mechanical thrombectomy (MT), as well as the in‐hospital mortality during the different pandemic periods in 2020 compared to the corresponding periods in 2019. Secondarily, we analyzed differences in outcomes between patients with and without concurrent COVID‐19. Results We included 429,841 cases with AIS, of which 1268 had concurrent COVID‐19. Hospitalizations for AIS declined during both pandemic wave periods in 2020 (first wave: −10.9%, second wave: −4.6%). MT rates were consistently higher throughout 2020 compared to 2019, whereas the IVT rate dropped during the second wave period (16.0% vs. 17.0%, p, There was a substantial decline in hospitalizations for acute ischemic stroke during the two COVID‐19 pandemic waves in Germany, with a smaller reduction during the second wave of the pandemic. Acute ischemic stroke patients still frequently received acute stroke care, including recanalization treatments during the entire year of 2020, irrespective of SARS‐CoV‐2 status.

Background and Purpose: Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many countries have introduced strict hygiene measures of social distancing to prevent further spreading of the disease. This may have led to a decreased presentation to hospital of patients with acute medical conditions and time-dependent management, such as stroke. Methods: We conducted a nationwide cohort study using administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke (AIS), transient ischemic attack, or intracerebral hemorrhage. Data from a total of 1463 hospitals in Germany were included. We compared case numbers and treatment characteristics of pandemic (March 16 to May 15, 2020) and prepandemic (January 16 to March 15, 2020) cases and also with corresponding time period in 2019. Results: We identified a strong decline for hospitalization of AIS (−17.4%), transient ischemic attack (−22.9%), and intracerebral hemorrhage (−15.8%) patients during the pandemic compared with prepandemic period. IVT rate in patients with AIS was comparable (prepandemic versus pandemic: 16.4% versus 16.6%, P =0.448), whereas mechanical thrombectomy rate was significantly higher during the pandemic (8.1% versus 7.7%, P =0.044). In-hospital mortality was significantly increased in patients with AIS during the pandemic period (8.1% versus 7.6%, P =0.006). Conclusions: Besides a massive decrease in absolute case numbers, our data suggest that patients with AIS who did seek acute care during the pandemic, continued to receive acute recanalization treatment in Germany.

Neben der Behandlung kardiovaskularer Risikofaktoren steht vor allem die Pravention und Therapie von Sekundarkomplikationen im Mittelpunkt der ambulanten Schlaganfallnachsorge. Das Spektrum zu beachtender Komplikationen nach einem Schlaganfall wandelt sich dabei im zeitlichen Verlauf und stellt eine spezifische Herausforderung in der ambulanten Schlaganfallnachsorge dar. Der Beitrag gibt Hinweise zur Bedeutung, zum Umgang, zur Diagnose und zur Behandlung des vielfaltigen Spektrums nichtvaskularer Komplikationen nach einem Schlaganfall im Rahmen der ambulanten Schlaganfallnachsorge. Post-Stroke-Depressionen (PSD), Angststorungen und die Post-Stroke-Fatigue sind haufige Komplikationen nach einem Schlaganfall, die eine rechtzeitige Diagnose und Therapie erfordern. Innerhalb der ersten 6 Monate nach einem Schlaganfall liegt die Inzidenz einer neu aufgetretenen Demenz bei ca. 20 %. Auch hier konnen therapeutische und praventive Ansatze gerade im Fruhstadium der Erkrankung nachfolgende Belastungen und Pflegebedurftigkeit verzogern. Rund jede zweite Neudiagnose einer Epilepsie bei Patienten uber 60 Jahren lasst sich auf die Folgen eines Schlaganfalls zuruckfuhren. Sturze und deren Verletzungsfolgen stellen eine weitere wichtige Komplikation und Ursachen fur eine erneute Rehospitalisierung nach einem Schlaganfall dar. Obwohl bis zu 50 % aller Schlaganfallpatienten uber chronische Schmerzen in Folge des Schlaganfalls klagen, werden diese haufig nicht ausreichend beachtet. Das weite Spektrum an Sekundarkomplikationen nach einem Schlaganfall stellt eine komplexe, langfristige und multidisziplinare Herausforderung dar, welche die sektorenubergreifende Interaktion einer Vielzahl von Akteuren erfordert.

Background Registry data demonstrate a high risk of recurrent stroke and rehospitalization rates after first-time stroke in Germany compared to the international level. Meanwhile, a report of the Institute for Applied Quality Assurance in the Healthcare System (aQua institute) pointed out the potential for improvement of post-stroke care in Germany. Objective To establish perspectives for improvement of outpatient post-stroke care in Germany. Methods Critical discussion of important aspects of post-stroke care, presentation of the current structures of healthcare provision and possibilities for improvement of post-stroke care. Results Post-stroke care in Germany is predominantly carried out by general practitioners. Currently, standard healthcare procedures do not provide a comprehensive supportive system of structured and cross-sectoral aftercare after ischemic stroke. Special attention must be paid to the treatment of cardiovascular risk factors according to the guidelines, a specific and rapid provision of assist devices and physiotherapy as well as prevention and treatment of stroke-associated complications. Previous investigations have revealed sometimes clear deficits in the provision of treatment. The reasons include but are not limited to sectoral barriers that are difficult to overcome. New concepts of post-stroke care for improvement of these deficits are currently undergoing clinical testing. Conclusion Ischemic stroke should be considered as a complex chronic disease and should be treated accordingly after discharge from acute inpatient treatment. Emphasis should be placed on the optimization of interdisciplinary and cross-sectoral cooperation and support for general practitioners in the outpatient post-stroke care. New concepts of post-stroke care have the potential for improvement of the current healthcare structures.

Introduction Previous studies showed insufficient control of cardiovascular risk factors (CVRF) and high stroke recurrence rates among ischemic stroke patients in Germany. Currently, no structured secondary prevention program exists in clinical routine. We present the trial design and pilot phase results of a complex intervention to improve stroke care after hospital discharge in Germany. Patients and methods SANO is a cluster-randomized trial with 30 participating regions across Germany aiming to enrol 2,790 patients (drks.de, DRKS00015322). Study intervention combines both structural and patient-centred elements. Study development was based on the Medical Research Council framework for complex interventions. In 15 intervention regions, a cross-sectoral multidisciplinary network is established to enhance CVRF control as well as detection and treatment of post-stroke complications. Recommendations on CVRF are based on high-quality secondary prevention guidelines. Study physicians use motivational interviewing and agree with patients on therapeutic targets. While hospitalised, patients also receive dietary counselling and a health-passport to track their progress. During regular visits, CVRF management and potential complications are monitored. The intervention is compared to 15 regions providing usual care. The primary endpoint is the combination of recurrent stroke, myocardial infarction and death assessed 12 months after enrolment and adjudicated in a blinded manner. Results Eighteen patients were enrolled in a pilot phase that demonstrated feasibility of patient recruitment and study procedures. Conclusion SANO is investigating a program to reduce outcome events after ischemic stroke by implementing a complex intervention. If successful, the program may be implemented in routine care on national level in Germany.

Objective: A multigenetic pro-inflammatory profile may increase stroke risk. We investigated whether a higher number of pro-inflammatory genetic variants are associated with ischaemic stroke risk and whether other risk factors further elevate this risk. Methods: In a case-control study with 470 ischaemic stroke patients (cases) and 807 population controls, we investigated 23 haplotypes or alleles in 16 inflammatory genes (interleukin [IL]1A, IL1B, IL1 receptor antagonist, IL6, IL6 receptor, IL10, tumour necrosis factor-a; C-C motif chemokine ligand 2, C-C motif chemokine receptor 5, C-reactive protein (CRP), intercellular adhesion molecule 1, transforming growth factor β1, E-Selectin, selenoprotein S, cluster determinant 14, histone deacetylase 9 [HDAC9]). We constructed an extended gene score (EGS) as the sum of all individual risk alleles and analysed its effect on stroke, just as its association and interaction with cardiovascular risk factors and infectious scores (IgG antibodies against 5 respectively IgA antibodies against 4 microbial antigens). Results: Cases were less likely to carry the minor allele of IL10 rs1800872 and more likely to carry the HDAC9 allele rs11984041 and the pro-inflammatory haplotype of CRP, although the latter was not statistically significant in our study. Overall, cases tended to have more pro-inflammatory alleles and haplotypes than controls (mean ± SD 13.25 ± 2.25 and 13.04 ± 2.41, respectively). However, the EGS only slightly and not significantly increased the risk of stroke (OR 1.04, 95% CI 0.99–1.09). Its effect was neither associated with included risk factors nor with IgA and IgG infectious scores, and we found no significant interaction effects. Conclusion: A more pro-inflammatory genetic profile might increase stroke risk to some extent. This potential effect is most likely independent of established cardiovascular risk factors and the infectious burden of an individual.

Background Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes. Methods We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses. Results The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile. Conclusion These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

ObjectiveTo determine the occurrence of intracranial haemorrhagic complications (IHC) on heparin prophylaxis (low-dose subcutaneous heparin, LDSH) in primary spontaneous intracerebral haemorrhage (ICH) (not oral anticoagulation-associated ICH, non-OAC-ICH), vitamin K antagonist (VKA)-associated ICH and non-vitamin K antagonist oral anticoagulant (NOAC)-associated ICH.MethodsRetrospective cohort study (RETRACE) of 22 participating centres and prospective single-centre study with 1702 patients with VKA-associated or NOAC-associated ICH and 1022 patients with non-OAC-ICH with heparin prophylaxis between 2006 and 2015. Outcomes were defined as rates of IHC during hospital stay among patients with non-OAC-ICH, VKA-ICH and NOAC-ICH, mortality and functional outcome at 3 months between patients with ICH with and without IHC.ResultsIHC occurred in 1.7% (42/2416) of patients with ICH. There were no differences in crude incidence rates among patients with VKA-ICH, NOAC-ICH and non-OAC-ICH (log-rank p=0.645; VKA-ICH: 27/1406 (1.9%), NOAC-ICH 1/130 (0.8%), non-OAC-ICH 14/880 (1.6%); p=0.577). Detailed analysis according to treatment exposure (days with and without LDSH) revealed no differences in incidence rates of IHC per 1000 patient-days (LDSH: 1.43 (1.04–1.93) vs non-LDSH: 1.32 (0.33–3.58), conditional maximum likelihood incidence rate ratio: 1.09 (0.38–4.43); p=0.953). Secondary outcomes showed differences in functional outcome (modified Rankin Scale=4–6: IHC: 29/37 (78.4%) vs non-IHC: 1213/2048 (59.2%); p=0.019) and mortality (IHC: 14/37 (37.8%) vs non-IHC: 485/2048 (23.7%); p=0.045) in disfavour of patients with IHC. Small ICH volume (OR: volume ConclusionsHeparin administration for venous thromboembolism (VTE) prophylaxis in patients with ICH appears to be safe regarding IHC among non-OAC-ICH, VKA-ICH and NOAC-ICH in this observational cohort analysis. Randomised controlled trials are needed to verify the safety and efficacy of heparin compared with other methods for VTE prevention.

Background and Purpose— We sought to explore the effect of genetic imbalance on functional outcome after ischemic stroke (IS). Methods— Copy number variation was identified in high-density single-nucleotide polymorphism microarray data of IS patients from the CADISP (Cervical Artery Dissection and Ischemic Stroke Patients) and SiGN (Stroke Genetics Network)/GISCOME (Genetics of Ischaemic Stroke Functional Outcome) networks. Genetic imbalance, defined as total number of protein-coding genes affected by copy number variations in an individual, was compared between patients with favorable (modified Rankin Scale score of 0–2) and unfavorable (modified Rankin Scale score of ≥3) outcome after 3 months. Subgroup analyses were confined to patients with imbalance affecting ohnologs—a class of dose-sensitive genes, or to those with imbalance not affecting ohnologs. The association of imbalance with outcome was analyzed by logistic regression analysis, adjusted for age, sex, stroke subtype, stroke severity, and ancestry. Results— The study sample comprised 816 CADISP patients (age 44.2±10.3 years) and 2498 SiGN/GISCOME patients (age 67.7±14.2 years). Outcome was unfavorable in 122 CADISP and 889 SiGN/GISCOME patients. Multivariate logistic regression analysis revealed that increased genetic imbalance was associated with less favorable outcome in both samples (CADISP: P =0.0007; odds ratio=0.89; 95% CI, 0.82–0.95 and SiGN/GISCOME: P =0.0036; odds ratio=0.94; 95% CI, 0.91–0.98). The association was independent of age, sex, stroke severity on admission, stroke subtype, and ancestry. On subgroup analysis, imbalance affecting ohnologs was associated with outcome (CADISP: odds ratio=0.88; 95% CI, 0.80–0.95 and SiGN/GISCOME: odds ratio=0.93; 95% CI, 0.89–0.98) whereas imbalance without ohnologs lacked such an association. Conclusions— Increased genetic imbalance was associated with poorer functional outcome after IS in both study populations. Subgroup analysis revealed that this association was driven by presence of ohnologs in the respective copy number variations, suggesting a causal role of the deleterious effects of genetic imbalance.

Vorhofflimmern (VHF) ist die haufigste tachykarde Herzrhythmusstorung. Aufgrund des demographischen Wandels ist mit einer deutlichen Zunahme von VHF-Patienten in den nachsten Jahrzehnten zu rechnen. In der Metropolregion Rhein-Neckar leben mehr als 2 Mio. Menschen, von denen in etwa zwischen 40.000 und 50.000 betroffen sind. Die Stiftung Institut fur Herzinfarktforschung (IHF) Ludwigshafen hat in Kooperation mit den kardiologischen und neurologischen Kliniken sowie niedergelassenen Arzte und Apotheken der Metropolregion Rhein-Neckar das ARENA-Projekt Vorhofflimmern Rhein-Neckar initiiert, um die Versorgung und Prognose der VHF-Patienten zu verbessern und insbesondere die Schlaganfallprophylaxe zu optimieren. Dabei gliedert sich das Projekt in die Teilbereiche Intervention, Medikation und Migration. Ziele des Teilprojekts Intervention sind die Verbesserung der Kenntnisse uber VHF als Risikofaktor fur den Schlaganfall und die Verbesserung der Versorgung von Menschen mit diagnostiziertem oder unbekanntem VHF. Das Teilprojekt Medikation widmet sich der Therapieadharenz der antithrombotischen medikamentosen Therapie von Patienten mit VHF, wahrend das Teilprojekt Migration Unterschiede und Besonderheiten bei Patienten mit und ohne Migrationshintergrund erarbeitet.

Background: Physical activity (PA) is associated with lower risk of stroke. We tested the hypothesis that lack of pre-stroke PA is an independent predictor of poor outcome after first-ever ischemic stroke. Methods: We assessed recent self-reported PA and other potential predictors for loss of functional independence - modified Rankin Scale (mRS) > 2 - one year after first-ever ischemic stroke in 1370 patients registered between 2006 and 2010 in the Ludwigshafen Stroke Study, a population-based stroke registry. Results: After 1 year, 717 (52.3%) of patients lost their independence including 251 patients (18.3%) who had died. In multivariate logistic regression analysis lack of regular PA prior to stroke (Odds Ratio (OR) 1.7, Confidence Interval (CI) 1.1–2.5), independently predicted poor outcome together with higher age (65–74: OR 1.7; CI 1.1–2.8, 75–84 years: OR 3.3; CI 2.1–5.3; ≥85 years OR 14.5; CI 7.4–28.5), female sex (OR 1.5; CI 1.1–2.1), diabetes mellitus (OR 1.8; CI 1.3–2.5), stroke severity (OR 1.2; CI 1.1–1.2), probable atherothrombotic stroke etiology (OR 1.8; CI 1.1–2.8) and high leukocyte count (> 9.000/mm3; OR 1.4; CI 1.0–1.9) at admission. Subclassifying unknown stroke etiology, embolic stroke of unknown source (ESUS; n = 40, OR 2.2; CI 0.9–5.5) tended to be associated with loss of independence. Conclusion: In addition to previously reported factors, lack of PA prior to stroke as potential indicator of worse physical condition, high leukocyte count at admission as indicator of the inflammatory response and probable atherothrombotic stroke etiology might be independent predictors for non-functional independence in first-ever ischemic stroke.

Background and purpose The effects of the coronavirus disease 2019 (COVID‐19) pandemic on telemedical care have not been described on a national level. Thus, we investigated the medical stroke treatment situation before, during, and after the first lockdown in Germany. Methods In this nationwide, multicenter study, data from 14 telemedical networks including 31 network centers and 155 spoke hospitals covering large parts of Germany were analyzed regarding patients' characteristics, stroke type/severity, and acute stroke treatment. A survey focusing on potential shortcomings of in‐hospital and (telemedical) stroke care during the pandemic was conducted. Results Between January 2018 and June 2020, 67,033 telemedical consultations and 38,895 telemedical stroke consultations were conducted. A significant decline of telemedical (p, Telemedical stroke care in Germany was able to provide full service despite the COVID‐19 pandemic, but telemedical consultations declined abruptly during the lockdown period and normalized after relaxation of COVID‐19 measures in Germany. Although the majority of the participating network centers treated COVID‐19 patients, relevant shortcomings regarding telemedical stroke care were not reported. Our representative nationwide study demonstrates the robustness of teleconsultation services in Germany during the COVID‐19 pandemic in the first half of 2020.

Background and purpose Improving understanding of study contents and procedures might enhance recruitment into studies and retention during follow-up. However, data in stroke patients on understanding of the informed consent (IC) procedure are sparse. Methods We conducted a cross-sectional study among ischemic stroke patients taking part in the IC procedure of an ongoing cluster-randomized secondary prevention trial. All aspects of the IC procedure were assessed in an interview using a standardized 20-item questionnaire. Responses were collected within 72 h after the IC procedure and analyzed quantitatively and qualitatively. Participants were also asked their main reasons for participation. Results A total of 146 stroke patients (65 ± 12 years old, 38% female) were enrolled. On average, patients recalled 66.4% (95% confidence interval = 65.2%–67.5%) of the content of the IC procedure. Most patients understood that participation was voluntary (99.3%) and that they had the right to withdraw consent (97.1%); 79.1% of the patients recalled the study duration and 56.1% the goal. Only 40.3% could clearly state a benefit of participation, and 28.8% knew their group allocation. Younger age, higher graduation, and allocation to the intervention group were associated with better understanding. Of all patients, 53% exclusively stated a personal and 22% an altruistic reason for participation. Conclusions Whereas understanding of patient rights was high, many patients were unable to recall other important aspects of study content and procedures. Increased attention to older and less educated patients may help to enhance understanding in this patient population. Actual recruitment and retention benefit of an improved IC procedure remains to be tested in a randomized trial.

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Background and aims At present, “severe acute respiratory syndrome new coronavirus” (SARS-CoV-2) affects the whole world and has led to a pandemia with almost 2.000.000 infected patients in the mid of April 2020 (WHO). Thus, health care specialists primarily focus on therapy of corona disease 2019 (COVID-19) and a lot of effort has been undertaken to get more manpower on intensive care units. However, the number of patients with life threatening diseases other than COVID-19 like heart attacks or strokes has not changed at all. With a strong focus on COVID-19, there is a marked risk of diagnostic and therapeutic delays or misdiagnoses, potentially harming those patients. In this respect, we present two of those cases with the intent to improve the medical management of “traditional“ diseases in times of corona pandemia. Methods We present two patients with diseases others than SARS-CoV-2. Both cases were treated in our institution, a tertiary care hospital in the Southwest of Germany. Results One patient had a prolonged treatment on intensive care unit (ICU) because of heart failure following voluntary isolation because of fearing COVID-19 and subsequent shortage of medication. Another patient with hypothesis of COVID-19 of primary care physician because of fever and a history of skiing in a high risk region for SARS-CoV-2 was sent home for isolation. After disease progression, the patient presented in an external hospital with fever, pain in the right ear and tachypnea. Immediately, antibiotics were started at same day, but nevertheless, he developed a septic shock, leading to multi organ failure. In blood samples, bacteria Streptococcus pyogenes was found, without any signs of SARS-CoV-2-infection. Despite adequate antibiosis, the patient developed fixed pupils, brain edema and died because of massive brain edema. Conclusion Focusing only on COVID-19 may lead to delayed diagnosis and therapy in patients with “traditional diseases”. These two cases impressively clarify medical challenges in times of SARS-CoV-2 pandemia. It is important to emphasize that physicians and health care professionals have not only to focus on COVID-19 and virus associated diseases, but also on adequate drug supply, intake and monitoring and differential diagnoses, respectively.

Background Comparing health care parameters of acute ischemic stroke (AIS) patients with and without concurrent coronavirus disease 2019 (Covid-19, SARS-CoV-2 infection), may be helpful in terms of optimizing clinical and public health care during pandemic. Methods We evaluated a nationwide administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke with/without diagnosis of Covid-19 who were hospitalized during the time period from January 16th to May 15th, 2020. Data from a total of 1463 hospitals in Germany were included. We compared case numbers, treatment characteristics (intravenous thrombolysis, IVT; mechanical thrombectomy, MT; treated on an intensive care unit, stroke unit or regular ward) and in-hospital mortality of AIS with and without concurrent diagnosis of Covid-19. Results From a total of 30,864 hospitalized Covid-19 patients during the evaluation period in Germany, we identified a subgroup of 213 patients with primary diagnosis of AIS. Compared to the 68,700 AIS patients without Covid-19, this subgroup showed a similar rate of IVT (16.4% vs. 16.5%, p = 0.985) but a significantly lower rate of MT (3.8% vs. 7.9%, p = 0.017). In-hospital mortality rate was significantly higher in patients with AIS and concurrent Covid-19 compared to non-infected AIS patients (22.5% vs. 7.8%, p Conclusion These nationwide data point out differences in mortality and medical treatment regime between AIS patients with and without concurrent Covid-19. Since the pandemic is still ongoing, these data draw attention to AIS as a less frequent but often fatal comorbidity in Covid-19 patients.

Background Risk diseases and risk factors for stroke include atrial fibrillation, hypertension, diabetes mellitus, smoking, and elevated LDL-cholesterol. Due to modern treatment options, the impact of these risk diseases on subsequent cardiovascular events or death after a first stroke is less clear and needs to be elucidated. We therefore aimed to get insights into the persistence of adverse prognostic effects of these risk diseases and risk factors on subsequent stroke or death events 1 year after the first stroke by using the new weighted all-cause hazard ratio. Methods This study evaluates the 1 year follow-up of 470 first ever stroke cases identified in the area of Ludwigshafen, Germany, with 23 deaths and 34 subsequent stroke events. For this purpose, the recently introduced “weighted all-cause hazard ratio” was used, which allows a weighting of the competing endpoints within a composite endpoint. Moreover, we extended this approach to allow an adjustment for covariates. Results None of these risk factors and risk diseases, most probably being treated after the first stroke, remained to be associated with a subsequent death or stroke [weighted hazard ratios (95% confidence interval) for diabetes mellitus, atrial fibrillation, high cholesterol, hypertension, and smoking are 0.4 (0.2–0.9), 0.8 (0.4–2.2), 1.3 (0.5–2.5), 1.2 (0.3–2.7), 1.6 (0.8–3.6), respectively]. However, when analyzed separately in terms of death and stroke, the risk factors and risk diseases under investigation affect the subsequent event rate to a variable degree. Conclusions Using the new weighted hazard ratio, established risk factors and risk diseases for the occurrence of a first stroke do not remain to be significant predictors for subsequent events like death or recurrent stroke. It has been demonstrated that the new weighted hazard ratio can be used for a more adequate analysis of cardiovascular risk and disease progress. The results have to be confirmed within a larger study with more events.

Zum 01.10.2018 wurden die aktualisierten Zertifizierungskriterien fur Stroke-Units (SU) in Deutschland wirksam. Aufgrund des hohen Qualitatsniveaus waren an vielen Stellen nur geringe Anpassungen und Prazisierungen notwendig, ein Grosteil der Mindestmerkmale wurde fortgeschrieben. Fur das SU-Pflegepersonal wurde erstmals ein einheitlicher Stellenschlussel von ≥1,75 Vollkraften (VK) pro Monitorbett definiert, was die Versorgungsrealitat besser abbildet. Der evidenzbasierte Prozess der akuten Gefasbildgebung mittels Computertomographie-Angiographie (CTA), alternativ Magnetresonanz-Angiographie (MRA), ist nun mit einer Mindestrate von ≥20 % aller Hirninfarkte definiert. Dadurch soll die zeitnahe Identifizierung geeigneter Kandidaten fur eine endovaskulare Thrombektomie (ET) sichergestellt werden. Die Ultraschalldiagnostik hirnversorgender Arterien bleibt dennoch integraler Bestandteil der Zusatzdiagnostik nach zerebraler Ischamie, da dies erganzende Informationen generiert. Die erweiterte Detektion von Vorhofflimmern (VHF) ist als diagnostischer Mindeststandard neu aufgenommen und erfordert Masnahmen, die uber eine einmalige Langzeit-Elektrokardiographie(EKG) hinausgehen. Um die Zertifizierung telemedizinisch versorgter SU (Tele-SU) zu fordern, wurde der Mindeststandard an Schlaganfallpatienten auf ≥200 pro Jahr abgesenkt. Tele-SU in unmittelbarem Einzugsgebiet einer zertifizierten SU (

Zusammenfassung Hintergrund In Deutschland liefern Qualitätssicherungsprojekte zahlreiche Informationen zum akuten Schlaganfall, Daten aus Nachuntersuchungen liegen hingegen kaum vor. Ziel des Nachuntersuchungsprojekts war die Erhebung von Daten zu Lebenssituation, Rezidivereignissen, Medikation und Risikofaktoreneinstellung 3 Monate nach Schlaganfall oder TIA. Material und Methoden Im zweiten Halbjahr 2012 wurden alle im Qualitätssicherungsprojekt „Akuter Schlaganfall“ in Rheinland-Pfalz erfassten Patienten zu einer Nachuntersuchung nach 90 Tagen mittels eines Fragebogens eingeladen. Ergebnisse Von 8153 Patienten nahmen 3214 (39,4 %) an der Nachuntersuchung teil (Tod im Krankenhaus: n = 370, 4,5 %; dokumentierter Tod zwischen Entlassung und Tag 90: n = 268, 3,3 %; Widerspruch im stationären Aufenthalt n = 1423, 17,5 %; keine Teilnahme n = 2878; 35,3 %). Erneute TIAs/Schlaganfälle wurden bei 5,6 % der Patienten mit ischämischen Hirninfarkten (n = 2050) und bei jeweils 5,4 % der Patienten mit TIA (n = 934) oder intrazerebraler Blutung (ICB; n = 112) diagnostiziert; 316 (10,2 %) der Patienten gaben Krankenhausaufenthalte aus nicht zerebrovaskulären Gründen an. Mindestens eine Rehabilitationsbehandlung erhielten 64,2 % der Hirninfarkt-, 19,0 % der TIA- und 75,9 % der ICB-Patienten. Hilfe im Alltag benötigten 50,3 % der Hirninfarkt- und 63,4 % der ICB-Patienten, die überwiegend von Familienangehörigen geleistet wurde. In einem Alten-/Pflegeheim untergebracht waren 8,5 % der Patienten mit ischämischem Insult und 13,4 % der ICB-Patienten. Regelmäßige Blutdruckkontrollen berichteten 74,9 % und eine zielgerechte Blutdruckeinstellung ( Diskussion Die Ergebnisse legen ein deutliches Verbesserungspotenzial bez. Therapieadhärenz, Risikofaktorkontrollen und der Vermeidung von Rezidivereignissen und Rehospitalisierungen nach Schlaganfällen nahe, wenngleich unsere Ergebnisse v. a. durch die Quote an nicht teilnehmenden Patienten limitiert sind. Unterschiede in den Ergebnisparametern zwischen den Strukturgruppen sind im Wesentlichen durch Differenzen bei demografischen Faktoren und Vorerkrankungen bedingt.

Zusammenfassung Hintergrund Demografischer Wandel, Urbanisierung sowie eine zunehmende Spezialisierung der Akutversorgung von Schlaganfallpatienten erfordern eine Anpassung von Versorgungsstrukturen mit dem Ziel, auch Patienten in ländlichen Regionen leitliniengerecht behandeln zu können. Methodik Im Frühjahr 2016 wurde ein landesweites telemedizinisches Schlaganfallnetzwerk unter Einbeziehung aller 6 überregionalen Stroke Units im Land Rheinland-Pfalz etabliert. Die Zuständigkeit für den Konsildienst wechselt täglich zwischen den Kliniken und steht rund um die Uhr zur Verfügung. Alle Kriterien des OPS 8.98b werden erfüllt. Am Netzwerk teilnehmen können alle regionalen Stroke Units und Kliniken, die prädefinierte Kriterien erfüllen und nicht in regionaler Konkurrenz mit etablierten Stroke Units stehen. Ergebnisse Zu Projektbeginn am 01.04. 2016 nahmen 6 Kliniken teil, die alle eine regionale Stroke Unit unter internistischer Leitung besitzen. Innerhalb des ersten Jahres erfolgten 1568 telemedizinische Konsile. Die Diagnosen waren ischämische Infarkte (n = 802 Patienten; 51,2 %), intrazerebrale Blutungen (n = 46; 2,9%), transitorisch ischämische Attacken (TIA; n = 319; 20,4 %) und nicht vaskuläre Ursachen (sog. Stroke Mimics; n = 400; 25,5 %). Die Latenz zwischen Klinikaufnahme und Konsilbeginn betrug im Median 21 Minuten (Interquartilrange (IQR) 22 Minuten), die mediane Konsildauer lag bei 24 Minuten (IQR 22 Minuten). Bei den Patienten mit ischämischen Schlaganfällen betrug die Lyserate 12,5 % (n = 100). Eine mechanische Thrombektomie wurde nach Weiterverlegung in eines der Zentren bei 4,6 % (n = 37) der Patienten durchgeführt. Schlussfolgerung Die telemedizinische Netzwerkbildung ist geeignet, die landesweite Versorgung von Schlaganfallpatienten sicherzustellen. Weitere Analysen, insbesondere zum Outcome, werden benötigt.

ZusammenfassungVerkürzte Liegezeiten, wachsender administrativer Aufwand, eine zunehmende Komplexität in Diagnostik und Therapie und der wirtschaftliche Druck gehen mit einer Zunahme der Arbeitsdichte für Ärzte in neurologischen Kliniken einher. Eine zu hohe Arbeitsdichte kann die Behandlungsqualität beeinträchtigen und die Ausbildung von Assistenzärzten gefährden. In der Pflege, in psychiatrischen Kliniken und im Bereich der neurologischen Rehabilitation gibt es aktuell Ansätze, Mindestpersonalstandards einzuführen. Vor diesem Hintergrund plädieren die Autoren für:– die Einführung von Personaluntergrenzen für Ärzte in neurologischen Kliniken, aber auch für andere Berufsgruppen und andere medizinische Fächer– die Entwicklung eines Personalbemessungsinstruments, mit dessen Hilfe für jede Klinik ein angemessener Personalschlüssel festgelegt werden kann– eine Verbindlichkeit der Personalstandards einschließlich einer kompletten Gegenfinanzierung – realistische Übergangsfristen angesichts des aktuellen Ärztemangels

Regional differences in acute ischemic stroke (AIS) care are still reported for Germany but not fully understood. We aimed to analyze the impact of the level of urbanization on the application of proved treatment procedures and the incidence of hospitalized AIS cases in Germany.The level of urbanization of the 401 districts and district-free cities in Germany was defined according to the Federal Institute for Building, Urban Affairs and Spatial Research classification. Using nationwide administrative data, the application of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and the incidence of hospitalizations for AIS, were analyzed according to the place of residence of the patients. Data included all patients hospitalized for AIS in 2019 (n = 224,274) and sociodemographic information of 83,019,213 residents in Germany.Sparsely populated districts had a significantly higher incidence of hospitalizations for AIS than cities (age-standardized: 271.8 versus 242.3 per 100,000 inhabitants, P 0.001), but a lower use of MT (5.7% versus 8.4%, P 0.001). In the adjusted negative binomial regression model, rurality remained an independent predictor for MT use and the incidence of AIS hospitalizations. The proportion of IVT did not significantly differ between sparsely populated districts and cities (15.6% versus 17.2%, P = 0.021).Although there is a dense network of stroke units in Germany, the level of urbanization still influences AIS care, as we found a lower proportion of MT and a higher incidence of AIS hospitalizations in Germany's rural areas.

Die amyotrophe Lateralsklerose (ALS) ist mit einer erhohten Sterblichkeit assoziiert. Das Wissen um mogliche Todesursachen konnte zu einer Individualisierung der Palliativkonzepte fuhren und damit differenzierte palliative Behandlungswege begrunden. Es liegen bisher nur wenige systematische Daten zur Heterogenitat der ALS-bedingten Todesursachen vor. Analyse der unterschiedlichen Todesursachen in einer prospektiven populationsbasierten deutschen ALS-Patienten-Kohorte Auswertung von Daten des ALS-Registers Rheinland-Pfalz, in welchem prospektiv neu diagnostizierte Patienten zwischen Oktober 2009 und September 2012 erfasst und regelmasig nachuntersucht wurden. Aus der prospektiven Kohortenstudie wurden die Todesursachen ermittelt anhand von Angaben der behandelnden Arzte, der Angehorigen und mithilfe von Todesbescheinigungen der regionalen Gesundheitsamter in Rheinland-Pfalz. Insgesamt 148 von 200 registrierten ALS-Patienten waren zwischen dem Beginn der Erfassung am 01.10.2009 bis zum Ende der Nachbeobachtungsperiode am 30.09.2015 verstorben (74 %; 78 Manner, 70 Frauen). Die haufigste Todesursache war respiratorisches Versagen infolge einer Schwache der Atemmuskulatur (n = 91; 61 %). Weniger haufige Todesursachen waren Pneumonien (n = 13; 9 %), terminale Kachexie (n = 9; 6 %) sowie kardiovaskulare Ursachen einschlieslich eines plotzlichen Todes (n = 9; 6 %). Suizide (n = 3; 2 %) und Todesfalle im Rahmen einer konkurrierenden Erkrankung (n = 2) wurden selten berichtet. In 21 Fallen blieb die Todesursache unklar (14 %). Die Todesursachen unterschieden sich in Abhangigkeit vom ALS-Phanotyp nur tendenziell. Atemversagen war bei allen Patienten mit respiratorischem Phanotyp und bei 78 % der Patienten mit Flail-arm-Syndrom die Todesursache. Trotz der geringen Anzahl von Patienten mit zusatzlicher frontotemporaler Demenz (FTD) lies sich das Muster der Todesursachen zwischen den beiden Gruppen unterscheiden. Atemversagen wurde bei Patienten mit FTD tendenziell seltener beobachtet (33 % vs. 65 %), wahrend Pneumonien haufiger waren (27 % vs. 7 %). Atemversagen infolge einer Schwache der Atemmuskulatur ist die haufigste Todesursache bei ALS-Patienten. Pneumonien und Ernahrungsstorungen als Todesursache spielen hingegen eine geringere Rolle. Die phanotypische Auspragung der ALS gibt tendenzielle Hinweise auf die spatere Todesursache des Patienten. Die Differenzierung von ALS-Verlaufsformen ist eine wichtige Grundlage fur eine gezielte Patientenberatung uber den zu erwartenden Sterbeprozess und fur die Erstellung eines individuellen Palliativkonzeptes.

Chest pain units (CPUs) and stroke units (SUs) provide specialized multidisciplinary in-hospital management for acute chest pain and ischemic stroke. We analyzed exemplary equivalent quality benchmarks in both concepts.Data from the German CPU registry (2012-2015; 45 certified CPUs, 5881 patients) were compared with data from the SU registry of Rhineland-Palatinate (2011-2015; 29 SUs; 40,380 patients). Parameters comprised demographics, symptoms, diagnosis, medication, critical time intervals, therapeutics, and in-unit outcome.Non-ST-segment elevation myocardial infarction (47.4%) and ischemic stroke (63.0%) were the most frequent entities. An electrocardiogram was performed on average within 7 min in CPUs, cranial imaging within 49 min in SUs. The mean time interval from admission until coronary intervention or lysis was 42 min or 57 min, respectively. Rates of antiplatelet therapy (90.1% vs. 96.0%), brain imaging, and coronary angiography were high (99.3% vs. 81.1%) and the mortality was low (0.8% for CPUs vs. 3.6% for SUs). The length of stay was shorter in CPUs (1.5 days vs. 4.4 days).As reimbursement for emergency medicine in Germany was recently rearranged, quality benchmarking has gained incremental importance. Mandatory joint quality measurement in both concepts ensuring gap analysis and process improvement is encouraged.HINTERGRUND: Chest Pain Units (CPU) und Stroke Units (SU) bieten eine spezialisierte, multidisziplinäre stationäre Versorgung bei akutem Brustschmerz bzw. ischämischem Schlaganfall. Die Autoren untersuchten in der vorliegenden Studie exemplarisch korrespondierende Qualitätsmarker für beide Konzepte.Daten aus dem deutschen CPU-Register (2012–2015; 45 zertifizierte CPU, 5881 Patienten) wurden mit Daten aus dem Qualitätssicherungsprojekt Schlaganfallversorgung Rheinland-Pfalz (2011–2015; 29 SU; 40.380 Patienten) verglichen. Zu den untersuchten Parametern zählten Demografie, Symptome, Diagnosen, Medikation, kritische Zeitintervalle, therapeutische Maßnahmen sowie das innerklinische Outcome.Der Nicht-ST-Strecken-Hebungs-Infarkt (47,4 %) und der ischämische Schlaganfall (63,0 %) waren die häufigsten Entitäten. Ein EKG wurde im Mittel binnen 7 min geschrieben, die zerebrale Bildgebung innerhalb von 49 min durchgeführt. Die mittlere Dauer zwischen Aufnahme und Herzkatheteruntersuchung bzw. Lysetherapie betrug 42 bzw. 57 min. Die Raten für Therapie mittels Plättchenhemmung (90,1 vs. 96,0 %), Herzkatheteruntersuchung (81,1 %) und zerebrale Bildgebung (99,3 %) waren hoch, wohingegen die Mortalität niedrig war (0,8 % in den CPU vs. 3,6 % in den SU). Die Dauer des Aufenthalts in den SU war mit 4,4 Tagen länger als in den CPU (1,5 Tage).Nicht zuletzt infolge der Neuregelung zur Vergütung in der Notfallmedizin in Deutschland gewinnt die strukturierte Qualitätskontrolle zunehmend an Bedeutung. Ein verpflichtendes, gemeinsames Benchmarking zur Lückenanalyse und Prozessoptimierung sollte forciert werden.

Interventional patent foramen ovale (PFO) closure should be performed in patients aged 16 to 60 years (after extensive neurological and cardiological diagnostic work-up) with a history of cryptogenic ischaemic stroke and patent foramen ovale, with moderate or extensive right-to-left shunt. In patients with cryptogenic ischaemic stroke and patent foramen ovale, who reject a PFO closure, there is no evidence of superiority of oral anticoagulation over antiplatelet therapy. Therefore, secondary prevention should be performed with aspirin or clopidogrel. Atrial fibrillation, pericardial tamponade, and pulmonary embolism are reported complications during and after implantation of an occluder. However, these events are so rare that they should not influence the recommendation for implantation. This article is an abridged and translated version of the guideline published in Nervenarzt: Diener, HC., für die Deutsche Gesellschaft für Neurologie (DGN), Grau, A.J. et al. Nervenarzt (2018) 89: 1143. 10.1007/s00115-018-0609-y. Electronic supplementary material The online version of this article (10.1186/s42466-019-0008-2) contains supplementary material, which is available to authorized users.

Background and Purpose— Given inconclusive studies, it is debated whether clinical and imaging characteristics, as well as functional outcome, differ among patients with intracerebral hemorrhage (ICH) related to vitamin K antagonists (VKA) versus non–vitamin K antagonist (NOAC)-related ICH. Notably, clinical characteristics according to different NOAC agents and dosages are not established. Methods— Multicenter observational cohort study integrating individual patient data of 1328 patients with oral anticoagulation–associated ICH, including 190 NOAC-related ICH patients, recruited from 2011 to 2015 at 19 tertiary centers across Germany. Imaging, clinical characteristics, and 3-months modified Rankin Scale (mRS) outcomes were compared in NOAC- versus VKA-related ICH patients. Propensity score matching was conducted to adjust for clinically relevant differences in baseline parameters. Subgroup analyses were performed regarding NOAC agent, dosing and present clinically relevant anticoagulatory activity (last intake 30 ng/mL). Results— Despite older age in NOAC patients, there were no relevant differences in clinical and hematoma characteristics between NOAC- and VKA-related ICH regarding baseline hematoma volume (median [interquartile range]: NOAC, 14.7 [5.1–42.3] mL versus VKA, 16.4 [5.8–40.6] mL; P =0.33), rate of hematoma expansion (NOAC, 49/146 [33.6%] versus VKA, 235/688 [34.2%]; P =0.89), and the proportion of patients with unfavorable outcome at 3 months (mRS, 4–6: NOAC 126/179 [70.4%] versus VKA 473/682 [69.4%]; P =0.79). Subgroup analyses revealed that NOAC patients with clinically relevant anticoagulatory effect had higher rates of intraventricular hemorrhage (n/N [%]: present 52/109 [47.7%] versus absent 9/35 [25.7%]; P =0.022) and hematoma expansion (present 35/90 [38.9%] versus absent 5/30 [16.7%]; P =0.040), whereas type of NOAC agent or different NOAC-dosing regimens did not result in relevant differences in imaging characteristics or outcome. Conclusions— If effectively anticoagulated, there are no differences in hematoma characteristics and functional outcome among patients with NOAC- or VKA-related ICH. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT03093233.

IMPORTANCE: The association of surgical hematoma evacuation with clinical outcomes in patients with cerebellar intracerebral hemorrhage (ICH) has not been established. OBJECTIVE: To determine the association of surgical hematoma evacuation with clinical outcomes in cerebellar ICH. DESIGN, SETTING, AND PARTICIPANTS: Individual participant data (IPD) meta-analysis of 4 observational ICH studies incorporating 6580 patients treated at 64 hospitals across the United States and Germany (2006-2015). EXPOSURE: Surgical hematoma evacuation vs conservative treatment. MAIN OUTCOMES AND MEASURES: The primary outcome was functional disability evaluated by the modified Rankin Scale ([mRS] score range: 0, no functional deficit to 6, death) at 3 months; favorable (mRS, 0-3) vs unfavorable (mRS, 4-6). Secondary outcomes included survival at 3 months and at 12 months. Analyses included propensity score matching and covariate adjustment, and predicted probabilities were used to identify treatment-related cutoff values for cerebellar ICH. RESULTS: Among 578 patients with cerebellar ICH, propensity score–matched groups included 152 patients with surgical hematoma evacuation vs 152 patients with conservative treatment (age, 68.9 vs 69.2 years; men, 55.9% vs 51.3%; prior anticoagulation, 60.5% vs 63.8%; and median ICH volume, 20.5 cm(3) vs 18.8 cm(3)). After adjustment, surgical hematoma evacuation vs conservative treatment was not significantly associated with likelihood of better functional disability at 3 months (30.9% vs 35.5%; adjusted odds ratio [AOR], 0.94 [95% CI, 0.81 to 1.09], P = .43; adjusted risk difference [ARD], −3.7% [95% CI, −8.7% to 1.2%]) but was significantly associated with greater probability of survival at 3 months (78.3% vs 61.2%; AOR, 1.25 [95% CI, 1.07 to 1.45], P = .005; ARD, 18.5% [95% CI, 13.8% to 23.2%]) and at 12 months (71.7% vs 57.2%; AOR, 1.21 [95% CI, 1.03 to 1.42], P = .02; ARD, 17.0% [95% CI, 11.5% to 22.6%]). A volume range of 12 to 15 cm(3) was identified; below this level, surgical hematoma evacuation was associated with lower likelihood of favorable functional outcome (volume ≤12 cm(3), 30.6% vs 62.3% [P = .003]; ARD, −34.7% [−38.8% to −30.6%]; P value for interaction, .01), and above, it was associated with greater likelihood of survival (volume ≥15 cm(3), 74.5% vs 45.1% [P

Die Bedeutung von ausreichendem und ausreichend qualifiziertem Fachpersonal bei der patientennahen Versorgung ist seit langen Jahren diskutiert worden, insbesondere als Bestandteil der Strukturqualitat des Krankenhauses. Mit der Einfuhrung der fallpauschalierten Vergutung und den damit verbundenen Kalkulationsmethoden wurde die erlosbasierte Personalbedarfsrechnung bedeutend fur die interne Bestimmung von Personalbudgets. Am Beispiel der Neurologie wird dieses verdeutlicht. Der Komplexitat der Anforderungen an eine qualitatsgestutzte Personalausstattung wird durch eine reine Erlosorientierung nicht ausreichend begegnet. Die unterschiedlichen Instrumente der Personalbedarfsberechnung werden praxisnah eingefuhrt. Auch wenn verbindliche Vorgaben sinnvoll sind, bedarf es ausreichend Flexibilitat fur betriebliche Losungen.

Introduction Periodontitis is associated with increased serum lipopolysaccharide (LPS) activity, which may be one mechanism linking periodontitis with the risk of cardiovascular diseases. As LPS-carrying proteins including lipoproteins modify LPS-activity, we investigated the determinants of serum LPS-neutralizing capacity (LPS-NC) in ischemic stroke. The association of LPS-NC and Aggregatibacter actinomycetemcomitans, a major microbial biomarker in periodontitis, was also investigated. Materials and methods The assay to measure LPS-NC was set up by spiking serum samples with E. coli LPS. The LPS-NC, LPS-binding protein (LBP), soluble CD14 (sCD14), lipoprotein profiles, apo(lipoprotein) A-I, apoB, and phospholipid transfer protein (PLTP) activity, were determined in 98 ischemic stroke patients and 100 age- and sex-matched controls. Serum and saliva immune response to A. actinomycetemcomitans, its concentration in saliva, and serotype-distribution were examined. Results LPS-NC values ranged between 51–83% in the whole population. Although several of the LPS-NC determinants differed significantly between cases and controls (PLTP, sCD14, apoA-I, HDL-cholesterol), the levels did not (p = 0.056). The main determinants of LPS-NC were i) triglycerides (β = -0.68, p

Background and aims: Matrix metalloproteinase (MMP)-8 and myeloperoxidase (MPO) may contribute to cerebral damage in acute ischemic stroke. We tested the hypothesis that levels of MPO, MMP-8 and the ratio between MMP-8 and its regulator, tissue inhibitor of metalloproteinase (TIMP-1), are increased in acute ischemic stroke and its etiologic subgroups and they correlate with stroke severity. Methods: In a cross-sectional case-control study, serum concentrations of MMP-8, MPO and TIMP-1 were assessed within 24 h after admission in 470 first-ever ischemic stroke patients and 809 age-and sex-matched controls, randomly selected from the population. Odds ratios (OR) per decade of log transformed dependent variables were calculated and adjusted for age, sex and vascular risk factors. Results: Levels of MMP-8 (OR 4.9; 95% CI 3.4-7.2), MMP-8/TIMP-1 ratio (3.0; 2.2-4.1) and MPO (6.6; 4.0-11.0) were independently associated with ischemic stroke. MMP-8 levels differed between etiologic stroke subgroups (p = 0.019, ANOVA), with higher levels in cardioembolic stroke and stroke due to large vessel disease, and lower levels in microangiopathic stroke. MMP-8, MMP-8/TIMP-1 ratio and MPO (p

Beinahe jeder zweite Patient mit kryptogenem Schlaganfall hat ein persistierendes Foramen ovale (PFO). Das Konsensuspapier stellt zuerst die aktuelle Evidenz des interventionellen PFO-Verschlusses zusammen. Im Weiteren wird das Nutzen-Risiko-Verhaltnis der antithrombozytaren Therapie mit und ohne orale Antikoagulation im Verhaltnis zum PFO-Verschluss abgewogen. Abschliesend werden konsentierte Empfehlungsgrade formuliert. Sowohl der Nutzen der interventionellen als auch das Risiko der medikamentosen Behandlung waren bisher unzureichend belegt. Mit der Veroffentlichung weiterer randomisierter kontrollierter Studien und Metaanalysen lasst sich die Abwagung der Therapieoptionen valide beurteilen. Es zeigt sich eine signifikante Reduktion in der Inzidenz von erneuten Schlaganfallen bei Patienten mit interventionellem PFO-Verschluss im Vergleich zur medikamentosen Therapie. Die Komplikationsrate des interventionellen PFO-Verschlusses ist sehr niedrig. Die vorliegenden Daten zeigen, dass der interventionelle Verschluss des PFO einer alleinigen medikamentosen Therapie bei Patienten mit kryptogenem Schlaganfall im Alter unter 60 Jahren uberlegen ist.

Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH. Methods and results We pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P

BACKGROUND AND PURPOSE: We investigated whether university education is more likely in cervical artery dissection (CeAD)-patients than in age- and sex-matched patients with ischemic stroke (IS) due to other causes (non-CeAD-IS-patients). METHODS: Patients from the Cervical Artery Dissection and Ischemic Stroke Patients study with documented self-reported profession before onset of IS due to CeAD (n = 715) or non-CeAD causes (n = 631) were analyzed. In the reported profession, the absence or presence of university education was assessed. Professions could be rated as academic or non-academic in 518 CeAD and 456 non-CeAD patients. Clinical outcome at 3 months was defined as excellent if modified Rankin Scale was 0-1. RESULTS: University education was more frequent in CeAD-patients (100 of 518, 19.3%) than in non-CeAD-IS-patients (61 of 456, 13.4%, p = 0.008). CeAD-patients with and without university education differed significantly with regard to smoking (39 vs. 57%, p = 0.001) and excellent outcome (80 vs. 66%, p = 0.004). In logistic regression analysis, university education was associated with excellent outcome in CeAD-patients (OR 2.44, 95% CI 1.37-5.38) independent of other outcome predictors such as age (OR 0.97, 95% CI 0.84-0.99), NIHSS (OR 0.80, 95% CI 0.76-0.84) and local signs (OR 2.77, 95% CI 1.37-5.57). CONCLUSION: We observed a higher rate of university education in patients with CeAD compared with non-CeAD patients in our study population. University education was associated with favorable outcome in CeAD-patients. The mechanism behind this association remains unclear.

Background Worldwide, about 1.3 million annual ischaemic strokes (IS) occur in adults aged Key hypotheses/aims (1) Investigate transient triggers and clinical/sub-clinical chronic risk factors associated with cryptogenic IS in the young; (2) use cardiac imaging methods exceeding state-of-the-art to reveal novel sources for embolism; (3) search for covert thrombosis and haemostasis abnormalities; (4) discover new disease pathways using next-generation sequencing and RNA gene expression studies; (5) determine patient prognosis by use of phenotypic and genetic data; and (6) adapt systems medicine approach to investigate complex risk-factor interactions. Design Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is a prospective multi-centre case–control study enrolling patients aged 18–49 years hospitalised due to first-ever imaging-proven IS of undetermined etiology. Patients are examined according to a standardised protocol and followed up for 10 years. Patients are 1:1 age- and sex-matched to stroke-free controls. Key study elements include centralised reading of echocardiography, electrocardiography, and neurovascular imaging, as well as blood samples for genetic, gene-expression, thrombosis and haemostasis and biomarker analysis. We aim to have 600 patient–control pairs enrolled by the end of 2018. Summary SECRETO is aiming to establish novel mechanisms and prognosis of cryptogenic IS in the young and will provide new directions for therapy development for these patients. First results are anticipated in 2019.

Objectives The clinical spectrum of amyotrophic lateral sclerosis (ALS) is characterized by a considerable variation. Different phenotypes have been described by previous studies. We assessed clinical variability and prognostic relevance of these phenotypes in a prospective, population-based cohort of ALS patients in Rhineland-Palatinate, Germany. Methods Incident ALS cases, diagnosed between October 2009 and September 2012, were prospectively enrolled and classified according to established ALS phenotype classification (bulbar, classic, flail arm, flail leg, pyramidal, respiratory). Survival probability was described using Kaplan–Meier method. Moreover, the influence of an additional frontotemporal dementia (FTD) was analysed. Results Phenotypes of all 200 patients were determined. Bulbar and classic phenotypes accounted for 75% of all cases. Deterioration of functional impairment during disease progression was lowest in flail leg and pyramidal variants, and most pronounced in bulbar and classic phenotypes. A poor survival prognosis was observed for bulbar, classic or respiratory phenotypes. Patients with an additional FTD showed an even worse outcome. Conclusions Results suggest that ALS is a heterogeneous disease, as ALS phenotypes differ in disease progression and survival time. Patients classified as suffering from bulbar, classic and respiratory ALS, as well as those with an additional FTD, show a marked reduction of survival time.

Cervical artery dissection (CeAD) is a frequent cause of stroke among young patients. It is unclear how many CeADs occur asymptomatically or cause subtle and unspecific clinical symptoms. We hypothesize that CeAD remains often unrecognized. Accordingly, the incidence of CeAD might be higher and the stroke risk lower than generally assumed. Lack of CeAD-indicating clinical symptoms is regarded as the main cause of missed diagnoses. We further hypothesize that underrepresentation of asymptomatic and oligosymptomatic patients in CeAD studies may have biased the association between ischemia and local symptoms in CeAD patients as well as the associations of CeAD with risk factors or co-morbidities. We finally hypothesize that symptomatic CeAD may be preceded by an initial asymptomatic phase. According to this final hypothesis, the time of onset of CeAD should be considered uncertain. The issue of unrecognized CeAD is relevant, as it may affect the associations between CeAD and putative risk factors. Furthermore, the existence of clinically silent CeADs may explain why recurrent and familial CeAD have been rarely observed.