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Background: Irrespective of the great impact stroke exerts on the society as a whole and far-reaching advances in acute treatment and rehabilitation of stroke, so far outpatient services for post-stroke care have not been established on a national level in Germany., Objective and Methods: Against the background of this contemporary lack of care, in May 2020 the German Stroke Society (DSG) established the stroke aftercare commission. This position paper discusses structural models of future services addressing outpatient post-stroke care., Results and Discussion: The specialized care by a neurologist should be central to a multidisciplinary, interprofessional and transsectoral treatment. Structural concepts of post-stroke care must take regional differences but also effective strategies for quality control into account. Certification processes and appropriate financing of follow-up registries at state and federal levels may pave the way for improvement over the medium term. Structured outpatient post-stroke care services should be open to all subgroups of stroke patients. Additionally, innovative technologies can make an important contribution to post-stroke care; however, the implementation of specialized services demands adequate funding as well as separate financial incentives for the providers. The solution must carefully balance the advantages and disadvantages of the specific care and financing models. Currently the discussion of new models of post-stroke care is gaining new momentum, which opens up perspectives for the advancement of the otherwise still insufficient contemporary care structures., (© 2021. The Author(s).)

Long-term management after stroke has not been standardized in contrast to acute and rehabilitative stroke care. The fragmented outpatient sector of healthcare allows a high degree of flexibility but also variability in the quality of care provided. The commission on long-term stroke care of the German Stroke Society developed a concept on how to provide standardized multiprofessional long-term stroke care with a focus on patient-centered comprehensive care. We propose a diagnostic work-up in stages, with an initial patient-reported screening, followed by an adapted in-depth assessment of affected domains. This includes internistic domains (management of risk factors) and also genuine neurological domains (spasticity, cognitive deficits etc.) that must be considered. This information is then merged with patient expectations and prioritization to a standardized treatment plan. Special challenges for the implementation of such a comprehensive care system are the intersectoral and intrasectoral communication between healthcare providers, patients and relatives, the need to create a compensation system for providers and the establishment of appropriate quality management services. Digital health applications are helpful tools to provide aspects of diagnostics, treatment and communication in long-term stroke care., (© 2021. The Author(s).)

The acute treatment of stroke patients in Germany is of a very high standard, guaranteed by its system of stroke units. Stroke as a disease has an acute phase followed by a chronic phase that requires a high level of qualified aftercare given by multidisciplinary and interdisciplinary teams. In 2020, the German Stroke Society (DSG) founded a commission for long-term stroke care. The aim is to evaluate the current situation of long-term aftercare and suggest improvements for its structure. In this paper the status quo of aftercare is presented and possible deficits are identified. Contributions of various stakeholders from the German healthcare system are analyzed and different projects for post-acute care are presented. Germany has no acknowledged structured aftercare concepts for patients after stroke. The general practitioner-based care is currently the focus of patient management but without a greater, more coordinated integration of neurologists, guideline-led and quality-controlled aftercare will be harder to implement in the future. The assignment of duties and the necessary training standards for the specialist groups in order to comply with the guidelines do not exist. Besides medical health, the needs of physical, social and emotional domains are too seldom considered by a multiprofessional care team. Further developments of a regional care management concept are discussed. The results and costs of any aftercare concepts must be evaluated before widespread implementation., (© 2021. The Author(s).)

Background: Stroke and mortality rates in patients with transient ischemic attack (TIA) differ widely between community-based studies and research cohorts. Our aim therefore was to provide a reliable estimate for TIA patients treated in German neurology departments with an acute stroke unit., Methods: A total of 1951 consecutively admitted TIA patients were prospectively documented in 13 centers and 1480 (75.9%) gave consent for long-term follow-up. During a mean follow-up of 23.4 months, we assessed recurrent cerebrovascular events and cause of death in 1448 patients via standardized telephone interview including confirmation of endpoint events by the treating physician., Results: Overall 94 patients (6.5%) suffered a stroke and 118 patients (8.1%) died, 21 due to stroke. The Kaplan-Meier estimate for stroke during the first year was 4.4% (95% CI 3.2-5.6%) which corresponds to a relative risk of 9.5 (95% CI 7.4-12.3) compared to the population-based stroke incidence in Germany. The annual rates after the first year were 2.2% (95% CI 1.7-2.7%) for stroke and 3.2% (95% CI 2.7-3.8%) for death. Independent predictors for stroke during follow-up were age and previous cerebrovascular events. The ABCD(2) score did not provide any meaningful prediction of stroke risk at 90 days., Conclusion: While the in-hospital risk of stroke was low, long-term stroke rates in our well-defined multicenter hospital-based cohort were comparable to a large randomized trial. In patients with a well-established diagnosis of TIA, only age and previous cerebrovascular events seem to constitute independent predictors for stroke during long-term follow-up.

The possible predictive value of regional cerebral perfusion patterns with respect to the response to partial sleep deprivation (PSD) was evaluated in 15 major depressive patients (mean age = 54.9 years, mean Hamilton depression score = 21.6). Patients were studied with single photon emission computed tomography with technetium-99 m-D,L-hexamethyl-propylene amine oxime. Scans were performed on the morning before and after (at 08.00 h) PSD. Responders to PSD had significantly higher perfusion in the right orbitofrontal cortex than did non-responders before PSD. Multiple regression analysis indicated that right orbitofrontal/basal cingulate perfusion (r = -0.77, P < 0.001) before PSD, and left inferior temporal perfusion (r = 0.59, P = 0.01) after PSD, were fairly accurate predictors of change in Hamilton depression scores. Thus, it appears that the orbitofrontal cortex and the cingulate are involved in PSD and may serve as predictors of therapeutic response.

Seventeen patients who had been dependent on benzodiazepines for more than 0.5 years were subjected to abrupt withdrawal with carbamazepine (CBZ, 400 mg twice a day). Most patients were had been taking benzodiazepines because of panic disorder or neurosis. In 2 cases the patients were regarded as having high dose dependency. In 2 others withdrawal was discontinued because of loss of motivation or medical problems (HIV infection). During the withdrawal the patients were rated daily for anxiety, mood alterations, perception disturbances, neurological symptoms, and vegetative signs. Perception disturbances were noted in 14 patients. Most patients showed sleep disturbances, mood alterations or anxiety. Epileptic seizures, a well known complication of benzodiazepine withdrawal, did not occur. The CBZ treatment was well tolerated by all patients and caused no severe problems. Compared with a gradual tapering off of benzodiazepines, abrupt withdrawal plus CBZ medication seems to be better tolerated; in particular, the period of hospitalization for these patients can be shorter. Because anxiety, the reason for the benzodiazepine treatment in many cases, often recurs, the patients must be offered continuous after-care to prevent a new dependence.

The extent of psychic and physical disturbances of patients admitted to the Center of Psychiatry in Frankfurt/M. because of organic psychosyndromes in the year 1988 was analysed. Especially the results of the hospital treatment and the proceeding mode of caretaking were examined. Usually an unspecific state of confusion was the main reason for admittance of most of the patients (n = 59). The majority of the patients suffered from a mid-ranged to marked state of dementia. The results of the treatment for these patients was highly significantly worse compared to patients admitted with a psychosis or a depressive syndrome. A non-significant statistical correlation was found for the results of the medical treatment and medical diseases. Concerning the treatment with psychic drugs a pragmatistic order was used. Analysing the results no advantage of a treatment with up to 4 different drugs compared to a monotherapy could be found. Patients who were not treated with psychic active substances tended to have a poorer outcome. At the end of the stay in the hospital 25.4% of patients were classified with a good outcome after treatment, 49.2% had a slight degree of recovery.

All patients admitted to the Frankfurt Psychiatric Clinic suffering from organic psycho-syndromes were studied in a transversal survey. It was intended to evaluate the importance of clinical treatment within the psychiatric care system of a major city including various aspects of the diseases, psychosociological determinants and the continuation of service for these patients following clinical treatment. For the transversal survey a questionnaire was developed to record the psychopathological syndrome on admission, the order to referring patients to the clinic, outcome of treatment and service following clinical care. Patients suffering from organic psycho-syndromes represent a small quota of 4.2% according to the total admission rate. Within the group of elderly patients over 65 years of age it is remarkable that more cases with an affective psychosis were admitted than with organic psycho-syndromes. This small group of patients is in regard to interdisciplinary diagnostical and therapeutical proposals according to a high rate of multiple morbidity of distinct importance. The results of the presented study indicate the necessity to intensify the efforts of cooperation of psychiatric clinic, nursing homes and ambulatory care services for elderly patients with organic psycho-syndromes.

A moderately severe spasticity affecting all four limbs, but especially the legs and the right side, developed in a 36-year-old man with mucopolysaccharidosis II (Hunter syndrome) who for 6 months had suffered from pain in the neck radiating into the shoulder. Myelography, computed tomography and magnetic resonance imaging revealed thickening of the cervical meninges as the cause of the symptoms. A laminectomy was performed and the foramen magnum enlarged by an occipital craniotomy. At operation dorsal thickening of the dura was evident; thickened tissue was also palpable in front of the dural sac. Histological examination of a tissue sample revealed deposition of acid mucopolysaccharides. The gait of the patient was improved after the operation and the neck pain disappeared. Similar findings were present in other family members.