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Stroke is one of the most common neurological emergencies and requires rapid detection and treatment (time is brain). There is still insufficient knowledge about stroke warning signs. It is therefore of crucial importance that trained personnel in the preclinical setting recognize the relevant warning symptoms and collect the necessary information to quickly refer the patient to the appropriate additional care structure. For this purpose, training of the emergency medical services (EMS) and the correct triage are of particular importance. The on-site assessment of a patient with a suspected stroke by EMS should include airway, breathing, vital functions, a basic neurological examination, blood glucose testing and cardiac monitoring.Patients with suspected acute ischemic stroke should be brought to the nearest hospital with a stroke unit, ideally connected with a tertiary stroke centre. From there, once the primary diagnosis has been carried out and appropriate therapy initiated, the patient can be transferred to a thrombectomy center if necessary. To improve supply times, teleradiological networking plays a major role both between clinics of different levels of care and in communication between pre- and intra-hospital care providers. Also, the use of mobile stroke units can improve preclinical stroke care and reduce delays in access to intravenous thrombolytic therapy and mechanical thrombectomy. The identification of preclinical biomarkers could also save time.

The aim of this retrospective study was to analyze the incidence of lower urinary tract infections (LUTI) and antibiotic prescriptions within 12 months after initial prescription of anti-seizure medication (ASM) between January and December 2020 (index date) and to investigate the association between a broad spectrum of ASMs and the risk of LUTI in patients with epilepsy.This retrospective cohort study included a total of 9186 adult patients (≥18 years) with an initial diagnosis of epilepsy and a prescription of an ASM treated in 1284 general practices in Germany between January 2010 and December 2020 (index date). Six frequently prescribed ASMs with at least 1000 available patients were analyzed. Patients treated with one of six ASMs were matched to each other by propensity scores based on sex, age, and secondary diagnoses. Cox regression models were used to analyze the association between the use of ASM and LUTI risk.The cumulative LUTI incidence 12 months after the start of therapy was highest in patients treated with pregabalin (16.7%), followed by valproate (11.6%) and gabapentin (10.2%). A similar trend was observed for LUTI with antibiotic prescription (9.2% pregabalin, 6.8% valproate, 6.8% gabapentin). Conditional regression analyses revealed that pregabalin therapy was significantly positively associated with LUTI (HR: 1.76; 95% CI 1.29-2.39) and LUTI-based antibiotic prescription (HR: 2.16; 95% CI 1.43-3.27). Carbamazepine was associated with a significantly lower incidence of LUTI in women (HR: 0.47; 95% CI: 0.30-0.75), but not in men. No significant associations were observed for other ASMs.The present study identifies a significant positive association between ASM and LUTI incidence and antibiotic prescriptions in patients with epilepsy treated with pregabalin, whereas a protective effect was found for carbamazepine in women only. No significant associations were observed for the four remaining ASMs.

Stroke is one of the most common neurological emergencies and requires rapid detection and treatment (time is brain). There is still insufficient knowledge about stroke warning signs. It is therefore of crucial importance that trained personnel in the preclinical setting recognize the relevant warning symptoms and collect the necessary information to quickly refer the patient to the appropriate additional care structure. For this purpose, training of the emergency medical services (EMS) and the correct triage are of particular importance. The on-site assessment of a patient with a suspected stroke by EMS should include airway, breathing, vital functions, a basic neurological examination, blood glucose testing and cardiac monitoring.Patients with suspected acute ischemic stroke should be brought to the nearest hospital with a stroke unit, ideally connected with a tertiary stroke centre. From there, once the primary diagnosis has been carried out and appropriate therapy initiated, the patient can be transferred to a thrombectomy center if necessary. To improve supply times, teleradiological networking plays a major role both between clinics of different levels of care and in communication between pre- and intra-hospital care providers. Also, the use of mobile stroke units can improve preclinical stroke care and reduce delays in access to intravenous thrombolytic therapy and mechanical thrombectomy. The identification of preclinical biomarkers could also save time.

Objectives Memory complaints in patients with epilepsy have been well-studied. Although memory complaints are commonly reported by patients with chronic epilepsy, to date, few studies exist on memory complaints at the onset of epilepsy. The present study investigated the presence of memory complaints and their relation to mood and memory performance in patients after their first seizure. Thereby, we examined differences between individuals who received a diagnosis of epilepsy immediately with the occurrence of their first seizure and those who were diagnosed as having the first epileptic seizure, without fulfilling the ILAE criteria for the diagnosis of epilepsy. Methods Sixty-one patients participated in the study and completed, among others, a memory task and questionnaires on memory complaints and depression after their first epileptic seizure. We investigated the level of memory complaints and their correlation and accuracy in classification with a memory measure. We compared patients who received an epilepsy diagnosis after the first seizure with those who did not. Results Memory complaints did not correlate with objective memory performance. Classification into impaired/unimpaired showed low concordance between memory complaints and neuropsychological memory measures. After their first epileptic seizure, patients reported few memory complaints overall (10%), and there were no differences in memory complaints between patients with and without an epilepsy diagnosis. Conclusion At epilepsy onset, in contrast to established epilepsies, memory complaints are rare. Although influences of anticonvulsant drugs and seizures are not present at the beginning of epilepsy, this substantial absence of memory complaints at epilepsy onset emphasizes the need for comprehensive neurological and psychological treatment early with the given diagnosis. Treatment should focus on anticonvulsant drug regimens, patients’ concerns and convey realistic expectations.

Summary Objectives The aim of the present study was to evaluate the safety and efficacy of the add-on treatment of stiripentol (STP) in adult patients with severely pharmacoresistant focal or multifocal epilepsy. Methods Data on adult patients treated with STP from March 2007 to July 2020 and with at least one clinical follow-up (FU) were retrospectively reviewed. Data on tolerability, efficacy and concomitant medication were evaluated at baseline, 6 months (5.5 ± 1.6 months (mean ± SD)) and 12 months (13.1 ± 3.9 months (mean ± SD)). Results Data of 22 patients (54.5% male, mean age 34.4 ± 17.79 years (mean ± SD), including mean duration of epilepsy 17.6 ± 25.5 years (mean ± SD), median seizure frequency 30 ± 20 (median ± MAD) per month, and 63.6% being severely intellectually disabled, with 3 to 18 previous anti-seizure-drugs (ASD), were collected. After 6 months, 72.7% of the patients were still taking STP, and 31% of the patients were responders, including 13% who were seizure-free. The 12-month retention rate was 54.4 %, the response rate was 36.4% and 13.6% of patients were seizure-free at the 12-month FU. Reasons for discontinuation were increased seizure frequency, hyperammonaemia and encephalopathy. Conclusion STP seems to be a useful option in the treatment of patients with severely pharmacoresistant epilepsy. Prospective trials are necessary to examine the efficacy of STP in adult patients with pharmacoresistant focal epilepsy.

Pasteurella multocida can cause serious soft tissue infections and, less commonly, septic arthritis, osteomyelitis, and sepsis especially in immunocompromised hosts. P. multocida can cause meningitis or meningoencephalitis, occasionally with the formation of abscesses, but is rarely the cause of other neurological diseases. Miller Fisher Syndrome (MFS) is a parainfectious autoimmune disorder presenting with ophthalmoplegia, ataxia and areflexia.We present the case of a 59-year-old immunocompetent patient who developed an atypical Miller Fisher/ Guillain-Barré-overlap-syndrome associated with a phlegmon caused by P. multocida, an associated bacteremia and sepsis leading to long intensive care treatment. Initial differential diagnosis was wound botulism. Patient was treated by antibiotics, wound cleansing with VAC pump and intravenous immunoglobulins.With this case we were able to show that a P. multocida infection can trigger atypical Miller Fisher/ Guillain-Barré-overlap-syndrome and that this is an important differential diagnosis of wound botulism.

Most patients who die from sudden unexpected death in epilepsy (SUDEP) are found in the prone position. We evaluated whether changes in body position occur during generalized convulsive seizures (GCSs).GCSs in patients undergoing video-EEG-monitoring between 2007 and 2017 at epilepsy centers in Frankfurt and Marburg were analyzed in relation to changes in body position.A total of 494 GCSs were analyzed among 327 patients. At seizure onset, positions included supine (48.2 %), right lateral (19.0 %), left lateral (15.6 %), sitting or standing (14.0 %), and prone (3.2 %). Between seizure onset and the start of generalization, 57.5 % of participants altered body positions. During four seizures, patients adopted a prone position, while, in five seizures, patients moved from a prone position. Patients who experienced GCS onset while in a nonprone position had a 2.1 % risk of entering the prone position by the end of their seizure. In contrast, 56.2 % of those in an initial prone position remained so at the end of the GCS, with an odds ratio for maintaining that position of 60.2 (95 % confidence interval: 29.1-124.3; p0.001). The likelihood of ending up in the prone position post-GCS did not vary among patients with different nonprone starting positions (p = 0.147).Seizures in prone position occur during sleep and the highest risk for postictal prone positioning appears to be being in the prone position at GCS onset. Epilepsy patients should therefore be advised to go to sleep in a supine or lateral position to reduce their SUDEP risk.

Multiple-choice questions (MCQs) provide useful information about correct and incorrect answers, but they do not offer information about students' confidence.Ninety and another 81 medical students participated each in a curricular neurology multiple-choice exam and indicated their confidence for every single MCQ. Each MCQ had a defined level of potential clinical impact on patient safety (uncritical, risky, harmful). Our first objective was to detect informed (IF), guessed (GU), misinformed (MI), and uninformed (UI) answers. Further, we evaluated whether there were significant differences for confidence at correct and incorrect answers. Then, we explored if clinical impact had a significant influence on students' confidence.There were 1818 IF, 635 GU, 71 MI, and 176 UI answers in exam I and 1453 IF, 613 GU, 92 MI, and 191 UI answers in exam II. Students' confidence was significantly higher for correct than for incorrect answers at both exams (p 0.001). For exam I, students' confidence was significantly higher for incorrect harmful than for incorrect risky classified MCQs (p = 0.01). At exam II, students' confidence was significantly higher for incorrect harmful than for incorrect benign (p 0.01) and significantly higher for correct benign than for correct harmful categorized MCQs (p = 0.01).We were pleased to see that there were more informed than guessed, more uninformed than misinformed answers and higher students' confidence for correct than for incorrect answers. Our expectation that students state higher confidence in correct and harmful and lower confidence in incorrect and harmful MCQs could not be confirmed.

Background: Several morphometric magnetic resonance imaging parameters may serve for differential diagnosis of parkinsonism. The objective of this study was to identify which performs best in clinical routine. Methods: We acquired multicentric magnetization-prepared rapid gradient echo sequences in patients with Parkinson's disease (n=204), progressive supranuclear palsy (n=106), multiple system atrophy-cerebellar, (n = 21); multiple system atrophy-parkinsonian (n = 60), and healthy controls (n = 73), performed manual planimetric measurements, and calculated receiver operator characteristics with leave-one-out cross-validation to propose cutoff values. Results: The midsagittal midbrain area was reduced in PSP versus all other groups (P

Purpose Epilepsy surgery is an evidence-based treatment for drug-refractory focal epilepsy. We aimed to evaluate how well preoperative outcome estimates of epilepsy surgery in clinical practice correlated with postoperative outcome and to compare prediction by the clinical team with available scores (m-SFS, ESN). Method Retrospective cohort study including patients with drug-refractory focal epilepsy who underwent resective epilepsy surgery at Epilepsy Center Hessen, Marburg, between 1998-2016. Patients were categorized into four groups based on their estimated chance of postoperative seizure freedom documented in preoperative medical records. Variables required for calculation of m-SFS and ESN were also extracted from presurgical medical records. Seizure outcome using Engel/ILAE classifications was extracted from postoperative medical records. Results 148 patients were included and 98 had follow-up at 5 years. 69 (70%) had Engel I and 50 (51%) ILAE 1 outcome. Observed 5-year outcome for very good candidates was 20/22 (91%) Engel I and 14/22 (64%) ILAE 1, for good candidates 29/40 (73%) Engel I and 21/40 (53%) ILAE 1, for candidates with slightly reduced chance 11/18 (61%) Engel I and 9/18 (50%) ILAE 1 and for candidates with considerably reduced chance 1/5 (20%) Engel I and 1/5 (20%) ILAE 1.There were no significant differences in discrimination or overall performance between predictions by the clinical team, ESN and m-SFS. Conclusions Preoperative outcome estimates corresponded well with observed outcome indicating adequate patient counseling.

Background Clinical differentiation of parkinsonian syndromes is still challenging. Objectives A fully automated method for quantitative MRI analysis using atlas-based volumetry combined with support vector machine classification was evaluated for differentiation of parkinsonian syndromes in a multicenter study. Methods Atlas-based volumetry was performed on MRI data of healthy controls (n = 73) and patients with PD (204), PSP with Richardson's syndrome phenotype (106), MSA of the cerebellar type (21), and MSA of the Parkinsonian type (60), acquired on different scanners. Volumetric results were used as input for support vector machine classification of single subjects with leave-one-out cross-validation. Results The largest atrophy compared to controls was found for PSP with Richardson's syndrome phenotype patients in midbrain (−15%), midsagittal midbrain tegmentum plane (−20%), and superior cerebellar peduncles (−13%), for MSA of the cerebellar type in pons (−33%), cerebellum (−23%), and middle cerebellar peduncles (−36%), and for MSA of the parkinsonian type in the putamen (−23%). The majority of binary support vector machine classifications between the groups resulted in balanced accuracies of >80%. With MSA of the cerebellar and parkinsonian type combined in one group, support vector machine classification of PD, PSP and MSA achieved sensitivities of 79% to 87% and specificities of 87% to 96%. Extraction of weighting factors confirmed that midbrain, basal ganglia, and cerebellar peduncles had the largest relevance for classification. Conclusions Brain volumetry combined with support vector machine classification allowed for reliable automated differentiation of parkinsonian syndromes on single-patient level even for MRI acquired on different scanners. © 2016 International Parkinson and Movement Disorder Society

The Flynn effect describes an increase in intelligence quotient (IQ) in the general population of about 3 points per decade. While this effect is well established in healthy individuals, research exploring the link to brain pathologies is scarce. We investigated the Flynn effect in a German sample of 203 patients with epilepsy with left, right, and bilateral lesions. Intelligence quotient values were obtained using the Wechsler Adult Intelligence Scales (WAIS) III and IV. Our results showed a stable Flynn effect with nearly no difference in adjusted full scale IQ (FSIQ) scores (0.02 IQ points) between the WAIS-III and WAIS-IV samples. There were no significant interactions between the side of pathology and corrected IQ values. Our sample showed a tendency towards performing worse in the WAIS-IV in three out of four subscales independently of the Flynn effect, pointing out methodological differences between the newer Wechsler editions. However, although patients with bilateral lesions performed worst across all subscales, they exhibited a similar pattern as patients with lesions in the left or right hemisphere, indicating that also more severe forms of brain pathologies can profit from the mechanisms behind the Flynn effect.

Objectives To assess first clinical experiences with brivaracetam (BRV) in the treatment of epilepsies. Methods Data on patients treated with BRV from February to December 2016 and with at least one clinical follow-up were collected from electronic patient records. Data on safety and efficacy were evaluated retrospectively. Results In total, 93 patients were analyzed; 12 (12.9%) received BRV in monotherapy. The mean duration to follow-up was 4.85 months (MD = 4 months; SD = 3.63). Fifty-seven patients had more than one seizure per month at baseline and had a follow-up of more than 4 weeks; the rate of ≥50% responders was 35.1% (n = 20) in this group, of which five (8.8%) patients were newly seizure-free. In 50.5% (47/93), patients were switched from levetiracetam (LEV) to BRV, of which 43 (46.2%) were switched immediately. Adverse events (AE) occurred in 39.8%, with 22.6% experiencing behavioral and 25.8% experiencing non-behavioral AE. LEV-related AE (LEV-AE) were significantly reduced by switching to BRV. The discontinuation of BRV was reported in 26/93 patients (28%); 10 of those were switched back to LEV with an observed reduction of AE in 70%. For clinical reasons, 12 patients received BRV in monotherapy, 75% were seizure–free, and previous LEV-AE improved in 6/9 patients. BRV-related AE occurred in 5/12 cases, and five patients discontinued BRV. Conclusion BRV seems to be a safe, easy, and effective option in the treatment of patients with epilepsy, especially in the treatment of patients who have psychiatric comorbidities and might not be good candidates for LEV treatment. BRV broadens the therapeutic spectrum and facilitates personalized treatment.

Several morphometric magnetic resonance imaging parameters may serve for differential diagnosis of parkinsonism. The objective of this study was to identify which performs best in clinical routine.We acquired multicentric magnetization-prepared rapid gradient echo sequences in patients with Parkinson's disease (n=204), progressive supranuclear palsy (n=106), multiple system atrophy-cerebellar, (n = 21); multiple system atrophy-parkinsonian (n = 60), and healthy controls (n = 73), performed manual planimetric measurements, and calculated receiver operator characteristics with leave-one-out cross-validation to propose cutoff values.The midsagittal midbrain area was reduced in PSP versus all other groups (P 0.001). The midsagittal pons area was reduced in MSA-cerebellar, MSA-parkinsonian, and PSP versus PD patients and healthy controls (P 0.001). The midbrain/pons area ratio was lower in PSP (P 0.001) and higher in MSA-cerebellar and MSA-parkinsonian versus PD and PSP (P 0.001).The midsagittal midbrain area most reliably identified PSP, the midsagittal pons area MSA-cerebellar. The midbrain/pons area ratio differentiated MSA-cerebellar and PSP better than the magnetic resonance-Parkinson index. © 2017 International Parkinson and Movement Disorder Society.