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Zusammenfassung Hintergrund Um die Schlaganfallversorgung zu optimieren, wurden in Deutschland in den letzten Jahren verschiedene qualitätsfördernde Maßnahmen (qfM) in regional unterschiedlichem Maß eingeführt. Ob sich diese Maßnahmen über die Jahre flächendeckend etabliert haben, ist unklar. Methode Für die strukturbezogenen Analysen der Schlaganfallversorgung in Deutschland wurden alle relevanten dokumentierten Schlaganfälle (ICD-10) aus den Qualitätsberichten (QB) deutscher Krankenhäuser und eine repräsentative Stichprobe von Krankenversicherungsdaten (AOK) im Zeitraum von 2006 (QB)/2007 (AOK) bis 2017 verwendet. Diese Informationen wurden u. a. durch Angaben zu zertifizierten Stroke Units der Deutschen Schlaganfall-Gesellschaft (DSG) und Daten zur Führung von regionalen Schlaganfall-Registern der Arbeitsgemeinschaft Deutschsprachiger Schlaganfall-Register (ADSR) ergänzt. Zur Verfolgung der Veränderungen des Versor-gungsgeschehens im deutschen Bundesgebiet wurden die Daten mit geografischen Daten (Bundesamt für Kartographie und Geodäsie) verknüpft. Es erfolgten univariate Analysen der Daten und eine Trend-Analyse der verschiedenen qfM im Jahresverlauf (Konkordanzkoeffizient nach Kendall). Ergebnisse Die QB Analysen zeigten einen Anstieg kodierter Schlaganfälle in Krankenhäusern mit qfM um 14–20%. In 2006 wurden 80% der Schlaganfälle (QB) in einem Krankenhaus mit min. einer qfM kodiert, in 2017 95%. Diese Entwicklungen spiegelten sich auch in den AOK-Routinedaten wider, wobei in 2007 89% und in 2017 97% der Patient:innen unter mindestens einer qfM behandelt wurden. Dabei waren in 2007 bei 55% der behandelnden Krankenhäuser qfM vorhanden, in 2017 bei 72%. Schlussfolgerung Patient:innen werden inzwischen signifikant häufiger in Krankenhäusern mit Spezialisierung auf die Schlaganfallversorgung behandelt. Auch die verschiedenen qfM haben sich im Laufe der Jahre im gesamten Bundesgebet verbreitet, jedoch existieren noch Versorgungslücken, die geschlossen werden sollten, damit in Zukunft alle Patient:innen qualitativ hochwertig behandelt werden können.

In the last decade, ultrasound examination in neurology has been undergoing a significant expansion of its modalities. In parallel, there is an increasing demand for rapid and high-quality diagnostics in various acute diseases in the prehospital setting, the emergency room, intensive care unit, and during surgical or interventional procedures. Due to the growing need for rapid answers to clinical questions, there is particular demand for diagnostic ultrasound imaging. The Neuro-POCUS working group, a joint project by the European Academy of Neurology Scientific Panel Neurosonology, the European Society of Neurosonology and Cerebral Hemodynamics, and the European Reference Centers in Neurosonology (EAN SPN/ESNCH/ERcNsono Neuro-POCUS working group), was given the task of creating a concept for point-of-care ultrasound in neurology called "Neuro-POCUS". We introduce here a new ultrasound examination concept called point-of-care ultrasound in neurology (Neuro-POCUS) designed to streamline conclusive imaging outside of the ultrasound center, directly at the bedside. The aim of this study is to encourage neurologists to add quick and disease-oriented Neuro-POCUS to accompany the patient in the critical phase as an adjunct not a substitution for computed tomography, magnetic resonance imaging, or standard comprehensive neurosonology examination. Another goal is to avoid unwanted complications during imaging-free periods, ultimately resulting in advantages for the patient.Im letzten Jahrzehnt hat die Ultraschalldiagnostik in der Neurologie eine deutliche Ausweitung ihrer Modalitäten erfahren. Parallel dazu steigt der Bedarf an schneller und qualitativ hochwertiger Diagnostik bei verschiedenen akuten Erkrankungen sowohl im prähospitalen Umfeld, in der Notaufnahme, auf der Intensivstation und bei chirurgischen oder interventionellen Eingriffen. Die Neuro-POCUS Working Group, eine gemeinsame Aktivität des European Academy of Neurology Scientific Panel Neurosolonogy, der European Society of Neurosonology and Cerebral Hemodynamics und der European Reference Centers in Neurosonology (EAN SPN/ESNCH/ERcNsono Neuro-POCUS Working Group) hat sich zum Ziel gesetzt, ein Konzept des Point-of-Care-Ultraschalls in der Neurologie mit dem Namen „Neuro-POCUS“ zu erstellen. Die bildgebende Diagnostik wird durch den wachsenden Bedarf an schnellen Antworten auf klinische Fragen besonders herausgefordert. Wir stellen hier ein neues Konzept der Ultraschalluntersuchung vor, den sogenannten Point-of-Care-Ultraschall in der Neurologie (Neuro-POCUS), der eine aussagekräftige Diagnostik fernab des Ultraschalllabors direkt am Krankenbett ermöglichen soll. Ziel dieser Arbeit ist es, Neurologen zu ermutigen, den Patienten in der kritischen Phase mit einem schnellen und krankheitsorientierten Neuro-POCUS zu begleiten und nicht als Ersatz für die Computertomographie, die Magnetresonanztomographie oder die umfassende neurosonologische Standarduntersuchung zu dienen. Ein weiteres Ziel besteht darin, unerwünschte Komplikationen innerhalb bildgebungsfreier Zeiträume zu vermeiden und das outcome des Patienten Vorteile zu verbessern.

Background older patients are less frequently treated in stroke units (SUs). Clinicians do not seem convinced that older patients benefit from specialised treatment in SU similarly to younger patients. Objective our study aimed to compare older patients’ long-term outcomes with and without SU treatment. Methods this study used routinely collected health data of 232,447 patients admitted to hospitals in Germany between 2007 and 2017 who were diagnosed with ischaemic stroke (ICD 10 I63). The sample included 29,885 patients aged ≥90 years. The outcomes analysed were 10-, 30- and 90-day, and 1-, 3- and 5-year mortality and the combinations of death or recurrence, inpatient treatment and increase in long-term care needs. Bivariate chi-square tests and multivariable logistic regression analyses were used, adjusting for the covariates age, sex, co-morbidity, long-term care needs before stroke and socioeconomic status of the patients’ region of origin. Results between 2007 and 2017, 57.1% of patients aged Conclusions even very old patients with stroke benefit from SU treatment in the short and long term. Therefore, SU treatment should be the norm even in older patients.

Multiple sclerosis (MS) is the most common immune-mediated CNS disease, characterised by demyelination and progressive neurological disability. The B-cell activating factor BAFF has been described as one important factor in the pathophysiology of different autoimmune diseases.We measured BAFF levels in the serum and cerebrospinal fluid (CSF) in 50 consecutive patients with MS and 35 patients with infectious CNS disease (ID). 52 patients with other, non-inflammatory disorders (OND), served as controls.BAFF-serum levels in ID patients were higher than in patients diagnosed with MS (ID 0.55 ± 0.24 ng/ml, MS 0.43 ± 0.14 ng/ml, OND 0.45 ± 0.24 ng/ml;The ID patients' having higher absolute BAFF levels in the CSF than in the serum indicates that the increased BAFF CSF levels were caused by intrathecal synthesis rather than passive transfer

The National Institutes of Health Stroke Scale (NIHSS) score is the most frequently used score worldwide for assessing the clinical severity of a stroke. Prior research suggested an association between acute symptomatic seizures after stroke and poorer outcome. We determined the frequency of acute seizures after ischemic stroke in a large population-based registry in a central European region between 2004 and 2016 and identified risk factors for acute seizures in univariate and multivariate analyses. Additionally, we determined the influence of seizures on morbidity and mortality in a matched case–control design. Our analysis of 135,117 cases demonstrated a seizure frequency of 1.3%. Seizure risk was 0.6% with an NIHSS score at admission 31 score points. Seizure risk was significantly higher in the presence of acute non-neurological infections (odds ratio: 3.4; 95% confidence interval: 2.8–4.1). A lower premorbid functional level also significantly increased seizure risk (OR: 1.7; 95%CI: 1.4–2.0). Mortality in patients with acute symptomatic seizures was almost doubled when compared to controls matched for age, gender, and stroke severity. Acute symptomatic seizures increase morbidity and mortality in ischemic stroke. Their odds increase with a higher NIHSS score at admission.

Objective This study was designed to investigate the indirect neuroprotective properties of recombinant human erythropoietin (rhEPO) pretreatment in a rat model of transient middle cerebral artery occlusion (MCAO). Methods One hundred and ten male Wistar rats were randomly assigned to four groups receiving either 5,000 IU/kg rhEPO intravenously or saline 15 minutes prior to MCAO and bilateral craniectomy or sham craniectomy. Bilateral craniectomy aimed at elimination of the space-consuming effect of postischemic edema. Diagnostic workup included neurological examination, assessment of infarct size and cerebral edema by magnetic resonance imaging, wet–dry technique, and quantification of hemispheric and local cerebral blood flow (CBF) by flat-panel volumetric computed tomography. Results In the absence of craniectomy, EPO pretreatment led to a significant reduction in infarct volume (34.83 ± 9.84% vs. 25.28 ± 7.03%; p = 0.022) and midline shift (0.114 ± 0.023 cm vs. 0.083 ± 0.027 cm; p = 0.013). We observed a significant increase in regional CBF in cortical areas of the ischemic infarct (72.29 ± 24.00% vs. 105.53 ± 33.10%; p = 0.043) but not the whole hemispheres. Infarct size-independent parameters could not demonstrate a statistically significant reduction in cerebral edema with EPO treatment. Conclusions Single-dose pretreatment with rhEPO 5,000 IU/kg significantly reduces ischemic lesion volume and increases local CBF in penumbral areas of ischemia 24 h after transient MCAO in rats. Data suggest indirect neuroprotection from edema and the resultant pressure-reducing and blood flow-increasing effects mediated by EPO.

Um die Schlaganfallversorgung zu optimieren, wurden in Deutschland in den letzten Jahren verschiedene qualitätsfördernde Maßnahmen (qfM) in regional unterschiedlichem Maß eingeführt. Ob sich diese Maßnahmen über die Jahre flächendeckend etabliert haben, ist unklar.Für die strukturbezogenen Analysen der Schlaganfallversorgung in Deutschland wurden alle relevanten dokumentierten Schlaganfälle (ICD-10) aus den Qualitätsberichten (QB) deutscher Krankenhäuser und eine repräsentative Stichprobe von Krankenversicherungsdaten (AOK) im Zeitraum von 2006 (QB)/2007 (AOK) bis 2017 verwendet. Diese Informationen wurden u. a. durch Angaben zu zertifizierten Stroke Units der Deutschen Schlaganfall-Gesellschaft (DSG) und Daten zur Führung von regionalen Schlaganfall-Registern der Arbeitsgemeinschaft Deutschsprachiger Schlaganfall-Register (ADSR) ergänzt. Zur Verfolgung der Veränderungen des Versor-gungsgeschehens im deutschen Bundesgebiet wurden die Daten mit geografischen Daten (Bundesamt für Kartographie und Geodäsie) verknüpft. Es erfolgten univariate Analysen der Daten und eine Trend-Analyse der verschiedenen qfM im Jahresverlauf (Konkordanzkoeffizient nach Kendall).Die QB Analysen zeigten einen Anstieg kodierter Schlaganfälle in Krankenhäusern mit qfM um 14-20%. In 2006 wurden 80% der Schlaganfälle (QB) in einem Krankenhaus mit min. einer qfM kodiert, in 2017 95%. Diese Entwicklungen spiegelten sich auch in den AOK-Routinedaten wider, wobei in 2007 89% und in 2017 97% der Patient:innen unter mindestens einer qfM behandelt wurden. Dabei waren in 2007 bei 55% der behandelnden Krankenhäuser qfM vorhanden, in 2017 bei 72%.Patient:innen werden inzwischen signifikant häufiger in Krankenhäusern mit Spezialisierung auf die Schlaganfallversorgung behandelt. Auch die verschiedenen qfM haben sich im Laufe der Jahre im gesamten Bundesgebet verbreitet, jedoch existieren noch Versorgungslücken, die geschlossen werden sollten, damit in Zukunft alle Patient:innen qualitativ hochwertig behandelt werden können.In order to optimize stroke care, various quality-enhancing measures (qfM) have been introduced in Germany in recent years to varying degrees across regions, with the aim of achieving the best possible quality of care. It is unclear whether these measures have become established nationwide over the years.For the structural analyses of stroke care in Germany, all relevant documented strokes (ICD-10) from the quality reports (QB) of German hospitals and a representative sample of health insurance data (AOK) for the period from 2006 (QB)/2007 (AOK) to 2017 were used. This information was supplemented by data on certified stroke units from the German Stroke Society (DSG) and data on the maintenance of regional stroke registries from the Working Group of German-Speaking Stroke Registers (ADSR), among others. To track changes in patterns of care in Germany, the data were linked with geographic data (Federal Agency for Cartography and Geodesy). Univariate analyses of the data and a trend analysis of the different qfM over the year (Kendall concordance coefficient) were performed.The analyses (QB) showed an increase in coded strokes in hospitals with qfM between 14-20%. In 2006, 80% of strokes (QB) were coded in hospitals with at least one qfM and 95% in 2017. Comparing years, AOK data showed similar trends: in 2007, 89% of patients were treated in hospitals with at least one qfM and 97% in 2017. In 2007, 55% of treating hospitals had qfM and 72% in 2017.Meanwhile, patients are more often treated in hospitals that specialise in stroke care. In addition, the various qfM have spread across the nation over the years, but there are still gaps in care that should be addressed to ensure quality care for all patients in the future.

BACKGROUND: Quality assurance for acute in-hospital care in Germany is based on compulsory comparisons between institutions, so-called external quality assurance (EQA). The effectiveness of EQA has not yet been adequately studied. The purpose of the QUASCH project, which is supported by the Innovation Fund of the Federal Joint Committee, is to investigate the association between EQA and health care outcomes, specifically with respect to stroke. METHODS: The analyses were based on data from 379 825 patients insured by the AOK health insurance fund who were acutely admitted to a hospital because of stroke over the period 2007–2017. Data on 47 659 patients were derived from EQA documentation in the state of Hesse, in which stroke EQA had already been introduced in 2003; data on the remaining 332 166 patients were from other federal states, where 117 734 of these patients had been treated under EQA conditions. The association of EQA with mortality over the period of observation was analyzed by multivariate Cox regression, with the following covariates: age, sex, comorbidities, time period of occurrence, nursing care level, type of stroke, socio-economic deprivation in the region of origin, and treatment in a stroke unit. RESULTS: Compared to treatment without EQA, mortality risk under EQA in the state of Hesse was significantly lower (hazard ratio [HR]: 0.93; 95% confidence interval: [0.92; 0.95]). The reduction in mortality risk with EQA was somewhat lower in the other federal states (HR: 0.96 [0.95; 0.97]). Treatment in a stroke unit was associated with a mortality risk that was lower still (HR: 0.86 [0.85; 0.87]). Mortality risk rose with age, comorbidities, and need for nursing care; it was lower in women and in persons whose stroke occurred in a later period. CONCLUSION: Quality assurance measures are associated with lower mortality risk after stroke. The concentration of care in specially qualified institutions is associated with stronger effects than EQA alone.

Complex regional pain syndrome (CRPS) is an inadequate local response after a limb trauma, which leads to severe pain and autonomic and trophic changes of the affected limb. Autoantibodies directed against human β2 adrenergic and muscarinic M2 receptors (hβ2AR and hM2R) have been described in CRPS patients previously. We analyzed sera from CRPS patients for autoantibodies against hβ2AR, hM2R, and endothelial cells and investigated the functional effects of purified IgG, derived from 13 patients with CRPS, on endothelial cells. Eleven healthy controls, 7 radial fracture patients without CRPS, and 10 patients with peripheral arterial vascular disease served as control subjects. The CRPS-IgG, but not control IgG, bound to the surface of endothelial cells ( P0.001) and to hβ2AR and hM2R ( P0.05), the latter being reversed by adding β2AR and M2R antagonists. The CRPS-IgG led to an increased cytotoxicity and a reduced proliferation rate of endothelial cells, and by adding specific antagonists, the effect was neutralized. Regarding second messenger pathways, CRPS-IgG induced ERK1/2, p38, and STAT1 phosphorylation, whereas AKT phosphorylation was decreased at the protein level. In addition, increased expression of adhesion molecules (ICAM-1 and VCAM-1) on the mRNA level was induced by CRPS-IgG, thus inducing a pro-inflammatory condition of the endothelial cells. Our results show that patients with CRPS not only develop autoantibodies against hβ2AR and hM2R, but these antibodies also interfere with endothelial cells, inducing functional effects on these in vitro, and thus might contribute to the pathophysiology of CRPS.

Purpose During an ICU stay, changes in muscles and nerves occur that is accessible via neuromuscular sonography. Methods 17 patients recruited from the neurological and neurosurgical ICU (six women; 66 ± 3 years) and 7 healthy controls (three women, 75 ± 3 years) were included. Muscle sonography (rectus abdominis, biceps, rectus femoris and tibialis anterior muscles) using gray-scale values (GSVs), and nerve ultrasound (peroneal, tibial and sural nerves) analyzing the cross-sectional area (CSA) were performed on days 1 (t1), 3 (t2), 5 (t3), 8 (t4), and 16 (t5) after admission. Results Time course analysis revealed that GSVs were significantly higher within the patient group for all of the investigated muscles (rectus abdominis: F = 7.536; p = 0.011; biceps: F = 14.761; p = 0.001; rectus femoris: F = 9.455; p = 0.005; tibialis anterior: F = 7.282; p = 0.012). The higher GSVs were already visible at t1 or, at the latest, at t2 (tibialis anterior muscles). CSA was enlarged in all of the investigated nerves in the patient group (peroneal nerve: F = 7.129; p = 0.014; tibial nerve: F = 28.976, p F = 13.051; p = 0.001). The changes were visible very early (tibial nerve: t1; peroneal nerve: t2). The CSA of the motor nerves showed an association with the ventilation time and days within the ICU (t1 through t4; p Discussion We detected very early changes in the muscles and nerves of ICU-patients. Nerve CSA might be a useful parameter to identify patients who are at risk for difficult weaning. Therefore our observations might be severity signs of neuromuscular suffering for the most severe patients.

Background and Purpose— Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy. Methods— In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial. Results— Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47); P =0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted, P =0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73); P =0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed. Conclusions— SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT03767192.

BACKGROUND: Early recanalization of an occluded vessel is associated with a better clinical outcome in acute ischemic stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) is only available in a minority of patients and often fails to reopen the occluded vessel. Mechanical recanalization is more effective in this matter but only available for selected patients when a thrombectomy centre can be reached. Therefore, sonothrombolysis might represent an alternative or complementary approach. Here, we tested microbubble-mediated sonothrombolysis (mmSTL) in a thromboembolic stroke model for middle cerebral artery occlusion (MCAO) in rats. METHODS: Sixty-seven male Wistar rats underwent MCAO using an autologous full blood thrombus and were randomly assigned to four groups receiving rt-PA, mmSTL, a combination of both, or a placebo. Diagnostic workup included neurological examination, assessment of infarct size, and presence of intracerebral haemorrhage by magnetic resonance imaging (MRI) and presence of microbleedings in histological staining. RESULTS: Neurological examination revealed no differences between the treatment groups. In all treatment groups, there was a reduction in infarct size 24 hours after MCAO as compared to the placebo (P≤0.05), but there were no differences between the active treatment groups (P>0.05) (placebo 0.75±0.10 cm(3); mmSTL 0.43±0.07 cm(3); rt-PA 0.4±0.07 cm(3); mmSTL + rt-PA 0.27±0.08 cm(3)). Histological staining displayed intracerebral microbleedings in all animals. The frequency of gross bleeding detected by MRI did not differ between the groups (placebo 3; mmSTL 4; rt-PA 2; mmSTL + rt-PA 2; P>0.05) and was not associated with worse performance in clinical testing (P>0.05). There were no statistical differences in the mortality between the groups (P>0.05). CONCLUSIONS: Our study showed the efficacy and safety of mmSTL with or without rt-PA in an embolic rat stroke model using a continuous full blood thrombus. Sonothrombolysis might be useful for patients who need to be transported to a thrombectomy centre or for those with distal vessel occlusion.

Background The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380 % in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.Methods This analysis examined N=819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical control center (EMCC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (pResults 53.4 % of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7 % are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 % and 85.8 % are triaged or dispatched for the EMS. 74 % of all ON-Missions are located in urban areas, 26 % in rural areas; 81.3 % of rural operations are performed by the EMS. 66 % of OFF-Missions are in cities. 93.2 % of the remaining 34 % of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95 % CI 3.21-3.30; OROFF 3.18, 95 % CI 3.04-3.32). OFF-Missions last 47.2 minutes (SD 42.3; CI 46.9-47.4), while ON-Missions are processed after 79.7 minutes on average (SD 47.6; CI 79.6-79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.Conclusions This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

Dysphagia is common in critically ill neurological patients and is associated with a high mortality and morbidity. Data on the usefulness of flexible endoscopic examination of swallowing (FEES) in neurological intensive care unit (ICU) patients are lacking, raising the need for evaluation.FEES was performed in neurological intensive care patients suspected of dysphagia. We correlated findings with baseline data, disability status, pneumonia and duration of hospitalisation, as well as a need for mechanical ventilation or tracheotomy.This analysis consisted of 125 patients with suspected dysphagia. Most of the patients (81; 64,8%) suffered from acute stroke. Dysphagia was diagnosed using FEES in 90 patients (72%). FEES results led to dietary modifications in 80 patients (64%). The outcome at discharge was worse in dysphagic stroke patients diagnosed by FEES as compared to non-dysphagic stroke patients (As the clinical assessment of the patients often classified the dysphagia incorrectly, the broad use of FEES in ICU patients might help to adequately adjust patients' oral diet. This knowledge might contribute to lower mortality and morbidity.

Mechanical thrombectomy, in addition to intravenous (i.v.) thrombolysis is recommended for treatment of acute stroke in patients with large vessel occlusions (LVO) in the anterior circulation up to 6 h after symptom onset. We compared thrombectomy rates of eight university hospitals of the MIRACUM consortium to analyze the implementation of this guideline in clinical routine. Anonymized billing data in a standardized format were loaded into a local i2b2 data warehouse by applying already existing extract, transform and load (ETL) routines. A locally executed uniform SQL (structured query language) query delivered aggregated site data for all inpatients with a discharge diagnosis of ischemic stroke (ICD-10 I63) containing counts for type of acute treatment, type of admission and age groups, which were centrally analyzed with R. From 2014 to 2016, the thrombectomy rate almost doubled from a mean of 4.7% to 9.6%, although significant differences between centers exist (range in 2016: 5.8–17%). The number of drip-and-ship procedures increased in 3 out of 8 centers. There was no evidence for a decrease in thrombectomy rates during weekends/holiday or among patients older than 80 years, but this age group is more likely to receive i.v. recombinant tissue plasminogen activator (rtPA). The observed increase of thrombectomy rates and drip-and-ship procedures without a significant difference between weekdays and weekends or patients of different ages is substantiating a rapid implementation of stroke guidelines within the analyzed neurovascular centers. The prototype of the MIRACUM Data Integration Center already contributes to health services research in Germany.

Background An association between Tako-Tsubo cardiomyopathy (TTC) and underlying malignancies has been observed, suggesting that TTC might be the consequence of paraneoplastic phenomena. This study investigates the presence of autoantibodies against cardiomyocytes as well as adrenergic (β1, β2) and muscarinic (M2) receptors in patients with TTC. Methods and results Serum from 20 TTC patients and 20 controls with ischemic heart disease was obtained. Indirect immunofluorescence testing for intracellular autoantibodies against cardiomyocytes showed a homogenous distribution, as in both groups 9 of 20 sera displayed a characteristic binding pattern of antibodies including vascular walls and intracellular structures. Flow cytometry analysis revealed no difference between TTC and controls in the binding of autoantibodies to the surface antigens of cardiomyocyte HL-1 cells (p = 0.569, t-test). Flow cytometry analysis of nontransfected wild type cells (p = 0.633, t-test), M2 receptor-transfected cells (p = 0.687, t-test), β1 receptor-transfected cells (p = 0.444, t-test) and β2 receptor-transfected cells (p = 0.632, t-test) showed similar results for control and TTC sera. Likewise, the binding pattern of TTC patients with a history of neoplasia compared to those without or to controls did not differ significantly (p > 0.05, u-test). Conclusion Findings suggest that the presumed paraneoplastic etiology of TTC cannot be attributed to the formation of these antibodies.

Cerebrospinal fluid (CSF) flow is sensitive to many cerebral disorders. We aimed to develop a noninvasive bedside method to detect physiological and pathological CSF phenomena by measuring pulsation patterns of the third ventricle. By transcranial B-mode ultrasound, electrocardiography (ECG)-gated video loops of the third ventricle were acquired. "Speckle tracking" software was used to quantify the relative change of its width. We conducted measurements of nine cardiac cycles in 11 healthy subjects in sitting and in supine position during Valsalva maneuver to investigate the influence of an increased intracranial pressure on the relative deformation of the third ventricle. In one patient with occlusive hydrocephalus, 19 cardiac cycles were measured in sitting position before and after removal of a tumorous obstruction of the aqueduct of Sylvius. Healthy subjects expressed a pulse-related increased width of the third ventricle ([Formula: see text]: +5.69, 95% confidence interval [CI] = [4.38, 7.00]). No significant difference was found between the sitting and the supine position in healthy adults. In the preoperative state of occlusive hydrocephalus, we found a negative, pulse-related deformation ([Formula: see text]: -1.86, 95% CI = [-2.15, -1.58]) with delayed onset. After surgery, the deformation pattern resembled that of our healthy controls. The difference between pre- and postoperative condition was significant (p < 0.001). Transcranial B-mode sonography can be used to record small movements of the sidewalls of the third ventricle. This noninvasive bedside method is suitable to assess CSF pulsatility within the third ventricle and might be able to distinguish between physiological and pathological flows.

ZusammenfassungDie Untersuchung der hirnversorgenden Arterien mittels Doppler- und Duplexsonografie war bislang fester Bestandteil des bewährten Stroke-Unit-Konzepts. Dies hat sich mit der Neufassung der Schlaganfall-OPS geändert: neurosonografische Untersuchungen während der Stroke-Unit-Behandlung sind im Falle der Durchführung einer CT- bzw. MR-Angiografie nicht mehr gefordert. Nach Eintritt eines ischämischen Schlaganfalls laufen im betroffenen Gefäßsegment und den dazugehörigen Kollateralwegen komplexe, individuell unterschiedliche, hämodynamische Umstellungsprozesse ab, die für das Schicksal des Patienten entscheidend sind. Verschlüsse können persistieren, partiell oder komplett rekanalisieren, kollateral kompensiert werden oder nach Rekanalisation wieder re-okkludieren. Diese Prozesse in den ersten Stunden können mittels Ultraschall wie mit keiner anderen Methode verfolgt werden. Je früher die Untersuchung erfolgt, desto aufschlussreicher sind die Befunde, desto besser ist das pathophysiologische Verständnis und desto größer ist der individuelle Nutzen für therapeutische Entscheidungen. Vielfach werden CTA, MRA und Ultraschall in der Schlaganfallversorgung als kompetitive Methoden begriffen. In Wahrheit handelt es sich aber um komplementäre Verfahren, mit denen auf der Basis von sehr unterschiedlichen physikalischen Prinzipien Bilder erzeugt und Blutgefäße, Hirnperfusion und Blutflüsse dargestellt werden. Mit Blick auf eine spezielle klinische Fragestellung ist jeweils das eine oder andere Verfahren indiziert. Es obliegt dem klinisch verantwortlichen Neurologen hier die richtige Auswahl zu treffen und spezifische neurosonologische Kompetenz einzubringen. Ziel dieser Übersichtsarbeit ist es, Neurologinnen und Neurologen dazu zu motivieren, Neurosonologie speziell in der Akutphase des Schlaganfalls einzusetzen um sich selbst ein Bild zu machen, anstatt sich „ein Bild machen zu lassen“.

Ultrasonography of the extra- and intracranial vessels has been an essential part of the approved concept of stroke units in Germany. This review aims to highlight unique selling points of neurosonology in the acute phase of stroke.In acute ischemic stroke, occlusion or stenosis of an arterial segment induces individually variable and complex changes in cerebral hemodynamics. Acute arterial occlusion may persist, may partially or completely recanalize, re-occlude after initial recanalization or may be compensated by collateral blood flow. Ultrasonography is most suitable to monitor these hemodynamic changes in the early stages of a stroke. The earlier neurosonography is performed, the better the pathophysiological understanding is, and the more targeted are therapeutic efforts to limit acute neurovascular injury. A general view is that CT angiography and/or magnetic resonance imaging and neurosonographical techniques in acute stroke care are competitive and interchangeable. However, these methods are rather complementary since the visualization of blood vessels, cerebral perfusion and hemodynamic flow is based on different physical principles. Each method has particular advantages and limitations. With respect to the specific diagnostic question, one method or the other may be indicated. It is the responsibility of the treating neurologist to select the most appropriate imaging method and to provide specific competence in neurosonography. The main scope of this article is to motivate neurologists to apply neurosonography specifically in the acute phase of stroke in order to get an independent assessment and unique hemodynamic information instead of leaving neurovascular competence to radiologists. Purposeful use of neurosonologic techniques makes the difference in high quality stroke care.

Background: Although 20-30% of all strokes occur in the posterior circulation, few studies have explored the characteristics of patients with strokes in the posterior compared to the anterior circulation so far. Especially data on young patients is missing. Methods: In this secondary analysis of data of the prospective multi-centre European sifap1 study that investigated stroke and transient ischemic attack (TIA) patients aged 18-55 years, we compared vascular risk factors, stroke aetiology, presence of white matter hyperintensities (WMH) and cerebral microbleeds (CMB) between patients with ischaemic posterior circulation stroke (PCS) and those having suffered from anterior circulation stroke (ACS) based on cerebral MRI. Results: We diagnosed PCS in 612 patients (29.1%, 407 men, 205 women) and ACS in 1,489 patients (70.9%). Their age (median 46 vs. 47 years, p = 0.205) and stroke severity (modified Rankin Scale: both 2, p = 0.375, Barthel Index 90 vs. 85, p = 0.412) were similar. PCS was found to be more frequent among the male gender (66.5 vs. 60.1% with ACS, p = 0.003). Vertebral artery (VA) dissection was more often the cause of PCS (16.8%) than was carotid artery dissection of ACS (7.9%, p < 0.001). Likewise, small vessel disease (Trial of Org 10172 in Acute Stroke Treatment [TOAST] = 3, PCS: 14.7%, ACS: 11.8%) and stroke of other determined aetiology (TOAST = 4, PCS: 24.5%, ACS: 16.0%) were more frequent in those with PCS. Furthermore, patent foramen ovale (PFO; PCS: 31.1%, ACS: 25.4%, p = 0.029) was more often detected in patients with PCS. In contrast, large-artery atherosclerosis (TOAST = 1, PCS: 15.4%, ACS: 22.2%) and cardio-embolic stroke (TOAST = 2, PCS: 15.6%, ACS: 18.0%) were less frequent in those with PCS (p < 0.001) as were preceding cerebrovascular events (10.1 vs. 14.1%, p = 0.014), TIA (4.8 vs. 7.7%, p = 0.016) and smoking (53.2 vs. 61.0%, p = 0.001). The presence, extent, and location of WMH and CMB did not differ between the 2 groups. Conclusions: Our data suggested a different pattern of aetiology and risk factors in young patients with PCS compared to those with ACS. These findings especially call for a higher awareness of VA dissection and potentially for more weight of a PFO as a risk factor in young patients with PCS. Clinical trial registration-URL: http://www.clinicaltrials.gov; NCT00414583.

Background Risk factors for acute symptomatic seizures after stroke demonstrated in retrospective analyses should be confirmed in large population studies. While seizures following ischemic stroke have been studied intensively, less is known about seizure predictors in hemorrhagic stroke. This study sought to identify risk factors of acute symptomatic seizures and to elucidate associated short-term (in-hospital) morbidity and mortality rates in primary intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Methods We determined the frequency of all acute symptomatic seizures perceived by clinical staff after hemorrhagic stroke in a large population-based registry in a central European region between 2004 and 2016. Further, we analyzed risk factors for seizure occurrence, morbidity, and mortality in univariate and multivariate analyses. Results Of 297,120 stroke patients, 19,331 experienced a hemorrhagic stroke. Frequency of acute seizures (without semiological differentiation) in this subpopulation was 4% (4.0% in ICH and 3.6% in SAH). The risk for acute symptomatic seizures was significantly increased in both stroke types in the presence of an acute non-neurological infection (odds ratio: 2.0 for ICH and 4.2 for SAH). A lower premorbid functional level also significantly increased the seizure risk (odds ratio: 2.0 for ICH and 3.1 for SAH). The odds of in-hospital mortality in the presence of acute seizures were significantly reduced in ICH patients (odds ratio: 0.7) but not in SAH patients. Conclusion Acute symptomatic seizures are equally common in ICH and SAH patients in this registry. Seizure risk is invariably increased in the presence of acute non-neurological infection. Mortality is reduced in ICH patients with seizures, but the exact reason for this relationship is not clear and might represent a biased finding.

Background Ischemic stroke has rising prevalence in aging populations. Treatment depends on quick symptom recognition, transport to a hospital with a dedicated stroke care, imaging, and initiation of treatment, if indicated. The aim of this study is to show that transport, imaging, and treatment times depend on the severeness of the stroke, with more severe strokes being favored. Methods Statistical analysis was performed with data from a registry for quality assurance in stroke care in Hesse, Germany. Data was analyzed regarding ICD-10, and patients with I63 were further investigated. Patients with NIHSS ≥ 4 were included and subdivided into 4 ≤ NIHSS ≤ 11 (moderate stroke) and NIHSS ≥ 12 (severe stroke). Transport to hospital, time to image, and time to treatment were analyzed. Results Patients with severe strokes reach the hospital faster and in higher numbers in comparison to moderate strokes. If appropriate therapy is applied, in-hospital treatment regarding imaging is similar in both groups. Thrombolysis or endovascular treatment is initiated faster for severe strokes. Conclusion More public awareness of strokes is needed, specifically for moderate strokes to reach faster transport times to hospital as well as modern treatment options up to 24 hours for eligible patients. Individual standards need to be applied in each stroke treating hospital to guarantee the same fast treatment times for moderate and severe strokes.

Background Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines morbidity and mortality; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients. Methods The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. Results We investigated 152 patients. The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Pharyngeal-phase dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6-17] vs. 7 [4-12], p=.013; median mRS 5 [IQR 4-5] vs. 4 [IQR 3-5], p=.012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p=.107). FEES examinations revealed that only 30.9% of the patients had an adequate oral diet. A change of oral diet was associated with a better outcome at discharge (mRS; p=.006), less need of mechanical ventilation (p=.028), shorter period of hospitalisation (p=.044), and lower rates of pneumonia (p=.007) and mortality (p=.011). Conclusion Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adequately adjust the oral diet for the vast majority of stroke patients (69.1%), potentially avoiding severe complications. Trial registration The study was not registered

The Functional Oral Intake Scale (FOIS) is the most frequently used scale for the evaluation of functional oral intake by dysphagia patients. FOIS was validated using data from Videofluoroscopic Swallowing Study (VFSS). Until now, a validated German version of FOIS for Flexible Endoscopic Evaluation of Swallowing (FEES) is lacking. The aim of this study was a cross-cultural validation of the German version of FOIS (FOIS-G) for FEES. The translation of the original FOIS was carried out according to the Translation, Review, Adjudication, Pretesting, Documentation (TRAPD) translation methodology. For the validation process, six experienced language therapists (SLT) retrospectively analyzed charts of 93 stroke patients. Inclusion criteria were comprised of stroke, clinical examination by an SLT within 24 h of admission, and FEES within 72 h of admission. The validity was calculated by comparison with Modified Rankin Scale (MRS), Barthel Index (BI), the Penetration-Aspiration-Scale (PAS), and a water swallow test. Spearman rank correlation of all paired raters ranged from rs = 0.96 to rs = 0.99, and percentage agreement ranged from 81 to 94%. The overall agreement between all raters was calculated by Fleiss kappa (0.83) (s.e. 0.02). There is a significant correlation between the BI and the MRS with the FOIS-G (rs = 0.301, p = 0.003 for BI; rs = – 0.366, p rs = − 0.758, p rs = 0.470, p

Extra- and transcranial sonography of brain-supplying arteries is accepted worldwide in brain death protocols as a valid "ancillary" method of proving brain circulatory arrest. Color-coded duplex sonography and CT angiography have been newly incorporated in the fourth update of the German Medical Association's guidelines for the determination of the irreversible cessation of brain function ("brain death"), effective July 2015. The updated guidelines address in more detail the diagnostic procedures and the required qualifications of the examiners. The present article summarizes the guidelines and the recommendations regarding the application and documentation of ultrasound findings for the diagnosis of brain circulatory arrest in children and adults, as valid in Germany. The method, limitations, and procedure in the case of inconclusive findings are described. Age-related minimum values of mean arterial pressure for the diagnosis of cerebral circulatory arrest in children are presented. A concise overview of the respective regulations for the use of sonography for diagnosing brain death in other countries, especially in the countries neighboring Germany, is given.

The aim of the study described here was to evaluate the thrombolytic efficacy of combined treatment with the fibrin-selective plasminogen activator desmoteplase (DSPA) and therapeutic ultrasound (sonothrombolysis [STL]) compared with conventional rt-PA (recombinant tissue plasminogen activator) treatment in vitro. Lysis rates were determined by the weight loss of platelet-rich plasma (PRP) clots treated with rt-PA (60 kU/mL) or DSPA (2 μg/mL) combined with pulsed wave ultrasound (2 MHz, 0.179 W/cm(2)). To reveal the individual effects of medication and ultrasound, lysis rates were also determined for DSPA monotherapy and for combined treatment with rt-PA and ultrasound. Clots solely placed in plasma served as the control group. Lysis increased significantly with rt-PA (26.5 ± 7.8%) and DSPA (30.5 ± 6%) compared with the control group (18.2 ± 5.9%) (each p < 0.001). DSPA lysis was more effective than rt-PA lysis (without STL: p = 0.015, with STL: p = 0.01). Combined treatment with DSPA and 2-MHz STL significantly exceeded rt-PA lysis (32.8% vs. 26.5%, p < 0.001).

Paediatric opsoclonus-myoclonus syndrome (OMS) is in 50% of the cases associated with a neuroblastoma as a paraneoplastic syndrome and is associated with surface-binding antibodies against cerebellar granular neurons (CGN). To evaluate possible pathogenic effects of these autoantibodies on CGN we examined their influence on the MAPKinase enzymes ERK-1/2 and p38 using flow cytometry and phospho-specific antibodies. OMS IgG but not IgG from neuroblastoma without OMS or healthy controls induced phosphorylation of ERK-1/2 in cerebellar granular neurons (p

Background Computer-assisted planimetry is widely used in experimental stroke research to assess the size of the ischemic lesion or hemispheric volume. New method Only insufficient data exist on the training required to achieve sufficient reliability in planimetry. Therefore, planimetry was performed over 15 months by two blinded raters who were initially inexperienced in the method. For inter-rater reliability, the hemispheric and lesional volume of 227 male Wistar Unilever rats subjected to middle cerebral artery occlusion were determined in diffusion- and T2-weighted sequences. For the intra-rater agreement, one investigator assessed the hemispheric and lesional volume in 87 T2-weighted sequences twice within a six-week interval. The correlation was calculated using Krippendorff’s alpha and Bland-Altman plots illustrated the agreement. Results Inter-rater agreement increased during the first seven weeks and remained at high values (Krippendorff’s alpha > 0.88). For intra-rater agreement, Krippendorff’s alpha was 0.84 for hemispheric and 0.85 for lesional volume. The Bland-Altman plot indicated solid agreement between raters in the absence of systematic errors. Comparison with existing methods Simplified geometrical models or automated methods for planimetry can be used to determine lesional volume, but both approaches are inappropriate to assess hemispheric volume. Conclusion Computer-assisted planimetry can be an appropriate method to determine hemispheric or ischemic lesion volume in rodents but requires a sufficiently long learning period of approximately two months. Even an experienced investigator can generate data with serious variation. Inter- and intra-rater-dependent bias should be considered during the design and performance of respective studies.

ZusammenfassungDas vorliegende Positionspapier zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall beinhaltet eine Stellungnahme der Arbeitsgemeinschaft „Herz und Hirn“ der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. (DGK) und der Deutschen Schlaganfallgesellschaft e. V. (DSG), die in Zusammenarbeit mit der Stroke Unit-Kommission der DSG und dem Kompetenznetz Vorhofflimmern (AFNET) e. V. erstellt wurde.Vorhofflimmern ist in den Leitlinien der Europäischen Gesellschaft für Kardiologie als eine mindestens 30 Sekunden anhaltende Episode einer Vorhofarrhythmie mit fehlenden P-Wellen definiert. Die 30-Sekundengrenze ist arbiträr gewählt und es ist unbekannt, ob das Schlaganfallrisiko bei Episoden von länger als 30 Sekunden höher ist als bei kürzeren Episoden. Bei Patienten, die einen Schlaganfall erlitten haben, sollte die Detektion von Vorhofflimmern üblicherweise zu einer Umstellung der medikamentösen Sekundärprävention führen, da eine orale Antikoagulation einer Thrombozytenaggregationshemmung überlegen ist. Die Detektion eines bis dato nicht diagnostizierten Vorhofflimmerns sollte daher bei Patienten mit ischämischem Schlaganfall verbessert werden, um die medikamentöse Sekundärprävention des Schlaganfalls zu optimieren. In diesem Positionspapier werden interdisziplinär erarbeitete Standards für eine „strukturierte Rhythmusvisite“ auf der Stroke Unit und ein diagnostisches „Stufenschema“ zur Detektion von Vorhofflimmern vorgeschlagen. Das Positionspapier fasst zudem den gegenwärtigen Kenntnisstand zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall zusammen. Das Positionspapier soll den in der Versorgung von Schlaganfallpatienten tätigen Ärzten eine Handhabe geben, auch wenn bisher nicht abschließend geklärt ist, wie lange und mit welcher EKG-Methode Schlaganfallpatienten ohne bisher bekannte Herzrhythmusstörung bestmöglich monitoriert werden sollten. Dem Charakter eines Positionspapiers angemessen, wurde auf die Kennzeichnung von Evidenzgraden verzichtet, da es sich überwiegend um die Meinung von Experten handelt, die auf berichteten Fallserien und klinischer Erfahrung beruht und somit nicht mit einer Leitlinie gleichzusetzen ist und so auch nicht verstanden werden will.

This expert opinion paper on atrial fibrillation detection after ischemic stroke includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. This paper was endorsed by the Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork. In patients with ischemic stroke, detection of atrial fibrillation should usually lead to a change in secondary stroke prevention, since oral anticoagulation is superior to antiplatelet drugs. The detection of previously undiagnosed atrial fibrillation can be improved in patients with ischemic stroke to optimize stroke prevention. This paper summarizes the present knowledge on atrial fibrillation detection after ischemic stroke. We propose an interdisciplinary standard for a "structured analysis of ECG monitoring" on the stroke unit as well as a staged diagnostic scheme for the detection of atrial fibrillation. Since the optimal duration and mode of ECG monitoring has not yet been finally established, this paper is intended to give advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on the expert opinion, reported case series and clinical experience. Therefore, this paper is not intended as a guideline.

SummaryContext Data on quantification and regulation of adipsin in human cerebrospinal fluid (CSF) are sparse, and the physiological role of adipsin as an adipokine crossing the blood–brain barrier (BBB) is uncertain. Objectives This study quantified adipsin concentrations in paired serum and CSF samples of patients undergoing neurological evaluation and spinal puncture. Design A total of 270 consecutive patients with specified neurological diagnosis were included in this study without prior selection. Main outcome measures Adipsin serum and CSF concentrations were measured by ELISA. A variety of serum and CSF routine parameters were measured by standard procedures. Anthropometric data, medication and patient history were available. Results Adipsin concentrations ranged between 467 and 5148 ng/ml in serum and between 4·2 and 133·5 ng/ml in CSF. Serum adipsin concentrations were correlated positively with respective CSF concentrations and were approximately 40-fold higher when compared to CSF. The mean CSF/serum ratio for adipsin was 27 ± 22 × 10−3. Serum and CSF adipsin levels were independent of gender and significantly higher in overweight/obese individuals. Serum and CSF adipsin levels correlated significantly with age and were higher in patients suffering from diabetes mellitus or hypertension. CSF adipsin concentrations showed a significant correlation with markers of inflammation in CSF, but not with CSF total cell count or the presence of oligoclonal bands. Patients suffering from infectious diseases had higher CSF levels of adipsin than multiple sclerosis patients. Conclusions Adipsin is present in human CSF under pathophysiological conditions. The positive correlation between serum and CSF concentrations, the positive correlation between the CSF/serum ratios for adipsin and total protein and the lack of association with CSF cell count argue against an autochthonous production in the central nervous system. In contrast, the present data argue for a significant BBB permeability to adipsin.

Background: Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with vertebral artery dissection (VAD). However, there are limited data from recent, large international studies comparing risk factors and clinical features in patients with cervical artery dissection (CeAD) with other TIA or ischemic stroke (IS) patients of similar age and sex. Methods: We analysed demographic, clinical and risk factor profiles in TIA and IS patients ≤55 years of age with and without CeAD in the large European, multi-centre, Stroke In young FAbry Patients 1 (sifap1) study. Patients were further categorised according to age (younger: 18-44 years; middle-aged: 45-55 years), sex, and site of dissection. Results: Data on the presence of dissection were available in 4,208 TIA and IS patients of whom 439 (10.4%) had CeAD: 196 (50.1%) had CAD, 195 (49.9%) had VAD, and 48 had multiple artery dissections or no information regarding the dissected artery. The prevalence of CAD was higher in women than in men (5.9 vs. 3.8%, p < 0.01), whereas the prevalence of VAD was similar in women and men (4.6 vs. 4.7%, n.s.). Patients with VAD were younger than patients with CAD (median = 41 years (IQR = 35-47 years) versus median = 45 years (IQR = 39-49 years); p < 0.01). At stroke onset, about twice as many patients with either CAD (54.0 vs. 23.1%, p < 0.001) or VAD (63.4 vs. 36.6%, p < 0.001) had headache than patients without CeAD and stroke in the anterior or posterior circulation, respectively. Compared to patients without CeAD, hypertension, concomitant cardiovascular diseases and a patent foramen ovale were significantly less prevalent in both CAD and VAD patients, whereas tobacco smoking, physical inactivity, obesity and a family history of cerebrovascular diseases were found less frequently in CAD patients, but not in VAD patients. A history of migraine was observed at a similar frequency in patients with CAD (31%), VAD (27.8%) and in those without CeAD (25.8%). Conclusions: We identified clinical features and risk factor profiles that are specific to young patients with CeAD, and to subgroups with either CAD or VAD compared to patients without CeAD. Therefore, our data support the concept that certain vascular risk factors differentially affect the risk of CAD and VAD.

Objective The aim of the study was to confirm the diagnostic performance of dynamic myosonography with regard to its reliability to correctly identify fasciculations and to distinguish them from artefacts. Furthermore, interrater agreement regarding the identification of different muscle movements was investigated. Methods A total of 11 observers analysed 25 muscle ultrasound videos acquired using a standardized protocol. The video files illustrated fasciculations and artefacts (voluntary probe movements, voluntary contractions or swallowing and pulsating vessels) in different muscle groups. Results Fasciculations could be distinguished from artefacts with a sensitivity of 90.9% and specificity of 98.5%. Interrater agreement regarding the presence or absence of fasciculations showed an overall median of 100% (interquartile range, IQR: 96–100%). In every investigated muscle group, the median of the interpreter agreement was found to be 100% (correct ratings of all observers: submental muscles: 43 of 44; biceps muscles: 22 of 22; forearm flexors: 31 of 33; rectus abdominis muscles: 33 of 33; quadriceps muscles: 19 of 22; tibialis anterior muscles: 51 of 55; undefinable muscles: 65 of 66). Conclusion Dynamic myosonography is an extremely reliable tool with excellent interrater agreement to correctly identify fasciculations and to distinguish them from artefacts. Significance Myosonography should be further incorporated in clinical routine diagnostic work-up.

Background New evidence regarding stroke prevention in atrial fibrillation has been published. Implementing knowledge into clinical practice remains challenging. Aims To investigate oral anticoagulants in stroke patients documented in a nationwide registry. Methods The database is an obligatory federal-state-wide hospital-based registry that covers more than 95% of all ischemic strokes, transient ischemic attacks and intracerebral hemorrhages in a community of more than six million inhabitants (Hesse/Germany). We analyzed oral anticoagulants prescribed on discharge in patients with stroke or transient ischemic attack during 2006–2015. Results From 2006 to 2015, we annually selected median 20,895 patients. From 2006 to 2015, the proportion of patients treated with oral anticoagulants increased (9.8% to 24%). The annual proportion of patients with atrial fibrillation remained constant (median: 23%). In atrial fibrillation patients treated with oral anticoagulants, the age increased (median 2008/2009: 76.9 years vs. 2014/2015 79.4 years). The percentage of treated individuals in atrial fibrillation increased dramatically (2006: 30.1% to 2015: 74.5%); in 2015, 30.8% of these patients received vitamin K antagonists and 70.2% new oral anticoagulants. Independent factors associated with new oral anticoagulants therapy were a previous medication with new oral anticoagulants and a treatment on stroke unit. Between new oral anticoagulants- and vitamin K antagonists-treated patients (2015), no differences in age were noted (both mean: 79.4 years). Conclusions The new oral anticoagulants availability enhanced a general trend treating more target patients with oral anticoagulants.