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Background and purpose: Endovascular therapy (EVT) is increasingly reported for treatment of isolated posterior cerebral artery (PCA) occlusions although its clinical benefit remains uncertain. This study-level meta-analysis investigated the functional outcomes and safety of EVT and best medical management (BMM) compared to BMM alone for treatment of PCA occlusion stroke. Methods: We conducted a literature search in PubMed, Web of Science and Embase for studies in patients with isolated PCA occlusion stroke treated with EVT + BMM or BMM including intravenous thrombolysis. There were no randomized trials and all studies were retrospective. The primary outcome was modified Rankin Scale score of 0-2 at 3 months, while safety outcomes included mortality rate and incidence of symptomatic intracranial hemorrhage (sICH). Results: Twelve studies with a total of 679 patients were included in the meta-analysis: 338 patients with EVT + BMM and 341 patients receiving BMM alone. Good functional outcome at 3 months was achieved in 58.0% (95% confidence interval [CI] 43.83-70.95) of patients receiving EVT + BMM and 48.1% (95% CI 40.35-55.92) of patients who received BMM alone, with respective mortality rates of 12.6% (95% CI 7.30-20.93) and 12.3% (95% CI 8.64-17.33). sICH occurred in 4.2% (95% CI 2.47-7.03) of patients treated with EVT + BMM and 3.2% (95% CI 1.75-5.92) of patients treated with BMM alone. Comparative analyses were performed on studies that included both treatments and these demonstrated no significant differences. Conclusions: Our results demonstrate that EVT represents a safe treatment for patients with isolated PCA occlusion stroke. There were no differences in clinical or safety outcomes between treatments, supporting randomization of future patients into distal vessel occlusion trials. info:eu-repo/semantics/publishedVersion

Background and purpose Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff. Methods A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned. Results Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures. Conclusions In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

BACKGROUND AND PURPOSE Trimethylamine-N-oxide (TMAO) is a biomarker of the gut microbiome and correlates with the risk of cardiovascular diseases. However, conflicting data exist on the specific role of TMAO in ischaemic stroke patients. We aimed to analyze the time course of TMAO levels in stroke patients compared with controls. METHODS In this prospective, case-control study, patients suffering from ischaemic stroke (onset

Background and purpose Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. Methods Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to in-house standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. Results Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. Conclusions Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.

Background and purpose: Detection of atrial fibrillation is of vital importance because oral anticoagulation decreases the risk of a stroke by 64%. Current standards for stroke unit treatment require continuous electrocardiogram (ECG) monitoring for at least 24 h. Additionally, a 24-h HOLTER ECG (HOLTER) should be performed in selected patients. It remains unclear whether continuous monitoring at the bedside is equivalent to HOLTER for the detection of atrial fibrillation. Furthermore, we investigate how many additional patients with paroxysmal atrial fibrillation can be identified as a result of a longer duration of continuous monitoring. Methods: In this study, we prospectively compared the detection rates of HOLTER and 24-h monitoring at the Stroke Unit at the University of Heidelberg over a period of 9 months. Continuous monitoring was analyzed by trained nurses, HOLTER by cardiologists. Results: We included 370 patients with ischemic stroke or transient ischemic attack (TIA) in our study. Of these, 192 patients underwent HOLTER. Previously unknown atrial fibrillation was detected in 44 patients, 13 patients had no atrial fibrillation in baseline ECG, but atrial fibrillation was detected by continuous monitoring. In two patients, the HOLTER showed atrial fibrillation; both patients had also been detected by continuous monitoring. Median time to detection of the atrial fibrillation during continuous monitoring was 43 h after hospitalization. Conclusion: In this study, use of HOLTER does not give any additional benefit in comparison with continuous monitoring with intermittent analysis by trained staff alone. The median detection time of 43 h emphasizes the importance of longer continuous monitoring.

Background: The profile of patients with neurological diseases referred to specialized emergency rooms (ER) has not been reported and it is unknown whether a setting of decentralized ERs is associated with a high number of referrals because of inappropriate admissions. Methods: In this prospective study, consecutive patients of a specialized neurological ER were enrolled. Data encompassed time from symptom onset to admission, discharge diagnoses, data on hospitalization and on transfers to and from other ERs. Results: Thousand seven hundred and forty-three patients were enrolled. Most common diagnoses were cerebrovascular events (26.5%), headache disorders (13%) and seizures (12.7%). Time since onset of symptoms depended on who referred the patient (P

Background and purpose Intravenous thrombolysis (IVT) is the only approved pharmacological treatment for acute ischemic stroke. Off-label IVT for ischemic stroke is common. We aimed to analyse its safety in a large database. Methods This was a retrospective analysis of the safe implementation of treatments in stroke (SITS) thrombolysis registry with regard to 11 off-label criteria according to the European licence for alteplase. Symptomatic intracranial haemorrhage (SICH) according to SITS was defined as primary safety endpoint and SICH according to the European Cooperative Acute Stroke Study (ECASS II) definition and the National Institute of Neurological Disorders and Stroke definition as secondary safety endpoints. Multivariable logistic regression analyses after replacing missing values using multiple imputations were performed. Results Patients from 793 centres in 44 countries were included, mainly (95%) in Europe. A total of 56 258 patients who were treated with intravenous alteplase were included. Median age was 71 (IQR 61-78) years and median National Institutes of Health Stroke Scale score was 12 (IQR 7-17). A total of 16 740 (30%) patients received off-label IVT and 1037 (1.8%) patients suffered from SICH according to the SITS definition (SICH SITS). Median percentage of missing values per variable was 0.4%. The only two off-label criteria constituting independent positive and negative predictors for SICH SITS were high blood pressure (odds ratio, 1.39; 95% confidence interval, 1.08-1.80; P = 0.012) and minor stroke (odds ratio, 0.51; 95% confidence interval, 0.33-0.78; P = 0.002). Very severe stroke, previous stroke and diabetes, age and high glucose levels were additional independent predictors of SICH according to the ECASS II and National Institute of Neurological Disorders and Stroke definitions. Conclusions Thrombolysis appears to be safe with regard to SICH for most of the off-label criteria, especially for minor stroke, but is risky in patients with high blood pressure. Individual risk-benefit evaluation should be performed.

Background and purpose The temporal course of recanalization and its association with clinical outcome were analysed in our patients with cerebral sinus and/or venous thrombosis (CSVT) and follow-up magnetic resonance imaging (MRI). Methods Between January 1998 and September 2014 all patients from our institutions with CSVT were systematically analysed. Baseline data, treatment characteristics and follow-up MRI were retrospectively recorded. The status of recanalization was assessed as complete (CRec), partial (PRec) or failed recanalization. Clinical follow-up was measured with the modified Rankin Scale. Excellent outcome was defined as modified Rankin Scale 0–1. Results Ninety-nine patients were identified; 97% of these patients were treated with oral anticoagulation (OAC) and the median (min–max) time of OAC was 7 months (1–84). CRec was achieved in 57.6% (57/99), PRec in 29.3% (29/99) and only 13 (13.1%) patients did not recanalize. The median (min–max) time to PRec was 4 months (0.25–14) and to CRec 6 months (2–34). Median time to last clinical follow-up was 8 months (1–88); 91.8% (89/99) had an excellent outcome at last clinical follow-up and only 2.1% (2/99) died. Only thrombosis of the superior sagittal sinus was independently associated with successful recanalization (odds ratio 16, 95% confidence interval 2–138). No severe haemorrhagic complications and no recurrence of CSVT occurred within clinical follow-up. No association of outcome and recanalization status was found. Conclusions The recanalization rate of CSVT under OAC was high and the median time to CRec was 6 months. Thrombosis of the superior sagittal sinus is a positive predictor of recanalization. Outcome in this cohort was excellent but no significant association of outcome and recanalization status was found.

In Europe intravenous thrombolysis (IVT) for ischaemic stroke is still not approved for patients aged80 years. However, elderly patients are frequently treated based on individual decision making. In a retrospective observational study a consecutive and prospective stroke registry in southwest Germany was analysed.The data registry collected 101,349 patients with ischaemic stroke hospitalized from January 2008 to December 2012. Of these, 38,575 (38%) were aged 80 years and older and 10 286 (10.1%) underwent IVT. Favourable outcome at discharge was defined as modified Rankin Scale (mRS) ≤1 or not worse than prior to stroke. Multiple logistic regression models stratified by 10-year age groups were used to assess the relationship between IVT and mRS at discharge, adjusted for patient characteristics, admitting facility and length of hospital stay.The highest IVT rate was 15% in patients aged50 years, with a continuous decline down to 8% in patients aged ≥90 years. Adjusted odds ratios and 95% confidence intervals for patients 80-89 years of age were 2.20 (1.95-2.47) (P0.0001) and 1.25 (0.88-1.78) (P = 0.21) for patients90 years of age, compared to patients of the same age decade not treated with IVT.The evidence from routine hospital care in southwest Germany indicates that IVT is an effective treatment also for aged patients with ischaemic stroke in an age range between 80 and 89 years. Although no clear evidence for the effectiveness of IVT beyond 90 years was found, treatment should also be carefully considered in these patients. High age should not discourage from treatment.

Background and purpose Thrombus length has been reported as an important predictor of successful recanalization by intravenous thrombolysis but its influence on bridging thrombolysis has not been investigated yet. The effect of thrombus length on recanalization rates evaluated by catheter angiography early after intravenous bridging thrombolysis was analyzed. Methods Ninety-six consecutive patients with acute cerebral artery occlusion were included. Occlusion site and thrombus length on initial computed tomography angiography or magnetic resonance angiography were related to recanalization after intravenous bridging thrombolysis on the initial series of catheter angiography. Results Eleven of 96 patients (11.5%) showed successful recanalization (TICI 2a, 2b or 3) after intravenous bridging thrombolysis. Mean thrombus length in these patients was 10.8 mm as opposed to 15.6 mm in patients without successful recanalization. No thrombus longer than 16 mm showed complete recanalization. Binary logistic regression demonstrated a significant influence of thrombus length on probability of recanalization (odds ratio 0.78, 95% confidence interval 0.65–0.95; P = 0.014). Conclusions Thrombus length is a significant predictor of recanalization rates after bridging thrombolysis. Overall recanalization rate within the time frame until interventional treatment is started was 11.5% after bridging thrombolysis.

Repeated cranial computerized tomography scan examination in patients with elevated intracranial pressure is time consuming and requires patient transportation. We prospectively evaluated the diagnostic value of transcranial duplex sonography as a bedside tool for detection of the mass effect after space-occupying ischemic stroke and brain haemorrhage and for evaluating the width and dislocation of the ventricular system and the dislocation of brain mid-line structures. We used transcranial duplex sonography in 21 consecutive patients with space-occupying ischemic middle cerebral artery infarction and brain haemorrhage. The transcranial duplex sonography examinations were performed within 2 h before or after corresponding follow-up cranial computerized tomography scans. We measured the third ventricular width as a parameter for infratentorial and the mid-line shift for supratentorial space-occupying effect. In all patients, mid-line structures could be identified by transcranial duplex sonography. Significant third ventricular dilation was found subsequently in most patients with infratentorial mass effect, and mid-line shift occurred in all patients with supratentorial space-occupying lesions, respectively. The mean difference (absolute values) between transcranial duplex sonography and cranial computerized tomography measurements was 0.8 mm for the ventricular width (standard deviation 1 mm) and 1.1 mm for the mid-line shift (standard deviation: 1.46 mm), with a tendency for these parameters to be underestimated at higher values using transcranial duplex sonography. The linear correlation coefficients were R = 0.97 and R = 0.94, respectively. Transcranial duplex sonography appears to be a sufficiently reliable bedside method for evaluating the width and the lateral displacement of the third ventricle, as validated by cranial computerized tomography scan. Thus, it may be suitable for monitoring the space-occupying effect of both supra- and infratentorial strokes during treatment on critical care and stroke units.