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Objective: Cervical artery dissection (CAD) accounts for 10-20% of all strokes in young adults, but no randomised controlled trial has investigated the best secondary prevention after ischaemic stroke or transient ischaemic attack (TIA). Because only small numbers of patient with CAD have been prospectively documented and followed up, the authors aimed to investigate the prognosis under various prevention regimens., Methods: 30 German departments of neurology with acute stroke units prospectively documented 250 patients with acute ischaemic stroke or TIA due to CAD. A central follow-up (median 31 months) assessed recurrent stroke, recurrent CAD and death in 198 patients., Results: CAD was found more often in the carotid arteries (52.0%) than in the vertebral arteries (46.8%). Thirteen patients (5.2%, CI 3.1% to 8.6%) suffered a recurrent stroke during the acute hospital stay. The rate of recurrent CAD during the first year was 1.7% (95% CI 0.3% to 3.6%). The cumulative recurrent stroke rate during the first year was 10.7% (95% CI 6.5% to 14.9%) and 14.0% (95% CI 8.9% to 19.1%) over 3 years. After discharge, the rate of recurrent stroke up to 6 months in patients treated with anticoagulants was 2.0% (95% CI 0.6% to 7.1%) and in those treated with antiplatelets 16.7% (95% CI 5.8% to 39.2%), which was statistically significant (HR 0.11; CI 0.02 to 0.69, p=0.02)., Conclusions: This observational study confirms a high risk of early recurrent stroke following acute IS or TIA due to CAD. Whether anticoagulation provides any benefit over antiplatelets needs to be investigated in a randomised controlled trial.

Background: In Caucasian patients with acute stroke or transient ischemic attack (TIA) due to symptomatic intracranial atherosclerotic stenoses (ICAS), only limited data on the recurrent stroke rate and its associated risk factors have been reported. In view of the increasing options for endovascular interventions, we sought to investigate the prevalence, risk for recurrent stroke and mortality in these patients., Methods: A total of 304 consecutive patients with acute ischemic stroke or TIA due to 50-99% ICAS were prospectively documented in 19 German stroke centers. In 201 patients (68.1% of the survivors), a central biannual telephone follow-up could assess recurrent stroke and mortality up to a median of 2 years after the index event., Results: An ischemic cerebrovascular event attributable to symptomatic ICAS was found in 2.24% of the consecutively admitted patients. The overall cumulative recurrent stroke rate after admission was 17.9% (95% CI = 13.4-23.5) for the first year and 23.3% (95% CI = 17.8-29.8) over 3 years. After correction for age and sex, only previous stroke (HR = 2.11, 95% CI = 1.14-3.91) and diabetes (HR = 2.41, 95% CI = 1.33-4.37) were significantly associated with recurrent stroke., Conclusion: Although the prevalence of this etiology seems very low in patients admitted to German stroke centers, we found a high risk of recurrent stroke in patients with symptomatic ICAS. Whether endovascular interventions can reduce this high risk needs to be determined in a randomized trial., (Copyright (c) 2010 S. Karger AG, Basel.)

Background: Passive smoking is an established risk factor for coronary heart disease (CHD). Epidemiological studies suggest that passive smoking may also be associated with an increased risk of stroke. We estimate the burden of stroke due to passive smoking in Germany., Methods: Frequency of passive smoking was derived from the German national health survey. Nonsmokers who reported exposure to environmental tobacco smoke (ETS) at home were considered for analyses. The relative risk for stroke and passive smoking was derived by means of a meta-analysis from available cohort studies. We computed attributable risks for passive smoking and used data from official statistics to estimate stroke mortality due to ETS. Attributable stroke morbidity was calculated using the WHO-Global-Burden-of-Disease approach., Results: Passive smoking may account for 774 stroke-related deaths and 1837 incident first ever strokes in Germany every year. More strokes owing to passive smoking occur among women (1248) than among men (589). The majority of strokes attributable to ETS happen at the age of 65-84 years., Conclusion: ETS is a common exposure and stroke is a frequent disease. Though the relative risk of passive smoking on stroke mortality and morbidity is small, the impact on population health is substantial.

Background: Subjective risk factor perception is an important component of the motivation to change unhealthy life styles. While prior studies assessed cardiovascular risk factor knowledge, little is known about determinants of the individual perception of stroke risk., Methods: Survey by mailed questionnaire among 1483 participants of a prior public stroke campaign in Germany. Participants had been informed about their individual stroke risk based on the Framingham stroke risk score. Stroke risk factor knowledge, perception of lifetime stroke risk and risk factor status were included in the questionnaire, and the determinants of good risk factor knowledge and high stroke risk perception were identified using logistic regression models., Results: Overall stroke risk factor knowledge was good with 67-96% of the participants recognizing established risk factors. The two exceptions were diabetes (recognized by 49%) and myocardial infarction (57%). Knowledge of a specific factor was superior among those affected by it. 13% of all participants considered themselves of having a high stroke risk, 55% indicated a moderate risk. All major risk factors contributed significantly to the perception of being at high stroke risk, but the effects of age, sex and education were non-significant. Poor self-rated health was additionally associated with high individual stroke risk perception., Conclusion: Stroke risk factor knowledge was high in this study. The self perception of an increased stroke risk was associated with established risk factors as well as low perception of general health.

Background and Purpose: There is no consensus about indicators for measuring quality of acute stroke care in Germany. Therefore, a standardized process was initiated recently to develop and implement evidence-based indicators for the measurement of quality of acute hospital stroke care., Methods: Quality indicators were developed by a multidisciplinary board between November 2003 and December 2005. The process was initiated by the German Stroke Registers Study Group in cooperation with the German Stroke Society, the German Society of Neurology, the German Stroke Foundation, Regional Offices for Quality Assurance and other experts proven in the field. National and international recommendations were considered during the development process. The process was based on a systematic literature review, an independent external evaluation of the process and its results, and a prospective pilot study to evaluate the defined indicators in clinical practice., Results: Overall a set of 24 indicators was developed to measure performance of acute care hospitals in the 3 health care dimensions structure, process and outcome as well as in 3 treatment phases prehospital, in-hospital/acute and postacute. Practicability of the derived indicators was tested in a prospective pilot study. During a 2-month period, 1006 patients in 13 hospitals were documented. Application of the new indicator set was found to be feasible by participating physicians and hospitals. Median time to document the required information for 1 patient was 5 minutes. Nationwide implementation of the new indicator set within regional registers in Germany started since April 2006., Conclusions: The development of indicators to measure hospital performance in stroke care is an important step toward improving stroke care on a national level. The chosen standardized evidence-based approach ensures maximal transparency, acceptance and sustainability of the developed indicators in Germany.

Background: Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) within 3 h after onset of focal cerebral ischemia was approved in Germany in August 2000., Methods: 11 neurology departments with acute stroke units participated in the German Stroke Study Collaboration before (n = 2,925) and after (n = 3,204) approval of rt-PA in Germany and consecutively registered all patients admitted within 24 h following acute ischemic stroke., Results: Frequency of intravenous thrombolysis in patients admitted within 24 h after symptom onset increased from 4.8% before approval to 7.9% after approval of rt-PA. Among patients treated with rtPA, age increased significantly and the delay between symptom onset and imaging was significantly shorter in the second study period., Conclusions: The observed improvement in management and quantity of intravenous thrombolysis may be explained by greater experience and greater legal security following regulatory approval of rtPA., (Copyright (c) 2006 S. Karger AG, Basel.)

The role of a patent foramen ovale (PFO) in stroke is still regarded as controversial, as is the optimal strategy of secondary prevention for such patients. The best available evidence is derived from case-control studies, which in all show a statistically significant relationship but cannot be judged as conclusive for methodologic reasons. Besides paradoxic embolism, different pathomechanisms of stroke due to abnormalities of the atrial septum are possible that can rarely be verified in clinical routine. While the risk of stroke recurrence seems to be low at least for younger patients, to date no definite recommendations for secondary prevention can be given. Several ongoing randomized clinical trials might increase the store of evidence in this topic over the next years. However, primary and secondary risk seem to be substantially increased for the combined defect of PFO and atrial septum aneurysm. To allow further risk stratification, other potentially important factors such as shunt size and coagulation disorders should be targeted in future studies.

Background: The upcoming introduction of diagnosis related groups (DRG) as an exclusive base for future calculation of hospital proceeds in Germany requires a thorough analysis of cost data for various diseases., Objective: To compare the resulting combined cost weights of the Australian Refined DRG system (AR-DRG) with the proceeds based on actual per-day rates in stroke treatment., Patients and Methods: Between 1998 and 1999, data from 6520 patients (median age 68 years, 43% women) with acute stroke or transient ischemic attack (TIA) were prospectively documented in 15 departments of Neurology with an acute stroke unit, 9 departments of general Neurology and 6 departments of Internal Medicine. Prior to grouping cases into DRGs, all available data were transferred into ICD-10-SGB-V 2.0 or the Australian procedure system (MBS-Extended). Hospital proceeds for the respective cases were calculated based on per-day rates of the documenting hospitals., Results: The resulting cost weights demonstrate a good homogeneity compared to the length of stay. When introducing the AR-DRG with a uniform base rate in Germany, a relative decrease of hospital proceeds can be expected in Neurology Departments and for treatment of TIAs., Conclusion: Preservation of the existing structure of acute stroke care in Germany requires a supplement to a uniform base rate in Neurology departments.

Background and Purpose: Functioning and disability after ischemic stroke are clinically meaningful and of major relevance to patients. Despite many instruments available to assess these outcomes, little is known about their interrelation and predictive factors., Methods: We prospectively identified 4264 patients with acute ischemic stroke from 30 hospitals in Germany during a 1-year period between 1998 and 1999 and registered them in a common data bank. The patients were centrally followed up via telephone interview after 100 days and 1 year to assess various scales such as the Barthel Index (BI), modified Rankin Scale (MRS), extended Barthel Index (EBI), Short Form-36 Physical Functioning (SF-36 PF), and Center for Epidemiologic Studies-Depression short form (CES-D)., Results: Outcome status could be assessed in 67.2% of patients 100 days after hospital admission. Of these, 13.9% had died, 53.7% had regained functional independence (BI <95), 46.3% had no or mild residual symptoms (MRS < or =1), and 44.6% had no higher cognitive deficits on the EBI. Of the patients who personally answered the follow-up questions, 67% had no major physical disability (SF-36 PF <60), and 32.9% reported symptoms classified as depression (CES-D > or =10). The high percentage of patients reaching the maximum score (ceiling effect) in the BI was less pronounced in the MRS and SF-36 PF. The predictive factors for dichotomized outcomes on each scale were similar for adverse functioning and disability but varied considerably for depression., Conclusions: To avoid ceiling effects in outcome distribution of patients treated in specialized stroke centers, the MRS and SF-36 PF instruments are preferable to the BI. Parametric use of the SF-36 PF could further improve outcome measurement by considering individual treatment effects.