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Background and Purpose: Data on long-term survival and recurrence after stroke are lacking. We investigated time trends in ischemic stroke case-fatality and recurrence rates over 20-years stratified by etiological subtype according to the Trial of ORG 10172 in Acute Stroke Treatment classification within a population-based stroke register in Germany., Methods: Data was collected within the Erlangen Stroke Project, a prospective, population-based stroke register covering a source population of 105 164 inhabitants (2010). Case fatality and recurrence rates for 3 months, 1 year, and 5 years were estimated with Kaplan-Meier estimates. Sex-specific time trends for case-fatality and recurrence rates were estimated with Cox regression. We adjusted for age, sex, and year of event and stratified for etiological subtypes. A sensitivity analysis with competing risk analysis for time trends in recurrence were performed., Results: Between 1996 and 2015, 3346 patients with first ischemic stroke were included; age-standardized incidence per 100 000 was 75.8 in women and 131.6 in men (2015). Overall, 5-year survival probabilities were 50.4% (95% CI, 47.9-53.1) in women and 59.2% (95% CI, 56.4-62.0) in men; 5-year survival was highest in patients with first stroke due to small-artery occlusion (women, 71.8% [95% CI, 67.1-76.9]; men, 75.9% [95% CI, 71.3-80.9]) and lowest in cardioembolic stroke (women, 35.7% [95% CI, 31.0-41.1]; men, 47.8% [95% CI, 42.2-54.3]). Five-year recurrence rates were 20.1% (95% CI, 17.5-22.6) in women and 20.1% (95% CI, 17.5-22.7) in men; 5-year recurrence rate was lowest in women in stroke due to small artery occlusion 16.0% (95% CI, 11.7-20.1) and in men in large-artery atherosclerosis 16.6% (95% CI, 8.7-23.9); highest risk of recurrence was observed in undefined strokes (women, 22.3% [95% CI, 17.8-26.6]; men, 21.4% [95% CI, 16.7-25.9]). Cox regression revealed improvements in case-fatality rates over time with differences in stroke causes. No time trends in recurrence rates were observed., Conclusions: Long-term survival and recurrence varied substantially by first stroke cause. Survival probabilities improved over the past 2 decades; no major trends in stroke recurrence rates were observed.

About 80 % of all strokes are of ischemic origin. Among these the Trial of ORG 10 172 in Acute Stroke Treatment (TOAST) classification denotes five the etiological categories: large-artery atherosclerosis, cardioembolism, small-artery occlusion, strokes of undetermined etiology and strokes of other determined etiology, which are based on imaging and diagnostic findings. The object of research is the distribution of these TOAST categories in a demographically defined population and their impact on the need of care. The present study involves patients recruited within the population-based Erlangen Stroke Project (ESPro). The patients were analysed at time points after admission as well as 3 and 12 month after the event. results were presented as adjusted Odds Ratios (aOR). 1355 patients with a first-ever-in-a-lifetime ischemic stroke were registered in the Community of Erlangen. TOAST classification could be performed in 89 % (1206) of ischemic strokes. The etiological classification of brain infarctions resulted in 12 % large-artery atherosclerosis, 26 % cardioembolism, 24 % small-artery occlusion, 37 % strokes of undetermined etiology and 2 % strokes of other determined etiology. While 20 % of the patients were independent functionally at the Barthel index at admission, the number was 39 % after 12 month. The category large-artery atherosclerosis showed the strongest relationship with the occurring need of care. The aOR with very strong care needs 12.79 (95 % CI 3.71 -44.07) lay particularly high in comparison with an aOR of 6.95 (95 % CI 2.16 - 22.33) in the category cardioembolism. The TOAST classification provides an appropriate tool for estimating the need of care. In particular the patients in the TOAST category large-artery atherosclerosis showed a high level of a need of care at the long-term follow-up., (Georg Thieme Verlag KG Stuttgart New York.)

Objective: The multicenter, single-arm CABERNET trial evaluated outcomes in high-surgical-risk patients with carotid artery stenosis treated with the NexStent plus FilterWire EX/EZ Emboli Protection System., Background: For patients at high surgical risk, carotid artery stenting (CAS) offers a less invasive alternative to carotid endarterectomy (CEA)., Methods: The trial enrolled 454 high-surgical-risk patients with carotid stenosis by angiography > or = 50% for symptomatic patients and > or = 60% for asymptomatic patients. The comparator primary endpoint was the 1-year major adverse event (MAE, defined as any death, stroke, or myocardial infarction [MI]) rate. It was compared with a proportionally weighted objective performance criterion (OPC) of 12.1% representative of published CEA results in similar patients plus a prespecified noninferiority margin (delta) of 4%. A second primary endpoint was the composite rate of 30-day MAE plus late (31-365 days) ipsilateral stroke., Results: Symptoms of carotid stenosis were present in 24.2% of patients; 36.6% of patients were considered high-surgical-risk due to comorbid risk factors and 63.4% due to anatomic risk factors. The rate of 30-day MAE plus late ipsilateral stroke was 4.7% (20/438). The comparator primary endpoint of 1-year MAE was 11.6% (51/438) and was noninferior to the OPC of 12.1% (95% upper confidence interval of 14.5% versus OPC plus delta of 16.1%, P = 0.005). Late ipsilateral stroke was 0.7% and target vessel revascularization at 1 year was 2.4%., Conclusions: The CABERNET trial demonstrates that CAS with NexStent and FilterWire is noninferior to (equivalent or better than) traditional CEA at 1 year in high-surgical-risk patients based on historical controls., (2008 Wiley-Liss, Inc.)

The relationship between the apolipoprotein E (apoE) and beta-fibrinogen G/A-455 polymorphisms and cerebrovascular disease (CVD) was examined in the present study. We compared 227 patients with the subtypes of CVD (large-vessel disease, lacunar stroke, cardiac embolism, or undetermined pathomechanisms) with 225 control subjects. The occurrence of apoE isoforms (E2, E3, and E4) and the beta-fibrinogen G/A-455 genotype was determined in these individuals. No differences in apoE polymorphisms or allele frequencies between the CVD patients and control subjects were found. However, analysis of apoE genotypes as a function of stroke subtype revealed that the apoE4 allele was significantly more common in those patients with macroangiopathy-associated CVD. The only CVD risk factor that distinguished patients with the E4 allele from those with other apoE genotypes was elevated cholesterol. No association between the beta-fibrinogen G/A-455 polymorphism and CVD was found. However, homozygosity for the A allele was more common in patients with CVD resulting from large-vessel disease. These data demonstrate that the apoE4 allele and the AA genotype of the beta-fibrinogen G/A-455 polymorphism occur significantly more frequently in patients with CVD resulting from stenosis of large, brain-supplying vessels. Such genetic analyses may further our understanding of the etiology of cerebrovascular disease.

History: A 45-year-old woman from Turkey who had been living in Germany for 6 years, suddenly became short of breath, developed seizures and died within 2 minutes. There was no evidence of previous illness., Investigations: At autopsy a large hydatid and many other hydatids of varying sizes were found inside the left heart. Rupture of one of the hydatid cysts in the left atrium had caused embolism to the arterial system. The cyst walls showed typical laminar cuticular structure. The sediments of the cyst fluid contained scolices of Echinococcus granulosus, but no antibodies were demonstrated by indirect haemagglutination., Diagnosis and Conclusion: This is a rare case of Echinococcus granulosus infection, limited to the heart, which had followed an asymptomatic course until sudden death caused by arterial embolism of the hydatids. Such diagnosis should be considered in case of sudden death of persons from areas in which the disease is endemic.