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Background and purpose Many countries worldwide, including Germany, reported that the first wave of the coronavirus disease 2019 (COVID‐19) pandemic in early 2020 influenced the care of acute ischemic stroke (AIS) patients, but data are lacking for further pandemic wave periods. Methods We conducted a nationwide, retrospective, cross‐sectional study of all hospitalized patients with the main diagnosis of AIS in 2019 and 2020. Primary outcomes were the number of hospitalizations for AIS, the application of stroke unit care, intravenous thrombolysis (IVT), and mechanical thrombectomy (MT), as well as the in‐hospital mortality during the different pandemic periods in 2020 compared to the corresponding periods in 2019. Secondarily, we analyzed differences in outcomes between patients with and without concurrent COVID‐19. Results We included 429,841 cases with AIS, of which 1268 had concurrent COVID‐19. Hospitalizations for AIS declined during both pandemic wave periods in 2020 (first wave: −10.9%, second wave: −4.6%). MT rates were consistently higher throughout 2020 compared to 2019, whereas the IVT rate dropped during the second wave period (16.0% vs. 17.0%, p, There was a substantial decline in hospitalizations for acute ischemic stroke during the two COVID‐19 pandemic waves in Germany, with a smaller reduction during the second wave of the pandemic. Acute ischemic stroke patients still frequently received acute stroke care, including recanalization treatments during the entire year of 2020, irrespective of SARS‐CoV‐2 status.

Background Comprehensive, nationwide data regarding Parkinson's disease (PD) hospitalizations, coronavirus disease 2019 (COVID‐19) in‐hospital frequency, and COVID‐19‐associated inpatient mortality during the first wave of the COVID‐19 pandemic are not available. Objective To provide a nationwide analysis on hospitalized PD patients in Germany and evaluate the impact of the COVID‐19 pandemic. Methods We conducted a cross‐sectional study using an administrative claims database covering 1468 hospitals and 5,210,432 patient hospitalizations including a total of 30,872 COVID‐19+ cases between January 16 and May 15, 2020. Results Compared to 2019, hospitalizations for PD transiently decreased by up to 72.7% in 2020. COVID‐19 frequency was significantly higher in the population of 64,434 PD patients (693 being COVID‐19+) than in non‐PD patients (1.1% vs. 0.6%, P

Background and Purpose: Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many countries have introduced strict hygiene measures of social distancing to prevent further spreading of the disease. This may have led to a decreased presentation to hospital of patients with acute medical conditions and time-dependent management, such as stroke. Methods: We conducted a nationwide cohort study using administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke (AIS), transient ischemic attack, or intracerebral hemorrhage. Data from a total of 1463 hospitals in Germany were included. We compared case numbers and treatment characteristics of pandemic (March 16 to May 15, 2020) and prepandemic (January 16 to March 15, 2020) cases and also with corresponding time period in 2019. Results: We identified a strong decline for hospitalization of AIS (−17.4%), transient ischemic attack (−22.9%), and intracerebral hemorrhage (−15.8%) patients during the pandemic compared with prepandemic period. IVT rate in patients with AIS was comparable (prepandemic versus pandemic: 16.4% versus 16.6%, P =0.448), whereas mechanical thrombectomy rate was significantly higher during the pandemic (8.1% versus 7.7%, P =0.044). In-hospital mortality was significantly increased in patients with AIS during the pandemic period (8.1% versus 7.6%, P =0.006). Conclusions: Besides a massive decrease in absolute case numbers, our data suggest that patients with AIS who did seek acute care during the pandemic, continued to receive acute recanalization treatment in Germany.

In der Arbeit wird ein Uberblick uber mogliche Methoden zur Erfassung von Behandlungsrealitaten akuter Schlaganfallpatient*innen in Akutkrankenhausern gegeben. Unter Berucksichtigung spezifischer Vor- und Nachteile der unterschiedlichen Moglichkeiten erfolgt der gezielte Abgleich der Bezugsfalle aus einer strukturierten Analyse der deutschlandweiten DRG-Statistik und der Daten der Geschaftsstelle Qualitatssicherung Hessen zur Schlaganfallakutbehandlung (SA_HE) fur das Jahr 2018. Nach DRG-Statistik bzw. SA_HE wurden 2018 in Hessen 16.267 bzw. 15.643 akute ischamische Schlaganfallpatient*innen behandelt (ICD I63), davon waren 53,7 % bzw. 54,5 % Manner. Die Altersverteilung in ihrer Gesamtheit zeigte keinen signifikanten Unterschied, allerdings waren die >70-jahrigen Schlaganfallpatient*innen in der DRG-Statistik signifikant haufiger vertreten. Die Rate an systemischen Thrombolysen betrug nach beiden Datenquellen 16,5 %, die an mechanischer Thrombektomie 5,6 % bzw. 5,9 %. Die Analyse zeigt, dass nach einer rationalen Eingrenzung der einbezogenen Falle sowohl Fallzahlen, Geschlechter- und Altersverteilung wie auch die erfassten Raten an systemischer Thrombolyse und mechanischer Thrombektomie bei Bezug auf den Behandlungsort eine ausreichend hohe Ubereinstimmung ohne statistische Unterschiede aufweisen. Hieraus kann geschlossen werden, dass das untersuchte, gut kontrollierte Qualitatssicherungsregister eine ausreichend hohe Fallzahl an Schlaganfallpatient*innen mit erfolgten Akuttherapien erfasst. Es erscheint somit empfehlenswert, dass die strengen Vorgaben der Datenerhebung und -kontrolle bundesweit ubernommen werden. Hierdurch ware eine deutschlandweite kombinierte Analyse der Daten der Arbeitsgemeinschaft Deutschsprachiger Schlaganfall-Register (ADSR) und der DRG-Statistik moglich.

Background and Purpose— To date, there is still uncertainty about age and sex differences in access to stroke unit treatment and use of intravenous thrombolysis (IVT), while age and sex differences have not been investigated for the new treatment option of mechanical thrombectomy (MT). We, therefore, undertook a complete nationwide analysis of all hospitalized ischemic stroke patients in Germany from 2013 to 2017. Methods— We used the nationwide administrative database of the German Federal Statistical Office and investigated access to stroke unit treatment, IVT, MT, and in-hospital mortality. Patients were subdivided into 6 predefined age groups (20–44, 45–59, 60–69, 70–79, 80–89, and >90 years). Pooled overall and age group estimates were calculated using the random-effects model. To evaluate potential sex disparities, we estimated odds ratios (ORs) with 95% CIs. Results— A total of 1 112 570 patients were hospitalized for first or recurrent ischemic stroke from 2013 to 2017. Overall, stroke unit treatment increased significantly from 66.8% in 2013 to 73.5% in 2017, as did IVT (from 12.4% to 15.9%) and MT (from 2.4% to 5.8%; all P Conclusions— Access to stroke unit treatment has to be increased in both older patients and women of all ages. While there was no sex difference in IVT use, it is important to further investigate the significantly higher frequency of MT in women with ischemic stroke irrespective of age.

Background Since the coronavirus disease 2019 (COVID-19) has risen, several risk factors have been identified, predicting a worse outcome. It has been speculated that patients with Multiple sclerosis (MS) have an increased risk for a severe course of COVID-19 due to a suspected higher vulnerability. Therefore, we aimed to analyze the impact of comorbid MS on the outcome of patients with COVID-19 in Germany. Methods We conducted a retrospective cross-sectional study using the administrative database of all hospitalized patients diagnosed with PCR-confirmed COVID-19 (n = 157,524) in Germany during 2020. The cohort was stratified according to the presence (n = 551) or absence (n = 156,973) of comorbid MS, including discrimination of MS subtypes. Primary outcome measures were admission to the intensive care unit (ICU), use of invasive or non-invasive ventilation, and in-hospital mortality. Differences were investigated using rates and odds ratios as estimates. Pooled overall estimates, sex-stratified estimates, age-group stratified estimates, and MS subtype stratified estimates were calculated for all outcomes under the random-effects model. Results Among 157,524 patients hospitalized with COVID-19, 551 had a concurrent MS diagnosis (0.3%). Overall, univariate analysis showed lower rates of ICU admission (17.1% versus 22.7%, p p p Conclusions Although there might be differences in risk within the MS patients’ population, this large-scale nationwide analysis found no evidence for a worse outcome of COVID-19 in patients with comorbid MS compared to non-MS individuals.

Background Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes. Methods We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses. Results The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile. Conclusion These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Introduction During the first peak phase of the COVID-19 pandemic, the German Ministry of Health recommended that elective treatments should be postponed to increase hospital capacities. This has also compromised the capacity for application of specialized Parkinson's disease (PD) therapies to an unknown extent. Methods We conducted a nationwide cross-sectional study using administrative database of all hospitalized patients with main diagnosis of PD receiving multimodal complex treatment (PD-MCT), initial setup of levodopa/carbidopa intestinal gel (LCIG) or continuous subcutaneous apomorphine infusion (CSAI) in Germany. We compared case numbers and clinical characteristics of the pandemic (March 16th - May 15th, 2020) and post-lockdown (July 16th - September 15th, 2020) period with the pre-pandemic (January 16th - March 15th, 2020) and historical control period (March 16th - May 15th, 2019). Results We identified a strong decline for PD-MCT(-62.8%) and for the application of drug pump-based therapies (−69.4%) during the first peak phase of the pandemic as compared to the pre-pandemic period while specialized PD treatment procedures increased again in the post-lockdown phase. Advanced disease was a marker for PD-MCT patients during the pandemic period. Conclusion Besides the marked decline in specialized PD treatments during the first peak phase of the COVID-19 pandemic, we found recuperative effects for these procedures in the post-lockdown period without reaching pre-pandemic levels. Strengthening treatment capacities for PD patients, even in the event of a persistent pandemic, is urgently needed in order to maintain the quality of care.

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Background Comparing health care parameters of acute ischemic stroke (AIS) patients with and without concurrent coronavirus disease 2019 (Covid-19, SARS-CoV-2 infection), may be helpful in terms of optimizing clinical and public health care during pandemic. Methods We evaluated a nationwide administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke with/without diagnosis of Covid-19 who were hospitalized during the time period from January 16th to May 15th, 2020. Data from a total of 1463 hospitals in Germany were included. We compared case numbers, treatment characteristics (intravenous thrombolysis, IVT; mechanical thrombectomy, MT; treated on an intensive care unit, stroke unit or regular ward) and in-hospital mortality of AIS with and without concurrent diagnosis of Covid-19. Results From a total of 30,864 hospitalized Covid-19 patients during the evaluation period in Germany, we identified a subgroup of 213 patients with primary diagnosis of AIS. Compared to the 68,700 AIS patients without Covid-19, this subgroup showed a similar rate of IVT (16.4% vs. 16.5%, p = 0.985) but a significantly lower rate of MT (3.8% vs. 7.9%, p = 0.017). In-hospital mortality rate was significantly higher in patients with AIS and concurrent Covid-19 compared to non-infected AIS patients (22.5% vs. 7.8%, p Conclusion These nationwide data point out differences in mortality and medical treatment regime between AIS patients with and without concurrent Covid-19. Since the pandemic is still ongoing, these data draw attention to AIS as a less frequent but often fatal comorbidity in Covid-19 patients.

Regional differences in acute ischemic stroke (AIS) care are still reported for Germany but not fully understood. We aimed to analyze the impact of the level of urbanization on the application of proved treatment procedures and the incidence of hospitalized AIS cases in Germany.The level of urbanization of the 401 districts and district-free cities in Germany was defined according to the Federal Institute for Building, Urban Affairs and Spatial Research classification. Using nationwide administrative data, the application of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and the incidence of hospitalizations for AIS, were analyzed according to the place of residence of the patients. Data included all patients hospitalized for AIS in 2019 (n = 224,274) and sociodemographic information of 83,019,213 residents in Germany.Sparsely populated districts had a significantly higher incidence of hospitalizations for AIS than cities (age-standardized: 271.8 versus 242.3 per 100,000 inhabitants, P 0.001), but a lower use of MT (5.7% versus 8.4%, P 0.001). In the adjusted negative binomial regression model, rurality remained an independent predictor for MT use and the incidence of AIS hospitalizations. The proportion of IVT did not significantly differ between sparsely populated districts and cities (15.6% versus 17.2%, P = 0.021).Although there is a dense network of stroke units in Germany, the level of urbanization still influences AIS care, as we found a lower proportion of MT and a higher incidence of AIS hospitalizations in Germany's rural areas.

Zusammenfassung Hintergrund Die flächendeckende Bereitstellung evidenzgestützter Therapien zur Behandlung des akuten Schlaganfalls wird in Deutschland durch ein enges Netz von gegenwärtig mehr als 300 Stroke Units gewährleistet. Seit dem Jahr 2015 ist die Mechanische Thrombektomie (MT) als weitere Option zur Rekanalisation eines großen arteriellen Gefäßverschlusses der vorderen Zirkulation bis zu sechs Stunden nach Symptombeginn zugelassen und wird in besonderen Fällen auch darüber hinaus empfohlen. In der vorliegenden Arbeit werden die Entwicklung der regionalen Verfügbarkeit und Anwendungshäufigkeit der MT zwischen dem Jahr 2010 und 2015 dargelegt sowie Rückschlüsse für die Gestaltung der Versorgungsstruktur gezogen. Methoden Grundlage des analytischen Teils sind die regionalisierten DRG-Statistiken (www.destatis.de) u. a. aggregiert auf die Verwaltungsebene der Kreise und kreisfreien Städte für die wohnortbezogene Auswertung sowie die strukturierten Qualitätsberichte (sQB) der Krankenhäuser für die behandlungsortbezogene Auswertung im Hinblick auf die durchgeführten MT. Überdies finden die publizierten Daten zu Interventionen an den hirnversorgenden Gefäßen aus dem BQS-Register für das Modul E des DeGIR/DGNR-Modul- und Stufenkonzeptes Berücksichtigung. Ergebnisse Folgende Entwicklungen lassen sich aufzeigen:Ausgehend von einer bundesweiten MT-Rate von 0,7 % aller Schlaganfallpatienten mit Hirninfarkt in 2010 kam es in den folgenden Jahren zu einem stetigen Anstieg der Interventionszahlen mit einer zuletzt zwischen 2014 und 2015 sprunghaften Entwicklung auf 3,1 %. Die Streubreite variierte abhängig vom Wohnort zwischen 0 und 7,4 % (2014).In diesem Zeitraum verdoppelte sich die Anzahl der MT-kodierenden Klinken von 107 (2010) auf 209 (2015). Die Summe der Prozeduren stieg im selben Zeitraum um fast das Fünffache (von 1630 auf 7797), wobei eine klare Entwicklung hin zur Zentrumsbildung erkennbar ist. 2015 erfolgten bereits ca. 3/4 aller MT in Häusern mit > 50 Interventionen/Jahr.Bezogen auf die Wohnorte der Patienten wurde in 2014 nur noch bei Patienten aus 4 % (n = 18) der insgesamt 413 Städte/Kreise keine einzige MT durchgeführt, zeitgleich verfügte aber erst 1/4 dieser 413 Verwaltungsbezirke über Interventionsmöglichkeiten vor Ort.Die im BQS-Register für das Modul E erfassten MT-Zahlen beim akuten Schlaganfall übertreffen für viele Interventionskliniken teils in erheblichem Maße die administrativen Versorgungsdaten auf Basis der sQB-Daten. Diskussion Insgesamt erscheinen in Deutschland bereits sowohl die personellen als auch strukturellen Voraussetzungen für eine flächendeckende Implementierung der MT in die Schlaganfallakutversorgung günstig. Unter dem Aspekt der Behandlungsqualität ist die Entwicklung hin zu Interventionszentren mit ausreichend hohen Behandlungszahlen sinnvoll. Nun stellt die Etablierung individueller regionaler Zuweisungskonzepte bei gleichzeitigem Erhalt der gegenwärtig hohen Basiskompetenz bei der Schlaganfallversorgung in der Fläche durch Konsolidierung der regionalen Stroke Units eine wesentliche Aufgabe dar. Hinsichtlich einer weiteren realistischen Bedarfsplanung zur MT-Bereitstellung sind zuverlässige Leistungszahlen erforderlich, sodass die Abweichungen zwischen den BQS-Registerdaten und den offiziellen DRG-Statistiken bzgl. der dokumentierten MT zukünftig ausgeräumt werden sollten.

Die mechanische Thrombektomie (MT) stellt eine evidenzbasierte Therapieform bei Patienten mit akutem Hirninfarkt dar. Eine flachendeckende qualitative Bereitstellung der MT fur alle infrage kommenden Patienten innerhalb der kurzest moglichen Zeit stellt eine grose Herausforderung dar. Analyse der bundesweiten MT-Versorgungsrealitat anhand einer regionalisierten und klinikbezogenen Auswertung. Administrative Versorgungsdaten wurden anhand der DRG-Statistiken und der strukturierten Qualitatsberichte der Krankenhauser fur die Berichtsjahre 2010 und 2014 ausgewertet. Bezogen auf die Fallzahlen von Patienten mit akutem Hirninfarkt wurden die Raten und Veranderungen an systemischer Thrombolyse (STL) und MT in den 413 Kreisen und kreisfreien Stadten analysiert. Die Rate an rekanalisierenden Behandlungen ist im Zeitraum von 2010 zu 2014 bundesweit gestiegen (STL-Rate von 8,0 auf 11,6 %; MT-Rate von 0,7 auf 2,3 %). Je nach Wohnort des Patienten ergaben sich dabei hohe Streubreiten (STL = 3,4–26,7 %; MT = 0–7,4 %). Im Jahr 2014 wurden 5526 MT bei 244.757 Hirninfarkten kodiert. Insgesamt wurden 134 Krankenhausern mit mehr als 2 MT/Jahr ermittelt. 21 % aller MT wurden in nur 7 Kliniken mit >100 MT/Jahr durchgefuhrt. In 308 (75 %) der 413 Regionen wurde keine MT durchgefuhrt. Durch ein enges Netz an zertifizierten Stroke-Units mit flachendeckender Verfugbarkeit der STL sind in Deutschland ausgezeichnete strukturelle Voraussetzungen zur Behandlung von Patienten mit akutem Hirninfarkt etabliert. Bezogen auf das Ziel einer ubiquitaren Verfugbarkeit der MT ist noch Optimierungsbedarf erkennbar. Trotz Zunahme der Anzahl an Kliniken mit der Moglichkeit zur MT, ist ein Trend hin zu Interventionszentren mit uberregionalem Einzugsgebiet festzustellen.

Background Comprehensive administrative data on TIA and stroke cases and treatment modalities are fundamental for improving structural conditions and adjusting future strategies of stroke care. Methods The nationwide administrative database (German federal statistical office) was used to extract all adult inpatient TIA and stroke cases and corresponding procedural codes for the period 2011–2017. Numbers were specified according to age, sex, stroke unit (SU) and critical care treatment (ICU), early transfer, and in-hospital mortality. Findings Inpatient adult TIA/stroke cases increased from annually 102,406 / 250,199 (2011) to 106,245 / 264,208 (2017). 84% of strokes were ischemic (AIS) also having the highest relative increase most likely due to more accurate coding within the time period, 68.2% of AIS were treated on SUs. 78% of hemorrhagic strokes were intracerebral hematomas (ICH; rather than subarachnoid hemorrhages [SAH]). Hemorrhagic strokes were increasingly treated on SUs (32.6% [2011], 37.8% [2017]). 68.8% of SAH were treated on ICUs (ICH:36.3%, AIS:10.3%). Early transfer in AIS increased (2.0 to 3.1%). Hemorrhagic strokes were associated with higher in-hospital mortality (SAH:19.6%, ICH:28.2%, AIS:7.3%). Interpretation The absolute increase of strokes presumably reflects the aging society and more awareness for cerebrovascular disease. The relative increase of AIS may be attributable to an increased neurological expertise. The increasing amount of early transfers in AIS reflects new specialized treatment options. Our findings reflect the need for structural adjustments in inpatient stroke care.

Parkinson’s disease (PD) is a very common extrapyramidal movement disorder and currently the world’s fastest growing neurological disorder. In the course of disease progression, a majority of PD patients develop severe motor fluctuations which often cannot be adequately treated with common oral anti-Parkinsonian medications. With continuous subcutaneous apomorphine infusion (CSAI), levodopa–carbidopa intestinal gel infusion (LCIG), and deep brain stimulation (DBS), there exist three effective treatment options for advanced PD patients with motor fluctuations. In this study, we analyze the dynamics of implementation for these treatments in Germany over the years 2010–2017 based on the diagnosis-related group statistics and structured quality reports. All three intensified therapy measures are increasingly applied in Germany. The mean age of therapy implementation is rising and more male than female patients receive treatments. Although DBS is provided primarily in university hospitals with a caseload of at least two procedures per month, there exists a substantial proportion of DBS procedures which is conducted in hospitals with only a low caseload. Most of the drug pump implementations (CSAI and LCIG) are conducted in a large number of hospitals with an overall low case number. As we detect a strong rise of the implementation of these device-based therapies, it will be a challenging task to satisfy patient need and perpetuate high standards for these specialized procedures in the future.

Background Mechanical thrombectomy (MT) is a new evidence-based treatment option for large vessel occlusion in the anterior brain circulation. Using comprehensive administrative data from Germany, we analysed the nationwide development of intravenous thrombolysis (IVT) and MT in Germany between 2010 and 2016. Methods We considered all documented cases (n = 1,515,634) with a main diagnosis of the ICD-10-GM code I63 (ischemic stroke) and identified specific stroke recanalization therapy by using the corresponding Operating and Procedure Key for systemic thrombolysis and mechanical thrombectomy out of the DRG statistics. Regional analyses are based on data from the 413 German administrative districts and cities and the obligatory quality reports of all hospitals. We distinguished between rates of MT related to place of residence of patients and place of treatment. Results Coded ischemic strokes increased by 10.2% from 2010 (n = 206.688) to 2016 (n = 227.687). The rate of IVT increased from 8.9% in 2010 to 14.9% in 2016 and the rate of MT increased from 0.8% in 2010 to 4.7% in 2016 with a strong increase in 2015 and 2016. There was a high regional variability of MT according to place of residence of patients between 0 and 11.2% in 2016 with significant lower treatment rates in rural compared to urban areas (3.8 vs 5.4%). Mean age of patients treated with MT increased from 67.8 years in 2010 to 73.3 years in 2016 and almost reached the mean age of IVT treated patients (74.4 years). The number of hospitals coding MT increased from 91 to 193 from 2010 to 2016, but 80% of all MT procedures were performed in neurointerventional centers with ≥50 procedures/year in 2016. Conclusions The rate of IVT in patients with acute ischemic stroke in Germany continues to rise and has reached 14.9% nationwide. The increase of MT is even more pronounced and was triggered by the evidence after publication of the MT randomized trials. There is still a high regional variability with significant lower MT rates in rural areas.

Hohergradige atherosklerotisch bedingte extrakranielle Karotisstenosen sind fur 5–10 % aller ischamischen Schlaganfalle verantwortlich. Die Empfehlungen insbesondere zur Versorgung asymptomatischer Stenosen unterziehen sich aktuell einem Wandel. Gesammelte Erkenntnisse zu Indikationsstellung und Verteilung von Fallzahlen in Deutschland liegen nicht vor. Ebenso sind diesbezuglich weder Einfluss noch Umsetzung der im Jahr 2012 publizierten S3-Leitlinie untersucht. Routineversorgungsdaten wurden anhand der DRG („diagnosis-related groups“) -Statistiken und strukturierter Qualitatsberichte der Krankenhauser zur Haufigkeit operativer und interventioneller endovaskularer Eingriffe an symptomatischen und asymptomatischen Karotisstenosen in den Jahren 2010 und 2013 ausgewertet. Pro Jahr werden in Deutschland ca. 37.000 Karotisendarteriektomien (CEA) und 5000 Karotisangioplastien mit Stentversorgung (CAS) durchgefuhrt. Etwa 94 % der CEA und 62 % der CAS werden in Zentren mit > 25 Eingriffen pro Jahr durchgefuhrt. Lediglich 33 % der CEA und 39 % der CAS werden bei symptomatischen Stenosen vorgenommen. Rechnerisch zeigen sich eine Unterversorgung von symptomatischen und eine Uberversorgung von asymptomatischen Karotisstenosen. Es sollten Anstrengungen unternommen werden, um eine leitlinienkonformere Versorgung herzustellen und damit insbesondere das Schlaganfallrisiko beim Vorliegen einer atherosklerotischen symptomatischen Arteria-carotis-interna-Stenose zu reduzieren.

Promising advances in stroke medicine have been reported recently regarding specialized stroke unit (SU) care, expansion of the time window of iv thrombolysis (IVT), mechanical thrombectomy (MT), and decompressive hemicraniectomy (DHC) for malignant brain infarction. It remains unclear to what extent new evidence of therapeutic procedures is transferred to the "real-world" of everyday hospital care. We analyzed epidemiologic and procedural therapeutic trends of hospitalized acute stroke patients in Germany by the comparison of administrative hospital data of the years 2008 (n=219,359) and 2012 (n=239,394). Proportion of specialized SU care rose from 43.4% to 56.9%. Even in age-matched analysis women were less likely to obtain this procedure. Rate of IVT increased from 5.6% to 10.2%. 32% of IVT therapies in 2012 were performed in patients over 80 years. Number of MT increased exponentially from 298 to 3906 procedures. Number of DHC did not increase significantly (2008=636; 2011=796). A strong momentum in transferring scientific insights to the "real-world" stroke care in Germany was documented. Increase of IVT therapy is largely due to the increase of off-label treatment. Almost every 46 th patient

Nach wie vor entscheiden vor allem der Zeitpunkt der richtigen Diagnosestellung, der unmittelbare Beginn einer geeigneten spezifischen Therapie und die kompetente Behandlung auf einer Stroke-Unit die Langzeitprognose von Schlaganfallpatienten. Daher finden sich bundesweit Bestrebungen, die erforderliche fachliche Kompetenz und infrastrukturellen Voraussetzungen flachendeckend bereitzustellen. Divergierende regionale Gegebenheiten sowie okonomische Gesichtspunkte bestimmen hierbei die Merkmale der unterschiedlichen Versorgungskonzepte und das Zusammenspiel der beteiligten Kooperationspartner. Die vorliegende Arbeit stellt die Entwicklung hinsichtlich drei qualitativer Behandlungsparameter im Zeitraum von 2008 bis 2011 am Beispiel von vier regionalen Versorgungsmodellen gegenuber. Anhand der Datenbanken der DRG-Statistik fur die Berichtsjahre 2008 und 2011 wurden die Hospitalisierungsraten fur Patienten mit transitorisch ischamischen Attacken, ischamischen und hamorrhagischen Schlaganfallen, die Fallzahlen fur die Stroke-Unit-Behandlung sowie die Raten an systemischer Thrombolyse und mechanischer Thrombektomien in den Regionen Berlin, Ruhrgebiet, Ostwestfalen-Lippe (OWL) und Sudostbayern (TEMPiS) ausgewertet. Die Hospitalisierungsrate des ischamischen Schlaganfalls (Hirninfarkt, ICD I63) betrug im Zeitraum von 2008 bis 2011 durchschnittlich 294/100.000 Einwohner fur das Ruhrgebiet, 257/100.000 Einwohner fur OWL sowie jeweils 265/100.000 Einwohner fur Berlin und Sudostbayern. Die Schlaganfallkomplexbehandlungsquote lag im Jahr 2008 in Sudostbayern bei 31 % und im Jahr 2011 bei 47 %, die Vergleichswerte fur die ubrigen drei Regionen beliefen sich auf 42–44 %, respektive 58–59 %. Ausgehend von einer Rate systemischer Thrombolysen zwischen 4,2 und 7,4 % im Jahr 2008 fanden sich im Jahr 2011 fur die vier Versorgungsraume Steigerungsraten zwischen 41 und 145 %. Im Jahr 2011 lag nur im Ruhrgebiet die Thrombektomiequote mit 2 % aller Hirninfarkte uber dem Bundesdurchschnitt von 1,3 %. Der Schlaganfall ist in den vier untersuchten Regionen eine haufige Erkrankung. Fur die etablierten Therapieformen „Komplexbehandlung des Schlaganfalls“ und „systemische Thrombolyse“ lies sich im Verlauf des von uns gewahlten Beobachtungszeitraumes der positive Effekt strukturverbessernder Vorgehensweisen im Rahmen der vier unterschiedlichen regionalen Versorgungskonzepte nachweisen. Die aktuell noch als individueller Heilversuch zu betrachtende mechanische Thrombektomie wurde im Ruhrgebiet im Jahr 2011 signifikant haufiger angewendet als in den drei ubrigen Regionen. Zuvor war ein standardisiertes Zuweisungskonzept in der Metropolenregion etabliert worden.

Bundesweit bilden sich Netzwerke zur Verbesserung der Versorgung von Patienten mit akutem Schlaganfall, im Ruhrgebiet als Zusammenschluss von 26 neurologischen Kliniken. Parameter der Versorgungsqualitat sind u. a. „Stroke-Unit-Behandlung“ und „Lyserate“. Epidemiologische Daten beziehen sich meist auf Register, wenige Erkenntnisse uber Inzidenzen und den Grad spezialisierter Behandlung in der Routineversorgung liegen vor. Die Untersuchung basiert auf Daten aus DRG-Statistiken und strukturierten Qualitatsberichten 2008/2010 zur Versorgungsrealitat Schlaganfall im Ruhrgebiet. Die Aggregation der Fallzahlen fur Inzidenzen, Stroke-Unit-Behandlung und Lysetherapie auf Kreis-, Landes- und Bundesebene wurden analysiert. Die Inzidenz des ischamischen Schlaganfalls betrug 296/100.000/Jahr (Gesamtpopulation 5,2 Mio.), die landkreisbezogenen Spannweite 244–364. Auf einer Stroke-Unit wurden 56% der Patienten behandelt (Spannweite 18–80%; 2008: 43% [10–72%]). Die Lyseraten (ICD I63) lagen in 2008/2010 bei 6,4 bzw. 9,1% (0–11,2% bzw. 2,5–18,0%) und in 10 von 15 Kreisen signifikant uber dem Landesdurchschnitt. Der Schlaganfall ist eine haufige Erkrankung im Ruhrgebiet, die strukturelle Versorgungsqualitat (Stroke-Unit-Behandlung, Lyserate) ist uberdurchschnittlich hoch. Der heterogene Charakter der Region ermoglicht eine modellhafte Vernetzung zur Verbesserung der Versorgung u. a. durch einheitliche Behandlungsstandards und Strukturmasnahmen zur letztlich flachendeckenden Bereitstellung neuer Therapieverfahren. Die durchgefuhrte Analyse ermoglicht die Identifizierung des Optimierungspotenzials sowie das zeitnahe Monitoring von Veranderungsprozessen.

The amino acid hypusine is formed by post-translational modification of a lysine residue in eukaryotes and archaebacteria but up to now only the eukaryotic translation initiation factor eIF-5A has been known to contain this unique component. We isolated and purified a hypusine-containing protein from the thermophilic archaebacterium Sulfolobus acidocaldarius. The mainly cytosolic protein comprised about 0.03% of the post-ribosomal supernatant protein. No other hypusine-containing protein could be detected in S. acidocaldarius. The molar ratio of hypusine/hypusine-containing protein was 1:1. SDS/PAGE showed a molecular mass of 16.8 kDa; a pI of 7.8 for the native protein resulted from IEF. The N-terminus was blocked. Four cyanogen bromide fragments were partially sequenced and used to derive two 17-base oligonucleotide probes. A 3-kb HindIII fragment of genomic DNA hybridizing with both probes was cloned. By sequencing of exonuclease III deletion clones an open reading frame of 405 nucleotides was found coding for a protein of 135 amino acids with a molecular mass of 15 kDa. It contained all cyanogen bromide sequences analysed. Sequence alignment revealed that seven of eight residues around Lys40 in the Sulfolobus hypusine-containing protein were identical to the nonapeptides centered by hypusine in the three eIF-5A proteins sequenced so far. The Edman procedure gave no phenylthiohydantoin derivative for this position. For a central region of 44 residues a sequence similarity of 54% between the archaebacterial and eukaryotic proteins was calculated; for the total sequence about 33% similarity resulted. In addition, there were a number of conservative changes. The unique lysine modification surrounded by a conserved sequence strongly suggests a common ancestry of archaebacterial hypusine-containing protein and eIF-5A. Together with similarities in molecular mass and intracellular localization, it may point to an analogous biochemical function.

Summary Investigations of cell protein from various archaebacterial species representing about three fourths of the known phyla revealed that the ability to synthesize protein-bound deoxyhypusine and/or hypusine is apparently a common feature of all aerobic and anaerobic organisms of this kingdom. The deoxyhypusine contents varied between 6 and 78 nmol/g protein, the hypusine contents between 2 and 41 nmol/g protein. The lack or very low levels of hypusine corresponded to high concentrations of deoxyhypusine suggesting that deoxyhypusine may substitute for hypusine in its unknown function. The ability of Thermoproteus tenax, Pyrodictium occultum and Desulfurolobus ambivalens to hydroxylate deoxyhypusine in the absence of molecular oxygen points to another hydroxylation mechanism than that found in eukaryotes.

Hypusine, an unusual amino acid formed by post-translational modification of lysine, is normally determined by specific metabolic labelling followed by measurement of released radioactivity after protein hydrolysis. This paper describes a sensitive non-radioactive method for the determination of hypusine, involving complete protein hydrolysis and precolumn derivatization of the released amino acids with 4-dimethylaminoazobenzene-4'-sulphonyl chloride, followed by reversed-phase high-performance or medium-pressure liquid chromatography of the dabsylated derivatives. The detection limit of hypusine was about 500 fmol. Additionally, the hypusine-containing protein from the archaebacterium Sulfolobus acidocaldarius was purified. By applying the dabsylation method to the analysis of tryptic peptides derived from this protein, it was possible to determine the correct positioning of the hypusine residue in the amino acid sequence, which was not possible by the amino acid sequencing procedure alone.