Sowohl die Komplexität als auch dasweite Spektrumvaskulärerwienichtvaskulärer Komplikationen nach einem Schlaganfall stellt den ambulanten Behandler vor besondereHerausforderungen. In ihrem Leserbrief ergänzen Schwarz et al. die Liste nichtvaskulärer Komplikationen um das hochrelevante Themenfeld der Dysphagie und geben zugleich wichtige Hinweise zur Bedeutung und zum Management der Spastizität nach einem Schlaganfall. Der Leserbrief stellt somit eine beachtenswerte Ergänzung zu unserer Übersicht dar. Die Liste der relevanten Komplikationen ließe sich ungeachtet dessen noch erweitern. Bei der Entlassung aus der stationären Behandlung leidet ein Viertel der Schlaganfallpatienten unter einer Inkontinenz. Ein Jahr nach der Entlassung aus dem Krankenhaus sind es noch immer 15% [1].NebenkörperlichenLeiden determinieren zudem vor allem soziale Bedürfnisse die Lebensqualität der Betroffenen und verdienen somit verstärkte Beachtung in der Schlaganfallnachsorge [2]. AusderRelevanzundKomplexitätdes Themenfeldes leitet sich die Forderung nach einer strukturierten, sektorenübergreifenden und multidisziplinären ambulanten Nachsorge für Schlaganfallpatienten ab, wie sie flächendeckend noch immer nicht etabliert ist. Eben hierfür liefert der Leserbrief von Schwarz et al. indirekt nun weitere Argumente.

Background Besides the treatment of cardiovascular risk factors, the prevention and treatment of secondary complications is the main focus of outpatient poststroke care. The spectrum of noteworthy complications after a stroke changes during the course of the treatment and constitutes a specific challenge of outpatient poststroke care. Objective and methods This article provides references to the importance, management, diagnosis and treatment of the wide spectrum of nonvascular complications after stroke in the context of outpatient stroke aftercare. Results Poststroke depression (PSD), anxiety disorders and post-stroke fatigue are common complications after stroke, which require a timely diagnosis and treatment. Furthermore, the incidence of newly diagnosed dementia is 20% within the first 6 months after a stroke. Here too, therapeutic and preventive strategies especially in the early stage can delay the subsequent burden of the disease and the dependency on care. About half of every newly diagnosed epilepsy in patients older than 60 years is the result of a stroke. Falls and subsequent injuries are another important complication and a common reason for rehospitalization after a stroke. Although nearly 50% of patients suffer from chronic pain after a stroke this is often not sufficiently recognized. Conclusion The wide spectrum of secondary complications after a stroke constitutes a complex, sustained and multidisciplinary challenge, which requires a cross-sectoral interaction of various and numerous actors in outpatient poststroke care.

Beinahe jeder zweite Patient mit kryptogenem Schlaganfall hat ein persistierendes Foramen ovale (PFO). Das Konsensuspapier stellt zuerst die aktuelle Evidenz des interventionellen PFO-Verschlusses zusammen. Im Weiteren wird das Nutzen-Risiko-Verhältnis der antithrombozytären Therapie mit und ohne orale Antikoagulation im Verhältnis zum PFO-Verschluss abgewogen. Abschließend werden konsentierte Empfehlungsgrade formuliert. Sowohl der Nutzen der interventionellen als auch das Risiko der medikamentösen Behandlung waren bisher unzureichend belegt. Mit der Veröffentlichung weiterer randomisierter kontrollierter Studien und Metaanalysen lässt sich die Abwägung der Therapieoptionen valide beurteilen. Es zeigt sich eine signifikante Reduktion in der Inzidenz von erneuten Schlaganfällen bei Patienten mit interventionellem PFO-Verschluss im Vergleich zur medikamentösen Therapie. Die Komplikationsrate des interventionellen PFO-Verschlusses ist sehr niedrig. Die vorliegenden Daten zeigen, dass der interventionelle Verschluss des PFO einer alleinigen medikamentösen Therapie bei Patienten mit kryptogenem Schlaganfall im Alter unter 60 Jahren überlegen ist.

Almost every second patientwith cryptogenic stroke has a patent foramen ovale (PFO). This consensus document firstly provides an evidence-based overview on the diagnostics of PFO, current studies, interventional closure, and medical therapy in terms of platelet aggregation inhibitors and anticoagulation. Secondly, the risk–benefit balance of interventional versus antithrombotic therapy with and without oral anticoagulants in patients with cryptogenic stroke and PFO is discussed based on recent findings of randomized controlled clinical trials (RCTs) and meta-analyses. Ultimately, the consented recommendations and levels thereof are indicated. The published data demonstrate the superiority of interventional PFO closure. There is a significant reduction of recurrent strokes in patients with an interventional PFO closure device compared to medical therapy. The complication rate of the interventional therapy is low and particularly younger patients with cryptogenic stroke benefit from interventional PFO closure. In summary, interventional PFO closure is superior tomedical treatment in patientswith cryptogenic stroke aged <60years.

Die amyotrophe Lateralsklerose (ALS) ist mit einer erhöhten Sterblichkeit assoziiert. Das Wissen um mögliche Todesursachen könnte zu einer Individualisierung der Palliativkonzepte führen und damit differenzierte palliative Behandlungswege begründen. Es liegen bisher nur wenige systematische Daten zur Heterogenität der ALS-bedingten Todesursachen vor.

Background Amyotrophic lateral sclerosis (ALS) is associated with an increased mortality. Knowledge of possible causes of death could lead to an individualization of the palliative treatment concept and result in a differentiated palliative treatment pathway. Currently, only few systematic data are available on the heterogeneity of causes of death associated with ALS. Objective Analysis of the various causes of death in a prospective population-based German cohort of ALS patients. Material and methods Analysis of data of the Rhineland-Palatinate ALS registry in which newly diagnosed patients who had been identified between October 2009 and September 2012 were prospectively enrolled and followed up at regular intervals. From this prospective cohort study the causes of death were elicited based on information provided by the attending physicians, family members and by means of death certificates registered by the regional health authorities in Rhineland-Palatinate. Results Out of 200 ALS patients registered 148 died between register initiation on 1 October 2009 and the end of follow-up on 30 September 2015 (78 males and 70 females, death rate 74%). The most frequent cause of death was respiratory failure as a consequence of weakness of respiratory muscles (n = 91, 61%). Less frequent causes of death were pneumonia (n = 13, 9%), terminal cachexia (n = 9, 6%) and death from cardiovascular causes including sudden death (n = 9, 6%). Cases of suicide were rare (n = 3, 2%) as were deaths due to concurrent diseases (n = 2). In 21 cases (14%) the exact cause of death could not be clarified. Differences in the causes of death only showed a tendency towards the ALS phenotype. Respiratory failure was the cause of death in all patients with a respiratory phenotype and in 78% of patients with flail arm syndrome. Despite the low number of patients (8%) with additional frontotemporal dementia (FTD) a distinct difference in causes of death between those with and without FTD could be observed. Death due to respiratory failure was less frequent in ALS patients with FTD (33% vs. 65%) while pneumonia was more frequent (27% vs. 7%). Conclusion Respiratory failure was the most frequent cause of death in our cohort of ALS patients. In contrast, pneumonia and nutritional disorders played a less important role as the cause of death. The phenotypic expression of ALS might in part allow the cause of the prospective death to be predicted. Differentiation of ALS phenotypes is an important foundation for patient counseling on the process of dying to be expected and for the determination of an individual palliative concept.

Data on incidence of intracerebral haemorrhage (ICH) vary widely. Population-based data on predictors of ICH survival and functional outcome are rare. The Ludwigshafen Stroke Study is a prospective, population-based stroke registry which started in January 2006. All residents of the city of Ludwigshafen, Germany, who suffer from acute stroke or transient ischaemic attack are registered. Patients with first-ever primary intracerebral haemorrhage (FE-pICH) between 2006 and 2010 were included in the present analysis. Between January 1st, 2006 and December 31st, 2010, 152 patients suffered a FE-pICH. Crude and age-adjusted incidence rates per 100,000 for FE-pICH were 18.7 (95 % CI 15.9–21.9) and 11.9 (95 % CI 10.2–14.0), respectively, and remained stable over time. Case-fatality rates for FE-pICH were 27.0, 34.9 and 44.1 % at days 28, 90 and 365, respectively. In 21 patients, an (21.3 %) early do-not resuscitate-order was documented. Excluding these patients from multivariate analyses, National Institute of Health Stroke Scale (NIHSS) (OR 1.22, 95 % CI 1.08–1.36), hypercholesterolemia (OR 0.16, 95 % CI 0.05–0.55) and modified Rankin Scale (mRS) prior to stroke (OR 1.56, 95 % CI 1.06–2.3) were independently associated with risk of 1-year mortality, whereas NIHSS (OR 1.41, 95 % CI 1.20–1.66) and leukocyte count on admission (OR 1.48, 95 % CI 1.16–1.89) were independently associated with good or moderate functional outcome (mRS ≤ 3) after 1 year. Incidence of FE-ICH is in the lower range of those reported from other registries and remained stable over the observation period. Higher treatment rates for hypertension might partly account for this. Stroke severity as indicated by NIHSS was independently associated with mortality and functional outcome after 1 year. We found no association between aetiology and outcome in ICH patients.

Background and purposeAtrial fibrillation (AF) is amongst the most important etiologies of ischaemic stroke. In a population‐based stroke registry, we tested the hypothesis of low adherence to current guidelines as a main cause of high rates of AF‐associated stroke.MethodsWithin the Ludwigshafen Stroke Study (LuSSt), a prospective ongoing population‐based stroke register, we analyzed all patients with a first‐ever ischaemic stroke (FEIS) owing to AF in 2006 and 2007. We determined whether AF was diagnosed before stroke and assessed pre‐stroke CHADS2 and CHA2DS2‐VASc scores.ResultsIn total, 187 of 626 patients with FEIS suffered from cardioembolic stroke owing to AF, which was newly diagnosed in 57 (31%) patients. Retrospective pre‐stroke risk stratification according to CHADS2 score indicated low/intermediate risk in 34 patients (18%) and high risk (CHADS2 ≥ 2) in 153 patients (82%). Application of CHA2DS2‐VASc score reduced number of patients at low/intermediate risk (CHA2DS2‐VASc score 0–1) to five patients (2.7%). In patients with a CHADS2 score ≥ 2 and known AF (n = 106) before stroke, 38 (36%) were on treatment with vitamin K antagonists on admission whilst only in 16 patients (15%) treatment was in therapeutic range.ConclusionsOur study strongly supports the hypothesis that underuse of oral anticoagulants in high‐risk patients importantly contributes to AF‐associated stroke. CHA2DS2‐VASc score appears to be a more valuable risk stratification tool than CHADS2 score. Preventive measures should focus on optimizing pre‐stroke detection of AF and better implementation of present AF‐guidelines with respect to anticoagulation therapy.

Background and purposeRisk factors for IS in young adults differ between genders and evolve with age, but data on the age‐ and gender‐specific differences by stroke etiology are scare. These features were compared based on individual patient data from 15 European stroke centers.MethodsStroke etiology was reported in detail for 3331 patients aged 15–49 years with first‐ever IS according to Trial of Org in Acute Stroke Treatment (TOAST) criteria: large‐artery atherosclerosis (LAA), cardioembolism (CE), small‐vessel occlusion (SVO), other determined etiology, or undetermined etiology. CE was categorized into low‐ and high‐risk sources. Other determined group was divided into dissection and other non‐dissection causes. Comparisons were done using logistic regression, adjusting for age, gender, and center heterogeneity.ResultsEtiology remained undetermined in 39.6%. Other determined etiology was found in 21.6%, CE in 17.3%, SVO in 12.2%, and LAA in 9.3%. Other determined etiology was more common in females and younger patients, with cervical artery dissection being the single most common etiology (12.8%). CE was more common in younger patients. Within CE, the most frequent high‐risk sources were atrial fibrillation/flutter (15.1%) and cardiomyopathy (11.5%). LAA, high‐risk sources of CE, and SVO were more common in males. LAA and SVO showed an increasing frequency with age. No significant etiologic distribution differences were found amongst southern, central, or northern Europe.ConclusionsThe etiology of IS in young adults has clear gender‐specific patterns that change with age. A notable portion of these patients remains without an evident stroke mechanism according to TOAST criteria.

Background: Stroke etiology in ischemic stroke guides preventive measures and etiological stroke subgroups may show considerable differences between both sexes. In a population-based stroke registry we analyzed etiological subgroups of ischemic stroke and calculated sex-specific incidence and mortality rates. Methods: The Ludwigshafen Stroke Study is a prospective ongoing population-based stroke registry. Multiple overlapping methods of case ascertainment were used to identify all patients with incident stroke or transient ischemic attack. Modified TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria were applied for subgroup analysis in ischemic stroke. Results: Out of 626 patients with first-ever ischemic stroke in 2006 and 2007, women (n = 327) were older (73.5 ± 12.6 years) than men (n = 299; 69.7 ± 11.5 years; p < 0.001). The age-adjusted incidence rate of ischemic stroke was significantly higher in men (1.37; 95% CI 1.20–1.56) than in women (1.12; 95% CI 0.97–1.29; p = 0.04). Cardioembolism (n = 219; 35.0%), small-artery occlusion (n = 164; 26.2%), large-artery atherosclerosis (n = 98; 15.7%) and ‘probable atherothrombotic stroke’ (n = 84; 13.4%) were common subgroups of ischemic stroke. Stroke due to large-artery atherosclerosis (p = 0.025), current smoking (p = 0.008), history of smoking (p < 0.001), coronary artery disease (p = 0.0015) and peripheral artery disease (p = 0.024) was significantly more common in men than in women. Overall, 1-year survival was not different between both sexes; however, a significant age-sex interaction with higher mortality in elderly women (>85 years) was detected. Conclusions: Cardioembolism is the main source for ischemic stroke in our population. Etiology of ischemic stroke differs between sexes, with large-artery atherosclerotic stroke and associated diseases (coronary artery disease and peripheral artery disease) being more common in men.

Background:Churg-Strauss syndrome (CSS) is a rare systemic vasculitis. Case series with a focus on neurologic involvement are not common. With this study, we intended to evaluate the frequency and types of neurologic manifestations and complications at time of diagnosis and during follow-up of patients with CSS.Methods:In this monocentric study, consecutive patients of our hospital with first diagnosis of CSS based on the criteria of the American College of Rheumatology were included between 2001 and 2007. Each patient underwent a periodic follow-up with clinical and electrophysiologic examination. Data were obtained prospectively.Results:Fourteen patients were included. All patients had a hypereosinophilia and a history of asthma. Twelve of 14 patients had a neurologic involvement, mainly as an acute or subacute multiplex mononeuropathy (eight patients) or an axonal polyneuropathy (three patients). Three patients suffered from a neuropathy of cranial nerves, and two patients had a cerebral infarct. Mean follow-up period was 31 months. With immunosuppressive therapy, 13 patients had no additional neurologic complications, one patient suffered from a cerebral infarct. Initial neurologic symptoms as a result of peripheral neuropathy improved, but sequelae of axonal damage were persistently detectable.Conclusions:Even at time of diagnosis of a CSS, neurologic manifestations are common, especially as a multiplex mononeuropathy. With a consequent immunosuppressive therapy, new neurologic complications can be avoided for the most part.