PURPOSE:There is ongoing debate on which method of perfusion computed tomography (PCT) evaluation in ischemic stroke is the most appropriate for improved selection of patients for endovascular treatment. We sought to test different assessment methods for inter-rater reliability. METHODS:Twenty-six patients were enrolled prospectively before endovascular therapy for acute anterior circulation ischemic stroke. Three raters experienced in stroke imaging and blinded to other imaging and clinical information independently analyzed 22 technically successful PCT scans according to 3 prespecified assessment methods applied to cerebral blood flow (CBF)/cerebral blood volume (CBV) and time-to-peak (TTP) maps: (1) visual mismatch estimate (VME), (2) Alberta Stroke Program Early CT Score perfusion method (ASPECTS-PCT), and (3) quantitative perfusion ratios (qPRs): RCBF, RCBV, RTTP. Inter-rater agreement was assessed with Cohen's kappa, intraclass correlation coefficients (ICC), Bland-Altman plots, and global and descriptive statistics. RESULTS:Significant differences between raters were found with VME and ASPECTS-PCT (P < .001) but with qPRs only for CBV (P = .03). Inter-rater agreement for VME was at best moderate by kappa statistics (.51); moderate by ICC for all parametric maps of ASPECTS-PCT (.56-.62), strong for RTTP (.76), and excellent for RCBF (.92) and RCBV (.86). Pairwise comparisons revealed less scattering of individual values with qPRs and less deviation of mean differences from 0, suggesting minor systematic deviation by any 1 rater as compared with VME or ASPECTS-PCT. CONCLUSION:PCT evaluation methods used before endovascular therapy for acute anterior circulation stroke are subject to substantial inter-rater disagreement. QPRs in PCT evaluation had better inter-rater reliability than the often used VME and ASPECTS-PCT assessment.

BACKGROUND AND PURPOSE:Multiple structural white matter abnormalities have been described in patients with juvenile myoclonic epilepsy (JME). In the present study, the question of whether microstructural variations exist between the two subgroups of JME, with and without photoparoxysmal responses (PPR positive and negative), was addressed using diffusion tensor imaging.METHODS:A selection of 18 patients (eight PPR positive) from a tertiary epilepsy center diagnosed with JME and 27 healthy controls was studied. The following regions of interest were investigated: the ascending reticular activating system, lateral geniculate nucleus, genu of the internal capsule, ventromedial thalamus and inferior cerebellar peduncle.RESULTS:Widespread white matter microstructural abnormalities in JME and in particular in PPR positive cases were identified. PPR positive patients demonstrated increased fractional anisotropy in the ascending reticular activating system and ventromedial thalamus compared to PPR negative patients and healthy controls. Reduced fractional anisotropy of the lateral geniculate nucleus was observed in the entire JME group compared to healthy controls.CONCLUSIONS:Several microstructural variations between PPR positive and negative JME patients have been identified. Our findings highlight the pivotal role of the thalamus in the pathophysiology of primary generalized seizures and suggest that thalamo-premotor connections are both an essential part of epileptic networks and important in the pathogenesis of photosensitivity.

Aim To analyse perfusion CT (PCT) evaluation algorithms for their predictive value for outcome after endovascular therapy (ET) in acute ischaemic stroke. Materials and methods Twenty-six patients were prospectively enrolled to undergo endovascular therapy for moderate to severe [National Institute of Health Stroke Scale (NIHSS) score of ≥5] anterior circulation stroke ≤6 h of onset. PCT datasets were evaluated according to three algorithms: visual mismatch estimate (VME), Alberta Stroke Programme Early CT Score (ASPECTS) perfusion, and quantitative perfusion ratios (QPRs: RCBF, RCBV) of cerebral blood flow (CBF) and volume (CBV). Results were correlated with outcome measures [NIHSS score at discharge, NIHSS score change until discharge (ΔNIHSSA/D), mRS at 90 days (mRS90d)] and compared with a matched control group. Results Recanalization was achieved in 73%, median NIHSS score decreased from 14 to 5 at discharge. The treatment and control group did not differ by VME and ASPECTS perfusion, nor did VME correlate with any of the three outcome measures. ASPECTS perfusion was not predictive of any outcome measure in the ET group. RCBF and RCBV were associated with ΔNIHSSA/D in controls and, inversely, the ET group, but not with mRS90d. Receiver operating characteristic (ROC) analysis of RCBF (and RCBV) showed a positive predictive and negative predictive value of 87% (78%) and 74% (73%), respectively, for discriminating major neurological improvement (ΔNIHSSA/D <7 versus ≥7). Conclusions Implementation of QPRs for CBF and CBV are superior to clinically used VME and ASPECTS perfusion evaluation methods for predicting early outcome after ET for anterior circulation stroke.

Background: Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with vertebral artery dissection (VAD). However, there are limited data from recent, large international studies comparing risk factors and clinical features in patients with cervical artery dissection (CeAD) with other TIA or ischemic stroke (IS) patients of similar age and sex. Methods: We analysed demographic, clinical and risk factor profiles in TIA and IS patients ≤55 years of age with and without CeAD in the large European, multi-centre, Stroke In young FAbry Patients 1 (sifap1) study. Patients were further categorised according to age (younger: 18-44 years; middle-aged: 45-55 years), sex, and site of dissection. Results: Data on the presence of dissection were available in 4,208 TIA and IS patients of whom 439 (10.4%) had CeAD: 196 (50.1%) had CAD, 195 (49.9%) had VAD, and 48 had multiple artery dissections or no information regarding the dissected artery. The prevalence of CAD was higher in women than in men (5.9 vs. 3.8%, p < 0.01), whereas the prevalence of VAD was similar in women and men (4.6 vs. 4.7%, n.s.). Patients with VAD were younger than patients with CAD (median = 41 years (IQR = 35-47 years) versus median = 45 years (IQR = 39-49 years); p < 0.01). At stroke onset, about twice as many patients with either CAD (54.0 vs. 23.1%, p < 0.001) or VAD (63.4 vs. 36.6%, p < 0.001) had headache than patients without CeAD and stroke in the anterior or posterior circulation, respectively. Compared to patients without CeAD, hypertension, concomitant cardiovascular diseases and a patent foramen ovale were significantly less prevalent in both CAD and VAD patients, whereas tobacco smoking, physical inactivity, obesity and a family history of cerebrovascular diseases were found less frequently in CAD patients, but not in VAD patients. A history of migraine was observed at a similar frequency in patients with CAD (31%), VAD (27.8%) and in those without CeAD (25.8%). Conclusions: We identified clinical features and risk factor profiles that are specific to young patients with CeAD, and to subgroups with either CAD or VAD compared to patients without CeAD. Therefore, our data support the concept that certain vascular risk factors differentially affect the risk of CAD and VAD.

Background and Purpose: Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is the most effective and the only approved causal treatment in acute ischemic stroke. Summary of Case: We treated an 88-year-old hale woman with atrial fibrillation and acute left middle cerebral artery (MCA) infarction with intravenous thrombolysis. Directly thereafter, she developed an epileptic status. Immediate CT scan was normal. Fourteen hours later, it showed a normal left hemisphere but a fatal space-occupying contralateral MCA and anterior cerebral artery (ACA) infarction. Autopsy revealed thrombi in atria, large right MCA and ACA ischemia, and occlusion of two major visceral arteries. Conclusion: RtPA, though effective for the initial infarction, caused a rarely observed fatal adverse event, i.e. cardioembolism by detachment of atrial thrombi fragments, with an uncommon presentation as epileptic status. Stroke physicians’ awareness of this potential course will allow treatment in time. Abstract Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is the most effective and the only approved causal treatment within the first 4.5 hours of acute ischemic stroke [1]. Its most dreaded adverse event is symptomatic intracranial hemorrhage, which occurs in 2.4% [1] to 5.2% [2] of patients. Hence, most exclusion criteria are aimed to reduce bleeding risks. In contrast, cardioembolism to other vascular territories during or in direct course of thrombolysis for stroke is rarely observed in atrial fibrillation (AF) [3-5] and presence of intracardiac thrombus [6]. Although not systematically reported in large randomized controlled trials, up to 6.8% of thrombolysis patients with AF may have clinically significant cardioembolic strokes in other cerebrovascular territories possibly linked to rtPA [3]. Still, it is not the focus of stroke physicians which may oftentimes delay diagnosis and therapy [5]. and

Einleitung: Klinische Studiendaten verweisen auf einzelne Leistungsmerkmale des Kleinhirns innerhalb emotionaler Prozessebenen, welche der sozialen Kognition zugeordnet werden. Zur gesonderten Analyse der cerebellaren Funktionsmechanismen innerhalb dieser Prozessebenen wurden Ereignis-korrelierte Potentiale (ERP) der Erkennung varianter emotionaler Gesichtsausdrücke bei Kleinhirninfarkten untersucht. Methoden/Material: Zur klinischen Erfassung der Diskrimination emotionaler Gesichterausdrücke wurden neun Patienten mit cerebellaren Infarkten (6 Patienten unilateral, 3 Patienten bilateral) und neun Patienten mit einem vergleichbaren vaskulären Risikoprofil mit den Subtests 1 – 5 der Tübinger Affekt-Batterie (TAB) untersucht. Zur Evaluation der neuralen Merkmale der emotionalen Gesichtererkennung wurden die frühen und späten ERP für 120 farbige Gesichterabbildungen mit fünf unterschiedlichen Basisemotionen (neutral, fröhlich, ärgerlich, ängstlich, traurig) aus der Karolinska Directed Emotional Faces Database (KDEF) aufgezeichnet, welche in Berücksichtigung der ökologischen Validität pseudorandomisiert für 1200 ms innerhalb einer Abfolge von 579 Bildern unterschiedlicher emotionaler und nicht-emotionaler Szenen aus dem International Affective Picture System (IAPS) präsentiert wurden. Die ERP wurden mit einem hochauflösenden EEG-Sensornetz (129 channels) aufgezeichnet. Ergebnisse: Patienten mit einer Kleinhirnläsion wiesen klinisch Defizite in der Zuordnung visueller Gesichtsausdrücke (Subtest 5 der TAB; p = 0,042) auf. In dem ERP-Paradigma zeigten beide Patientengruppen für die frühe neutrale als auch emotionale Gesichtererkennung eine verstärkte N170. In der späten Phase der Gesichterkennung wies die Kontrollgruppe eine verstärkte späte Positivierung (late positive potentials; LPP) parietal für positive und negative gegenüber neutralen Gesichtsausdrücken um 600 ms auf, die Patienten mit einem Kleinhirninfakt hingegen nicht. In den Einzelanalysen war diese bei den Kleinhirninfarkten fehlende Potentialantwort signifikant für Furcht (p = 0,034) und Ärger (p = 0,049). Entsprechend der Dipolanalysen wurden bei den Kleinhirninfarkten die LPP für die Emotion Furcht inferior präfrontal links und für die Emotion Ärger neben superior temporal vor allem dorsofrontal generiert, während bei den Kontrollen die Generatoren der LPP für Furcht inferior präfrontal rechts und für Ärger superior temporal lokalisiert wurden. Neben dem Infarktvolumen ergab sich für die LPP eine signifikante Korrelation zum Crus I des Lobulus VII. Diskussion: Die klinischen und neurophysiologischen Ergebnisse vor allem der gestörten Erkennung negativer Gesichtsausdrücke bei Patienten mit einem Kleinhirninfarkt lassen auf eine spezifische cerebellare Komponente in der höhergeordneten Prozessierung sozialer Informationen schließen. In Berücksichtigung der unterschiedlich höheren, mutmaßlich kompensatorischen Aktivierungen des präfrontalen Cortex, und des Crus I als wesentlicher Störungsbereich innerhalb der Patientenstichprobe, weisen unsere Ergebnisse auf eine topographische Organisation mit einer spezifischen und eben keiner generellen Funktion des Kleinhirns in der Emotionsprozessierung.

Stroke-Units (SU) werden seit vielen Jahren durch die Deutsche Schlaganfallgesellschaft (DSG) und die Stiftung Deutsche Schlaganfall-Hilfe (SDSH) zertifiziert. Seit dem Jahre 2009 erfolgt dies in nunmehr 3. Generation mit der LGA InterCert des TÜV Rheinland. Mit der vorliegenden Arbeit werden die aktualisierten Zertifizierungskriterien vorgestellt, die ab dem Jahre 2012 gültig sein werden. Es konnten zahlreiche Kriterien und Definitionen weiter konkretisiert, präzisiert und verbliebene Grauzonen und Konfliktfelder reduziert werden. Auch wurde erstmals eine Trennung vorgenommen zwischen zertifizierungsrelevanten Minimalanforderungen und zusätzlichen Empfehlungen der SU-Kommission der DSG. Die Autoren möchten die SU-Betreiber auf diesem Wege ausdrücklich dazu motivieren, die Qualitätsmaßnahmen nicht an den Mindestanforderungen auszurichten, sondern gezielt darüber hinauszugehen. Zahlreiche Evidenzen sprechen dafür, dass dadurch nicht nur die Motivation des Personals und die Behandlungsqualität gesteigert, sondern gleichsam auch die ökonomische Situation verbessert werden kann.

Stroke units (SU) have been certified for many years by the German Stroke Society (DSG) and the German Stroke Aid Foundation (SDSH). Since 2009 this is now undertaken in the third generation by the LGA InterCert of the Technical Surveillance Society of Rhineland (TV Rheinland). This article presents the amended certification criteria which came into effect in 2012. Many criteria and definitions could be further defined and specified and residual grey areas and fields of conflict could be reduced. For the first time a distinction has been made between the minimum requirements relevant for certification and additional recommendations by the SU Commission of the DSG. In this manner the authors are aiming to motivate SU operators not just to align quality assurance measures to the minimum requirements but to deliberately go beyond them. There is a great deal of evidence to indicate that this will not only serve to increase the motivation of personnel and the quality of treatment but simultaneously the economic situation can also be improved.

Background: Although randomized clinical trials have reported significant improvement in mortality and functional outcome as measured with modified Rankin Scale (mRS) or Barthel index (BI) in stroke patients with space-occupying anterior circulation infarctions treated with hemicraniectomy, many clinicians are still concerned about the long-term health-related quality of life (HRQoL).Aim: Assessment of HRQoL after hemicraniectomy to holistically reevaluate clinical outcome.Methods: Eleven patients (6 men, 5 women; mean age 48 (SD 5.8) years) were examined at 9-51 months after hemicraniectomy. Test batteries comprised NIH stroke scale, BI, mRS, neuropsychological tests (Visual Object and Space Perception Battery and clock test), and HRQoL-scales (Short Form 36 Health Survey (SF-36), Nottingham Health Profile (NHP), Questions on Life Satisfaction, Hospital Anxiety and Depression Scale and EQ-5D).Results: Median values for NIHSS, Bland mRS were 11.5, 55 and 3.5. In HRQoL-scales, subscales related to physical mobility and functioning were consistently severely impaired, while subscales related to psychological well-being were impaired to a lesser extent. Mean scores for physical functioning and physical role were 10.5 and 12.5 in the SF-36, and 61.3 and 43.3 for physical mobility and energy in the NHP; emotional role and mental health scored 63.3 and 66.4 (SF-36), scores for emotional reaction and social isolation were 18.9 and 16.0 (NHP), respectively.Conclusion: Although, physical components of HRQoL are highly impaired, these stroke patients achieved a satisfying level of psychological well-being which was endorsed by a nearly unanimous retrospective appraisal of life-saving hemicraniectomy. (C) 2011 Elsevier B.V. All rights reserved.

In concern to the uncertain neural signature of the cerebellum in syntax processing, we investigated the Syntactic Positive Shift (SPS) for sentences with syntax violations in patients with cerebellar damage. In opposite to controls, patients showed no SPS around 300-650 ms for syntax violations. Interestingly, Minimum-Norm analysis of SPS revealed increased activity in supramarginal and homologous Broca area for syntax violations in patients with cerebellar infarction. Overall, our findings support the still growing knowledge of the involvement of the cerebellum in cerebral networks in syntactic processing as evidenced by a sensitive ERP component. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Background: Final infarct volume after thrombolysis for acute ischemic stroke depends on time to, and degree of reperfusion and residual blood flow, which is influenced by leptomeningeal collateralization. We evaluated the role of collateralization in the ischemic territory as a predictor of infarct size. Methods: Twenty-five patients (17 women, 8 men, mean age: 67.6 ± 12.4 years) selected by non-contrast-enhanced CT and CT angiography (CTA) underwent intra-arterial thrombolysis (iaT) within 6 h after symptom onset (mean 4.1 ± 1.3 h) for middle cerebral and terminal internal carotid artery (MCA/ICA) stroke. CTA was evaluated for collateralization using thick-slice coronal and axial maximum-intensity projection reconstructions according to a simple score, the CTA collateralization score (CTA-cs): 0 = no collateral filling, 1 = ≤50%, 2 = >50% but <100%, and 3 = 100% collateral filling. We analyzed the association between the final infarct volume on CT 5 days after the intervention and the CTA-cs, successful reperfusion (Thrombolysis in Myocardial Infarction, TIMI, grades 2 and 3) and time to treatment in a prospective study approved by our institutional review board, with informed consent from all patients. Results: Reperfusion was achieved in 72%. Asymptomatic and symptomatic parenchymal hemorrhage occurred in 2 patients (8%) each and hemorrhagic transformation in 4 (16%). CTA-cs (r = –0.63; p < 0.001) and postinterventional TIMI grade (r = –0.403; p = 0.046) were inversely associated with final infarct volume. After multiple regression analysis, CTA-cs and reperfusion remained as independent predictors of final infarct volume whereas time to treatment and initial stroke severity did not. Conclusion: The extent of collateralization and reperfusion are independent predictors of final infarct volume in acute MCA/ICA stroke treated with iaT. Time to treatment and stroke severity had no independent effect on final infarct volume.

Hintergrund: Die Patientenselektion für eine intraarterielle Thrombolyse (iaT) erfordert eine besondere Abwägung von Risiko, Verzögerung des Therapiebeginns und zusätzlichen Logistikanforderungen gegen einen möglichen Behandlungsvorteil. Ziel der Studie ist die Evaluation der Perfusions-CT (CTP) als Prädiktor des Outcome nach iaT bei akuten Verschlüssen im anterioren Stromgebiet.

Hintergrund: In den letzten Jahren ist deutlich geworden, dass der ischämische Schlaganfall zu einer schnellen und ausgeprägten Immunsuppression führt. Diese Immunsuppression geht u.a. mit einer Lymphopenie, einer verminderten HLA-DR Expression auf Monozyten sowie erhöhten Serum IL-6 Konzentrationen einher und stellt einen unabhängigen Risikofaktor für das Auftreten von bakteriellen Infektionen nach einem Schlaganfall dar. Gegenwärtig ist nur wenig darüber bekannt, in welchem Aktivierungszustand sich die im peripheren Blut überlebenden Lymphozyten befinden und welche Faktoren hier regulierend wirken. Neben pro- und antiinflammatorischen Zytokinen kann HMGB1 als starker Mediator einer proinflammatorischen Immunantwort wirken.