Abstract Background and aims Acute ischemic stroke treatment is a time-sensitive, interdisciplinary workflow demanding efficient communication and standardized protocols to ensure rapid and safe care. Smartphone applications offer the potential to enhance communication within the acute workflow. Modifying this high-risk process requires structured implementation. We aim to evaluate the impact of app-based single call activation (SCA) introduced via stroke team training (STT) on door-to-needle-times (DNT) at our comprehensive stroke center. Methods A comprehensive stroke center implemented STT prior to launching an app-based SCA using “Join” in April 2024. The neurologist alerts the stroke team (neurologists, ED nurses, radiology technicians, neuroradiologists, stroke unit nurses) via app-based SCA and conveys key information, enabling preemptive resource preparation. Weekly one-hour STT sessions, comprising briefing, simulation, and debriefing, began before app-start in clinical routine. Median DNT for patients receiving intravenous thrombolysis (IVT) was compared before (T1) and after (T2) implementing STT and SCA. Results SCA and STT were successfully integrated. N=316 SCAs were conducted in clinical routine and n=184 professionals participated in 23 STTs. Among 225 IVT-treated patients analyzed (T1: n=111; T2: n=114), median DNT decreased significantly from 27 minutes (IQR 16–46) to 19.5 minutes (IQR 14–36). Linear regression adjusted for imaging modality (CT/MRI), trichotomized NIHSS, time window (<4.5h/>4.5h), and SCA status(yes/no) identified SCA as an independent predictor of reduced DNT [β −0.187; CI: −18.769 to −0.600]. Conclusions App-based SCA implementation introduced by STT allows the stroke team to act in concert, significantly shortening DNT. Linear regression reveals SCA as an independent factor for reduced DNT. Conflict of interest TN: nothing to disclose; HW: nothing to disclose; MS: nothing to disclose; CF: nothing to disclose; IA: nothing to disclose; WP : reports grants from the German Research Foundation, LOEWE (research funding of the federal state of Hesse); royalties or licenses STROKE TEAM-Training (LAERDAL medical); payment or honoraria from LAERDAL medical, Alexion, Pfizer-BMS, Boehringer Ingelheim and AstraZeneca; support for attending meetings and/or travel from LAERDAL medical, Alexion and Pfizer-BMS; OA-F: nothing to disclose; RS: nothing to disclose; AB: nothing to disclose; JE: nothing to disclose Figure 1 - belongs to Results

Abstract Background and aims Recent years have shown an increase in research regarding biomarkers to detect neuroaxonal injury. Neurofilament light chain (NfL), a scaffolding axonal protein, has already demonstrated promising diagnostic and prognostic value in virtually all neurological diseases including stroke and other cerebrovascular disorders. The aim of this study is to conduct a systematic review that explores the diagnostic and prognostic relevance of blood NFL in patients with cerebrovascular disease in order to provide clinicians with a comprehensive and up-to-date overview to facilitate informed interpretation. Methods We systematically searched multiple literature databases following the PRISMA guidelines for systematic reviews, focusing on investigations on NFL in cerebrovascular diseases. Results We identified 984 recent publications and after reviewing abstracts for relevance 171 trials and experiments were assessed. The review is divided into five chapters: 1) the preclinical evidence of Nf metabolism and different methods of measuring, 2) predictive properties of NfL in the context of future cerebrovascular events providing a table of all trials published up until 2026 3) prognosis regarding outcome and rehabilitation after stroke 4) rare cerebrovascular diseases, such as CADASIL and 5) intracerebral hemorrhage (ICH). Conclusions NfL seems to be a very sensitive biomarker of neuroaxonal damage with promising results across different types of neurovascular disease in both acute and chronic stroke phases. Research data support its use in multiple clinical settings but validation studies in real-world contexts are needed. Conflict of interest Mark A. Kreye: nothing to disclose, Johannes Teller: nothing to disclose, Hans Worthmann: nothing to disclose, Maria M. Gabriel: nothing to disclose, Lorenzo Barba: nothing to disclose.

Background: Timely treatment of ischaemic stroke with intravenous thrombolysis (IVT) and endovascular treatment (EVT) depends on efficient communication within a multiprofessional team. Mobile applications can streamline communication and documentation processes in acute stroke care. Objective: This study aims to implement a mobile app to facilitate digital documentation and communication in acute stroke care and evaluate its impact on documentation rates and treatment times. Furthermore, a user experience survey was performed to gather information about the app usage in an acute medical process. Design: The study is designed as an observational post-market clinical follow-up cohort study. Methods: The mobile app ‘Join’ was implemented in a tertiary stroke care centre. Feasibility was assessed by monitoring documentation rates and process times, that is, ‘door-to-needle time’ (DNT) and ‘door-to-groin time’ (DGT). All patients treated for suspected stroke or transitory ischaemic attack were included in a 6-month period prior to (T1) and a 3-month period after (T2) implementation of the Join app. User experience was evaluated through a standardized survey including technical features. Results: The interface between the mobile application, hospital information, picture archiving and communication, and quality assurance system as well as various magnetic resonance imaging/computer tomography scanners was implemented for acute stroke care. A total of 504 stroke patients was treated, 334 in T1 and 170 in T2. Of these, 65 received IVT and 87 received endovascular treatment (EVT). DNT (T1 vs T2, 27.5 vs 32 min, p = 0.987) and DGT (T1 vs T2, 50 vs 61.5 min, p = 0.481) were numerically longer during T2. Documentation rates increased threefold for all patients and 1.5 times for those receiving recanalization therapy. The survey revealed that documentation (76%) and case information retrieval (52%) were the most used app features, while other functionalities were less frequently utilized. Conclusion: Implementing a mobile app facilitated real-time digital documentation accessible to the entire stroke care team. The introduction of the app did not improve treatment times for patients receiving acute recanalizing therapies. We recommend systematic training programmes to promote user acceptance and effective use.

Background:For patients with large vessel occlusion (LVO) admitted to primary stroke centers (PSC) without neuro-interventional capabilities, timely transfer to comprehensive stroke centers (CSC) is crucial. In this study, we compared the transport time of ground- and air-based transfer for patients receiving endovascular treatment at our CSC. Methods:In a retrospective cohort study, consecutive ischemic stroke patients with LVO who were transferred ground- or air-based to our CSC between October 2018 and December 2022 were examined. 170 patients with LVO from five PSCs within a radius of 55 to 85 km to the CSC were included. Patients were transported either with an emergency rescue helicopter (ERH), a ground ambulance (GA), GA accompanied by an emergency physician vehicle (EPV), or in a mobile intensive care unit (MICU) and were accordingly divided into air-based (61 patients) and ground-based (109 patients) main transport groups. Results:The analysis revealed a significant difference between air- and ground-based transport groups (75 vs. 82 min, p = 0.01). After calculating the transport time in relation to the covered ground distance, air-based transport was shorter by a median of 0.15 min per kilometer. In a comparison of the individual means, ERH was faster than GA and EPV (both p < 0.001). Only few transports were done by MICU and they mainly showed very long transfer times. The complication rates were generally low with only minor complications and no deaths reported in both groups. However, they were more frequently observed in the land-based transport group (20.2% vs. 8.2%, p = 0.04). Conclusion:In the present analysis, air-based transport was faster than ground-based transport for the secondary transfer of patients with stroke due to LVO in the observed regional conditions. Both air- and land-based transport appear to be safe. No serious complications occurred during transport, while complications were more frequent in the ground-based transport group.

BackgroundPatients undergoing cardiac surgery or percutaneous valve replacement may experience long-term neurologic and neuropsychiatric complications. The impact of postoperative delirium (POD) on these long-term complications remains controversial. We intended to illustrate the neurological and neuropsychiatric outcome associated with the occurrence of POD in patients undergoing elective cardiac surgery or percutaneous valve replacement.MethodsWe included 179 patients who underwent elective cardiac surgery or percutaneous valve replacement. Patients were evaluated postoperatively for delirium status. Neurological (score A) and neuropsychiatric (score B) outcomes were assessed using a structured examination protocol and interview at 1 year postoperatively and combined into a composite neurological and neuropsychiatric score (score A + B). Cognitive function was examined using the Montreal Cognitive Assessment (MoCA). Depression, fatigue and quality of life were assessed using the Beck's Depression Inventory (BDI), the Fatigue Impact Scale (FIS) and the Short-Form Health Survey (SF-12). Clinical outcome was assessed using the Barthel-Index (BI) and Frailty Index (FI). All data were collected prospectively.ResultsOne year after cardiac surgery or percutaneous valve replacement, a high number of patients suffered from neurological and neuropsychiatric symptoms with depressive symptoms (n = 36, 20.1%) and symptoms of fatigue (n = 72, 40.2%). Multivariable regression analysis showed that POD was associated with higher values on the A + B composite score, indicating worse neurological and neuropsychiatric outcome (POD status: b:1.172; 95%-CI, 0.070–2.273, p = 0.037; age: b:0.134; 95%-CI, 0.086–0.182, p < 0.001; NYHA classification at 1 year: b:1.998; 95%-CI,1.169–2.828, p < 0.001; rehospitalization b:1.786; 95%-CI, 0.640–2.932, p = 0.002). Patients with POD had lower postoperative MoCA scores (p = 0.001) and lower scores on both the SF12 Physical (p = 0.022) and the SF12 Mental Component Summary (p = 0.048). POD was not associated with depressive symptoms (p = 0.855), fatigue (p = 0.122) or rehospitalization (p = 0.379).ConclusionsPOD in patients undergoing cardiac surgery or percutaneous valve replacement was independently associated with worse long-term neurological and neuropsychiatric outcome. POD may be a relevant prognostic marker indicating the need for specific follow-up services, whereas other clinical parameters were not predictive of outcome.

Fibrotic scar formation after stroke serves a dual role: while essential for providing structural support during post-ischemic recovery, excessive fibrosis in the chronic phase of stroke impairs regenerative processes including axonal regrowth and neovascularization. The temporal dynamics of fibrosis are critical determinants of functional outcomes, as the balance between protective scarring and regenerative capacity differs across distinct stroke phases. Consequently, strategic modulation of fibrotic processes to preserve regenerative potential represents a promising therapeutic approach in stroke recovery. To understand the cellular mechanisms underlying this fibrotic response, we investigated stromal progenitor cell composition in the post-stroke brain. The vast majority of stromal progenitor cells (SPCs) are pericytes, with minorities comprising perivascular fibroblasts (PVFs) and vascular smooth muscle cells. We demonstrate that ischemic stroke drives a long-term shift in this composition, characterized by sustained expansion of the PVF population and excessive laminin deposition in the peri-infarct region, effects that persist for at least six months post-stroke. Single-cell RNA sequencing revealed sustained transcriptional and compositional alterations in the SPC population throughout chronic post-stroke phase, driven by AP-1-mediated signaling via TNFα in both PVFs and pericytes. These changes correlate with long-term vasomotor dysfunction and capillary constriction in the peri-infarct region at six weeks post-stroke. Ischemic stroke drives aberrant, persistent PVF accumulation at the capillary bed with implications for post-stroke cerebrovascular dysfunction and recurrent stroke. Taken together, these findings reveal that ischemic stroke drives an aberrant long-term mis-localization of PVFs to the capillary bed that may have clinically-relevant implications for post-stroke cerebrovascular function as well as potential ramifications for recurrent stroke.

BACKGROUND:Paxlovid is a combination of the antiviral agents nirmatrelvir and ritonavir indicated for the oral treatment of high-risk, symptomatic patients with coronavirus disease 2019 (COVID-19). As real-world data on the plasma concentrations of nirmatrelvir/ritonavir (Paxlovid) are limited, the aim of this study was to investigate nirmatrelvir/ritonavir plasma trough levels in a clinical setting using therapeutic drug monitoring. METHODS:A prospective, noninterventional, multicenter, observational clinical study was conducted in which the plasma trough levels of nirmatrelvir/ritonavir were simultaneously determined by using liquid chromatography tandem mass spectrometry in patients with symptomatic COVID-19. The blood samples were collected on days 1, 3, and 5 after the first full-dose day (day 0), and patient data such as sex, height, weight, renal function, liver enzymes, and concomitant (co-) medications were obtained to describe the plasma levels with respect to potential influencing factors. RESULTS:A total of 46 blood samples from 21 patients were analyzed. The geometric mean C min was 4997 ng/mL for nirmatrelvir and 529.4 ng/mL for ritonavir. The plasma concentrations covered a wide range, the highest being observed in patients with advanced age and renally excreted comedications. Patients older than 65 years had a significantly higher risk of achieving excessive plasma trough concentrations above 8840 ng/mL for nirmatrelvir and 1440 ng/mL for ritonavir compared with younger patients (odds ratio 11.2, 95% confidence interval 1.04-120.4). CONCLUSIONS:The plasma trough concentrations of nirmatrelvir and ritonavir in patients treated for symptomatic COVID-19 were higher than the reference values of 2210 ng/mL for nirmatrelvir and 360 ng/mL for ritonavir stated in the product characteristics. Advanced age and renally eliminated comedication were identified as possible influencing factors that warrant further investigation.

Objectives:Stroke is a severe complication in patients with left ventricular assist devices (LVAD), significantly affecting quality of life and potentially leading to death. This study aimed to illustrate the clinical features, outcomes, and risk factors associated with stroke in LVAD patients, with the goal of identifying potential treatment targets. Methods:In a study of 249 consecutive patients who underwent LVAD implantation, detailed evaluations were conducted regarding clinical characteristics, perioperative management, cardiovascular risk factors, comorbidities, and brain imaging. The etiology, treatment, and outcomes were subsequently assessed in individuals who encountered a stroke. Results:Eighty-three cerebrovascular events (CVE) occurred in 54/249 patients during a median study period of 2.2 years (0.4-3.5) with 53 ischemic events and 22 intracranial hemorrhages (ICH). Early peri- or postoperatively CVE in context to the LVAD implantation were identified in 31 patients. Competing risks regression analysis revealed that postoperative dialysis was associated with higher risk for CVE, considering death as competing risk event (HR 3.617; 95%-CI: 1.78-7.35; p ≤ 0.001). Modified Rankin Scale at outpatient visit did not differ in early CVE [3 (IQR 2-5) vs. 3 (IQR2-4), p = 0.146]. Late CVE frequently occurred during hospitalization for sepsis or in cardiac rehabilitation [n = 16/41 events (39%)]. Competing risk analysis treating death and heart transplantation as competitors identified history of stroke as associated factor [HR 3.564; 95%-CI (1.67-7.169); p = 0.001]. Mortality was not associated with CVE [with n = 27/54 (50%) vs. without CVE 94/195 (48.2%) p = 0.183]. Conclusion:Patients who require postoperative dialysis face a heightened risk for early cerebrovascular events (CVE) during and after LVAD implantation. Additionally, a history of stroke and complicated clinical courses should increase awareness regarding the potential for impending CVE in the long term.

BACKGROUND:Telemedicine is well established in acute stroke care and significantly contributes to widespread access to treatment. In intensive care, telemedicine is increasingly used to reduce mortality and complications. The German Society of Anesthesiology and Intensive Care Medicine (DGAI) also recommends telemedical consultations for neurological indications. METHODS:The aim of this survey was to assess structure, usage and need for telemedicine consultations for non-neurologically managed intensive care units and to determine whether there is a need to expand telemedicine stroke networks to include neurointensive care. A national cross-sectional survey was conducted, targeting all 22 German telemedicine stroke networks. The survey included 27 questions on structural aspects of intensive care units, the utilization of telemedical consultations and experiences with tele-neurointensive diagnostics and therapy. Additionally, a sub-study was conducted in six spoke hospitals within the telemedicine stroke network East Saxony (SOS-TeleNET). RESULTS:Of the 22 networks contacted, 17 (77%) responded. Of these, 11 (65%) regularly received consultation requests from intensive care units, most of which were handled by teleneurologists. The most common indications consisted of ischemic and hemorrhagic strokes, epileptic seizures as well as prognosis assessment and therapy goal adjustments. Several networks indicated interest in expanding telemedicine services for neurological care in intensive care units. CONCLUSIONS:The survey highlights a notable need for telemedicine neurointensive care consultations. Expanding telemedicine infrastructure in this field could contribute to improving the quality of care.

Telestroke networks aim to improve acute stroke care within their catchment area. Through a teleconsultation service, the network centers provide support to network hospitals that lack continuous neurological expertise for acute stroke management decisions. Although the importance of telemedical treatment in stroke care is steadily increasing, so far no standards exist for the organization of the teleconsultation service in networks. To ensure a high-level of quality for all processes and measures concerning telemedical stroke treatment, the commission for telemedical stroke care of the German Stroke Society (Deutsche Schlaganfall-Gesellschaft, DSG) created the following recommendations on how to organize a teleconsultation service within a telestroke network. The recommendations are the result of an adjustment process between the authors and include guidance on requirements, qualifications, processes and quality management within the teleconsultation service.

Background and objectives Postoperative delirium is a frequent and severe complication after cardiac surgery. Activity of butyrylcholinesterase (BChE) has been discussed controversially regarding a possible role in its development. This study aimed to investigate the relevance of BChE activity as a biomarker for postoperative delirium after cardiac surgery or percutaneous valve replacement. Methods A total of 237 patients who received elective cardiothoracic surgery or percutaneous valve replacement at a tertiary care centre were admitted preoperatively. These patients were tested with the Montreal Cognitive Assessment investigating cognitive deficits, and assessed for postoperative delirium twice daily for three days via the 3D-CAM or the CAM-ICU, depending on their level of consciousness. BChE activity was measured at three defined time points before and after surgery. Results Postoperative delirium occurred in 39.7% of patients ( n = 94). Univariate analysis showed an association of pre- and postoperative BChE activity with its occurrence ( p = 0.037, p = 0.001). There was no association of postoperative delirium and the decline in BChE activity (pre- to postoperative, p = 0.327). Multivariable analysis including either preoperative or postoperative BChE activity as well as age, MoCA, type 2 diabetes mellitus, coronary heart disease, type of surgery and intraoperative administration of red-cell concentrates was performed. Neither preoperative nor postoperative BChE activity was independently associated with the occurrence of postoperative delirium ( p = 0.086, p = 0.484). Preoperative BChE activity was lower in older patients (B = -12.38 (95% CI: -21.94 to -2.83), p = 0.011), and in those with a history of stroke (B = -516.173 (95% CI: -893.927 to -138.420), p = 0.008) or alcohol abuse (B = -451.47 (95% CI: -868.38 to -34.55), p = 0.034). Lower postoperative BChE activity was independently associated with longer procedures (B = -461.90 (95% CI: -166.34 to -757.46), p = 0.002), use of cardiopulmonary bypass (B = -262.04 (95% CI: -485.68 to -38.39), p = 0.022), the number of administered red cell-concentrates (B = -40.99 (95% CI: -67.86 to -14.12), p = 0.003) and older age (B = -9.35 (95% CI: -16.04 to -2.66), p = 0.006). Conclusion BChE activity is not independently associated with the occurrence of postoperative delirium. Preoperative BChE values are related to patients’ morbidity and vulnerability, while postoperative activities reflect the severity, length and complications of surgery.

Abstract Background Acute stroke treatment is time-critical. To provide qualified stroke care in areas without 24/7 availability of a stroke neurologist, the concept of teleneurology was established, which is based on remote video communication through telemedicine organized by telestroke networks. Data on the effectiveness and efficiency of stroke treatment via teleneurology is very scarce and is therefore partly questioned in the healthcare sector. The aim was to evaluate stroke care in hospitals with and without teleneurology in Northern Germany. Methods We conducted a retrospective case–control data analysis using health insurance claims data for the years 2018 to 2021. Based on pre-defined criteria, two models were defined and clinical as well as health economic parameters were compared. In model 1, we compared patients from hospitals with and without support by a telestroke network, while in model 2, we compared patients from hospitals with and without support by a telestroke network, including only districts without a certified stroke unit. Assessed parameters were age, length of stay, patients’ comorbidities, inpatient costs, reasons for discharge, qualified stroke care treatment according to operation and procedure codes (OPS) and intravenous thrombolysis (IVT) rates. Results Hospitals supported by a telestroke network improved their rate of stroke care according to OPS and increased more than three-fold their IVT rate (p = 0.042). In comparison, patients from hospitals with support by a telestroke network had a higher number and rate of qualified stroke care according to OPS (model 1: 73.6% vs 2.2%, p < 0.001 and model 2: 57.0% vs 3.8%, p < 0.001), higher rate of IVT (model 1: 9.5% vs. 0.0%, p = 0.027 and model 2: 10.3% vs 0.0%, p = 0.056) and a lower rate of secondary transfers to another hospital (model 1: 5.9% vs. 28.9%, p < 0.001 and model 2: 5.6% vs 30.1%, p < 0.001). Inpatient costs were lower in cases treated in hospitals with support by a telestroke network (model 1: 4,476€ vs. 5,549€, p = 0.03 and model 2: 4,374€ vs. 5,309€, p = 0.02). In multivariate analysis costs were independently associated with length of stay and patient transfer to another hospital but not with support by a telestroke network. Conclusion Hospitals with support by a telestroke network are associated with improved qualified stroke care resulting in higher rates of IVT and stroke care according to OPS codes as well as lower rates of onward transfers. Costs per patient were independently associated with transfer rates and length of hospital stay.

Background Elevated levels of asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) are accompanied by endothelial dysfunction and predict adverse outcome after ischemic stroke. Via induction of oxidative stress, dimethylarginines are possibly linked to the inflammatory cascade after stroke that is known to considerably contribute to secondary progression of brain injury. We sought to investigate the association between dimethylarginines and inflammatory mediators in patients with acute ischemic stroke. Methods Plasma levels of ADMA and SDMA were measured in prospectively collected blood samples of 58 patients with acute ischemic stroke. Blood samples were taken at 6 hours, 12 hours, 24 hours, 3 days and 7 days after onset of symptoms. Analyses of ADMA and SDMA were done by high-performance liquid chromatography-tandem mass spectrometry. Monocyte chemotactic protein-1 (MCP-1), matrix metalloproteinase-9 (MMP-9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), interleukin-6 (IL-6), C-reactive protein (CRP) and S100B as markers of inflammation and brain damage were determined by commercially available immunometric assays. Patient data were compared with control data from 32 age-adjusted healthy volunteers. Baseline stroke severity was evaluated by the National Institutes of Health Stroke Scale (NIHSS) (NIHSS 0 to 1: mild stroke; NIHSS 2 to 8: moderate stroke; NIHSS ≥9: severe stroke). Results Plasma ADMA and SDMA levels significantly correlated with blood levels of inflammatory mediators up to day 7 after stroke. On multiple stepwise linear regression analysis ADMA correlated with TIMP-1 at 6 hours, 24 hours, 3 days and 7 days, MMP-9 at 12 hours and IL-6 at 7 days ( P <0.05) while SDMA correlated with MCP-1 at 6 hours, 24 hours, 3 days and 7 days as well as IL-6 at 3 days and 7 days ( P <0.05). Conclusions The levels of the vasoactive compound ADMA as well as levels of its structural isomer SDMA are associated with levels of inflammatory mediators after acute ischemic stroke. Further studies need to elucidate the cause and effect relationship of these crucial players.

Ischemic stroke is one of the leading causes of death worldwide and the most frequent cause of permanent disability in adulthood. The acute treatment of stroke is time-critical and, according to the time is brain principle, it is important to determine as soon as possible whether recanalization treatment that can save the penumbra is possible. Intravenous thrombolysis (IVT) and, if a large vessel occlusion is identified, endovascular treatment (EVT) possibly in combination with IVT, are recommended. Further treatment in a stroke unit is another important component of acute stroke treatment. The best secondary preventive treatment must already be initiated in the acute phase. The cause of stroke guides making decisions on the ideal secondary preventive strategy. The most important etiologies of stroke are cardiac embolism, atherosclerotic macroangiopathy and cerebral microangiopathy (small vessel disease). Less frequent causes are dissections of arteries supplying the brain or vasculitis. In up to 20-30% of all cases, however, no clear etiology can be determined despite intensive investigation of the cause. This means corresponding uncertainty in the optimal secondary prevention that consists in particular of an anticoagulant medication adapted to the etiology, treatment of cardiovascular risk factors and if necessary surgical or interventional desobliterative procedures. This article describes the diagnostic procedure and the evidence-based treatment of ischemic stroke.

Background Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. Main body Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the “flying/driving interentionalists” are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. Conclusion The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.

Der ischämische Schlaganfall stellt eine der häufigsten Todesursachen weltweit und die häufigste Ursache von permanenter Behinderung im Erwachsenenalter dar. Die Akuttherapie des Schlaganfalls ist zeitkritisch, und es gilt nach dem Time-is-brain-Prinzip, so rasch wie möglich zu prüfen, ob eine rekanalisierende Therapie möglich ist, welche die Penumbra retten kann. Als medikamentöse Therapie kommen die intravenöse Thrombolyse (IVT) und bei Identifikation eines Großgefäßverschlusses eine endovaskuläre Therapie (EVT) ggf. in Kombination mit einer IVT infrage. Die Weiterbehandlung auf einer Stroke Unit ist eine weitere wichtige Säule der Schlaganfallakuttherapie. Bereits in der Akutphase muss die beste sekundärprophylaktische Therapie eingeleitet werden. Die Schlaganfallursache leitet die Entscheidungsfindung zur optimalen sekundärpräventiven Strategie. Die wichtigsten Ätiologien des Schlaganfalls sind die kardiale Embolie, die atherosklerotisch bedingte Makroangiopathie sowie die zerebrale Mikroangiopathie („small vessel disease“). Seltenere Ursachen sind Dissektionen hirnversorgender Arterien oder Vaskulitiden. In bis zu 20–30

In patients with left ventricular assist device (LVAD), infections and thrombotic events represent severe complications. We investigated device-specific local and systemic inflammation and its impact on cerebrovascular events (CVE) and mortality. In 118 LVAD patients referred for 18 F-FDG-PET/CT, metabolic activity of LVAD components, thoracic aortic wall, lymphoid and hematopoietic organs, was quantified and correlated with clinical characteristics, laboratory findings, and outcome. Driveline infection was detected in 92/118 (78%) patients by 18 F-FDG-PET/CT. Activity at the driveline entry site was associated with increased signals in aortic wall (r = 0.32, p < 0.001), spleen (r = 0.20, p = 0.03) and bone marrow (r = 0.20, p = 0.03), indicating systemic interactions. Multivariable analysis revealed independent associations of aortic wall activity with activity of spleen (β = 0.43, 95% CI 0.18–0.68, p < 0.001) and driveline entry site (β = 0.04, 95% CI 0.01–0.06, p = 0.001). Twenty-two (19%) patients suffered CVE after PET/CT. In a binary logistic regression analysis metabolic activity at the driveline entry site missed the level of significance as an influencing factor for CVE after adjusting for anticoagulation (OR = 1.16, 95% CI 1–1.33, p = 0.05). Metabolic activity of the subcutaneous driveline (OR = 1.13, 95% CI 1.02–1.24, p = 0.016) emerged as independent risk factor for mortality. Molecular imaging revealed systemic inflammatory interplay between thoracic aorta, hematopoietic organs, and infected device components in LVAD patients, the latter predicting CVE and mortality.

BACKGROUND In patients with left ventricular assist devices (LVADs) ischemic and hemorrhagic stroke are dreaded complications. Predictive markers for these events are lacking. This study aimed to investigate the prevalence and predictive value of microembolic signals (MES) for stroke, detected by Transcranial Doppler sonography (TCD) in patients with HeartMate 3 (HM 3) or HeartWare (HW). METHODS A thirty-minute bilateral TCD monitoring of the middle cerebral artery (MCA) was performed in 62 outpatients with LVAD (HM 3 N=31, HW N=31) and 31 healthy controls. Prevalence and quantity of MES were investigated regarding clinical and laboratory parameters. Cerebrovascular events (CVE) were recorded on follow-up at 90 and 180 days. RESULTS MES were detected in six patients with HM 3, three patients with HW, and three controls. Within the LVAD groups, patients on monotherapy with vitamin-K-antagonist (VKA) without antiplatelet therapy were at risk for a higher count of MES (negative binomial regression: VKA: 1; VKA + ASA: Exp(B)=0.005, 95%CI 0.001 - 0.044; VKA + clopidogrel: Exp(B)=0.012, 95%CI 0.002 - 0.056). There was no association between the presence of MES and CVE or death on follow-up (p>0.05). CONCLUSION For the first time, the prevalence of MES was prospectively investigated in a notable outpatient cohort of patients with HM 3 and HW. Despite optimized properties of the latest LVAD devices, MES remain detectable depending on antithrombotic therapy. No association between MES and CVE could be detected.