The detection of paroxysmal atrial fibrillation (pAF) in patients presenting with ischaemic stroke shifts secondary stroke prevention to oral anticoagulation. In order to deal with the time‐ and resource‐consuming manual analysis of prolonged electrocardiogram (ECG)‐monitoring data, we investigated the effectiveness of pAF detection with an automated algorithm (AA) in comparison to a manual analysis with software support within the IDEAS study [study analysis (SA)].

Objective Prolonged monitoring times (72 hours) are recommended to detect paroxysmal atrial fibrillation (pAF) after ischemic stroke but this is not yet clinical practice; therefore, an individual patient selection for prolonged ECG monitoring might increase the diagnostic yield of pAF in a resource-saving manner. Methods We used individual patient data from 3 prospective studies (ntotal = 1,556) performing prolonged Holter-ECG monitoring (at least 72 hours) and centralized data evaluation after TIA or stroke in patients with sinus rhythm. Based on the TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) guideline, a clinical score was developed on one cohort, internally validated by bootstrapping, and externally validated on 2 other studies. Results pAF was detected in 77 of 1,556 patients (4.9%) during 72 hours of Holter monitoring. After logistic regression analysis with variable selection, age and the qualifying stroke event (categorized as stroke severity with NIH Stroke Scale [NIHSS] score ≤5 [odds ratio 2.4 vs TIA; 95% confidence interval 0.8–6.9, p = 0.112] or stroke with NIHSS score >5 [odds ratio 7.2 vs TIA; 95% confidence interval 2.4–21.8, p < 0.001]) were found to be predictive for the detection of pAF within 72 hours of Holter monitoring and included in the final score (Age: 0.76 points/year, Stroke Severity NIHSS ≤5 = 9 points, NIHSS >5 = 21 points; to Find AF [AS5F]). The high-risk group defined by AS5F is characterized by a predicted risk between 5.2% and 40.8% for detection of pAF with a number needed to screen of 3 for the highest observed AS5F points within the study population. Regarding the low number of outcomes before generalization of AS5F, the results need replication. Conclusion The AS5F score can select patients for prolonged ECG monitoring after ischemic stroke to detect pAF. Classification of evidence This study provides Class I evidence that the AS5F score accurately identifies patients with ischemic stroke at a higher risk of pAF.

Introduction: Atrial fibrillation remains one of the most common causes of ischemic stroke. The diagnosis of paroxysmal atrial fibrillation (pAF) frequently escapes routine diagnostic due to its intermittent and asymptomatic occurrence. Currently prolonged monitoring times (72h) are recommended, but did not find their way into everyday practice. Therefore an individual patient selection for prolonged ECG-monitoring might increase the diagnostic yield of pAF in a resource-saving and cost-effective manner. Methods: We used individual patient data from three prospective studies (n total =1556) which performed a prolonged Holter ECG-monitoring (at least 72 h) and centralized data evaluation after ischemic stroke (IDEAS 72h monitoring, Find-AF 7 days and Find-AF randomised 3 times 10 days monitoring) in patients presenting with sinus rhythm. The score was developed on the IDEAS cohort and internally (bootstrapping) and externally (Find-AF and Find-AF randomised data) validated following the TRIPOD guideline. Results: pAF was detected in 77 of 1556 patients (49 (4.3%) IDEAS, 20 (9.0%) Find-AF, 8 (4.0%) Find-AF randomized ). After logistic regression analysis with variable selection, age and the qualifying stroke event (categorised as stroke with NIH-SS <=5 (OR 2.4; 95%CI 0.8-6.9, p=0.112) or stroke with NIH-SS >5 (OR 7.2; 95% CI 2.4-21.8, p<0.001) were found to be predictive for the detection of pAF within the prolonged Holter monitoring and were included in the final score ( A ge, S troke S everity: NIHSS > 5 , ASS5 ). The score was shown to keep its discriminative performance (IDEAS, AUC 0.76) on the external validation cohort (Find-AF, Find-AF-randomized, AUC 0.75). When ASS5-score and CHADS2-score were applied to classify patients into high and low-risk patients according to the score’s particular Youden-index, the ASS5-score was statistically significant better in discriminating between high- and low-risk patients than the CHADS 2 -score (NRI 0.22 with p=0.047; ROC-AUC 0.75 for ATISS5 and 0.61 for CHADS 2 -Score with p = 0.0032). Conclusion: ASS5-score can be used by clinicians to select patients for prolonged ECG-monitoring after ischemic stroke to detect pAF.

Orale Non-Vitamin-K-Antikoagulanzien sind nach nunmehr über fünf Jahren aus der Praxis nicht mehr wegzudenken. Mittlerweile liegen zahlreiche Untersuchungen über die Anwendung dieser Medikamente unter Praxisbedingungen (Real-World-Daten) vor. Im Rahmen dieser praktischen Anwendung haben sich viele Fragen aufgetan, die zum Teil beantwortet werden können, andere sind allerdings noch Gegenstand weiterer Untersuchungen.

Mit einer hochauflösenden Schallsonde können im B-Bild unproblematisch oberflächennahe periphere Nerven dargestellt werden. Auf diese Weise können Engpasssyndrome, über elektrophysiologische Auffälligkeiten hinaus, im Hinblick auf morphologische Veränderungen dargestellt werden. In dieser Arbeit wird, beschränkt auf den N. medianus und den N. ulnaris, die Untersuchungstechnik dargestellt, typische Normalbefunde präsentiert und darüber hinaus auch häufige pathologische Befunde (u. a. Carpaltunnelsyndrom, Luxation des N. ulnaris) dargestellt. Therapeutische Konsequenzen und für den Operateur relevante Befunde werden diskutiert.

Die Ursache für einen Hirninfarkt bleibt auch nach umfassender Diagnostik in etwa einem Drittel der Ereignisse unklar [1]. Bei diesen kryptogenen Schlaganfällen sind breite differenzialdiagnostische Erwägungen notwendig. Auch die Bedeutung pathologischer Befunde bleibt für die Entstehung des Schlaganfalls häufig unklar und therapeutische Konsequenzen sind oft Gegenstand von Diskussionen.

Background and Purpose— Adequate diagnosis of atrial fibrillation (AF), including paroxysmal AF, is an important part of stroke workup. Prolonged ECG monitoring may improve the detection of paroxysmal, previously undiagnosed AF (unknown AF). Therefore, we evaluated systematic 72-hour Holter ECG monitoring to detect unknown AF for the workup of patients with stroke. Methods— Unselected survivors of a stroke or transient ischemic attack (TIA) without known AF were enrolled in a prospective, multicenter cohort study of 72-hour Holter ECG monitoring in 9 German secondary and tertiary stroke centers between May 2010 and January 2011. In addition to standardized workup of stroke pathogenesis according to the German Stroke Unit protocol, all patients underwent 72-hour Holter ECG monitoring directly after admission. All ECGs were centrally analyzed by 2 independent observers. We determined the proportion of unknown AF and compared the detection rates of 72- and 24-hour monitoring. Results— A total of 1135 patients were enrolled (mean age, 67 years [SD, 13.1 years], 45% women, 29% TIA). Unknown AF was detected in 49 out of 1135 patients (4.3%, [95% confidence interval, 3.4–5.2%]) by 72-hour ECG monitoring. Unknown AF was diagnosed in 29 patients (2.6%) within the first 24 hours of ECG monitoring, and in 20 more patients only by 72 hours of ECG monitoring. The number needed to screen by 72-hour ECG was 55 patients (95% confidence interval [35–123]) for each additional AF diagnosis. Patients with unknown AF were significantly older and had more often a history of previous stroke. Patients with unknown AF were equally distributed within categories of pathogenesis according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Conclusions— In unselected survivors of stroke or TIA, 72-hour ECG monitoring is feasible and improves the detection rate of silent paroxysmal AF.

Despite 3 recent randomized clinical trials, the management of patients with cryptogenic stroke and patent foramen ovale remains unsettled. The primary results of Evaluation of the STARFlex Septal Closure System in Patients with a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism Through a Patent Foramen Ovale (CLOSURE), Percutaneous Closure of Patent Foramen Ovale in Cryptogenic Stroke (PC), and Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment (RESPECT) were the same; the intent to treat analysis for the primary end point in all 3 trials failed to demonstrate superiority of device closure compared with medical therapy. CLOSURE put the brakes on indiscriminate device closure of patent foramen ovales in patients with cryptogenic stroke or transient ischemic attack. RESPECT suggested, but did not prove, that highly selected patients without vascular risk factors, with a cortical infarct on baseline magnetic resonance imaging and a substantial patent foramen ovale shunt may benefit from the Amplatzer device during a multiple-year period. In the absence of definitive clinical trial results, the precise definition of which patient subgroups should be considered for patent foramen ovale device closure should be agreed to by the stakeholder societies and the Food and Drug Administration.

Operative treatment of asymptomatic carotid stenosis is well established since results of Asymptomatic Carotid Atherosclerosis Study (ACAS) trial and Asymptomatic Carotid Surgery Trial (ACST) were published. However, advances in medical treatment and recent trials that revealed success of “best medical treatment” over interventional treatment for stenosis of brain supplying arteries have raised the question, if “best medical treatment” should be considered as first option in case of asymptomatic carotid stenosis.

BACKGROUND:In patients with patent foramen ovale (PFO) there is evidence supporting the hypothesis of a change in right-to-left shunt (RLS) over time. Proven, this could have implications for the care of patients with PFO and a history of stroke. The following study addressed this hypothesis in a cohort of patients with stroke and PFO.METHODS:The RLS volume assessed during hospitalisation for stroke (index event/T0) was compared with the RLS volume on follow-up (T1) (median time between T0 and T1 was 10 months). In 102 patients with a history of stroke and PFO the RLS volume was re-assessed on follow-up using contrast-enhanced transcranial Doppler/duplex (ce-TCD) ultrasound. A change in RLS volume was defined as a difference of ≥20 microembolic signals (MES) or no evidence of RLS during ce-TCD ultrasound on follow-up.RESULTS:There was evidence of a marked reduction in RLS volume in 31/102 patients; in 14/31 patients a PFO was no longer detectable. An index event classified as cryptogenic stroke (P < 0.001; OD = 39.2, 95% confidence interval 6.0 to 258.2) and the time interval to the follow-up visit (P = 0.03) were independently associated with a change in RLS volume over time.CONCLUSIONS:RLS volume across a PFO decreases over time, especially in patients with cryptogenic stroke. These may determine the development of new strategies for the management in the secondary stroke prevention.

Background: Since doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with identical standard and outcome 24 h and 7 days a week our aim was to examine if acute stroke patients defined by onset‐admission time (OAT) of ≤ 3 h were treated differently or had distinct outcome when admitted during off duty hours (day versus night and weekend versus weekdays) and if any differences in treatment or outcome were apparent when comparing patients admitted in the year 2003 with patients admitted in the year 2006. Methods: We analyzed 2003–2006 data of a prospective registry and grouped patients by time, day, and year of admission. The evaluation was limited to patients that were diagnosed with ischaemic stroke and with OAT of ≤ 3 h. Medical and sociodemographic items, use of thrombolytic treatment, complications during clinical course and place of discharge were obtained. Clinical state on admission and discharge was assessed using the modified Rankin scale. Comparison with chi‐square test, t ‐test and logistic regression was performed. Results: Patient’s characteristics, rate of thrombolysis, and outcome were independent from time or day of admission. Proportion of patients with good clinical state at discharge increased significantly from 2003 to 2006 together with a higher rate of rTPA treatment without increase of intracranial hemorrhage. Proportion of patients discharged in good clinical condition after rTPA treatment increased from 34% to 44%. Conclusions: Stroke treatment in potential candidates for thrombolytic therapy revealed no impairment on weekend or at night already in 2003. During 4 years, it was possible to increase rate of rTPA treatment from 8.9% to 21.8% without increment of complications or death, confirming that rTPA is safe and can be implemented with full daily and weekly coverage.

Von verschiedenen Seiten wurde vermutet, dass durch die Einführung des Abrechnungssystems nach „diagnosis-related groups“ (DRG) Fehlanreize zur vorzeitigen Entlassung von Patienten aus Krankenhäusern geschaffen wurden („blutige Entlassung“). In dieser Studie soll bei Schlaganfallpatienten aus den Jahren 2003 bis 2006 untersucht werden, ob eine Reduktion der Verweildauer und eine Entlassung in schlechterem klinischem Zustand in Zusammenhang mit der DRG-Einführung aufgetreten ist. Es soll ferner untersucht werden, ob die vorgenannten Größen durch eine Veränderung der Patientenkollektive und eine Verbesserung des Behandlungserfolgs beeinflusst wurden.

An association of passively watching a soccer game with an incidence of cardiovascular events was previously reported. With access to the stroke database of the Federal State of Hesse, Germany, we examined whether the incidence of cerebrovascular events was elevated during the Federation Internationale de Football Association (FIFA) World Cup in Germany from 9 June to 9 July 2006 on days of matches involving the German team and whether particular characteristics were noted in stroke patients on these days. We analyzed a prospective stroke registry and calculated incidence ratios for the 7 days of matches played by the German team as compared with the control period ranging from May 2006 to July 2006 using a Poisson regression with a log link to model the number of cerebrovascular events per day for all patients and for subgroups of patients, grouped according to sex, severity of stroke, type of stroke and risk factors. About 2,918 patients with ischemic stroke or intracerebral hemorrhage were included. The regression model did not disclose a higher incidence of cerebrovascular events on days of matches played by the German team. Onset admission time on these days was significantly reduced. In contrast to recent observations regarding cardiac events, we found no effect of passively watching soccer games on incidence of stroke or intracerebral hemorrhage, probably because of the different underlying pathophysiologies of stroke and cardiac events. Onset admission time was slightly reduced on days when a German match was played, probably since more strokes occurred under observation of potential support persons, reflecting the tendency of German people to gather to watch matches played by the national team.

The muscle-relaxing 5-HT2 receptor antagonist cyclobenzaprine is structurally closely related to amitriptyline. It is widely used to treat patients presenting with back pain and fibromyalgia. Very rarely cyclobenzaprine toxicity can result in extrapyramidal symptoms, but occurrence of torticollis has not been reported so far. We report on a patient presenting with torticollis and myoclonic movements after treatment with cyclobenzaprine, who was successfully treated with intravenous biperiden. This case might be additional evidence for the necessity of appropriate dosage in case of liver impairment. Secondly there are possibly consequences as regards the therapy of motor side effects.

Background and purpose:We compared characteristics and treatment success of ischaemic stroke patients admitted during daytime on working days (office hours) with patients admitted on weekend or nighttime (non-office hours) to test if differences in presentation or restraints of medical care during non-office hours determine outcome in stroke patients.Methods:We analyzed a prospective stroke registry and grouped patients according to admission on office hours and non-office hours. Clinical state on admission, risk factors, sociodemographic items, complications, place of discharge, and clinical state on discharge were recorded.Results:A total of 37 396 stroke patients were evaluated. Onset-admission time on Monday was significantly elevated and on weekend significantly reduced. Number of patients with treatment success did not differ between patient groups whilst mortality within 7 days, proportion of embolic stroke, overall mortality and rate of complications where higher in patients admitted during non-office hours, rate of thrombolytic treatment was significantly higher during non-office hours. After adjustment for clinical state and admission latency, risk for severe outcome or death was independent from time of admission.Conclusion:Considering the fact that stroke patients admitted during non-office hours were in more severe clinical condition we found no differences in outcome. Fear of impaired access to sophisticated treatment options during non-office hours could be dispelled by the fact, that rate of thrombolytic treatment was even higher during night and weekend. Therefore, our data do not confirm a weekend effect or night effect on stroke treatment. Delay in request of medical care of mildly affected patients that suffer from stroke on weekends confirms need for educational efforts.

Introduction: Appropriate therapeutic management for secondary stroke prevention (SSP) in stroke patients and patent foramen ovale (PFO) remains uncertain. Assumption of paradoxical embolism (PDE) supposes a venous thrombotic source. Diagnosis of deep vein thrombosis (DVT) of lower extremity/pelvis veins (LEPV) not only strengthens the hypothesis of PDE, simultaneously determine the therapy for SSP. The aim of this study was to assess the frequency of DVT detected by sonography in a cohort of stroke patients diagnosed of PFO. The study might help to understand which factors are associated with the diagnosis of DVT in order to optimize the diagnostic management.