Hans-Peter Haring

Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging.

BACKGROUNDnThe early post-traumatic vegetative state (VS) is compatible with recovery. Various clinical and laboratory tests have failed to predict recovery so we assessed the value of cerebral magnetic-resonance imaging (MRI) in prediction of recovery.nnnMETHODSn80 adult patients in post-traumatic VS had cerebral MRI between 6 weeks and 8 weeks after injury. MRIs were reviewed by three neuroradiologists for the number, sizes, and location of brain lesions. Three neurologists assessed the patients at the time of MRI and at 2 months, 3 months, 6 months, 9 months, and 12 months after injury using the Glasgow Outcome Scale.nnnFINDINGSnAt 12 months, 38 patients had recovered while 42 patients remained in the VS. The demographic characteristics and causes and severity of injury were similar in patients in persistent VS (PVS) and those who recovered (NPVS). An average of 6.1 different brain areas were injured in patients in PVS compared with 4.6 areas in patients who had NPVS. Patients in PVS revealed a significantly higher frequency of corpus callosum, corona radiata, and dorsolateral brainstem injuries than did patients who recovered. Logistic regression analysis showed that corpus callosum and dorsolateral brainstem injuries were predictive of non-recovery. The adjusted odds ratios for non-recovery of patients with a corpus callosum lesion and dorsolateral brainstem injury were 213.8 (95% CI 14.2-3213.3), and 6.9 (11-42.9), respectively. In contrast, clinical characteristics, such as initial score on the Glasgow Coma Scale, age, and pupillary abnormalities failed to predict recovery.nnnINTERPRETATIONnCerebral MRI findings in the subacute stage after head injury can predict the outcome of the post-traumatic VS. Corpus callosum and dorsolateral brainstem lesions are highly significant in predicting non-recovery.

Attenuated Corticomedullary Contrast: An Early Cerebral Computed Tomography Sign Indicating Malignant Middle Cerebral Artery Infarction: A Case-Control Study

BACKGROUND AND PURPOSEnNo neuroradiological markers have been characterized that support a timely decision for decompressive surgery in malignant middle cerebral artery (MCA) infarction (mMCAI). This case-control study was designed to analyze whether early cerebral CT (CCT) scanning provides reliable information for the prospective selection of stroke patients at risk of developing mMCAI.nnnMETHODSnThirty-one pairs (n=62) were formed with cases (mMCAI) and controls (acute but not malignant MCA infarction) closely matched in terms of age, sex, and stroke etiology. CCT was performed within 18 hours of stroke onset and analyzed by a blinded neuroradiologist according to a defined panel of 12 CCT criteria.nnnRESULTSnIn terms of predicting mMCAI, the criteria of extended MCA territory hypodensities >67% and >50%, hemispheric brain swelling, midline shift, and hyperdense MCA sign exhibited high specificity (100%, 93. 5%, 100%, 96.7%, and 83.9%, respectively) but low sensitivity (45.2%, 58.1%, 12.9%, 19.4%, and 70.9%, respectively). Two criteria yielded high sensitivity (subarachnoid space compressed, 100%; cella media compressed, 80.6%) but low specificity (29% and 74.2%, respectively). The criterion of attenuated corticomedullary contrast yielded both high specificity (96.8%) and sensitivity (87.1%). The latter remained as the crucial criterion [Exp(B)=90.8; 95% CI, 5.8 to 1427. 5] in a 2-tailed logistic regression analysis with the strongest correlating parameters (Spearman correlation factor >/=0.6 or </=-0.6).nnnCONCLUSIONSnThe analysis of CCT scans within 18 hours of stroke onset revealed an attenuated corticomedullary contrast as the crucial CCT criterion, which, with both sufficient sensitivity and specificity, predicted mMCAI with 95% certainty.

Timing of stenting of symptomatic carotid stenosis is predictive of 30‐day outcome

For patients with symptomatic carotid stenosis, benefit from carotid artery stenting (CAS) highly depends on the 30‐day stroke and death rates. Identification of predictors of unfavourable outcome would help guide the patient selection. We analysed the influence of clinical and angiographic factors on the 30‐day outcomes of 77 consecutive patients who underwent CAS for ≥60% symptomatic carotid stenosis within 180u2003days of transient ischaemic attack or moderate stroke (modified Rankin Scale score ≤3). The 30‐day composite end‐point for stroke (7.8%) and death of any cause (1.3%) was 9.1%. Patients with complicated CAS were older than patients with uncomplicated CAS (mean age 75.1u2003±u20038.2 vs. 65.9u2003±u20039.5u2003years, Pu2003=u20030.015) and underwent stenting significantly earlier after the qualifying event: median delay 1.5u2003weeks (range: 0.2–3.0) vs. 3.2u2003weeks (range: 0.5–26), Pu2003=u20030.004. In multivariate logistic regression analyses, age [odds ratio (OR)u2003=u20031.148; 95% confidence interval (CI): 1.011–1.304 and Pu2003=u20030.033] and delay of treatment <2u2003weeks (ORu2003=u200322.399; 95% CI: 2.245–223.445 and Pu2003=u20030.008) remained the only variables significantly associated with 30‐day outcome. CAS carries a considerable risk in old patients and when performed early (<2u2003weeks) after the qualifying event. Future reports should address the timing of CAS.

Cerebrospinal Fluid (CSF) Pharmacokinetics of Intraventricular Vancomycin in Patients with Staphylococcal Ventriculitis Associated with External CSF Drainage

We studied the efficacy and pharmacokinetics of intraventricularly administered vancomycin in three patients with shunt-associated staphylococcal ventriculitis. We instilled 10 mg of the drug intraventricularly every 24 hours. Cerebrospinal fluid (CSF) levels were measured 1 hour after instillation and then every 2 hours. Peak vancomycin levels reached a mean of 292.9 microg/mL. The mean trough levels, measured immediately before readministration of vancomycin, were 7.6 microg/mL; this level has proved to be sufficient for maintaining the necessary steady-state serum concentration of vancomycin. All three patients were cured clinically and bacteriologically, and CSF parameters returned to normal within 5-13 days. No side effects were observed. Our results suggest that intraventricularly administered vancomycin is a valuable therapeutic strategy for treating shunt-associated staphylococcal ventriculitis. In addition, we provide evidence that 10 mg of vancomycin, administered intraventricularly every 24 hours, allows maintenance of therapeutic drug levels in the CSF for at least 24 hours.

Thrombolysis Beyond the Guidelines Two Treatments in One Subject Within 90 Hours Based on a Modified Magnetic Resonance Imaging Brain Clock Concept

Background and Purpose— We report the first case of 2 intravenous thrombolysis treatments within 90 hours in a patient with early recurrent stroke. Summary of Review— A 50-year-old man had improved significantly after intravenous thrombolysis for acute stroke. On the fourth day, he deteriorated dramatically because of recurrent stroke. Evidence of vessel reocclusion and profound perfusion/diffusion mismatch constituted the rationale for a second thrombolysis treatment, which resulted in vessel recanalization and significant neurologic improvement. Conclusion— The pathophysiological information obtained by multimodal magnetic resonance imaging may suit as a brain clock when repeat thrombolysis treatment is considered for early recurrent stroke.

HPV vaccine: a cornerstone of female health a possible cause of ADEM?

JO N 2 86 7 sequences revealed disseminated lesions in the right frontal subcortical area and brainstem (Fig. 1a) and the cervical spinal cord (Fig. 2a–b). Peripheral leukocyte count was increased (14.6 × 109/L), while all other routine laboratory parameters including C-reactive protein were normal. Cerebrospinal fluid examination showed 10 cells/μl, mostly lymphocytes, normal protein and glucose content, and negative oligoclonal bands. All blood cultures and extensive serologic testing on bacterial and neurotropic viral agents were negative. In view of the clinical and MRI findings the diagnosis of ADEM was made. Treatment with high-dose corticosteroids was followed by rapid neurological improvement. After three weeks neurological recovery was complete, corresponding with resolution of the MRI abnormalities (Fig. 1b, 2c). ADEM is classically described as a monophasic demyelinating disease of the central nervous system that typically follows a febrile infection or vaccination. The characteristics include a prodromal phase with unspecific symptoms, rapid onset encephalopathy and multifocal neurologic deficits. It is now recognized that up to one-third of patients will have relapses in the future [7], and definitions for the variants “recurrent ADEM” and “multiphasic ADEM” have been suggested [6]. ADEM often poses a diagnostic and prognostic dilemma. Important differential diagnoses are clinical isolated syndrome (CIS) and multiple sclerosis (MS). Past descriptions of “ADEM confined to the brainstem” may also have been classified as CIS with brainstem involvement [6]. Some patients are diagnosed with MS in the long run. Thus repeat MRI follow-ups have been recommended to detect new lesions according to “dissemination in time” [2, 4]. Viktoria Schäffer Sibylle Wimmer Iuliana Rotaru Raffi Topakian Hans-Peter Haring Franz T. Aichner

Prognostic value of admission C-reactive protein in stroke patients undergoing IV thrombolysis

ObjectiveTo test the hypothesis that pre-treatment Creactive protein (CRP) predicts outcome in stroke patients undergoing intravenous thrombolysis (IVT) treatment.MethodsWe analyzed the data of 111 consecutive patients with IVT within 6 hours of stroke onset for stroke involving the middle cerebral artery territory and admission CRP ≤ 6 mg/dl.ResultsCRP levels were consistently, yet non-significantly lower in patients with unfavourable outcome definitions. Median (range) CRP levels were 0.3 (0–5.9) mg/dl vs. 0.4 (0–5.7) mg/dl (p = 0.13) in patients dependent or dead after 3 months (modified Rankin Scale score > 2; n = 59) vs. independent patients (n = 52); 0.2 (0.1–1.5) mg/dl vs. 0.4 (0–5.9) mg/dl (p = 0.28) in patients dead after 3 months (n = 14) versus survivors (n = 97); and 0.2 (0.1–0.7) mg/dl vs. 0.4 (0–5.9) mg/dl (p = 0.09) in patients with significant neurological deterioration within 24 hours (increase in ≥ 4 points on National Institute of Health Stroke scale; n = 9) vs. patients without early deterioration (n = 102). Independent predictors of dependency/death after 3 months, identified by multivariate logistic regression analyses, were baseline NIHSS score (OR = 1.31, 95 % CI 1.16–1.48, p < 0.001), time from onset to treatment (OR = 1.01, 95 % CI 1.0–1.02, p = 0.024), and presence of diabetes (OR = 8.16, 95 % CI 1.18–56.5, p = 0.033).ConclusionPre-treatment CRP clearly failed to predict outcome in stroke patients treated with IVT. Our findings contradict previously published work and highlight the need for further research on this topic.

Postprocedural high-density lipoprotein cholesterol predicts carotid stent patency at 1 year

The durability of carotid artery stenting (CAS) is affected by the occurrence of myointimal proliferation and in‐stent restenosis (ISR). We aimed to identify clinical, angiographic, and laboratory predictors of ISR, paying special attention to postprocedural metabolic factors. A total of 102 consecutive patients with successful CAS for ≥70% atherosclerotic internal carotid artery stenosis were followed up with neurological assessment and duplex sonography 1u2003day, 1u2003month, and 1u2003year after CAS. Lipid profile and hemoglobin A1c were tested at the 1‐month follow‐up visit. Ten (10%) patients had ISR ≥50% after 1u2003year. Compared with patients without ISR (nu2003=u200392), patients with ISR were more often current smokers (33% vs. 70%, Pu2003=u20030.034) and had significantly lower 1‐month high‐density lipoprotein (HDL) cholesterol: median (range) 47 (24–95) mg/dl vs. 39.5 (25–50) mg/dl, Pu2003=u20030.031. Multivariate logistic regression analyses identified 1‐month HDL cholesterol >45u2003mg/dl as the only independent predictor of carotid stent patency at 1u2003year (Pu2003=u20030.033, ORu2003=u20030.09, 95% CI 0.01–0.83). Postprocedural HDL cholesterol levels predict carotid stent patency at 1u2003year. With the possibility of elevation of HDL cholesterol by lifestyle changes and medication, this finding may have implications for the future management of patients undergoing CAS.

Hypocalcemic choreoathetosis and tetany after bisphosphonate treatment

On the basis of several randomized controlled trials, zoledronic acid, a highly potent and long-acting bisphosphonate, is emerging as the new standard of care for managing skeletal morbidity in patients with advanced cancers involving bone.1 Symptomatic hypocalcemia after treatment with bisphosphonates has been described before.2,3 To our knowledge, this is the first report on a patient with hypocalcemic choreoathetosis after bisphophonate therapy. An 85-year-old man received an infusion of 4 mg zoledronic acid because of prostate cancer with extensive bone metastases. The day after the infusion, he developed perioral paresthesia and numbness and tingling in his extremities. He complained of new-onset debilitating fatigue and diffuse pain and stiffness in both legs. He was unable to stand or walk without the help of two people, while prior to bisphosphonate treatment he had been able to walk approximately 1,000 meters before claudication due to lumbar spine stenosis limited further walking. On admission, he appeared fidgety and gave the impression of general restlessness. He had increased tone, decreased distal sensation, and diminished reflexes in both legs. Plantar responses were flexor. Muscle power was normal, and there were no signs of disturbance of vigilance or mental function. His speech was slightly slurred. From time to time, he had selflimited painful tetanic spasms in both legs. The most striking neurological disturbances were brief paroxysms of unilateral or bilateral choreoathetoid arm movements. These episodes lasted up to a minute and occasionally appeared precipitated by movements such as reaching out. His past medical history was unremarkable for movement disorders and medication interfering with extrapyramidal motor systems or with psychotropic effects. Lesions in the basal ganglia and spinal cord compression were ruled out by magnetic resonance imaging. Laboratory tests revealed extreme hypocalcemia (0.7 mmol/L; normal: 2.15–2.6 mmol/L), while all other electrolytes were in the normal range. Calcium concentration corrected for albumin was identical to the measured calcium level. Creatine phosphokinase (CK) was highly elevated (2858 U/L; normal: 24–171 U/L), indicating rhabdomyolysis, while the myocardial-specific isoenzyme of CK was in the normal range ( 10% of CK). Parathyroid hormone (PTH) was significantly elevated (195 pg/mL; normal: 15–65 pg/mL). Electrocardiography (ECG) showed normofrequent sinus rhythm (70 bpm) with marked QT interval prolongation (496 ms). After initiation of treatment with calcium and vitamin D, the spells of choreoathetosis and tetany in his legs resolved within a few days and ECG showed normalization of QT time. Electrophysiological studies were compatible with mild to moderate distal symmetric axonal and demyelinating polyneuropathy. The patient declined further evaluation of the polyneuropathy because of lack of symptoms and was discharged from hospital with mild residual hypocalcemia after complete resolution of the presenting neurological symptoms. Neurological complications of hypocalcemia seem to be the consequence of loss of inhibition, primary neuronal hyperexcitability, or changes in permeability of muscle membranes. Clinically evident hypocalcemia, regardless of its cause, generally presents in milder forms and is usually the result of a chronic disease state.4 In patients with prostate cancer, increased calcium utilization by extensive osteoblastic metastases is hypothesized to be the primary phenomenon inducing hypocalcemia and compensatory hyperparathyroidism. In these patients, bisphosphonates may further reduce serum calcium and increase PTH levels, which could limit therapeutic effectiveness of bisphosphonates unless calcium supplementation were given in doses sufficient to maintain PTH in the normal range.5 We suppose that in our patient, preexisting asymptomatic chronic hypocalcemia worsened and was unmasked after bisphosphonate therapy. Rhabdomyolysis may have further reduced the level of metabolically active calcium by elevation of phosphates (from CK), lactate, and other anions that chelate calcium.4 Our case report illustrates that zoledronic acid may trigger severe symptomatic hypocalcemia with neuromuscular complications and new-onset movement disorders. To minimize adverse events, assessment and correction of calcium homeostasis before initiating zoledronate therapy are recommended.3

Prädiktoren des Schlaganfall-Outcome nach intravenöser Thrombolyse – Daten des Österreichischen Stroke Unit Registers

BACKGROUNDnIntravenous thrombolysis (IVT) for acute ischaemic stroke is safe and effective in routine clinical use. We aimed to identify baseline predictors of excellent outcome after 3 months, defined by a modified Rankin Scale score<or=1.nnnMETHODnWe analysed data entered in the Austrian Stroke Unit Registry up to February 28th 2007.nnnRESULTSnEight hundred and twelve patients received IVT after admission to a stroke unit within 3 hours of stroke onset. Of 386 patients with complete follow-up at 3 months, 201 (52.1%) had an excellent outcome. Multivariate regression analyses identified age (odds ratio (OR) 0.96; 95% confidence intervals (CI) 0.94-0.98; p<0.0005) and admission score on the National Institute of Health Stroke Scale (NIHSS; OR 0.87; 95% CI 0.84-0.91; p<0.0005) to be independent predictors of excellent outcome.nnnCONCLUSIONSnAge and admission NIHSS score were found to powerfully predict outcome after IVT. However, results may be compromised by the loss to follow-up bias.SummaryBACKGROUND: Intravenous thrombolysis (IVT) for acute ischaemic stroke is safe and effective in routine clinical use. We aimed to identify baseline predictors of excellent outcome after 3 months, defined by a modified Rankin Scale score ≤1. METHOD: We analysed data entered in the Austrian Stroke Unit Registry up to February 28th 2007. RESULTS: Eight hundred and twelve patients received IVT after admission to a stroke unit within 3 hours of stroke onset. Of 386 patients with complete follow-up at 3 months, 201 (52.1%) had an excellent outcome. Multivariate regression analyses identified age (odds ratio (OR) 0.96; 95% confidence intervals (CI) 0.94–0.98; p < 0.0005) and admission score on the National Institute of Health Stroke Scale (NIHSS; OR 0.87; 95% CI 0.84–0.91; p < 0.0005) to be independent predictors of excellent outcome. CONCLUSIONS: Age and admission NIHSS score were found to powerfully predict outcome after IVT. However, results may be compromised by the loss to follow-up bias.ZusammenfassungGRUNDLAGEN: Die intravenöse Thrombolyse (IVT) gilt in der klinischen Routine als sichere und effektive Therapie des akuten ischämischen Schlaganfalls. Unser Ziel war die Identifikation von Baseline-Prädiktoren eines exzellenten 3-Monats-Outcomes (modified Rankin Scale Score ≤1). METHODIK: Wir analysierten Daten des Österreichischen Stroke Unit Registers (Eingaben bis 28. Februar 2007). ERGEBNISSE: Von 812 Patienten, die innerhalb 3 Stunden nach Einsetzen der Schlaganfallsymptome auf eine Stroke Unit aufgenommen und in der Folge mit IVT behandelt wurden, lag bei 386 ein 3-Monats-follow-up vor. 201 der 386 (52,1 %) Patienten hatten dabei ein exzellentes Outcome. Multivariate Regressionsanalysen identifizierten Alter (odds ratio [OR] 0,96; 95 % Konfidenzintervalle [CI] 0,94–0,98; p < 0,0005) und initialen National Institute of Health Stroke Scale (NIHSS) Score (OR 0,87; 95 % CI 0,84–0,91; p < 0,0005) als unabhängige Prädiktoren eines exzellenten 3-Monats-Outcomes. SCHLUSSFOLGERUNGEN: Alter und initialer NIHSS-Score sind starke Prädiktoren für das Outcome nach Thrombolyse. Unsere Ergebnisse werden durch den hohen Verlust an Follow-up-Daten geschmälert.