Michael Spiegel

Common Carotid Dissection A Sign of Emergency

Patient 1 was a 58-year-old man who was brought to the emergency department after he collapsed in the kitchen. On arrival, the patient was comatose and did not react to pain stimuli. He was hypotensive (blood pressure 70/50 mm Hg), and ECG showed sinus tachycardia (120/min) with left bundle-branch block. Tests for troponin T were negative, and his D-dimer level was 3771 μg/L (normal range: 0 to 190 μg/L). Because of tachypnea and developing respiratory insufficiency, intubation became necessary. A massive pulmonary embolism was initially suspected. Patient 2 was a 47-year-old man who suddenly collapsed with aphasia, right-sided hemiparesis, and progressive loss of consciousness. After intubation and during transportation to the emergency department, he was hypertensive, but on arrival he became hypotensive (blood pressure 80/60 mm Hg). An ECG showed sinus tachycardia (127/min) and marked ST depression in V5 and V6. Tests for troponin T were negative, and his D-dimer level was 212 μg/L. Cerebral …Patient 1 was a 58-year-old man who was brought to the emergency department after he collapsed in the kitchen. On arrival, the patient was comatose and did not react to pain stimuli. He was hypotensive (blood pressure 70/50 mm Hg), and ECG showed sinus tachycardia (120/min) with left bundle-branch block. Tests for troponin T were negative, and his D-dimer level was 3771 μg/L (normal range: 0 to 190 μg/L). Because of tachypnea and developing respiratory insufficiency, intubation became necessary. A massive pulmonary embolism was initially suspected. Patient 2 was a 47-year-old man who suddenly collapsed with aphasia, right-sided hemiparesis, and progressive loss of consciousness. After intubation and during transportation to the emergency department, he was hypertensive, but on arrival he became hypotensive (blood pressure 80/60 mm Hg). An ECG showed sinus tachycardia (127/min) and marked ST depression in V5 and V6. Tests for troponin T were negative, and his D-dimer level was 212 μg/L. Cerebral …

Juveniler Schlaganfall in Österreich – Daten aus dem Österreichischen Schlaganfallregister

In recent years, many aspects of juvenile stroke have been addressed in medium-sized case series. We have analyzed stroke severity, etiology, risk factors, and outcome in different age groups in the large dataset of the Austrian Stroke Unit Registry. In the nationwide Austrian Stroke Unit Registry 13,440 men and women with ischemic stroke or transient ischemic attack were recorded between March 2003 and February 2007. A number of important disease characteristics were documented by a stroke specialist upon admission of a patient and at discharge from the stroke unit and during a 3-month follow-up interview. A total of 749 patients (5.6%) were 18 to 45 years old and 1895 (14.1%) 18 to 55 years. Arterial dissection and cardiac/paradoxical embolism were the most common causes of stroke up to an age of 45. With a steeply increasing frequency of standard vascular risk factors, micro- and macroangiopathic causes of stroke substantially gain weight after the fourth decade of life. At 3-month follow-up, good clinical outcome (mRS 0-2) and death were 88.3% and 1.4% in the young (<or=55 years), and 65.3 (9.2%) in subjects aged 56 years and over. In multivariate analysis, young age (<or=55 years) predicted a good clinical outcome (Odds Ratio [95% confidence interval] 3.4 [2.4-5.0]) independently from stroke severity (NIH-SS), concomitant risk factors, stroke etiology, and thrombolytic therapy. Young men experience a significant delay in the onset-to-door time in comparison to other segments of the population. Increasing awareness about the relevance of stroke in the young is a valuable target for future health campaigns.SummaryIn recent years, many aspects of juvenile stroke have been addressed in medium-sized case series. We have analyzed stroke severity, etiology, risk factors, and outcome in different age groups in the large dataset of the Austrian Stroke Unit Registry. In the nationwide Austrian Stroke Unit Registry 13,440 men and women with ischemic stroke or transient ischemic attack were recorded between March 2003 and February 2007. A number of important disease characteristics were documented by a stroke specialist upon admission of a patient and at discharge from the stroke unit and during a 3-month follow-up interview. A total of 749 patients (5.6%) were 18 to 45 years old and 1895 (14.1%) 18 to 55 years. Arterial dissection and cardiac/paradoxical embolism were the most common causes of stroke up to an age of 45. With a steeply increasing frequency of standard vascular risk factors, micro- and macroangiopathic causes of stroke substantially gain weight after the fourth decade of life. At 3-month follow-up, good clinical outcome (mRS 0–2) and death were 88.3% and 1.4% in the young (≤55 years), and 65.3 (9.2%) in subjects aged 56 years and over. In multivariate analysis, young age (≤55 years) predicted a good clinical outcome (Odds Ratio [95% confidence interval] 3.4 [2.4–5.0]) independently from stroke severity (NIH-SS), concomitant risk factors, stroke etiology, and thrombolytic therapy. Young men experience a significant delay in the onset-to-door time in comparison to other segments of the population. Increasing awareness about the relevance of stroke in the young is a valuable target for future health campaigns.ZusammenfassungViele Aspekte des juvenilen Schlaganfalls wurden bereits an kleinen bis mittelgroßen Fallserien beschrieben. Wir analysierten den großen Datensatz des Österreichischen Stroke Unit Registers in Hinblick auf Schweregrad, Ätiologie, Risikofaktoren und Outcome von Schlaganfällen in den verschiedenen Altersgruppen. Im österreichweiten Stroke Unit Register wurden zwischen März 2003 und Februar 2007 13.440 Männer und Frauen mit ischämischem Schlaganfall oder einer transitorisch-ischämischen Attacke jenseits des 18. Lebensjahres registriert. Eine Vielzahl von Parametern wurde bei Aufnahme und Entlassung, sowie in einem 3-Monats-Follow-up erhoben 749 (5,6 %) Patienten waren zwischen 18 und 45 bzw. 1895 (14,1 %) zwischen 18 und 55 Jahre alt. Unter den bekannten Schlaganfallätiologien waren in der jungen Population (18.–45. Lebensjahr) die Dissektion und kardiale paradoxe Embolie die häufigsten. Ab der 4. Lebensdekade nahmen – parallel zum Anstieg der vaskulären Risikofaktoren – die Häufigkeit von arteriosklerotisch bedingter Mikro- und Makroangiopathie zu. Im 3-Monats-Follow-up waren 1.4 % der jungen Schlaganfallpatienten (≤55 Jahre) und 9,2 % der über 55-Jährigen verstorben, eine gutes klinisches Outcome (mRS 0–2) wurde bei 88,3 % bzw. 65,3 % beobachtet. In der multivariaten Analyse war junges Alter (≤55 Jahre) ein signifikanter Prädiktor für Selbständigkeit nach 3 Monaten (Odds Ratio [95 % Konfidenzintervall] 3,4 [2,4–5,0]) unabhängig von Geschlecht, NIH-SS bei Aufnahme, begleitenden Risikofaktoren, erfolgter Lysetherapie und Ätiologie. Bei jungen Männern ist die Zeitspanne zwischen Manifestation des Schlaganfalls und Eintreffen im Krankenhaus signifikant länger als in der restlichen Population, was Anlass zu entsprechenden Aufklärungskampagnen geben sollte.

[Implementation of thrombolysis in acute stroke--10-year results of the Innsbruck stroke registry].

SummaryBACKGROUND: Randomized controlled trials have yielded evidence for the efficacy and safety of intravenous alteplase in the therapy of acute ischemic stroke. A large patient registry has recently confirmed the safe implementation of this therapy in the clinical routine setting. METHODS: Between January 1998 and December 2007 302 stroke patients were treated with 0.9 mg/kg rt-PA at the stroke unit of the Innsbruck University Hospital. Severity and circumstances of the stroke event, indicators of pre- and intrahospital management as well as safety and outcome at three months were prospectively assessed in the local thrombolysis database. RESULTS: The number of patients receiving intravenous thrombolysis increased continuously from 2 patients in 1998 to 67 in 2007 and 87 patients in 2008. 43% of our patients were females. The median age and NIHSS-score on admission was 67 and 16, respectively. The mean onset-to-needle time decreased from 171 min to 110 min – mainly due to a substantial shortening of the door-to-needle time from 105 min to 45 min. A proportion of 41% of our patients were treated in the main working time while 59% received rt-PA during night and weekend service. A total of 38% of our patients were functionally independent at three months (mRS 0–2). Once considering the high initial stroke severity in our patient series and correcting the NIHSS scores to levels usually seen in randomized control trials and patient registries, 56% of our patients would reach a good outcome (mRS 0–2). The rate of symptomatic intracranial bleedings was low at 6.3%. CONCLUSION: Our data reinforce that intravenous thrombolysis is safe in the treatment of acute ischemic stroke in clinical routine setting. Establishment of modern stroke services and the implementation of structural operating procedures have contributed to an increase in the number of treated patients and a parallel decrease in door-to-needle time at our hospital. Widespread educational programs in the general community, introduction of optimized pre-hospital triage algorithms as well as the potential extension of the 3-hour window to 4.5 hours all are suitable measures to further extend the benefit of i.v. thrombolysis to large proportion of stroke patients.ZusammenfassungHINTERGRUND: Die Wirksamkeit der systemischen Thrombolyse mit rekombinantem Gewebs- Plasminogen-Aktivator (rt-PA) beim akuten ischämischen Schlaganfall wurde in klinischen Studien dokumentiert . Die Umsetzung der Studienergebnisse in den klinischen Alltag ist bei Einhaltung der Richtlinien gegeben. STUDIENDESIGN: Im Zeitraum von 1998–2007 wurden an der Universitätsklinik für Neurologie in Innsbruck 302 PatientInnen mit akutem ischämischem Schlaganfall mit rt-PA in einer Dosis von 0,9 mg/kg Körpergewicht systemisch lysiert. Der initiale Schweregrad, prä- und intrahospitale Organisationsabläufe, die Sicherheit und das funktionelle Outcome nach drei Monaten wurden anhand validierter Parameter prospektiv in einer Datenbank erfasst. ERGEBNISSE: Die Lysefrequenz stieg kontinuierlich von initial 2 (1998) auf zuletzt 67 (2007) bzw. 87 (2008) pro Jahr. 43% der PatientInnen waren Frauen. Das durchschnittliche Alter lag bei 67 Jahren, der NIHSS-Score bei Aufnahme betrug im Mittel 16. Die mittlere Onset-to-needle-time verkürzte sich von 171 min auf 110 min – v.a. bedingt durch eine Verbesserung der Door-to-needle-time von 105 min auf 45 min. In der Regeldienstzeit wurden 41%, im Nacht- und Wochenenddienst 59% der PatientInnen lysiert. 38% der PatientInnen waren nach drei Monaten funktionell unabhängig (mRS 0–2). Bei Anpassung und Korrektur des Schweregrades entsprechend der internationalen Studien erreichen 56% ein gutes Outcome. Die Rate an symptomatischen intracerebralen Blutungen betrug 6,3%. KONKLUSION: Die Daten belegen die Sicherheit der i.v. Thrombolyse beim ischämischen Schlaganfall in der klinischen Routine und zeigen, dass Verbesserungen der Infrastruktur, der prä- und intrahospitalen Organisationsabläufe an der Stroke Unit Innsbruck zu einer gesteigerten Lyserate führten, verbunden mit einer Verkürzung der mittleren Door-to-needle-time. Durch Aufklärungskampagnen der Bevölkerung, Verbesserung der Triagealgorithmen im Notarztwesen und der Ausweitung des Lysezeitfensters von 3 auf 4,5 Stunden nach Symptombeginn kann die Therapiefrequenz in Zukunft noch gesteigert werden.

Einsatz der Thrombolyse beim akut ischämischen Schlaganfall

SummaryBACKGROUND: Randomized controlled trials have yielded evidence for the efficacy and safety of intravenous alteplase in the therapy of acute ischemic stroke. A large patient registry has recently confirmed the safe implementation of this therapy in the clinical routine setting. METHODS: Between January 1998 and December 2007 302 stroke patients were treated with 0.9 mg/kg rt-PA at the stroke unit of the Innsbruck University Hospital. Severity and circumstances of the stroke event, indicators of pre- and intrahospital management as well as safety and outcome at three months were prospectively assessed in the local thrombolysis database. RESULTS: The number of patients receiving intravenous thrombolysis increased continuously from 2 patients in 1998 to 67 in 2007 and 87 patients in 2008. 43% of our patients were females. The median age and NIHSS-score on admission was 67 and 16, respectively. The mean onset-to-needle time decreased from 171 min to 110 min – mainly due to a substantial shortening of the door-to-needle time from 105 min to 45 min. A proportion of 41% of our patients were treated in the main working time while 59% received rt-PA during night and weekend service. A total of 38% of our patients were functionally independent at three months (mRS 0–2). Once considering the high initial stroke severity in our patient series and correcting the NIHSS scores to levels usually seen in randomized control trials and patient registries, 56% of our patients would reach a good outcome (mRS 0–2). The rate of symptomatic intracranial bleedings was low at 6.3%. CONCLUSION: Our data reinforce that intravenous thrombolysis is safe in the treatment of acute ischemic stroke in clinical routine setting. Establishment of modern stroke services and the implementation of structural operating procedures have contributed to an increase in the number of treated patients and a parallel decrease in door-to-needle time at our hospital. Widespread educational programs in the general community, introduction of optimized pre-hospital triage algorithms as well as the potential extension of the 3-hour window to 4.5 hours all are suitable measures to further extend the benefit of i.v. thrombolysis to large proportion of stroke patients.ZusammenfassungHINTERGRUND: Die Wirksamkeit der systemischen Thrombolyse mit rekombinantem Gewebs- Plasminogen-Aktivator (rt-PA) beim akuten ischämischen Schlaganfall wurde in klinischen Studien dokumentiert . Die Umsetzung der Studienergebnisse in den klinischen Alltag ist bei Einhaltung der Richtlinien gegeben. STUDIENDESIGN: Im Zeitraum von 1998–2007 wurden an der Universitätsklinik für Neurologie in Innsbruck 302 PatientInnen mit akutem ischämischem Schlaganfall mit rt-PA in einer Dosis von 0,9 mg/kg Körpergewicht systemisch lysiert. Der initiale Schweregrad, prä- und intrahospitale Organisationsabläufe, die Sicherheit und das funktionelle Outcome nach drei Monaten wurden anhand validierter Parameter prospektiv in einer Datenbank erfasst. ERGEBNISSE: Die Lysefrequenz stieg kontinuierlich von initial 2 (1998) auf zuletzt 67 (2007) bzw. 87 (2008) pro Jahr. 43% der PatientInnen waren Frauen. Das durchschnittliche Alter lag bei 67 Jahren, der NIHSS-Score bei Aufnahme betrug im Mittel 16. Die mittlere Onset-to-needle-time verkürzte sich von 171 min auf 110 min – v.a. bedingt durch eine Verbesserung der Door-to-needle-time von 105 min auf 45 min. In der Regeldienstzeit wurden 41%, im Nacht- und Wochenenddienst 59% der PatientInnen lysiert. 38% der PatientInnen waren nach drei Monaten funktionell unabhängig (mRS 0–2). Bei Anpassung und Korrektur des Schweregrades entsprechend der internationalen Studien erreichen 56% ein gutes Outcome. Die Rate an symptomatischen intracerebralen Blutungen betrug 6,3%. KONKLUSION: Die Daten belegen die Sicherheit der i.v. Thrombolyse beim ischämischen Schlaganfall in der klinischen Routine und zeigen, dass Verbesserungen der Infrastruktur, der prä- und intrahospitalen Organisationsabläufe an der Stroke Unit Innsbruck zu einer gesteigerten Lyserate führten, verbunden mit einer Verkürzung der mittleren Door-to-needle-time. Durch Aufklärungskampagnen der Bevölkerung, Verbesserung der Triagealgorithmen im Notarztwesen und der Ausweitung des Lysezeitfensters von 3 auf 4,5 Stunden nach Symptombeginn kann die Therapiefrequenz in Zukunft noch gesteigert werden.

Images in cardiovascular medicine. Common carotid dissection: a sign of emergency.

Patient 1 was a 58-year-old man who was brought to the emergency department after he collapsed in the kitchen. On arrival, the patient was comatose and did not react to pain stimuli. He was hypotensive (blood pressure 70/50 mm Hg), and ECG showed sinus tachycardia (120/min) with left bundle-branch block. Tests for troponin T were negative, and his D-dimer level was 3771 μg/L (normal range: 0 to 190 μg/L). Because of tachypnea and developing respiratory insufficiency, intubation became necessary. A massive pulmonary embolism was initially suspected. Patient 2 was a 47-year-old man who suddenly collapsed with aphasia, right-sided hemiparesis, and progressive loss of consciousness. After intubation and during transportation to the emergency department, he was hypertensive, but on arrival he became hypotensive (blood pressure 80/60 mm Hg). An ECG showed sinus tachycardia (127/min) and marked ST depression in V5 and V6. Tests for troponin T were negative, and his D-dimer level was 212 μg/L. Cerebral …Patient 1 was a 58-year-old man who was brought to the emergency department after he collapsed in the kitchen. On arrival, the patient was comatose and did not react to pain stimuli. He was hypotensive (blood pressure 70/50 mm Hg), and ECG showed sinus tachycardia (120/min) with left bundle-branch block. Tests for troponin T were negative, and his D-dimer level was 3771 μg/L (normal range: 0 to 190 μg/L). Because of tachypnea and developing respiratory insufficiency, intubation became necessary. A massive pulmonary embolism was initially suspected. Patient 2 was a 47-year-old man who suddenly collapsed with aphasia, right-sided hemiparesis, and progressive loss of consciousness. After intubation and during transportation to the emergency department, he was hypertensive, but on arrival he became hypotensive (blood pressure 80/60 mm Hg). An ECG showed sinus tachycardia (127/min) and marked ST depression in V5 and V6. Tests for troponin T were negative, and his D-dimer level was 212 μg/L. Cerebral …

Einsatz der Thrombolyse beim akut ischämischen Schlaganfall@@@Implementation of thrombolysis in acute stroke – 10-year results of the Innsbruck stroke registry: 10-Jahres-Ergebnisse an der Stroke Unit Innsbruck

SummaryBACKGROUND: Randomized controlled trials have yielded evidence for the efficacy and safety of intravenous alteplase in the therapy of acute ischemic stroke. A large patient registry has recently confirmed the safe implementation of this therapy in the clinical routine setting. METHODS: Between January 1998 and December 2007 302 stroke patients were treated with 0.9 mg/kg rt-PA at the stroke unit of the Innsbruck University Hospital. Severity and circumstances of the stroke event, indicators of pre- and intrahospital management as well as safety and outcome at three months were prospectively assessed in the local thrombolysis database. RESULTS: The number of patients receiving intravenous thrombolysis increased continuously from 2 patients in 1998 to 67 in 2007 and 87 patients in 2008. 43% of our patients were females. The median age and NIHSS-score on admission was 67 and 16, respectively. The mean onset-to-needle time decreased from 171 min to 110 min – mainly due to a substantial shortening of the door-to-needle time from 105 min to 45 min. A proportion of 41% of our patients were treated in the main working time while 59% received rt-PA during night and weekend service. A total of 38% of our patients were functionally independent at three months (mRS 0–2). Once considering the high initial stroke severity in our patient series and correcting the NIHSS scores to levels usually seen in randomized control trials and patient registries, 56% of our patients would reach a good outcome (mRS 0–2). The rate of symptomatic intracranial bleedings was low at 6.3%. CONCLUSION: Our data reinforce that intravenous thrombolysis is safe in the treatment of acute ischemic stroke in clinical routine setting. Establishment of modern stroke services and the implementation of structural operating procedures have contributed to an increase in the number of treated patients and a parallel decrease in door-to-needle time at our hospital. Widespread educational programs in the general community, introduction of optimized pre-hospital triage algorithms as well as the potential extension of the 3-hour window to 4.5 hours all are suitable measures to further extend the benefit of i.v. thrombolysis to large proportion of stroke patients.ZusammenfassungHINTERGRUND: Die Wirksamkeit der systemischen Thrombolyse mit rekombinantem Gewebs- Plasminogen-Aktivator (rt-PA) beim akuten ischämischen Schlaganfall wurde in klinischen Studien dokumentiert . Die Umsetzung der Studienergebnisse in den klinischen Alltag ist bei Einhaltung der Richtlinien gegeben. STUDIENDESIGN: Im Zeitraum von 1998–2007 wurden an der Universitätsklinik für Neurologie in Innsbruck 302 PatientInnen mit akutem ischämischem Schlaganfall mit rt-PA in einer Dosis von 0,9 mg/kg Körpergewicht systemisch lysiert. Der initiale Schweregrad, prä- und intrahospitale Organisationsabläufe, die Sicherheit und das funktionelle Outcome nach drei Monaten wurden anhand validierter Parameter prospektiv in einer Datenbank erfasst. ERGEBNISSE: Die Lysefrequenz stieg kontinuierlich von initial 2 (1998) auf zuletzt 67 (2007) bzw. 87 (2008) pro Jahr. 43% der PatientInnen waren Frauen. Das durchschnittliche Alter lag bei 67 Jahren, der NIHSS-Score bei Aufnahme betrug im Mittel 16. Die mittlere Onset-to-needle-time verkürzte sich von 171 min auf 110 min – v.a. bedingt durch eine Verbesserung der Door-to-needle-time von 105 min auf 45 min. In der Regeldienstzeit wurden 41%, im Nacht- und Wochenenddienst 59% der PatientInnen lysiert. 38% der PatientInnen waren nach drei Monaten funktionell unabhängig (mRS 0–2). Bei Anpassung und Korrektur des Schweregrades entsprechend der internationalen Studien erreichen 56% ein gutes Outcome. Die Rate an symptomatischen intracerebralen Blutungen betrug 6,3%. KONKLUSION: Die Daten belegen die Sicherheit der i.v. Thrombolyse beim ischämischen Schlaganfall in der klinischen Routine und zeigen, dass Verbesserungen der Infrastruktur, der prä- und intrahospitalen Organisationsabläufe an der Stroke Unit Innsbruck zu einer gesteigerten Lyserate führten, verbunden mit einer Verkürzung der mittleren Door-to-needle-time. Durch Aufklärungskampagnen der Bevölkerung, Verbesserung der Triagealgorithmen im Notarztwesen und der Ausweitung des Lysezeitfensters von 3 auf 4,5 Stunden nach Symptombeginn kann die Therapiefrequenz in Zukunft noch gesteigert werden.

Common Carotid Dissection

Patient 1 was a 58-year-old man who was brought to the emergency department after he collapsed in the kitchen. On arrival, the patient was comatose and did not react to pain stimuli. He was hypotensive (blood pressure 70/50 mm Hg), and ECG showed sinus tachycardia (120/min) with left bundle-branch block. Tests for troponin T were negative, and his D-dimer level was 3771 μg/L (normal range: 0 to 190 μg/L). Because of tachypnea and developing respiratory insufficiency, intubation became necessary. A massive pulmonary embolism was initially suspected. Patient 2 was a 47-year-old man who suddenly collapsed with aphasia, right-sided hemiparesis, and progressive loss of consciousness. After intubation and during transportation to the emergency department, he was hypertensive, but on arrival he became hypotensive (blood pressure 80/60 mm Hg). An ECG showed sinus tachycardia (127/min) and marked ST depression in V5 and V6. Tests for troponin T were negative, and his D-dimer level was 212 μg/L. Cerebral …Patient 1 was a 58-year-old man who was brought to the emergency department after he collapsed in the kitchen. On arrival, the patient was comatose and did not react to pain stimuli. He was hypotensive (blood pressure 70/50 mm Hg), and ECG showed sinus tachycardia (120/min) with left bundle-branch block. Tests for troponin T were negative, and his D-dimer level was 3771 μg/L (normal range: 0 to 190 μg/L). Because of tachypnea and developing respiratory insufficiency, intubation became necessary. A massive pulmonary embolism was initially suspected. Patient 2 was a 47-year-old man who suddenly collapsed with aphasia, right-sided hemiparesis, and progressive loss of consciousness. After intubation and during transportation to the emergency department, he was hypertensive, but on arrival he became hypotensive (blood pressure 80/60 mm Hg). An ECG showed sinus tachycardia (127/min) and marked ST depression in V5 and V6. Tests for troponin T were negative, and his D-dimer level was 212 μg/L. Cerebral …