Neurological research and practice最新文献

Background: Guidelines generally advise against reperfusion therapy in patients with mild stroke (NIHSS ≤ 5) and non-disabling symptoms. However, stroke severity can fluctuate, and clinical scores may not fully capture tissue at risk. Reliance on non-contrast CT (NCCT), potentially missing perfusion deficits or large vessel occlusions (LVOs). Advanced imaging-including CT angiography (CTA) and CT perfusion (CTP)-can reveal significant hypoperfusion in otherwise mild presentations. This study aimed to quantify the proportion of increased tissue-at-risk volumes (Tmax + 6s ≥ 15 mL) in patients with mild acute ischaemic stroke and identify associated factors and outcomes.

Methods: We included consecutive AIS patients within 24 h of onset from multicentre stroke registries in Australia and Indonesia. Only those with baseline NCCT, CTA, and CTP were analysed. Patients were stratified into NIHSS ≤ 5 and > 5. Tissue-at-risk was defined as Tmax + 6s ≥ 15 mL. Clinical, imaging, and outcome data were compared, and predictors of poor functional outcome (mRS 3-6 at 90-day) were assessed.

Results: Of 655 patients, 314 had NIHSS ≤ 5. Among these, 22.9% exhibited Tmax + 6s ≥ 15 mL, indicating significant hypoperfusion. This subgroup had worse 90-day outcomes (26.4% mRS 3-6 vs. 9.5%, p < 0.001). Tmax + 6s ≥ 15 mL, hypertension, and LVO were independently associated with poor outcome (adjusted ORs: 2.51, 3.15, and 2.74 respectively). ROC analysis demonstrated moderate discrimination of Tmax + 6s volume for poor functional outcome.

Conclusions: A substantial proportion of mild stroke patients harbour treatable perfusion deficits. CT perfusion provides essential prognostic information beyond clinical severity, supporting its role in guiding therapeutic decisions-even in low NIHSS presentations where standard imaging may otherwise overlook tissue at risk.

Background: In the general population, cognitive impairment and dementia are more common in individuals with prior myocardial injury, defined as elevated levels of high-sensitive cardiac troponin (hs-cTn). In stroke patients, data on the link between myocardial injury and cognitive outcome are scarce. We aimed to analyze the association between the severity of myocardial injury (degree of hs-cTn elevation), presence of acute myocardial injury (dynamic change in elevated hs-cTn values > 20% in serial measurements) and cognitive performance over time after acute ischemic stroke.

Methods: This is a prespecified analysis of the prospective multicenter observational PRediction of Acute coronary syndrome in acute Ischemic StrokE (PRAISE) study. PRAISE included 254 patients with an acute ischemic stroke or transient ischemic attack (TIA) and myocardial injury in 26 centers in Germany. Patients underwent cognitive assessment at baseline and before hospital discharge using the Montreal Cognitive Assessment (MoCA) and at three and twelve months after the index event using the Telephone Interview for Cognitive Status (TICS). We used linear regression to analyze the associations between cognitive performance and (1) severity of myocardial injury and (2) presence of acute myocardial injury. The association between hs-cTn and TICS scores over time was examined using inverse probability weighted generalized linear models.

Results: Severity of myocardial Injury was associated with lower MoCA scores (adjusted beta - 2.6, 95% CI -4.0 - -1.2, p < 0.001) and higher proportion of cognitive impairment (i.e. MoCA score < 26 points) (adjusted OR 2.9, 95%CI 1.3-6.7, p = 0.012). Acute myocardial injury was associated with better cognitive performance (adjusted beta 1.8, 95% CI 0.4-3.1, p = 0.011). We found no association between hs-cTn and cognitive decline over twelve months.

Conclusions: In patients with ischemic stroke, the severity of myocardial injury in general but not the presence of acute myocardial injury at time of stroke is associated with cognitive impairment.

Trial registration: Clinicaltrials.gov NCT03609385 https://clinicaltrials.gov/study/NCT03609385?term=NCT03609385&rank=1 Date of registration 6th July 2018.

Background: Deciding on intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with reported recent direct oral anticoagulant (DOAC) intake remains challenging due to concerns about hemorrhagic risk and the absence of randomized controlled trial evidence. This study aimed to provide a comprehensive characterization of all AIS patients with reported recent DOAC intake-regardless of IVT eligibility-treated at a comprehensive stroke center that routinely measures calibrated anti-facor IIa/Xa activity at admission.

Methods: In this retrospective study, clinical and procedural data from AIS patients with recent DOAC intake and calibrated anti-factor IIa/Xa activity measured within three hours of admission were analyzed. Patients were treated at the University Hospital Essen between March 2017 and October 2023.

Results: Among 469 included patients, anti-factor IIa/Xa activity was ≤ 30 ng/ml in 28%, > 30- ≤ 50 ng/ml in 9%, > 50- ≤ 75 ng/ml in 9%, > 75- ≤ 100 ng/ml in 9% and > 100 ng/ml in 45%. Lower DOAC levels correlated with severe stroke symptoms at admission (ρ = - 0.263, p < 0.001). IVT was administered to 33.5% of patients with DOAC levels ≤ 50 ng/ml, compared to only 4% among those with levels > 50 ng/ml, the majority of whom received prior reversal with idarucizumab. Symptomatic intracranial haemorrhage (sICH) occurred in 4% of IVT-treated and 1% of non-IVT-treated patients, without association to anticoagulation status.

Conclusions: A considerable proportion of AIS patients with recent DOAC intake exhibited minimal or no anticoagulant activity at presentation. Those with the lowest levels also showed highest stroke severity. IVT was safe across all DOAC level groups, with low and comparable sICH rates. These findings support the rationale for a randomized trial evaluating IVT without prior DOAC level testing.

Background: Previous studies have demonstrated that patients with Parkinson's disease (PD) exhibit pathologically increased beta band activity (12-35 Hz) in the basal ganglia, which peaks at an individual frequency and correlates with symptom severity. The purpose of this study was to determine whether different beta peak measures can serve as predictors for deep brain stimulation (DBS) contact selection.

Methods: Subthalamic local field potentials were acquired from 27 patients with PD (8 female, 59.0 ± 8.9 years) with (ON) and without (OFF) dopaminergic medication. Peak amplitudes and frequencies were detected in the low (12-20 Hz) and high beta band (21-35 Hz), and their predictive value for the motor symptom improvement, the therapeutic window and the optimal stimulation contact were analyzed.

Results: In particular, the power ratio of the highest low beta peak ON versus OFF medication explained 23.7% of the variance in the therapeutic window.

Conclusion: Our results demonstrate that beta peak measures can serve as valuable markers to estimate contact selection to achieve an optimal DBS outcome in patients with PD.

Trial registration: Not applicable.

Introduction: The German Dementia Registry (DEMREG) is a large-scale national prospective biomarker-based study for cognitive impairment and dementia, providing an integrated clinical research platform for research studies.

Methods: The DEMREG study longitudinally collects demographic, clinical, genetic, biological, and imaging data, along with risk factors and treatment information from real-world settings. Comprehensive clinical assessments are conducted yearly. This extensive resource enables researchers to investigate current diagnostic and treatment practices and explore the complex relationships between risk factors and outcomes. The registry is now active across 22 sites in Germany, all members of the the German Memory Clinic Network (DNG), with more than 500 patients recruited to date, and is expected to include up to 1.000 patients annually.

Perspective: The DEMREG study represents a large nationally harmonized cohort of detailed real-world clinical and biological data from patients with cognitive impairment and dementia, enabling insights into long-term dynamics and treatment responses. This infrastructure has the potential to foster collaborative research and roll out healthcare innovations across different settings in Germany. In this context, a substudy will soon be conducted to evaluate long-term safety and efficacy measures of the new monoclonal antibodies targeting amyloid plaques in a clinical setting.

Trial registration: The protocol is registered at German Clinical Trials Register (DRKS00027547), Date of Registration: 01.04.2022.

Background: Non-convulsive status epilepticus (NCSE) is a common definitive or exclusion diagnosis in patients with disorders of consciousness (DOC) on neurological or interdisciplinary intensive care units (ICU). Special expertise is required to ensure reliable diagnosis, targeted therapy management, and individual prognostication, particularly as NCSE is identified based solely on clinical and electroencephalographic findings.

Main body: This narrative state-of-the-art review compiles and critically discusses the existing literature on various aspects of NCSE. We focus on the reliable initial diagnosis and further monitoring of NCSE using the Salzburg criteria and the 2HELP2B score, therapy options beyond current guideline recommendations, and prognosis assessment using established scores and metrics, such as STESS, SACE, EMSE, and END-IT. With compact tables and clear illustrations, comprehensive insights are presented in a concise structure to provide clear guidance for daily practice.

Conclusion: NCSE is a common and complex disease entity observed in the ICU that requires dedicated and specialised diagnostics, therapy, monitoring, and outcome assessment. Evidence-based recommendations are now available for each of these critical processes to guide caregivers and relatives. However, the availability of continuous (cEEG), quantitative (qEEG) electroencephalography in the ICU and expertise in its interpretation are limiting factors in many clinical settings. This problem is becoming increasingly pronounced due to the reduced or complete lack of reimbursement for c/qEEG in the context of intensive care medicine in many countries.

Background: Atrial fibrillation (AF) is a common condition in older adults, often associated with increased risks of cognitive decline and frailty. White matter hyperintensities (WMH), visible on neuroimaging and quantified by the Fazekas score, have been linked to both cognitive and physical impairments. However, the relationship between WMH, cognitive decline, and frailty in older adults with AF remains relatively underexplored.

Methods: This study analyzed data from 86 participants in the SAGE-AF cohort, a two-year prospective multicenter cohort study of older adults with AF, who also had neuroimaging performed for clinical indications. WMH severity was assessed by independent reviewers using Fazekas scores from brain imaging. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA), and frailty was assessed at baseline as well as 1- and 2-year follow-up visits by trained examiners as part of the SAGE-AF study protocol. Participants were characterized based on the severity of their white matter hyperintensities and compared to baseline and two-year cognitive and physical functional status. Longitudinal regression models were used to adjust for demographic, clinical, and geriatric covariates.

Results: Participants with higher Fazekas scores (grades 2-3) demonstrated significantly lower baseline and follow-up MoCA scores and were more likely to meet frailty criteria over a two-year follow-up period. After adjusting for multiple factors known to influence cognitive decline, greater white matter hyperintensity (Fazekas grades 2-3) remained associated with a 2.6-fold increased risk of cognitive impairment at (p = 0.04) and a 2.7-fold increased risk of frailty at (p = 0.02).

Conclusion: Higher Fazekas scores are related to cognitive decline and frailty in older adults with AF, emphasizing WMH as a critical biomarker for aging-related impairments. Neuroimaging tools like Fazekas scoring could enhance risk stratification and inform targeted interventions for this vulnerable population.

Background: Chronic pain represents the defining and quality-of-life limiting feature in patients with cancer pain (CP) or chronic non-cancer pain (CNCP) and is often treated with opioids. Over time, opioid use is frequently accompanied by necessity of an increasing dose due to pharmacological tolerance and progress of the underlying diseases. The potential side effects were found to correlate with accelerating doses. More recently, the opioid crisis in the United States has drawn attention to the adverse effects and toxicities. Until today it is unclear what high-dose opioid therapy is and guidelines are inconsistent regarding an evidence-based threshold.

Objectives: This systematic review and meta-analysis aim to determine a threshold for high-dose opioid therapy. A systematic literature search was conducted in 4 databases from earliest publication available until May 2025. Studies were eligible if participants with CP or CNCP were able to self-titrate their opioid dosage to reach a sufficient pain relief.

Methods: 4305 records were screened. Nineteen included studies with a total of 3111 participants investigating eight different opioids were included. The studies were assessed for risk of bias. Results were synthesised as oral morphine equivalents (OMEs).

Results: The meta-analysis found a weighted mean of 74.7 mg OME per day and the 97.5% percentile corresponded to about 138 mg/d (range 134-139 mg/d) as a "high dose". In CNCP the limit was 78 mg/d (range 74-78 mg/d), whereas in CP it reached 288 mg/d (range 280-289 mg/d; p < 0.01).

Conclusion: Despite the overall moderate risk of bias of the included studies and the heterogeneity in underlying pain conditions, the reference range of typically prescribed dosages in a broad study population could be investigated. These systematically derived thresholds may enhance physicians' awareness in carefully tailoring opioid treatments and thereby contribute to improved pharmacotherapy safety.

Prospero identifier: CRD42020219256.

Background: With the global prevalence of hyperuricemia and gout rising, accumulating evidence has linked acute gout flares to a transient rise in major adverse cardiovascular events, including myocardial infarction and stroke. However, the reverse association, whether acute stroke is associated with an increased incidence of gout flares, has been inadequately investigated. The aim of this single-center cohort study, coupled with a systematic review and meta-analysis, was to evaluate the incidence and characteristics of gout flares in the early post-stroke period.

Methods: A systematic review and meta-analysis of published studies was conducted, incorporating data from a cohort of acute stroke patients admitted to a tertiary care stroke center. Eligible studies reported in-hospital gout flares among patients with acute ischemic or hemorrhagic stroke. Pooled estimates were calculated using random-effects models. The systematic review was pre-registered in PROSPERO (CRD420251061747).

Results: We identified three studies (one involving only acute ischemic stroke, two including both ischemic and hemorrhagic stroke), encompassing a total of 13,722 acute stroke patients, including our institutional cohort. The pooled incidence of in-hospital gout flares was 4% (95% CI, 2-6%; I²=88.1%). The pooled mean time to flare onset was 6.3 days post-stroke (95% CI, 4.09-8.44; I²=96.6%), and 64% of flares involved the paretic limb (95% CI, 33-90%; I²=62.1%). Among flare patients, 85% were male (95% CI, 40-100%; I²=84.5%), 97% had ischemic stroke (95% CI, 94-99%; I²=0%), and 61% were newly diagnosed with gout or hyperuricemia during hospitalization (95% CI, 48-73%; I²=0%). In our cohort, 50% and 12.5% of flare patients presented with delirium and aphasia, respectively; all patients received colchicine treatment with complete symptom resolution.

Conclusions: Gout flares occur in one out of every 25 acute stroke patients, particularly in men presenting with acute ischemic stroke within the first week after symptom onset, and frequently involve the paretic limb. In over half of cases, the flare uncovers previously undiagnosed gout or hyperuricemia, emphasizing the need for systematic evaluation, particularly in patients with delirium or impaired communication, where diagnosis may be delayed. Early colchicine initiation warrants consideration given its anti-inflammatory effects and potential to reduce stroke recurrence.