Neurological research and practice最新文献

Background: Paradoxical embolism is a potential pathophysiology in patients with acute ischemic stroke or transient ischemic attack (TIA) and patent foramen ovale (PFO) or atrial septal defect (ASD). We sought to determine the frequency of deep vein thrombosis (DVT) detection by standardized lower extremity venous compression ultrasound (LE-CUS) in patients with acute cerebral ischemia and cardiac right-to left shunt due to PFO or ASD on transoesophageal echocardiogram (TEE).

Methods: We analysed consecutive patients (01/2015-12/2020) with acute cerebral ischemia and PFO or ASD on TEE, who received DVT screening by LE-CUS per institutional standard. We determined clinical baseline variables including shunt-size categorized as small, medium or large, and analysed the frequency of DVT. We performed multivariable analysis to identify predictors for presence of DVT on LE-CUS.

Results: Among 1564 patients with acute ischemic stroke (n = 1326) or TIA (n = 238) who received TEE, 390 patients had PFO and 10 patients ASD, of whom 274 were screened for DVT by LE-CUS (153 [55.8%] female, age 64 years [51-76], NIHSS score 4 [1-9.5]). Of these, 55 patients (20.1%) had DVT on LE-CUS. Among patients with DVT, 23 of 76 patients (30.3%) who received LE-CUS within 72 h from admission compared to 32 of 198 patients (16.2%) who received LE-CUS at later time points had presence of DVT (p = 0.012). The percentage of patients with DVT tended to be higher among patients with cryptogenic ischemic stroke compared to patients with other stroke etiologies (21.8% [49 of 225] vs. 12.2% [6 of 49]; p = 0.168). Presence of DVT was associated with female sex (OR 2.24, 95%CI 1.09-4.62), NIHSS score (OR 1.06, 95%CI 1.03-1.10), Wells score (OR 1.54, 95%CI 1.11-2.13) and shunt size (OR 3.32, 95%CI 1.86-5.91).

Conclusions: Our data suggest a high diagnostic yield (> 20%) of standardized screening for DVT with LE-CUS in patients with acute cerebral ischemia and PFO or ASD. This particularly applies to females, patients with more severe baseline deficits and large right-to-left shunt. These findings may not be generalizable to all patients with PFO or ASD and need prospective validation.

Background: To evaluate the long-term efficacy and safety of fremanezumab over a 2-year period in a real-world setting.

Methods: This retrospective, observational, single-center cohort study included 165 patients with episodic migraine (EM) or chronic migraine (CM) who received fremanezumab treatment. The primary endpoint was the change in monthly migraine days (MMDs) from baseline to months 1-24. The secondary endpoints included changes in Migraine Disability Assessment (MIDAS) scores, adverse events, response rates, predictors for responders, and treatment persistence.

Results: In the entire cohort, the MMD changes from baseline at 3, 6, 12, and 24 months were  - 7.2 ± 4.7,  - 8.1 ± 6.3,  - 8.4 ± 5.1, and  - 9.6 ± 6.0 days, respectively (p < 0.001). After 3, 6, 12, and 24 months, the ≥ 50% response rates were 57.0%, 63.6%, 63.5%, and 69.0%, respectively. The MIDAS score significantly decreased in the total sample and the EM and CM groups. No significant difference in efficacy was found between the monthly and quarterly dosing groups. Adverse events, mainly injection site reactions, occurred in 13.3% of the patients, and 2.4% of the participants discontinued treatment due to side effects. There were different clinical backgrounds between non-responders, and early and ultra-late responders, including psychiatric complications, medication overuse headache, and pulsatile headache. The treatment continuation rates at 12, 18, and 24 months were 73.5%, 65.4%, and 58.0%, respectively, with higher persistence in patients who received quarterly dosing than in those who received monthly dosing (p < 0.001).

Conclusion: Fremanezumab is effective and well tolerated for long-term migraine prophylaxis.

Background: Despite considerable previous research, to what degree white matter lesions (WML) may be epileptogenic remains unclear. Therefore, the decision of initiating treatment with antiseizure medication (ASM) can be challenging in patients with only WML on neuroimaging. In this prospective study we assessed whether the prevalence, localization or severity of WML impact the risk of seizure recurrence in patients aged 60 years or older after first-time seizures.

Methods: Data was analyzed from 168 patients, aged ≥ 60 years-old who had experienced a previous unprovoked seizure and had either a potentially epileptogenic lesion or WML on neuroimaging. The frequency of seizure recurrence was documented after 6, 12, and 24 months. Pearson´s chi-square test of independence (categorical variables) and the independent Student´s t-test (continuous variables) were used to analyze intergroup differences. Binary logistic regressions were calculated to examine the influence of WML locations as a predictor of seizure recurrence. Kaplan-Meier survival analyses and log-rank statistics were performed to determine the cumulative recurrence rates between the groups.

Results: Fifteen patients had only potentially epileptogenic lesions on neuroimaging (EPI) and 93 showed WML only (OWML). Sixty patients showed both of them on neuroimaging (EWML). Frontal and parieto-occipital were the predominant WML locations. Neither severity nor location of WML had a significant impact on recurrence rates. The two-year cumulative probability of becoming seizure-free was significantly lower in the EPI group compared to the EWML (χ² [1] = 4.425, p = 0.035) and the OWML group (χ² [1] = 13.094, p < 0.001). A significant association between interictal epileptiform discharges in EEG and seizure recurrence was found in OWML patients (p = 0.004).

Conclusion: We could not find any association between prevalence, severity or location of WML and seizure recurrence after first seizures in the elderly. Therefore, treatment with ASM should be started with caution in those patients. Our results show a trend of WML not having epileptogenic potential, but further studies are needed to get better evidence.

Trial registration: ClinicalTrials.gov Protocol Registration and Results, NCT06836687, AZ 199/17, release: 03/19/2024 retrospectively registered. https://register.

Clinicaltrials: gov/prs/beta/studies/S000EBC700000025/recordSummary.

Background: Weaning from mechanical ventilation (MV) and tracheal cannula (TC) during neurological early rehabilitation (NER) is mostly successful. However, some patients leave NER with TC/MV, requiring home-based specialized intensive care nursing (HSICN). Data on medical and demographic characteristics and long-term outcomes of these patients are limited.

Methods: A multicentric retrospective observational study across five German NER hospitals collected data from neurological patients with TC/MV at discharge. The study aimed to assess patients' health status at NER discharge, and to identify predictors of post-discharge survival. Survival rates were analyzed using Kaplan-Meier estimates; further predictors of survival post-discharge were analyzed using Cox regression.

Results: Among 312 patients, the one-year survival rate was 61.9%, decreasing to 38.1% after approximately 4 years. Older age, higher overall morbidity and discharge with MV were associated with an increased likelihood of death, while a longer stay in NER correlated with survival.

Conclusions: Patients requiring HSICN after discharge from NER have a high mortality rate. Identifying survival predictors may help to identify patients at risk, and thus could be integrated into the decision-making process for NER discharge. The high mortality post-discharge warrants an evaluation of the current post-hospital care model. Optimizing therapeutic care in the HSICN setting may have the potential to reduce mortality and neuro-disability, and enhance the quality of life in these neurologically severely affected patients.

Trial registration: The trial OptiNIV - Retrospective study of post-hospital intensive care in neurological patients has been retrospectively registered in the German Clinical Trials Register (DRKS) since 28.10.2022 with the ID DRKS00030580.

Magnetic resonance imaging (MRI) is a critical diagnostic tool and monitoring modality for multiple sclerosis (MS), frequently employing gadolinium-based contrast agents (Gd). However, concerns regarding the accumulation of Gd have prompted international guidelines (MAGNIMS-CMSC-NAIMS, 2021) to advocate for the limitation of Gd utilization. Consequently, we assessed of the impact of the 2021 guidelines on the use of Gd in MRI in MS patients in Germany by conducting a retrospective analysis of MRI data from 12,833 MS patients in the German MS Register (2019-2024). Generalized additive models were employed to analyze Gd use trends over time by MRI type (cranial, spinal, combined). From 2020 to 2024, a significant decline in Gd use was observed, with percentages dropping from 74.2 to 41.2% in cranial MRI, from 78.2 to 39.2% in spinal MRI and from 81.8 to 59.0% in combined MRI (p < 0.001). The most substantial decline occurred within the initial five years of MS. Gd use in MS MRI scans has significantly decreased in line with the updated guidelines. Nevertheless, its persistent utilization in over one-third of cases necessitates further examination.

Introduction: Active cancer (AC) associates strongly with ischemic stroke (IS). Intravenous thrombolysis (IVT) is often contraindicated in AC, and endovascular treatment (EVT) is considered the gold treatment standard, although data on its safety and efficacy is scarce.

Methods: Digital records of patients receiving EVT in a tertiary university hospital with comprehensive stroke center from 2016 to 2022 were assessed. Demographic, clinical, and laboratory parameters were extracted and compared between patients with and without AC. In-hospital mortality was set as the primary outcome.

Results: 39 AC and 297 non-AC patients were included. No significant differences were reported in demographic and baseline stroke parameters (NIHSS, mRS, stroke etiology). In-hospital mortality did not differ between groups (11/39 vs. 57/297, p > 0.99). Successful recanalization, change in mRS and NIHSS from admission to discharge, periinterventional complications, and stroke-related mortality were also comparable. Significantly fewer AC patients received IVT. In the binary logistic regression analysis (adjusting for confounder variables), older age, large artery atherosclerosis, unsuccessful recanalization, and higher admission NIHSS were independent predictors of all-cause in-hospital mortality (aOR): 1.04, 95% confidence interval (CI): 1.01-1.08; OR: 3.21, 95% CI: 1.03-9.92, OR: 7.28, 95% CI: 3.61-15.1, OR: 1.07, 95% CI: 1.01-1.14, p-value < 0.05, respectively).

Conclusions: EVT was shown as safe and effective in AC patients as in non-AC patients. Long-term functional outcomes are often poorer in AC, due to the cancer itself, but given how oncological treatment depends on functional status, AC patients should be considered for EVT.

Background: In Germany, the approach to treatment optimization for patients with advanced Parkinson's disease (PD) is considered somewhat conservative. The MANAGE-PD tool ( www.managepd.eu ) was developed to help identify patients with advanced PD and to facilitate treatment decision making and appropriate allocation of patients to device-aided therapies (DAT). This prospective, non-interventional study aimed to investigate the real-world disease burden of PD and treatment optimization after MANAGE-PD implementation.

Methods: Adult PD patients (N = 278) visited specialist clinics and neurologist's practices in Germany in 2022. Disease burden was assessed using the Unified PD rating scale (UPDRS parts II-IV), the non-motor symptoms scale (NMSS) and the 8-item Parkinson's disease Questionnaire (PDQ-8). Data on planned treatment changes were collected. Data were analyzed by disease control categories according to the MANAGE-PD tool.

Results: Mean scores for motor and non-motor symptoms, quality of life, and comorbidity burden were worse in patients with lower disease control measured by MANAGE-PD. For 52.8% of patients in Category 2 (inadequately controlled-might benefit from oral optimization), no change in oral treatment was planned. No change in oral treatment and no DAT initiation was planned for 37.9% and 65.0% of patients in Category 3 (inadequately controlled-might benefit from DAT). Patient refusal and needing more time to decide were the most common reasons for not making treatment changes.

Conclusions: This study supports the validity of MANAGE-PD by showing its high association with disease burden and emphasizes the importance of timely provision of necessary information to enable informed decisions about treatment optimization.

Background: Ischemic stroke can lead to neuropsychiatric sequelae such as depression and post-traumatic stress disorder (PTSD), resulting in poorer functional outcomes. The POST-stroke PSYchological DIStress PostPsyDis; NCT01187342) study aimed to investigate whether ischemic lesions in the striatum increase the risk of depression and PTSD after stroke.

Methods: This monocenter, observational, case-control study included 84 ischemic stroke patients with striatal (n = 54) and non-striatal ischemic brain lesions (n = 30). Primary study endpoints included symptoms of depression (assessed via the Geriatric Depression Scale; GDS-30) and PTSD (assessed via the Posttraumatic Symptom Scale; PTSS-10) 90 days post-stroke. A normative functional connectome was used to obtain a measure of striatal connectivity to the rest of the brain ("striatal network"). Network damage scores were used to estimate damage of each lesion to the striatal network.

Results: Patients with striatal lesions had higher GDS-30 scores at 90 days post-stroke (median 5.6 vs. 3.0; Cohen's d = 0.39; p = 0.057), indicating a small to moderate effect. However, no meaningful group differences were observed in the incidence of depression or PTSD. In multivariable regression analyses, striatal infarction had an adjusted beta coefficient (β) of 1.9 (95%CI 0.19-3.7; p = 0.076) for GDS-10 and 1.8 (95%CI -1.9-5.5; p = 0.25) for PTSS-10 scores after 90 days. Only female sex was independently associated with PTSD severity (adjusted β = 5.1, 95% CI 1.3-8.8; p = 0.008). Analyzing lesion connectivity to the striatal network did not change these findings.

Conclusions: Taken together, the PostPsyDis study suggests a high rate of psychiatric morbidity in stroke patients. Moreover, the study suggests increased neuropsychiatric symptoms in patients with striatal lesions. There is a clear need for larger studies to investigate the role of the striatum in post-stroke neuropsychiatric disorders.

Trial registration: ClinicalTrials.gov (NCT01187342) Registered 23 August 2009, https://clinicaltrials.gov/study/NCT01187342 .

Background: Mobility is crucial for participation and quality of life in individuals with sensorimotor impairments, yet scientific evidence on its course in real-world settings is limited. So-called wearables for measuring physical activity might help to overcome this knowledge gap allowing daily measurements of mobility. The aim of the present study is to examine the relationship between clinical walking tests and inertial measurement unit-based mobility tracking in the community setting of stroke and spinal cord injury (SCI) survivors.

Methods: At a single observational time point, the precision of the activity tracker was evaluated in a standardized parcours in healthy subjects and stroke or SCI survivors (n=57). This was followed by a multicenter observational cohort study (n=116 participants), in which the mobility of stroke and SCI survivors was assessed over 8 months immediately after discharge from acute inpatient rehabilitation. Daily distances covered in the community setting were recorded using the activity tracker. Established walking tests-including the 10-meter walk test (10MWT) and the timed up and go test (TUG)-were conducted at baseline, as well as at 4- and 8-month follow up visits. The relationship between daily distances in the ambulatory setting and 10MWT or TUG performance at discrete study visits (baseline, 4 months (midterm), and 8 months (final) after hospital discharge) was analyzed using regression models.

Results: The precision of the activity tracker in measuring covered distance in a standardized parcours varied by mobility type. The highest precision was achieved in manual wheelchair users (deviation from zero: -1.5±1.03% (p=0.15) while the least favorable precision was observed in participants with SCI and significant walking impairment (-14.6±2% (p<0.001). The widely used 10MWT speed showed a relationship with the ambulatory daily distance. The regression coefficients [m/(1m/s)] were: 874 (95% CI: 578-1171) at baseline (p<0.001), 895 (95% CI: 614-1176) at midterm (p<0.001), and 824 (95% CI: 537-1112) at the final visit (p<0.001). Interestingly, in the category of good walkers with the most favorable walking speeds the daily covered distance unmasked distinct subgroups with shorter and longer daily distances.

Conclusions: For SCI and stroke survivors, especially medium to fast walkers, activity tracking in real-world settings adds valuable insight beyond clinical walking tests. Clinical studies on rehabilitative interventions for mobility improvement should consider real-life daily distance as a key endpoint.

Background: Tenecteplase (TNK) offers promising efficacy and safety data for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) and pharmacological advantages over alteplase (rt-PA), justifying its gradual adoption as primary thrombolytic agent. At our tertiary care center, we transitioned from rt-PA to TNK, providing valuable real-world insights into this process, including its use beyond the 4.5-hour time window.

Methods: We retrospectively analyzed our stroke registry to compare clinical and procedural data from AIS patients treated with rt-PA (up to 6 months before transition) and those treated with TNK (up to 6 months after transition, starting June 2024). Primary endpoints included treatment metrics, such as door-to-needle (DTN), door-to-imaging (DTI), imaging-to-needle (ITN), door-to-groin and door-to-recanalization times. Safety outcomes comprised rate of any intracranial hemorrhage (ICH), symptomatic ICH (sICH), parenchymatous hematoma type 2 (PH 2) and post-thrombolysis angioedema. A semiquantitative questionnaire evaluated satisfaction with TNK and changes in lysis behavior among nurses and physicians 3 months post-implementation.

Results: During the twelve-month period (December 1, 2023 - November 30, 2024), 276 patients underwent IVT. Median DTN times were significantly shorter with TNK (n = 138) compared to rt-PA (n = 138) (TNK 27 min [IQR 19-39] vs. rt-PA 34 min [IQR 25-62]; p = 0.011). No significant differences were observed in safety outcomes, including any ICH (TNK 9% vs. rt-PA 6%; p = 0.30), sICH (2% vs. 1%; p = 0.31), PH 2 rates (1% in both groups), or angioedema (3% vs. 1%; p = 0.18). Staff satisfaction with TNK was high, citing advantages in preparation, administration, and time efficiency. Importantly, no changes in lysis behavior were reported following the transition.

Conclusions: Transitioning to TNK in routine practice at a tertiary care center seems feasible with reduced ITN and consequently DTN times. Functional outcomes at discharge were comparable without significant difference in the rate of (s)ICH. Overall, the transition to TNK was well-received by medical staff, highlighting TNK's practical advantages in acute stroke care.

Trial registration: N.A.