0000000000205296
AUTHOR
Werner Hacke
Clinical Syndromes, Pathogenesis, and Differential Diagnosis
The temporal sequence of signs and symptoms in patients with cerebral ischemia provides important information for the analysis of underlying pathophysiologic mechanisms and in the search for a major hemodynamic or embolic cause. The signs reported and symptoms assessed are useful for localization of the ischemic region of the brain and identification of the affected vascular territories. Even in the case of a typical clinical picture the clinical findings alone are often insufficient for unequivocal anatomic and pathologic identification, however important they may be in the choice of diagnostic and therapeutic measures. In the first few hours after cerebral ischemia, determining the progno…
Pathophysiology of Cerebral Ischemia
The weight of the brain amounts to only 2% of total body weight, but it receives 15% of the cardiac output and uses 20% of the oxygen consumed by the body. The energy supply is provided almost exclusively by glucose metabolism. The substrate for this is stored in the brain in the form of glucose or glycogen and is sufficient to cover the energy requirements for only about 1 min. Consequently, there is a delicate equilibrium between oxygen and nutrient supply from the blood and the energy requirements of the brain. Disturbances in neurologic function appear after a few seconds of ischemia, although they are not necessarily persistent at first.
New Strategy to Reduce the Global Burden of Stroke
The socioeconomic and health effect of stroke and other noncommunicable disorders (NCDs) that share many of the same risk factors with stroke, such as heart attack, dementia, and diabetes mellitus, is huge and increasing.1–4 Collectively, NCDs account for 34.5 million deaths (66% of deaths from all causes)3 and 1344 million disability-adjusted life years lost worldwide in 2010.2 The burden of NCDs is likely to burgeon given the aging of the world’s population and the epidemiological transition currently observed in many low- to middle-income countries (LMICs).5,6 In addition, there is low awareness in the population about these NCDs and their risk factors,7–10 particularly in LMICs.11 These…
Zeitbasiertes Management des akuten Schlaganfalls
Progression in medical research and economic needs require new planning and organization of treatment strategies. This does also apply for stroke treatment: New pathophysiological knowledge, positive results of thrombolytic therapy and the demostrated importance of early treatment at Stroke Units justify that stroke must be regarded as an emergency. Timing is of utmost importance. Time-based management serves as a planning model for a new stroke treatment strategy. The treatment process is divided into three phases: alarming, pre-hospital and in-hospital phase. The effectiveness of each of these phases is influenced by several variables (personnel, technical equipment, course of the disease…
Prevalence of atrial fibrillation in intracerebral hemorrhage
Background and purpose Oral anticoagulation (OAC) is an effective preventive therapy for ischemic stroke in atrial fibrillation (AF). The management of anticoagulation in AF patients with previous intracerebral hemorrhage (ICH) is challenging. The aim of this study was to determine the prevalence of AF after acute ICH in a consecutive monocenter cohort, and to document the subsequent management with respect to OAC. Methods Consecutive patients with spontaneous ICH were prospectively included within 19 months. Diagnosis of AF was based on medical history, 12-lead electrocardiogram (ECG), 24-h and continuous ECG monitoring. CHADS2 scores and patient medication were recorded at admission and a…
Der Schlaganfall als medizinischer Notfall
Studies into the pathophysiology of acute ischaemic stroke have indicated that treatment options are likely to be optimised when early signs of stroke are recognised and treatment is initiated within 3 hours from symptom onset. For most patients there is a long delay between the onset of symptoms and the start of therapy. Many factors are responsible for this time delay: signs and symptoms often go unrecognised by patients, relatives and bystanders and stroke is not given a high priority by medical staff. Although a small number of stroke patients is treated as emergency and attended to by the emergency medical services within this time window, this number could easily be increased by inten…
Treatment and Prophylaxis
Following a stroke, the patient’s neurologic deficit may be most impressive, but his treatment and prognosis depend largely upon accompanying systemic disorders. Acute treatment, for instance, must take into consideration such things as cardiovascular disorders (myocardial infarction, valve defects, arrhythmias, hypertension), disorders of renal function, and diabetes mellitus. The early detection and treatment of such systemic problems can help to prevent complications that would be difficult to control later. Thus, in a patient with latent heart disease hypervolemic therapy with low molecular weight dextran may in fact elicit right heart failure and pulmonary edema instead of helping the …
Common variation in PHACTR1 is associated with susceptibility to cervical artery dissection
Item does not contain fulltext Cervical artery dissection (CeAD), a mural hematoma in a carotid or vertebral artery, is a major cause of ischemic stroke in young adults although relatively uncommon in the general population (incidence of 2.6/100,000 per year). Minor cervical traumas, infection, migraine and hypertension are putative risk factors, and inverse associations with obesity and hypercholesterolemia are described. No confirmed genetic susceptibility factors have been identified using candidate gene approaches. We performed genome-wide association studies (GWAS) in 1,393 CeAD cases and 14,416 controls. The rs9349379[G] allele (PHACTR1) was associated with lower CeAD risk (odds ratio…
EP46* First pass effect and associated clot characteristics in the EXCELLENT registry – Interim analysis
Introduction EXCELLENT (NCT03685578) is a prospective, single-arm, multicenter, real-world international registry of mechanical thrombectomy (MT) for stroke with the EmboTrap device as first line treatment. The study entails thrombus analysis of specimens collected with each MT pass. Aim of the Study To compare rates of mRS 0–2 at 90 days and clot characteristics in subjects with and without first pass effect (FPE). Methods FPE was defined as mTICI 2c/3 after one pass and non-FPE as mTICI 2c/3 after >1 pass as adjudicated by an independent core lab. Clot analysis was performed by independent central labs blinded to clinical data. mRS at 90 days was scored by investigators blinded to procedu…
Applied Anatomy of the Cerebral Arteries
Four arteries supply the brain with blood: the two carotid and the two vertebral arteries. Although these four vessels are ultimately interlinked via a basal arterial network, the circle of Willis, and anastomoses at the brain surface, Heubner’s anastomoses, it is useful to distinguish anterior (carotid anterior and middle cerebral) and posterior (vertebrobasilar posterior cerebral) vascular territories (Gillian 1957, 1968; Lazorthes 1961; Kaplan and Ford 1966; Ganshirt 1972; Seeger 1978; Dorndorf 1983; Duus 1983).
Epidemiology and Classification of Strokes
Epidemiology concerns the occurrence and distribution of diseases in the population. By prevalence is meant the number of cases of the disease at a particular moment in a given group of persons, for example, in the entire population of a certain territory or in a clearly demarcated population group. Incidence refers to the number of new cases of the disease occurring in a population in a particular period of time. Figures on prevalence and incidence are meaningful only if the given disease is unequivocally defined. If the definition is too specific, many cases are not included (false-negative cases), whereas too broad a definition leads to many false-positive identifications (Table 3.1). Di…