European Headache Federation consensus on technical investigation for primary headache disorders

The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.

β-Blockers, Pneumonia, and Outcome After Ischemic Stroke

Background and Purpose—

Increased sympathetic drive after stroke is involved in the pathophysiology of several complications including poststroke immunudepression. β-Blocker (BB) therapy has been suggested to have neuroprotective properties and to decrease infectious complications after stroke. We aimed to examine the effects of random pre- and on-stroke BB exposure on mortality, functional outcome, and occurrence of pneumonia after ischemic stroke.

Methods—

Data including standard demographic and clinical variables as well as prestroke and on-stroke antihypertensive medication, incidence of pneumonia, functional outcome defined using modified Rankin Scale and mortality at 3 months were extracted from the Virtual International Stroke Trials Archive. For statistical analysis multivariable Poisson regression was used.

Results—

In total, 5212 patients were analyzed. A total of 1155 (22.2%) patients were treated with BB before stroke onset and 244 (4.7%) patients were newly started with BB in the acute phase of stroke. Mortality was 17.5%, favorable outcome (defined as modified Rankin Scale, 0–2) occurred in 58.2% and pneumonia in 8.2% of patients. Prestroke BB showed no association with mortality. On-stroke BB was associated with reduced mortality (adjusted risk ratio, 0.63; 95% confidence interval, 0.42–0.96). Neither prestroke BB nor on-stroke BB showed an association with functional outcome. Both prestroke and on-stroke BB were associated with reduced frequency of pneumonia (adjusted risk ratio, 0.77; 95% confidence interval, 0.6–0.98 and risk ratio, 0.49; 95% confidence interval, 0.25–0.95).

Conclusions—

In this large nonrandomized comparison, on-stroke BB was associated with reduced mortality. Prestroke and on-stroke BB were inversely associated with incidence of nosocomial pneumonia. Randomized trials investigating the potential of β-blockade in acute stroke may be warranted.

[New aspects of stroke medicine]

Systemic thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) remains the only effective and approved medical treatment of acute ischemic stroke. Several studies have demonstrated the importance of rapid recanalization. The efficacy of thrombectomy has so far not been sufficiently shown in randomized clinical trials; therefore, inclusion of suitable patients in one of the currently ongoing randomized trials is of great importance. The early treatment with magnesium after acute ischemic stroke during the pre-hospital phase did not prove to be neuroprotective. Intermittent pneumatic compression of the lower extremities in immobilized stroke patients effectively prevents deep venous thrombosis and pulmonary embolism. In patients with lacunar stroke the combination of aspirin and clopidogrel is not superior to aspirin alone and causes more bleeding complications. The novel oral anticoagulants are superior to warfarin in secondary prevention and carry a lower risk of intracranial and systemic bleeding complications. New studies will investigate whether dabigatran or rivaroxaban are superior to aspirin in secondary prevention after cryptogenic stroke.

Impaired velocity perception in patients with lesions of the cerebellum

In three psychophysical experiments, cerebellar patients were impaired in making perceptual judgments of the velocity of moving stimuli. Performance was normal when the judgment concerned the position of the stimuli (Experiment 1). The dissociation between the velocity and position tasks suggests the cerebellar group was selectively impaired in velocity perception. EOG data were obtained in Experiments 2 and 3 to assess whether the deficit was oculomotor in origin. Perceptual errors were not correlated with the occurrence of intrusive eye movements. These results provide a novel demonstration of the role of the cerebellum in perceptual functions that require precise timing.

[Diagnostic and treatment of acute ischemic stroke]

The incidence of first stroke in Germany is about 200.000, most of which are ischemic. The benefit of stroke unit treatment and systemic thrombolysis has been shown in large randomized trials. Diagnostic work-up besides neurologic examination includes cerebral imaging by CT or MR imaging including angiography, ultrasound of brain supplying arteries, ECG and Holter ECG and - if indicated - transesophageal echocardiography. Aspirin is the cornerstone of early secondary prevention in the acute phase, thereafter secondary prevention is determined by stroke etiology. Carotid endarterectomy or stent-assisted angioplasty are indicated in patients with hemodynamic or arterio-arterial stroke etiologies due to high-grade carotid stenosis. For cardioembolism due to atrial fibrillation, oral anticoagulation with vitamin K-antagonists or new oral anticoagulants should be started after the acute phase. In patients with non-cardioembolic stroke etiologies, platelet inhibitors are used for secondary prevention.