[New treatment strategies for intraventricular hemorrhage]

The presence of additional intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH) is associated with a much higher mortality and worse functional outcome. Although evidence-based specific treatment options for this entity are still lacking, knowledge about the pathophysiology of IVH has grown in recent decades, leading to the development of promising treatment strategies. Intraventricular fibrinolysis (IVF) accelerates IVH resolution and removal from the ventricular system. The additional usage of lumbar drains probably reduces the incidence of permanent posthemorrhagic hydrocephalus. The influence of these treatment modalities on functional outcome is currently being investigated in ongoing studies. The present article gives an overview of pathophysiological and clinical aspects of IVH, emphasizing novel treatment options.

Feasibility of cerebral blood volume mapping by flat panel detector CT in the angiography suite: first experience in patients with acute middle cerebral artery occlusions

BACKGROUND AND PURPOSE

A new FPCT application offers the possibility of perfusion (FPCT CBV) and parenchymal (FPCT) imaging within the angiography suite. We tested the hypothesis that findings in FPCT CBV and FPCT would correlate with those obtained using MSCT and PCT.

MATERIALS AND METHODS

In 16 patients with acute MCA occlusion, FPCT CBV was performed immediately posttreatment. The volume of tissue having abnormal CBV values was determined by FPCT CBV and PCT images. Stroke volume on follow-up MSCT was determined, CBV values in the effected parenchyma were measured, and FPCT images were reviewed.

RESULTS

In 6 cases, we found a FPCT CBV value identical or higher (hyperemia) in comparison with the contralateral side. In 10 cases, we found CBV lesions with values lower (oligemia) than the contralateral brain tissue. We found a high correlation of CBV lesion volume on FPCT CBV images to stroke volume on follow-up MSCT (r = 0.9, P < .05) in the oligemia group. Absolute FPCT CBV and PCT CBV values were comparable and showed good correlation (r = 0.9, P < .05). In 8 patients, contrast medium extravasation was visible.

CONCLUSIONS

The new FPCT application allows assessment of CBV in acute stroke patients. Our initial results indicate that these measurements may predict final infarct volume. The ability to assess this key parameter of cerebral perfusion within the angiographic suite may improve the management of these patients.

Use of Tomosynthesis in Intraoperative Digital Specimen Radiography - Is a Reduction of Breast Re-excision Rates Possible?

Aim: A prospective clinical study was done to see whether it is possible to reduce the rate of re-excisions using digital breast tomosynthesis (DBT) compared commercial FFDM. Material and Method: Between 1/2011 and 5/2011 we diagnosed an invasive breast cancer (BI-RADS 5) in 100 patients. After histological verification we performed breast-conserving therapy with intraoperative imaging using one of 2 different systems: 1. Tomosynthesis (Siemens, Erlangen, Germany), amorphous selenium, Tungsten source, focus 0.1 mm, resolution 85 µm, pixel pitch, 8 l/mm, range: 50°, 25 projections, time for scanning > 20 s, geometry: same scanning scope, reconstruction: filtered back projection; or 2. Inspiration™ (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm, pixel pitch, 8 l/mm as the standard. The 100 radiograms obtained with both systems were prospectively shown on a monitor to 3 radiologists. Results: Out of a total of 100 patients with histologically proven breast cancer (BI-RADS 6) no re-excision was necessary in 78 patients. A retrospective analysis (n = 22) demonstrated an increase in sensitivity of tomosynthesis compared to the Inspiration™ at a magnification of 1.0 : 1.0 of 8 % (p < 0.05), i.e., in 8 patients re-excision would not have been necessary with tomosynthesis. Conclusion: Tomosynthesis has a significant higher sensitivity (p < 0.05) compared with a commercial FFDM system. Studies with higher numbers of patients will be necessary to evaluate this method.

Radiopacity of intracerebral hemorrhage correlates with perihemorrhagic edema

BACKGROUND

Experimental evidence indicates that iron plays a key role in edema formation after intracerebral hemorrhage (ICH). We investigated the relationship between ICH radiopacity on CT as a marker of hematoma iron content and perihemorrhagic edema (PHE) after ICH.

METHODS

We retrospectively investigated patients with spontaneous lobar and ganglionic supratentorial ICH who received follow-up CT scans during the first 7days after symptom onset (d1, d2-4, d5-7). Measurements of ICH and edema volumes were taken using a semiautomatic threshold-based volumetric algorithm. Radiopacity of the blood clot was determined using the mean Hounsfield unit (HU) count of the ICH.

RESULTS

A total of 117 patients aged 71.92±11.55years with spontaneous ICH (34.63±32.44ml) were included in the analysis. Mean ICH radiopacity was 59.7±3.4HU. We found significantly larger relative PHE at d2-4 (1.7±0.9 vs. 1.3±0.8; P=0.032) and d5-7 (2.0±1.3 vs. 1.3±0.9; P=0.007) and larger peak relative PHE (2.3±1.6 vs. 1.6±1.1; P=0.006) in patients with ICH radiopacity >60HU (n=59), as compared to patients with ICH radiopacity <60HU (n=58).

CONCLUSIONS

Higher ICH radiopacity, reflecting higher in vivo hematoma iron content, is associated with more PHE after ICH.

Changes in cognitive function over 3 years after first-ever stroke and predictors of cognitive impairment and long-term cognitive stability: the Erlangen Stroke Project

BACKGROUND AND PURPOSE

Cognitive impairment (CI) is frequent after stroke, but data from population-based stroke cohorts on the natural course of CI are limited. The purpose of this study was to determine changes in cognitive status over 3 years after stroke.

METHODS

Data were collected from the Erlangen Stroke Project, an ongoing population-based stroke registry. The Mini-Mental State Examination (MMSE) for assessing global cognitive function was used; CI was defined as an MMSE score <24.

RESULTS

From February 1998 to January 2006, 630 patients with first-ever stroke were included. Prevalence rates of CI at 3 months, 1 and 3 years were 15, 13, and 12%. In multivariable analysis, stroke severity, i.e. Barthel index (p < 0.001), age (OR = 1.03; 95% CI = 1.00-1.05) and diabetes mellitus (OR = 2.03; 95% CI = 1.13-3.67) were associated with CI at 3 months. Recovery rate from CI at 3 months after stroke was found to be 31% over the following 3 years. Intact cognitive function rate was 71% over 3 years and inversely associated with age (OR = 0.96; 95% CI = 0.96-0.94) and stroke severity (p < 0.001).

CONCLUSION

CI is frequent among stroke survivors and associated with age, stroke severity, and diabetes mellitus, but recovery occurs in approximately one third of the patients over the course of 3 years. Factors affecting intact cognitive function over time are increasing age and stroke severity.

Multiple sclerosis relapses are not associated with exercise

Since multiple sclerosis (MS) often affects physically active young individuals, it is important to know if exercise can result in increased disease activity. Therefore we used a self-report questionnaire to examine the relationship of different levels of sports activity and relapses in 632 patients with MS. In order to analyse whether subjective recall might have biased the results, we performed, in a subgroup of our sample, an objective assessment of clinical data and physical fitness parameters. We were unable to find any association between sports activity and clinical relapses in either of the two analyses. The group with highest activity even shows the lowermost mean values, standard deviations and range concerning the number of relapses. Our data suggest that physical activity has no significant influence on clinical disease activity.

Therapeutic hypothermia for space-occupying Herpes simplex virus encephalitis

Development of space-occupying edema in patients with severe Herpes simplex virus encephalitis is a major factor for high morbidity and mortality. Conventional intracranial pressure-lowering modalities are limited and more aggressive treatment options for such patients have rarely been described. This article reports on a HIV-positive patient with Herpes simplex type 2 encephalitis and elevated intracranial pressure refractory to medical therapy. Induced moderate hypothermia of 33 °C resulted in fast and sustained control of intracranial pressure. After three months, the patient had a fairly good functional outcome with a Glasgow Outcome Scale score of 4.

Significant decreases of circulating endothelial cells but no changes of endothelial progenitor cells or mesenchymal stem cells during antidepressant treatment

Objective

We examined leukocyte numbers, circulating endothelial progenitor cells (CD34+, CD133+), circulating mesenychmal stem cells (CD105+) and circulating endothelial cells (CD146+) at the beginning, after 4 weeks and at the end of an inpatient antidepressant treatment.

Methods

24 insufficiently pretreated inpatients with major depression were included. At admission, after four weeks and at demission blood samples were obtained, and cell numbers were counted by flow cytometric analysis (FACS). At each examination the severity of the depression was evaluated with the Beck Depression Inventory (BDI). We were especially interested in the changes of cell numbers during the antidepressant treatment. The data were statistically analyzed using SPSS 14.0.

Results

The mean BDI score fell from 34 ± 7 at the beginning to 26.5 ± 6.6 after four weeks and 13.5 ± 5.7 at demission. The longer the overall duration of the depressive illness, the higher the number of leukocytes at admission (P < 0.0001). The lower the depression score at demission, the lower the final number of leukocytes (P < 0.001). During the antidepressant treatment the BDI depression score improved significantly (P < 0.0001). The number of CD146+ cells showed a significant decrease (P < 0.006). We did not find any significant changes of circulating CD34+, CD105+, or CD133+ cells during the antidepressant treatment.

Conclusions

The leukocyte results suggest an activation of the immune system in major depression and a deactivation due to antidepressant treatment.

Sonographic monitoring of ventricle enlargement in posthemorrhagic hydrocephalus

BACKGROUND AND OBJECTIVE

Intraventricular hemorrhage often leads to obstructive hydrocephalus, necessitating placement of extraventricular drainage to prevent increasing intracranial pressure and subsequent herniation. For clamping and removal of the drainage, repeated CT scans are required to rule out recurrent hydrocephalus. We performed a prospective observational study on the use of transcranial duplex sonography to monitor changes in width of the lateral ventricles during clamping as an alternative to CT.

METHODS

Patients with hydrocephalus after intracranial or subarachnoid hemorrhage were monitored by transcranial duplex sonography (TDS). Serial examinations were carried out before and directly after placement of extraventricular or lumbar drainage as well as every 12 hours until 48 hours after removal of all drainages. Clinicians were blinded for all ultrasound results. Receiver operating characteristic analysis and calculation of the positive and negative predictive values was used to identify the optimal cutoff point in increased ventricle width that best predicted reopening of the drainage by the clinician.

RESULTS

Ninety-two attempts to clamp either lumbar or extraventricular drainage were monitored in 37 patients during a 1-year period. A cutoff value for increase of ventricular width of 5.5 mm yielded high sensitivity (100%) and specificity (83%) in combination with a 100% negative predictive value for reopening of the drainage.

CONCLUSIONS

TDS can be used to monitor ventricular width in experienced neurologic intensive care units. Because of its noninvasive character and suitability for bedside use, it offers a valuable alternative to repeated CT scans.

Characteristics and Outcome of Patients with Early Complete Neurological Recovery after Thrombolysis for Acute Ischemic Stroke

<i>Background:</i> Recombinant tissue plasminogen activator (rt-PA) is the only approved specific therapy for acute ischemic stroke. This study analyzes demographic and clinical characteristics of patients with early complete neurological recovery after thrombolysis. <i>Methods:</i> Data of 320 consecutive patients treated with rt-PA within 3 h of stroke onset at our facility between April 2006 and March 2009 were extracted from our prospective institutional stroke and thrombolysis database. Baseline demographic parameters, risk factors, clinical characteristics as well as neuroradiologic findings of patients with complete recovery 24 h after treatment and at hospital discharge were analyzed. Outcome was evaluated using the modified Rankin Scale at 90 days. <i>Results:</i> Thirty patients (9.4%) were asymptomatic 24 h after thrombolysis and 70 (22%) at hospital discharge. Patients with complete recovery were younger, more often male, had milder stroke symptoms, less often cardioembolic strokes, fewer bleeding complications and more often normal follow-up imaging. In addition, in-hospital time was shorter and these patients retained a better functional outcome at 90 days. Only 1 patient who had completely recovered at hospital discharge died during the follow-up time. In multivariate regression analysis, only the National Institute of Health Stroke Score (NIHSS) on admission was predictive for complete recovery at both examined time points. <i>Conclusion:</i> Rapid complete recovery can be achieved in up to a fifth of acute stroke patients treated with thrombolysis. These patients are younger and have milder strokes, less often with cardioembolic origin. Better outcome and lower mortality are sustained at 3 months.

Health care situation of patients with relapsing-remitting multiple sclerosis receiving immunomodulatory therapy: a retrospective survey of more than 9000 German patients with MS

BACKGROUND AND PURPOSE

First-line immunomodulatory treatment with interferon-beta or glatiramer acetate is accepted as effective basic therapy in patients with relapsing-remitting multiple sclerosis (RRMS). However, a considerable portion of patients does not benefit from treatment.

METHOD

To test basic immunomodulatory treatment under real-life conditions, we retrospectively analyzed clinical and subclinical disease activity within the last 12 months in a cohort of 9916 patients with RRMS, of which 7896 patients were receiving immunomodulatory treatment. In addition, factors associated with treating physicians' consideration of a switch of current treatment were assessed.

RESULTS

The majority of treated patients (approximately 66%) experienced no relapse during the last 12 months. However, in line with common clinical study findings, about one-third (approximately 34%) of patients had relapses. When MRI data were taken into account, approximately one-quarter (24%) of patients would qualify for therapy escalation to monoclonal antibody natalizumab. Relapse rate in the preceding year (the year directly prior to the start of retrospective data collection) was strongly associated with considering a switch of current treatment. In addition, therapy switch was more often considered in younger patients. The relationship between MRI findings in the absence of clinical symptoms and consideration of a treatment switch was not as clear.

CONCLUSIONS

This analysis confirms that disease progression occurs in a considerable proportion of patients with RRMS. These patients should be considered for therapy escalation.

Abstract P2-15-02: Web-Based Patient-Intake Process for Breast Care Center: The Patient Experience

Background: An important driver of health information technology will be an increased incorporation of self-reported patient health data into patient care workflow. We undertook this study to determine the feasibility, satisfaction, and challenges reported by patients related to the introduction of an electronic patient intake tool in an outpatient breast care clinic. Methods: A web-based self-reported new patient intake process was implemented in 2008 at an urban multi-disciplinary breast care clinic. The system was based on a platform developed by Dynamic Clinical Systems (DCS) which was designed to collect, warehouse, and provide reporting of data to inform patient treatment decisions. Patients new to the Breast Care Center with either breast symptoms or a newly diagnosed breast cancer were provided a weblink for data entry prior to the clinic visit. Patients were asked questions regarding medical/family history, symptoms, and psychosocial well-being. Data regarding the survey were compared among age groups using the chi square test.

Results: The first full calendar year for which data were collected was 1/1/09-12/31/09 during which 1218 women responded to the survey. Data were evaluated among 4 age groups: 0-18 (n=9), 19-49 (n=508), 50-69 (n=586), and ≥70 (n=115). 400 women (36%) were newly diagnosed with breast cancer; 106 (10%) of respondents had stage IV breast cancer. Overall 94.3% of patients took the survey themselves; 87% took the survey at home, compared to 7% in the doctors’ office. 89% reported using a high-speed (DSL, cable, wireless) internet connection. 69% of respondents completed the survey in less than one hour. Patients who completed the survey in the clinic (n=55) cited lack of access to the internet as the most common reason the survey was not completed in advance of the clinic visit (n=21). 64% of patients indicated e-mail as their preferred contact method; fewer women over 70 preferred e-mail contact to phone compared to younger groups (43%; P&lt;0.001), although even in this group, e-mail was the preferred mode of contact. 77% of patients reported satisfaction (41%) or high satisfaction (36%) with the survey system, with no difference in satisfaction seen among age groups (p=0.5).

Conclusion: Assessment of patients’ experience using a self-reported web-based patient intake form was conducted during the first full year of implementation. Most patients successfully completed the survey and indicated a high satisfaction level with its use. However, some differences were seen between age groups. Overall, &lt;2% of patients reported inability to access the internet. Electronic collection of self-reported patient data is not only feasible, but well accepted and has potential to facilitate patient care and treatment, reduce consultation time directed to collecting medical history, and allow standardized data collection for research and continuous quality improvement.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-15-02.

[Therapeutic hypothermia in neurological critical care]

Therapeutic hypothermia (TH) is very effective for the treatment of acute experimental brain injury. In contrast to other neuroprotective methods or pharmacological agents, TH represents the only clinically proven neuroprotective therapy. TH led to a decreased mortality rate and improved functional outcome in patients with cardiac arrest. Investigations in severe head trauma are inconclusive up to now. Other important indications such as ischemic stroke remain to be investigated properly. Recent phase II studies are on the way to test safety and feasibility in the early time window of stroke including thrombolysis. The recent article describes the status and perspectives including open questions for hypothermia in neurological intensive care.