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Dargvainiene J, Jensen-Kondering U, Bender B, Berg D, Brüggemann N, Flüh C, Markewitz R, Neumann A, Röben B, Röcken C, Royl G, Schulte C, Wandinger KP, Weiler C, Margraf NG, Kuhlenbäumer G. Aβ38 and Aβ43 do not differentiate between Alzheimer's disease and cerebral amyloid angiopathy. Ann Clin Transl Neurol 2024; 11:806-811. [PMID: 38186185 DOI: 10.1002/acn3.51987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/23/2023] [Accepted: 12/10/2023] [Indexed: 01/09/2024] Open
Abstract
Differential diagnosis between Alzheimer's disease (AD) and cerebral amyloid angiopathy (CAA) using cerebrospinal fluid (CSF) biomarkers is challenging. A recent study suggested that the addition of Aβ38 and Aβ43 to a standard AD biomarker panel (Aβ40, Aβ42, t-tau, p-tau) to improve the differential diagnosis. We tested this hypothesis in an independent German cohort of CAA and AD patients and controls using the same analytical techniques. We found excellent discrimination between AD and controls and between CAA and controls, but not between AD and CAA. Adding Aβ38 and Aβ43 to the panel did not improve the discrimination between AD and CAA.
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Affiliation(s)
- Justina Dargvainiene
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulf Jensen-Kondering
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Benjamin Bender
- Department of Radiology, Diagnostical and Interventional Neuroradiology, University Hospital of Tübingen, Tübingen, Germany
| | - Daniela Berg
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Norbert Brüggemann
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Robert Markewitz
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Benjamin Röben
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Department of Pathology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Georg Royl
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Schulte
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Caroline Weiler
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Nils G Margraf
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
| | - Gregor Kuhlenbäumer
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University (CAU), Kiel, Germany
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Lee JI, Günther A, Paus S, Royl G, Weyen U, Wissel J, Zeuner KE, Klebe S. [Improvement of the treatment of patients with spastic movement disorder after stroke]. Nervenarzt 2024; 95:133-140. [PMID: 37987799 PMCID: PMC10850175 DOI: 10.1007/s00115-023-01571-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Spastic movement disorder (SMD) develops in up to 43% of cases as a sequela of stroke. In the event of a functionally relevant or daily life impairing SMD or to avoid an impending complication, the medicinal treatment of a focal, multifocal and segmental increase in muscle tone with botulinum neurotoxin A (BoNT-A) is recommended; however, treatment data reveal a lack of guideline-conform treatment with BoNT‑A in Germany. OBJECTIVE The aim of the reported expert meeting was to discuss solutions to the incorrect treatment and undertreatment of patients with SMD and to formulate consensus recommendations to improve the care situation. METHODS At a consensus meeting held in April 2022, eight experts from the fields of neurology, physical medicine and rehabilitation discussed the causes for the incorrect treatment and undertreatment and formulated consensus solution approaches. RESULTS Possible reasons for the current incorrect treatment and undertreatment in SMD management in Germany include insufficient awareness of SMD among physicians, a lack of treatment capacities, a lack of information transfer in discharge management as well as staff shortages in the specialized inpatient and outpatient SMD treatment centers. The committee therefore recommended a patient pathway in which affected patients with SMD are provided with correctly implemented BoNT‑A treatment in combination with physical measures. CONCLUSION The recommended treatment pathway for use in stroke patients is intended to close gaps in care and thus ensure guideline-conform treatment of post-stroke SMD.
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Affiliation(s)
- John-Ih Lee
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
| | - Albrecht Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Sebastian Paus
- Fachabteilung Neurologie, GFO Kliniken Troisdorf, Troisdorf, Deutschland
| | - Georg Royl
- Klinik für Neurologie, Neurovaskuläres Zentrum, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - Ute Weyen
- BG Universitätsklinikum Bergmannsheil Bochum, Bochum, Deutschland
| | - Jörg Wissel
- Neurorehabilitation, Vivantes Klinikum Spandau, Berlin, Deutschland
| | - Kirsten E Zeuner
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Stephan Klebe
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Deutschland
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Koch PJ, Rudolf LF, Schramm P, Frontzkowski L, Marburg M, Matthis C, Schacht H, Fiehler J, Thomalla G, Hummel FC, Neumann A, Münte TF, Royl G, Machner B, Schulz R. Preserved Corticospinal Tract Revealed by Acute Perfusion Imaging Relates to Better Outcome After Thrombectomy in Stroke. Stroke 2023; 54:3081-3089. [PMID: 38011237 DOI: 10.1161/strokeaha.123.044221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/04/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The indication for mechanical thrombectomy (MT) in stroke patients with large vessel occlusion has been constantly expanded over the past years. Despite remarkable treatment effects at the group level in clinical trials, many patients remain severely disabled even after successful recanalization. A better understanding of this outcome variability will help to improve clinical decision-making on MT in the acute stage. Here, we test whether current outcome models can be refined by integrating information on the preservation of the corticospinal tract as a functionally crucial white matter tract derived from acute perfusion imaging. METHODS We retrospectively analyzed 162 patients with stroke and large vessel occlusion of the anterior circulation who were admitted to the University Medical Center Lübeck between 2014 and 2020 and underwent MT. The ischemic core was defined as fully automatized based on the acute computed tomography perfusion with cerebral blood volume data using outlier detection and clustering algorithms. Normative whole-brain structural connectivity data were used to infer whether the corticospinal tract was affected by the ischemic core or preserved. Ordinal logistic regression models were used to correlate this information with the modified Rankin Scale after 90 days. RESULTS The preservation of the corticospinal tract was associated with a reduced risk of a worse functional outcome in large vessel occlusion-stroke patients undergoing MT, with an odds ratio of 0.28 (95% CI, 0.15-0.53). This association was still significant after adjusting for multiple confounding covariables, such as age, lesion load, initial symptom severity, sex, stroke side, and recanalization status. CONCLUSIONS A preinterventional computed tomography perfusion-based surrogate of corticospinal tract preservation or disconnectivity is strongly associated with functional outcomes after MT. If validated in independent samples this concept could serve as a novel tool to improve current outcome models to better understand intersubject variability after MT in large vessel occlusion stroke.
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Affiliation(s)
- Philipp J Koch
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
| | - Linda F Rudolf
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Peter Schramm
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Lukas Frontzkowski
- Department of Neurology (L.F., G.T., R.S.) University Medical Center Hamburg Eppendorf, Germany
| | - Maria Marburg
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Christine Matthis
- Department of Social Medicine and Epidemiology (C.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Jens Fiehler
- Department of Neuroradiology (J.F.) University Medical Center Hamburg Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (L.F., G.T., R.S.) University Medical Center Hamburg Eppendorf, Germany
| | - Friedhelm C Hummel
- Neuro-X Institute and Brain Mind Institute, Swiss Federal Institute of Technology, Geneva, Switzerland (F.C.H.)
- Neuro-X Institute and Brain Mind Institute, Swiss Federal Institute of Technology (EPFL Valais), Clinique Romande de Réadaptation, Sion, Switzerland (F.C.H.)
- Clinical Neuroscience, University of Geneva Medical School, Switzerland (F.C.H.)
| | - Alexander Neumann
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Thomas F Münte
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
| | - Georg Royl
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
| | - Björn Machner
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
- Department of Neurology, Schoen Clinic Neustadt, Holstein, Germany (B.M.)
| | - Robert Schulz
- Department of Neurology (L.F., G.T., R.S.) University Medical Center Hamburg Eppendorf, Germany
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Grosse GM, Hüsing A, Stang A, Kuklik N, Brinkmann M, Nabavi D, Sparenberg P, Weissenborn K, Gröschel K, Royl G, Poli S, Michalski D, Eschenfelder CC, Weimar C, Diener HC. Early or late initiation of dabigatran versus vitamin-K-antagonists in acute ischemic stroke or TIA: The PRODAST study. Int J Stroke 2023; 18:1169-1177. [PMID: 37306492 PMCID: PMC10676026 DOI: 10.1177/17474930231184366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND The optimal timing of initiating or resuming anticoagulation after acute ischemic stroke (AIS) or transient ischemic attack (TIA) in patients with atrial fibrillation (AF) is debated. Dabigatran, a non-vitamin K oral anticoagulant (NOAC), has shown superiority against vitamin K antagonists (VKA) regarding hemorrhagic complications. AIMS In this registry study, we investigated the initiation of dabigatran in the early phase after AIS or TIA. METHODS PRODAST (Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA) is a prospective, multicenter, observational, post-authorization safety study. We recruited 10,039 patients at 86 German stroke units between July 2015 and November 2020. A total of 3,312 patients were treated with dabigatran or VKA and were eligible for the analysis that investigates risks for major hemorrhagic events within 3 months after early (⩽ 7 days) or late (> 7 days) initiation of dabigatran or VKA initiated at any time. Further endpoints were recurrent stroke, ischemic stroke, TIA, systemic embolism, myocardial infarction, death, and a composite endpoint of stroke, systemic embolism, life-threatening bleeding and death. RESULTS Major bleeding event rates per 10,000 treatment days ranged from 1.9 for late administered dabigatran to 4.9 for VKA. Early or late initiation of dabigatran was associated with a lower hazard for major hemorrhages as compared to VKA use. The difference was pronounced for intracranial hemorrhages with an adjusted hazard ratio (HR) of 0.47 (95% confidence interval (CI): 0.10-2.21) for early dabigatran use versus VKA use and an adjusted HR of 0.09 (95% CI: 0.00-13.11) for late dabigatran use versus VKA use. No differences were found between early initiation of dabigatran versus VKA use regarding ischemic endpoints. CONCLUSIONS The early application of dabigatran appears to be safer than VKA administered at any time point with regards to the risk of hemorrhagic complications and in particular for intracranial hemorrhage. This result, however, must be interpreted with caution in view of the low precision of the estimate.
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Affiliation(s)
- Gerrit M Grosse
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Anika Hüsing
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Nils Kuklik
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Marcus Brinkmann
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Center for Clinical Trials Essen, University Hospital Essen, Essen, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | | | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | | | - Christian Weimar
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
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5
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Rhein S, Inderhees J, Herrmann O, Othman A, Begemann K, Fleming T, Nawroth PP, Klika KD, Isa R, König IR, Royl G, Schwaninger M. Glyoxal in hyperglycaemic ischemic stroke - a cohort study. Cardiovasc Diabetol 2023; 22:173. [PMID: 37438755 DOI: 10.1186/s12933-023-01892-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/17/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Hyperglycaemia is frequent in acute ischemic stroke and denotes a bad prognosis, even in the absence of pre-existing diabetes. However, in clinical trials treatment of elevated glucose levels with insulin did not improve stroke outcome, suggesting that collateral effects rather than hyperglycaemia itself aggravate ischemic brain damage. As reactive glucose metabolites, glyoxal and methylglyoxal are candidates for mediating the deleterious effects of hyperglycaemia in acute stroke. METHODS In 135 patients with acute stroke, we used liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) to measure glyoxal, methylglyoxal and several of their glycated amino acid derivatives in serum. Results were verified in a second cohort of 61 stroke patients. The association of serum concentrations with standard stroke outcome scales (NIHSS, mRS) was tested. RESULTS Glucose, glyoxal, methylglyoxal, and the glyoxal-derived glycated amino acid Nδ-(5-hydro-4-imidazolon-2-yl)ornithine (G-H1) were positively correlated with a bad stroke outcome at 3 months as measured by mRS90, at least in one of the two cohorts. However, the glycated amino acids Nε-carboxyethyllysine (CEL) and in one cohort pyrraline showed an inverse correlation with stroke outcome probably reflecting lower food intake in severe stroke. Patients with a poor outcome had higher serum concentrations of glyoxal and methylglyoxal. CONCLUSIONS The glucose-derived α-dicarbonyl glyoxal and glycated amino acids arising from a reaction with glyoxal are associated with a poor outcome in ischemic stroke. Thus, lowering α-dicarbonyls or counteracting their action could be a therapeutic strategy for hyperglycaemic stroke.
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Affiliation(s)
- Sina Rhein
- Institute for Experimental and Clinical Pharmacology and Toxicology, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
- German Centre for Cardiovascular Research, (DZHK), Hamburg-Lübeck-Kiel, Germany
| | - Julica Inderhees
- Institute for Experimental and Clinical Pharmacology and Toxicology, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
- German Centre for Cardiovascular Research, (DZHK), Hamburg-Lübeck-Kiel, Germany
- Bioanalytic Core Facility, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Oliver Herrmann
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Alaa Othman
- Bioanalytic Core Facility, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Kimberly Begemann
- Institute for Experimental and Clinical Pharmacology and Toxicology, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Thomas Fleming
- Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany
- German Research Centre for Diabetes Research, Düsseldorf, Germany
| | - Peter P Nawroth
- Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany
| | - Karel D Klika
- Molecular Structure Analysis, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rakad Isa
- Department of Neurology, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Inke R König
- German Centre for Cardiovascular Research, (DZHK), Hamburg-Lübeck-Kiel, Germany
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Markus Schwaninger
- Institute for Experimental and Clinical Pharmacology and Toxicology, Center for Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany.
- German Centre for Cardiovascular Research, (DZHK), Hamburg-Lübeck-Kiel, Germany.
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6
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Milling TJ, Middeldorp S, Xu L, Koch B, Demchuk A, Eikelboom JW, Verhamme P, Cohen AT, Beyer-Westendorf J, Michael Gibson C, Lopez-Sendon J, Crowther M, Shoamanesh A, Coppens M, Schmidt J, Albaladejo P, Connolly SJ, Bastani A, Clark C, Concha M, Cornell J, Dombrowski K, Fermann G, Fulmer J, Goldstein J, Kereiakes D, Milling T, Pallin D, Patel N, Refaai M, Rehman M, Schmaier A, Schwarz E, Shillinglaw W, Spohn M, Takata T, Venkat A, Welker J, Welsby I, Wilson J, Van Keer L, Verschuren F, Blostein M, Eikelboom J, Althaus K, Berrouschot J, Braun G, Doeppner T, Dziewas R, Genth-Zotz S, Greinacher P, Hamann F, Hanses F, Heide W, Kallmuenzer B, Kermer P, Poli S, Royl G, Schellong S, Schnupp S, Schwarze J, Spies C, Thomalla G, von Mering M, Weissenborn K, Wollenweber F, Gumbinger C, Jaschinski U, Maschke M, Mochmann HC, Pfeilschifter W, Pohlmann C, Zahn R, Bouzat P, Schmidt J, Vallejo C, Floccard B, Coppens M, van Wissen S, Arellano-Rodrigo E, Valles E, Alikhan R, Breen K, Hall R, Crowther M, Albaladejo P, Cohen A, Demchuk A, Schmidt J, Wyse D, Garcia D, Prins M, Nakamya J, Büller H, Mahaffey KW, Alexander JH, Cairns J, Hart R, Joyner C, Raskob G, Schulman S, Veltkamp R, Meeks B, Zotova E, Ahmad S, Pinto T, Baker K, Dykstra A, Holadyk-Gris I, Malvaso A, Demchuk A. Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors. Circulation 2023; 147:1026-1038. [PMID: 36802876 DOI: 10.1161/circulationaha.121.057844] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented. METHODS Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society of Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome. RESULTS There were 479 patients enrolled (mean age, 78 years; 54% male, 86% White; 81% anticoagulated for atrial fibrillation at a median time of 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 patients (10%); in 16 patients, this occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors. CONCLUSIONS In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02329327.
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Affiliation(s)
- Truman J Milling
- Seton Dell Medical School Stroke Institute, Dell Medical School, University of Texas at Austin (T.J.M.)
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Nijmegenthe Netherlands (S.M.)
| | - Lizhen Xu
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
| | - Bruce Koch
- Alexion, AstraZeneca Rare Disease, BostonMA (B.K.)
| | - Andrew Demchuk
- Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, AlbertaCanada (A.D.)
| | - John W Eikelboom
- Department of Medicine, McMaster University, HamiltonOntario Canada. (J.W.E., M. Crowther)
| | - Peter Verhamme
- Center for Molecular and Vascular Biology, University of Leuven, Belgium (P.V.)
| | | | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Hematology and Hemostasis, University Hospital Dresden, Germany (J.B-W.)
| | | | - Jose Lopez-Sendon
- Instituto de Investigación Hospital Universitario, La PazMadridSpain (J. L-S.)
| | - Mark Crowther
- Department of Medicine, McMaster University, HamiltonOntario Canada. (J.W.E., M. Crowther)
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands (M. Coppens)
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, France (J.S.)
| | | | - Stuart J Connolly
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
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7
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Jensen-Kondering U, Margraf NG, Weiler C, Maetzler W, Dargvainiene J, Falk K, Philippen S, Bartsch T, Flüh C, Röcken C, Möller B, Royl G, Neumann A, Brüggemann N, Roeben B, Schulte C, Bender B, Berg D, Kuhlenbäumer G. Characterizing mixed location hemorrhages/microbleeds with CSF markers. Int J Stroke 2023:17474930231152124. [PMID: 36622021 DOI: 10.1177/17474930231152124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is a common cause of lobar and subarachnoid hemorrhages in the elderly. A diagnosis of CAA requires multiple lobar hemorrhagic lesions (intracerebral hemorrhage and/or cerebral microbleeds) and/or cortical superficial siderosis (cSS). In contrast, hemorrhagic lesions located in the deep structures are the hallmark of hypertensive arteriopathy (HTN-A). They are an exclusion criterion for CAA, and when present with lobar hemorrhagic lesions considered a separate entity: mixed location hemorrhages/microbleeds (MLHs). We compared clinical, radiological, and cerebrospinal fluid (CSF) marker data in patients with CAA, MLH, and Alzheimer's disease (AD), and healthy controls (HCs) and used it to position MLH in the disease spectrum. PATIENTS AND METHODS Retrospective cohort study of consecutive patients with CAA (n = 31), MLH (n = 31), AD (n = 28), and HC (n = 30). Analysis of clinical, radiological, CSF biomarker (Aß42, Aß40, t-tau, and p-tau), and histopathological data in patients each group. RESULTS cSS was significantly more common in CAA than MLH (45% vs 13%, p = 0.011), and cSS in MLH was associated with intracerebral hemorrhage (ICH) (p = 0.037). Aß42 levels and the Aß42/Aß40 ratio, diagnostic groups followed the order HC > MLH > CAA > AD and the opposite order for t-tau and p-tau. No clear order was apparent forAß40. Aß40 and Aß42 levels as well as the Aß42/Aß40 ratio were lower in both CAA and MLH patients with cSS than in patients without cSS. Aß40 and Aß42 levels were higher in CAA and MLH patients with lacunar infarcts than in those without. CONCLUSION Our data suggest that MLH and CAA are mutually not exclusive diagnoses, and are part of a spectrum with variable contributions of both CAA and HTN-A.
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Affiliation(s)
- Ulf Jensen-Kondering
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Nils G Margraf
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Caroline Weiler
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Walter Maetzler
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Justina Dargvainiene
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Kim Falk
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Sarah Philippen
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Bettina Möller
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Georg Royl
- Department of Neurology, University Medical Center Schleswig Holstein, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Norbert Brüggemann
- Department of Neurology, University Medical Center Schleswig Holstein, Lübeck, Germany.,Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Benjamin Roeben
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany
| | - Claudia Schulte
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany
| | - Benjamin Bender
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Daniela Berg
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Gregor Kuhlenbäumer
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
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8
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Amoey DC, Thranitz J, Münte TF, Royl G. Acute Stroke and Atrial Fibrillation: Risk of Incorrect NOAC Dosage When Estimating Renal Function From Plasma Creatinine Only. Front Neurol 2022; 13:907912. [PMID: 35865641 PMCID: PMC9294157 DOI: 10.3389/fneur.2022.907912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Cardioembolic stroke (CS) due to atrial fibrillation (AF) bears a high risk of unfavorable outcome. Treatment with a non-vitamin K antagonist oral anticoagulant (NOAC) reduces this risk. NOAC dosage occurs on a thin line during the acute phase of the stroke unit when the patient is threatened by both recurrent CS and a hemorrhagic stroke. It is often adapted to renal function—usually glomerular filtration rate (GFR)—to prevent both under- and overdosing. This study investigates the hypothetical risk of incorrect NOAC dosage after acute stroke when relying on plasma creatinine alone in comparison to a more exact renal function assessment including urine collection. Methods In a cohort study on consecutive 481 patients treated in a stroke unit with acute stroke and AF, the GFR estimated from plasma creatinine (eGFR) was compared to concurrent creatinine clearance measurement (CrCl) from urine collection regarding the hypothetically derived NOAC dosage. Results The risk of incorrect dosage (mean, 95% confidence interval) was 6.9% (4.8–9.5), 26% (23–31), 38% (33–42), and 20% (16–23) for apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. The overall risk for incorrect dosage of any NOAC was 23% (21–25). Thresholds for age and admission eGFR were optimized to achieve an overall risk below 5% by additional CrCl measurements in selected patients (apixaban <36 ml/min and any age, dabigatran <75 ml/min and >70 y, edoxaban >36 ml/min and >58 y, rivaroxaban <76 ml/min and >75 y, any NOAC <81 ml/min and >54 y). The resulting portion of patients requiring an additional CrCl measurement was 10, 60, 80, 55, and 65% for apixaban, dabigatran, edoxaban, rivaroxaban, and any NOAC, respectively. Conclusions There is a considerable risk of incorrect NOAC dosage in patients with acute CS treated in a stroke unit that can be lowered by targeted CrCl measurements in selected patients.
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Affiliation(s)
- Danial C. Amoey
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Julia Thranitz
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Thomas F. Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
- *Correspondence: Georg Royl
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9
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Cirkel C, Cirkel A, Royl G, Frydrychowicz A, Tharun L, Deichmann S, Rody A, Münte TF, Machner B. On the quest for hidden ovarian teratomas in therapy-refractory anti-NMDA receptor encephalitis: a case report. Neurol Res Pract 2022; 4:15. [PMID: 35462557 PMCID: PMC9036800 DOI: 10.1186/s42466-022-00181-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-NMDA-receptor (anti-NMDAR) encephalitis is often associated with ovarian teratoma (OT). The best management of anti-NMDAR encephalitis patients with normal imaging studies (pelvic ultrasound/MRI) but clinically high risk of OT (e.g., female, adult, black) is unclear. We report on the surprising diagnostic quest in a young black woman with anti-NMDAR encephalitis, in whom invasive procedures could finally disclose two OTs that were hidden from the initial non-invasive diagnostics. CASE REPORT The patient presented with a one-week history of psychotic symptoms, developing oro-facial dyskinesia, seizures and coma, eventually requiring mechanical ventilation. NMDA-receptor antibodies were positive in serum and cerebrospinal fluid. Pelvic MRI and transabdominal ultrasound were normal. Exploratory laparoscopy was also unremarkable at first, but due to a suspicious echogenic mass (15 mm) in the right ovary on perioperative transvaginal ultrasound, an ovarian incision was performed which led to the detection of a first OT and its removal via ovarian-preserving cystectomy. Following a severe therapy-refractory clinical course despite aggressive immunotherapy and tumor removal, 6 months later bilateral oophorectomy was performed as ultima ratio, disclosing a second micro-OT (6 mm) in the left ovary. Unfortunately, the patient has not improved clinically yet. CONCLUSIONS In therapy-refractory anti-NMDAR encephalitis with high risk of OT, small and bilateral OTs hidden from primary non-invasive diagnostics should be considered, which may trigger further invasive diagnostic procedures.
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Affiliation(s)
- Christoph Cirkel
- Department of Gynecology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Anna Cirkel
- Department of Neurology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Alex Frydrychowicz
- Department of Radiology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Lars Tharun
- Institute of Pathology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Achim Rody
- Department of Gynecology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Thomas F Münte
- Department of Neurology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Björn Machner
- Department of Neurology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
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10
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Margraf NG, Jensen-Kondering U, Weiler C, Leypoldt F, Maetzler W, Philippen S, Bartsch T, Flüh C, Röcken C, Möller B, Royl G, Neumann A, Brüggemann N, Roeben B, Schulte C, Bender B, Berg D, Kuhlenbäumer G. Cerebrospinal Fluid Biomarkers in Cerebral Amyloid Angiopathy: New Data and Quantitative Meta-Analysis. Front Aging Neurosci 2022; 14:783996. [PMID: 35237145 PMCID: PMC8884145 DOI: 10.3389/fnagi.2022.783996] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/03/2022] [Indexed: 01/31/2023] Open
Abstract
Background To evaluate the diagnostic accuracy of cerebrospinal fluid (CSF) biomarkers in patients with probable cerebral amyloid angiopathy (CAA) according to the modified Boston criteria in a retrospective multicentric cohort. Methods Beta-amyloid 1-40 (Aβ40), beta-amyloid 1-42 (Aβ42), total tau (t-tau), and phosphorylated tau 181 (p-tau181) were measured in 31 patients with probable CAA, 28 patients with Alzheimer’s disease (AD), and 30 controls. Receiver-operating characteristics (ROC) analyses were performed for the measured parameters as well as the Aβ42/40 ratio to estimate diagnostic parameters. A meta-analysis of all amenable published studies was conducted. Results In our data Aβ42/40 (AUC 0.88) discriminated best between CAA and controls while Aβ40 did not perform well (AUC 0.63). Differentiating between CAA and AD, p-tau181 (AUC 0.75) discriminated best in this study while Aβ40 (AUC 0.58) and Aβ42 (AUC 0.54) provided no discrimination. In the meta-analysis, Aβ42/40 (AUC 0.90) showed the best discrimination between CAA and controls followed by t-tau (AUC 0.79), Aβ40 (AUC 0.76), and p-tau181 (AUC 0.71). P-tau181 (AUC 0.76), Aβ40 (AUC 0.73), and t-tau (AUC 0.71) differentiated comparably between AD and CAA while Aβ42 (AUC 0.54) did not. In agreement with studies examining AD biomarkers, Aβ42/40 discriminated excellently between AD and controls (AUC 0.92–0.96) in this study as well as the meta-analysis. Conclusion The analyzed parameters differentiate between controls and CAA with clinically useful accuracy (AUC > ∼0.85) but not between CAA and AD. Since there is a neuropathological, clinical and diagnostic continuum between CAA and AD, other diagnostic markers, e.g., novel CSF biomarkers or other parameters might be more successful.
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Affiliation(s)
- Nils G. Margraf
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
- *Correspondence: Nils G. Margraf,
| | - Ulf Jensen-Kondering
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Caroline Weiler
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Frank Leypoldt
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
- Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel/Lübeck, Germany
| | - Walter Maetzler
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Sarah Philippen
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Bettina Möller
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Georg Royl
- Department of Neurology, University Medical Center Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Norbert Brüggemann
- Department of Neurology, University Medical Center Schleswig Holstein, Campus Lübeck, Lübeck, Germany
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Benjamin Roeben
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany
| | - Claudia Schulte
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany
| | - Benjamin Bender
- Department of Neuroradiology, Diagnostical and Interventional Neuroradiology, University Hospital of Tübingen, Tübingen, Germany
| | - Daniela Berg
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Gregor Kuhlenbäumer
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
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11
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Sporns PB, Kemmling A, Minnerup H, Meyer L, Krogias C, Puetz V, Thierfelder K, Duering M, Kaiser D, Langner S, Massoth C, Brehm A, Rotkopf L, Kunz WG, Karch A, Fiehler J, Heindel W, Schramm P, Royl G, Wiendl H, Psychogios M, Minnerup J. CT Hypoperfusion-Hypodensity Mismatch to Identify Patients With Acute Ischemic Stroke Within 4.5 Hours of Symptom Onset. Neurology 2021; 97:e2088-e2095. [PMID: 34649883 DOI: 10.1212/wnl.0000000000012891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 09/15/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To test the hypothesis that CT hypoperfusion-hypodensity mismatch identifies patients with ischemic stroke within 4.5 hours of symptom onset. METHODS We therefore performed the Retrospective Multicenter Hypoperfusion-Hypodensity Mismatch for The identification of Patients With Stroke Within 4.5 Hours study of patients with acute ischemic stroke and known time of symptom onset. The predictive values of hypoperfusion-hypodensity mismatch for the identification of patients with symptom onset within 4.5 hours were the main outcome measure. RESULTS Of 666 patients, 548 (82.3%) had multimodal CT within 4.5 hours and 118 (17.7%) beyond 4.5 hours. Hypoperfusion-hypodensity mismatch was visible in 516 (94.2%) patients with symptom onset within and in 30 (25.4%) patients beyond 4.5 hours. CT hypoperfusion-hypodensity mismatch identified patients within 4.5 hours of stroke onset with 94.2% (95% confidence interval [CI] 91.9%-95.8%) sensitivity, 74.6% (95% CI 66.0%-81.6%) specificity, 94.5% (95% CI 92.3%-96.1%) positive predictive value, and 73.3% (95% CI 64.8%-80.4%) negative predictive value. Interobserver agreement for hypoperfusion-hypodensity mismatch was substantial (κ = 0.61, 95% CI 0.53-0.69). DISCUSSION Patients with acute ischemic stroke with absence of a hypodensity on native CT (NCCT) within the hypoperfused core lesion on perfusion CT (hypoperfusion-hypodensity mismatch) are likely to be within the time window of thrombolysis. Applying this method may guide the decision to use thrombolysis in patients with unknown time of stroke onset. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT04277728. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that CT hypoperfusion-hypodensity mismatch identifies patients with stroke within 4.5 hours of onset.
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Affiliation(s)
- Peter B Sporns
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - André Kemmling
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Heike Minnerup
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Lennart Meyer
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Christos Krogias
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Volker Puetz
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Kolja Thierfelder
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Marco Duering
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Daniel Kaiser
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Soenke Langner
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Christina Massoth
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Alex Brehm
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Lukas Rotkopf
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Wolfgang G Kunz
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - André Karch
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Jens Fiehler
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Walter Heindel
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Peter Schramm
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Georg Royl
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Heinz Wiendl
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Marios Psychogios
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany
| | - Jens Minnerup
- From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany.
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12
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Cirkel A, Wandinger KP, Ditz C, Leppert J, Hanker L, Cirkel C, Neumann A, Brocke J, Höftberger R, Komorowski L, Perner S, Leypoldt F, Wagner-Altendorf T, Münte TF, Royl G. Paraneoplastic encephalomyeloradiculits with multiple autoantibodies against ITPR-1, GFAP and MOG: case report and literature review. Neurol Res Pract 2021; 3:48. [PMID: 34635185 PMCID: PMC8504129 DOI: 10.1186/s42466-021-00145-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/23/2021] [Indexed: 11/12/2022] Open
Abstract
Background Recently, antibodies against the alpha isoform of the glial-fibrillary-acidic-protein (GFAPα) were identified in a small series of patients with encephalomyelitis. Coexisting autoantibodies (NMDA receptor, GAD65 antibodies) have been described in a few of these patients. We describe a patient with rapidly progressive encephalomyeloradiculitis and a combination of anti-ITPR1, anti-GFAP and anti-MOG antibodies. Case presentation and literature review A 44-year old caucasian woman with a flu-like prodrome presented with meningism, progressive cerebellar signs and autonomic symptoms, areflexia, quadriplegia and respiratory insufficiency. MRI showed diffuse bilateral T2w-hyperintense brain lesions in the cortex, white matter, the corpus callosum as well as a longitudinal lesion of the medulla oblongata and the entire spinal cord. Anti-ITPR1, anti-GFAP and anti-MOG antibodies were detected in cerebrospinal fluid along with lymphocytic pleocytosis. Borderline tumor of the ovary was diagnosed. Thus, the disease of the patient was deemed to be paraneoplastic. The patient was treated by surgical removal of tumor, steroids, immunoglobulins, plasma exchange and rituximab. Four months after presentation, the patient was still tetraplegic, reacted with mimic expressions to pain or touch and could phonate solitary vowels. An extensive literature research was performed. Conclusion Our case and the literature review illustrate that multiple glial and neuronal autoantibodies can co-occur, that points to a paraneoplastic etiology, above all ovarian teratoma or thymoma. Clinical manifestation can be a mixture of typically associated syndromes, e.g. ataxia associated with anti-ITPR1 antibodies, encephalomyelitis with anti-GFAPα antibodies and longitudinal extensive myelitis with anti-MOG antibodies. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00145-w.
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Affiliation(s)
- Anna Cirkel
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.
| | - Klaus-Peter Wandinger
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Jan Leppert
- Department of Neurosurgery, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Lars Hanker
- Department of Gynecology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Christoph Cirkel
- Department of Gynecology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Jan Brocke
- Neurological Rehabilitation Center, Segeberger Kliniken, Bad Segeberg, Germany
| | | | - Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Sven Perner
- Department of Pathology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Research Center Borstel, Leibniz Lung Center, 23538 Lübeck and, 23845, Borstel, Germany
| | - Frank Leypoldt
- Department of Neurosurgery, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Department of Neurology, University Hospital of Schleswig-Holstein Kiel, Kiel, Germany
| | | | - Thomas F Münte
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany.,Institute of Psychology II, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, University Hospital of Schleswig-Holstein Lübeck, Lübeck, Germany
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13
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Ribbat-Idel J, Stellmacher F, Jann F, Kalms N, König IR, Ohlrich M, Royl G, Klotz S, Kurz T, Kemmling A, Roessler FC. Development and reliability of the histological THROMBEX-classification rule for thrombotic emboli of acute ischemic stroke patients. Neurol Res Pract 2021; 3:50. [PMID: 34538282 PMCID: PMC8451083 DOI: 10.1186/s42466-021-00149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/09/2021] [Indexed: 11/14/2022] Open
Abstract
Background Thrombus histology has become a potential diagnostic tool for the etiology assessment of patients with ischemic stroke caused by embolic proximal vessel occlusion. We validated a classification rule that differentiates between cardiac and arteriosclerotic emboli in individual stroke patients. We aim to describe in detail the development of this classification rule and disclose its reliability. Methods The classification rule is based on the hypothesis that cardiac emboli arise out of separation thrombi and arteriosclerotic emboli result from agglutinative thrombi. 125 emboli recovered by thrombectomy from stroke patients and 11 thrombi serving as references for cardiac (n = 5) and arteriosclerotic emboli (n = 6) were Hematoxylin and eosin, Elastica-van Gieson and CD61 stained and rated independently by two histopathologists blinded to the presumed etiology by several pre-defined criteria. Intra- and interobserver reliabilities of all criteria were determined. Out of the different criteria, three criteria with the most satisfactory reliability values were selected to compose the classification rule that was finally adjusted to the reference thrombi. Reliabilities of the classification rule were calculated by using the emboli of stroke patients. Results The classification rule reached intraobserver reliabilities for the two raters of 92.9% and 68.2%, respectively. Interobserver reliability was 69.9%. Conclusions A new classification rule for emboli obtained from thrombectomy was established. Within the limitations of histological investigations, it is reliable and able to distinguish between cardioembolic and arteriosclerotic emboli. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00149-6.
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Affiliation(s)
- Julika Ribbat-Idel
- Institute of Pathology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Florian Stellmacher
- Institute of Pathology, Research Center Borstel - Leibniz Lung Center, 23845, Borstel, Germany
| | - Florian Jann
- Department of Neurology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385, Gießen, Germany
| | - Nicolas Kalms
- Department of Neurology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385, Gießen, Germany
| | - Inke R König
- Institute of Medical Biometry and Statistics, University of Lübeck, Ratzeburger Allee 160 (House 24), 23562, Lübeck, Germany
| | - Marcus Ohlrich
- Department of Neurology, Sana Kliniken Lübeck GmbH, Kronsforder Allee 71-73, 23560, Lübeck, Germany
| | - Georg Royl
- Department of Neurology and Center of Brain, Behaviour and Metabolism, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Stefan Klotz
- Department of Cardiovascular and Thoracic Surgery, Segeberger Kliniken, Am Kurpark 1, 23795, Bad Segeberg, Germany
| | - Thomas Kurz
- Department of Internal Medicine II/Cardiology, Angiology, and Intensive Care Medicine, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Andrè Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Hellmut-Hartert-Straße 1, 67655, Kaiserslautern, Germany
| | - Florian C Roessler
- Department of Neurology, Justus-Liebig-University Gießen, Klinikstraße 33, 35385, Gießen, Germany.
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14
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Göbel CH, Karstedt SC, Münte TF, Göbel H, Wolfrum S, Lebedeva ER, Olesen J, Royl G. Explicit Diagnostic Criteria for Transient Ischemic Attacks Used in the Emergency Department Are Highly Sensitive and Specific. Cerebrovasc Dis 2020; 50:62-67. [PMID: 33279892 DOI: 10.1159/000512182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Making a correct diagnosis of a transient ischemic attack (TIA) is prone to errors because numerous TIA mimics exist and there is a shortage of evidence-based diagnostic criteria for TIAs. In this study, we applied for the first time the recently proposed explicit diagnostic criteria for transient ischemic attacks (EDCT) to a group of patients presenting to the emergency department of a large German tertiary care hospital with a suspected TIA. The aim was to determine the sensitivity and specificity of the EDCT in its clinical application. METHODS A total of 128 patients consecutively presenting to the emergency department of the University Hospital of Lübeck, Germany, under the suspicion of a TIA were prospectively interviewed about their clinical symptoms at the time of presentation. The diagnosis resulting from applying the EDCT was compared to the diagnosis made independently by the senior physicians performing the usual diagnostic work-up ("gold standard"), allowing calculation of sensitivity and specificity of the EDCT. RESULTS EDCT achieved a sensitivity of 96% and a specificity of 88%. When adding the additional criterion F ("the symptoms may not be better explained by another medical or mental disorder"), specificity significantly increased to 98%. CONCLUSIONS The data show that the EDCT in its modified version as proposed by us are a highly useful tool for clinicians. They display a high sensitivity and specificity to accurately diagnose TIAs in patients referred to the emergency department with a suspected TIA.
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Affiliation(s)
- Carl H Göbel
- Department of Neurology, University of Lübeck, Lübeck, Germany, .,Institute of Psychology II, University of Lübeck, Lübeck, Germany, .,Kiel Migraine and Headache Centre, Kiel, Germany,
| | - Sarah C Karstedt
- Department of Neurology, University of Lübeck, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, Lübeck, Germany.,Kiel Migraine and Headache Centre, Kiel, Germany
| | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, Lübeck, Germany
| | | | - Sebastian Wolfrum
- Interdisciplinary Emergency Department, University of Lübeck, Lübeck, Germany
| | - Elena R Lebedeva
- Department of Neurology, Ural State Medical University, Yekaterinburg, Russian Federation
| | - Jes Olesen
- Danish Headache Center, Department of Neurology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, Lübeck, Germany
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15
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Thranitz J, Knauth M, Heldmann M, Küchler J, Münte TF, Royl G. Elevation of intracranial pressure affects the relationship between hemoglobin concentration and neuronal activation in human somatosensory cortex. Hum Brain Mapp 2020; 41:2702-2716. [PMID: 32128949 PMCID: PMC7294068 DOI: 10.1002/hbm.24973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 11/25/2022] Open
Abstract
During neuronal activation, a local decrease of deoxygenated hemoglobin concentration (deoxy‐Hb) occurs which is the basis of functional brain imaging with blood oxygenation level dependent functional magnetic resonance imaging (BOLD‐fMRI). Elevated intracranial pressure (eICP) has been shown to impair functional deoxy‐Hb changes. This study investigated this effect and its relation to the underlying neuronal activity in the human primary somatosensory cortex (SI). Functional near‐infrared spectroscopy (fNIRS) during somatosensory evoked potentials (SEP) monitoring was performed on 75 subjects during conditions of median nerve stimulation (MNS) and resting state, combined with normal breathing (NB) and eICP by escalating breathing maneuvers (breath holding [BH], Valsalva maneuver with 15 mmHg [V15] and 35 mmHg expiratory pressure [V35]). During NB, fNIRS revealed a typical oxygenated hemoglobin concentration (oxy‐Hb) increase with deoxy‐Hb decrease during MNS enabling SI brain mapping. Breathing maneuvers associated eICP produced a known global change of oxy‐Hb and deoxy‐Hb with and without MNS. When subtracting measurements during resting state from measurements during MNS, neither functional oxy‐Hb nor deoxy‐Hb changes could be recovered while SEPs remained unchanged. In conclusion, Valsalva‐induced eICP prevents oxy‐Hb and deoxy‐Hb changes during neuronal activation in SI. This finding raises questions on the validity of oxy‐Hb‐ and deoxy‐Hb‐based brain imaging (e.g., BOLD‐fMRI) during eICP.
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Affiliation(s)
- Julia Thranitz
- Department of Neurology, Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Martin Knauth
- Department of Internal Medicine, Schön Klinik Neustadt, Neustadt in Holstein, Germany
| | - Marcus Heldmann
- Department of Neurology, Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Thomas F Münte
- Department of Neurology, Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
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16
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Göbel CH, Karstedt SC, Münte TF, Göbel H, Wolfrum S, Lebedeva ER, Olesen J, Royl G. ICHD-3 is significantly more specific than ICHD-3 beta for diagnosis of migraine with aura and with typical aura. J Headache Pain 2020; 21:2. [PMID: 31910800 PMCID: PMC6947981 DOI: 10.1186/s10194-019-1072-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/24/2019] [Indexed: 01/03/2023] Open
Abstract
Background In the emergency room, distinguishing between a migraine with aura and a transient ischemic attack (TIA) is often not straightforward and mistakes can be harmful to both the patient and to society. To account for this difficulty, the third edition of the International Classification of Headache disorders (ICHD-3) changed the diagnostic criteria of migraine with aura. Methods One hundred twenty-eight patients referred to the emergency room at the University Hospital of Lübeck, Germany with a suspected TIA were prospectively interviewed about their symptoms leading to admission shortly after initial presentation. The diagnosis that resulted from applying the ICHD-3 and ICHD-3 beta diagnostic criteria was compared to the diagnosis made independently by the treating physicians performing the usual diagnostic work-up. Results The new ICHD-3 diagnostic criteria for migraine with aura and migraine with typical aura display an excellent specificity (96 and 98% respectively), and are significantly more specific than the previous ICHD-3 beta classification system when it comes to diagnosing a first single attack (probable migraine with aura and probable migraine with typical aura). Conclusions The ICHD-3 is a highly useful tool for the clinical neurologist in order to distinguish between a migraine with aura and a TIA, already at the first point of patient contact, such as in the emergency department or a TIA clinic.
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Affiliation(s)
- Carl H Göbel
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany. .,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany. .,Kiel Migraine and Headache Centre, 24149, Kiel, Germany.
| | - Sarah C Karstedt
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany.,Kiel Migraine and Headache Centre, 24149, Kiel, Germany
| | - Thomas F Münte
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany
| | - Hartmut Göbel
- Kiel Migraine and Headache Centre, 24149, Kiel, Germany
| | - Sebastian Wolfrum
- Interdisciplinary Emergency Department, University of Lübeck, 23538, Lübeck, Germany
| | - Elena R Lebedeva
- Department of Neurology, Ural State Medical University, Yekaterinburg, Russia
| | - Jes Olesen
- Danish Headache Center, Department of Neurology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Georg Royl
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany
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17
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Broocks G, Kniep H, Schramm P, Hanning U, Flottmann F, Faizy T, Schönfeld M, Meyer L, Schön G, Aulmann L, Machner B, Royl G, Fiehler J, Kemmling A. Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization. J Neurointerv Surg 2019; 12:747-752. [DOI: 10.1136/neurintsurg-2019-015308] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/17/2019] [Accepted: 10/29/2019] [Indexed: 11/04/2022]
Abstract
BackgroundBenefit of thrombectomy in patients with a low initial Alberta Stroke Program Early CT Score (ASPECTS) is still uncertain. We hypothesized that, despite low ASPECTS, patients may benefit from endovascular recanalization if good collaterals are present.MethodsIschemic stroke patients with large vessel occlusion in the anterior circulation and an ASPECTS of ≤5 were analyzed. Collateral status (CS) was assessed using a 5-point-scoring system in CT angiography with poor CS defined as CS=0–1. Clinical outcome was determined using the modified Rankin Scale (mRS) score after 90 days. Edema formation was measured in admission and follow-up CT by net water uptake.Results27/100 (27%) patients exhibited a CS of 2–4. 50 patients underwent successful vessel recanalization and 50 patients had a persistent vessel occlusion. In multivariable logistic regression analysis, collateral status (OR 3.0; p=0.003) and vessel recanalization (OR 12.2; p=0.009) significantly increased the likelihood of a good outcome (mRS 0–3). A 1-point increase in CS was associated with 1.9% (95% CI 0.2% to 3.7%) lowered lesion water uptake in follow-up CT .ConclusionEndovascular recanalization in patients with ASPECTS of ≤5 but good collaterals was linked to improved clinical outcome and attenuated edema formation. Collateral status may serve as selection criterion for thrombectomy in low ASPECTS patients.
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18
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Royl G, Fokou TJ, Chunder R, Isa R, Münte TF, Wandinger KP, Schwaninger M, Herrmann O, Valdueza JM, Brocke J, Willkomm M, Willemsen D, Auffarth GU, Mindorf S, Brix B, Chamorro A, Planas A, Urra X. Antibodies against neural antigens in patients with acute stroke: joint results of three independent cohort studies. J Neurol 2019; 266:2772-2779. [PMID: 31359201 DOI: 10.1007/s00415-019-09470-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke (IS) and hemorrhagic stroke (HemS) typically lead to a breakdown of the blood-brain barrier with neural antigen presentation. This presentation could potentially generate destructive auto-immune responses. Pre-existing antineuronal and antiglial antibodies (AA), predominantly NMDA receptor antibodies, have been reported in patients with stroke. This article summarizes three independent prospective studies, the Lübeck cohort (LC), Barcelona cohort (BC), and Heidelberg cohort (HC), exploring the frequency and clinical relevance of AA in patients with acute stroke (AS). METHODS In all cohorts together, 344 consecutive patients admitted with AS (322 × IS, 22 × HemS) were screened for AA in serum at admission. Clinical outcome parameters as well as a second AA screening were available at 30 days in the LC or at 90 days in the BC. A control group was included in the BC (20 subjects free from neurological disease) and the HC (78 neurological and ophthalmological patients without evidence for stroke). RESULTS The rate of positivity for AA was similar in control subjects and AS patients (13%, 95% CI [7%, 22%] vs. 13%, 95% CI [10%, 17%]; p = 0.46) with no significant difference between cohorts (LC 25/171, BC 12/75, HC 9/98). No patient had developed new AA after 30 days, whereas 2 out of 60 patients had developed new AA after 90 days. AA positive patients did not exhibit significant differences to AA negative patients in stroke subtype (LC, BC), initial stroke severity (BC, LC, HC), infarct volume (BC), and functional status at admission (BC, LC, HC) and follow-up (BC, LC). CONCLUSIONS AS does not induce AA to a relevant degree. Pre-existing AA can be found in the serum of stroke patients, but they do not have a significant association with clinical features and outcomes.
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Affiliation(s)
- Georg Royl
- Department of Neurology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany. .,Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany.
| | - Tsafack Judicael Fokou
- Department of Neurology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | | | - Rakad Isa
- Department of Neurology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Thomas F Münte
- Department of Neurology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.,Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Klaus-Peter Wandinger
- Department of Neurology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.,Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Holstein, Germany
| | - Markus Schwaninger
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany.,Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany.,Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Oliver Herrmann
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | | | - Jan Brocke
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Martin Willkomm
- Geriatric Research Group, Krankenhaus Rotes Kreuz, Lübeck, Germany
| | | | - Gerd U Auffarth
- Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany
| | | | - Britta Brix
- Euroimmun Medizinische Labordiagnostika, Lübeck, Germany
| | - Angel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Anna Planas
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Department of Brain Ischemia and Neurodegeneration, Institut d'Investigacions Biomèdiques de Barcelona, Consejo Superior de Investigaciones Científicas, Barcelona, Spain
| | - Xabier Urra
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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19
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Prasuhn J, Royl G, Wandinger KP, Brüggemann N, Neumann A, Münte TF. Transient Generalized Chorea in Influenza A Encephalopathy. Tremor Other Hyperkinet Mov (N Y) 2018; 8:591. [PMID: 30402339 PMCID: PMC6214816 DOI: 10.7916/d8f495tp] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/17/2018] [Indexed: 12/01/2022]
Abstract
Background Influenza A infections are a rare cause of movement disorders. Previously described patients have suffered from acute-onset myoclonus and/or dystonia or post-viral parkinsonism. Case Report We present the case of a 74-year-old female patient with transient generalized chorea due to influenza A-mediated encephalopathy. Discussion We discuss whether the clinical presentation and the magnetic resonance imaging changes may be attributable to cytokine-mediated encephalopathy or to direct cytotoxic effects of the virus. Additionally, we would like to make clinicians aware of this clinical sign in the context of viral encephalopathy.
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Affiliation(s)
- Jannik Prasuhn
- Department of Neurology, University of Lübeck, Lübeck, DE.,Institute of Neurogenetics, University of Lübeck, Lübeck, DE
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, DE
| | - Klaus P Wandinger
- Department of Neurology, University of Lübeck, Lübeck, DE.,Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Lübeck, DE
| | - Norbert Brüggemann
- Department of Neurology, University of Lübeck, Lübeck, DE.,Institute of Neurogenetics, University of Lübeck, Lübeck, DE
| | | | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, DE
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Al-Khaled M, Brüning T, Gottwald C, Roessler F, Royl G, Eckey T. Comparing outcome and recanalization results in patients with anterior circulation stroke following endovascular treatment with and without a treatment with rt-PA: A single-center study. Brain Behav 2018; 8:e00974. [PMID: 29761023 PMCID: PMC5943750 DOI: 10.1002/brb3.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/11/2018] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Endovascular treatment (ET), in addition to a therapy with intravenous recombinant tissue plasminogen activator IV rt-PA in patients with acute ischemic stroke, has been found to improve outcome. However, data about ET in patients who have not received therapy with rt-PA due to contraindications for IV rt-PA are sparse. Comparison of ET with IV rt-PA versus ET alone in patients with stroke is done using a proximal intracranial arterial occlusion (internal carotid artery, middle cerebral artery (M1-Segment)). METHODS During a 5-year period (2011-2016), 236 patients (mean age, 69 ± 14 years; 46% women; median NIHSS score 13 ± 5) who were treated at the Department of Neurology and Neuroradiology at the University of Lübeck, undergoing ET with or without IV rt-PA were included and analyzed. RESULTS A total of 144 patients (61%) underwent ET + IV rt-PA, and 92 patients (39%) underwent ET only. The ET with IV rt-PA is associated with a higher rate of favorable functional outcomes (mRS≤2) at discharge from hospital (51.4% vs. 23.1%, p < .001) and lower rate of in-hospital mortality (9% vs. 19.6%, p = .019) and symptomatic intracerebral hemorrhage [sICH] (2.1% vs. 8.7%; p = .019) compared to ET, whereas the modified treatment in cerebral infarction score (mTICI) did not differ between the groups.In the adjusted logistic regression analysis, the ET + IV rt-PA was associated with an increased probability of favorable functional outcome (OR, 4.3; 95% confidence interval [CI], 2.2-8.5; p < .001). For the in-hospital mortality (OR, 0.74; 95% CI, 0.29-1.9; p = .76) and sICH (OR, 0.3; 95% CI, 0.07-1.2; p = .09), no differences were found. CONCLUSION Recanalization results after endovascular treatment are not relevantly improved in patients receiving rt-PA. However, an additional therapy with IV rt-PA has a positive impact on functional outcome.
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Affiliation(s)
| | - Toralf Brüning
- Department of Neurology University of Lübeck Lübeck Germany.,Department of Neurology Bundeswehrkrankenhaus Hamburg Germany
| | - Carina Gottwald
- Department of Neurology University of Lübeck Lübeck Germany.,Department of Neurology Bundeswehrkrankenhaus Hamburg Germany
| | - Florian Roessler
- Department of Neurology University of Lübeck Lübeck Germany.,Department of Neurology University of Giessen Giessen Germany
| | - Georg Royl
- Department of Neurology University of Lübeck Lübeck Germany
| | - Thomas Eckey
- Department of Neuroradiology University of Lübeck Lübeck Germany
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Abstract
A hiccup is a reflex movement with diffusely distributed afferents and efferents in the thorax; its functional relevance is controversial. In its physiological form, it is mostly a minor complaint that stops spontaneously and rarely leads to medical consultation. However, prolonged agonizing hiccups represent serious deterioration of quality of life. Chronic hiccups by definition last for more than 48 h, with gastroesophageal reflux being the frequent underlying disease. Various other causes affect multiple organ systems, some with serious underlying diseases. A hiccup may be the only symptom at the first manifestation of some neurological disorders. In neuroimaging a lesion of the medulla oblongata is often seen. A NMO and an ischemic stroke with Wallenberg syndrome are 2 frequently underlying neurological diseases, but other inflammatory and vascular diseases and tumors of the central nervous system may be present. No optimal evidencebased recommendations for diagnosis and management of chronic hiccups are available. The search for the underlying disease often requires an interdisciplinary approach by internists, neurologists, and otolaryngologists. Symptomatic treatment may be necessary even before diagnosis. Persistent hiccups, a common problem in oncological palliative care, are often challenging. Proton pump inhibitor or prokinetics are used for treating underlying gastroesophageal reflux and baclofen with or without gabapentin in other cases. Anticonvulsants, antipsychotics, antidepressants, and calcium channel blockers represent other alternative treatment possibilities. In therapy-refractory cases, invasive procedures such as the selective phrenic nerve block are available. More studies are needed to help deal with the diagnostic and therapeutic challenge that hiccups present for neurologists.
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Aulmann LF, Busch K, Zegelin A, Eckey T, Neumann A, Boppel T, Brehmer M, Moritz C, Schlüter A, Royl G, Schramm P, Kemmling A. Abstract 182: Thermal Imaging as a Diagnostic Biomarker in Acute Ischemic Stroke. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose:
With highly portable mobile infrared cameras thermal imaging during acute stroke triage has become possible. The purpose of this pilot study was to evaluate the pattern of superficial facial skin temperature in patients with acute proximal arterial occlusion of the anterior circulation compared to non-ischemic controls. We hypothesize, that temperature dysregulation in stroke with associated thermal pattern may be used to predict presence of proximal vessel occlusion.
Methods:
In 46 patients suffering from acute occlusion in the anterior circulation (ICA: 17, M1-MCA: 13, M2-MCA: 16) infrared thermal imaging of the face was performed before endovascular treatment. Asymmetric temperature patterns were evaluated visually. Quantitative temperature values were obtained from regions of interest (ROIs) placed symmetrically on the left and right half of on the facial thermal image. Presence and side of vessel occlusion was correlated with temperature measurements.
Results:
Regional facial asymmetric temperature was readily visible at 0.5°C. Temperature differences ranged from 0.5 to 1.5° C in stroke patients, and <0.5°C in controls. In 16 of 17 patients with ICA occlusion, facial asymmetric temperature was detected (in 13 lower temperatures on ipsilateral side, in 3 on the contralateral side). In 11 of 13 patients with M1-MCA occlusion, facial asymmetric temperature was detected (in 8 lower temperatures on the contralateral side, 3 on the ipsilateral side). In 15 of 16 patients with an occlusion of M2-segment, asymmetric temperature pattern was apparent, however no clear trend with regard. In 16 of 20 controls, no asymmetric temperature pattern >0.5°C was observed.
Conclusion:
Thermal imaging could serve as a fast point-of-care test to detect asymmetrical pattern in facial temperature as a predictor of proximal vessel occlusion in stroke. However, the current method is prone to imaging artifacts and reliability of detected asymmetry is moderate.
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Affiliation(s)
| | - Kira Busch
- UKSH Lübeck - Institut für Neuroradiologie, Lübeck, Germany
| | - Andrea Zegelin
- UKSH Lübeck - Klinik für Anästhesiologie und Intensivmedizin, Lübeck, Germany
| | - Thomas Eckey
- UKSH Lübeck - Institut für Neuroradiologie, Lübeck, Germany
| | | | - Tobias Boppel
- UKSH Lübeck - Institut für Neuroradiologie, Lübeck, Germany
| | - Moritz Brehmer
- UKSH Lübeck - Institut für Neuroradiologie, Lübeck, Germany
| | | | | | - Georg Royl
- UKSH Lübeck - Klinik für Neurologie, Lübeck, Germany
| | - Peter Schramm
- UKSH Lübeck - Institut für Neuroradiologie, Lübeck, Germany
| | - André Kemmling
- UKSH Lübeck - Institut für Neuroradiologie, Lübeck, Germany
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Al-Khaled M, Matthis C, Binder A, Mudter J, Schattschneider J, Pulkowski U, Strohmaier T, Niehoff T, Zybur R, Eggers J, Valdueza JM, Royl G. Dysphagia in Patients with Acute Ischemic Stroke: Early Dysphagia Screening May Reduce Stroke-Related Pneumonia and Improve Stroke Outcomes. Cerebrovasc Dis 2016; 42:81-9. [DOI: 10.1159/000445299] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/07/2016] [Indexed: 11/19/2022] Open
Abstract
Background: Dysphagia is associated with poor outcome in stroke patients. Studies investigating the association of dysphagia and early dysphagia screening (EDS) with outcomes in patients with acute ischemic stroke (AIS) are rare. The aims of our study are to investigate the association of dysphagia and EDS within 24 h with stroke-related pneumonia and outcomes. Methods: Over a 4.5-year period (starting November 2007), all consecutive AIS patients from 15 hospitals in Schleswig-Holstein, Germany, were prospectively evaluated. The primary outcomes were stroke-related pneumonia during hospitalization, mortality, and disability measured on the modified Rankin Scale ≥2-5, in which 2 indicates an independence/slight disability to 5 severe disability. Results: Of 12,276 patients (mean age 73 ± 13; 49% women), 9,164 patients (74%) underwent dysphagia screening; of these patients, 55, 39, 4.7, and 1.5% of patients had been screened for dysphagia within 3, 3 to <24, 24 to ≤72, and >72 h following admission. Patients who underwent dysphagia screening were likely to be older, more affected on the National Institutes of Health Stroke Scale score, and to have higher rates of neurological symptoms and risk factors than patients who were not screened. A total of 3,083 patients (25.1%; 95% CI 24.4-25.8) had dysphagia. The frequency of dysphagia was higher in patients who had undergone dysphagia screening than in those who had not (30 vs. 11.1%; p < 0.001). During hospitalization (mean 9 days), 1,271 patients (10.2%; 95% CI 9.7-10.8) suffered from stroke-related pneumonia. Patients with dysphagia had a higher rate of pneumonia than those without dysphagia (29.7 vs. 3.7%; p < 0.001). Logistic regression revealed that dysphagia was associated with increased risk of stroke-related pneumonia (OR 3.4; 95% CI 2.8-4.2; p < 0.001), case fatality during hospitalization (OR 2.8; 95% CI 2.1-3.7; p < 0.001) and disability at discharge (OR 2.0; 95% CI 1.6-2.3; p < 0.001). EDS within 24 h of admission appeared to be associated with decreased risk of stroke-related pneumonia (OR 0.68; 95% CI 0.52-0.89; p = 0.006) and disability at discharge (OR 0.60; 95% CI 0.46-0.77; p < 0.001). Furthermore, dysphagia was independently correlated with an increase in mortality (OR 3.2; 95% CI 2.4-4.2; p < 0.001) and disability (OR 2.3; 95% CI 1.8-3.0; p < 0.001) at 3 months after stroke. The rate of 3-month disability was lower in patients who had received EDS (52 vs. 40.7%; p = 0.003), albeit an association in the logistic regression was not found (OR 0.78; 95% CI 0.51-1.2; p = 0.2). Conclusions: Dysphagia exposes stroke patients to a higher risk of pneumonia, disability, and death, whereas an EDS seems to be associated with reduced risk of stroke-related pneumonia and disability.
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Leithner C, Füchtemeier M, Jorks D, Mueller S, Dirnagl U, Royl G. Infarct Volume Prediction by Early Magnetic Resonance Imaging in a Murine Stroke Model Depends on Ischemia Duration and Time of Imaging. Stroke 2015; 46:3249-59. [PMID: 26451016 DOI: 10.1161/strokeaha.114.007832] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 09/02/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Despite standardization of experimental stroke models, final infarct sizes after middle cerebral artery occlusion (MCAO) vary considerably. This introduces uncertainties in the evaluation of drug effects on stroke. Magnetic resonance imaging may detect variability of surgically induced ischemia before treatment and thus improve treatment effect evaluation. METHODS MCAO of 45 and 90 minutes induced brain infarcts in 83 mice. During, and 3 and 6 hours after MCAO, we performed multiparametric magnetic resonance imaging. We evaluated time courses of cerebral blood flow, apparent diffusion coefficient (ADC), T1, T2, accuracy of infarct prediction strategies, and impact on statistical evaluation of experimental stroke studies. RESULTS ADC decreased during MCAO but recovered completely on reperfusion after 45 and partially after 90-minute MCAO, followed by a secondary decline. ADC lesion volumes during MCAO or at 6 hours after MCAO largely determined final infarct volumes for 90 but not for 45 minutes MCAO. The majority of chance findings of final infarct volume differences in random group allocations of animals were associated with significant differences in early ADC lesion volumes for 90, but not for 45-minute MCAO. CONCLUSIONS The prediction accuracy of early magnetic resonance imaging for infarct volumes depends on timing of magnetic resonance imaging and MCAO duration. Variability of the posterior communicating artery in C57Bl6 mice contributes to differences in prediction accuracy between short and long MCAO. Early ADC imaging may be used to reduce errors in the interpretation of post MCAO treatment effects on stroke volumes.
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Affiliation(s)
- Christoph Leithner
- From the Department of Experimental Neurology, Charité Universitätsmedizin, Berlin, Germany (C.L., M.F., D.J., S.M., U.D., G.R.); Center for Stroke Research Berlin, Berlin, Germany (C.L., D.J., S.M., U.D., G.R.); NeuroCure Cluster of Excellence, Berlin, Germany (C.L., U.D.); German Center for Neurodegenerative Diseases (DZNE) (M.F., U.D.) and German Center for Cardiovascular Diseases (DZHK) (U.D.), Berlin site, Charitéplatz, Berlin, Germany; and Department of Neurology, University of Lübeck, Lübeck, Germany (G.R.).
| | - Martina Füchtemeier
- From the Department of Experimental Neurology, Charité Universitätsmedizin, Berlin, Germany (C.L., M.F., D.J., S.M., U.D., G.R.); Center for Stroke Research Berlin, Berlin, Germany (C.L., D.J., S.M., U.D., G.R.); NeuroCure Cluster of Excellence, Berlin, Germany (C.L., U.D.); German Center for Neurodegenerative Diseases (DZNE) (M.F., U.D.) and German Center for Cardiovascular Diseases (DZHK) (U.D.), Berlin site, Charitéplatz, Berlin, Germany; and Department of Neurology, University of Lübeck, Lübeck, Germany (G.R.)
| | - Devi Jorks
- From the Department of Experimental Neurology, Charité Universitätsmedizin, Berlin, Germany (C.L., M.F., D.J., S.M., U.D., G.R.); Center for Stroke Research Berlin, Berlin, Germany (C.L., D.J., S.M., U.D., G.R.); NeuroCure Cluster of Excellence, Berlin, Germany (C.L., U.D.); German Center for Neurodegenerative Diseases (DZNE) (M.F., U.D.) and German Center for Cardiovascular Diseases (DZHK) (U.D.), Berlin site, Charitéplatz, Berlin, Germany; and Department of Neurology, University of Lübeck, Lübeck, Germany (G.R.)
| | - Susanne Mueller
- From the Department of Experimental Neurology, Charité Universitätsmedizin, Berlin, Germany (C.L., M.F., D.J., S.M., U.D., G.R.); Center for Stroke Research Berlin, Berlin, Germany (C.L., D.J., S.M., U.D., G.R.); NeuroCure Cluster of Excellence, Berlin, Germany (C.L., U.D.); German Center for Neurodegenerative Diseases (DZNE) (M.F., U.D.) and German Center for Cardiovascular Diseases (DZHK) (U.D.), Berlin site, Charitéplatz, Berlin, Germany; and Department of Neurology, University of Lübeck, Lübeck, Germany (G.R.)
| | - Ulrich Dirnagl
- From the Department of Experimental Neurology, Charité Universitätsmedizin, Berlin, Germany (C.L., M.F., D.J., S.M., U.D., G.R.); Center for Stroke Research Berlin, Berlin, Germany (C.L., D.J., S.M., U.D., G.R.); NeuroCure Cluster of Excellence, Berlin, Germany (C.L., U.D.); German Center for Neurodegenerative Diseases (DZNE) (M.F., U.D.) and German Center for Cardiovascular Diseases (DZHK) (U.D.), Berlin site, Charitéplatz, Berlin, Germany; and Department of Neurology, University of Lübeck, Lübeck, Germany (G.R.)
| | - Georg Royl
- From the Department of Experimental Neurology, Charité Universitätsmedizin, Berlin, Germany (C.L., M.F., D.J., S.M., U.D., G.R.); Center for Stroke Research Berlin, Berlin, Germany (C.L., D.J., S.M., U.D., G.R.); NeuroCure Cluster of Excellence, Berlin, Germany (C.L., U.D.); German Center for Neurodegenerative Diseases (DZNE) (M.F., U.D.) and German Center for Cardiovascular Diseases (DZHK) (U.D.), Berlin site, Charitéplatz, Berlin, Germany; and Department of Neurology, University of Lübeck, Lübeck, Germany (G.R.)
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Ohlrich M, Royl G. Singultus – Diagnostik und Therapie. Akt Neurol 2014. [DOI: 10.1055/s-0034-1367057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- M. Ohlrich
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck
| | - G. Royl
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck
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Stubbe T, Ebner F, Richter D, Engel O, Klehmet J, Royl G, Meisel A, Nitsch R, Meisel C, Brandt C, Brandt C. Regulatory T cells accumulate and proliferate in the ischemic hemisphere for up to 30 days after MCAO. J Cereb Blood Flow Metab 2013; 33:37-47. [PMID: 22968321 PMCID: PMC3597367 DOI: 10.1038/jcbfm.2012.128] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Local and peripheral immune responses are activated after ischemic stroke. In our present study, we investigated the temporal distribution, location, induction, and function of regulatory T cells (Tregs) and the possible involvement of microglia, macrophages, and dendritic cells after middle cerebral artery occlusion (MCAO). C57BL/6J and Foxp3(EGFP) transgenic mice were subjected to 30 minutes MCAO. On days 7, 14, and 30 after MCAO, Tregs and antigen presenting cells were analyzed using fluorescence activated cell sorting multicolor staining and immunohistochemistry. A strong accumulation of Tregs was observed on days 14 and 30 in the ischemic hemisphere accompanied by the elevated presence and activation of microglia. Dendritic cells and macrophages were found on each analyzed day. About 60% of Foxp3(+) Tregs in ischemic hemispheres were positive for the proliferation marker Ki-67 on days 7 and 14 after MCAO. The transfer of naive CD4(+) cells depleted of Foxp3(+) Tregs into RAG1(-/-) mice 1 day before MCAO did not lead to a de novo generation of Tregs 14 days after surgery. After depletion of CD25(+) Tregs, no changes regarding neurologic outcome were detected. The sustained presence of Tregs in the brain after MCAO indicates a long-lasting immunological alteration and involvement of brain cells in immunoregulatory mechanisms.
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Affiliation(s)
- Tobias Stubbe
- Center for Anatomy, Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Abstract
Neurological chief complaints often lead patients into the emergency room. In order to establish standard emergency workups it is important to know the frequency of neurological chief complaints. Therefore, we performed a retrospective study on 4,132 consecutive neurological patients in the emergency room over a 1-year period. The most frequent chief complaint was headache (20%) followed by motor deficit (13%), vertigo (12%) and epileptic seizure (11%). In conclusion, the neurological workup in the emergency room can be optimized by establishing clinical decision-making rules for the four most frequent chief complaints.
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Affiliation(s)
- G Royl
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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Royl G, Ploner CJ, Leithner C. Dizziness in the Emergency Room: Diagnoses and Misdiagnoses. Eur Neurol 2011; 66:256-63. [DOI: 10.1159/000331046] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 07/06/2011] [Indexed: 11/19/2022]
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Leithner C, Müller S, Füchtemeier M, Lindauer U, Dirnagl U, Royl G. Determination of the brain-blood partition coefficient for water in mice using MRI. J Cereb Blood Flow Metab 2010; 30:1821-4. [PMID: 20842161 PMCID: PMC3023928 DOI: 10.1038/jcbfm.2010.160] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cerebral blood flow (CBF) quantification is a valuable tool in stroke research. Mice are of special interest because of the potential of genetic engineering. Magnetic resonance imaging (MRI) provides repetitive, noninvasive CBF quantification. Many MRI techniques require the knowledge of the brain-blood partition coefficient (BBPC) for water. Adopting an MRI protocol described by Roberts et al (1996) in humans, we determined the BBPC for water in 129S6/SvEv mice from proton density measurements of brain and blood, calibrated with deuterium oxide/water phantoms. The average BBPC for water was 0.89 ± 0.03 mL/g, with little regional variation within the mouse brain.
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Affiliation(s)
- Christoph Leithner
- Department of Experimental Neurology, Charité-Universitätsmedizin, Center for Stroke Research Berlin, Berlin, Germany.
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Lindauer U, Dirnagl U, Füchtemeier M, Böttiger C, Offenhauser N, Leithner C, Royl G. Pathophysiological interference with neurovascular coupling - when imaging based on hemoglobin might go blind. Front Neuroenergetics 2010; 2. [PMID: 20953238 PMCID: PMC2955428 DOI: 10.3389/fnene.2010.00025] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 07/20/2010] [Indexed: 01/09/2023]
Abstract
Assessing neuronal activity by non-invasive functional brain imaging techniques which are based on the hemodynamic response depends totally on the physiological cascade of metabolism and blood flow. At present, functional brain imaging with near infrared spectroscopy (NIRS) or BOLD-fMRI is widely used in cognitive neuroscience in healthy subjects where neurovascular coupling and cerebrovascular reactivity can be assumed to be intact. Local activation studies as well as studies investigating functional connectivity between brain regions of the resting brain provide a rapidly increasing body of knowledge on brain function in humans and animals. Furthermore, functional NIRS and MRI techniques are increasingly being used in patients with severe brain diseases and this use might gain more and more importance for establishing their use in the clinical routine. However, more and more experimental evidence shows that changes in baseline physiological parameters, pharmacological interventions, or disease-related vascular changes may significantly alter the normal response of blood flow and blood oxygenation and thus may lead to misinterpretation of neuronal activity. In this article we present examples of recent experimental findings on pathophysiological changes of neurovascular coupling parameters in animals and discuss their potential implications for functional imaging based on hemodynamic signals such as fNIRS or BOLD-fMRI. To enable correct interpretation of neuronal activity by vascular signals, future research needs to deepen our understanding of the basic mechanisms of neurovascular coupling and the specific characteristics of disturbed neurovascular coupling in the diseased brain.
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Affiliation(s)
- Ute Lindauer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany
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Füchtemeier M, Leithner C, Offenhauser N, Foddis M, Kohl-Bareis M, Dirnagl U, Lindauer U, Royl G. Elevating intracranial pressure reverses the decrease in deoxygenated hemoglobin and abolishes the post-stimulus overshoot upon somatosensory activation in rats. Neuroimage 2010; 52:445-54. [PMID: 20420930 DOI: 10.1016/j.neuroimage.2010.04.237] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 02/19/2010] [Accepted: 04/20/2010] [Indexed: 10/19/2022] Open
Abstract
BOLD fMRI localizes activated brain areas by measuring decreases of deoxygenated hemoglobin (deoxy-Hb) caused by neurovascular coupling. To date, it is unclear whether intracranial pressure (ICP) modifies deoxy-Hb signaling for brain mapping. In addition, ICP elevation can test whether the BOLD post-stimulus undershoot, a transient hypo-oxygenation following functional activation, is due to vascular compliance rather than elevated cerebral metabolic rate of oxygen (CMRO(2)). We addressed these questions by studying the effect of ICP elevation on neurovascular coupling. In anesthetized rats, a cranial window was implanted over the somatosensory cortex. Using laser Doppler flowmetry and optical spectroscopy, changes in cerebral blood flow (CBF), cerebral blood volume (CBV) and deoxy-Hb were measured during electrical forepaw stimulation. Neuronal activity was monitored by somatosensory evoked potentials. ICP was elevated by subarachnoideal and intracisternal infusion of artificial cerebrospinal fluid. ICP elevation did not abrogate neurovascular coupling. However, the concomitant deoxy-Hb decrease was reduced (ICP=14mmHg) and reversed (ICP=28mmHg). Therefore, the validity of BOLD fMRI has to be questioned during increased ICP. Moreover, the amplitude of the deoxy-Hb post-stimulus overshoot was reduced with ICP elevation. CMRO(2) was not elevated during the post-stimulus response. Therefore, these data provide experimental evidence that the BOLD post-stimulus undershoot is a passive vascular phenomenon.
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Affiliation(s)
- Martina Füchtemeier
- Department of Experimental Neurology and Center for Stroke Research, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10098 Berlin, Germany
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Leithner C, Royl G, Offenhauser N, Füchtemeier M, Kohl-Bareis M, Villringer A, Dirnagl U, Lindauer U. Pharmacological uncoupling of activation induced increases in CBF and CMRO2. J Cereb Blood Flow Metab 2010; 30:311-22. [PMID: 19794398 PMCID: PMC2949119 DOI: 10.1038/jcbfm.2009.211] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Neurovascular coupling provides the basis for many functional neuroimaging techniques. Nitric oxide (NO), adenosine, cyclooxygenase, CYP450 epoxygenase, and potassium are involved in dilating arterioles during neuronal activation. We combined inhibition of NO synthase, cyclooxygenase, adenosine receptors, CYP450 epoxygenase, and inward rectifier potassium (Kir) channels to test whether these pathways could explain the blood flow response to neuronal activation. Cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO(2)) of the somatosensory cortex were measured during forepaw stimulation in 24 rats using a laser Doppler/spectroscopy probe through a cranial window. Combined inhibition reduced CBF responses by two-thirds, somatosensory evoked potentials and activation-induced CMRO(2) increases remained unchanged, and deoxy-hemoglobin (deoxy-Hb) response was abrogated. This shows that in the rat somatosensory cortex, one-third of the physiological blood flow increase is sufficient to prevent microcirculatory increase of deoxy-Hb concentration during neuronal activity. The large physiological CBF response is not necessary to support small changes in CMRO(2). We speculate that the CBF response safeguards substrate delivery during functional activation with a considerable 'safety factor'. Reduction of the CBF response in pathological states may abolish the BOLD-fMRI signal, without affecting underlying neuronal activity.
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Affiliation(s)
- Christoph Leithner
- Department of Experimental Neurology, Charité Universitätsmedizin, Center for Stroke Research Berlin, Berlin, Germany
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Klohs J, Baeva N, Steinbrink J, Bourayou R, Boettcher C, Royl G, Megow D, Dirnagl U, Priller J, Wunder A. In vivo near-infrared fluorescence imaging of matrix metalloproteinase activity after cerebral ischemia. J Cereb Blood Flow Metab 2009; 29:1284-92. [PMID: 19417756 DOI: 10.1038/jcbfm.2009.51] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Matrix metalloproteinases (MMPs) have been implicated in the pathophysiology of cerebral ischemia. In this study, we explored whether MMP activity can be visualized by noninvasive near-infrared fluorescence (NIRF) imaging using an MMP-activatable probe in a mouse model of stroke. C57Bl6 mice were subjected to transient middle cerebral artery occlusion (MCAO) or sham operation. Noninvasive NIRF imaging was performed 24 h after probe injection, and target-to-background ratios (TBRs) between the two hemispheres were determined. TBRs were significantly higher in MCAO mice injected with the MMP-activatable probe than in sham-operated mice and in MCAO mice that were injected with the nonactivatable probe as controls. Treatment with an MMP inhibitor resulted in significantly lower TBRs and lesion volumes compared to injection of vehicle. To test the contribution of MMP-9 to the fluorescence signal, MMP9-deficient (MMP9(-/-)) mice and wild-type controls were subjected to MCAO of different durations to attain comparable lesion volumes. TBRs were significantly lower in MMP9(-/-) mice, suggesting a substantial contribution of MMP-9 activity to the signal. Our study shows that MMP activity after cerebral ischemia can be imaged noninvasively with NIRF using an MMP-activatable probe, which might be a useful tool to study MMP activity in the pathophysiology of the disease.
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Affiliation(s)
- Jan Klohs
- Department of Experimental Neurology, Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, Berlin 10117, Germany.
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Royl G, Balkaya M, Lehmann S, Lehnardt S, Stohlmann K, Lindauer U, Endres M, Dirnagl U, Meisel A. Effects of the PDE5-inhibitor vardenafil in a mouse stroke model. Brain Res 2009; 1265:148-57. [PMID: 19368809 DOI: 10.1016/j.brainres.2009.01.061] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 01/26/2009] [Accepted: 01/26/2009] [Indexed: 10/21/2022]
Abstract
Recent experimental studies in rodents suggest that treatment with inhibitors of phosphodiesterase type 5 (PDE5) (tadalafil, sildenafil, zaprinast) not only increases cerebral blood flow but also improves functional recovery after stroke. Here, we investigated in a mouse model of stroke the effects of vardenafil on survival, functional outcome and lesion size after experimental stroke. Mice were subjected to experimental stroke by occlusion of the middle cerebral artery (MCAO) for 45 min. A group of mice received vardenafil (twice 10 mg/kg body weight per day orally over 14 days) starting 3 h after MCAO. Control animals received the vehicle only. Survival, body weight, and behavior were monitored over 4 weeks and brain lesions were measured by T2-weighted MRI, hematoxylin/eosin -- as well as GFAP-staining of cryostat sections, subsequently. The mortality in MCAO-operated animals amounted to 45% until day 10 after stroke and no significant difference in survival between the vardenafil- and vehicle-treatment groups was observed. Compared to sham-operated animals, MCAO-operated mice from both treatment groups demonstrated a significant weight loss until day 5 and regained their body weight by day 14 after ischemia. There was no significant difference between the vardenafil and vehicle-treated MCAO groups. In behavioral studies (sucrose consumption and pole test), analyzing sensorimotor functions as well as a parameter of depression-like symptoms, we observed no significant effect of vardenafil treatment on functional recovery in our model of stroke. Although we observed a trend towards less hemispherical atrophy in the vardenafil compared to the vehicle-treated group four weeks after MCAO our data do not suggest a functionally relevant CNS-tissue protective or regenerative effect in murine stroke.
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Affiliation(s)
- Georg Royl
- Department of Experimental Neurology, Charité-Universitaetsmedizin, Berlin, Germany.
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35
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Leithner C, Gertz K, Schröck H, Priller J, Prass K, Steinbrink J, Villringer A, Endres M, Lindauer U, Dirnagl U, Royl G. A flow sensitive alternating inversion recovery (FAIR)-MRI protocol to measure hemispheric cerebral blood flow in a mouse stroke model. Exp Neurol 2008; 210:118-27. [DOI: 10.1016/j.expneurol.2007.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 09/21/2007] [Accepted: 10/10/2007] [Indexed: 10/22/2022]
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Prüss H, Prass K, Ghaeni L, Milosevic M, Muselmann C, Freyer D, Royl G, Reuter U, Baeva N, Dirnagl U, Meisel A, Priller J. Inducible nitric oxide synthase does not mediate brain damage after transient focal cerebral ischemia in mice. J Cereb Blood Flow Metab 2008; 28:526-39. [PMID: 17851454 DOI: 10.1038/sj.jcbfm.9600550] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nitric oxide produced by the inducible nitric oxide synthase (iNOS) is believed to participate in the pathogenic events after cerebral ischemia. In this study, we examined the expression of iNOS in the brain after transient focal cerebral ischemia in mice. We detected differential expression of exons 2 and 3 of iNOS mRNA (16-fold upregulation at 24 to 72 h after middle cerebral artery occlusion, MCAO) compared with exons 6 to 8, 12 to 14, 21 to 22, and 26 to 27 (2- to 5-fold upregulation after 72 and 96 h), which would be compatible with alternative splicing. Expression levels of iNOS mRNA were too low for detection by the Northern blot analysis. Using specific antibodies, we did not detect any iNOS immunoreactivity in the mouse brain 1 to 5 days after MCAO, although we detected iNOS immunoreactivity in the lungs of mice with stroke-associated pneumonia, and in mouse and rat dura mater after lipopolysaccharide administration. In chimeric iNOS-deficient mice transplanted with wild-type bone marrow (BM) cells expressing the green fluorescent protein (GFP) or in wild-type mice transplanted with GFP(+) iNOS-deficient BM cells, no expression of iNOS was detected in GFP(+) leukocytes invading the ischemic brain or in resident brain cells. Moreover, both experimental groups did not show any differences in infarct size. Analysis of three different strains of iNOS-deficient mice and wild-type controls confirmed that infarct size was independent of iNOS deletion, but strongly confounded by the genetic background of mouse strains. In conclusion, our data suggest that iNOS is not a universal mediator of brain damage after cerebral ischemia.
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Affiliation(s)
- Harald Prüss
- Department of Experimental Neurology, Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Royl G, Füchtemeier M, Leithner C, Megow D, Offenhauser N, Steinbrink J, Kohl-Bareis M, Dirnagl U, Lindauer U. Hypothermia effects on neurovascular coupling and cerebral metabolic rate of oxygen. Neuroimage 2008; 40:1523-32. [PMID: 18343160 DOI: 10.1016/j.neuroimage.2008.01.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 01/22/2008] [Indexed: 10/22/2022] Open
Abstract
Neuronal activation is accompanied by a local increase in cerebral blood flow (CBF) and in cerebral metabolic rate of oxygen (CMRO(2)), caused by neurovascular and neurometabolic coupling. Hypothermia is used as a neuroprotective approach in surgical patients and therapeutically after cardiac arrest or stroke. The effect of hypothermia on neurovascular coupling is of interest for evaluating brain function in these patients, but has not been determined so far. It is not clear whether functional hyperaemia actually operates at subnormal temperatures. In addition, decreasing brain temperature reduces spontaneous CMRO(2) following a known quantitative relationship (Q(10)). Q(10) determination may serve to validate a recently introduced CMRO(2) measurement approach relying on optical measurements of CBF and hemoglobin concentration. We applied this method to investigate hypothermia in a functional study of the somatosensory cortex. Anesthetized Wistar rats underwent surgical implantation of a closed cranial window. Using laser Doppler flowmetry and optical spectroscopy, relative changes in CBF and hemoglobin concentration were measured continuously. At the same time, an electroencephalogram (EEG) was recorded from the measurement site. By the application of ice packs, whole-body hypothermia was induced, followed by rewarming. Spontaneous EEG, CBF and CMRO(2) were measured, interleaved by blocks of electrical forepaw stimulation. The Q(10) obtained from spontaneous CMRO(2) changes of 4.4 (95% confidence interval 3.7-5.1) was close to published values, indicating the reliability of the CMRO(2) measurement. Lowering brain temperature decreased functional changes of CBF and CMRO(2) as well as amplitudes of somatosensory evoked potentials (SEP) to the same degree. In conclusion, neurovascular and neurometabolic coupling is preserved during hypothermia.
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Affiliation(s)
- Georg Royl
- Department of Experimental Neurology, Charité Universitätsmedizin Berlin, 10098 Berlin, Germany.
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Royl G, Katchanov J, Stachulski F, Schultze J, Ploner CJ, Endres M. Diagnostic pitfall: wound botulism in an intoxicated intravenous drug abuser presenting with respiratory failure. Intensive Care Med 2007; 33:1301. [PMID: 17393137 DOI: 10.1007/s00134-007-0620-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Georg Royl
- Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Juri Katchanov
- Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Frank Stachulski
- Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jörg Schultze
- Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Prass K, Royl G, Lindauer U, Freyer D, Megow D, Dirnagl U, Stöckler-Ipsiroglu G, Wallimann T, Priller J. Improved reperfusion and neuroprotection by creatine in a mouse model of stroke. J Cereb Blood Flow Metab 2007; 27:452-9. [PMID: 16773141 DOI: 10.1038/sj.jcbfm.9600351] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Stroke leads to energy failure and subsequent neuronal cell loss. Creatine and phosphocreatine constitute a cellular energy buffering and transport system, and dietary creatine supplementation was shown to protect neurons in several models of neurodegeneration. Although creatine has recently been found to reduce infarct size after cerebral ischemia in mice, the mechanisms of neuroprotection remained unclear. We provide evidence for augmented cerebral blood flow (CBF) after stroke in creatine-treated mice using a magnetic resonance imaging (MRI)-based technique of CBF measurement (flow-sensitive alternating inversion recovery-MRI). Moreover, improved vasodilatory responses were detected in isolated middle cerebral arteries obtained from creatine-treated animals. After 3 weeks of dietary creatine supplementation, minor changes in brain creatine, phosphocreatine, adenosine triphosphate, adenosine diphosphate and adenosine monophosphate levels were detected, which did not reach statistical significance. However, we found a 40% reduction in infarct volume after transient focal cerebral ischemia. Our data suggest that creatine-mediated neuroprotection can occur independent of changes in the bioenergetic status of brain tissue, but may involve improved cerebrovascular function.
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Affiliation(s)
- Konstantin Prass
- Department of Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
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40
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Royl G, Leithner C, Sellien H, Müller JP, Megow D, Offenhauser N, Steinbrink J, Kohl-Bareis M, Dirnagl U, Lindauer U. Functional imaging with Laser Speckle Contrast Analysis: Vascular compartment analysis and correlation with Laser Doppler Flowmetry and somatosensory evoked potentials. Brain Res 2006; 1121:95-103. [PMID: 17030028 DOI: 10.1016/j.brainres.2006.08.125] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Revised: 08/18/2006] [Accepted: 08/29/2006] [Indexed: 11/18/2022]
Abstract
Laser Speckle Contrast Analysis (LASCA), a novel, high-resolution blood flow imaging method, was performed on rat somatosensory cortex during functional activation. In the same animals, cerebral blood flow (CBF) was measured with Laser Doppler Flowmetry. To obtain a quantitative estimate of the underlying neuronal activity, somatosensory evoked potentials were recorded simultaneously with an epidural EEG. Our results show that: 1. CBF changes measured by LASCA or LDF are nonlinearly dependent on the magnitude of electrical neural activity revealed by somatosensory evoked potentials. 2. The magnitude of relative CBF changes measured by LASCA and LDF shows a strong correlation. 3. LASCA imaging localizes the highest relative changes of CBF in microcirculatory areas, with a smaller contribution by larger vessels. This study demonstrates that LASCA is a reliable method that provides 2D-imaging of CBF changes that are comparable to LDF measurements. It further suggests that functional neuroimaging methods based on CBF enhance areas of microcirculation and thus might prove more accurate in localizing neural activity than oxygenation related methods like BOLD-fMRI.
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Affiliation(s)
- Georg Royl
- Department of Experimental Neurology, Charité Universitätsmedizin Berlin, 10098 Berlin, Germany.
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Lindauer U, Royl G, Leithner C, Kühl M, Gold L, Gethmann J, Kohl-Bareis M, Villringer A, Dirnagl U. No Evidence for Early Decrease in Blood Oxygenation in Rat Whisker Cortex in Response to Functional Activation. Neuroimage 2001; 13:988-1001. [PMID: 11352605 DOI: 10.1006/nimg.2000.0709] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Using optical methods through a closed cranial window over the rat primary sensory cortex in chloralose/urethane-anesthetized rats we evaluated the time course of oxygen delivery and consumption in response to a physiological stimulus (whisker deflection). Independent methodological approaches (optical imaging spectroscopy, single fiber spectroscopy, oxygen-dependent phosphorescence quenching) were applied to different modes of whisker deflection (single whisker, full whisker pad). Spectroscopic data were evaluated using different algorithms (constant pathlength, differential pathlength correction). We found that whisker deflection is accompanied by a significant increase of oxygenated hemoglobin (oxy-Hb), followed by an undershoot. An early increase in deoxygenated hemoglobin (deoxy-Hb) proceeded hyperoxygenation when spectroscopic data were analyzed by constant pathlength analysis. However, correcting for the wavelength dependence of photon pathlength in brain tissue (differential pathlength correction) completely eliminated the increase in deoxy-Hb. Oxygen-dependent phosphorescence quenching did not reproducibly detect early deoxygenation. Together with recent fMRI data, our results argue against significant early deoxygenation as a universal phenomenon in functionally activated mammalian brain. Interpreted with a diffusion-limited model of oxygen delivery to brain tissue our results are compatible with coupling between neuronal activity and cerebral blood flow throughout stimulation, as postulated 110 years ago by C. Roy and C. Sherrington (1890, J. Physiol. 11:85--108).
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Affiliation(s)
- U Lindauer
- Department of Experimental Neurology, Charité Hospital, 10098 Berlin, Germany
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Kohl M, Lindauer U, Royl G, Kuhl M, Gold L, Villringer A, Dirnagl U. Physical model for the spectroscopic analysis of cortical intrinsic optical signals. Phys Med Biol 2000; 45:3749-64. [PMID: 11131197 DOI: 10.1088/0031-9155/45/12/317] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We used Monte Carlo simulations and the diffusion approximation to estimate correction terms for the analysis of reflectance spectra of cortical intrinsic optical signals. These corrections depend on scattering and absorption properties, i.e. they are dependent on assumptions on the tissue blood content and oxygen saturation. The analysis was applied to reflectance spectra acquired during whisker barrel stimulation in the rat where attenuation spectra were converted to changes in oxygenated and deoxygenated haemoglobin concentration. The description of the experimental data as judged by the residual and sensitivity to variations of wavelength was considerably improved when the correction terms were included. Inclusion of the correction does have a considerable impact on the time course of deoxyhaemoglobin concentration changes. In contrast to the calculation without correction terms, there is no indication for an early increase in deoxyhaemoglobin ('early dip'). This finding might further current interpretation of the coupling between neuronal activation and oxygen extraction and supply.
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Affiliation(s)
- M Kohl
- Department of Neurology, Charité, Humboldt University Berlin, Germany
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Abstract
In urethane anesthetized rats many lateral geniculate neurons display a strong very slow oscillatory behavior in the range of 0.025-0.01 Hz. One of the aims of the present study was to determine whether very slow oscillatory activity in this range can also be obtained in barbiturate anesthetized and in awake animals, respectively. Although very slow oscillations were found in geniculate neurons both during awakeness and during anesthesia, significant differences in peak frequencies of oscillations under the three experimental conditions (barbiturate, urethane, awake) were demonstrated. In addition, we have tested the influence of glutamate antagonists and GABA agonists as well as antagonists on the very slow oscillatory activity in urethane anesthetized rats. Very slow oscillatory activity which could be blocked by the continuous illumination of the eyes was re-induced by iontophoresis of NMDA and non-NMDA glutamate antagonists. GABA(A) as well as GABA(B) agonists also caused a significant re-induction of very slow oscillatory activity under light conditions. In the dark, muscimol, a GABA(A) agonist, significantly enhanced the very slow oscillatory activity, i.e. muscimol either induced it or reduced the frequency of very slow oscillations. For the whole sample, GABA antagonists did not have a significant influence on the very slow oscillatory activity. Autocorrelation analysis based on the spike interval histograms and determination of the spectrum of autocorrelograms revealed the significance of periodicity.
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Affiliation(s)
- D Albrecht
- Institute of Physiology, Charité, Humboldt University Berlin, Germany.
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