[Diagnosis and treatment of acute ischemic insults]

In cases of stroke a distinction is made between a transient ischemic attack (TIA), a manifest ischemic infarction and cerebral hemorrhage. Cerebral ischemia can be caused by large vessel disease, small vessel disease, embolic causes, rare causes or stroke of unknown etiology. Acute diagnostic tests include a neurological examination, computed tomography (CT) and/or magnetic resonance imaging (MRI) with angiography, electrocardiography (ECG), and laboratory tests. The basic treatment of patients with TIA or acute ischemic infarction is performed in the stroke unit and includes monitoring of respiratory function, cardiac function, treatment of potential heart failure, detection of swallowing disorders, prophylaxis of thromboembolism, control of blood pressure and elevated blood sugar levels, and lowering of elevated body temperature. In patients with cardioembolic infarction, oral anticoagulation is initiated depending on the severity of the stroke and the size of the stroke on imaging.

Safety profile of a special butterbur extract from Petasites hybridus in migraine prevention with emphasis on the liver

Background:

Butterbur supplements are available in the USA and Canada and are commonly used for treating migraines. Petadolex, a special butterbur extract from Petasites hybridus, is a natural herbal product and the only butterbur extract with proven clinical efficacy in migraine prevention. The Complimentary Migraine Guidelines of the AAN mention butterbur as level A recommendation for the prevention of chronic episodic migraine. However, these guidelines have been retired.

Methods:

We review suspected serious liver cases, pyrrolizidine alkaloids, regulatory issues, preclinical and clinical data of the special butterbur extract Petadolex.

Results:

The RUCAM (Roussel Uclaf Causality Assessment Method) test found no probable relationship between the butterbur root extract Petadolex® and cases of serious liver injury. Two cases of non-serious reversible liver enzyme elevations were rated as probably related to Petadolex®. The safety is supported by preclinical data in animals as well as in-vitro toxicology experiments. In addition, Petadolexis free of detectable levels of pyrrolizidine alkaloids.

Conclusion:

There is no evidence that the special butterbur root extract Petadolex poses a substantial risk of liver injury for patients.

Two Models for Outcome Prediction

Objectives: Accurately predicting disease progress from a set of predictive variables is an important aspect of clinical work. For binary outcomes, the classical approach is to develop prognostic logistic regression (LR) models. Alternatively, machine learning algorithms were proposed with artificial neural networks (ANN) having become popular over the last decades. Although some studies have compared predictive accuracies of LR and ANN models, some concerns regarding their methodological quality have been voiced. Our comparison has the advantage of being based on two large independent data sets allowing for elaborate model development and independent validation.

Methods: From the German Stroke Database, a learning data set including 1754 prospectively recruited patients with acute ischemic stroke was used. Utilizing LR and ANN, two prognostic models were developed predicting restitution of functional independence and survival after 100 days. The resulting models were applied to classify 1470 patients with acute ischemic stroke; this test data set was collected independently from the learning data. Error fractions in the test data were determined, and differences in error fractions between the algorithms were calculated with 95% confidence intervals.

Results: For most prognostic models, error fractions in the test data were below 40%. There was no difference between the algorithms except for the model predicting completely versus incompletely restituted or deceased patients (difference in error fractions = 4.01% [2.10-5.96%], p = 0.0001).

Conclusions: The conscientiously applied LR remains the gold standard for prognostic modelling; however, ANN can be an alternative automated “quick and easy” multivariate analysis.

Almotriptan in der Routine-Behandlung akuter Migräneattacken: eine Post-Marketing-Studie mit 899 Patienten

In einer Postmarketing-Studie konnten 899 Patientinnen und Patienten mit Migräne bis zu 3 konsekutive Migräneattacken mit Almotriptan (12,5 mg) behandeln. Dokumentiert wurden so 2131 behandelte Migräneattacken. Eine Wirkung nach 2 Stunden, d. h. eine Besserung der Kopfschmerzen von schwer oder mittelschwer auf leichte oder keine Kopfschmerzen wurde bei 84,5% der behandelten Migräneattacken berichtet. Der Prozentsatz der Patienten, die nach 2 Stunden schmerzfrei waren betrug 41,4%. Almotriptan wurde gut vertragen, nur 29 unerwünschte Ereignisse wurden dokumentiert.

Lower Cervical Disc Prolapse May Cause Cervicogenic Headache: Prospective Study in Patients Undergoing Surgery

In 1983 Sjaastad published for the first time diagnostic criteria for cervicogenic headache. Until now there have been no prospective studies investigating whether cervical disc prolapse can cause cervicogenic headache. Between July 2002 and July 2003 50 patients with cervical disc prolapse proven by computed tomography, myelography or magnetic resonance imaging were recruited and prospectively followed for 3 months. Patients were asked at different time points about headache and neck pain by questionnaires and structured interviews. These data were collected prior to and 7 and 90 days after surgery for the disc prolapse. Fifty patients with lumbar disc prolapse, matched for age and sex, undergoing surgery were recruited as controls. Headache and neck pain was diagnosed according to International Headache Society (IHS) criteria. Twelve of 50 patients with cervical disc prolapse reported new headache and neck pain. Seven patients (58%) fulfilled the 2004 IHS criteria for cervicogenic headache. Two of 50 patients with lumbar disc prolapse had new headaches. Their headaches did not fulfil the criteria for cervicogenic headache. One week after surgery, 8/12 patients with cervical disc prolapse and headache reported to be pain free. One patient was improved and three were unchanged. Three months after cervical prolapse surgery, seven patients were pain free, three improved and two unchanged. This prospective study shows an association of low cervical prolapse with cervicogenic headache: headache and neck pain improves or disappears in 80% of patients after surgery for the cervical disc prolapse. These results indicate that pain afferents from the lower cervical roots can converge on the cervical trigeminal nucleus and the nucleus caudalis.

Prevalence of Cluster Headache in a Population-Based Sample in Germany

A population-based sample of 6000 inhabitants of the city of Essen in Germany was screened using a standard questionnaire for possible cluster headache (CH). Fifty-six percent responded ( N = 3336, 50.5% of them women, mean age 44.7 ± 12.7 years). All suspected cases ( N = 182) were interviewed by a neurologist. Four subjects with CH (three men) were identified. The 1-year prevalence of CH was estimated to be 119/100 000 (95% confidence interval 3, 238/100 000).

Thrombolysis and thrombectomy in patients treated with dabigatran with acute ischemic stroke: Expert opinion

Systemic thrombolysis with rt-PA is contraindicated in patients with acute ischemic stroke anticoagulated with dabigatran. This expert opinion provides guidance on the use of the specific reversal agent idarucizumab followed by rt-PA and/or thrombectomy in patients with ischemic stroke pre-treated with dabigatran. The use of idarucizumab followed by rt-PA is covered by the label of both drugs.

Placebo-Controlled Comparison of Effervescent Acetylsalicylic Acid, Sumatriptan and Ibuprofen in the Treatment of Migraine Attacks

Acetylsalicylic acid (ASA) in combination with metoclopramide has been frequently used in clinical trials in the acute treatment of migraine attacks. Recently the efficacy of a new high buffered formulation of 1000 mg effervescent ASA without metoclopramide compared to placebo has been shown. To further confirm the efficacy of this new formulation in comparison with a triptan and a nonsteroidal anti-inflammatory drug (ibuprofen) a three-fold crossover, double-blind, randomized trial with 312 patients was conducted in Germany, Italy and Spain. Effervescent ASA (1000 mg) was compared to encapsulated sumatriptan (50 mg), ibuprofen (400 mg) and placebo. The percentage of patients with reduction in headache severity from moderate or severe to mild or no pain (primary endpoint) was 52.5% for ASA, 60.2% for ibuprofen, 55.8% for sumatriptan and 30.6% for placebo. All active treatments were superior to placebo ( P < 0.0001), whereas active treatments were not statistically different. The number of patients who were pain-free at 2 h was 27.1%, 33.2%, 37.1% and 12.6% for those treated with ASA, ibuprofen, sumatriptan or placebo, respectively. The difference between ASA and sumatriptan was statistically significant ( P = 0.025). With respect to other secondary efficacy criteria and accompanying symptoms no statistically significant differences between ASA and ibuprofen or sumatriptan were found. Drug-related adverse events were reported in 4.1%, 5.7%, 6.6% and 4.5% of patients treated with ASA, ibuprofen sumatriptan or placebo. This study showed that 1000 mg effervescent ASA is as effective as 50 mg sumatriptan and 400 mg ibuprofen in the treatment of migraine attacks regarding headache relief from moderate/severe to mild/no pain at 2 h. Regarding pain-free at 2 h sumatriptan was most effective.

One-Year Prevalence and Socio-Cultural Aspects of Chronic Headache in Turkish Immigrants and German Natives

The aim of this research was to study the prevalence of chronic headache (CH) and associated socio-cultural factors in Turkish immigrants and native Germans. Five hundred and twenty-three Turkish and German company employees were screened using a standard questionnaire. Those who suffered from headaches were also examined by a neurologist. Complete data were available for 471 (90%) subjects. Thirty-four participants (7.2%) had CH. Two independent factors for association with CH could be identified: overuse of acute headache medication (OR = 72.5; 95% CI 25.9-202.9), and being a first-generation Turkish immigrant compared with native Germans (OR = 4.4; 95% CI 1.4-13.7). In contrast, the factor associated with chronic headache was not increased in second-generation Turkish immigrants. Medication overuse was significantly more frequent in first-generation Turkish immigrants (21.6%) compared with second-generation Turkish immigrants (3.3%) and native Germans (3.6%; X2 = 38.0, P < 0.001). First-generation Turkish immigrants did not contact headache specialists at all, compared with 2.8% of second-generation Turkish immigrants and 8.8% of native Germans ( X2 = 118.4, P < 0.001). Likewise no first-generation Turkish immigrant suffering from CH received headache preventive treatment, compared with 6.6% of native Germans ( X2 = 19.1, P = 0.014). The data from this cross-sectional study reveal a high prevalence of chronic headache as well as a very low utilization of adequate medical care in first-generation Turkish immigrants in Germany.

The Fixed Combination of Acetylsalicylic acid, Paracetamol and Caffeine is more Effective than Single Substances and Dual Combination for the Treatment of Headache: a Multicentre, Randomized, Double-Blind, Single-Dose, Placebo-Controlled Parallel Group Study

We investigated efficacy, safety, and tolerability of two tablets of the fixed combination of 250 mg acetylsalicylic acid (ASA) + 200 mg paracetamol + 50 mg caffeine (Thomapyrin®) in comparison with two tablets of 250 mg ASA + 200 mg paracetamol, two tablets of 500 mg ASA, two tablets of 500 mg paracetamol, two tablets of 50 mg caffeine, and placebo in patients who were used to treating their episodic tension-type headache or migraine attacks with non-prescription analgesics. For the primary endpoint ‘time to 50% pain relief’ in the intention-to-treat dataset ( n = 1743 patients), the fixed combination of ASA, paracetamol and caffeine was statistically significantly superior to the combination without caffeine ( P = 0.0181), the mono-substances ASA ( P = 0.0398), paracetamol ( P = 0.0016), caffeine ( P < 0.0001) and placebo ( P < 0.0001). All active treatments except caffeine differed significantly ( P < 0.0001) from placebo. The superior efficacy of the triple combination could also be shown for all secondary endpoints such as time until reduction of pain intensity to 10 mm, weighted sum of pain intensity difference (%SPIDweighted), extent of impairment of daily activities, global assessment of efficacy. All treatments were well tolerated. The incidence of adverse events observed was low.

European Headache Federation consensus on technical investigation for primary headache disorders

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

β-Blockers, Pneumonia, and Outcome After Ischemic Stroke

Background and Purpose—

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

Methods—

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

Results—

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

Conclusions—

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

[New aspects of stroke medicine]

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

Impaired velocity perception in patients with lesions of the cerebellum

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

[Diagnostic and treatment of acute ischemic stroke]

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