Treatment of stroke on an intensive stroke unit: a novel concept

In industrialised nations stroke ranks as number three among causes of death and is the most frequent cause of disability in old age. Demographic changes will result in stroke gaining increasing importance for individuals as well as for society as a whole. Stroke is already a major cost factor for healthcare and social security systems because of its high long-term costs. Therapeutic nihilism, although still widespread among patients and some physicians, is no longer justified. Long-term outcome after stroke can be significantly improved by providing therapy in wards specialised in early rehabilitation, so-called 'stroke units'. Recent magnetic resonance imaging (MRI) and positron emission tomography (PET) studies, as well as lysis therapy studies have shown that the first 3-6 h are crucially important. For this reason, the concept of "intensive stroke units" also called "intensive care stroke units" has been implemented in Germany. The goal of an intensive stroke unit is the optimal care of stroke patients under intensive care conditions for the first 3-4 days with the aim of improving outcome, long-term morbidity, and reducing long-term healthcare costs. Another important objective is the development and research of new therapeutic concepts and approaches that are based on pathophysiological considerations. A further goal is the initiation of specific therapies depending on the suspected underlying pathophysiology, for example, local or systemic thrombolysis, full-dose heparinisation, platelet aggregation inhibitors, oral anticoagulants, neuroprotective agents, decompression craniotomy, sympathomimetically supported volume therapy and hypothermia. A final objective is to minimise the number of complications through intensive monitoring. Basic acute management includes optimal oxygen supply, rapid normalisation of blood glucose and body temperature, volume therapy, maintaining a high blood pressure and cardiac output to improve remaining cerebral perfusion in the presence of ischaemically impaired autoregulation, treating cerebral oedema, prophylaxis of thrombosis, and early mobilisation. Rapid and easy access to computerised tomography (CT), MRI, Doppler and duplex scanning of the brain-supplying blood vessels, and echocardiography is essential. The ready availability of intensive care monitoring (blood pressure, electrocardiography, central venous pressure, transcranial Doppler (TCD), TCD embolism detection, cerebral pressure, electroencephalography and cardiac output is also imperative. We would like to stress at this point that this manuscript is a personal view describing stroke care in Germany. Many of the principles described have not been widely adopted elsewhere, perhaps in part due to a lack of available facilities. However, many of our recommendations are based on logical principles and thus, we feel, bear further scrutiny.

Skin microvascular adaptations during maturation and aging of hairless mice

Using intravital fluorescence microscopy in the ears of hairless mice, we determined skin microvascular adaptations during the process of aging from juvenile to adult and senescent life (6-78 wk). Despite an increase of ear area within the first 36 wk, the number and branching pattern of both arteriolar and venular microvessels remained constant during the whole life period. Both arterioles and venules exhibited an increase in length, diameter, and intervascular distance up to the age of 36 wk. With the increase of the size of the ears, the observation that cutaneous capillary density remained unchanged implied new capillary formation. During aging to 78 wk, capillary density in the ears was reduced to approximately 40%. Functional analysis revealed an appropriate hyperemic response to a 2-min period of ischemia during late juvenile and adult life, which, however, was markedly reduced during senescence. Thus, except for capillaries, there is no indication for age-related new vessel formation. The process of aging from adult to senescent life does not cause any significant remodeling but is associated with a decrease of nutritive perfusion and a functional impairment to respond to stimuli such as ischemia.

[Pathological rupture of the distal biceps tendon after long-term androgen substitution]

QUESTION

Is the long-standing use of androgenes able to cause tendon lesions with pathological tendon ruptures?

METHOD

In a case of a rupture of the distal biceps tendon after long-standing testosterone-substitution it is tried to show the connection between the use of androgenes and pathological tendon rupture by the help of the patients treatment documents, the X-rays and sonograms, the histological findings and the results of the clinical examination.

RESULTS

For the first time a case with a rupture of the distal biceps tendon after long-standing testosterone-substitution for the support of a genital transformation is described. Since other tendon damaging factors could be excluded the suspicion of tendon alteration caused by androgenes is obvious.

CONCLUSION

Looking at tendon ruptures of professionals and even amateur sportsmen the possible connection between long-standing use of androgenes and tendon damage has to be considered.

[Significance of revision of the occupational illness legislation for evaluating intervertebral disk damage]

QUESTION

Are there any radiological criterions which are able to indicate the profession related disease No. 2108?

METHODS

The medical documents and x-rays of the whole spine of 390 back pain patients who applied for a profession related disease of the spine were evaluated. Those patients who fulfilled the professional claims for acknowledgement of the profession related disease were compared to those who didn't fulfill these conditions.

RESULTS

Concerning the segmental alterations of the cervical and the lumbal spine specific allocation frequencies were found. The dominance of L3/4 in the comparison group was conspicuous. Looking at the allocation frequencies of the cervical and lumbal disc alterations in view of affection heaviness it was obvious, that the predominating slight alterations mainly were located in the central parts of the cervical and the lumbal spine whereas bad alterations mainly were found in the lower parts. Regarding this matter test and comparison groups behaved the same way. Looking at the allocation frequencies concerning single respectively multiple alterations it was found that in the comparison group single respectively bisegmentale alterations could be recognized even in duplicate than in the test group in which the multiple alterations were dominant. The comparison of the cervical and the lumbal spine regarding chondrotic? spondylotic, slight and bad alterations in all mentioned features the next deeper located segment was affected particularly in the test group. Therefore a distal shift of the chondrotic alterations could be recognized. In case of the spondylotic affections it was the other way round: a cranial shift was conspicuous.

CONCLUSION

After doing heavy labour for years only a few isolated multiple affections of the lumbal spine are found. On the strength of this fact the proof of exclusively in the lumbal spine located alterations doesn't allow the acknowledgement of a profession related disease. However, a distal shift of osteochondrotic alterations respectively a cranial shift of spondylotic affections in the lumbal spine is suspicous for being job-related. L3/4 takes a very special place in the differential diagnosis of profession related disease of the spine. In the test group this part of the lumbal spine showed bad alterations much more frequent. The affection of L3/4 pleads against a considerable participation of mechanical influences and therefore against a profession related disease. Singular or bisegmental disc affections are out of question for being a profession related disease because these alterations are seen much more frequent in the comparison than in the test group.

[The treatment of hip dysplasia or dislocation with Fettweis' immobilization cast]

To verify the success of the cast immobilisation in a squatting position in the treatment of dysplasia and dislocation of the hip 41 children were reviewed whereby lapses up to 13 years had to be considered. In 9 hips the cast immobilisation leaded to an unsatisfactory result so that the joints had to be revised operatively. In the remaining 48 hips 31 (65%) were cured, 15 (31%) showed a light, 2 (4%) a grave remaining dysplasia. One hip joint showed an ischemic necrosis of the femoral head which corresponds to a rate of necrosis of 2.1%. As the concerned patient was treated with spreader pants in spite of the high grade of luxation of her hip it more likely that this avascular necrosis is caused by the preceding treatment and not by the cast immobilisation itself. Factors with negative effects on the result or bad prognostic signs respectively, were poor initial findings and reluxation during cast immobilization. The start of therapy had no noticeable influence on the result. On the other hand this factor was very important for the permanence of treatment. In hips with remaining dysplasia very often a clinical hypermobility was found. A positive Trendelenburg-sign was seen in the hip with defect-healed avascular necrosis of the femoral head and furthermore in 2 other hips with evident remaining dysplasia of the acetabulum. In comparison to other methods, the cast immobilisation according to Fettweis shows a low rate of avascular necrosis of the femoral head and a forced supplementary development of the dysplastic acetabulum. Because of its wide range of indication and its small rate of complications the Fettweis plaster cast is a very reliable method for the treatment of dysplasia and dislocation of the hip in infancy and early childhood.