[Tandem occlusions in acute ischemic stroke]. / Tandemokklusionen beim akuten Schlaganfall.

CLINICAL ISSUE: Acute strokes caused by tandem occlusions include an atherosclerotic or dissective stenosis/occlusion of the extracranial internal carotid artery (eICA) in combination with an intracranial vessel occlusion. STANDARD TREATMENT: Endovascular treatment can be technically challenging but is definitely superior to intravenous thrombolysis alone and achieves good clinical results comparable to those from solitary intracranial occlusions. LATEST STUDY RESULTS: Although there are still no prospectively randomized studies on endovascular treatment for tandem occlusions, currently available data favor acute stenting of the eACI followed by intracranial thrombectomy. PURPOSE OF THE ARTICLE: This review discusses endovascular treatment options for tandem occlusions based on currently available data.

[Chiari malformation]. / Chiari-Malformation.

Chiari malformation is one of the most common congenital anomalies involving both skeletal and neuronal structures. Magnetic Resonance Imaging(MRI) is nowadays considered the imaging technique of choice for the diagnosis of Chiari malformations. Computed Tomography (CT) scans may provide additional information about skeletal anomalies.

[First occurrence of an organic manic schizophreniform syndrome followed by catatonia induced by anti-NMDA-receptor encephalitis]. / Erstmanifestation eines organischen manisch-schizophreniformen Syndroms mit nachfolgender Katatonie bei NMDA-Rezeptor-Antikörper-positiver Encephalitis.

We report on a 39-year-old female patient who developed catatonia after there had been schizomanic symptoms in the six months before. At admission the patient exhibited catatonia, a tetraspastic syndrome and focal epileptic seizures. The cranial MRI revealed bilateral subcortical hyperintense lesions which took up contrast agent. Examination of the cerebrospinal fluid disclosed a lymphocytic pleocytosis and autochthone oligoclonal bands. In the serum autoantibodies against the NMDA-NR-1 receptor were reproducibly detected. A detailed search for a tumour was negative. In detail, we could exclude a neoplasm of the ovaries which is often present in the paraneoplastic type of anti-NMDA-receptor encephalitis. Therefore we assume an autoimmune, not paraneoplastic, encephalitis in our patient. The symptoms improved significantly after an immunosuppressive therapy - initially with glucocorticoids followed by rituximab - had been initiated. This case illustrates that an autoimmune encephalitis should be looked for when first psychotic symptoms occur.

Mobile stroke unit for diagnosis-based triage of persons with suspected stroke.

BACKGROUND: In this feasibility study, we tested whether prehospital diagnostic stroke workup enables rational decision-making regarding treatment and the target hospital in persons with suspected stroke. METHODS: A mobile stroke unit that delivers imaging (including multimodal brain imaging with CT angiography and CT perfusion), point-of-care-laboratory analysis, and neurologic expertise directly at the emergency site was analyzed for its use in prehospital diagnosis-based triage of suspected stroke patients. RESULTS: We present 4 complementary cases with suspected stroke who underwent prehospital diagnostic workup that enabled direct diagnosis-based treatment decisions and reliable triage regarding the most appropriate medical facility for that individual, e.g., a primary hospital vs specialized centers of a tertiary hospital. CONCLUSIONS: This preliminary report demonstrates the feasibility of prehospital diagnostic stroke workup for immediate etiology-specific decision-making regarding the necessary time-sensitive stroke treatment and the most appropriate target hospital.

Persistent hyperglycemia at 24-48 h in acute hyperglycemic stroke patients is not associated with a worse functional outcome.

BACKGROUND: Recently, it was shown that the relation between admission glucose and functional outcome after ischemic stroke is described by a J-shaped curve, with a glucose range of 3.7-7.3 mmol/l associated with a favorable outcome. We tested the hypothesis that persistence of hyperglycemia above this threshold at 24-48 h after stroke onset impairs 3-month functional outcome. METHODS: We analyzed all patients with glucose >7.3 mmol/l on admission from the Acute STroke Registry and Analysis of Lausanne (ASTRAL). Patients were divided into two groups according to their subacute glucose level at 24-48 h after last well-being time (group 1: ≤7.3 mmol/l, group 2: >7.3 mmol/l). A favorable functional outcome was defined as a modified Rankin Score (mRS) ≤2 at 3 months. A multiple logistic regression analysis of multiple demographic, clinical, laboratory and neuroimaging covariates was performed to assess predictors of an unfavorable outcome. RESULTS: A total of 1,984 patients with ischemic stroke were admitted between January 1, 2003 and October 20, 2009, within 24 h after last well-being time. In the 421 patients (21.2%) with admission glucose >7.3 mmol/l, the proportion of patients with a favorable outcome was not statistically significantly different between the two groups (59.2 vs. 48.7%, respectively). In multiple logistic regression analysis, unfavorable outcome was significantly associated with age (odds ratio, OR: 1.06, 95% confidence interval, 95% CI: 1.03-1.08 for every 10-year increase), National Institute of Health Stroke Score, NIHSS score, on admission (OR: 1.16, 95% CI: 1.11-1.21), prehospital mRS (OR: 12.63, 95% CI: 2.61-61.10 for patients with score >0), antidiabetic drug usage (OR: 0.36, 95% CI: 0.15-0.86) and glucose on admission (OR: 1.16, 95% CI: 1.02-1.31 for every 1 mmol/l increase). No association was found between persistent hyperglycemia at 24-28 h and outcome in either diabetics or nondiabetics. CONCLUSIONS: In ischemic stroke patients with acute hyperglycemia, persistent hyperglycemia (>7.3 mmol/l) at 24-48 h after stroke onset is not associated with a worse functional outcome at 3 months whether the patient was previously diabetic or not.

[Value of MR spectroscopy in infectious and inflammatory brain diseases]. / Wertigkeit der MR-Spektroskopie bei infektiösen und entzündlichen Hirnerkrankungen.

Proton magnetic resonance spectroscopy (MRS) is a non-invasive method for measuring cerebral metabolite concentrations in various pathologic conditions. This review discusses the MRS findings in the most common infectious and inflammatory brain diseases.

Device-associated infections in the intensive care units of Cyprus: results of the first national incidence study.

BACKGROUND: Surveillance of healthcare-associated infections (HCAIs) has become an integral part of infection control programs in several countries, especially in the intensive care unit (ICU) setting. In contrast, surveillance data on the epidemiology of ICU-acquired infections in Cyprus are limited. The aim of this study was to assess the risk of ICU-acquired infections and to identify areas for improvement in Cypriot hospitals by comparing observed incidence rates with international benchmarks and by specifying the microbiological and antibiotic resistance profiles of infecting organisms. MATERIALS AND METHODS: An active surveillance protocol was introduced in the ICUs of the four major public hospitals in Cyprus, based on the methodology of the US National Nosocomial Infections Surveillance system. RESULTS: During February to December 2007, 2,692 patients who were hospitalized in ICUs for a mean length of stay of 5 days acquired 214 infections for an overall incidence rate of 15.8 infections per 1,000 patient-days [95% confidence interval (CI): 13.8-18.1]. Bloodstream infections, pneumonias and urinary tract infections accounted for 80.4% of all infections; of these, 87.8% were device-related. Central line-associated bloodstream infection (CL-BSI) posed the greatest risk (18.6 cases per 1,000 central line-days; 95% CI 14.9-22.9), followed by ventilator-associated pneumonia (VAP) (6.4 cases per 1,000 ventilator-days; 95% CI 4.5-8.8) and catheter-associated urinary tract infection (2.8 cases per 1,000 urinary catheter-days; 95% CI 1.9-4.1). Most frequently isolated pathogens included Pseudomonas aeruginosa (21.6% of all isolates), coagulase-negative Staphylococcus (11.7%), Enterococcus spp. (11.3%) and Staphylococcus aureus (9.2%). Overall, 29.8% of P. aeruginosa isolates were imipenem-resistant and 68.2% of S. aureus were methicillin-resistant. The crude excess mortality rate associated with ICU-acquired infections was 33.2% (95% CI 24.9-41.9%) and the mean post-infection stay in the ICUs was 21.6 days (95% CI 17.0-26.2). CONCLUSION: In comparison to international benchmarks, the markedly high rate of CL-BSI, the high rate of VAP and the resistance patterns of major infecting pathogens identified in this study emphasize the need to improve current practices for appropriate use and management of invasive devices in Cypriot ICUs.

Circulating serotypes and antimicrobial sensitivity of Streptococcus pyogenes isolates from children in Cyprus.

The most common T-serotypes among group A streptococci (n = 88) isolated from pharyngeal samples of children referred to a tertiary hospital in Cyprus for pharyngitis or scarlet fever during a 14-month period (2003-2004) were T28 (25%), T8/25/Imp19 (22.7%) and T12 (9.1%). All 88 isolates were sensitive to penicillin and clindamycin, but 1.1% and 18.2% of isolates were resistant to erythromycin and tetracycline, respectively. Macrolide consumption was estimated at 1.7 defined daily doses/1000 inhabitants/day. The low percentage of resistance to macrolides may have been related, at least in part, to the low consumption of macrolides.

Increased prevalence of Chlamydophila pneumoniae but not Epstein-Barr antibodies in essential hypertensives.

Conflicting data exist regarding the relationship between Chlamydophila pneunoniae (C. pneumoniae) and hypertension. In this study, both C. pneumoniae IgG and IgA titres and Epstein-Barr virus antibody levels were measured in 146 sustained hypertensives defined by 24 h ambulatory blood pressure monitoring (ABPM) and 54 normotensives. C. pneumoniae antibodies were measured by microimmunofluorescence test. IgG > or = 80 and IgA > or = 40 were defined as elevated antibody titres. Epstein-Barr antibodies were measured in order to investigate whether a possible association exists between hypertension and other, similarly widespread in the general population, intracellular microorganisms. All participants underwent casual blood pressure (BP) readings and 24 h ABPM. Subjects having mean 24 h systolic/diastolic ambulatory BP>125/80 mmHg, with or without antihypertensive medication were defined as hypertensives. Controls were free of any history or clinical evidence of hypertension, cardiovascular or pulmonary disease. Of the total participants, 77 hypertensives (52.7%) and 10 normotensives (18.5%) had IgA titres > or = 40 (crosstabs P < 0.000), whereas 76 hypertensives (52.1%) and 15 normotensives (27.8%) had IgG titres > or = 80, (crosstabs P < 0.002). No difference was found in Epstein-Barr antibodies, between hypertensives and normotensives. In conclusion, C. pneumoniae, but not Epstein-Barr, antibody levels were found significantly higher in sustained hypertensives, suggesting high frequency of chronic C. pneumoniae, infections in this specific group of patients.

Precursors of atherosclerosis in a random sample from a Hellenic population: the Athens Study.

BACKGROUND: Atheromatosis, the principal lesion in atherosclerotic cardiovascular disease, is associated with increased levels of blood pressure, serum cholesterol, cigarette smoking and other variables. As these lesions are thought to appear first in childhood, this study was designed to assess the levels of these atherosclerotic precursors in children living in Athens, Greece. METHODS: The following parameters were measured in a random sample of 4117 school children aged 6-18 years, living in the centre of Athens: body mass index, blood pressure, serum lipids, glucose, uric acid, calcium, phosphorus, creatinine, and haematocrit. RESULTS: Mean levels of blood pressure, total cholesterol, cigarette smoking and body mass index increased with age in both sexes, levels being similar to those of children in developed countries. Smoking started at elementary school, and by puberty had reached adult levels. High levels of systolic blood pressure ( > or = 130 mmHg) and total cholesterol ( > or = 5.68 mmol/l) were seen in 22% and 13% of children respectively. Triglyceride and glucose levels did not increase with age; high-density lipoprotein cholesterol decreased and uric acid increased from 14 to 18 years, but only in boys. Levels of body mass index, total cholesterol, triglycerides, high-density lipoprotein and uric acid above the mean population values were found in 25% of children, and glucose levels above the mean in 50%. Multiple linear regression analysis showed a positive correlation between systolic blood pressure and age, body mass index, uric acid, sex, glucose, triglycerides and high-density lipoprotein cholesterol (in that order), and between diastolic blood pressure and age, body mass index and triglycerides. CONCLUSIONS: These findings indicate that the levels and prevalence of precursors of atherosclerosis are higher than expected in a southern European population, and are similar to those found in developed countries. This would indicate a need for greater awareness among the Greek population of preventive measures against developing cardiovascular disease.

Serum calcium and blood pressure in Greek girls.

In a random sample of 492 girls 12-15-years-old total serum calcium appeared to be correlated with blood pressure. Adolescents with total serum calcium equal to a greater than the cohort mean (2.5 mmol/l) had higher systolic blood pressures than those with a value below the cohort mean. This was present at all ages.

Coronary heart disease risk factors in a random sample of Athenian adults. The Athens Study.

Risk factors for cardiovascular diseases not previously investigated in Greece were studied in a random sample of 4,097 Athenian adults. Mean systolic and diastolic blood pressures increased with age in both sexes. Similar findings were observed for mean serum total cholesterol up to age 50 years, but no significant changes were observed in older persons. Smoking was more common for men than for women and less common in those aged more than 50 years. Mean values of body mass index were higher for men than for women in those less than 45 years, but the opposite was observed for the older age groups. The age-adjusted prevalence rate of borderline hypertension was 10.1% for men and 9.1% for women and of stable hypertension (greater than 160/95 mmHg), 8.1% and 8.6%, respectively; the age-adjusted prevalence rate of obesity was 23.5% for men and 23.2% for women and of hypercholesterolemia (total cholesterol greater than or equal to 260 mg/100 ml), 20.1% for men and 17.3% for women. The associations of age and systolic blood pressure and of age and diastolic blood pressure persisted even after controlling for body mass index, total cholesterol, and smoking. In the examined representative sample, the prevalence rates of risk factors for cardiovascular diseases are the same or greater than those in industrialized countries.

CH50 and C3 component of complement in Hansen's disease.

Although a variety of complement values have been reported in leprosy, we found no difference in the CH50 and C3 in the sera of 30 normal persons and 233 lepromatous patients. No statistically significant difference was observed in CH50 and C3 values between healthy controls and lepromatous patients taken as a whole or separated into the different types of the disease spectrum (P greater than 0.1). A statistical difference in C3 titers was found between health controls and borderline patients (P less than 0.05 greater than 0.01) but the sample number is too small to be valid. An important number of sera tested had low and an equally important number had high complement values. Sera with high and low values are important because high values are found in acute inflammatory reactions and low values demonstrate complement activation. Discrepancies in reported results are probably due not only to differences in the methods used, storage and limited number of sera tested, but mainly to the stage of the disease and the drug's administration.