Performance and clinical outcomes in telestroke remain robust during the COVID-pandemic: insight into the NEVAS network.

BACKGROUND: The COVID-19 pandemic had significant impact on global healthcare, including stroke management. Telemedical stroke networks have emerged with positive results for patient outcome in rural areas without stroke expertise. However, telestroke faced enormous on-site challenges during the pandemic. So far, data on performance and clinical outcomes in telestroke settings during the COVID-pandemic are scarce. METHODS: We retrospectively analyzed data from stroke patients treated in four spoke hospitals of the Bavarian telestroke network NEVAS in 2020-2021 and 2019 as reference year and compared the 3 years for various parameters. Primary outcome was functional outcome according to the modified Rankin scale (mRS). Secondary outcome parameters included time intervals, periprocedural intracranial hemorrhage rates, and mortality. RESULTS: In 2019-2021, 2820 patients were treated for acute ischemic stroke with an admission decrease of 10% during the pandemic. Of those, 241 received only IVT and 204 were transferred to our center for MT. Door-to-imaging, door-to-needle, and symptom-onset-to-groin times remained comparable in the 3 years. Complication rates remained at a low level. Good clinical outcome rates (mRS 0-2) at discharge remained stable for all stroke patients (82-84%) and for those treated with IVT (64-77%). Good clinical outcome rates at 3 month follow-up for MT patients declined in 2020 (23% vs. 35% in 2019) but recovered again in 2021 (42%). Mortality rates did not increase for all patient groups analyzed. CONCLUSIONS: Stroke care remained robust during the COVID-pandemic within our network, indicating that well-established telestroke networks can overcome unexpected critical challenges such as a pandemic, guaranteeing best practice stroke care in rural areas.

Basilar artery occlusion: drip-and-ship versus direct-to-center for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria (NEVAS).

BACKGROUND: Recent clinical trials revealed a substantial clinical benefit for mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO). While urban areas are sufficiently covered with comprehensive stroke centers and MT expertise, rural areas lack such resources. Structured telemedical stroke networks offer rural hospitals instant consultation by stroke experts, enabling swift administration of intravenous thrombolysis (IVT) on-site and transportation for MT. For BAO patients, data on performance and clinical outcomes in telemedical stroke networks are lacking. METHODS: We retrospectively analyzed data from patients with acute BAO eligible for MT: those treated directly in our comprehensive stroke center (direct-to-center/DC) and those treated in rural hospitals that were telemedically consulted by the Neurovascular Network of Southwest Bavaria (NEVAS) and transferred to our center for MT (drip-and-ship, DS). Key time intervals, stroke management performance and functional outcome after 90 days were compared. RESULTS: Baseline characteristics, including premorbid status and stroke severity, were comparable. Time from symptom onset to IVT was identical in both groups (118 min). There was a delay of 180 min until recanalization in DS patients, mainly due to patient transport for MT. Procedural treatment time intervals, success of recanalization and complications were comparable. Clinical outcome at 3 months follow-up of DS patients was not inferior to DC patients. CONCLUSION: We show for the first time that patients with BAO in rural areas benefit from a structured telemedicine network such as NEVAS, regarding both on-site processing and drip-and-ship for MT. Clinical outcomes are comparable among DS and DC patients.

[Interdisciplinary neurovascular networks: state of the art]. / Interdisziplinäre neurovaskuläre Netzwerke: eine Standortbestimmung.

BACKGROUND: In order to treat the complete spectrum of neurovascular diseases at a high level of quality, which goes beyond the purely acute treatment of stroke, the German Stroke Society (DSG) together with the German Societies for Neurosurgery and Neuroradiology developed a certification procedure for neurovascular networks (NVN). Structurally, a NVN consists of a coordinating center with at least three neurovascular network partners with a certified stroke unit. From 2018 to 2020 a total of 15 NVN have so far been audited and certified according to this new standard. OBJECTIVE: How efficient are the NVN? Are high standards maintained? MATERIAL AND METHODS: The reports of the audits were analyzed. The data were taken from the period 2017-2019. RESULTS: The 15 NVN treated a total of 86,510 stroke patients in the years examined and were networked with a total of 107 partner clinics, which were situated an average of 25 km from the coordinating center and transferred a total of 2726 patients. The coordinating centers performed 2463 thrombectomies and treated 2383 patients with nontraumatic intracerebral bleeding. In 712 patients with acute aneurysmatic subarachnoid hemorrhages endovascular treatment was carried out and clipping in 401. The audit was successful in the majority of the NVN. CONCLUSION: The certification process of NVN has been successfully established and the audits proved to be a useful instrument for quality control and improvement. The 15 NVN are highly efficient and treat more than one quarter of stroke patients in German stroke units.

[Ability to drive with cerebrovascular diseases : Position paper of the German societies DGNB, DGN, DGNC, DGNR, DSG and GNP]. / Fahreignung bei Hirngefäßerkrankungen : Positionspapier der DGNB, DGN, DGNC, DGNR, DSG und GNP.

The regulations for ability to drive with cerebrovascular diseases in the German Driving License Regulations (Fahrerlaubnisverordnung, FeV) and German Guidelines for the Evaluation of Driving Ability of the Federal Highway Research Institute (BASt) are not up to date with the current medical knowledge and are not consistent with comparable regulations regarding cardiovascular diseases. This is particularly true for the assessment of future risks for a sudden loss of control during driving. The present position paper of six medical and neuropsychological societies in Germany presents the current conditions for the assessment of driving ability of patients a cerebrovascular diesease and recommends an estimation of the ability to drive founded on the current state of scientific knowledge. It addresses the following: 1. Physical and mental functional limitations and the possibilities for compensation, which if necessary enable a fitness to drive under conditions or within limits, including the importance of behavioral or personality changes and cognitive deficiencies that interfere with safety. 2. The potential danger due to a sudden loss of control as a result of a transient ischemic attack (TIA) new stroke event, or another cardiovascular event while driving. A summary in the form of a table provides physicians and expert assessors with assistance for the most important cerebrovascular diseases.

[Diagnostic and treatment standards for cerebral sinus venous thrombosis : Results of an online survey of German stroke units]. / Diagnose- und Behandlungsstandards der zerebralen Sinus­/Venenthrombose : Ergebnisse einer Onlineumfrage an deutschen Stroke-Units.

BACKGROUND AND PURPOSE: The aim of this survey was to characterize the current diagnostic and therapeutic strategies for thrombosis of the cerebral sinus and veins (CVT) performed in German stroke units (SU). METHODS: Between September 2015 and January 2016 all clinical heads of certified SUs in Germany were invited to participate in a standardized online survey. The survey concentrated on the basic characteristics of SUs, diagnostic and therapeutic procedures and was made anonymous if so desired. Frequencies were expressed as percentages and differences between regional stroke units (RSU) and supraregional (i. e. comprehensive) SUs (SRSU) were compared with the χ2-test or Fisher's test RESULTS: A total of 107 SU heads participated (response rate 42.8%) and 55.1% of these were RSUs. In 77.2% the diagnosis is made by magnetic resonance imaging angiography (MR-A, RSU 81.1% vs. SRSU 72.3%; p = 0.29). Of the SUs 79.1% determined d­dimer if CVT is suspected (79.3% vs. 78.7%; p = 0.94) and 88.5% carried out screening for thrombophilia (89.5% vs. 87.2%; p = 0.72). Intravenous unfractionated heparin (67.2% vs. 70.2%; p = 0.74) or subcutaneous low molecular weight heparin (32.8% vs. 29.8%; p = 0.74) are first line therapy in all SUs. Invasive procedures, such as hypothermia (3.7% vs. 10.6%; p = 0.25), hemicraniectomy (26% vs. 63.9%; p = 0.0001), endovascular techniques (11.1% vs. 40.4%; p = 0.0007) and systemic thrombolysis (5.5% vs. 10.6%; p = 0.47) are performed more frequently in SRSUs. Of the SUs 18.5% already use new oral anticoagulants (10.7% vs. 27.7%; p = 0.027). Most of the SUs organize a follow-up visit (70.9% vs. 76.6%; p = 0.52) with a MRI (94.2% vs. 91.1%; p = 0.7) within the first 6 months. CONCLUSION: The survey revealed substantial homogeneity between RSUs and SRSUs and standards are mostly in line with the guidelines. Non-established procedures, such as invasive therapeutic procedures and the administration of new oral anticoagulants were used significantly more often in SRSUs.

[Not Available]. / IQWiG Arbeitspapier GA15-02: "Stents zur Behandlung intrakranieller Stenosen: VISSIT Studie und Akutbehandlung in Deutschland". Kommentar des Berufsverbandes der Neuroradiologen (BDNR), der Deutschen Gesellschaft für Neuroradiologie (DGNR), der Deutschen Gesellschaft für Neurologie (DGN) und der Deutschen Schlaganfall-Gesellschaft (DSG).

There is an ongoing discussion about reimbursement of stent-angioplasty for the treatment of intracranial stenoses in Germany. The discussion was initiated by the statutory health insurance companies after publication of the SAMMPRIS study results, which were in favor for medical management compared to stent-angioplasty with the Wingspan® stent system. A report (Rapid report N14-01) mainly based on SAMMPRIS was written by the German Institute for Quality and Efficiency in Health Care (IQWiG) and serves as a basis for the decision-making process. This report was previously commented by the medical societies involved. Limitations of the SAMMPRIS trial and vital indications for intracranial stenting were outlined in this comment (acute vessel occlusion, hemodynamic impairment, recurrent symptoms under medical treatment). Currently also emergency stent procedures are a matter of debate. In this context a second IQWiG report was commissioned (GA 15 - 02) addressing the results of the VISSIT trial, the transferability of the results of the first report to emergency treatments and the practice of emergency intracranial stent treatment in Germany. Regarding transferability of results the main conclusion was that there was no evidence that the results of the studies analyzed for the first report (mainly SAMMPRIS) could not be transferred to emergency treatments. From a medical professional and scientific standpoint it is inacceptable to compare outcomes of a secondary prophylactic treatment with emergency procedures. The analysis of emergency treatments in Germany based on retrospective case series with a cumulative number of 31 patients. Since most emergency procedures are performed in a clinical context and are not necessarily subject to scientific evaluation, this does not reflect current practice in Germany. The first part of this statement briefly outlines the design of SAMMPRIS and VISSIT and the interpretation of the trial results from a professional perspective. The current state of discussion regarding reimbursement of intracranial stenting is summarized. The second section contains a detailed comment on the current IQWiG report GA15-02 "Stents for the treatment of intracranial artery stenosis: VISSIT study and acute treatment in Germany".

IQWiG Arbeitspapier GA15-02: "Stents zur Behandlung intrakranieller Stenosen: VISSIT Studie und Akutbehandlung in Deutschland" : Kommentar des Berufsverbandes der Neuroradiologen (BDNR), der Deutschen Gesellschaft für Neuroradiologie (DGNR), der Deutschen Gesellschaft für Neurologie (DGN) und der Deutschen Schlaganfall-Gesellschaft (DSG).

There is an ongoing discussion about reimbursement of stent-angioplasty for the treatment of intracranial stenoses in Germany. The discussion was initiated by the statutory health insurance companies after publication of the SAMMPRIS study results, which were in favor for medical management compared to stent-angioplasty with the Wingspan® stent system. A report (Rapid report N14-01) mainly based on SAMMPRIS was written by the German Institute for Quality and Efficiency in Health Care (IQWiG) and serves as a basis for the decision-making process. This report was previously commented by the medical societies involved. Limitations of the SAMMPRIS trial and vital indications for intracranial stenting were outlined in this comment (acute vessel occlusion, hemodynamic impairment, recurrent symptoms under medical treatment).Currently also emergency stent procedures are a matter of debate. In this context a second IQWiG report was commissioned (GA 15 - 02) addressing the results of the VISSIT trial, the transferability of the results of the first report to emergency treatments and the practice of emergency intracranial stent treatment in Germany6. Regarding transferability of results the main conclusion was that there was no evidence that the results of the studies analyzed for the first report (mainly SAMMPRIS) could not be transferred to emergency treatments. From a medical professional and scientific standpoint it is inacceptable to compare outcomes of a secondary prophylactic treatment with emergency procedures. The analysis of emergency treatments in Germany based on retrospective case series with a cumulative number of 31 patients. Since most emergency procedures are performed in a clinical context and are not necessarily subject to scientific evaluation, this does not reflect current practice in Germany.The first part of this statement briefly outlines the design of SAMMPRIS and VISSIT and the interpretation of the trial results from a professional perspective. The current state of discussion regarding reimbursement of intracranial stenting is summarized. The second section contains a detailed comment on the current IQWiG report GA15-02 "Stents for the treatment of intracranial artery stenosis: VISSIT study and acute treatment in Germany".

[Revised certification criteria for regional and national stroke units in Germany]. / Aktualisierte Zertifizierungskriterien für regionale und überregionale Stroke-Units in Deutschland.

The revised criteria for regional and national German stroke units (SU) defined by the SU commission of the German Stroke Society come into effect on 1 July 2015. Due to the already high level of quality, various aspects only needed minor adjustments and definitions; therefore, the majority of minimum structural standards were carried forward. For medical personnel thresholds for when staff further recruitment is necessary were defined for the first time. The current evidence for endovascular thrombectomy (ET) resulted in enhanced standards for acute brain vessel imaging, network formation and timely transport between regional and national SUs with and without ET capability. It further confirmed certification criteria for national SUs that have been valid since 2012: at least two neurointerventionalists as staff members enabling ET on a 24/7 basis. Diagnostic of atrial fibrillation (AF) has been newly implemented following current evidence and internal audits on an annual basis have now become obligatory. Overall, activities to ensure and improve quality must not only be restricted to the minimally required criteria of SU certification but should also incorporate recommendations of the SU commission. The continuous further development of German SU in recent years underlines the importance of the certification procedure as a guarantee of a minimum standard and as the driving force of sustainable quality improvements.

[Prediction in cerebrovascular diseases]. / Prädiktion bei zerebrovaskulären Erkrankungen.

Prediction of the outcome of cerebrovascular diseases or of the effects and complications of various forms of treatment are essential components of all stroke treatment regimens. This review focuses on the prediction of the stroke risk in primary prevention, the prediction of the risk of secondary stroke following a transient ischemic attack (TIA), the estimation of the outcome following manifest stroke and the treatment effects, the prediction of secondary cerebrovascular events and the prediction of vascular cognitive impairment following stroke. All predictive activities in cerebrovascular disease are hindered by the translation of predictive results from studies and patient populations to the individual patient. Future efforts in genetic analyses may be able to overcome this barrier and to enable individual prediction in the area of so-called personalized medicine. In all the various fields of prediction in cerebrovascular diseases, three major variables are always important: age of the patient, severity and subtype of the stroke. Increasing age, more severe stroke symptoms and the cardioembolic stroke subtype predict a poor outcome regarding both survival and permanent disability. This finding is somewhat banal and will therefore never replace the well experienced clinician judging the chances of a patient and taking into account the personal situation of this patient, e.g. for initiation of a rehabilitation program. Besides the individualized prediction, in times of restricted economic resources and increasing tendency to clarify questions of medical treatment in court, it seems unavoidable to use prediction in economic and medicolegal interaction with clinical medicine. This tendency will be accompanied by difficult ethical problems which neurologists must be aware of. Improved prediction should not be used to allocate or restrict resources or to restrict medically indicated treatment.

[Cerebral vasculitis with delirium in neurosyphyllis]. / Lues-assoziierte zerebrale Vaskulitis mit delirantem Syndrom.

ANAMNESIS AND CLINICAL FINDINGS: In a 40-year-old man with delirium, right-sided facial palsy and anisocoria (right > left) were noticed. He had been suffering from headaches for four weeks prior to admission. The patient's HI-virus status was positive and he used illicit drugs regularly. Therefore, the symptoms were initially thought to be drug-induced. EXAMINATION AND DIAGNOSIS: Laboratory tests showed a pleocytosis of the cerebrospinal fluid (CSF) with 929 cells/µl. The MRI of the brain revealed several ischemic strokes in the territories of the middle cerebral artery and posterior cerebral artery in the left hemisphere. A highly positive IgG CSF/serum index confirmed the diagnosis of neurosyphilis. TREATMENT AND COURSE: An antibiotic regime with penicillin was administered, during which the clinical symptoms remitted and the liquor pleocytosis nearly normalized. The intracranial stenoses persisted for three months even after therapy with nimodipine, atorvastatin, and antibiotics. Therefore they are presumed to be a result of the lues-associated vasculitis. CONSEQUENCE: In patients with delirium the initially suspected underlying condition needs to be challenged. Early cerebral MRI, lumbar puncture and ultrasound of the cerebral arteries are mandatory to exclude menigoencephalitis.

[FEES in the stroke unit: recommendations for implementation in the clinical routine]. / FEES auf der Stroke-Unit : Empfehlungen zur Umsetzung im klinischen Alltag.

Dysphagia occurs in about 50 % of patients with acute stroke, is strongly related to early complications, such as aspiration pneumonia and is a major cause of increased morbidity and mortality in acute stroke. Flexible endoscopic evaluation of swallowing (FEES) has proven to be an easy to use, non-invasive tool for assessment of dysphagia in acute stroke, significantly adding accuracy to the clinical evaluation of dysphagia. With respect to the growing use of FEES in German stroke units this article summarizes recommendations for implementation and execution.A 3-step process is recommended to acquire the relevant knowledge and skills for carrying out FEES. After a systematic training (first step), swallowing endoscopy should be done under close supervision (second step) which is then followed by independent practice coupled with indirect supervision (third step). In principle, FEES should adopt a team approach involving both neurologists and speech language pathologists (SLP) or alternatively speech therapists. The allocation of responsibilities between these two professions should be kept flexible and should be adjusted to the individual level of education. Reducing the role of the SLP to mere assistance work in particular should be avoided. To enhance interprofessional communication and to allow for a smooth and efficient workflow, endoscopic grading of stroke-related dysphagia should adopt a standardized score that also includes protective and rehabilitative measures as well as nutritional recommendations. A major task for the future is to develop an educational curriculum for FEES that takes the specific needs of stroke unit care into account and is applicable to both physicians and SLPs.