Communicative impairment and its neural correlates in Alzheimer's disease and frontotemporal dementia.

OBJECTIVE: Communication skills can deteriorate in neurodegenerative diseases such as Alzheimer's disease (AD) and frontotemporal dementia (FTD); however, their clinical assessment and treatment in patient care can be challenging. In the present study, we aimed to quantify the distinctive communication resources and barriers reported by patients and their relatives in AD and FTD and associated these communicative characteristics with clinical parameters, such as the degree of cognitive impairment and atrophy in language-associated brain areas. METHODS: We assessed self-reported communication barriers and resources in 33 individuals with AD and FTD through an interview on daily-life communication, using the Aachener KOMPASS questionnaire. We correlated reported communication barriers and resources with atrophy from high-resolution 3T brain magnetic resonance imaging, neuropsychological assessment, and neurodegenerative markers from cerebrospinal fluid. RESULTS: Communicative impairment was higher in FTD compared to AD. Increased reported communication barriers in our whole sample were associated with the atrophy rate in the left middle temporal lobe, a critical site within the neuronal language network, and with depressive symptoms as well as the semantic word fluency from neuropsychological assessment. The best model for prediction of communicative impairment included the diagnosis (AD or FTD), semantic word fluency, and depressive symptoms. CONCLUSIONS: Our study demonstrates that communication barriers and resources can be successfully assessed via a structured interview based on self-report and report of patients' relatives in practice and are reflected in neuroimaging specific for AD and FTD as well as in further clinical parameters specific for these neurodegenerative diseases. This can potentially open new treatment options for clinical practice and patient care.

Left atrial appendage thrombus in acute stroke: diagnostic accuracy of CT angiography compared to transesophageal echocardiography.

OBJECTIVES: To evaluate the value of an extended emergency computed tomography angiography (CTA) including cardiac imaging in patients with acute ischemic stroke for the detection of left atrial appendage (LAA) thrombus compared to transesophageal echocardiography (TEE) as a reference standard. MATERIALS AND METHODS: We conducted a retrospective case-control study of patients with presumed acute ischemic stroke who had undergone non-ECG-gated CTA for the craniocervical vessels with an extended coverage including the heart in the context of emergency stroke evaluation and for whom TEE was available as part of the routine stroke diagnostic. We selected cases with evidence of LAA thrombus in TEE and controls without LAA thrombus in TEE in a 1:3 ratio. Two independent observers analyzed CTA images for presence of LAA thrombus and were blinded to the presence of thrombus in TEE. RESULTS: Twenty-two patients with LAA thrombus in TEE, and 66 patients without LAA thrombus in TEE were included. The detection of LAA thrombus using CTA showed a sensitivity of 63.6%, a specificity of 81.8%, a positive predictive value of 53.9% and a negative predicted value of 87.1%. Interobserver agreement was only moderate (Cohen´s κ = 0.43). CONCLUSIONS: An extended emergency CTA including cardiac imaging can be helpful in early risk stratification in patients with stroke of cardioembolic origin. However, our data show that a standard CTA of craniocervical vessels with extended coverage of the heart is of limited value when compared to TEE, the standard method of detecting LAA thrombi.

Epicardial adipose tissue thickness assessed by CT is a marker of atrial fibrillation in stroke patients.

Epicardial adipose tissue is involved in the pathophysiology of atrial fibrillation (AF). This study aimed to analyze its relevance as a stroke etiology marker. A retrospective study of acute ischemic stroke patients with large vessel occlusion was conducted, periatrial epicardial adipose tissue thickness (pEATT) on admission computed tomography angiography was measured. One hundred and twenty-one patients with AF-related stroke and 94 patients with noncardioembolic stroke were included. Patients with AF-related stroke had increased pEATT. CT-measured left-sided pEATT was an independent predictor of AF-related stroke (adjusted odds ratio per 1 mm increase = 1.27, 95% CI = 1.05-1.53, p = 0.012). pEATT is an independent marker of AF-related stroke.

Implementation of a telemedicine geriatric co-evaluation in the emergency department: a prospective pilot study.

  INTRODUCTION: Complex drug management is a common challenge in the treatment of geriatric patients. Pandemic scenarios, such as the current one (COVID-19), call for a reduction of face-to-face meetings, especially for elderly patients. Therefore, the aim of the present study was to compare the innovative concept of applying telemedical assessment to geriatric patients in the emergency department (ED) with ED standard treatment. The therapeutic recommendations regarding drug management from the two assessments were compared. A special focus was the use of potentially inadequate drugs (PIMs) for geriatric patients according to the “Fit for the Aged” (FORTA) classification. METHODS: 50 patients (40% female) aged ≥70 years and assessed with an Identification of Seniors at Risk Score (ISAR score) of ≥2 admitted to the ED were prospectively enrolled in this study between November 2017 and February 2018. In addition to the standard treatment in the ED, co-evaluation via video transmission was independently carried out by a board-certified geriatrician. Drug recommendations by ED physicians (A) and the geriatrician (B) were compared. RESULTS: There was a significantly higher frequency of recommendations regarding changes to preexisting medication (p <0.001, n = 50) via geriatric telemedicine in comparison with standard ED treatment. The geriatrician intervened significantly more often than the ED physicians: discontinuation of a drug, p <0.001; start of a new drug, p = 0.004; dose change of a drug, p = 0.001; n = 50). Based on the additional therapy recommendations of the geriatrician, the amount of medication taken by the patient was significantly reduced compared with standard ED treatment (ED assessment t(49) = 0.622 vs geriatrician’s assessment t(49) = 4.165; p <0.001; n = 50). Additionally, the number of PIMs was significantly reduced compared with standard medical treatment (p <0.001). The geriatrician changed 53.9% of the drugs (35/65) whereas the ED physicians changed only 12.3% (8/65). Recommendations for immediate drug therapy, however, were made more frequently by ED physicians (p <0.039, n = 50). DISCUSSION: An early assessment of elderly emergency patients by a geriatrician had a significant impact on the number of drug interventions in the ED. The number of PIMs could be significantly reduced. Whether this also has a positive effect on the further inpatient course needs to be investigated in further prospective studies. The study was retrospectively registered at ClinicalTrials.gov (NCT04148027).  .

The assessment of dermatological emergencies in the emergency department via telemedicine is safe: a prospective pilot study.

The aim of the study was to examine the feasibility and safety of telemedicine for dermatological emergency patients in the emergency department. This observational study was monocentric, open, prospective and two-arm randomized [control group (n = 50) and teledermatology group (n = 50)]. The control group was conventionally recruited directly by a dermatologist. In the teledermatology group patients, images of the skin lesions and clinical parameters were transferred to a tablet PC (personal computer) by an emergency physician and telemedically assessed by a dermatologist without patient contact. Subsequently, the dermatologist, who was previously telemedically contacted, then personally examined the patient in the emergency department. The treatment time between the control group and the teledermatology group was also recorded and compared. The agreement in suspected diagnosis between teledermatological evaluation and clinical evaluation of the same physician in the teledermatology group was 100%. The treatment time [mean (minutes) ± standard deviation] of the control group was 151 ± 71, that of the teledermatology group was 43 ± 38 (p < 0.001). The use of emergency telemedicine is safe and effective and provides a viable alternative for clinical care of emergency patients.

Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study.

AIM: Knowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS. METHODS: Patients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients. RESULTS: Twenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4-6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation. CONCLUSIONS: Signs of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.

Neurogenic pulmonary edema following seizures: A retrospective computed tomography study.

INTRODUCTION: Data on the frequency and clinical relevance of neurogenic pulmonary edema (NPE) following epileptic seizures are limited. The aim of the present study was to analyze computed tomography (CT) examinations in patients with previous seizures. METHOD: Incidence of NPE and related clinical factors were retrospectively assessed in patients admitted because of epileptic seizures who underwent thoracic CT imaging as part of emergency diagnostics. RESULTS: Between January 2010 and January 2016, we included all patients admitted with the International Classification of Diseases (ICD) diagnosis code of epileptic seizure or epilepsy and who underwent CT imaging, including visualization of the lungs, as part of emergency diagnostics. Of the 47 included patients, 26 patients had suffered from generalized convulsive seizures (GCS), 17 patients had focal seizures with impaired and 4 without impaired consciousness. Signs of NPE were present in 5 out of 47 patients; all 5 patients had GCS prior to thoracic CT scan (i.e., 19% of patients with GCS). In four out of five cases, a single seizure was described; in one case, the seizure was only partially witnessed, but the indirect clinical signs strongly suggested a GCS. Related factors such as the initial respiratory rate or the initial pCO2 value were not significantly different in patients with and without signs of NPE. CONCLUSIONS: The highly selected and biased patient group warrants caution in the interpretation of the study results. Our data, however, confirm that signs of NPE appear to be rather frequent in patients with GCS. Its clinical significance as regards morbidity and sudden death in epilepsy is discussed.

[Risk factors for hypertensive and cerebral amyloid angiopathy associated intracerebral hemorrhage: a retrospective comparison]. / Risikofaktoren für hypertensive und zerebrale Amyloidangiopathie-assoziierte intracerebrale Blutungen: ein retrospektiver Vergleich.

INTRODUCTION: The aim of this study was to compare possible risk factors for the most common forms of spontaneous intracerebral hemorrhage (ICH), namely hypertensive and cerebral amyloid angiopathy (CAA) associated ICH. METHODS: Retrospectively, different parameters and factors were compared in patients with hypertensive ICH (n = 141) and patients with a CAAassociated ICH (n = 95). These included age, INR value and blood pressure at admission, cardiovascular risk factors as well as pre-medication. The Chi-square test with the Yates' continuity correction and the t-test were used as test methods. RESULTS: Patients of the group with CAA-associated ICH were significantly older than patients with a hypertensive ICH (p = 0.001). In addition, there was a significantly higher incidence of acetylsalicylic acid prior treatment (p = 0.042) and a previous stroke (p = 0.048) in the CAA patients. Patients of both groups had a high proportion of arterial hypertension as pre-diagnosis, which was significantly more common in patients with hypertensive ICH (p < 0,001). Patients with a hypertensive ICH also had significantly higher systolic and diastolic blood pressure values (p < 0.001) and higher INR values (p = 0.005) at admission. A subgroup analysis of all patients without anticoagulation (ZAA group: n = 78, hypertensive ICB group: n = 99) showed similar results. However, there was no significant difference (p = 0.037) for a previous stroke, but there was a significant difference in premedication with a statin (p = 0.032). DISCUSSION: Arterial hypertension is a relevant risk factor in both forms of intracerebral hemorrhage and should therefore receive adequate prophylaxis. For a more detailed classification of the other risk factors, further studies with larger cases are necessary.

Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes.

Concentrations of serum creatine kinase (CK) and serum lactate are frequently measured to help differentiate between generalized tonic-clonic seizures (GTCS) and syncope. The aim of this prospective cohort study was to systematically compare these two markers. The primary outcome is the measurement of serum lactate and CK in blood samples drawn within 2 h of the event in patients admitted with either a GTCS (n = 49) or a syncope (n = 36). Furthermore, the specificity and sensitivity of serum lactate and CK are determined as diagnostic markers in distinguishing between GTCS and syncope. GTCS patients have significantly higher serum lactate levels compared to syncope patients (p < 0.001). In contrast, CK does not differ between groups at admission. Regarding the first hour after the seizure, we identify a cut-off for serum lactate of 2.45 mmol/l for diagnosing GTCS as the cause of an impairment of consciousness with a sensitivity of 0.94 and a specificity of 0.93 (AUC: 0.97; 95% CI 0.94-1.0). In the second hour after the event, the ROC analysis yields similar results (AUC: 0.94; 95% CI 0.85-1.0). Serum lactate is a sensitive and specific diagnostic marker to discriminate GTCS from syncope and is superior to CK early after admission to the emergency department.

Weekend effect in endovascular stroke treatment: do treatment decisions, procedural times, and outcome depend on time of admission?

BACKGROUND: Epidemiologic studies identified a 'weekend effect' or 'out-of-hours effect', which implies that procedural and clinical outcomes of patients with stroke, who are admitted out-of-hours, are less favorable than for patients admitted during working-hours. OBJECTIVE: To determine (1) whether our procedural times and clinical outcome were affected by an out-of-hours effect and (2) whether the decision in favor of, or against, endovascular stroke treatment (EST) depends on the time of admission. METHODS: Between February 2010 and January 2015, 6412 consecutive patients presenting with symptoms of acute ischemic stroke were evaluated for EST eligibility according to established local protocols and generally accepted consensus criteria, and dichotomized into working-hours and out-of-hours cohorts according to admission times. Within both groups, patients given EST were identified and the rate of treatment decision, procedural times, and clinical outcome were compared and analyzed. RESULTS: Clinical and radiological features of patients admitted in working-hours and out-of-hours did not differ significantly. Procedural times and clinical outcome were not affected by an out-of-hours effect (p≥0.054). 221/240 (92.1%) out-of-hours patients and 154/166 (92.8%) working-hours patients who were eligible for EST were transferred to the angiography suite for EST (p=0.798). The rationale not to treat patients who were eligible for EST did not differ between working-hours and out-of-hours admission (p=0.756). CONCLUSIONS: It is possible to produce competitive procedural times regardless of the time of admission and to prevent a treatment decision bias when standard operating procedures are applied consistently.

Grading of proximal internal carotid artery (ICA) stenosis by Doppler/duplex ultrasound (DUS) and computed tomographic angiography (CTA): correlation and interrater reliability in real-life practice.

Doppler/duplex ultrasound (DUS) and computed tomographic angiography (CTA) are frequently applied methods to assess the degree of proximal internal carotid artery (ICA) stenoses in patients with acute ischemic stroke. This study evaluated the agreement and interrater reliability (IR) of both methods using a revised DUS grading system as well as different criteria (ECST/NASCET) under real-life conditions. CTA and DUS data of 281 proximal ICA stenoses [143 patients; 65.7 % male; age (mean (years) ± SD, range) 72.2 ± 11.1, 40-99] were retrospectively analyzed. For both methods, two independent raters estimated the degree of stenosis according to NASCET and ECST criteria. DUS raters applied revised German DUS criteria. For agreement and IR assessment, the linear weighted Kappa statistic was used. Correlation between DUS and CTA was substantial irrespective of the applied classification [weighted Kappa: 0.77 (NASCET)/0.79 (ECST)]. IR for DUS was almost perfect (weighted Kappa: 0.94) and better than for CTA [weighted Kappa: 0.78 (NASCET)/0.78 (ECST)]. In a real-life setting, CTA and DUS assessments of the degree of proximal ICA stenoses agreed substantially irrespective of the criteria applied (ECST/NASCET). For DUS, IR was better than for CTA.

Autoantibodies in complex regional pain syndrome bind to a differentiation-dependent neuronal surface autoantigen.

Complex regional pain syndrome, which is characterised by pain and trophic disturbances, develops frequently after peripheral limb trauma. There is an increasing evidence of an involvement of the immune system in CRPS, and recently we showed that CRPS patients have autoantibodies against nervous system structures. Therefore we tested the sera of CRPS patients, neuropathy patients and healthy volunteers for surface-binding autoantibodies to primary cultures of autonomic neurons and differentiated neuroblastoma cell lines using flow cytometry. Thirteen of 30 CRPS patients, but none of 30 healthy controls and only one of the 20 neuropathy sera had specific surface binding to autonomic neurons (p<0.001). The majority of the sera reacted with both sympathetic and myenteric plexus neurons. Interestingly, 6/30 CRPS sera showed binding to undifferentiated SH-SY5Y neuroblastoma cells. However, differentiation of SH-SY5Y into a cholinergic phenotype induced a surface antigen, which is recognised by 60% of CRPS sera (18/30), but not by controls (p<0.001). Our data show that about 30-40% of CRPS patients have surface-binding autoantibodies against an inducible autonomic nervous system autoantigen. These data support an autoimmune hypothesis in CRPS patients. Further studies must elucidate origin and function of these autoantibodies in CRPS.