German guidelines on the diagnosis and treatment of neurosyphilis.

INTRODUCTION: In view of the importance of neurosyphilis and the difficulties encountered in diagnosing it, the S1 guideline "Neurosyphilis" has been published by the German Society for Neurology (DGN) in accordance with the stipulations of the Association of the Scientific Medical Societies in Germany (AWMF). The present article is an abridged translation of that German guideline. MAIN RECOMMENDATIONS: (a) Neurosyphilis can manifest as early neurosyphilis (meningitis, meningovascular neurosyphilis or syphilitic gummas) or late neurosyphilis (tabes dorsalis, general paresis). (b) The following diagnostic criteria help to establish the presence of probable neurosyphilis (always point iv, accompanied by any two of points i to iii): (i) subacute or chronic neuro-psychiatric symptoms; (ii) increased cerebrospinal fluid (CSF) cell count or signs of blood-CSF barrier disruption; (iii) positive effect of anti-neurosyphilis antibiotic therapy on clinical course and CSF findings; (iv) positive TPHA/TPPA or FTA test in serum. (c) The diagnosis of neurosyphilis is confirmed by the subsequent detection of intrathecal production of antibodies against Treponema pallidum. (d) In neurosyphilis, treatment with intravenous penicillin or ceftriaxone for 14 days is recommended. (e) The following parameters can be used to assess a therapeutic effect: clinical findings, serum VDRL, and CSF cell count. CONCLUSION: The German guideline on the diagnosis and treatment of neurosyphilis is a practical tool to support clinicians in diagnosing and treating patients with neurosyphilis. This article is an abridged translation of this guideline (Klein MW, J.; Angstwurm, K.; Esser, S.; Hahn, K.; Matschke, M.; Scheithauer, S.; Schoefer, H.; Sturzenegger, M.; Wildemann, B. Neurosyphilis, S1-Leitlinie. Deutsche Gesellschaft für Neurologie, Leitlinien für Diagnostik und Thearpie in der Neurologie 2020).

A Thalamic-Fronto-Parietal Structural Covariance Network Emerging in the Course of Recovery from Hand Paresis after Ischemic Stroke.

AIM: To describe structural covariance networks of gray matter volume (GMV) change in 28 patients with first-ever stroke to the primary sensorimotor cortices, and to investigate their relationship to hand function recovery and local GMV change. METHODS: Tensor-based morphometry maps derived from high-resolution structural images were subject to principal component analyses to identify the networks. We calculated correlations between network expression and local GMV change, sensorimotor hand function and lesion volume. To verify which of the structural covariance networks of GMV change have a significant relationship to hand function, we performed an additional multivariate regression approach. RESULTS: Expression of the second network, explaining 9.1% of variance, correlated with GMV increase in the medio-dorsal (md) thalamus and hand motor skill. Patients with positive expression coefficients were distinguished by significantly higher GMV increase of this structure during stroke recovery. Significant nodes of this network were located in md thalamus, dorsolateral prefrontal cortex, and higher order sensorimotor cortices. Parameter of hand function had a unique relationship to the network and depended on an interaction between network expression and lesion volume. Inversely, network expression is limited in patients with large lesion volumes. CONCLUSION: Chronic phase of sensorimotor cortical stroke has been characterized by a large scale co-varying structural network in the ipsilesional hemisphere associated specifically with sensorimotor hand skill. Its expression is related to GMV increase of md thalamus, one constituent of the network, and correlated with the cortico-striato-thalamic loop involved in control of motor execution and higher order sensorimotor cortices. A close relation between expression of this network with degree of recovery might indicate reduced compensatory resources in the impaired subgroup.

Dynamic changes of intramural hematoma in patients with acute spontaneous internal carotid artery dissection.

BACKGROUND: We prospectively investigated temporal and spatial evolution of intramural hematomas in patients with acute spontaneous internal carotid artery dissection using repeated magnetic resonance imaging over six-months. AIM: The aim of the present study was to assess dynamic changes of intramural hematoma in patients with acute spontaneous internal carotid artery dissection at multiple follow-up time-points with T1w, PD/T2w, and magnetic resonance angiography. METHODS: We performed serial multiparametric magnetic resonance imaging in 10 patients with spontaneous internal carotid artery dissection on admission, at days 1, 3, 7-14 and at months 1·5, 3, and 6. We calculated the volume and extension of the hyperintense intramural hematoma using T1w and PD/T2w fat suppressed sequences and assessed the degree of stenosis due to the hematoma using magnetic resonance angiography. RESULTS: Mean interval from symptom onset to first magnetic resonance imaging was two-days (SD 2·7). Two patients presented with ischemic stroke, three with transient ischemic attacks, and five with pain and local symptoms only. Nine patients had a transient increase of the intramural hematoma volume, mainly up to day 10 after symptom onset. Fifty percent had a transient increase in the degree of the internal carotid artery stenosis on MRA, one resulting in a temporary occlusion. Lesions older than one-week were predominantly characterized by a shift from iso- to hyperintese signal on T2w images. At three-month follow-up, intramural hematoma was no longer detectable in 80% of patients and had completely resolved in all patients after six-months. CONCLUSIONS: Spatial and temporal dynamics of intramural hematomas after spontaneous internal carotid artery dissection showed an early volume increase with concomitant progression of the internal carotid artery stenosis in 5 of 10 patients. Although spontaneous internal carotid artery dissection overall carries a good prognosis with spontaneous hematoma resorption in all our patients, early follow-up imaging may be considered, especially in case of new clinical symptoms.

Interhemispheric cerebral blood flow balance during recovery of motor hand function after ischemic stroke--a longitudinal MRI study using arterial spin labeling perfusion.

BACKGROUND: Unilateral ischemic stroke disrupts the well balanced interactions within bilateral cortical networks. Restitution of interhemispheric balance is thought to contribute to post-stroke recovery. Longitudinal measurements of cerebral blood flow (CBF) changes might act as surrogate marker for this process. OBJECTIVE: To quantify longitudinal CBF changes using arterial spin labeling MRI (ASL) and interhemispheric balance within the cortical sensorimotor network and to assess their relationship with motor hand function recovery. METHODS: Longitudinal CBF data were acquired in 23 patients at 3 and 9 months after cortical sensorimotor stroke and in 20 healthy controls using pulsed ASL. Recovery of grip force and manual dexterity was assessed with tasks requiring power and precision grips. Voxel-based analysis was performed to identify areas of significant CBF change. Region-of-interest analyses were used to quantify the interhemispheric balance across nodes of the cortical sensorimotor network. RESULTS: Dexterity was more affected, and recovered at a slower pace than grip force. In patients with successful recovery of dexterous hand function, CBF decreased over time in the contralesional supplementary motor area, paralimbic anterior cingulate cortex and superior precuneus, and interhemispheric balance returned to healthy control levels. In contrast, patients with poor recovery presented with sustained hypoperfusion in the sensorimotor cortices encompassing the ischemic tissue, and CBF remained lateralized to the contralesional hemisphere. CONCLUSIONS: Sustained perfusion imbalance within the cortical sensorimotor network, as measured with task-unrelated ASL, is associated with poor recovery of dexterous hand function after stroke. CBF at rest might be used to monitor recovery and gain prognostic information.

Normative MR cervical spinal canal dimensions.

PURPOSE: To provide normal values of the cervical spinal canal and spinal cord dimensions in several planes with respect to spinal level, age, sex, and body height. MATERIALS AND METHODS: This study was approved by the institutional review board; all individuals provided signed informed consent. In a prospective multicenter study, two blinded raters independently examined cervical spine magnetic resonance (MR) images of 140 healthy volunteers who were white. The midsagittal diameters and areas of spinal canal and spinal cord, respectively, were measured at the midvertebral levels of C1, C3, and C6. A multivariate general linear model described the influence of sex, body height, age, and spinal level on the measured values. RESULTS: There were differences for sex, spinal level, interaction between sex and level, and body height, while age had significant yet limited influence. Normative ranges for the sagittal diameters and areas of spinal canal and spinal cord were defined at C1, C3, and C6 levels for men and women. In addition to a calculation of normative ranges for a specific sex, spinal level, age, and body height data, data for three different height subgroups at 45 years of age were extracted. These results show a range of the spinal canal dimensions at C1 (from 10.7 to 19.7 mm), C3 (from 9.4 to 17.2 mm), and C6 (from 9.2 to 16.8 mm) levels. CONCLUSION: The dimensions of the cervical spinal canal and cord in healthy individuals are associated with spinal level, sex, age, and height. Online supplemental material is available for this article.

Does normalized signal intensity of cervical discs on T2 weighted MRI images change in whiplash patients?

PURPOSE: We tested the hypothesis that whiplash trauma leads to changes of the signal intensity of cervical discs in T2-weighted images. METHODS AND MATERIALS: 50 whiplash patients (18-65 years) were examined within 48h after motor vehicle accident, and again after 3 and 6 months and compared to 50 age- and sex-matched controls. Signal intensity in ROI's of the discs at the levels C2/3 to C7/T1 and the adjacent vertebral bodies were measured on sagittal T2 weighted MR images and normalized using the average of ROI's in fat tissue. The contrast between discs and both adjacent vertebrae was calculated and disc degeneration was graded by the Pfirrmann-grading system. RESULTS: Whiplash trauma did not have a significant effect on the normalized signals from discs and vertebrae, on the contrast between discs and adjacent vertebrae, or on the Pfirrmann grading. However, the contrast between discs and adjacent vertebrae and the Pfirrmann grading showed a strong correlation. In healthy volunteers, the contrast between discs and adjacent vertebrae and Pfirrmann grading increased with age and was dependent on the disc level. CONCLUSION: We could not find any trauma related changes of cervical disc signal intensities. Normalized signals of discs and Pfirrmann grading changed with age and varied between disc levels with the used MR sequence.

Imaging of acute cervical spine trauma: when to obtain which modality.

The current knowledge and evidence around the merits of different imaging modalities for the evaluation of cervical spine injuries are reviewed. The National Emergency X-Radiography Use Study, Canadian Cervical Spine rule, and American College of Radiology appropriateness criteria are reviewed and summarized. The advantages and disadvantages of available imaging modalities for selected cervical spine injury patterns are also illuminated to simplify the decision making on when to use which modality.

Cervical muscle area measurements in whiplash patients: Acute, 3, and 6 months of follow-up.

PURPOSE: To investigate the role of the cervical spine muscles in whiplash injury. We hypothesized that (i) cervical muscle hypotrophy would be evident after a 6-month follow-up and, (ii) cervical muscle hypotrophy would correlate with symptom persistence probably related to pain or inactivity. MATERIALS AND METHODS: Ninety symptomatic patients (48 females) were recruited from our emergency department and examined within 48 h, and at 3, and 6 months after a motor vehicle accident. MRI cross-sectional muscle area (CSA) measurements were performed bilaterally of the cervical extensor and sternocleidomastoid muscles using transverse STIR (Short Tau inversion Recovery) sequences at the C2 (deep and total dorsal cervical extensor muscles), C4 (sternocleidomastoid muscles) and C5 (deep and total dorsal cervical extensor muscles) levels. Two blinded raters independently performed the measurements at each time point. First, CSA changes over time were analyzed and, second, CSAs were correlated with clinical outcomes (EuroQuol, Whiplash Disability Score, neck pain intensity [VAS], cervical spine mobility). RESULTS: There was a high agreement of CSA measurements between the two raters. Women consistently had smaller CSAs than men. There were no significant changes of CSAs over time at any of the three levels. There were no consistent significant correlations of CSA values with the clinical scores at all time points except with the body mass index. CONCLUSION: Our results do not support a major role of cervical muscle volume in the genesis of symptoms after whiplash injury.

CCSVI and MS: a statement from the European Society of neurosonology and cerebral hemodynamics.

To systematically review the ultrasonographic criteria proposed for the diagnosis of chronic cerebrospinal venous insufficiency (CCSVI). The authors analyzed the five ultrasonographic criteria, four extracranial and one intracranial, suggested for the diagnosis of CCSVI in multiple sclerosis (MS), together with the references from which these criteria were derived and the main studies that explored the physiology of cerebrospinal drainage. The proposed CCSVI criteria are questionable due to both methodological and technical errors: criteria 1 and 3 are based on a scientifically incorrect application of data obtained in a different setting; criteria 2 and 4 have never been validated before; criterion 2 is technically incorrect; criteria 3 and 5 are susceptible to so many external factors that it is difficult to state whether the data collected are pathological or a variation from the normal. It is also unclear how it was decided that two or more of these five ultrasound criteria may be used to diagnose CCSVI, since no validation of these criteria was performed by different and independent observers nor were they blindly compared with a validated gold-standard investigation. The European Society of Neurosonology and Cerebral Hemodynamics (ESNCH) has considerable concerns regarding the accuracy of the proposed criteria for CCSVI in MS. Therefore, any potentially harmful interventional treatment such as transluminal angioplasty and/or stenting should be strongly discouraged.

Lesions to primary sensory and posterior parietal cortices impair recovery from hand paresis after stroke.

BACKGROUND: Neuroanatomical determinants of motor skill recovery after stroke are still poorly understood. Although lesion load onto the corticospinal tract is known to affect recovery, less is known about the effect of lesions to cortical sensorimotor areas. Here, we test the hypothesis that lesions of somatosensory cortices interfere with the capacity to recover motor skills after stroke. METHODS: Standardized tests of motor skill and somatosensory functions were acquired longitudinally over nine months in 29 patients with stroke to the pre- and postcentral gyrus, including adjacent areas of the frontal, parietal and insular cortices. We derived the recovery trajectories of each patient for five motor subtest using least-squares curve fitting and objective model selection procedures for linear and exponential models. Patients were classified into subgroups based on their motor recovery models. Lesions were mapped onto diffusion weighted imaging scans and normalized into stereotaxic space using cost-function masking. To identify critical neuranatomical regions, voxel-wise subtractions were calculated between subgroup lesion maps. A probabilistic cytoarchitectonic atlas was used to quantify of lesion extent and location. RESULTS: Twenty-three patients with moderate to severe initial deficits showed exponential recovery trajectories for motor subtests that relied on precise distal movements. Those that retained a chronic motor deficit had lesions that extended to the center of the somatosensory cortex (area 2) and the intraparietal sulcus (areas hIP1, hIP2). Impaired recovery outcome correlated with lesion extent on this areas and somatosensory performance. The rate of recovery, however, depended on the lesion load onto the primary motor cortex (areas 4a, 4p). CONCLUSIONS: Our findings support a critical role of uni-and multimodal somatosensory cortices in motor skill recovery. Whereas lesions to these areas influence recovery outcome, lesions to the primary motor cortex affect recovery dynamics. This points to a possible dissociation of neural substrates for different aspects of post-stroke recovery.

Are there cervical spine findings at MR imaging that are specific to acute symptomatic whiplash injury? A prospective controlled study with four experienced blinded readers.

PURPOSE: To compare the magnetic resonance (MR) imaging findings in patients with acute whiplash injury with those in matched control subjects. MATERIALS AND METHODS: In a prospective multicenter controlled study, from 2005 to 2008, 100 consecutive patients underwent 1.5-T MR imaging examinations of the cervical spine within 48 hours after a motor vehicle accident. Findings in these patients were compared in a blinded fashion with those in 100 age- and sex-matched healthy control subjects. Four blinded independent readers assessed the presence of occult vertebral body and facet fractures, vertebral body and facet contusions, intervertebral disk herniations, ligamentum nuchae strains, ligamentum nuchae tears, muscle strains or tears, and perimuscular fluid. Accuracy (as compared with clinical findings) and interobserver reliability were calculated. RESULTS: Accuracy of MR imaging and interreader reliability were generally poor (sensitivity, 0.328; specificity, 0.728; positive and negative likelihood ratios, 1.283 and 1.084, respectively). MR imaging findings significantly associated with whiplash injuries were occult fracture (P<.01), bone marrow contusion of the vertebral body (P=.01), muscle strain (P<.01) or tear (P<.01), and the presence of perimuscular fluid (P<.01). While 10 findings thought to be specific for whiplash trauma were significantly (P<.01) more frequent in patients (507 observations), they were also regularly found in healthy control subjects (237 observations). There were no serious occult injuries that required immediate therapy. CONCLUSION: MR imaging at 1.5 T reveals only limited evidence of specific changes to the cervical spine and the surrounding tissues in patients with acute symptomatic whiplash injury compared with healthy control subjects.

Alterations of the transverse ligament: an MRI study comparing patients with acute whiplash and matched control subjects.

OBJECTIVE: The objective of our study was to evaluate whether there is injury to the transverse ligament of the atlas in patients with acute whiplash. MATERIALS AND METHODS: Ninety patients with an acute (< 48 hours) symptomatic whiplash-associated injury and 90 healthy age- and sex-matched asymptomatic control subjects (mean age of patients and control subjects, 36 years) were included. The maximal sagittal thickness of the transverse ligament was measured on midsagittal T1 volumetric interpolated breath-hold examination (VIBE) images and transverse reformatted VIBE images. The signal intensity of the transverse ligament was measured on transverse STIR images and on transverse reformatted T1 VIBE images before and after IV administration of gadoterate. Contrast between the transverse ligament and CSF and alterations of contrast after gadoterate injection were calculated. RESULTS: Patients had a minimally thicker transverse ligament (posttraumatic swelling) than control subjects, and the difference in thickness was significant in men only (p = 0.03). In patients, a significant signal alteration of the transverse ligament (p = 0.03) was seen on STIR (posttraumatic edema) and native VIBE sequences. The contrast between the transverse ligament and the CSF on VIBE images was significantly (p = 0.005) lower in patients than in control subjects. With the application of a contrast agent, the contrast difference between the transverse ligament and CSF in patients and control subjects was less pronounced (p = 0.038). There was no abnormal uptake of contrast agent by the transverse ligament or CSF. CONCLUSION: The results of our study indicate possible involvement of the transverse ligament in whiplash injury. Although MRI may be helpful to study injury-related changes of anatomic structures in cohorts, it is not suited for individual diagnosis because the alterations are too small.

A smooth transition protocol for patients with multifocal motor neuropathy going from intravenous to subcutaneous immunoglobulin therapy: an open-label proof-of-concept study.

Intravenous immunoglobulin (IVIG) is the first-line therapy for multifocal motor neuropathy (MMN). This open-label multi-centre study (NCT00701662) assessed the efficacy, safety, and convenience of subcutaneous immunoglobulin (SCIG) in patients with MMN over 6 months, as an alternative to IVIG. Eight MMN patients (42-66 years), on stable IVIG dosing, received weekly SCIG at doses equivalent to previous IVIG using a "smooth transition protocol". Primary efficacy endpoint was the change from baseline to week 24 in muscle strength. Disability, motor function, and health-related quality of life (HRQL) endpoints were also assessed. One patient deteriorated despite dose increase and was withdrawn. Muscle strength, disability, motor function, and health status were unchanged in all seven study completers who rated home treatment as extremely good. Four experienced 18 adverse events, of which only two were moderate. This study suggests that MMN patients with stable clinical course on regular IVIG can be switched to SCIG at the same monthly dose without deterioration and with a sustained overall improvement in HRQL.

Cervical muscle area measurements in acute whiplash patients and controls.

PURPOSE: To quantitatively compare the muscle cross-sectional areas (CSAs) of the cervical muscles in symptomatic acute whiplash patients versus healthy controls. We hypothesized, that symptomatic whiplash patients have smaller cervical muscle CSAs than matched controls and that smaller cervical muscle CSAs in women might explain that women more frequently are symptomatic after whiplash injury than men. MATERIALS AND METHODS: Prospective controlled study. Thirty-eight consecutive acute whiplash patients were examined within 48 h after a motor vehicle accident and 38 healthy age- and sex-matched controls, each half female, half male, were examined with the same protocol. MRI CSA measurements were performed of the deep and total cervical extensor muscles as well as the sternocleidomastoid muscles using transversal STIR (Short T1 Inversion Recovery) sequences on level C2, C4, and C5 by two blinded raters. Clinical symptoms were assessed with patient questionnaires (EuroQuol 5D, Specific Whiplash Questionnaire, head- and neck pain intensity [VAS]). RESULTS: Agreement of measurements between the two raters was high (intraclass correlation 0.52 to 0.85 for the different levels). No significant difference in age and body mass index were seen between patients and controls and the distribution of genders across groups was identical. There were no significant differences between patients and controls for all CSAs. Women had consistently smaller CSAs than men. The CSAs showed no significant correlation with the pain intensity of neck pain and headache but a consistent tendency of less neck pain and more headache with greater CSAs. CONCLUSION: This small study provides no evidence that subjects with smaller CSAs of cervical extensor muscles have a higher risk in developing symptoms after a whiplash injury and confirms smaller CSA in women.

Incidence, clinical presentation and imaging findings of cavernous malformations of the CNS. A twenty-year experience.

QUESTIONS UNDER STUDY: Up to 88% of cavernous malformations (CMs) of the central nervous system can become symptomatic and cause long-term disability. The aim of this study was to document the characteristics of CMs in the catchment area of our institution. METHODS: We retrospectively analysed newly discovered CMs over a 20-year observation period, as well as the frequency of familial forms in the catchment area. RESULTS: In the period from 1985-2004, a total of 347 patients were investigated. The cohort included about 75% symptomatic CM cases. A total of 1.31 and 0.55 symptomatic and asymptomatic cases, respectively, were newly diagnosed per annum per 100'000 inhabitants. Symptomatic CMs were diagnosed on average at the age of 36 years (range: newborn to 79 years old). There were slightly more patients who presented with evidence of acute bleeding (28%) than those with seizures (26%). Most intracranial lesions were supratentorial in location (54%). Lesion size was predominately below 3 cm (range: 0.2 to 8 cm). Symptomatic CMs (average: 1.75 cm) were significantly larger (p <.0001) than asymptomatic ones (average 0.91 cm). When compared to medical literature, there was a relatively high frequency of multiple CMs (18.9%), which were more common in the familial form (62%). CONCLUSIONS: The observed frequency of CM, including multiple lesions in a single individual and the familial form of this pathological entity appears relatively high compared to medical literature.

New Frontiers in Subcutaneous Immunoglobulin Treatment.

Subcutaneous immunoglobulin (SCIG) treatment provides stable serum immunoglobulin G (IgG) levels, is associated with fewer systemic adverse events than intravenous immunoglobulin (IVIG) treatment, and offers the convenience of home therapy. In clinical practice, IVIG is still used preferentially for initiation of treatment in newly diagnosed patients with primary immunodeficiency (PI) and for immunomodulatory therapy, such as treatment of peripheral neuropathies, when high doses are believed to be necessary. The authors discuss recent experience in using SCIG in place of IVIG in these settings. SCIG has been successfully used for initiation of therapy in previously untreated PI patients. Seventeen of 18 PI patients achieved serum IgG levels ≥5 g/L after the loading phase. Daily treatment was well tolerated and provided opportunities for patient/parent training in self-infusion. SCIG has been used for maintenance therapy in multifocal motor neuropathy (MMN) in three recent clinical trials, with good efficacy and tolerability results. Seven of eight MMN patients maintained serum IgG levels of 14-22 g/L with a mean dose of 272 mg/kg/week, had stable muscle strength, and felt comfortable with self-administration. Four patients with polymyositis or dermatomyositis achieved improvement in serum creatine kinase levels and muscle strength with SCIG therapy. Recent experience with SCIG suggests that traditional concepts of immunoglobulin therapy may be challenged to increase available therapy options. SCIG can be used to achieve high IgG levels within several days in untreated PI patients and to maintain high serum levels, as shown in patients with MMN.

IVIg dose increase in multifocal motor neuropathy: a prospective six month follow-up.

In this prospective, non-randomized 6-month observational study we evaluated the efficacy of intravenous immunoglobulin (IVIg) dose increase in patients with multifocal motor neuropathy (MMN). Diagnosis according to AAEM criteria, repetitive IVIg treatment for at least one year, persistent paresis and conduction block, stable symptoms and findings for at least six months were inclusion criteria. Nine patients (7 men) were identified and approved to standardized increase of IVIg dose. Patients were monitored using clinical scores and electrophysiological studies. Dose was increased from a baseline of 0.5 g/kg per month [mean, range: 0.1-1.1], given at variable intervals [4-12 weeks] to 1.2 g/kg per month given over 3 consecutive days planned for 6 cycles. If the patients' motor function did not improve after two cycles they entered step two: Dose was increased to 2 g/kg per month given over 5 consecutive days. The increased dose was maintained for 6 months. Assessments were performed by the same investigator, not involved in the patient's management, at baseline, after 2 and after 6 months. Following dose increase, motor function significantly improved in 6 patients (p = 0.014), 2 patients entered step two, 1 patient withdrew due to absent efficacy. Higher doses of IVIg caused more side effects, however, transient and rarely severe (p = 0.014). IVIg dose increase may improve motor functions in patients with stable MMN on long-term IVIg therapy independent of baseline dose. Improvement of motor function was associated with shorter disease duration (p = 0.008), but not with degree of muscle atrophy (p = 0.483). The treatment strategy to try to find the lowest effective dose and the longest tolerated interval might lead to underdosing in the long-term in many patients.

Quality of life in survivors after cervical artery dissection.

BACKGROUND AND PURPOSE: Little data exists about longterm outcome, quality of life (QOL) and its predictors after spontaneous cervical artery dissections (sCAD). METHODS: Clinical and radiological data of 114 patients with sCAD were collected prospectively. Six patients died within 3 months, the remaining 108 were contacted after a mean of 1498 days (range: 379-3455), 99 survivors (92 %) replied. QOL, assessed with the stroke-specific QOL scale (SSQOL), and functional abilities, measured with modified Rankin Scale (mRS) were compared, and predictors of QOL were analyzed. Subgroup analyses were performed for patients with ischemic stroke, those with isolated local symptoms or transient ischemic symptoms and those without significant disabilities (mRS 0-1) at follow-up. RESULTS: Seventy-one of 99 patients (72 %) had no significant disability, but only 53 (54 %) reported a good QOL (SS-QOL > or = 4). Compared to the self-rated premorbid QOL of all patients, SS-QOL was impaired after sCAD (p < 0.001); impairment of QOL was observed in patients with ischemic stroke (p < 0.001), in patients with isolated local or transient ischemic symptoms (p < 0.038) and those without significant disabilities at follow-up (p = 0.013). Nevertheless, low mRS was associated with better overall QOL (Kendall's tau > 0.5). High National Institute of Health Stroke Scale score on admission and higher age were independent predictors of impaired QOL (p < 0.05). CONCLUSION: QOL is impaired in almost half of long-term survivors after sCAD, even in patients with local or transient symptoms or without functional disability. Impairment of QOL is a surprisingly frequent long-term sequela after sCAD and deserves attention as an outcome measure in these patients.