Factors associated with fatal outcome in posterior reversible encephalopathy syndrome: a retrospective analysis of the Berlin PRES study.

Although often reversible, fatal outcome in posterior reversible encephalopathy syndrome (PRES) is well known. However, data on predictors of PRES-associated in-hospital death are scarce. In this study, we aimed to investigate predictors of in-hospital death in a large cohort. Radiological report databases between January 1999 and February 2015 were retrospectively searched for patients with PRES. Patients were included if they met criteria for PRES after detailed investigation of clinical charts and imaging studies. Various clinical, paraclinical and brain MRI data as well as data on in-hospital mortality were analyzed. 151 patients were included into the study, 64% were female. Seventeen (11.2%) patients died during hospital stay. In univariate analyses, higher age (p = 0.04), higher levels of C-reactive protein (p < 0.001), etiology of PRES (sepsis and chemotherapy; p = 0.02), altered coagulation (p = 0.002), altered mental state at onset (p = 0.03), and subarachnoid hemorrhage (SAH; p = 0.01) were related to in-hospital death. In multivariate analyses adjusted for age and sex, elevated CRP levels (OR 1.1 95% CI 1.1-1.2), altered coagulation (OR 5.1 95% CI 1.8-14.7), subarachnoid hemorrhage (OR 10.1 95% CI 2.2-46.1) and altered mental state (OR 3.3; 95% CI 1.1-9.4) were independently associated with in-hospital death. Altered mental state, subarachnoid hemorrhage as well as the higher levels of CRP and altered coagulation were significantly more frequent in patients who died in hospital. However, prospective studies are warranted to establish predictors of fatality in patients with PRES.

Circulating insulin-like growth factor binding protein-3 predicts one-year outcome after ischemic stroke.

BACKGROUND: Insulin-like Growth Factor-1 (IGF-1) and Insulin-like Growth Factor Binding Protein-3 (IGFBP-3) have been ascribed neuroprotective effects. We sought to determine whether levels of IGF-1 and IGFBP-3 predict functional outcome after ischemic stroke. METHODS: IGF-1 and IGFBP-3 levels were measured in the first week after stroke in patients with first ischemic stroke who were enrolled in the Berlin Cream&Sugar Study. National Institutes of Health Stroke Scale (NIHSS) was collected at admission. Lesion volume was determined from acute MRI if available. Functional outcome according to the modified Rankin Scale (mRS) was assessed after one year. In multivariate analyses we identified parameters associated with unfavourable functional outcome (mRS>2). RESULTS: We included 100 patients. 21 patients had an unfavourable functional outcome. IGF-1 levels were<- 2 standard deviation score (SDS) in 7 patients, and>2 SDS in 12 patients. IGFBP-3 levels werethe 95(th) percentile. Low levels of IGFBP-3 (p=0.002), NIHSS at admission (p=0.043) and age (p=0.001) were associated with unfavourable functional outcome in the univariate analyses. In multivariate analysis including IGFBP-3, IGF-1, age, thrombolysis and NIHSS only low IGFBP-3 levels (OR 7.2, 95%CI 1.8-29.0, p=0.006) were associated with unfavourable functional outcome. If lesion volume was incuded (n=71), only IGFBP-3 levels (OR 7.2, 95%CI 1.5-35.5, p=0.015) were associated with unfavourable functional outcome. CONCLUSION: IGFBP-3 levels after ischemic stroke may independently predict functional outcome after one year.

Discharge status and in-hospital mortality in posterior reversible encephalopathy syndrome.

BACKGROUND: Posterior reversible encephalopathy syndrome is a serious and increasingly recognized disorder, but data from observational studies on outcome and mortality in posterior reversible encephalopathy syndrome (PRES) are scarce. We aimed to determine the frequency and associations of in-hospital death and discharge status in a large cohort of patients with PRES. METHOD: We retrospectively reviewed the radiological report databases of our university hospitals between January 1999 and March 2011 for patients with PRES. Patients fulfilling the criteria for PRES after detailed investigation of clinical charts and imaging studies were included. Clinical charts, paraclinical and brain imaging data at onset as well as available data on in-hospital mortality and discharge status were analyzed. RESULTS: A total of 103 patients were included. Five (4.8%) patients died during hospital stay, 27 (26.2%) remained hospitalized after discharge. In univariate analyses, significant differences were found between patients discharged home from hospital and patients referred to rehabilitation or who died in hospital for the following variables: severe edema (P = 0.013), etiology of PRES (P = 0.001), altered mental state at onset (P = 0.003), altered coagulation (P = 0.004), and length of hospital stay >30 days (P < 0.001). CONCLUSION: Features of a severe course of PRES such as severe edema and altered mental state are significantly more frequent in patients who were referred to inpatient rehabilitation or died in hospital. Prospective studies are warranted to establish factors that are associated with unfavorable outcome in PRES.

Posterior reversible encephalopathy syndrome in children: radiological and clinical findings - a retrospective analysis of a German tertiary care center.

PURPOSE: To report the radiological and clinical spectrum of posterior reversible encephalopathy syndrome (PRES) in children in a German tertiary referral center. METHODS: The radiological report data bases of the authors' university hospitals were searched for paediatric patients with PRES. Clinical and paraclinical data as well as various imaging features at symptom onset and during follow-up were tabulated in patients fulfilling the criteria for PRES. RESULTS: A total of 18 paediatric patients with PRES were included into the study. Mean age was 9 years (IQR 7-12), 38.9% were females. Most frequent predisposing causes were renal and haemato-oncologic diseases frequently associated with endotheliotoxic cytostatic medication. Frontal lesions occurred as frequently as parietal lesions followed by occipital lesions. The superior frontal sulcus topographic lesion pattern occurred as frequent as the parieto-occipital one. In 38% of cases residual lesions were encountered with focal laminar necroses being most frequent. Initial clinical syndromes associated with PRES included seizures in 18, altered mental state in 5, and hemiparesis and visual disturbances in 2 children. Mean arterial blood pressure at onset of PRES was 140/85 mmHg (IQR systolic: 124-169, diastolic: 78-93 mmHg). CONCLUSION: Paediatric PRES in this cohort comprises a broad radiological and clinical spectrum. The occurrence of frontal lesions, a superior frontal sulcus associated lesion pattern, and the development of focal laminar necrosis appear to be frequent in children.

New vessels after stroke: postischemic neovascularization and regeneration.

The formation of new blood vessels after acute ischemic stroke is one of the most promising approaches to future therapies in the emerging field of stroke medicine. Angiogenesis and postnatal vasculogenesis are the underlying mechanisms of the formation of new blood vessels. Bone marrow-derived endothelial progenitor cells (EPCs) are thought to play an important role in neovascularization and during the regenerative processes after a vascular injury as well as in the maintenance of endothelial integrity. This review summarizes possible mechanisms of angiogenesis, postischemic neovascularization and regeneration with a focus on the potential role of EPCs as a risk marker and as a therapeutic target in stroke medicine.

Peripheral endothelial function and arterial stiffness in women with migraine with aura: a case-control study.

BACKGROUND: Vascular dysfunction may be involved in migraine pathophysiology and contribute to the increased risk of ischemic stroke in migraine, particularly in women with migraine with aura (MA). However, data on endothelial function in MA are controversial. Here, we investigated whether systemic endothelial function and arterial stiffness are altered in women with MA, using a novel peripheral arterial tonometry device for the first time. METHODS: Twenty-nine female MA patients without comorbidities and 30 healthy women were included, and carotid intima-media thickness was assessed by a standardized procedure. Endothelial function was assessed using peripheral arterial tonometry. Reactive hyperaemic response of digital pulse amplitude was measured following 5 minutes of forearm occlusion of the brachial artery. Arterial stiffness was assessed by fingertip tonometry derived and heart-rate-adjusted augmentation index. RESULTS: No differences were found in peripheral arterial tonometry ratio (2.3 ± 0.6 vs 2.2 ± 0.8; p = 0.58) and left carotid intima-media thickness (in µm: 484 ± 119 vs 508 ± 60; p = 0.37). Women with MA had higher heart-rate-averaged augmentation index [median (interquartile range, IQR) of 5 (IQR 0.5 to 18) vs -5 (IQR -16.8 to 8.3), p = 0.005] and heart-rate-adjusted augmentation index [1 (IQR -6 to 12.5) vs -8 (IQR -20.3 to 2.5), p = 0.008] than healthy controls. CONCLUSION: Peripheral endothelial function is not impaired in women with MA, but they have greater arterial stiffness. This may contribute to the increased stroke risk in women with MA.

Clinical and radiological differences in posterior reversible encephalopathy syndrome between patients with preeclampsia-eclampsia and other predisposing diseases.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a serious maternal complication in pregnancy, but data on the clinicoradiological differences to other etiologies of PRES are scarce. In this study, we aimed to investigate the clinical and imaging characteristics of PRES in preeclampsia-eclampsia patients compared with other predisposing diseases in a large cohort. METHODS: We retrospectively reviewed the radiological report data bases between January 1999 and August 2010 for patients with PRES. Patients fulfilling the criteria for PRES after detailed investigation of clinical charts and imaging studies were separated into patients with eclampsia-preeclampsia and other predisposing causes. Various imaging features at onset of symptoms and on follow-up as well as clinical and paraclinical data were analyzed. RESULTS: A total of 24 patients with preeclampsia-eclampsia associated PRES and 72 patients with PRES of other predisposing causes were included into the study. In preeclampsia-eclampsia patients, headaches were significantly more frequent as initial PRES-related symptom (P < 0.001), whereas altered mental state was significantly less frequent (P = 0.001). Thalamus, midbrain, and pons affection was significantly less frequent in preeclampsia-eclampsia associated PRES (P = 0.01). Preeclampsia-eclampsia patients had significantly less severe edema, less cytotoxic edema, hemorrhage and contrast enhancement, while more frequent complete resolution of edema and less frequent residual structural lesions were seen on follow-up imaging. CONCLUSION: In our PRES cohort, we found major clinicoradiological differences between preeclampsia-eclampsia and other predisposing causes pointing toward a less severe course of disease in preeclampsia-eclampsia.

The clinical and radiological spectrum of posterior reversible encephalopathy syndrome: the retrospective Berlin PRES study.

The aim of the study was to characterize the clinical and radiological spectrum of posterior reversible encephalopathy syndrome (PRES) in a large cohort. The radiological report data bases of the authors' university hospitals were searched for patients with PRES. Various imaging features at onset of symptoms and on follow-up as well as clinical and paraclinical data were tabulated in those patients fulfilling the criteria for PRES. Exploratory univariate analyses were performed. A total of 96 patients with PRES were included into the study. Wide differences in lesion location, diffusivity, distribution pattern, edema severity, hemorrhage, underlying diseases, symptoms, mean arterial pressure (MAP) and coagulation status were encountered. Hemorrhage occurred significantly more frequently in patients with altered coagulation state and was significantly associated with higher edema grades and with the presence of cytotoxic edema. There was a significant difference in MAP between toxic associations with higher MAP in infection, eclampsy and autoimmune disorders, while lower MAP was found in chemotherapy and immunsupression. In 82% of patients complete or near complete resolution of edema was noted during follow-up. Higher MAP levels were associated with incomplete edema resolution. In 43% of patients residual lesions were seen with a relatively even distribution between focal gliosis, infarction, posthemorrhagic residua, atrophy and laminar necrosis. PRES in this large hospital-based retrospective study comprises a wide radiological and clinical spectrum. Residual lesions were encountered more frequently than commonly expected. Our results point towards a differential contribution of high blood pressure to the course of PRES in different underlying etiologies.

Impact of low mini-mental status on health outcome up to 5 years after stroke: the Erlangen Stroke Project.

Cognitive deficits are frequent stroke sequelae. Data from population-based stroke cohorts on the impact of cognitive deficits on long-term outcome are scarce. The purpose of this study was to investigate the impact of low mini-mental status on health outcome up to 5 years after first-ever stroke. Data were collected from the Erlangen Stroke Project, a population-based stroke registry covering a source population of 103,000 inhabitants. The Mini-Mental State Examination (MMSE) was used to assess global cognitive function. Health outcome included limitations in instrumental activities of daily living (IADL, Frenchay Activities Index), low independence in activities of daily living (ADL, Barthel Index), depressive symptoms (Zung Self Rating Depression Scale), and institutionalization. Using multivariate logistic regression analysis, association of an education-adjusted MMSE score ≤ 24 with these health outcomes was investigated within distinct models at 12, 36, and 60 months after stroke as well as predictors at 3 months for low IADL. A total of 705 patients with first-ever stroke were included. Institutionalization, low levels of ADL and IADL (p < 0.001) are associated with a MMSE score ≤ 24 over 5 years after stroke. Predictors at 3 months for low IADL are low mini-mental status up to 3 years after stroke (OR 2.69, 95% CI 1.2-5.8) as well as older age (p < 0.001), and stroke severity (p < 0.001) up to 5 years. A low mini-mental status has an independent impact on long-term health outcome after stroke. Our results emphasize the importance of cognitive status screening to identify stroke survivors at risk and manage and treat these patients more efficiently.

Changes in cognitive function over 3 years after first-ever stroke and predictors of cognitive impairment and long-term cognitive stability: the Erlangen Stroke Project.

BACKGROUND AND PURPOSE: Cognitive impairment (CI) is frequent after stroke, but data from population-based stroke cohorts on the natural course of CI are limited. The purpose of this study was to determine changes in cognitive status over 3 years after stroke. METHODS: Data were collected from the Erlangen Stroke Project, an ongoing population-based stroke registry. The Mini-Mental State Examination (MMSE) for assessing global cognitive function was used; CI was defined as an MMSE score <24. RESULTS: From February 1998 to January 2006, 630 patients with first-ever stroke were included. Prevalence rates of CI at 3 months, 1 and 3 years were 15, 13, and 12%. In multivariable analysis, stroke severity, i.e. Barthel index (p < 0.001), age (OR = 1.03; 95% CI = 1.00-1.05) and diabetes mellitus (OR = 2.03; 95% CI = 1.13-3.67) were associated with CI at 3 months. Recovery rate from CI at 3 months after stroke was found to be 31% over the following 3 years. Intact cognitive function rate was 71% over 3 years and inversely associated with age (OR = 0.96; 95% CI = 0.96-0.94) and stroke severity (p < 0.001). CONCLUSION: CI is frequent among stroke survivors and associated with age, stroke severity, and diabetes mellitus, but recovery occurs in approximately one third of the patients over the course of 3 years. Factors affecting intact cognitive function over time are increasing age and stroke severity.

Does external counterpulsation augment mean cerebral blood flow in the healthy brain? Effects of external counterpulsation on middle cerebral artery flow velocity and cerebrovascular regulatory response in healthy subjects.

BACKGROUND AND PURPOSE: External counterpulsation (ECP) noninvasively improves myocardial and organ perfusion via diastolic augmentation. The effects on cerebral blood flow velocities (CBFV) and hemodynamics are controversial. In this study, the effect of active ECP treatment on CBF in healthy subjects was continuously measured. METHODS: In 9 healthy volunteers (mean age 34.1 ± 11.1 years, 4 females), 20-min active ECP treatment was performed. CBFV in the middle cerebral artery were detected via transcranial Doppler. CBFV were registered continuously before, during and after ECP. The protocol was repeated twice. RESULTS: At onset of ECP, immediate changes in CBFV were observed: peak diastolic blood flow velocities increased from baseline to treatment (63 vs. 76 cm/s; p < 0.001) and diastolic blood flow augmentation was maintained throughout ECP. Peak systolic (87 vs. 78 cm/s; p < 0.001) and end-diastolic velocities (40 vs. 28 cm/s; p < 0.001) decreased significantly, while mean CBFV maintained constant (59 vs. 58 cm/s; not significant). The pulsatility index and resistance index as indirect parameters for peripheral vascular resistance increased during ECP (pulsatility index 0.79 vs. 0.89, p < 0.001; resistance index 0.54 vs. 0.64; p < 0.001). CONCLUSIONS: ECP did not increase mean CBFV in healthy subjects even though peak diastolic CBFV were significantly augmented. Changes in CBFV and transcranial Doppler waveform characteristics suggest that the mean flow of the middle cerebral artery is maintained stable via cerebrovascular autoregulatory mechanisms.

[Headache and hypertension. Myth and evidence]. / Kopfschmerz und Bluthochdruck. Mythos und Evidenz.

The relationship between headache and hypertension has been debated for many years. Although most studies have shown that chronic hypertension and headache are not associated, the myth of a hypertensive headache still exists. There are several reasons why the "hypertension headache" misperception persists: Hypertension is an epiphenomenon of pain. Headache is a common side effect of some antihypertensive drugs. Headache is the most common presenting symptom of hypertensive encephalopathy, followed by seizures, focal neurological deficits and loss of consciousness. This review summarizes the existing literature and highlights the relationship between headache, hypertension and disease with a focus on hypertensive encephalopathy and posterior reversible encephalopathy syndrome with acute endothelial damage.

[Elevated troponin and ECG alterations in acute ischemic stroke and subarachnoid hemorrhage]. / Troponinerhöhung und EKG-Veränderungen bei Schlaganfall und Subarachnoidalblutung.

Vascular diseases are the most common cause of death and disability in industrialised countries. Ischaemic heart disease and cerebrovascular disease frequently coexist in one patient. Therefore it is not surprising that raised troponin levels and ECG changes are detected comparatively often in acute stroke; however these changes do not always indicate myocardial infarction. Clinical and experimental data suggest that some kind of neurologically mediated myocardial injury exists--especially in subarachnoid hemorrhage--but not as a manifestation of concomitant ischaemic heart disease. This review summarises the frequency and possible pathophysiological mechanisms. In any case, raised troponin levels and ECG changes after acute stroke are of negative prognostic value, and a cardiological diagnostic work-up should be done.

A low-cost and simple method to stop intraoperative leakage-type bleeding: use of the vancomycin-oxidized regenerated cellulose (ORC) sandwich.

Intraoperative bleeding may cause life-threatening complications in patients if such bleeding cannot be brought under control. Various materials are available for stopping such bleeding. However, there are some difficulties in the acquisition and application of these materials. The aim of this study was to investigate the efficiency of the low-cost and simple-to-prepare vancomycin-oxidized regenerated cellulose (ORC) sandwich in surgical bleeding control. Thirty New Zealand rabbits were used for this purpose. The animals were separated into three groups as group 1 (n = 10), control group; group 2 (n = 10), oxidized regenerated cellulose (ORC) group; and group 3 (n = 10), vancomycin-ORC sandwich group. Left thoracotomies were performed on the rabbits under general anesthesia, and bleeding was created in the parietal pleura. The amount of bleeding in the groups was measured and compared. The amount of bleeding in the group in which the vancomycin-ORC sandwich was used was found to be less, compared to the other two groups. According to these results, we conclude that the vancomycin-ORC sandwich can be used safely in the control of intraoperative leakage-type bleeding, as the vancomycin-ORC sandwich is a low-cost, easily applied, and easily acquired material.