Background and purpose
In contrast to anterior circulation stroke (ACS), there is no evidence from randomized trials that mechanical thrombectomy (MT) with modern stent retrievers or ...thromboaspiration is safe and effective in posterior circulation stroke (PCS).
Methods
The present analysis was based on the prospective multicentre Registry on Revascularization in Ischemic Stroke Patients (REVASK) in Germany. Demographic data, periprocedural times and complications, recanalization rates, and functional outcome at discharge and after 3 months were compared between 139 consecutive patients with PCS (84.9% basilar artery, 16.5% vertebral artery and 4.3% posterior cerebral artery occlusion) and 961 patients with ACS treated with MT.
Results
Compared to ACS, PCS patients were significantly younger (65 vs. 69 years, P = 0.021) and had a lower median National Institutes of Health Stroke Scale (NIHSS) score at baseline (12 vs. 15, P = 0.024). Patients with PCS had a significantly longer time delay between symptom onset and both start and end of the MT procedure. Successful recanalization and thrombectomy passes did not significantly differ between the two groups. No symptomatic intracranial haemorrhage occurred in PCS compared to 3% in ACS (P = 0.010). The median NIHSS score at discharge was 3 in PCS and 4 in ACS. Favourable functional outcome at 3 months (modified Rankin Scale 0–2 38.0% vs. 42.6%, P = 0.392) and mortality (33.7% vs. 30.8%, P = 0.539) did not differ significantly between PCS and ACS.
Conclusions
The study suggests that MT in PCS shows a lower risk of symptomatic intracranial haemorrhage and similar effectiveness compared to ACS. PCS patients also seem to benefit from MT started beyond 6 h after symptom onset.
BACKGROUNDThe guidelines of the German Society for Neurology regarding the diagnostics and treatment of acute ischemic stroke contain the general recommendation of treatment on a stroke unit (SU) and ...the use of recanalizing treatment (intravenous thrombolysis, IVT; mechanical thrombectomy, MT) in appropriate patients. The nationwide availability of all three components represents a large organizational and healthcare political challenge. OBJECTIVEUpdated nationwide analysis of treatment rates in Germany based on a regionalized evaluation. METHODSBased on the patient's place of residence, nationwide data of all hospitalized patients were evaluated using the German diagnosis-related groups (DRG) statistics from 2018 and compared with previous years. The rates for SU treatment, IVT and MT in the 412 German regional districts were analyzed. The 412 regions were grouped according to the degree of urbanization. RESULTSNationwide, a total of 224,647 patient cases with a main diagnosis of acute ischemic stroke were treated in 1382 hospitals in Germany in 2018. Overall, relatively high treatment rates were determined (SU = 73.3%; IVT = 16.4%; MT = 6.5%). Only 10.2% of treatments in the SU were performed on a SU located at a hospital with no neurology department. The regionalized analysis showed large treatment ranges for all three therapeutic components, with significantly lower treatment rates in regions with a lower degree of urbanization (SU, IVT, MT rates: urban = 75.4%, 17.4%, 7.5% and rural = 67.1%; 15.4%, 5.3%, respectively). CONCLUSIONHospitalized healthcare in Germany shows high treatment rates for both SU admission and acute recanalization treatment in patients with acute ischemic stroke; however, there is further optimization potential in rural regions.
Mechanical thrombectomy (MT) has become an evidence-based therapy for stroke patients with proximal vessel occlusion of the anterior cerebral circulation. Nationwide availability of MT for all ...eligible patients within the shortest possible time window is a major challenge.
Nationwide analysis of the rates of systemic thrombolysis (STL) and MT in Germany according to region and hospital-based evaluation.
The evaluation involved data analysis of the diagnosis-related groups (DRG) statistics and structured quality reports of hospitals for 2010 and 2014. The rates and changes of STL and MT were evaluated in the 413 German districts with reference to the corresponding case number of patients with acute ischemic stroke.
Nationwide recanalization treatment rates increased from 2010 to 2014 both for STL (from 8.0% to 11.6%) and MT (from 0.7% to 2.3%). High variations were observed depending on the patient's place of residence (STL = 3.4-36.7%, MT = 0-7.4%). In 2014 a total of 5526 MT were coded in a total of 244,757 ischemic strokes. A total of 134 hospitals with more than 2 MT per year were identified; however, 21% of the nationwide MTs were performed in only 7 hospitals with more than 100 MT/year. In 308 (75%) of the 413 districts, not a single MT was performed.
Due to a narrow net of certified stroke units with nationwide availability of STL, excellent structural conditions for treatment of acute stroke patients are already established in Germany. With regard to the nationwide availability of MT, there is still a need for optimization. Despite the increasing number of hospitals providing MT as an emergency procedure, a trend toward large intervention centers with supraregional catchment areas can be observed.
Zusammenfassung
Häufige Ursache eines akuten ischämischen Schlaganfalls ist eine atherosklerotische Veränderung der Halsschlagader. Es ist bisher nicht eindeutig geklärt, welche Veränderungen das ...Risiko eines Schlaganfalls definieren. Mit der stetig verbesserten Qualität von Ultraschalluntersuchungen gelingt es zunehmend, unterschiedliche Veränderungen in atherosklerotischen Plaques darstellen zu können. Sollte auf diesem Wege eine bessere diagnostische Identifizierung von „Risikoplaques” gelingen, so könnte die therapeutische Entscheidung, ob und insbesondere wie eine Karotisstenose behandelt werden muss, in erheblich rationalerer Art erfolgen. In dieser Übersicht werden aktuelle Entwicklungen in der Ultraschalldiagnostik atherosklerotischer Gefäßwandveränderungen insbesondere der Arteria carotis interna beschrieben. Stattgehabte technische Entwicklungen sowie die Rationale der kontrastmittelgestützten Darstellung der Plaque-Neovaskularisation werden vor dem Hintergrund methodischer Limitationen und möglicher weiterer Entwicklungen erläutert.
Phase inversion harmonic imaging (PIHI) with newer contrast agents can display parameters of cerebral perfusion either using the established ipsilateral approach, or the novel bilateral approach in ...which both hemispheres are assessed in one examination. The aim of this study was to evaluate the potential of PIHI in detecting pathological perfusion in acute stroke, using the bilateral approach. Patients with a hemispheric syndrome presenting within 12 hours after symptom onset were examined with PIHI (SonoVue®; bolus kinetics, fitted model function) using the bilateral approach if possible. Semi-quantitative perfusion related parameters (time to peak intensity (TPI) and peak width (PW)) were evaluated, and results correlated to follow up cerebral computed tomography (CCT) scans. In these four preliminary cases (one ipsilateral, three bilateral), PIHI was able to identify the ischaemic region because the function could not be fitted to the data. In one case, there was a difference between a core region where no perfusion was seen, and a surrounding region where hypoperfusion was detected (prolonged TPI and reduced PW). PIHI was able to predict the localisation and size of the eventual infarction even if no early CCT signs were seen. Furthermore, in one case, a surrounding hypoperfused region was identified, where tissue survived after recanalisation of the initially occluded middle cerebral artery. Using the bilateral approach, two advantages in comparison with the ipsilateral approach were obvious: cortical structures could be evaluated, and only one examination was needed to compare unaffected (ipsilateral) with affected (contralateral) tissue. These results should be confirmed by more cases, and should also be correlated to acute perfusion/diffusion weighted MRI data.
Severe atherosclerotic extracranial carotid artery stenosis accounts for 5-10 % of all ischemic strokes. Currently, therapeutic recommendations are undergoing changes, particularly regarding the ...treatment of asymptomatic stenosis. Consolidated knowledge on the indications, nationwide distribution and numbers of cases are not available. Moreover, the impact and grade of implementation of the recently published national S3 guidelines on the reality of medical treatment remain unclear.
Analysis of administrative hospital data involving the diagnosis-related groups (DRG) statistics and structured quality reports for 2010 and 2013 to evaluate the procedural therapy trends concerning operative and interventional approaches for symptomatic and asymptomatic carotid artery stenoses.
In Germany approximately 37,000 carotid endarterectomies (CEA) and approximately 5,000 carotid angioplasties with stenting (CAS) are carried out per year. Approximately 94 % of CEA and 62 % of CAS are performed in centers with more than 25 procedures per year. Only 33 % of CEA and 39 % of CAS are related to symptomatic stenosis.
Mathematically, an undertreatment of symptomatic and an overtreatment of asymptomatic carotid artery stenoses become apparent. Efforts should be made to achieve inpatient medical treatment conforming to the national S3 guidelines, in particular to adequately reduce the risk of stroke recurrence in patients with atherosclerotic symptomatic carotid artery stenosis.
Transcranial B-mode sonography is an easy to use bedside imaging modality to monitor significant changes of the brain parenchyma such as in malignant middle cerebral infarction or intracerebral ...hemorrhage. The elevation of intracranial pressure can be followed with various neurosonographical techniques: Measurements of the ventricular width, midline shift, arterial resistance, and optic nerve sheath diameter. They should be viewed as complementary to each other and to other imaging modalities. Repeated cCT and MRI may be avoided in unstable patients by bedside neurosonography in the hands of an experienced physician. Monitoring of evolving hydrocephalus using serial measurements of the third and lateral ventricles can be used to guide therapeutic decisions such as the removal of a ventricular drainage. The cessation of cerebral blood flow in the case of intracranial pressure exceeding systemic arterial pressure is an important part of brain death diagnostics. Early demonstration of a sufficient temporal bone window is needed in patients in whom brain death may be expected. Cerebrovascular autoregulation is an integer component of the brain's blood supply and is compromised in a variety of neurological diseases. In neurological/neurosurgical patients in the intensive care unit, its assessment allows for extended neuromonitoring and control of therapeutic procedures.
Networking structures are constructed to improve daily care of acute stroke patients, in the Ruhr area by the association of 26 neurological departments. Quality of care can be measured by the rate ...of stroke unit treatment and of thrombolysis. Epidemiological data are mainly derived from registers resulting in sparse insight into incidence and rate of specialized care in daily practice.
The study involved data analysis of diagnosis-related groups (DRG) statistics and structured quality reports for 2008 and 2010 for depiction of the quality of routine treatment. Aggregation of the number of cases for incidence, rate of stroke unit treatment and thrombolysis district, province, and nation wide were analyzed.
In 5.2 million inhabitants, the incidence of ischemic stroke (ICD I63) was 296/100,000 in 2010 (district-wise range 244-364) and 56% of patients were treated on a stroke unit (range 18-80%; 2008: 43%, range 10-72%). The rate of thrombolysis (ICD I63) was 6.4% and 9.1% in 2008 and 2010 (2008 range 0-11.2%, 2010 range 3.9-18.0%), respectively, which was significantly above the provincial average in 10 out of 15 districts.
Ischemic stroke is a common disease in the area and the quality of care (e.g. stroke unit treatment and thrombolysis rate) is above average. The heterogeneous character of the region allows an exemplary networking aiming for the improvement of routine patient care, e.g. by the implementation of homogeneous standards and structural measures for the implementation of novel therapies. The current analysis allows the identification of the potential for optimization and monitoring of any changes.
The long-term prognosis of stroke patients is still dependent in particular on the timing of a correct diagnosis, immediate initiation of a suitable specific therapy and competent treatment in a ...stroke unit. Therefore, nationwide attempts are being made to establish a comprehensive coverage of the necessary specific competence and infrastructural requirements. Divergent regional circumstances and economic viewpoints determine the characteristics of the various healthcare concepts and the interplay between participating cooperation partners. This article compares the development with respect to three qualitative treatment parameters exemplified by four regional healthcare models during the time period 2008-2011.
The hospitalization rates for patients with transitory ischemic attacks, ischemic and hemorrhagic stroke, the case numbers for stoke unit treatment and the rates of systemic thrombolysis and mechanical thrombectomy in the regions of Berlin, the Ruhr Area, Ostwestfalen-Lippe and southeast Bayern (TEMPiS) are presented based on the data from the DRG statistical reports for the years 2008 and 2011.
The average hospitalization rates for ischemic stroke patients (brain infarct ICD 163) in the time period from 2008 to 2011 were 294 per 100,000 inhabitants for the Ruhr Area, 257 per 100,000 inhabitants for Ostwestfalen-Lippe and 265 per 100,000 inhabitants each for Berlin and southeast Bayern. The complex stroke treatment quota for southeast Bayern in 2008 was 31 % and 47 % in 2011 and the respective quotas for the other regions studied were 42-44 % and 58-59 %. The rate of systemic thrombolysis in 2008 ranged between 4.2 % and 7.4 % and in 2011 the increase in the range for the 4 regions studied was between 41 % and 145 %. In 2011 the thrombectomy quota of 2 % in the Ruhr Area was the only one which was above the national average of 1.3 % of all brain infarcts.
Stroke is a common disease in the four regions studied. For the established forms of therapy, complex treatment of stroke and systemic thrombolysis, the positive effect of structurally improved approaches in the four different regional treatment concepts could be confirmed during the course of the observational time period selected. Mechanical thrombectomy which is currently still considered to be an individual healing attempt, was used significantly more often in the Ruhr Area in 2011 than in the other three regions studied. A standardized referral procedure had previously been established in the metropolitan regions.
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