Distribution and evolution of acute interventional ischemic stroke treatment in Germany from 2010 to 2016

Background: Mechanical thrombectomy (MT) is a new evidence-based treatment option for large vessel occlusion in the anterior brain circulation. Using comprehensive administrative data from Germany, we analysed the nationwide development of intravenous thrombolysis (IVT) and MT in Germany between 2010 and 2016. Methods: We considered all documented cases (n = 1,515,634) with a main diagnosis of the ICD-10-GM code I63 (ischemic stroke) and identified specific stroke recanalization therapy by using the corresponding Operating and Procedure Key for systemic thrombolysis and mechanical thrombectomy out of the DRG statistics. Regional analyses are based on data from the 413 German administrative districts and cities and the obligatory quality reports of all hospitals. We distinguished between rates of MT related to place of residence of patients and place of treatment. Results: Coded ischemic strokes increased by 10.2% from 2010 (n = 206.688) to 2016 (n = 227.687). The rate of IVT increased from 8.9% in 2010 to 14.9% in 2016 and the rate of MT increased from 0.8% in 2010 to 4.7% in 2016 with a strong increase in 2015 and 2016. There was a high regional variability of MT according to place of residence of patients between 0 and 11.2% in 2016 with significant lower treatment rates in rural compared to urban areas (3.8 vs 5.4%). Mean age of patients treated with MT increased from 67.8 years in 2010 to 73.3 years in 2016 and almost reached the mean age of IVT treated patients (74.4 years). The number of hospitals coding MT increased from 91 to 193 from 2010 to 2016, but 80% of all MT procedures were performed in neurointerventional centers with ≥50 procedures/year in 2016. Conclusions: The rate of IVT in patients with acute ischemic stroke in Germany continues to rise and has reached 14.9% nationwide. The increase of MT is even more pronounced and was triggered by the evidence after publication of the MT randomized trials. There is still a high regional variability with significant lower MT rates in rural areas

Mechanical thrombectomy in acute ischemic stroke : Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN

The original version of this consensus statement on mechanical thrombectomy was approved at the European Stroke Organisation (ESO)-Karolinska Stroke Update conference in Stockholm, 16-18 November 2014. The statement has later, during 2015, been updated with new clinical trials data in accordance with a decision made at the conference. Revisions have been made at a face-to-face meeting during the ESO Winter School in Berne in February, through email exchanges and the final version has then been approved by each society. The recommendations are identical to the original version with evidence level upgraded by 20 February 2015 and confirmed by 15 May 2015. The purpose of the ESO-Karolinska Stroke Update meetings is to provide updates on recent stroke therapy research and to discuss how the results may be implemented into clinical routine. Selected topics are discussed at consensus sessions, for which a consensus statement is prepared and discussed by the participants at the meeting. The statements are advisory to the ESO guidelines committee. This consensus statement includes recommendations on mechanical thrombectomy after acute stroke. The statement is supported by ESO, European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR), and European Academy of Neurology (EAN).Peer reviewe

Standards of Practice in Acute Ischemic Stroke Intervention: International Recommendations

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Spreading depolarizations cycle around and enlarge focal ischaemic brain lesions

How does infarction in victims of stroke and other types of acute brain injury expand to its definitive size in subsequent days? Spontaneous depolarizations that repeatedly spread across the cerebral cortex, sometimes at remarkably regular intervals, occur in patients with all types of injury. Here, we show experimentally with in vivo real-time imaging that similar, spontaneous depolarizations cycle repeatedly around ischaemic lesions in the cerebral cortex, and enlarge the lesion in step with each cycle. This behaviour results in regular periodicity of depolarization when monitored at a single point in the lesion periphery. We present evidence from clinical monitoring to suggest that depolarizations may cycle in the ischaemic human brain, perhaps explaining progressive growth of infarction. Despite their apparent detrimental role in infarct growth, we argue that cycling of depolarizations around lesions might also initiate upregulation of the neurobiological responses involved in repair and remodelling

Biebricher, Thomas: Geistig-moralische Wende. Die Erschöpfung des deutschen Konservatismus, 320 S., Matthes & Seitz, Berlin 2018.

Peer Reviewe

Liberale Krisendiagnosen in der Zwischenkriegszeit: Moritz Julius Bonn und Alfred Weber

Nach dem Ende des Ersten Weltkriegs schien eine europäische Neuordnung im Sinne internationaler Zusammenarbeit, gemeinsamer liberaler Werte und demokratischer Regierungsformen greifbar zu sein. Kaum jemand ahnte, wie rasch die ideellen Grundpfeiler des westlichen Modells, die US-Präsident Wilson in seinem 14-Punkte-Plan skizziert hatte, durch multiple Krisen erschüttert würden. Die Situation unterschied sich sehr deutlich von den epochalen Zäsuren der Jahre 1945 oder 1989, als die liberale Ordnung in Westeuropa eine historische Legitimation für sich beanspruchte. Nach 1918 zeichnete sich bald ab, dass kein Spielraum für eine selbstgewisse liberaldemokratische Verortung am „Ende der Geschichte“ vorhanden war. Anstelle einer Rückkehr zum optimistischen Fortschrittsparadigma drohte allenthalben Regression

Pathologie der Gesellschaft und liberale Vision: Ralf Dahrendorfs Erkundung der deutschen Demokratie

Dahrendorfs "Gesellschaft und Demokratie in Deutschland" ist in besonderer Weise von den Umständen der noch jungen Bundesrepublik geprägt; das Werk gehört "heute selber zur Frühgeschichte dieses Staates und seiner Gesellschaft". Der Soziologe Dahrendorf (geb. 1929) hatte eine Zeitdiagnose in nationalpädagogischer Absicht und mit sozialliberalem Impetus verfasst - "politischer Traktat, Einführungsvorlesung und Theorie der Demokratie" in einem. Seine Untersuchung war "ein Plädoyer für das Prinzip der liberalen Demokratie" (S. 27). In der Trias von historischer Erklärung, soziologischer Analyse und engagierter politischer Theorie bleibt "Gesellschaft und Demokratie" bis heute eine Ausnahme und kann wirkungsgeschichtlich kaum überschätzt werden

Letter to the Editor: Analysis of stroke patient migration for mechanical thrombectomy and changes in neurointerventional center size in Germany

Abstract Aim and methods To analyse nationwide changes in neurointerventional center size of all German hospitals performing mechanical thrombectomy (MT) in stroke patients from 2016 to 2019. Furthermore, we assessed cross-district patient migration for MT for the first time using hospitals’ structured quality reports and German Diagnosis-Related Groups data in 2019. Findings Number of hospitals performing more than 100 MT procedures/year doubled in Germany from 2016 (n = 36) to 2019 (n = 71), and these neurointerventional centers performed 71% of all MT procedures in 2019. The overall increase in MT procedures was largely driven by these high-volume neurointerventional centers with ability to perform MT 24/7 (121% increase as compared with 8% increase in hospitals performing less than 100 MT procedures/year). The highest cross-district patient mobility/transfer of stroke patients for MT was observed in districts adjacent to these high-volume neurointerventional centers with existing neurovascular networks. Conclusion The substantial increase in MT procedures observed in Germany between 2016 and 2019 was almost exclusively delivered by high-volume stroke centers performing more than 100 MT procedures per year in established neurovascular networks. As there is still a reasonable number of districts with low MT rates, further structural improvement including implementation of new or expansion of existing neurovascular networks and regional tailored MT triage concepts is needed