Dijagnostika stenoza intrakranijskih arterija primjenom transkranijskog bojom kodiranog ultrazvuka

Transcranial Doppler (TCD) scenography has been widely used as a diagnostic tool for intracranial hemodynamic alterations and in the last decade transcranial color-coded real-time sonography (TCCS) have been added to conventional TCD sonography in order to improve diagnostic yield. TCCS can reliably assess the 50% and <50% basal artery narrowing, and has proved useful for noninvasive management of patients with symptomatic intracranial stenoses.Transkranijski dopler (TCD) upotrebljava se kao dijagnostička metoda za intrakranijske hemodinamske poremećaje, a u zadnjem desetljeću uvođenje transkranijskog bojom kodiranog ultrazvuka (transcranial color-coded sonography - TCCS) doprinijelo je poboljšanju dijagnostike. Primjenom TCCS-a moguće je procijeniti suženje arterija na bazi mozga što se pokazalo kao vrijedna neinvazivna metoda kod stenoza intrakranijskih arterija

Rizični čimbenici za nastanak cerebrovaskularnih bolesti s osvrtom na prevenciju

Stroke risk factors can be divided into those with evidence-based relationship and those with supposed relationship to ischemic stroke, and into potentially treatable risk factors and risk factors with no therapeutic options. Age, gender and race are risk factors with no therapeutic options, while among treatable stroke risk factors most important are high blood pressure, atrial fibrillation, patent foramen ovale, cardiac disorders, diabetes mellitus, hiperhomocysteinemia, hiperlipidemia, and living conditions such as smoking and heavy alcohol drinking. Data about the use of antioxidant vitamins (A,C,E,) are still controversial as well as the role of infection in the development of atherosclerosis.Rizični čimbenici za nastanak moždanog udara mogu se podijeliti na one kod kojih je povezanost s moždanim udarom dokazana i na one kod kojih se ta povezanost pretpostavlja, na one na koje se može terapijski djelovati i one na koje se ne može djelovati. Rizični čimbenici na koje se ne može djelovati su dob, spol, rasa, dok su među onima na koje se može djelovati najvažniji povišen tlak, atrijska fibrilacija, otvoreni foramen ovale, srčani poremećaji, šećerna bolest, hiperhomocisteinemija, hiperlipidemija, te čimbenici povezani s načinom života, kao što su pušenje i prekomjerno pijenje alkohola. Podaci o primjeni antiokdisativnih vitamina (A, C i E) još uvijek nisu nedvosmisleni, što također vrijedi i za ulogu upale u nastanku ateroskleroze

Dijagnostika stenoza intrakranijskih arterija primjenom transkranijskog bojom kodiranog ultrazvuka

Transcranial Doppler (TCD) scenography has been widely used as a diagnostic tool for intracranial hemodynamic alterations and in the last decade transcranial color-coded real-time sonography (TCCS) have been added to conventional TCD sonography in order to improve diagnostic yield. TCCS can reliably assess the 50% and <50% basal artery narrowing, and has proved useful for noninvasive management of patients with symptomatic intracranial stenoses.Transkranijski dopler (TCD) upotrebljava se kao dijagnostička metoda za intrakranijske hemodinamske poremećaje, a u zadnjem desetljeću uvođenje transkranijskog bojom kodiranog ultrazvuka (transcranial color-coded sonography - TCCS) doprinijelo je poboljšanju dijagnostike. Primjenom TCCS-a moguće je procijeniti suženje arterija na bazi mozga što se pokazalo kao vrijedna neinvazivna metoda kod stenoza intrakranijskih arterija

Profound influence of different methods for determination of the ankle brachial index on the prevalence estimate of peripheral arterial disease

BACKGROUND: The ankle brachial index (ABI) is an efficient tool for objectively documenting the presence of lower extremity peripheral arterial disease (PAD). However, different methods exist for ABI calculation, which might result in varying PAD prevalence estimates. To address this question, we compared five different methods of ABI calculation using Doppler ultrasound in 6,880 consecutive, unselected primary care patients ≥65 years in the observational getABI study. METHODS: In all calculations, the average systolic pressure of the right and left brachial artery was used as the denominator (however, in case of discrepancies of ≥10 mmHg, the higher reading was used). As nominators, the following pressures were used: the highest arterial ankle pressure of each leg (method #1), the lowest pressure (#2), only the systolic pressure of the tibial posterior artery (#3), only the systolic pressure of the tibial anterior artery (#4), and the systolic pressure of the tibial posterior artery after exercise (#5). An ABI < 0.9 was regarded as evidence of PAD. RESULTS: The estimated prevalence of PAD was lowest using method #1 (18.0%) and highest using method #2 (34.5%), while the differences in methods #3–#5 were less pronounced. Method #1 resulted in the most accurate estimation of PAD prevalence in the general population. Using the different approaches, the odds ratio for the association of PAD and cardiovascular (CV) events varied between 1.7 and 2.2. CONCLUSION: The data demonstrate that different methods for ABI determination clearly affect the estimation of PAD prevalence, but not substantially the strength of the associations between PAD and CV events. Nonetheless, to achieve improved comparability among different studies, one mode of calculation should be universally applied, preferentially method #1

Unsolved Issues in the Management of High Blood Pressure in Acute Ischemic Stroke

High blood pressure is common in acute stroke patients. Very high as well as very low blood pressure is associated with poor outcome. Spontaneous fall of blood pressure within the first few days after stroke was associated both with neurological improvement and impairment. Several randomized trials investigated the pharmacological reduction of blood pressure versus control. Most trials showed no significant difference in their primary outcome apart from the INWEST trial which found an increase of poor outcome when giving intravenous nimodipine. Nevertheless, useful information can be extracted from the published data to help guide the clinician's decision. Blood pressure should only be lowered when it is clearly elevated, and early after onset, reduction should be moderate but may be achieved rapidly. No clear recommendations can be given on the substances to use; however, care should be taken with intravenous calcium channel blockers and angiotensin receptor antagonists. Two ongoing randomized trials will help to solve the questions on blood pressure management in acute stroke

Low stroke incidence in the TEMPiS telestroke network during COVID-19 pandemic - effect of lockdown on thrombolysis and thrombectomy

Background: During the COVID-19 pandemic emergency departments have noted a significant decrease in stroke patients. We performed a timely analysis of the Bavarian telestroke TEMPiS "working diagnosis" database. Methods Twelve hospitals from the TEMPiS network were selected. Data collected for January through April in years 2017 through 2020 were extracted and analyzed for presumed and definite ischemic stroke (IS), amongst other disorders. In addition, recommendations for intravenous thrombolysis (rtPA) and endovascular thrombectomy (EVT) were noted and mobility data of the region analyzed. If statistically valid, group-comparison was tested with Fisher's exact test considering unpaired observations and ap-value < 0.05 was considered significant. Results: Upon lockdown in mid-March 2020, we observed a significant reduction in recommendations for rtPA compared to the preceding three years (14.7% [2017-2019] vs. 9.2% [2020], p = 0.0232). Recommendations for EVT were significantly higher in January to mid-March 2020 compared to 2017-2019 (5.4% [2017-2019] vs. 9.3% [2020], p = 0.0013) reflecting its increasing importance. Following the COVID-19 lockdown mid-March 2020 the number of EVT decreased back to levels in 2017-2019 (7.4% [2017-2019] vs. 7.6% [2020], p = 0.1719). Absolute numbers of IS decreased in parallel to mobility data. Conclusions: The reduced stroke incidence during the COVID-19 pandemic may in part be explained by patient avoidance to seek emergency stroke care and may have an association to population mobility. Increasing mobility may induce a rebound effect and may conflict with a potential second COVID-19 wave. Telemedical networks may be ideal databases to study such effects in near-real time

Low stroke incidence in the TEMPiS telestroke network during COVID-19 pandemic – effect of lockdown on thrombolysis and thrombectomy

Background During the COVID-19 pandemic emergency departments have noted a significant decrease in stroke patients. We performed a timely analysis of the Bavarian telestroke TEMPiS "working diagnosis" database. Methods Twelve hospitals from the TEMPiS network were selected. Data collected for January through April in years 2017 through 2020 were extracted and analyzed for presumed and definite ischemic stroke (IS), amongst other disorders. In addition, recommendations for intravenous thrombolysis (rtPA) and endovascular thrombectomy (EVT) were noted and mobility data of the region analyzed. If statistically valid, group-comparison was tested with Fisher's exact test considering unpaired observations and ap-value < 0.05 was considered significant. Results Upon lockdown in mid-March 2020, we observed a significant reduction in recommendations for rtPA compared to the preceding three years (14.7% [2017-2019] vs. 9.2% [2020], p = 0.0232). Recommendations for EVT were significantly higher in January to mid-March 2020 compared to 2017-2019 (5.4% [2017-2019] vs. 9.3% [2020], p = 0.0013) reflecting its increasing importance. Following the COVID-19 lockdown mid-March 2020 the number of EVT decreased back to levels in 2017-2019 (7.4% [2017-2019] vs. 7.6% [2020], p = 0.1719). Absolute numbers of IS decreased in parallel to mobility data. Conclusions The reduced stroke incidence during the COVID-19 pandemic may in part be explained by patient avoidance to seek emergency stroke care and may have an association to population mobility. Increasing mobility may induce a rebound effect and may conflict with a potential second COVID-19 wave. Telemedical networks may be ideal databases to study such effects in near-real time

The “Flying Intervention Team”: A Novel Stroke Care Concept for Rural Areas

Background: Endovascular treatment of large vessel occlusion in acute ischemic stroke patients is difficult to establish in remote areas, and time dependency of treatment effect increases the urge to develop health care concepts for this population. Summary: Current strategies include direct transportation of patients to a comprehensive stroke center (CSC) ("mothership model") or transportation to the nearest primary stroke center (PSC) and secondary transfer to the CSC ("drip-and-ship model"). Both have disadvantages. We propose the model "flying intervention team." Patients will be transported to the nearest PSC; if telemedically identified as eligible for thrombectomy, an intervention team will be acutely transported via helicopter to the PSC and endovascular treatment will be performed on site. Patients stay at the PSC for further stroke unit care. This model was implemented at a telestroke network in Germany. Fifteen remote hospitals participated in the project, covering 14,000 km(2) and a population of 2 million. All have well established telemedically supported stroke units, an angiography suite, and a helicopter pad. Processes were defined individually for each hospital and training sessions were implemented for all stroke teams. An exclusive project helicopter was installed to be available from 8 a.m. to 10 p.m. during 26 weeks per year. Key Messages: The model of the flying intervention team is likely to reduce time delays since processes will be performed in parallel, rather than consecutively, and since it is quicker to move a medical team rather than a patient. This project is currently under evaluation (clinicaltrials NCT04270513)