Evaluation of serum S100B as a surrogate marker for long-term outcome and infarct volume in acute middle cerebral artery infarction

BACKGROUND: An easily accessible and valid surrogate marker for interventional stroke trials is needed. OBJECTIVE: To investigate the usefulness of various S100B serum measures to predict long-term outcome and infarct volume in patients with acute stroke. DESIGN: Inception cohort study. SETTING: Tertiary care university hospital. PATIENTS: Thirty-nine patients (mean +/- SD age, 69.1 +/- 11.5 years) with acute nonlacunar middle cerebral artery infarction presenting less than 6 hours after symptom onset. MAIN OUTCOME MEASURES: Functional outcome 6 months after stroke (modified Rankin scale score) and final infarct volume on day 7 by means of standardized volumetry of brain images. Serum S100B level was determined at hospital admission and 24, 48, 72, 96, 120, and 144 hours after symptom onset. RESULTS: Single S100B measures obtained 48 and 72 hours after stroke onset demonstrated the highest Spearman rank correlations with modified Rankin scale scores (rho = 0.68 and rho = 0.67, respectively; P<.001) and infarct volume (rho = 0.95 and rho = 0.94, respectively; P<.001). A 48-hour S100B value of 0.37 microg/L or less revealed a sensitivity of 0.87 and a specificity of 0.78 in predicting an independent functional outcome. In a multivariate model, S100B emerged as an outcome predictor that was independent of age, sex, stroke severity, etiology, lesion side, and risk factors. CONCLUSIONS: Single S100B values obtained 48 and 72 hours after stroke onset provide the highest predictive values with respect to functional outcome and infarct volume in nonlacunar middle cerebral artery infarction. More complex measures of the S100B kinetic (ie, area under the curve or peak value) were not superior. Therefore, these single S100B measures appear to be useful surrogate end points in acute interventional stroke trials.     

Early functional recovery and the fate of the diffusion/perfusion mismatch in patients with proximal middle cerebral artery occlusion

BACKGROUND: The relationship between early neurological recovery, time to recanalization and the salvage of hypoperfused, but not diffusion-restricted tissue was investigated. METHODS: In 17 patients with acute middle cerebral artery occlusion, a multiparametric stroke MRI protocol was performed < 6 h after symptom onset, as well as at day 2 and 7. Recanalization was monitored with transcranial Doppler or with conventional angiography (during local thrombolysis). Functional improvement was defined as a change of > or = 4 points on the National Institutes of Health Stroke Scale score. RESULTS: In patients with functional improvement, 78% (median, range 66-95%) of the acute mean transit time (MTT) lesion escaped infarction compared with 28% (median, range -13 to 78%) in patients without neurological improvement (p < 0.01). Similarly, the percentage of tissue with a time-to-peak (TTP) delay of > or = 2 s not progressing to infarction was 80 and 4% in the groups with and without improvement, respectively (p < 0.01). Neurological improvement was more frequent in patients with early (< or = 3 h after presentation) recanalization, due to the salvage of larger areas of initially hypoperfused tissue. CONCLUSIONS: The salvage of hypoperfused tissue is a major factor influencing early neurological improvement.     

Ueber das Verhalten der elastischen Fasern bei pathologischen Zuständen der Haut

Ohne ZusammenfassungHierzu Taf. X–XV.     

A rare anomaly of the anterior communicating artery complex hidden by a large broad-neck aneurysm and disclosed by three-dimensional rotational angiography

Double fenestration of the anterior communicating artery (ACoA) complex associated with an aneurysm is a very rare finding and is usually caused by ACoA duplication and the presence of a median artery of the corpus callosum (MACC). We present a patient in whom double fenestration was not associated with ACoA duplication or even with MACC, representing therefore, a previously unreported anatomic variation. A 43 year old woman experienced sudden headache and the CT scans showed subarachnoid haemorrhage (SAH). On admission, her clinical condition was consistent with Hunt and Hess grade II. Conventional digital subtraction angiography (DSA) was performed and revealed multiple intracranial aneurysms arising from both middle cerebral arteries (MCA) and from the ACoA. Three-dimensional rotational angiography (3D-RA) disclosed a double fenestration of the ACoA complex which was missed by DSA. The patient underwent a classic pterional approach in order to achieve occlusion of both left MCA and ACoA aneurysms by surgical clipping. The post-operative period was uneventful. A rare anatomical variation characterised by a double fenestration not associated with ACoA duplication or MACC is described. The DSA images missed the double fenestration which was disclosed by 3D-RA, indicating the importance of 3D-RA in the diagnosis and surgical planning of intracranial aneurysms.     

Stenting beim akuten Schlaganfall

Eine hämodynamische Insuffizienz aufgrund von Pseudookklusionen oder Verschlüssen der A. carotis interna ist eine seltene Ursache des akuten Schlaganfalls. Eine akute Revaskularisation des Gefäßes kann die zerebrale Perfusion wieder herstellen.Diese retrospektive Studie zeigt, dass eine akute Stentimplantation mit proximalen und distalen Protektionssystemen bei Patienten mit Verschluss oder Pseudookklusion der A. carotis interna und unzureichender Kollateralisation technisch möglich ist und weitere hämodynamisch bedingte Infarkte verhindern kann. Demgegenüber steht eine erhöhte Rate von Reperfusionssyndromen mit intrakraniellen Blutungen; eine periinterventionelle intensivmedizinische Überwachung und Einstellung des Blutdrucks auf normotone Werte wird empfohlen.     

Roentgenographic findings in patients with pacemakers (author's transl)]

Early roentgenographic documentation of the position of an implanted pacemaker by roentgenograms in two planes and fluoroscopy establishes the necessary basis for the roentgenographic examinations in identifying pacemaker malfunction. Early and late causes of pacemaker malfunction in 250 patients are described. Early complications arise at the tip of the electrode: displacement with or against the direction of blood flow, penetration or perforation of the myocardium and false implantation into the coronary sinus. Later causes of pacemaker failure have to be searched mainly in the electrode itself and the battery: damage to the cable or displacement of the battery. The problems of radiologic assessment of the state of charge of the battery are discussed.