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Biomedical subjects

W Hacke

Publications and source records attributed to W Hacke.

At least 109 records · Page 6Linked to original sources
PubMed1999

[Therapy of increased intracranial pressure in space-occupying media infarcts].

Following complete middle cerebral artery (MCA) infarction, up to 10% of all patients develop space-occupying brain edema. Despite intensive care therapy, 80% of these patients die due to transtentorial herniation. Over the past years, two alternative therapeutical options for the therapy of space-occupying MCA infarction have been developed. Decompressive surgery effectively decreases ICP and helps to improve outcome of these patients. Mortality can be reduced from 80% to less than 20%. Moderate hypothermia induced within the first hours after stroke has been shown to decrease ICP as well. However, the routine use of this therapy should not be recommended since further clinical studies are available. Knowledge on indications and limitations of different antiedema therapies will allow an effective therapy of increased ICP.

Brain Edema↗
PubMed1999

Update in thrombolytic therapy.

Several studies have proven the usefulness of thrombolytic agents in the therapy of ischemic stroke. Data from open and small placebo-controlled trials show a relationship between recanalization and an improved clinical outcome. Three large scaled studies have examine the effect of streptokinase treatment. Because of an increasing mortality the results of these studies were negative, and so streptokinase should not be used to treat acute ischemic stroke. In contrast, three rt-PA studies with together more than 2000 patients showed a significant benefit. Recent meta-analyses including data of all these trials show an odds ratio for death and disability of 0.67 (95 p. 100 CI 0.56; 0.8). The number needed to treat to prevent one death or disability is 11 in a 6 hour time window and 7 in a 3 hour time window. These are impressive numbers that are rarely found in other areas of internal or neurological medicine. The most important risk of thrombolytic therapy is the occurrence of intracerebral hemorrhage, which is reported as between 0-18 p. 100, but which is not associated with increased morbidity or mortality. At present, thrombolytic therapy cannot be recommended for all patients with acute stroke. Careful selection and experiences with this therapy and its risks are necessary.

Clinical Trials as Topic↗
PubMed1999

Thrombolysis in acute ischemic stroke: controlled trials and clinical experience.

Thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) is approved in the United States for treatment of acute ischemic stroke. Approval was granted after a large, randomized, placebo-controlled study by the National Institute of Neurological Disorders and Stroke (NINDS) showed a significant improvement in 3-month outcomes with rtPA despite a significant risk for symptomatic hemorrhage. Two other trials, the first and second European Cooperative Acute Stroke Study (ECASS I and II), have shown comparable results, but neither was statistically positive for the predefined primary end point. An analysis of the risk/benefit profile of rtPA therapy based on the results of these three trials indicates that the treatment is effective and, when administered within 3 hours of symptom onset at a dose of 0.9 mg/kg, the benefits by far outweigh the risks for eligible patients. Even with the 6-hour time window of the two ECASS trials, a combined analysis of the three studies shows the number of disabled or dead patients to be significantly reduced. Preliminary data collected on the use of rtPA outside of clinical trials in the United States and Europe suggest that, when rtPA is used according to the trial protocol, the risks and benefits are similar to those observed in clinical trials. However, even within the United States, rtPA is underutilized. The most substantial treatment barrier is the narrow time window, which may be expanded if long-term experience shows that this is possible. Most stroke patients arrive at the hospital too late to be eligible for screening and treatment. Education of the public and physicians may help to overcome this difficulty.

Acute Disease↗
PubMed1999

[Continuing medical education (CME) in neurology. Concept of the German Society of Neurology (DGN) and the Neurology Section of the Professional League of German Neurologic Medicine (BVDN)].

Continuous medical education in Neurology (CME-Neurology) has been promoted in a concept organized by both the German society of neurology, German association for occupational interests of neurologists and psychiatrists). CME-Neurology has been started in January 1999 and is closely adapted to the CME guidelines of neurology section of UEMS and EFNS. The program shall serve to the maintenance and upgrading of knowledge skills and competence of postgraduate training in neurology.

Education, Medical, Continuing↗
PubMed1998

Assessment of neuropsychological changes in patients with arteriovenous malformation (AVM) after radiosurgery.

PURPOSE: The purpose of this study was to investigate neuropsychological effects of radiosurgery in patients with cerebral arteriovenous malformation (AVM), with special focus on attention and memory. This report describes the study setup and presents the first results during a follow-up of up to 1 year. MATERIALS AND METHODS: Seventy-nine patients were studied before, acutely after radiosurgery, and during the regular follow-up (subacute phase: Weeks 6-12, chronic phase: Months 6-12). Radiosurgery was performed using a modified linear accelerator (minimum doses to the target volume: 15-22 Gy, median 20 Gy). Estimated whole brain dose was 0.5 to 2 Gy. Neuropsychological testing included assessment of general intelligence (Wechsler Adult Intelligence Scale), attention (modified Trail-Making Test A, Digit Symbol Test, D2 Test, Wiener Determination Machine) and memory (Rey Auditory Verbal Learning Test, Benton Visual Retention Test). During follow-up, alternate test versions were used. Neuropsychological deficits were defined as a test score of at least one standard deviation (SD) below the mean of the normal distribution. RESULTS: The pretherapeutic evaluation revealed marked deviations from the normal population; 24% had deficits in intelligence (range 23-31% in different subtests), attention (35%, 23-59%) and memory (48%, 31-61%). The overall percentage of aberrant results was reduced by 12% (memory) to 14% (attention) in the chronic phase up to 12 months after therapy. The improvement in test scores was significant (p < 0.05) in 3 of 4 subtests of attention functions. CONCLUSIONS: The acute tolerance of radiosurgery seems to be very good in these patients, showing no relevant increase in number of patients with neuropsychological deficits. Although the long-term follow-up needs to be further increased, our data indicate a tendency to slight improvement in the overall neuropsychological performance of AVM patients in the chronic phase after radiosurgery.

Adult↗
PubMed1998

Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators.

BACKGROUND: Thrombolysis for acute ischaemic stroke has been investigated in several clinical trials, with variable results. We have assessed the safety and efficacy of intravenous thrombolysis with alteplase (0.9 mg/kg bodyweight) within 6 h of stroke onset. METHODS: This non-angiographic, randomised, double-blind, trial enrolled 800 patients in Europe, Australia, and New Zealand. Computed tomography was used to exclude patients with signs of major infarction. Alteplase (n=409) and placebo (n=391) were randomly assigned with stratification for time since symptom onset (0-3 h or 3-6 h). The primary endpoint was the modified Rankin scale (mRS) at 90 days, dichotomised for favourable (score 0-1) and unfavourable (score 2-6) outcome. Analyses were by intention to treat. FINDINGS: 165 (40.3%) alteplase-group patients and 143 (36.6%) placebo-group patients had favourable mRS outcomes (absolute difference 3.7%, p=0.277). In a posthoc analysis of mRS scores dichotomised for death or dependency, 222 (54.3%) alteplase-group and 180 (46.0%) placebo-group patients had favourable outcomes (score 0-2; absolute difference 8.3%, p=0.024). Treatment differences were similar whether patients were treated within 3 h or 3-6 h. 85 (10.6%) patients died, with no difference between treatment groups at day 90+/-14 days (43 alteplase, 42 placebo). Symptomatic intracranial haemorrhage occurred in 36 (8.8%) alteplase-group patients and 13 (3.4%) placebo-group patients. INTERPRETATION: The results do not confirm a statistical benefit for alteplase. However, we believe the trend towards efficacy should be interpreted in the light of evidence from previous trials. Despite the increased risk of intracranial haemorrhage, thrombolysis with alteplase at a dose of 0.9 mg/kg in selected patients may lead to a clinically relevant improvement in outcome.

Adolescent↗
PubMed1998

Herpes simplex virus encephalitis: cranial magnetic resonance imaging and neuropathology in a mouse model.

We performed a long-term magnetic resonance imaging (MRI) study in a mouse model of herpes simplex virus encephalitis. Mice were infected with herpes simplex virus type 1 (HSV-1) strain F. A 1.5-T cranial MRI scanner with standard spin-echo sequences was used. Neuropathological studies included immunohistochemistry. The presence of HSV DNA in brain tissue was determined with a polymerase chain reaction assay. Clinical assessment was performed daily: within the first 2 weeks the animals were severely affected and recovered thereafter. MRI and histopathological abnormalities corresponded well. HSV DNA was detectable initially and at 6 months. Extent and severity of structural abnormalities increased at 6 months. MRI offers a new in vivo approach for the detection of structural changes in the disease course of experimental herpes simplex virus encephalitis.

Animals↗
PubMed1998

Stroke from internal carotid artery occlusion during mumps infection.

During the terminal incubation period of severe mumps infection, a 40-year-old patient suffered from large infarction in the right middle cerebral artery territory. The proximal right internal carotid artery (ICA) was occluded on angiography. Computed tomography of the neck detected a hemorrhage located ventromedial to the right common carotid artery. Four months later the right ICA was partly recanalized. Carotid surgery revealed an atherosclerotic plaque and a vessel wall, which was fragile and less compact than usually. A strong inflammatory reaction to mumps infection may have contributed to the pathogenesis of the cervical hemorrhage and to acute thrombosis and occlusion of the ICA.

Adult↗
PubMed1998

Ultrastructural connective tissue abnormalities in patients with spontaneous cervicocerebral artery dissections.

The cause of spontaneous cervicocerebral artery dissection is unknown. An underlying arteriopathy due to a connective tissue disorder has often been presumed. We studied 25 patients with proven nontraumatic dissections. The ultrastructural morphology of dermal connective tissue components was assessed by transmission electron microscopy of skin biopsies. Ultrastructural abnormalities were seen in 17 (68%) patients, resembling in some cases the aberrations found in Ehlers-Danlos syndrome type II or III. These observations indicate a correlation of cervical artery dissections with connective tissue abnormalities. A structural abnormality in the extracellular matrix potentially caused by basic molecular defects is suggested and warrants further exploration.

Adult↗
PubMed1998

Moderate hypothermia and brain temperature in patients with severe middle cerebral artery infarction.

Elevated temperature is known to facilitate neuronal injury after ischemia. After head injury a gradient between temperature and body temperature of up to 3 degrees C higher in the brain has been reported. Hypothermia may limit some of the deleterious metabolic consequences of such increased temperature. In 20 patients who had suffered severe ischemic stroke in the middle cerebral artery (MCA) territory, intracerebral temperature combined with ICP monitoring was recorded using two different thermocouples, with epidural, and parenchymatous measurements. Mild hypothermia was induced using cooling blankets. Patients were kept at 33 degrees C core temperature for 48 to 72 hours. In all patients brain temperature exceeded body-core temperature by at least up to 1 degree C (range 1.0-2.1 degrees C). Systemic cooling was effective and sustained hypothermic (33-34 degrees C) brain temperatures. With mild hypothermia critically elevated ICP values could be controlled. 12 patients survived the hemispheric stroke with a mean Barthel index of 70. Severe side effects of hypothermia were not detected. After MCA stroke, human intracerebral temperature is higher than central body-core temperature. Mild hypothermia in the treatment of severe cerebral ischemia using cooling blankets is safe and does not lead to severe side effects. Mild hypothermia can help to control critically elevated ICP values in severe space-occupying stroke and may improve clinical outcome in these patients.

Adult↗
PubMed1998

[Systemic thrombolysis with plasminogen activator in chronic stroke patients].

Following the study protocol, we stratified the 615 patients of ECASS I according age (< or =/-70 years) and analysed the response to intravenous rt-PA in both subgroups. The older patients (248) suffered from the same stroke severity as the younger patients (367) experienced, however, a more severy clinical course (placebo group after 3 months after stroke: Barthel Index 50 vs. 85, mortality 24% vs. 11%). Treatment with rt-PA increased the proportion of undisabled patients at 3 months after stroke onset significantly only in the younger patients. The risk for brain parenchymal hemorrhage was increased by the factor of 4.7 and 4.6 in both age groups. It is obviously harder to achieve an undisabled state by systemic thrombolysis in the elderly. Facing the risk of brain hemorrhage associated with rt-PA, the risk-benefit-ratio may be less favourable in patients over 70 years.

Activities of Daily Living↗
PubMed1998

["Paradoxical" herniation after decompressive trephining].

The intracranial space is divided into two large compartments by the tentorium. The hydrostatic pressure of spinal fluid is responsible for buoyancy of the brain within these compartments. In patients with craniectomy this equilibrium is exposed to atmospheric pressure. We report on four cases of reversible herniation after either bilateral or unilateral decompressive craniectomy performed for increased intracranial pressure (ICP) and failure of conservative ICP treatment. All four patients had survived a severe neurological disease (encephalitis, subdural haematoma, stroke) which required craniectomy to control raised ICP. All were successfully weaned from the ventilator and awake and CT scans showed no space-occupying lesion anymore. The patients showed a typical "sunken pattern" at the trepanation site. All patients developed clinical signs of transtentorial herniation (i.e. unilateral dilated pupils, deteriorated alertness, and extensor posturing) shortly after either diagnostic or presumed therapeutic lumbar puncture. One patient developed herniation a second time while in the typical 30 degrees upright position. After craniectomy, transtentorial herniation is possible even in the absence of increased ICP. It is related to a negative gradient between atmospheric and intracranial pressure, which is enhanced by changes in the CSF compartment following lumbar puncture. Lumbar puncture should be avoided if possible and, when necessary, only be performed in the head-down position. Acute therapy in these cases is quite simple; it requires flat or even head-down positioning and early cranioplasty.

Adult↗
PubMed1998

[Color-coded duplex ultrasound imaging of intimal fibromuscular dysplasia of the carotid artery].

Traditionally, intra-vitamin diagnosis of fibromuscular dysplasia (FMD) of brain supplying arteries is a domain of conventional selective angiography. We are aware of only two publications reporting of ultrasound displayed intimal and medial variants of carotid artery FMD, in one case each. We present a patient in whom color-coded duplex-sonography revealed a web-like carotid artery bulb stenosis meeting the specific criteria of a subtype of intimal FMD.

Brain↗
PubMed1998

[Hyperbaric oxygen therapy (HBO) after acute focal cerebral ischemia].

For a large number of patients with stroke no therapeutic option can be offered, even after approval of thrombolytic therapy for treatment of acute ischemic stroke in the US. In cerebral ischemia local anoxia and energy failure lead to further cellular damage and finally to complete stroke. All therapeutic concepts try to salvage structurally intact tissue which is at risk for irreversible damage (so-called penumbra). Hyperbaric oxygen (HBO) treatment has been reported in animal models of cerebral ischemia, and in a few clinical reports. In general, the results of these studies have been promising. This review focuses on the clinical perspective of HBO therapy and summarizes both the clinical and experimental data available on HBO therapy following ischemic stroke.

Acute Disease↗
PubMed1998

Acute ischaemic stroke: revascularizing therapy. Stroke Council of the American Heart Association.

The principal goals of thrombolytic therapy for stroke are early restitution of cerebral blood flow, reduction of ischaemia, and attenuation of neurological disability through lysis of an occluding thrombus and consequent rapid restoration of circulation in the affected territory. Therapy should be initiated as soon as possible, at least within 4-6 h of stroke onset, to prevent major infarction and to salvage the hypoperfused but potentially viable zone adjacent to the central ischaemic area known as the ischaemic penumbra. This survey focuses on the safety and efficacy of thrombolytic therapy in acute ischaemic stroke in clinical trials. The results of two successful major randomized studies using tissue plasminogen activator (t-PA) were recently published. Intravenous thrombolysis seemed to be effective in improving functional and neurological outcome in a clearly defined subgroup of patients meeting the inclusion criteria of the studies. However, the identification of those patients proved to be difficult and depended on expertise in recognizing the early infarction signs on initial computed tomography. Since treating ineligible patients is associated with an unacceptable risk of intracranial bleeding complications and death, intravenous thrombolysis should only be performed at selected centres in selected patients.

Cerebral Revascularization↗