Background and Purpose— Tirofiban is a highly selective, fast-acting nonpeptide glycoprotein IIb/IIIa platelet receptor antagonist with a short half-life time. Glycoprotein IIb/IIIa antagonists are effective for the treatment of acute coronary syndromes proven in large clinical trials. Safety and efficacy in patients with ischemic stroke are uncertain. This was addressed in the Safety of Tirofiban in acute Ischemic Stroke (SaTIS) trial. Methods— Two hundred sixty patients with acute ischemic stroke were randomized in a placebo-controlled, prospective, open-label treatment, blinded outcome reading multicenter trial. Subjects with a National Institutes of Health Stroke Scale between 4 and 18 received intravenously either tirofiban or placebo within 3 to 22 hours after symptom onset for 48 hours. The primary end point was the rate of cerebral bleeding as measured in follow-up CT scans 2 to 7 days after inclusion. The secondary end point was clinical efficacy within 1 week (National Institutes of Health Stroke Scale, modified Rankin Scale) and after 5 months (Barthel Index, modified Rankin Scale). Results— The rate of cerebral hemorrhagic transformation (I/II) and parenchymal hemorrhage (I/II) did not differ between both groups (tirofiban 36 of 120; placebo 33 of 124: OR, 1.18; 95% CI, 0.66 to 2.06). Mortality after 5 months was significantly lower in patients treated with tirofiban (3 of 130 [2.3%] versus 11 of 126 [8.7%]; OR, 4.05; 95% CI, 1.1 to 14.9). No difference in neurological/functional outcome was found after 1 week and after 5 months. Conclusions— We conclude that tirofiban might be safe in acute moderate ischemic stroke even when administered within a large time window after symptom onset and might save lives in the late outcome. Clinical Trial Registration— URL: www.strokecenter.org/trials/ . Trial name: SaTIS. Enrollment began before July 1, 2005.

Since 1986, German ultrasound criteria for grading carotid stenosis have followed the local diameter reduction percentage consistent with the definition used in the European Carotid Surgery Trial (ECST) definition. To overcome the confusion caused by the coexisting grading method used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET), a German interdisciplinary council on carotid artery stenosis has recommended the implementation of the NASCET grading system (distal diameter reduction percentage) as the standard. The multi-parametric German "DEGUM ultrasound criteria" consisting of combined Doppler and imaging criteria have consequently been revised and transferred to the NASCET definition. In addition, a novel differentiation between main (primary) and additional (secondary) criteria has been proposed. When these ultrasound criteria are combined, vascular sonography allows reliable grading of carotid disease.

Background and Purpose— There is no consensus about indicators for measuring quality of acute stroke care in Germany. Therefore, a standardized process was initiated recently to develop and implement evidence-based indicators for the measurement of quality of acute hospital stroke care. Methods— Quality indicators were developed by a multidisciplinary board between November 2003 and December 2005. The process was initiated by the German Stroke Registers Study Group in cooperation with the German Stroke Society, the German Society of Neurology, the German Stroke Foundation, Regional Offices for Quality Assurance and other experts proven in the field. National and international recommendations were considered during the development process. The process was based on a systematic literature review, an independent external evaluation of the process and its results, and a prospective pilot study to evaluate the defined indicators in clinical practice. Results— Overall a set of 24 indicators was developed to measure performance of acute care hospitals in the 3 health care dimensions structure, process and outcome as well as in 3 treatment phases prehospital, in-hospital/acute and postacute. Practicability of the derived indicators was tested in a prospective pilot study. During a 2-month period, 1006 patients in 13 hospitals were documented. Application of the new indicator set was found to be feasible by participating physicians and hospitals. Median time to document the required information for 1 patient was 5 minutes. Nationwide implementation of the new indicator set within regional registers in Germany started since April 2006. Conclusions— The development of indicators to measure hospital performance in stroke care is an important step toward improving stroke care on a national level. The chosen standardized evidence-based approach ensures maximal transparency, acceptance and sustainability of the developed indicators in Germany.

Summary and critique. Advantages of method. TCD is a noninvasive test effective in monitoring blood velocities in large intracranial arteries. It uses small, potentially portable, relatively inexpensive equipment. The test can be repeated and therefore allows the detection of changes over time and after various physiologic studies or pharmacologie intervention, and during various postural and positional changes. TCD can also be used to monitor changes during surgery or other interventions.

No abstract

Plasma protein C exerts anticoagulatory effects by inactivating factors V and VIII. Hereditary protein C deficiency is transmitted as an autosomal dominant disorder. Homozygous individuals usually develop purpura fulminans as newborns; heterozygous protein C-deficient individuals are at increased risk for venous thrombosis and pulmonary embolism. However, arterial thrombosis has been only rarely observed. We describe a young patient with heterozygous protein C deficiency who experienced a severe stroke due to thrombotic occlusion of the left middle cerebral artery. (Stroke 1990;21:1077-1080) P rotein C is a plasmaglycoprotein with a molecular weight of 62 kDa. Its synthesis by the liver depends on vitamin K. The inactive form of protein C is converted to the active protein C a by thrombin in the presence of Ca . Combination of thrombin with the cofactor thrombomodulin on the surface of endothelial cells greatly accelerates the activation rate of protein C.1 Protein C a acts as an anticoagulant by inactivating factors V a and VIII a . Protein C a also exerts profibrinolytic properties by inactivating plasminogen activator inhibitor 1. Protein S, which is also a vitamin K-dependent plasma protein synthesized by the liver and the endothelium, enhances the activity of protein Ca. 23Protein C deficiency is inherited as an autosomal dominant trait with incomplete penetrance. Heterozygous individuals have an increased risk of venous thrombosis and thromboembolism at a young age. 4 Homozygous protein C deficiency is rare and leads to a purpura fulminans-like syndrome in neonates. Homozygous individuals usually die within the first months of life unless treated with replacement of protein C during the acute phase, followed by lifelong anticoagulation. 55 Two types of protein C deficiency are known. Most common is type I, in which both the absolute concentration of protein C and its functional activity are reduced. In type II protein C deficiency the activity is reduced whereas the concentration of protein C is normal. 3 We describe a young patient with heterozygous protein C deficiency. Occlusion of the left middle cerebral artery led to a severe ischemic stroke. Received December 11, 1989; accepted February 28, 1990. Case ReportAfter suffering from a headache for several days, a 32-year-old mechanic acutely developed a brachiofacial hemiparesis of his right side and global aphasia. Cranial computed tomography showed an extensive ischemic infarct in the territory of the left middle cerebral artery (Figure 1). Occlusion of the left middle cerebral artery at its proximal stem was demonstrated by transtemporal Doppler sonography (Figure 2). Duplex scanning of the extracranial carotid arteries did not show arteriosclerotic lesions but revealed reduced blood flow velocities on the left. Since the Doppler sonographic data were unequivocal, cerebral angiography was not done.The patient had been healthy until this event, and there were no obvious precipitants of thrombosis (i.e., no trauma, intoxication, or dehydration). His on...

Continuous-wave Doppler sonography is a reliable method for detecting severe subclavian stenosis and occlusion as well as subclavian steal. Intermediate stages leading to subclavian steal can also be detected. These are characterized by a cardiac-phase-dependent alternating flow direction in the vertebral artery. Some cases of proximal subclavian or proximal vertebral artery stenosis produce a systolic deceleration of flow in the vertebral artery. Stenosis and occlusion of the subclavian artery as well as stenosis of the subclavian and vertebral arteries can be distinguished. The pulse curve changes described can be reversed by a vascular by-pass. Alternating flow direction or systolic deceleration of flow in the radial artery could also be observed or induced in a iatrogenic model using Cimino's a-v fistula in the arm in patients on dialysis. The results in beginning subclavian steal situations can be applied in principle to other collateral circulations, and in particular to the hemodynamics in the region of watersheds.

No abstract