Background: Undoubtedly, overlooking a stroke can result in severe disability or even death. However, identifying stroke patients in the prehospital setting poses a significant challenge. While the Face–Arm–Speech–Time (FAST) score is widely used, its effectiveness has been questioned because of its focus on symptoms primarily associated with anterior circulation strokes. In response to this limitation, we developed the innovative FAST4D score and conducted a comparative analysis of stroke detection rates between the novel FAST4D score and the FAST score. Methods: This prospective, multicenter proof-of-concept study aimed to assess stroke detection rates using both the FAST score and the new FAST4D score, which incorporates additional items such as the acute onset of diplopic images, deficit in the field of vision, dizziness/vertigo, and dysmetria/ataxia. Following their presentation to emergency medical services, all patients suspected of having a stroke and those diagnosed with a stroke upon discharge were included in this study. The diagnostic performance of the novel FAST4D score was evaluated and compared with that of the FAST score. Results: Between May 2019 and June 2021, a total of 1469 patients (749 female) were enrolled, with 1035 patients discharged with the diagnosis of stroke. Notably, 259 patients were identified solely through the FAST4D score. This resulted in a significantly higher rate of correctly identified as having had a stroke (stroke detection rate, sensitivity) with the new FAST4D score (93%) compared with the established FAST score (78%) (p < 0.001). This resulted in a reduction in false negative diagnoses by 65%. Conclusions: The novel FAST4D score demonstrated a 15-percentage increase in the stroke detection rate. This heightened detection rate holds the potential for more accurate patient allocation to stroke units, consequently reducing the time to revascularization.

Brain injured patients often need deep sedation to prevent or treat increased intracranial pressure. The mainly used IV sedatives have side effects and/or high context-sensitive half-lives, limiting their use. Inhalative sedatives have comparatively minor side effects and a brief context-sensitive half-life. Despite the theoretical advantages, evidence in this patient group is lacking. A Germany-wide survey with 21 questions was conducted to find out how widespread the use of inhaled sedation is. An invitation for the survey was sent to 226 leaders of intensive care units (ICU) treating patients with brain injury as listed by the German Society for Neurointensive Care. Eighty-nine participants answered the questionnaire, but not all items were responded to, which resulted in different absolute counts. Most of them (88%) were university or high-level hospital ICU leaders and (67%) were leaders of specialized neuro-ICUs. Of these, 53/81 (65%) use inhalative sedation, and of the remaining 28, 17 reported interest in using this kind of sedation. Isoflurane is used by 43/53 (81%), sevoflurane by 15/53 (28%), and desflurane by 2. Hypotension and mydriasis are the most common reported side effects (25%). The presented survey showed that inhalative sedatives were used in a significant number of intensive care units in Germany to treat severely brain-injured patients.

Background: Severe strokes often require deep sedation, yet the optimal sedation regimen remains unclear. This comparative study compared the efficacy of achieving target sedation depth using inhaled (isoflurane) versus intravenous (propofol) sedation. Methods: This prospective, observational, proof-of-concept study was conducted between July 2022 and June 2023 at two University Hospitals with dedicated neurological intensive care units. We included conservatively treated patients with severe space-occupying strokes (ischemic or haemorrhagic) requiring deep sedation. Patients received either inhaled or intravenous sedation. Sedation targets were defined in the morning rounds using the Richmond-Agitation-Sedation-Scale and were assessed at two subsequent time points (7 p.m. and 7 a.m.) during hospital stay. The primary outcome was the number of days where the predefined sedation target was achieved at both time points, comparing between the two sedation regimens. Secondary and safety outcomes included the incidence of delirium, pneumonia, functional outcomes, mortality, and vasopressor doses. Results: Seventy-nine patients (age 71 [63–81] years, 31 female) were included. Patients sedated with isoflurane achieved the sedation target significantly more often, with 182/444 (41%) compared to 80/497 (16%) assessments in patients sedated with propofol (RR 1.4; 95%-CI: 1.3–1.6). This effect was consistent across all sedation stages, specifically in the deep sedation targets (RR 1.5; 95%-CI: 1.2–1.9) and no-sedation target (RR 5.1; 95%-CI: 2.8–9.4). Secondary and safety outcomes revealed no significant differences. Conclusions: Isoflurane sedation offers a benefit for invasively ventilated stroke patients with respect to sedation targets. Specifically, isoflurane facilitates faster awakening when transitioning from deep sedation to awakening. These data encourage further confirmatory studies for specific stroke-patient groups.

Background: Stroke is a time-critical emergency in which rapid diagnosis and treatment are essential to improve outcomes. While Emergency Medical Services (EMS) facilitate structured prehospital stroke care, a proportion of patients bypass EMS and self-present to emergency departments (EDs), potentially causing treatment delays. This study compares process times and outcomes between EMS-transported and self-presenting stroke patients. Methods: We conducted a retrospective analysis of prospectively collected data from 1805 patients with suspected stroke admitted between May 2019 and June 2021 to two hospitals in Germany. Patients were classified as EMS-transported or self-presenting. Process times included door-to-needle time (DNT), symptom onset to first medical contact (FMC), and intravenous thrombolysis (IVT) rates. Data are presented as mean ± standard deviation or median [interquartile range] for continuous variables and as number (%) for categorical variables. Results: A total of 1940 patients with suspected stroke were included. For the main analysis comparing EMS transport and self-presentation, 1805 patients (1525 EMS, 280 self-presenting) were evaluated. EMS patients were significantly older than self-presenting patients (73.1 ± 15.1 vs. 65.3 ± 14.9 years, p < 0.001). The median time from symptom onset to first medical contact was 114 [95–132] minutes in EMS patients and 727 [420–1440] minutes in self-presenting patients (p < 0.001). IVT was administered in 119/1197 (9.9%) EMS patients and 18/254 (7.1%) self-presenting patients (p = 0.158) among those with documented information on thrombolysis. Door-to-needle time was slightly but significantly longer in self-presenting patients (median 35 [32–54] vs. 30 [28–34] minutes, p < 0.001), while both groups remained well within certification targets. Conclusions: Self-presenting stroke patients experienced markedly longer prehospital delays and lower intravenous thrombolysis rates compared to EMS-transported patients, although the difference in IVT rates was not statistically significant. In-hospital door-to-needle times were comparable between groups. These findings highlight the need for targeted public education to improve stroke symptom recognition and timely EMS activation.

Background and Purpose: Internal carotid artery dissection is a leading cause of ischemic stroke in younger patients, though many cases lack a definitive etiology for the wall injury. This study evaluated whether the length of the styloid process (SP) and its spatial proximity to the internal carotid artery (ICA) are associated with ICA dissection. Methods: We included patients with extracranial ICA dissection and control subjects without ICA dissection treated between 2005 and 2025 at a German tertiary stroke center in a propensity score matched (1:2) cohort study. SP length and minimal SP-ICA distance were measured bilaterally on CT angiography using standardized multiplanar reconstructions. Characteristics of SP were compared by etiology (spontaneous vs. traumatic). Conditional logistic regression accounting for the matched design was used to evaluate associations between SP anatomy and ICA dissection. Results: The cohort included 65 patients with ICA dissection (median age 48 years [43–55, IQR], 44.6% females, 73.8% spontaneous, 26.2% traumatic) and 130 matched controls. Patients with ICA dissection exhibited significantly longer SP (median 33.0 [29.0–39.8, IQR] mm versus 31.3 [27.2–37.2, IQR] mm; p = 0.033) and a higher SP length/neck length index (p = 0.046). No differences were found in the minimal SP-ICA distance (p = 0.206) or between traumatic and spontaneous etiologies (p = 0.989). In conditional logistic regression, SP length was not independently associated with ICA dissection (adjusted odds ratio [aOR] 1.13 per 5 mm, 95% CI 0.95–1.36), whereas a shorter minimal SP-ICA distance was (aOR 0.89 per mm, 95% CI 0.79–0.99). Conclusions: Our results indicate a modest association between SP length and ICA dissection that was not independent of SP-ICA proximity in the matched multivariable analysis. The styloid complex may contribute to a mechanical predisposition for arterial wall injury in a subset of patients. SP morphometry can be readily assessed on CT angiography; its value as an imaging marker requires prospective validation.

Objectives: Stroke is a leading cause of disability worldwide, requiring timely intervention with intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). This study evaluates real-world stroke management in a regional stroke unit, focusing on IVT administration and EVT transfer logistics. Design: A sub-analysis was performed using prospectively collected data from an observational study. Setting: This study took place at a regional, non-university stroke unit in Germany, serving approximately 253,000 inhabitants. Participants: A total of 2436 patients were admitted for suspected stroke between May 2019 and June 2021. Outcome Measures: Outcome measures included IVT administration rates, reasons for IVT non-administration, and EVT transfer logistics for acute ischemic stroke (AIS) patients. Results: Of 952 stroke cases, 14.8% received IVT, with a mean door-to-needle time (DNT) of 41 ± 36 min. The most common reasons for IVT non-administration were unclear or elapsed symptom onset (51.8%), anticoagulation (7.9%), resolving symptoms (18.4%), and intracranial hemorrhage (7.1%). EVT transfers occurred in 6.7% of AIS patients, with a mean door-in-door-out (DIDO) time of 81 ± 36 min. Conclusions: This study highlights the low IVT rate, primarily due to delayed hospital presentation, and the limited number of EVT transfers. The prolonged DIDO times emphasize the urgent need for streamlined transfer protocols to optimize stroke care delivery.