Background and purpose: This study investigated the utility of pain-related evoked potentials (PREP's) elicited by a nociceptive electrical stimulation of the skin (= electrically evoked nociceptive potentials) in early detection of diabetic small-fiber neuropathy. Methods: We studied 36 'young'(19-35 years) and 24 'older'(36-65 years) healthy subjects as well as 35 patients (35-64 years) with diabetes and neuropathic symptoms and 22 patients (34-64 years) with diabetes without neuropathic symptoms. Only patients with normal standard nerve conduction testing were included. Results: In patients with neuropathic symptoms, we found a significant increase in PREP latencies and decrease of amplitudes elicited from both, upper and lower limbs. In non-symptomatic diabetic patients, we observed PREP abnormalities from lower limbs only. Conclusions: These data suggest that the method of pain-related evoked potentials elicited by a nociceptive electrical stimulation of the skin may contribute to the early detection of diabetic sensory neuropathy.

BACKGROUND AND PURPOSE: Long-term antiplatelet therapy is effective at reducing recurrence after ischemic stroke. However, the relative safety and efficacy of combined aspirin-dipyridamole or clopidogrel are not known in patients with acute ischemic stroke. METHODS: The factorial PRoFESS secondary prevention trial assessed antiplatelet and blood pressure-lowering strategies in 20 332 patients, 1360 of whom were randomized within 72 hours of ischemic stroke to combined aspirin (Asp; 25 mg BID) and extended-release dipyridamole (ER-DP; 200 mg BID, n=672) or clopidogrel (75 mg/d, n=688). The primary outcome for this post hoc subgroup analysis was functional outcome at 30 days; secondary outcomes included recurrence and death by 90 days. Analyses were adjusted for baseline prognostic variables and blood pressure treatment assignment. RESULTS: Patients were representative of the whole trial (age 67 years, National Institutes of Health Stroke Scale score 3, small-artery occlusion 59%), and baseline variables were similar between treatment groups. The mean time from stroke to recruitment was 58 hours. By 90 days, treatment was no longer being taken in 121 (18%) patients randomized to Asp/ER-DP and in 86 (12.5%) assigned to clopidogrel (P=0.006). Combined death or dependency (shift analysis of modified Rankin Scale score at day 30) did not differ between treatment groups (odds ratio [OR]=0.97; 95% CI, 0.79 to 1.19). Nonsignificant trends to reduced recurrence (OR=0.56; 95% CI, 0.26 to 1.18) and vascular events (OR=0.71; 95% CI, 0.36 to 1.37) were present with Asp/ER-DP. Rates of death, major bleeding, and serious adverse events did not differ between treatment groups. CONCLUSIONS: Treatment with combined Asp/ER-DP vs clopidogrel in 1360 patients with acute, mild ischemic stroke did not differ in terms of effects on functional outcome, recurrence, death, bleeding, or serious adverse events. Both treatments were practical to administer.

BACKGROUND: Little is known about the best antiplatelet treatment immediately after ischaemic stroke or transient ischaemic attack (TIA). The EARLY trial aimed to compare outcome in patients given aspirin plus extended-release dipyridamole twice daily either within 24 h of stroke or TIA or after 7 days of aspirin monotherapy. METHODS: In 46 stroke units in Germany, patients aged 18 years or more who presented with symptoms of an acute ischaemic stroke that caused a measurable neurological deficit (National Institutes of Health stroke scale score </=20) were randomly assigned to receive 25 mg aspirin plus 200 mg extended-release dipyridamole open-label twice daily or 100 mg aspirin monotherapy open-label once daily for 7 days. Patients were randomised by use of a pseudorandom number generator. All patients were then given open-label aspirin plus extended-release dipyridamole for up to 90 days. The primary endpoint was modified Rankin scale score as recorded by centralised, blinded assessment by telephone (tele-mRS) at 90 days. Vascular adverse events (non-fatal stroke, TIA, non-fatal myocardial infarction, and major bleeding complications) and mortality were assessed in a composite safety and efficacy endpoint. Patients were analysed as treated. This trial is registered, number NCT00562588. FINDINGS: Between July, 2007, and February, 2009, 543 patients were treated: 283 received early aspirin plus extended-release dipyridamole and 260 received aspirin plus extended-release dipyridamole after 7 days on aspirin. At day 90, 154 (56%) patients in the aspirin plus early extended-release dipyridamole group and 133 (52%) in the aspirin plus later extended-release dipyridamole group had no or mild disability (tele-mRS 0 or 1; difference 4.1%, 95% CI -4.5 to 12.6, p=0.45). 28 patients in the early initiation group and 38 in the late initiation group reached the composite endpoint (hazard ratio 0.73, 95% CI 0.44-1.19 p=0.20). INTERPRETATION: Early initiation of aspirin plus extended-release dipyridamole within 24 h of stroke onset is likely to be as safe and effective in preventing disability as is later initiation after 7 days. FUNDING: Boehringer Ingelheim.

BACKGROUND AND PURPOSE: Several predictive scores have been developed and validated for stratifying cerebrovascular patients based on the risk of future (cerebro)vascular events. We aimed to prospectively compare the predictive accuracy of the Essen Stroke Risk Score, Stroke Prognostic Instrument, Hankey score, and the Life Long After Cerebral ischemia score. METHODS: Between August 2005 and December 2006, we included 2381 patients from 10 German stroke centers with an acute nondisabling ischemic stroke or transient ischemic attack and with prospective assessment of clinical variables for calculation of the predictive scores. A total of 1897 patients (79.7%) could be followed up for a median of 1 year. To evaluate the performance of each model, we calculated the area under the curve by receiver operating characteristic. In addition, we used the recommended cutoff values for calculation of sensitivity and specificity for stroke or the combined outcome of stroke or cardiovascular death. RESULTS: The Kaplan-Meier estimate for the overall annual stroke risk was 4.8% and for recurrent stroke or cardiovascular death 6.6%. We could confirm the predictive value of all 4 previously developed scores with a marginally superior performance of the SPI-II. CONCLUSIONS: In patients with acute nondisabling ischemic stroke or transient ischemic attack, all 4 scores are able to stratify the risk of recurrent stroke or the combined outcome. Simple point scores (Essen Stroke Risk Score, Stroke Prognostic Instrument) may help to raise awareness for medical prevention in clinical routine and increase compliance with risk factor modification.

OBJECTIVE: The aim of the study was to better describe the long term clinical course and electrophysiologic and radiologic findings in isolated degeneration of the posterior column. METHODS: Four patients with the presenting symptoms of a progressive tabetic ataxia were followed up clinically and electrophysiologically over up to 15 years between 1997 and 2008. They received standardized neurological examinations, electrophysiologic testing with SEP, MEP, NCV, EMG, autonomic testing and cardiac evaluation, head and spine MRI, laboratory evaluation including CSF analysis. RESULTS: Progressive gait ataxia due to pallhypasthesia and loss of position sense with areflexia remained the only symptoms. Pes cavus deformity was a notable clinical feature in all cases. There was no involvement of other systems and all patients remained fully ambulatory. There was no cardiac involvement. Electrophysiology was characterized by absent cortical tibial SEP with normal lumbar complexes and normal nerve conduction studies and transcortical magnetic stimulation as well as sympathetic skin response. MRI of the cord was normal. Laboratory analysis and CSF were unrevealing. CONCLUSION: Isolated degeneration of the posterior column is a rare condition with a clinically benign course without progression involving other systems and characteristic electrophysiologic findings (isolated loss of cortical tibial-SEP with normal lumbar leads). Pes cavus deformity seems to be an unusual but typical clinical feature. The etiology is most likely a sporadic degenerative disease of the cord.

In primary prevention, aspirin reduces the risk of stroke but not of myocardial infarction in women while in men only the risk of myocardial infarction but not stroke could be significantly reduced. Only aspirin has been shown to be safe and effective in large randomized trials in the first 48 hours after ischemic stroke. Aspirin/dipyridamole and clopidogrel both reduce the risk of a combined cardiovascular outcome in long-term secondary prevention compared to aspirin alone. More potent antiplatelet drugs or combination of aspirin and clopidogrel prevent more ischemic events, but also lead to more bleeding complications. No benefit of oral anticoagulants could be shown in patients with non-cardioembolic stroke. In patients with atrial fibrillation oral anticoagulation is more effective than aspirin in stroke prevention. The choice between oral anticoagulants and aspirin in these patients depends on age and the individual risk factor profile. Patients with symptomatic intracranial stenosis have a higher risk of intracerebral bleeding with oral anticoagulation compared to high dose aspirin. Aspirin is the recommended treatment in stroke patients with a patent foramen ovale.