[Comprehensive stroke unit]. / Erweiterte Stroke-Unit.

The concept of a "comprehensive stroke unit" (in German: Erweiterte Stroke-Unit) is an additional structural option for those stroke units already certified in Germany. Its aim is to complement the semi-intensive management of stroke unit patients in Germany by early mobilisation and neuropsychological rehab procedures. This concept is recommended in many European countries as well. It is based on the proof of efficacy of the combined treatment package in several randomised controlled trials. According to the Helsingborg Declaration, every stroke patient in Europe should have access to a chain of care best provided by a comprehensive stroke unit. Both early mobilisation and rehabilitation treatment can be integrated and continued without creating an interface between the acute stroke unit and the general neurological or medical ward. The monitoring beds of the acute stroke unit and the non-monitoring "enhanced care" beds are located within the same geographical area of the hospital and are run as a comprehensive stroke care entity. Continuous management of the acute stroke patients by the same team on the same unit means an increase in quality of care, better usage of staff resources and an additional gain in time. The scientific background of the advantages of a comprehensive stroke unit is described as are the structural and staff requirements. The clientel particularly benefiting from treatment on wards with enhanced care beds is described, and the spectrum of treatment services is defined. This concept will be used as the basis for an add-on qualification of already certified German stroke units. An important step was to fit the requirements of the comprehensive stroke unit to the already existing facilities and their infrastructures. From an economic point of view, the comprehensive stroke unit is expected to be cost-effective, either balanced or even positive.

[Quantifying stenosis of the internal carotid artery: which ultrasound criteria are relevant?]. / Quantifizierung von A. carotis interna-Stenosen: Welche Ultraschallkriterien sind geeignet?

UNLABELLED: Therapeutic decisions in cases of arteriosclerotic stenosis of the internal carotid artery usually depend mainly on the degree of stenosis. However, the recommendations with regard to suitable ultrasonographic criteria are so controversial that even authors of repute describe "confusion" and "chaos in methodology". AIM: The aim of this study is to assess which of the most frequently recommended sonographic criteria for stenosis best fulfill the requirements of an exact quantification of stenoses of the internal carotid artery. METHOD: In 42 consecutive cases the preoperative ultrasound findings were compared with the degree of stenosis in surgically removed specimens. The sonographic technique employed consisted of the analysis of 2 direct and 3 indirect hemodynamic criteria of stenosis. In 34 of these cases planimetry was performed, too. The specimens were obtained by eversion thrombendarteriectomy or arteriotomy; for determination of the degree of stenosis a Paladur molded cylinder was prepared and measured. RESULTS: Quantification of the haemodynamic criteria carries provided well with the endarterectomy specimens. Only in two cases there was a deviation of more than 10 %; however, in these two cases a change with time in the degree of stenosis was probably responsible for the discrepancy. In contrast, planimetry usually underestimated the degree of stenosis: In 61 % of the findings the ultrasonographic results differed by more than 10 % from the reference standard. CONCLUSION: Quantification of stenosis of the internal carotid artery should be made using a combination of direct and indirect haemodynamic ultrasonographic criteria.

[De novo formation of a cavernoma in association with a preformed venous malformation during immunosuppressive treatment]. / Neuformation eines Cavernoms bei begleitender, vorbestehender venöser Malformation unter immunsuppresiver Behandlung.

We report the clinical course of a 48 year old woman, who underwent a cranial MRI-examination in 1995, which confirmed the diagnosis of encephalomyelitis disseminata, but also showed a left temporal venous malformation without evidence of prior hemorrhage. Three month after immunosuppressive treatment with Methotrexate in 1997 begun, first hemorrhage in the left temporal lobe occurred with de novo formation of a cavernoma in association to the known venous malformation. The lesion was totally removed after stereotactic guided craniotomy without any complication. The pathogenetic relationship of de novo cavernomas and associated venous malformations and the remarkable association with immunosuppressive treatment will be discussed.

Bilateral white matter lesions following severe meningococcal meningoencephalitis.

Occasionally, striking abnormalities are found on MRI in patients with mild neurological disturbances. In most of these cases the diagnosis is not immediately evident and the history does not provide an unequivocal explantation. We present a patient with extensive symmetrical white matter abnormalities in the posterior temporal, temporo-occipital and parietal regions, 24 years after documented severe meningococcal meningoencephalitis. A meningitic vasculitis, affecting the insular branches of the middle cerebral arteries, could have been responsible for these changes.

[The manifestations of extrapulmonary tuberculosis]. / Erscheinungsformen der extrapulmonalen Tuberkulose.

Seven weeks after a generalized cerebral seizure a 27-year-old woman from Ghana developed nausea, vomiting and weight loss, gradually increasing over two weeks. Cranial computed tomography revealed several hyperdense formations with extensive associated oedema and a midline shift. Among extensive biochemical tests only a raised erythrocyte sedimentation rate of 24/50 mm and leukopenia of 2,600/microliters (with normal differential count) were notable. Diagnostic laparotomy was performed because of sonographic and computed tomographic evidence of enlarged abdominal lymph nodes. Histological examination of representative lymph nodes and of tiny nodules deposited on the peritoneum revealed caseous granulomatous inflammation. Mycobacterium tuberculosis was cultured from these specimens. Antituberculosis treatment was started with 0.3 g/d isoniazid, 0.6 g/d rifampicin, 2 g/d pyrazinamide and 1 g/d streptomycin, plus dexamethasone, 4 mg four times daily. After eight weeks treatment an intracerebral focus, removed to exclude neoplasm, proved histologically to be a tuberculoma. Only after four months was it possible to reduce the glucocorticoid dosage to prednisone, 20 mg/d. The antituberculosis treatment was continued for 18 months, with only isoniazid and rifampicin taken during the last 14 months. Final clinical and biochemical examinations were unremarkable. Computed tomography demonstrated regression of the abdominal lymph nodes and the cerebral foci. The patient was without any symptoms.

Isolated ophthalmoplegia of abduction.

A case of transient complete bilateral paresis of abduction is reported without esotropia. Loss of vestibular ocular reflex (VOR) responses of the abducting eye and intactness of all other slow VOR reactions were the leading symptoms. Since bilateral lesions of the pontine gaze centers in this initially comatose patient without signs of increased intracranial pressure were excluded, bilateral lesions of the abducens nerves appeared improbable. In view of normal function of the ascending tract of Deiters bilateral paramedian lesions between the vestibular and abducens nuclei appeared to be more likely. Clinical course with relatively rapid recovery after administration of thiamine, theoretical considerations, and some earlier reports led to the conclusion that in some metabolic-toxic disorders--apparently in this case of Wernicke's encephalopathy--intrapontine connections in the paraabducens area may be selectively vulnerable. A similar effect on oligosynaptic connections to the medial rectus nucleus could lead to a disordered inhibition of this muscle. The term "posterior INO of Lutz" should no longer be used because of the lack of any anatomical and physiological evidence for its existence.

[Hemangioblastomas of the central nervous system. A clinical study]. / Hämangioblastome des Zentralnervensystems. Eine klinische Studie.

In a survey of 46 patients with haemagioblastoma of the CNS (Neurology Dept. University Hamburg, 1950-1980) most (n = 40) were found to have angioblastomas of the cerebellum (Lindau tumors). Of these patients 21 were re-examined in 1983. Headache was the most frequent initial symptom (43%), and within this group one-third (10%-15%) had dizziness, sensorymotor deficits and cerebellar gait disturbances. Signs of elevated intracranial pressure much more often led to the correct diagnosis than dizziness or dystaxia. After the introduction of CCT to the diagnostic procedure the combined evaluation of angiography of the vertebral arteries and CCT always permitted the correct diagnosis. The low neurosurgical mortality rate (13.5%) has decreased to 0% within the last decade. No relapses were found in 21 re-examinations including CCT and EOG compared to a frequency of 9.7% in all 46 cases. Significantly less often than expected from other data we found: signs of possible hereditary influence (0%), multiple tumor localization combined with angiomatosis retinae (0%), polyglobulia (10.8%). Psychopathologically relevant signs (45.6%) were, in all cases, combined with signs of increased intracranial pressure. The results of our re-examination demonstrate that late postoperative deficits as well as possible relapses are earlier and more precisely evaluated by the combined use of clinical examination, CCT and EOG.

VER analysis of the chiasmal syndrome.

In the evaluation of chiasmal syndromes the efficiency of VER analysis could be enhanced by separate stimulation of the temporal and nasal half of the visual field. The report is based on data of 27 patients with compressive chiasmal lesions. VER findings have been correlated with the visual fields meticulously plotted with a Tuebingen perimeter and/or an Octopus computer perimeter. Alterations in both parameters have been graded in three groups. The degree of alteration correlated fairly well for both test procedures. Not only was a reduction of VER amplitude observed for the affected hemifield, but a latency delay as well. A discrete damage in the nasal hemifield may be detected even earlier by means of VER half field analysis than by conventional subjective perimetry.

Clinical aspects of spontaneous necrosis of pituitary tumors (pituitary apoplexy).

Among 586 surgically treated tumors of the pituitary gland 72 cases (12.3%) of spontaneous necrosis of the tumor were found. However only in 10 cases (1.7%) were there clues of an additional rupture of the tumor with signs of meningeal reaction in the CSF. Cases with a relatively benign clinical course and signs of regression are more frequent than generally assumed. Spontaneous necrosis with and without rupture is much more frequent in endocrinologically inactive tumors (including prolactinomas) as opposed to STH- and ACTH-cell adenomas. Analyzing the patient material the clinical symptomatology and the differential diagnosis of spontaneous necrosis of the tumor with and without rupture are discussed.

Possibilities of simultaneous analysis of phasic pupillary light reflex and visual evoked potentials.

A report of first results of a simultaneous analysis of the phasic pupillary light reflex and visual evoked potentials (VEP). It is shown that combination of pupillography with VEP analysis can be of some use in the diagnosis of conductive defects of the optic nerve (e.g. optic neuritis). Furthermore, the simultaneous analysis allows distinction between subclinical disturbances of the afferent and efferent arcs of the pupillary light reflex. Assuming a lesion of the afferent arc secondary to damage to the optic nerve, an increase of both the pupillomotor and the VEP latencies is seen. With lesions of the efferent arc (e.g. in the case of a third nerve palsy) only the pupillomotor latency is altered. Potentialities and disadvantages of the method are discussed.

Benign encephalitis: electro-oculographic analysis of opsoclonus.

Two cases of benign encephalitis are described, which showed opsoclonus associated with myoclonic jerks of the body and face, and with cerebellar dystaxia in one case. EOG and EEG analysis during the course of these cases showed: 1. opsoclonic eye movements were triggered by saccadic and non-saccadic eye movements, 2. decrease of luminancy and loss of fixation were releasing, but not triggering opsoclonic bursts during the initial stages, 3. eye closure had the strongest trigger effect, which lasted very long and allowed an objective description of the (benign) course of the illness, 4. besides conjugate, mostly horizontal, spontaneous eye movements oblique and vertical ones were also obtained. Monocular and disconjugate eye movements were seen only during the initial stages, 5. statistical analysis of the frequency of single eye movements during periods of opsoclonic bursts showed that, in the course of the disease the variability of frequencies decreased and the degree of fast frequencies increased, particularly with open eyes, 6. the frequent coincidence of opsoclonus and lesions of the cerebellum or of the cerebellar pathways is striking, but the initially distinct EEG changes, the very different trigger modes and certain pathoanatomically described cases without any cerebellar lesion indicate the more general character of the disturbance. 7. the entity of opsoclonus, body tremulousness, and benign encephalitis has to be differentiated from other syndromes including the sign opsoclonus by recording the EEG and EOG during the course of the disease; this might lead to very useful diagnostic and prognostic information.

Videopupillographic and VER investigations in patients with congenital and acquired lesions of the optic radiation.

In 9 patients with congenital and acquired lesions of the optic radiation, videopupillographic investigations have been employed to determine the pupillographic threshold in the homonymous field defect. The study includes 3 patients suffering from congenital porencephalic cysts. The pupillary response was graded as akinetic, hypokinetic or eukinetic. These classifications yield some diagnostic clues as to the nature of the lesion. An attempt was made using the VER response in these patients to correlate the findings.

[Videoprocessing pupillographic perimetry in hemianopsia (author's transl)]. / Fernsehbildanalytische pupillographische perimetrie bei Hemianopsie.

In cases of homonymous hemianopsia, with the aid of pupillographic perimetry it is possible to differentiate between infra- or suprageniculate lesions. Principally the validity of Wernicke's theory remains unchanged. However in processes in the central visual pathways a hemihypokinesia of varying degree may be found. In the blind visual fields so far in our cases a congruence between pupillographic and perimetric thresholds has not been confirmed. The phenomenon of hemihypokinesia of the pupil is discussed.

Botulism: clinical neurophysical findings.

Four cases of mild botulinus type B intoxication are reported with the clinical neurophysiological studies. Electromyographically tetanic stimulation of the N. ulnaris initially led to tetanic potentiation of the muscle action potential. After an interval without any symptoms tetanic reduction became apparent between the fourth and seventh week of the illness. The electroneurographic finding was normal during the observation period of three months. Infrared reflex pupillographic studies revealed that the cholinergic autonomous synapses were disturbed for a period much longer than the symptoms clinically established. The speed at which the pupillographic findings returned to normal varied considerably according to the patient. Electroencephalographic results indicated generalized groups of slow high amplitude waves in three of the four cases during the period of observation. The pathophysiology of botulinus intoxication is discussed with a consideration of the literature and the results of this study.

Simultaneous recording of pupillary hippus and EEG. Report of a case.

Pupillary hippus was observed and recorded in a man of 44 years, who had epileptic seizures, chronic alcoholism with liver disease and Primidon intoxication, during a period of unconsciousness of 24 h. During this time the simultaneous records of the EEG and pupillogram over a long period of time revealed that the basic EEG rhythm and hippus had the same frequency. Both recordings were temporarily in phase, time-locked, and could be blocked by painful and acoustic stimuli. The etiology and interpretation of hippus are discussed.

[Leber's optic atrophy - an interdisciplinary study (author's transl)]. / Die Lebersche Optikusatrophie. (Eine interdisziplinäre Studie).

Clinical-neurological, electrocephalographic, ophthalmological and genetic observations of a family with related persons with Leber's optic atrophy is described. 6 male subjects of the altogether ca. 100 members of the family tree stretching over 4 generations were manifestly affected relatives - that is possible carriers, an unusually large number of EEG's were abnormal, and, less often, colour vision disturbances were seen. The results suggest that Leber's optic atrophy is a hereditary neuro-ophthalmological systemic condition, whose most striking symptom is the optic atrophy. The genetic factors of the condition are also discussed.

[Pupillary reflex dynamics studied with infrared pupillography]. / Untersuchunger zur Pupillen-Lichtreflex-Dynamik mittels Infrarot-Reflexpupillographie.

With a modified method of infrared pupillography--especially developed for the use in clinical neurological routine diagnosis--the time course of the direct phasic pupillary light reflex in man was investigated under physiological and pathological conditions. The described method allows a high resolution of the time course of the light reflex and is superior to kinematographic as well as video-methods described so far. Normally the physiological time parameters are bilaterally symmetrical, also in cases of so-called physiological anisocoria. On the other hand in pathological anisocorias of various etiology pronounced side-differences and abnormal time parameters can be found. Also in cases of isocoria with clinically no abnormal findings of pupillomotor response pathological side-differences can be determined by infrared pupillography. Disturbances of the afferent arc, of the efferent arc and of combination of those as well as pupillary abnormalities to be located in the midbrain area, can be exactly analyzed and documented. Furthermore the method allows an objective documentation of the course in cases of dysfunction of the autonomic nervous system, like in intoxications, or to monitor drug-induced therapeutical measurements. The investigations and findings indicate that infrared pupillography, an objective method for analyzing the dynamics of the pupillary light reflex, is suitable for clinical neurological routing diagnosis.

[Cryptogenetic facial paralysis. Studies on the disease course]. / Kryptogenetische Fazialisparese. Verlaufsuntersuchungen

A report on 22 patients with idiopathic facial paralysis is given. A systematic interdisplinary examination in short intervals was carried out. The efficiency of the more time consuming and technically more difficult methods was checked. At the same time it was investigated whether as a result of these findings new aspects of early therapy and prognosis could be expected.