[Differential diagnostics of diseases of the brachial plexus]. / Differenzialdiagnose von Erkrankungen des Plexus brachialis.

Progressive, atrophic, asymmetrically distributed flaccid paresis of arm and hand muscles represents a frequent symptom of neuromuscular diseases that can be attributed to injury of the arm nerves, the plexus or the cervical roots. A timely and exact diagnosis is mandatory; however, the broad spectrum of differential diagnoses often represents a diagnostic challenge. A large variety of neuromuscular disorders need to be considered, encompassing autoimmune mediated inflammatory neuropathic conditions, such as multifocal motor neuropathy, as well as chronic degenerative and nerve compression disorders. This review provides an overview of the most frequent disorders of the upper plexus and cervical roots and summarizes the characteristic clinical features as well as electrodiagnostic and laboratory test results. In addition the diagnostic value of magnetic resonance imaging and sonography is discussed.

Clinical impact of hyperattenuation of adrenal glands on contrast-enhanced computed tomography of polytraumatised patients.

OBJECTIVE: To evaluate the prognostic value of hyperattenuating adrenal glands on contrast-enhanced CT of polytraumatised patients. METHODS: Two hundred ninety-two patients (195 men and 97 women, mean age 45.3 ± 23.3 years) were included in this retrospective study. CT examinations were performed 60 s after intravenous injection of contrast material. Image analysis was performed by two radiologists. Patients were assigned to one of two groups according to the attenuation of the adrenal gland [group 1: adrenal glands ≥ inferior vena cava (IVC); group 2: adrenal glands < IVC]. RESULTS: Eighteen patients (42.2 years ± 24.2) were assigned to group 1 and 274 patients (48.4 years ± 22.4) to group 2. The average adrenal density was 150.8 ± 36.1 HU in group 1 and 83.7 ± 23.6 HU in group 2 (P < 0.0001). Eight of the 18 patients in group 1 (44.4%) and 33 of the 274 patients in group 2 (12.4%) died during hospitalisation (P < 0.05). Mean adrenal enhancement was significantly higher in patients who died (101.9 ± 40.6 HU) compared with survivors (86.1 ± 27.0 HU; P < 0.001). CONCLUSION: Hyperattenuation of adrenal glands is associated with a higher mortality rate in polytraumatised patients and may serve as a predictor of poor clinical outcome. KEY POINTS: • Hyperattenuating adrenal glands can be observed in 6.2% of polytraumatised patients. • Hyperattenuating adrenal glands indicate poor clinical outcome in polytraumatised patients. • In polytraumatised patients, hyperattenuating adrenal glands are associated with a high mortality rate. • Adrenal enhancement is higher amongst patients who died than amongst survivors.

[Subtle focal diffusion abnormality in the hippocampus]. / Subtile fokale Diffusionsstörung im Hippokampus.

A 53-year-old female patient presented with sudden onset confusion and disorientation. Further neurological examination was unremarkable and the patient showed a complete recovery after several hours. A magnetic resonance imaging (MRI) examination performed 2 days later revealed a tiny focal lesion in the lateral hippocampus in the diffusion weighted images consistent with transient global amnesia.

A case of relapsing-remitting neuroborreliosis? Challenges in the differential diagnosis of recurrent myelitis.

We report the case of a 31-year-old woman with 4 episodes of myelitis with pleocytosis, a positive Borrelia burgdorferi serology with positive antibody indices, and full recovery each time after antibiotic and steroid treatment, suggesting neuroborreliosis. We nevertheless believe that recurrent neuroborreliosis is improbable based on the levels of the chemokine CXCL13 in cerebrospinal fluid and favor the diagnosis of post-infectious autoimmune-mediated transverse myelitis possibly triggered by an initial neuroborreliosis as the cause of the relapses observed in our patient. We demonstrate the diagnostic steps and procedures which were important in the differential diagnosis of this unusual and challenging case.

[Neuroradiologic diagnostic and interventional procedures for diseases of the skull base]. / Neuroradiologische Diagnostik und Interventionen bei Prozessen an der Schädelbasis.

Besides image-guided biopsy techniques, the emphasis in the interdisciplinary cooperation between head and neck surgery and neuroradiology is on vessel-occluding and preserving measures. Knowledge of dangerous anastomoses between extracranial and intracranial vessels is crucial. The principles of vessel-occluding procedures including materials are presented and illustrated with case examples. Embolization of glomus tumors or epistaxis and preoperative permanent vessel occlusion techniques are demonstrated as well as vessel-preserving therapies, such as placement of covered stents for improving tumor resectability or after iatrogenic laceration of the internal carotid artery.

Peak inspiratory flow through the Genuair inhaler in patients with moderate or severe COPD.

The Genuair inhaler is a new multidose dry powder inhaler for the delivery of aclidinium bromide - a novel, long-acting, muscarinic antagonist in development for the treatment of chronic obstructive pulmonary disease (COPD). The primary aim of this study was to assess the inspiratory flow characteristics through Genuair in patients with moderate or severe COPD. Using a three-period cross-over design, 48 patients were randomised to inhale placebo powder through Genuair, HandiHaler A (slow, deep inhalation as per manufacturer's instructions) or HandiHaler B (fast, forceful inhalation). Three measurements of peak inspiratory flow (PIF), 10min apart, were recorded for each method of administration. The highest and average PIFs for the three attempts (mean+/-standard deviation) generated through the Genuair inhaler were 97.7+/-15.7 and 92.0+/-15.4L/min, respectively. Furthermore, 97% of inhalations with the Genuair inhaler were successful (activation of trigger threshold mechanism) and optimal (PIF> or =45L/min). The highest and average PIFs generated through HandiHaler A and B were significantly lower than with the Genuair inhaler. In conclusion, patients with moderate or severe COPD were able to generate sufficient inspiratory airflow through the Genuair inhaler to reliably inhale the full dose and reset the inhaler.

[Problems and possible solutions in evaluation of dichotic discrimination tests for children]. / Probleme und Lösungsansätze bei der Auswertung des dichotischen Diskriminationstests für Kinder.

Uttenweiler's dichotic discrimination test is a valuable contribution to the diagnosis of auditory perception disorders. With this test it is possible to establish whether there is a deficit in a patient's ability to discriminate between differing spoken signals to each ear, as shown in a study contrasting elementary school age children with normal hearing with children having auditory perception disorders. Until now only a limited comparison of test results has been possible, as previous test modes have required an increase in volume when words could not be completely distinguished. A further problem is that very different hearing abilities may give rise to the same test configurations. This study presents an alternative test method that allows a direct individual comparison of results. The volume of the words spoken is no longer increased when words are not adequately understood. In addition, a point system is introduced that enables a quantitative analysis of the same test performances. This new evaluation scale is explained on the basis of actual examples.

Latissimus dorsi myocutaneous free flap vascularised by an extra-anatomic graft in the lower limb following traumatic disruption of the popliteal artery.

A case is presented in which the thoracodorsal artery of a latissimus dorsi free flap was anastomosed to an autogenous reverse saphenous bypass graft. The bypass graft was used to revascularise a leg with traumatic disruption of the popliteal artery and an open comminuted fracture of the distal tibia and fibula with extensive soft tissue loss. At 2-year follow up, isotope scans showed patency of the extra-anatomic graft and a good flow into the thoracodorsal artery.

The Moberg volar advancement flap for digital reconstruction.

The volar advancement flap described by Moberg in 1964 has been used to restore normal sensation to soft tissue deficits of the thumb. Application of this same technique for finger tip injuries was later suggested by Snow, but differences in digital blood supply led to dorsal tip necrosis and selection of other reconstructive techniques by many surgeons. Other methods have the disadvantages of widened two-point discrimination, a tender pulp scar, or an unacceptable donor site. The volar advancement flap applied to fingers restores normal to nearly normal sensation, an adequate pulp with minimal deformity. Our experience with the volar advancement flap in 69 digits from 1969 to 1978 is reviewed. Preservation of the dorsal perforating vessels is most important in successfully executing this procedure. No dorsal tip or flap necrosis occurred. Two-point discrimination was normal or within 2 mm of contralateral values in every digit. Full range of motion, or less than 5 degrees extension loss, was recorded in all fingers that were normal prior to operation. Our results suggest this to be a safe as well as effective adjunct in the treatment of finger tip injuries.