Neuro-Ophthalmology at the Bedside: A Clinical Guide.

Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.

Geriatric Basics for the Neurohospitalist.

Due to the increasing age of the population, neurohospitalists are more frequently caring for old and very old people. Fundamental definitions and topics related to geriatric medicine are therefore of particular importance. In this review, common issues encountered in geriatric patients hospitalized on the neurology service are discussed. Focus is put on the geriatric assessment, multiprofessional diagnostic and therapeutic procedures, geriatric syndromes, pharmacotherapy of the aged, delirium, pain, and palliative management as they are relevant for the neurohospitalist. In addition, ethical questions are addressed.

A blood based 12-miRNA signature of Alzheimer disease patients.

BACKGROUND: Alzheimer disease (AD) is the most common form of dementia but the identification of reliable, early and non-invasive biomarkers remains a major challenge. We present a novel miRNA-based signature for detecting AD from blood samples. RESULTS: We apply next-generation sequencing to miRNAs from blood samples of 48 AD patients and 22 unaffected controls, yielding a total of 140 unique mature miRNAs with significantly changed expression levels. Of these, 82 have higher and 58 have lower abundance in AD patient samples. We selected a panel of 12 miRNAs for an RT-qPCR analysis on a larger cohort of 202 samples, comprising not only AD patients and healthy controls but also patients with other CNS illnesses. These included mild cognitive impairment, which is assumed to represent a transitional period before the development of AD, as well as multiple sclerosis, Parkinson disease, major depression, bipolar disorder and schizophrenia. miRNA target enrichment analysis of the selected 12 miRNAs indicates an involvement of miRNAs in nervous system development, neuron projection, neuron projection development and neuron projection morphogenesis. Using this 12-miRNA signature, we differentiate between AD and controls with an accuracy of 93%, a specificity of 95% and a sensitivity of 92%. The differentiation of AD from other neurological diseases is possible with accuracies between 74% and 78%. The differentiation of the other CNS disorders from controls yields even higher accuracies. CONCLUSIONS: The data indicate that deregulated miRNAs in blood might be used as biomarkers in the diagnosis of AD or other neurological diseases.

Verbal and nonverbal memory impairment in aphasia.

Repetition is frequently impaired in aphasia, most strikingly in conduction aphasia. The still not fully answered question is whether this relates to a linguistic deficit or to a general impairment of working memory extending to other modalities as well. To contribute to this problem, we assessed 49 aphasic and 50 non-aphasic stroke patients using an aphasia test plus three memory tests in forward and backward fashion, taxing verbal, numerical, spatial, and facial retention. The results show that in aphasics there is a memory gradient declining gradually from verbal to nonverbal content reflecting aphasia severity and that aphasics generally perform worse than non-aphasics, even if they present with similar cerebral lesions.

Do patients with motor neuron disease suffer from disorders of taste or smell?

Olfactory or gustatory dysfunction has been described in patients with motor neuron disease. This disorder along with other degenerative diseases has been tentatively linked with the olfactory vector hypothesis according to which a toxic agent may enter the organism via the nasal mucosa. In our study we assessed 26 patients diagnosed as suffering from motor neuron disease at various stages and compared them with 26 matched controls using 'Sniffin' Sticks' for smell and taste strips for taste testing. The two groups did not differ with respect to either ability. The smell test correlated with age, but not with the duration of the disease. We concluded that neither olfaction nor gustation seem to be linked to or influenced by the disease, making the causation by a toxin entering the body via the nasal or oral route rather unlikely as well as a degenerative process encompassing sensory pathways.

Evaluation of the Unified Wilson's Disease Rating Scale (UWDRS) in German patients with treated Wilson's disease.

Wilson's disease (WD) is an inherited autosomal-recessive disorder of copper metabolism characterized by a wide variety of neurological, hepatic, and psychiatric symptoms. The aim of the present study was the development and evaluation of a clinical rating scale, termed Unified Wilson's Disease Rating Scale (UWDRS), to assess the whole spectrum of clinical symptoms in WD. Altogether 107 patients (mean age 37.6 +/- 11.9 years; 46 male, 61 female) with treated WD participated in the study. Cronbach's alpha as a measure of the internal consistency for the entire scale was 0.92, whereas the intraclass correlation coefficient (ICC) was 0.98 (confidence interval (CI(95%)) 0.97-0.99), indicating an excellent interrater reliability as determined in 32 patients. Besides the total score was significantly correlated with the earning capacity of the patients as indicated by an estimated Spearman's rho approximately 0.54 (CI(95%) 0.40-0.69, P < 0.001). In summary, the UWDRS appears to be a promising tool to assess the disease severity in WD. Its usefulness in clinical research and drug trials should be further addressed.

[Are anti-dementia drugs worthwhile?]. / Lohnen Antidementiva?

The efficacy of the acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine for Alzheimer's disease is well-documented by a number of studies. In Germany, the three substances are approved for the treatment of mild to moderate Alzheimer's disease; the glutamate antagonist memantine is approved for the treatment of moderate to severe Alzheimer's disease. The health economical benefit of these medicines is disputed and ultimately depends on the health policy evaluation. However, from the medical perspective, every newly diagnosed case of Alzheimer's disease justifies a therapeutic attempt. In a given case, changing between the three approved acetylcholinesterase inhibitors or memantine may be indicated. Whether a combination of the substances has advantages is currently being tested.

Taste disorders in acute stroke: a prospective observational study on taste disorders in 102 stroke patients.

BACKGROUND AND PURPOSE: The aim of the study was to assess whether and how frequently patients with acute first-ever stroke exhibit gustatory dysfunction. METHODS: We performed a 1-year prospective observational study. Gustatory function was assessed using the standardized "taste strips" test. In addition, we assessed olfactory function, swallowing, stroke location, comorbidities, and the patients' medication. RESULTS: A total of 102 consecutive patients were enrolled (45 female, 57 male; mean age, 63 years); 31 of them (30%) exhibited gustatory loss and 7 (6%) had lateralized impairment of taste function. Predictors of impaired taste function were male gender (P=0.003), high National Institutes of Health Stroke Scale (NIHSS) score at admission (P=0.009), coexisting swallowing dysfunction (P=0.026), and a stroke of partial anterior circulation subtype (PACS) (P=0.008). In particular, in hypogeusic patients the lesion was most frequently localized in the frontal lobe (P=0.009). Follow-up examinations in 14 patients indicated improvement of taste sensitivity. CONCLUSIONS: Taste disorders after stroke are frequent. A significant association was found for male gender, high NIHSS score, swallowing disorder, and PACS, particularly in the frontal lobe. Generally, taste disorders after stroke seem to have a good prognosis.

Does improved problem-based teaching influence students' knowledge at the end of their neurology elective? An observational study of 40 students.

BACKGROUND: Elective programs for medical students in the last year of their university training are poorly evaluated. The goal of this study was to determine the gain in theoretical and practical skills in a group of students during their elective in neurology. Students were trained by either conventional teaching methods or applying improved problem-based teaching. METHOD: A test of 78 multiple choice questions regarding both, theoretical and practical aspects of clinical neurology, was presented to 21 students (9 female, 12 male). This group of students (group A) was trained according to the conventional teaching method. A subsequent group of students (intervention group B; n = 19; 9 female; 10 male) was educated using a modified teaching method that consisted of more problem-based learning, gathering experience with neurosonological and neurophysiological principles and in intense bedside teaching. The test was performed at the beginning and end of their elective period. The percentage increase in the tests was taken as the primary endpoint. In addition, all students were asked about their degree of satisfaction with the elective in general. RESULTS: Students of both groups did not differ with regard to age, gender, number of semesters, score of last examination and score of the test at the beginning of the elective. However, students who participated in the problem-based teaching group (group B) performed significantly better in the test at the end of the elective (increase 16.3% +/- 15.5) than those who were trained according to the conventional teaching program (percentage increase 6.3% +/- 9.4; p = 0.017). Students of both groups were highly satisfied with the elective in general. CONCLUSION: More problem-based teaching including practical exercises and intense bed-side teaching significantly improved students' performance. Thus, adaptation of teaching covering these aspects should be encouraged and might improve the neurological knowledge and skills of the students.

Electrocerebral silence with preserved but reduced cortical brain perfusion.

Isoelectric electroencephalogram in conformance with clinical findings is strongly suggestive of brain death. In clinical practice, isoelectric electroencephalogram in not-brain-dead patients is rarely seen. We report on a 53-year-old patient who suffered ischaemic encephalopathy after cardiopulmonary arrest. He had residual brainstem function with sufficient spontaneous breathing and evidence of cerebral blood flow on single photon emission computed tomography scan, but his electroencephalogram was isoelectric. He survived this condition for more than 7 weeks. This case demonstrates that isoelectric electroencephalogram can not be equated with brain death, and that in prognostic assessment both clinical findings and supportive technical methods are mandatory.

Multiple brain abscesses caused by Fusobacterium nucleatum treated conservatively.

BACKGROUND: Multiple brain abscesses are serious neurological problems with high mortality and disabling morbidity. The frequency is rising as a result of AIDS and the increasing number of immunocompromised patients. CASE STUDY: A 59-year-old woman developed signs and symptoms of diffuse brain dysfunction including fever and neck stiffness. A brain CT scan demonstrated nine contrast-enhancing ring-shaped lesions. Analysis of the cerebrospinal fluid using PCR-technique revealed DNA of Fusobacterium nucleatum. Conservative treatment with antibiotics was successful. The patient recovered with only mild cognitive deficits. RESULTS: The experience of our patient and the review of the literature indicate that multiple brain abscesses due to Fusobacterium nucleatum are rare. The most probable source is oral infection. CONCLUSION: Multiple brain abscesses may be caused by Fusobacterium nucleatum. Cerebrospinal fluid analysis using PCR technique is helpful with diagnosis. Conservative management can be successful.