[Verbal memory disorders provoked by a variety of stokes]. / Topisch-neuropsychologische Diagnostik sprachlicher Gedächtnisdefizite nach kortikalen Durchblutungsstörungen.

In recent years a consensus has been reached about the neuroanatomical substrate of verbal memory, but this state of knowledge has not yet been implemented in clinical practice. One reason for this may be that most of the neuroscientific studies on verbal memory used different neuropsychological instruments and that only a small set of patient groups with the same etiology but different lesion sites were analysed. Returning to three earlier studies, we analyse the possibility to make differential judgements on the verbal memory impairments of four different patient groups by using the California Verbal Learning Test (CVLT). We compare patients with left-sided (n = 16) and right-sided (n = 10) posterior cerebral artery infarcts and patients with infarcts of the left (n = 10) or right (n = 21) frontal lobe, and we integrated data about their retention errors that had not been analysed so far. Our findings reveal significant differences between these patient groups, concerning the quantitative aspects of impairments, and also the profiles of memory errors (recall, interference and perseverations). Our study documents a relation between the site of the lesion and the type of verbal memory impairment, agreeing with some of the most recent neuroscientific findings. Starting from this observation we try to define a neuropsychological pattern of memory impairment which enables differential clinical diagnoses using the CVLT as a memory test.

[Analysis of the need for clinical neuropsychology in inpatient neurological rehabilitation (phases C and D)--an empirical study of 788 patients]. / Analyse des Bedarfs an klinischer Neuropsychologie in der stationären neurologischen Rehabilitation (Phase C und D)--eine empirische Studie an 788 Patienten.

Recently, several studies concerning the need for neuropsychologists in early or in out-patient rehabilitation settings have been submitted; however, an analysis of classical in-patient neurological rehabilitation which is most important by virtue of its numerical impact has not yet been performed. An empirical study focussing on the need for neuropsychologists during in-patient rehabilitation (phases C and D) is discussed. The two-year study records deficits observed among all patients with damage to the central nervous system (n = 788) admitted to a neurological rehabilitation clinic in north-western Germany. The deficits were divided into the following groups: memory, visual-constructional, deficits involving the planning process, attention deficits and emotional disturbances. Depending on the deficits displayed, patients were prescribed either individual or group therapy, or a combination of both. An empirical pattern of job distribution for neuropsychologists is calculated for the first time based upon findings of the study, which concern the time required for neuropsychological diagnostics, neuropsychological therapy, consultation of relatives and a fixed time-budget established for team supervision and documentation.

Visual search and visual target detection in patients with infarctions of the left or right posterior or the right middle brain artery.

We compared visual target detection and search performance of patient groups with infarctions of (1) the right middle brain artery (R-MBA) and with neglect; (2) the left posterior artery (L-PBA), (3) the right posterior artery (R-PBA), the latter two groups had contralesional hemianopias, or (4) with right hemisphere lesions without hemianopia or neglect. We found that: (1) The first three groups differed from the fourth (control) group in omissions. (2) The first three groups differed only in horizontal search but not in target detection. (3) No vertical search deficit was present for either group. (4) R-MBA patients found increasingly more targets in visual search from left to right, R-PBA patients had problems with the outermost contralesional column, L-PBA patients showed a generally slowed and more variable search pattern. Infarctions of left and R-PBA therefore resulted in different visual search patterns. The behavior of the patients with R-MBA is consistent with Kinsbourne's (1992) interactive inhibition theory of neglect.

Profiles of patients with left prefrontal and left temporal lobe lesions after cerebrovascular infarcations on California Verbal Learning Test-like indices.

We compared memory disorders of three patient groups suffering from brain lesions with a word list corresponding to the California Verbal Learning Test (CVLTgcor). Dependent measures were learning rate and efficiency, retention, and strategic control of the learning process. Compared to a control group of patients with right hemispheric lesions, a left Arteria cerebri posterior (LACP) group showed general memory deficits, an inflated recency effect, and increased serial clustering. A left prefrontal cortex (LPFC) group documented slowed learning and increased recall after semantic cues. Discriminant analysis correctly classified 86.11% of the patients. It is argued that (a) the CVLT helps to cover differences in memory disorders recently discussed in cognitive neuropsychology; (b) differences between PFC and ACP patients become evident only if strategic aspects of learning and increased recall after semantic cueing are taken into account. The results are discussed within the framework of recent cognitive neuropsychological findings and with a distinction between fronto-subcortical and cortical memory disorders.

Assessment of quality of survival in patients with surgically treated meningioma.

A prospective study carried out between 1982 and 1991 encompassed 179 patients who had been operated upon for meningiomas (Neurosurgical University Clinic Heidelberg and Mannheim). History, neurological status, neuroradiological findings, surgical procedure and histology were documented. Within the framework of regular postoperative reexaminations, indices were recorded regarding life quality as standardized by Karnofsky and Spitzer. Following HRDP (Hamburg Rating Scale for Emotional Disturbances), a depression score was evaluated with 32 patients pre and postoperatively. Psychosocial disturbances, which can develop a permanent character, were observed, particularly within the first 12 months after the operation. Depressive moods were noticed quite frequently. The age of the patients proved to be a decisive prognostic factor.

[Intracerebral metastasis of a bronchial carcinoid tumor]. / Intrazerebrale Metastasierung eines Bronchuskarzinoids.

The authors report on a female patient of 45 years of age suffering from multiple intracerebral metastases of a bronchial carcinoid. Neurologically, intermittent short-term disturbances of word finding were noticeable. Multiple cerebral foci surrounded by pronounced concomitant oedemas were seen in MR and CT with inhomogeneous contrasts. The diagnosis was confirmed histologically by treatment concepts besides radiotherapy (1, 15, 17) are: intravenous administration of cisplatinum (14), interferon (16) and cyproheptadine (9). The treatment course adopted by the authors is based on an aetiopathogenetic approach, using somatostatin analogues. In the case under report, the somatostatin analogue SMS-201-995 (Sandostatin Sandoz) was applied in doses of 3 x 100 micrograms for a period of eight weeks, in short-term combination with daily doses of methyl prednisolone 40 mg (Urbason Höchst). With this treatment course the patient became free from complaints. No increased growth of the cerebral foci of infection could be observed neuroradiologically during the follow-up period of up to now six months.

Quality of life in patients with intracranial tumors on the basis of Karnofsky's performance status.

This prospective clinical trial (1983-1989) compares life-quality scores according to Karnofsky in patients with intra-cranial who had been operated upon. Karnofsky's performance status was evaluated during a follow-up period of 36 months. The patients were between 20 to 77 years of age; 132 patients had an astrocytoma grade III or IV; 42 patients with brain metastases were investigated; 72 had an astrocytoma grade I + II, and 144 had a meningioma. The median survival in patients with astrocytomas grade III or IV was 12 months; a short period with nearly normal activity (Karnofsky score 75) was followed by rapid deterioration. In patients with brain metastases, postoperatively the median functional ability reached its highest value three weeks after treatment and then decreased continuously (average score from 50-25). In patients with astrocytomas grade I and II, life-quality was reasonably good (mean score up to 75). The score was observed to increase slightly during the first year after treatment. A performance status improvement up to 80 could be obtained in patients with meningiomas; however, 35% were left unfit for work.

Head activator as a potential serum marker for brain tumour analysis.

Some human brain tumours, especially those derived from neuroectodermal or neural crest cells, contain elevated levels of head activator (HA). Such tumours release HA into the general circulation resulting in up to 1000-fold higher HA serum concentrations. The diagnostic value for brain tumour analysis was studied by measuring HA serum levels before and after human brain tumour surgery. It was found that complete removal of the tumour resulted in normal HA serum levels postsurgically. Incomplete resection was accompanied by a marked decrease, but not a return to normal HA levels. Surgery as such did not influence HA serum levels, since no change was observed pre- and postsurgically in patients with normal HA serum levels. This confirms the potential usefulness of HA as a serum marker to monitor brain tumour progression, successful tumour removal and relapse.

Occupational risk factors for brain tumors: results from a population-based case-control study in Germany.

In a population-based case-control study in the Rhein-Neckar-Odenwald area (containing 1.3 million inhabitants) of the Federal Republic of Germany (FRG), risk factors were assessed for brain tumor development in 226 cases with primary brain tumors (ICD-9 191, 192.1, 192.0) and 418 population controls, interviewed by a standardized questionnaire. The analysis of occupational risk factors and smoking is presented. No elevated risk was found for smoking. Similarly, no significant effects were found for most occupations. Five specific occupational groups were examined because of a priori determination that they were of interest. Some categories showed slightly elevated risks but in none was the elevation statistically significant. A significant increase in risk for brain tumor development was found associated with working in electrical occupations for women (relative risk [RR] = 5.2; 95 percent confidence interval [CI] 1.4-20.1) but not for men (RR = 0.9, 95 percent CI 0.3-2.3).

Elevated levels of head activator in human brain tumors and in serum of patients with brain and other neurally derived tumors.

In normal human tissue high concentrations of the neuropeptide head activator are found in the hypothalamus, in the retina, and in the gastro-intestinal tract. Up to 100-fold elevated levels of head activator over neighbouring tissue were found in tumors of the brain, especially in tumors of neural origin like astrocytoma and glioblastoma, but also in meningioma. Coincident with elevated tissue levels, an increased secretion into the general circulation was observed. Elevated levels of head activator in the blood were also observed in patients with tumors in peripheral locations, especially in tumors of gastrointestinal tract and/or of neuroendocrine origin. After tumor removal, the head activator levels in the blood dropped to normal values suggesting a possible role of head activator in neuroendocrine tumorigenesis.

Pharmacokinetics and CSF penetration of moxalactam in antibiotic prophylaxis in neurosurgery.

Moxalactam, a new oxa-beta-lactam antibiotic, suggests a possible role in prophylaxis in neurosurgery. Therefore, CSF penetration of Moxalactam was determined in 12 patients with absence of clinical or laboratory evidence of meningitis. In the dose employed (25 mg/kg 3 times/day) CSF samples showed a penetration of Moxalactam through the blood-cerebrospinal barrier with concentrations higher than 0.1 microgram/ml which persisted for more than seven hours. The drug was well tolerated and adverse effects were not observed.

Prognostic factors for postsurgical hearing and facial nerve function in cases of cerebellopontine angle-tumours. The meaning of brain stem evoked response audiometry (BERA).

Presurgical and postsurgical brain stem evoked response audiometry (BERA) examinations were done in patients with tumours of the posterior cranial fossa. A correlation exists between the extent of presurgical BERA-alterations and postsurgical hearing-power and facial nerve function. Small tumours (less than 1 cm) correlate generally with small BERA-alterations and show a good prognosis. Conservation of hearing in cases of larger tumours can only be expected when BERA-alterations are small. Prognosis is generally bad in cases of big tumours (greater than 3 cm). BERA-alterations on the contralateral side point to an additional brain stem compression which can normalize after surgery.

Effect of radiographic contrast media on complement components C3 and C4: generation of C3b-like C3 and C4b-like C4.

Various water soluble iodinated radiographic contrast media (RCM) have been studied for their effect on complement components C3 and C4, purified and in serum. Hepatotropic RCM, and at higher concentration also some nephrotropic RCM, were found to exert a direct effect on purified C3 and C4. RCM treated human C3 and C4 are characterized by (a) loss of haemolytic function, (b) retention of activity in the formation of fluid phase C3 convertases and (c) an antigenic relationship to activated C3 and C4 (C3b and C4b, respectively). This direct alteration of C3 and C4 can probably also occur in serum since loss of haemolytic function is observed at similar RCM concentrations after incubation of serum and of purified components. It is concluded that RCM treated C3 and C4 represent altered forms of these components that resemble C4b and C3b in activity and conformation (C3b-like C3 and C4b-like C4). The alteration is probably caused by binding of RCM, exerting a mild denaturing effect. C3b-like C3 is a potential activator of the alternative pathway, and both C3b-like C3 and C4b-like C4 are known to be cleaved by serum inactivators. A possible pathological significance of the generation of C3b-like C3, C4b-like C4 and their split products remains to be evaluated.

The value of spinal computed tomography in diagnosis of herniated lumbar discs.

In this study the diagnostic value and topographical accuracy of spinal computed tomography (CT) in hte preoperative diagnosis of lumbar disc herniations were tested in 36 patients with surgically proven herniated discs. All patients also underwent metrizamide myelography. CT findings and myelograms were compared and correlated with the surgical observations. Especially in demonstrating exact diagnosis (lateral or more medial protrusion), and in showing the extent of upward or downward displacement of free disc material, CT provides valuable preoperative information. As a non-invasive diagnostic procedure, spinal CT scan may replace lumbar myelography in many patients with radicular lumbar pain.

[The value of CT in the pre-operative diagnosis of disc prolapse (author's transl)]. / Die Wertigkeit der CT bei der präoperativen Diagnostik von Bandscheibenvorfällen.

A disc prolapse can be directly visualised by CT. Forty patients with a clinical diagnosis of disc prolapse were examined pre-operatively. The following criteria were noted: 1. Level, 2. lateralisation, 3. medial or lateral position, 4. differentiation between protrusion and sequestration, 5 displacement of the sequestrum. In 38 patients surgery was performed. Criteria 1 to 3 had been correctly diagnosed in 35 and 34 resp. and Ct proved equally reliable in respect of criteria 4 and 5. It is concluded that the combination of clinical examination and CT provides adequate diagnostic information before surgery. Myelography should be used only where there is still doubt.

The structure of the flavoenzyme glutathione reductase.

The three-dimensional structure of the dimeric flavoenzyme glutathione reductase from human erythrocytes has been elucidated by an X-ray diffraction analysis at 0.3 nm resolution. The polypeptide chain has been traced, and the binding positions of FAD, NADP and glutathione have been determined. A mechanism for the electron transfer is discussed.