Prognosis of acute polyneuritis requiring artificial ventilation.

We compared two selected groups of patients with acute Guillain-Barré syndrome requiring artificial ventilation. Both groups were treated with conventional therapy, group A (n = 35) between 1970 and 1978, group B (n = 21) between 1979 and 1983. Neither plasmapheresis nor any other immunosuppressive treatment was applied. Significant differences were found favouring group B: There was a decline of mortality from about 60% to less than 10% (p less than 0.001) and a smaller number of severe complications due to improvement of supportive care.

The complete apallic syndrome--a case report.

In six patients with apallic syndrome the EEG was isoelectric, although the patients were breathing spontaneously and vegetative functions remained stable for a long period of time. No cortical somatosensory evoked potentials could be recorded in four of the patients examined. Cranial CT performed in three patients revealed extensive hypodensity of the cortex, whereas the brain stem showed no major damage. This syndrome is labelled a "complete apallic syndrome". None of our patients, and none of the 23 patients described in the literature, recovered.

Masseter inhibitory reflex threshold: a novel technique for electrophysiological investigation of trigeminal nerve lesions.

The masseter inhibitory reflex was investigated in 60 healthy volunteers, in 38 patients with trigeminal nerve branch lesions in the majority due to dental surgery, and in 9 patients with facial sensory loss and weakness caused by brain hemisphere lesions. The reflex threshold (TR) was almost symmetric both in normal subjects and in the patients with hemisphere lesions. In peripheral trigeminal hypaesthesia, elevation of TR on the lesioned side proved the most sensitive electrophysiological parameter. There was, moreover, some correspondence between the degree of sensory loss in hypaesthesic skin areas and elevation of TR, and recovery from the lesion was associated with TR normalization. Supratentorial lesions, in contrast, may influence the reflex pattern rather than reflex excitability.

[Alcohol and the peripheral nervous system]. / Alkohol und peripheres Nervensystem.

The most frequent consequence of chronic alcohol intake is a toxic polyneuropathy. It results from inadequate nutrition, mainly deficiency of thiamine and other B vitamins. Additionally there is a direct neurotoxic effect of ethanol. Signs and symptoms are 1. distal sensory disturbances with pain, paresthesia, and numbness in a glove and stockings-pattern, 2. weakness and atrophy of distal muscles, pronounced in the lower limbs, 3. loss of tendon jerks, 4. affection of autonomic fibers. Therapy consists in absolute alcohol abstinence, high-caloric nutrition, parenteral thiamine and other vitamins. Against paresthesia and pain, carbamazepine, salicylates, amitryptiline are effective. Parenteral tioctacid may be tried. The prognosis of alcoholic polyneuropathy is favorable, with alcohol abstinence, within several months up to a few years. In chronic alcoholic patients peripheral nerves frequently are injured by compression during alcohol intoxication. Peroneal nerve lesions result from compression in the region of the neck of the fibula during a prolonged lying position, the radial nerve is injured during sitting with the upper arm placed on the backrest of a bench. Usually pressure palsies resolve spontaneously. Rhabdomyolysis is a rare but life-threatening complication of alcoholic delirium. Symptoms are severe muscle pain, swelling of extremities, pigmenturia. The major complications of rhabdomyolysis are renal and respiratory failure, and cardiac arrhythmias due to electrolyte imbalance. Intensive care is needed with control of hyperkalemia, hydration, alkalinization of urine, hemodialysis if indicated.

[Immunoglobulin therapy of neuromuscular diseases]. / Immunglobulintherapie neuromuskulärer Erkrankungen.

High-dose intravenous immunoglobulin (IVIG) is effective in myasthenia gravis (MG), Guillain-Barré syndrome (GBS), and chronic inflammatory polyneuropathy (CIDP). The effect is equivalent to plasmapheresis (PE), and in GBS perhaps superior. IVIG may be effective, even if PE or corticosteroids have been ineffective -- and vice versa. IVIG may well become the therapy of first choice in MG, GBS, and CIDP as it is easily administered, there are no serious side-effects and there exists no risk of virus transmission. Future studies will show if a combination of PE and IVIG is superior to either of the two treatment schedules alone.

Reliability of electroencephalogram in the diagnosis of brain death.

The definition of brain death includes the irreversible loss of all brainstem and forebrain functions. The electroencephalogram (EEG), used to test forebrain functions, is part of the diagnostic armamentarium and is considered necessary even after primary infratentorial lesions. A review of both the current literature as well as new data on an interrater agreement and intrarater stability study provide the basis for a discussion on the reliability of EEG recording in this context and on the definition of brain death. Under normal conditions, the presence of an electrocerebrally inactive EEG is a valid indicator of brain death. However, the reliability and accordingly the validity of the EEG is restricted by technical problems and limited intrarater stability and interrater agreement.

Non-herpes simplex encephalitis is early exclusion of herpes simplex etiology possible?

Since effective antiviral treatment is available for herpes simplex encephalitis (HSE), early diagnosis or exclusion of herpes simplex etiology is essential for prognosis. In a retrospective study of 25 cases of acute viral encephalitis not caused by herpes simplex virus (non-HSE), we investigated whether HSE can be excluded in the early phase before serological evidence is present. Using clinical means, history, investigations of CSF (protein, cells), EEG, and CCT, HSE could not be excluded with reliability. This is because clinical signs and laboratory results are not pathognomonic for any form of viral encephalitis, even if periodic activity in EEG and temporal attenuation in CCT are more frequent in HSE than in other forms of encephalitis. Therefore, in all cases of severe encephalitis, acyclovir therapy should be initiated early.

[Cryptococcal meningitis]. / Cryptococcen-Meningitis.

Cryptococcal meningitis is a life-threatening disease. Headache, vomiting, cranial nerve symptoms and mental changes are the most common symptoms, but as many as 15% may have no symptoms referable to the CNS. For chemotherapy four drugs are available: namely amphotericin B, 5-fluorocytosine, miconazole and ketoconazole. Most cases have been treated by combination of amphotericin B and 5-fluorocytosine. The intrathecal administration of amphotericin B should be considered for patients who fail to respond to the usual intravenous therapy. The case is reported of a patient who died due to hydrocephalus, and the CSF-levels of the administered drugs are presented. Some pitfalls of therapy are discussed.

[Limitations of neurologic intensive care]. / Grenzen neurologischer Intensivmedizin.

The indication for intensive care in incurable neurological diseases is discussed. An attempt is made to analyse the problem by presenting two cases of multiple sclerosis and two other cases of amyotrophic lateral sclerosis. There is a clear indication for intensive-care treatment in all cases with life-threatening symptoms and complications, provided there seems to be a chance of reversibility in spite of an eventually poor prognosis. If there is no chance of improvement, and the illness has reached its terminal stage, we do not think, that intensive care is of any benefit for the patient. However, we are not able to make a decision should he insist on such a treatment. When the patient is doomed to die in any case, there is no obligation to inform him about a life-prolonging treatment which is not indicated.

[Listeriosis of the central nervous system]. / Zur Listeriose des Zentralnervensystems.

Listeriosis of the CNS is an inflammatory disease of the central nervous system that occurs mostly sporadically or occasionally as a limited epidemic. The pathogens are generally ingested with the food. Whether or not the infection becomes manifest in an exposed person depends on the number of pathogens ingested, on the virulence of the Listeria strain and on the individual disposition. It appears to be of decisive importance for an infection that the cellular immunodefense mediated by the T cells is disturbed; however, even persons without any previous disease worth mentioning may be affected. The characteristics of the various CNS manifestations are demonstrated via the case histories of 12 own patients (acute meningitis and meningoencephalitis, brain stem encephalitis, brain abscess, meningoencephalitis with infected cerebral infarct, chronic recidivating encephalitis). Early neurological focal signs and symptoms, combined with CSF findings atypical for bacterial CNS disease, should not be taken lightly and may point to listeriosis even though they are not specific for CNS listeriosis. The decisive criterion is the proof of the pathogen in the blood or CSF or the proof of antibody titre changes in the serum. Recent CSF diagnostic methods such as CSF lactate determination and the identification of IgG-positive B lymphocytes are useful in differentiating between viral and noninflammatory CNS disease; most important for follow-up are repeat CSF examinations. High-dosage ampicillin or amoxycillin treatment combined with gentamycin is the therapy of choice in CNS listeriosis. The bactericidal effect achieved thereby is desirable especially if immunodefense is disturbed. Prognosis of CNS listeriosis depends on the underlying disease in each case. The high mortality even among persons who had been healthy before the infection, is at least in part due to delayed diagnosis.

[Clinical aspects of acute lesions of the brain stem of inflammatory origin]. / Klinik akuter Läsionen des Hirnstamms entzündlicher Genese.

The diagnostic considerations of an inflammatory brainstem disease and its symptoms are shown in 22 cases. The diagnosis based on a topodiagnostic decision and the demonstration of an inflammatory genesis. The topodiagnosis has to take into consideration that a symptom can be caused by both a central lesion as well as a peripheral nerve lesion. Electrophysiological methods (EEG, Nerve conduction velocity, reflex studies and evoked potentials) were of only minor use in these decisions. The somatosensory evoked potentials demonstrated 5 central lesions and were far more useful than the other methods. The CCT demonstrated a brainstem lesion in one case. In fifty percent of the cases, symptoms caused by both peripheral and central nerve lesions were demonstrated. Thus, there is no clear border between a brainstem encephalitis and a peripheral neuropathy (Fisher-Syndrome or Guillain-Barré-Syndrome). The inflammatory genesis was proven by CSF in 12 cases. An inflammatory disease was supported in the other cases through the exclusion of another genesis by means of CCT, NMR, Doppler sonography, angiography and an observation of the course of the illness.

[Acute polyneuritis in non-A, non-B hepatitis]. / Akute Polyneuritis bei Hepatitis-nonA-nonB.

Neurologic involvement may occur in the course of acute viral hepatitis; acute polyneuritis is an extremely infrequent manifestation. Hepatic failure, leading to death on the 10th day of disease, became manifest in a 26-year-old man on the 6th day of postinfectious polyneuritis Guillain-Barré-Strohl requiring ventilation. Clinical aspects, additional diagnostic assessment and post mortem findings supported diagnosis of nonA-non-B hepatitis. A causal connection between both disease entities appears likely.

[Clinical experience with short-term afterloading therapy in comparison with conventional brachytherapy in the treatment of gynecologic tumors]. / Klinische Erfahrungen bei der Afterloading-Kurzzeittherapie im Vergleich zur konventionellen Brachytherapie bei der Behandlung gynäkologischer Tumoren.

The short-term afterloading therapy (AL-ST) with high dose rates (DR) and remote control prevents the risk of a radiation exposure of the staff, facilitates the optimization of the dose distribution in space, makes the treatment easier for patients and hospital, and allows a considerable increase of the treatment capacity without additional need of staff or capital. AL-ST works with another dose distribution in time than the conventional brachytherapy, so a higher fractionation of high-dose-rate afterloading is substituted for the classical protraction of low-dose-rate brachytherapy. 2072 patients with gynecologic tumors were treated by AL-ST between 1974 and 1983. 1762 out of them (964 carcinomas of the cervix, 677 carcinomas of the body, and 121 vaginal tumors, metastases and urethral carcinomas) could be checked up for at least twelve months up to more than five years, which allowed an evaluation with regard to recurrence-free survival rate, local absence of tumors, and side effects. The five-year survival rates obtained by primary and post-operative AL-ST are compared to historical control groups of our own hospital and to the international results. The results, related to the stages, are at least equivalent; several groups show a statistically significant improvement compared to conventional brachytherapy. The incidence of early and late reactions in bladder and rectum showed a statistically significant decrease after AL-ST and was dependent on the dose in a statistically highly significant manner (p = 0.001). In addition to the well-known advantages of AL-ST, the following may be mentioned: 1. The intracavitary application was made without general anaesthesia, only with sedation by drugs, which prevented the primary treatment mortality. 2. An ambulatory treatment was possible in about 40% of the cases due to the time-sparing and patient-sparing method--the advantages are evident. 3. The therapeutic efficacy is increased and the risk of side effects in bladder and rectum is decreased by the better radiobiologic (same DR) and dosimetric adaption of AL-ST and percutaneous high-voltage therapy.

[Radiation dosage of premature infants caused by roentgen imaging of the thorax]. / Strahlenbelastung Frühgeborener durch Röntgenaufnahmen des Thorax.

The X-ray pictures of the thorax from premature infants must be prepared by conditions of neonatal intensive care. For this X-ray pictures are available very often single-puls generators only. The radiation exposure is dependent prominently on the type of the generator. The radiation exposure was compared between single-puls generators and 6-puls generators. The dosimetry was performed with CaF2-thermoluminescent dosimeters. The results of measurement demonstrated: In the radiation fields the radiation exposure is considerable higher by the single-puls generators than by the 6-puls generators. The indication to X-ray pictures of the thorax from premature infants under conditions of bed-side with single-puls generators must be very accuratly.

[Experiences with high dosage immunoglobulin G in neuromuscular diseases]. / Erfahrungen mit hochdosiertem Immunglobulin G bei neuromuskulären Erkrankungen.

High-dose intravenous immunoglobulin G (IVIG) was used as alternative treatment in 39 patients with crisis in myasthenia gravis (MG), acute polyneuritis (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP). Of 10 patients with MG, 3 recovered completely, 5 patients improved except for long-standing ocular signs, 1 patient was weaned from artificial ventilation, and one patient did not improve after IVIG, but did so after plasma exchange. 25 GBS patients were treated with IVIG, progression of weakness was stopped in 24; 12 showed complete or near complete recovery and 6 improved markedly. Of 4 patients with CIDP, 2 responded definitely. The majority of patients with MG, GBS, CIDP, respond to IVIG treatment. The effect seems to be equivalent to plasma exchange. In GBS, IVIG may be superior. Side effects of IVIG are negligible, and there is no risk of transmission of AIDS-, hepatitis-, or other viruses.

Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial.

OBJECTIVE: Space-occupying hemispheric infarctions, requiring neurocritical care treatment, demonstrate high mortality and morbidity rates. This study was performed to determine the beneficial effects of decompressive craniotomy on mortality and morbidity rates. DESIGN: Open, nonrandomized, control trial. Outcome was rated at discharge from the hospital (Glasgow Outcome Scale) and at follow-up (Barthel Index, Oxford Handicap Scale). SETTING: Patient recruitment from the Department of Neurology, University of Heidelberg (primary care center) over 65 months. PATIENTS: Thirty-two patients were prospectively selected for surgical treatment; 21 patients were treated conservatively. INTERVENTIONS: Extended craniotomy and dura patch enlargement were performed in all surgically treated patients. MEASUREMENTS AND MAIN RESULTS: At discharge, the outcome of six (18.8%) of 32 surgically treated patients was good compared with 0 (0%) of 21 conservatively treated patients. Fifteen (46.9%) of 32 surgically treated patients were moderately to severely disabled compared with five (23.8%) of 21 conservatively treated patients, and 11 (34.4%) of 32 surgically treated patients died compared with 16 (76.2%) of 21 conservatively treated patients. At follow-up in surgically treated patients, the Barthel Index (mean 62.6) showed an excellent level of daily activity in one patient, minimal assistance (Barthel Index of > or = 60) in 15 patients, and dependency in five patients. The Oxford Handicap Scale indicated no handicap in one patient, moderate handicaps in 15 patients, and moderately severe handicaps in five patients. In the control group, all five surviving patients needed assistance and all but one patient demonstrated a moderately severe handicap. CONCLUSIONS: Hemicraniotomy may improve survival in massive hemispheric stroke victims, decreasing mortality rates to < 35%. The disability rate remains high (24%), although some patients seem to benefit significantly.