[Recurrent pain and swelling of the left leg in a 49-year-old male patient]. / Rezidivierende Beinschwellungen und Schmerzen im linken Bein bei einem 49-jährigen Patienten.

A 49-year-old male patient presented due to recurrent pain and swelling in the left leg. The patient had had deep venous thrombosis with pulmonary embolism 5 years previously. Since then, he had been treated with Vit-k-antagonists. Pronounced paraumbilical collateral circulation of unknown origin was striking. Doppler sonographic evaluation pointed to May-Thurner syndrome. This was confirmed by phlebography. Venous stenting of the stenosis in the left iliac vein achieved long-term symptom improvement. This case report is intended to draw attention to the rare May-Thurner syndrome as an important differential diagnosis of deep vein thrombosis and, at the same time, identify diagnostic and therapeutic treatment strategies.

Home-based alcohol prevention program for parents and children: A randomized controlled trial.

Objective To evaluate the effectiveness of a home-based alcohol prevention program to delay initiation of alcohol use in children. Methods In 2011, a total of 1349 sixth-grade children (M=12.15, SD=0.47) and their mothers who could read and write Dutch were recruited from primary schools in the northern part of the Netherlands. They participated in a cluster randomized controlled trial with two conditions; (1) intervention group (5 modules which families received by mail every 4weeks over 5months), (2) control group (a factsheet information brochure). An independent statistician allocated the schools to the conditions (allocation ratio (1:1)). Participants and data-analyst were blind to randomization. The primary outcome was alcohol initiation. Results Of the participants, 680 were randomized to the intervention and 669 to the control condition. In the intervention condition (N=540) 5.4% of the children drank alcohol compared to 7.1% in the control condition (N=601). The difference was not significant (OR=.99, 95% CI=.96-1.02, p=52). Conclusion The present study showed no effects of 'In control: No alcohol!' on alcohol initiation. A critical evaluation of program design and content, and future studies in different target groups, are suggested. The trial is registered at trialregister.nl, number NTR2474.

[Diagnostics of vascular diseases as a cause for acute abdomen]. / Diagnostik vaskulärer Erkrankungen als Ursache für das akute Abdomen.

Vascular pathologies are rare causes of an acute abdomen. If the cause is a vascular disease a rapid diagnosis is desired as vascular pathologies are associated with high mortality. A differentiation must be made between arterial and venous diseases. An occlusion of the superior mesenteric artery is the most common reason for acute mesenteric ischemia but intra-abdominal arterial bleeding is also of great importance. Venous pathologies include thrombotic occlusion of the portal vein, the mesenteric vein and the vena cava.Multi-detector computed tomography (MDCT) is predestined for the diagnostics of vascular diseases of the abdomen. Using multiphasic contrast protocols enables reliable imaging of the arterial and venous vessel tree and detection of disorders with high sensitivity and specificity. Although conventional angiography has been almost completely replaced by MDCT as a diagnostic tool, it is still of high importance for minimally invasive interventions, for example in the management of gastrointestinal bleeding.

[Biomechanical investigation of fixed-angle plate osteosynthesis of the proximal humerus]. / Biomechanische Untersuchung der winkelstabilen Plattenosteosynthese am proximalen Humerus.

INTRODUCTION: Proximal humeral fractures are common in the elderly population and are often associated with osteoporosis. Fixation of unstable proximal humeral fractures is problematic due to loss of fixation in osteoporotic bone. Fixed-angle devices are intended to provide superior mechanical stability due to the principle of an internal fixator. The NCB(R)-PH (non-contact-bridging proximal humerus) plate is a new fixed-angle device that locks the screws to the plate by secondary insertion of a locking cap. The aim of this study was to investigate if and to what extent NCB-PH plates applied in the locked mode provide higher mechanical stability in a proximal humerus fracture model. METHODS: For this investigation 16 (8 pairs) fresh frozen cadaveric humeri were used. An AO/ASIF 11-B 1 fracture of the proximal humerus was created in each bone and fixed with the NCB-PH plate. In a paired setting one bone was fixed with the plate in the locked mode and the other with the plate in the non-locked mode. The bones were then subjected to 100 cycles of axial loading and interfragmentary motion was measured. Bones surviving this test were subjected to load-to-failure testing and the force at which failure occurred was recorded. RESULTS: Bones fixed with the plate in the locked mode showed a statistically significant lower (51%) interfragmentary rotation compared to bones fixed with the plate in the non-locked mode. There was also a tendency for the bones fixed with the plate in the locked mode to fail first under higher forces (16%) during load-to-failure testing. CONCLUSION: The NCB-PH plate provides superior interfragmentary stability when used in the locked mode in a human cadaveric proximal humerus fracture model. Therefore, we recommend that all screws should be inserted in the locked mode. The results suggest that the NCB-PH plate in the locked mode provides higher primary postoperative stability thus permitting early functional treatment of the patient.

Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography.

The purpose of this study was to explore the accuracy of multi-detector row helical CT (MDCT), using a biphasic mesenteric angiography protocol for evaluation of acute mesenteric ischemia (AMI). In total, 79 consecutive patients with clinical signs of AMI underwent contrast enhanced 16- or 40-channel MDCT. MDCT findings were correlated with surgery, endoscopy and clinical outcome. Sensitivity, specificity, and positive and negative predictive values were calculated using the patients in which AMI had been excluded as a control group. In 28 patients the final diagnosis was AMI. In 27 patients (96.4%) MDCT correctly diagnosed AMI (specificity of 97.9%). A sensitivity of 93%, specificity of 100%, and positive and negative predictive values of 100% and 94%, respectively were achieved for the CT findings of visceral artery occlusion, intestinal pneumatosis, portomesenteric venous gas or bowel wall thickening in combination with either portomesenteric thrombosis or solid organ infarction. Our findings suggest that mesenteric MDCT angiography is an accurate tool for fast diagnostic work-up of patients with suspected AMI.

Pitfalls in detection of acute gastrointestinal bleeding with multi-detector row helical CT.

Contrast-enhanced multi-detector row helical CT angiography is establishing itself as an accurate, rapid, and non-invasive diagnostic modality in patients with acute gastrointestinal bleeding. On arterial phase MDCT images ongoing hemorrhage can be revealed as an area of active extravasation of contrast material within the bowel lumen. This pictorial essay gives a short overview of current diagnostic modalities in assessing acute GI tract bleeding, typical MDCT findings, and depicts potential pitfalls in the detection of acute GI bleeding with MDCT.

Acute gastrointestinal bleeding: value of MDCT.

Contrast-enhanced multidetector row helical computed tomography (MDCT) scanning is establishing itself as a rapid, noninvasive, and accurate diagnostic method in suspected acute gastrointestinal bleeding. Active bleeding can be depicted as an area of focal high attenuation within the bowel lumen on arterial phase MDCT images. New MDCT technologies facilitate three-dimensional image reconstruction, and higher temporal resolution is available with new MDCT scanner generations. This allows for the acquisition of arterial- and portal-venous phase images of the whole abdomen, revealing potential bleeding sources and simultaneously depict morphological changes in the abdomen, such as intestinal tumors. This article gives an overview of available diagnostic modalities in assessing gastrointestinal (GI) tract hemorrhage, with a special emphasis on new MDCT technology.

Evaluation of accordance of magnetic resonance volumetric and flow measurements in determining ventricular stroke volume in cardiac patients.

BACKGROUND: Cardiovascular magnetic resonance imaging (CMR) has become an established noninvasive method for evaluating ventricular function utilizing three-dimensional volumetry. Postprocessing of volumetric measurements is still tedious and time consuming. Stroke volumes obtained by flow quantification across the aortic root or pulmonary trunk could be utilized to increase both speed of workflow and accuracy. PURPOSE: To assess accuracy of stroke volume quantification using MR volumetric imaging compared to flow quantification in patients with various cardiac diseases. Strategies for the augmentation of accuracy in clinical routine were deduced. MATERIAL AND METHODS: 78 patients with various cardiac diseases-excluding intra- or extracardiac shunts, regurgitant valvular defects, or heart rhythm disturbance-underwent cardiac function analysis with flow measurements across the aortic root and cine imaging of the left ventricle. Forty-six patients additionally underwent flow measurements in the pulmonary trunk and cine imaging of the right ventricle. RESULTS: Left ventricular stroke volume (LVSV) and stroke volume of the aortic root (SVAo) correlated with r=0.97, and Bland-Altman analysis showed a mean difference of 0.11 ml and a standard error of estimation (SEE) of 4.31 ml. Ninety-two percent of the data were within the 95% limits of agreement. Right ventricular stroke volume (RVSV) and stroke volume of the pulmonary trunk (SVP) correlated with a factor of r=0.86, and mean difference in the Bland-Altman analysis was fixed at -2.62 ml (SEE 8.47 ml). For RVSV and SVP, we calculated r=0.82, and Bland-Altman analysis revealed a mean difference of 1.27 ml (SEE 9.89 ml). LVSV and RVSV correlated closely, with r=0.91 and a mean difference of 2.79 ml (SEE 7.17 ml). SVAo and SVP correlated with r=0.95 and a mean difference of 0.50 ml (SEE 5.56 ml). CONCLUSION: Flow quantification can be used as a guidance tool, providing accurate and reproducible stroke volumes of both ventricles. Combining both offers a highly accurate tool to gauge ventricular function in a routine clinical setting, increasing workflow speed.

DNA fragmentation in chronic glomerulonephritis: an immunohistological analysis.

BACKGROUND: Experimental data suggest that apoptosis plays an important pathophysiological role in glomerulonephritis by restoring tissue structure after proliferation of intrinsic renal cells and infiltration of leukocytes. Relatively little is known of apoptosis in human glomerulonephritis, particularly in predicting renal function during follow-up. METHODS: In order to colocalize different markers for cell damage in renal tissue from patients with different forms of glomerulonephritis (GN), a series of semithin sections from 34 kidney biopsies were studied retrospectively. Normal kidney from a nephrectomy specimen with a small renal adenocarcinoma served as a control. DNA fragmentation, expression of tissue transglutaminase II, BAX and BCL-2 were visualized immunohistochemically. In some renal biopsies, immunohistochemical staining for activated caspase 3 was performed. Proinflammatory markers (C-reactive protein, leukocytes), serum creatinine, creatinine clearance, total proteinuria, albuminuria, alpha(1)-microglobulin and IgG excretion were determined at the time of biopsy. Serum creatinine and total proteinuria were assessed 6 and 12 months after renal biopsy. RESULTS: Nuclei with different degrees of DNA fragmentation were mainly found in epithelial cells of tubules, but also in glomerular cells, regardless of the form of GN studied. Transglutaminase II expression was found only in cells with a strong staining for DNA fragmentation. DNA fragmentation localized to glomerular cells was more pronounced in proliferative than in non-proliferative forms of GN, being most abundant in patients with rapid progressive GN. Staining for activated caspase 3 in selected biopsies confirmed the presence of apoptosis. BAX and BCL-2 staining was detected within the same cells, but exhibited a different intracellular distribution. In proliferative GN, the extent of DNA damage in tubular epithelial cells significantly corresponds with the concentration of serum creatinine (p < 0.04) and with urinary excretion of alpha(1)-microglobulin (p < 0.01) at the time of biopsy. A significant correlation (p < 0.01) was seen between glomerular DNA fragmentation and follow-up total proteinuria 12 months after biopsy for proliferative forms of GN. The damaged glomerular area (e.g. mesangial sclerosis) significantly correlated with DNA fragmentation in proliferative, but not in nonproliferative GN at the time of biopsy. Furthermore, glomerular damaged showed a significant correlation with tubular DNA damage in proliferative GN. CONCLUSION: In glomerular cells, apoptosis may be important for the clearance of proliferating cells whereas in tubules, cell damage showed dependence on the degree of tubular injury mediated by inflammation and/or proteinuria. Although the degree of apoptosis in tubular cells correlates with serum creatinine in proliferative GN at the time of biopsy, it is of limited use to predict future renal function.

[Complaints in the follow-up of conservatively treated distal radius fractures--predictors in the initial radiograph]. / Beschwerden im Verlauf nach konservativ behandelten distalen Radiusfrakturen--Prädiktoren aus der initialen Röntgenaufnahme.

PURPOSE: Radius fractures are frequent in adults, and the long-term results of conservative treatment remain disappointing. This study examines predictors for the clinical outcome in the initial radiograph. This will help to identify patients who will benefit from surgical treatment. MATERIALS AND METHODS: A cohort study including a standardized telephone interview (Cooney score) was used to identify all conservatively treated patients with a distal radius fracture over a five-year period. The additional selection criteria were: over 15 years old, initial X-ray available, patient reachable by phone for the follow-up interview. The following measurements were taken from the initial radiograph: radius-base angle, radial shortening, radiopalmar angle and intraarticular displacement. Correlations and a simple test to predict negative outcome were computed. RESULTS: Of the initially identified 2211 patients with distal radius fracture, 179 also fulfilled the other criteria. The patients were 56.2 years old on average (standard deviation SD = +/- 22.45 years) and 72 % were female. 60 % of the fractures were on the right side. The average follow-up was 4.3 years (SD +/- 1.66). The Cooney score results averaged 85 points (with 100 being the optimal and maximum score), indicating good or very good functional results in the long term follow-up for 61 % of patients. However, 31 % received a rating of fair or poor and therefore had an unfavorable outcome. With respect to the correlations, age and shortening of the radius (but not gender) had a significant influence on the functional result. Using an age of 75 years or above and a radial shortening of at least 4 mm to predict an unfavorable outcome, the sensitivity is only 16 %, but the positive predictive value is 73 % and the specificity is 96 %. CONCLUSION: In the analysis of the initial radiographs after distal radius fracture, age and radial shortening primarily correlate with functional results after four years after conservative treatment. Using the values age > or = 75 and radial shortening > or = 4 mm, it is possible to predict an unfavorable functional outcome with a positive predictive value of 73 %. This could aid in the indication of operative treatment.

[Interobserver agreement in the assessment of pulmonary infiltrates on chest radiography in community-acquired pneumonia]. / Detektion pneumonischer Infiltrate bei ambulant erworbener Pneumonie: Ubereinstimmung in der Befundung der Röntgen-Thoraxaufnahme.

PURPOSE: To assess interobserver agreement (IOA) in the diagnosis of pulmonary infiltrates on chest x-rays for patients with community-acquired pneumonia (CAP). MATERIALS AND METHODS: From 7/2002 to 12/2005, 806 adults with CAP were included in the multicenter study "CAPNETZ" (7 hospitals). Inclusion criteria were clinical signs of pneumonia and pulmonary opacification on chest x-rays. Each x-ray was reevaluated by two radiologists from the university hospital in consensus reading against the interpreter at the referring hospital in regard to: presence of infiltrate (yes/no/equivocal), transparency (50%), localization, and pattern of infiltrates (alveolar/interstitial). The following parameters were documented: digital or film radiography, hospitalization, fever, findings of auscultation, microbiological findings. RESULTS: The overall IOA concerning the detection of infiltrates was 77.7% (n=626; CI 0.75-0.81), the infiltrates were not verified in 16.4% (n=132) by the referring radiologist with equivocal findings in 5.9% (n=48). The IOA of the different clinical centers varied between 63.2% (n=38, CI 0.48-0.78) and 92.3% (n=65, CI 0.86-0.99). The IOA for the diagnosis of infiltrates was significantly higher for inpatients with 82.6% (n=546; CI 0.80-0.85) than for outpatients with 55.2 % (n=80; CI 0.47-0.63), p<0.0001. The IOA of infiltrates with a transparency >50% was 95.1% (n=215; CI 0.92-0.98) versus 80.4% (n=403; CI 0.77-0.84) for infiltrates with a transparency >50% (p<0.0001). In patients with positive auscultation, the IOA was higher (p=0,034). Chest x-rays of patients with antibiotic therapy or an alveolar infiltrate showed more equivocal findings compared to patients without these features. CONCLUSION: There is considerable interobserver variability in the diagnosis of pulmonary infiltrates on chest radiographs. The IOA is higher in more opaque infiltrates, positive auscultation and inpatients.

DNA fragmentation in acute and chronic rejection after renal transplantation.

Acute and chronic rejections are important denominators for the long-term function of renal grafts. One important indicator of cell damage is enzymatic DNA fragmentation. To investigate possible mechanisms, the rate of DNA fragmentation (TUNEL staining), the expression of tissue transglutaminase II (a marker of advanced DNA damage), and 8-hydroxy-2'-deoxyguanosine (8-OhdG), an indicator of oxidative injury of nucleic acids, were studied by immunohistochemistry. Semithin sections of renal biopsies revealed 23 patients to show acute interstitial rejections (Banff 97 IA, IB); eight patients, acute vascular rejection (Banff 97 IIA, IIB); and 20 patients, chronic allograft nephropathy (Banff 97 I to III). Correlations were calculated between apoptotic cells and serum creatinine at the time of biopsy and after 6 months. In acute rejection, the proximal tubular cells were apoptotic, particularly in regions with mononuclear infiltrates. In consecutive sections, these apoptotic tubular cells also showed damage by reactive oxygen species (positive 8-OhdG staining). Patients with acute interstitial rejection revealed the highest number of tubular DNA fragmentation (14.9 +/- 10.3) versus chronic allograft nephropathy (9.2 +/- 5.6) as TUNEL-positive cells per 80,000 micro m(2) (P < .05). Patients with acute vascular rejection showed a low degree of tubular apoptosis (6.8 +/- 5.1). There was no significant difference in glomerular DNA fragmentation between acute interstitial and chronic rejections: acute interstitial rejection = 7.1 +/- 5.9 versus chronic allograft nephropathy=6.1 +/- 3.9 TUNEL-positive cells per 80,000 micro m(2). There was a significant negative correlation between the degree of tubular (P < .01) and glomerular (P < .05) apoptosis and the serum creatinine at the time of biopsy as well as after 6 months in all patients irrespective of the Banff class. However, there was heterogeneity in the correlation between renal function and the degree of apoptosis in the glomerular and tubular compartments in the various Banff classes. A positive correlation (P < .01) was observed between the degree of tubular apoptosis and serum creatinine at 6 months after biopsy among patients with acute vascular rejection (Banff 97 IIA, IIB). The present data revealed a high degree of tubular DNA fragmentation associated with oxidative stress in acute interstitial rejection. Nevertheless, apoptosis did not generally negatively influence future renal function and may be important to clear proliferating cells. Apoptosis may also play a different pathophysiological role depending on the type of rejection.

[An unusual foreign body in the upper gastrointestinal tract causing nonspecific abdominal pain]. / Ungewöhnlicher Fremdkörper im oberen Gastrointestinaltrakt als Ursache eines unklaren Abdomens.

The risk of penetration of vena cava filters through the wall of the vena cava is estimated to be as high as 25%, although clinical symptoms are observed far less frequently in patients with this complication. Due to the close relationship between vena cava and duodenum, the latter can be injured by dislocated filters. We describe the presentation, evaluation, and treatment of a patient with a cava filter protruding into the duodenum, and we review the literature.

Hemicraniectomy and moderate hypothermia in patients with severe ischemic stroke.

BACKGROUND AND PURPOSE: We compared the clinical course of 36 consecutive patients with severe acute ischemic stroke (more than two thirds of the middle cerebral artery territory) treated with hemicraniectomy (CE; n=17) or moderate hypothermia (MH; n=19) in terms of intracranial pressure control, mortality, and specific treatment parameters. METHODS: Over a period of 18 months, patients with severe ischemic stroke were treated with CE when the nondominant hemisphere was affected and with MH when the dominant hemisphere was affected. MH (33 degrees C) was induced with either cold blankets and fans (n=11) or endovascular cooling (n=8). Intracranial pressure was monitored invasively in all cases. RESULTS: Age, sex, cranial CT findings, level of consciousness, and time to treatment were similar between the 2 groups; significant differences were noted in National Institute of Health Stroke Scale (NIHSS) score (20 [range, 18 to 22] and 17 [range, 16 to 18] for MH and CE, respectively) but were not present when NIHSS score was corrected for aphasia (17 [range, 15 to 19] and 17 [range, 16 to 18] for MH and CE, respectively). Mortality was 12% for CE and 47% for MH; 1 patient treated with MH died as a result of treatment complications (sepsis) and 3 of intracranial pressure crises that occurred during rewarming. Duration of mechanical ventilation and of neurological intensive care unit stay did not significantly differ, but duration of catecholamine application and maximal catecholamine dosage were significantly higher in the MH group. CONCLUSIONS: In patients with severe ischemic stroke, CE results in lower mortality and lower complication rates compared with MH. Both treatment modalities, however, are associated with intensive medical treatment and a prolonged stay in the neurological intensive care unit.

Effect and feasibility of controlled rewarming after moderate hypothermia in stroke patients with malignant infarction of the middle cerebral artery.

BACKGROUND AND PURPOSE: Moderate hypothermia has been found to reduce intracranial pressure (ICP) significantly in patients who have severe middle cerebral artery infarction. However, during passive rewarming, ICP continuously rises and some patients suffer transtentorial herniation. METHODS: We investigated the question of whether slower rewarming leads to slower increase in ICP and slower decrease in cerebral perfusion pressure (CPP). Furthermore, we studied feasibility of slow, controlled rewarming. ICP, CPP, and core body temperature were monitored continuously. Achievement of rewarming protocol was assessed by hit rate of temperature target intervals. Side effects of hypothermia were assessed. RESULTS: Rates of change of both ICP and CPP were correlated significantly with increase in temperature (ICP r=0.62, P=0.002; CPP r=-0.50, P=0.017). In feasibility analysis of 13 controlled rewarmed patients, hit rate of temperature target intervals was 63% (median; range 48% to 81%); hit rate within the target interval or below was 79% (median; range 62% to 94%). CONCLUSIONS: Slow, controlled rewarming is feasible and may be used for ICP and CPP control after moderate hypothermia for space-occupying infarction.

Multimodal online monitoring in middle cerebral artery territory stroke.

BACKGROUND AND PURPOSE: Patients with large middle cerebral artery infarction and elevated intracranial pressure (ICP) who are undergoing invasive intensive care therapy require technical monitoring. However, the effectiveness of the current gold standard, measurement of ICP, is limited. Furthermore, the effects of what is considered to be standard antiedema medical treatment are not fully understood. We studied whether multimodal monitoring can help to overcome this problem. METHODS: ICP, cerebral perfusion pressure (CPP), and partial brain tissue oxygen pressure (PbrO(2)) were continuously measured within the white matter of the frontal lobe unilaterally or bilaterally. We analyzed the effects of antiedema drugs and looked for pattern changes in the PbrO(2) before transtentorial herniation in patients in whom this could not be prevented. Furthermore, complications were registered. RESULTS: We performed 27 measurements in 21 patients. A total of 297 antiedema drug administrations were analyzed in 11 patients. Hyper-HAES and mannitol were most often associated with an increase in CPP and PbrO(2), whereas the use of thiopental and tromethamine led to negative or contrary effects, although ICP was decreased in every case. Pattern changes in the PbrO(2) curve could be observed between 6 to 18 hours before transtentorial herniation. No bleeding complication or infections were observed. CONCLUSIONS: Multimodal monitoring can be used to monitor antiedema drug effects. Our data suggest that with multimodal monitoring, pathophysiological changes could be predicted considerably in advance. ICP alone is of questionable use. Furthermore, this method might help to optimize the timing of invasive therapy in space-occupying infarction.

Different origins of cochlear efferents in some bat species, rats, and guinea pigs.

The origin of olivocochlear efferents was studied in the rat, the guinea pig, and the bats Rhinolophus, Rhinopoma, Tadarida, and Phylostomus by retrograde labeling with HRP and the fluorescent dye fast blue. In all species with the exception of Rhinolophus rouxi two types of cochlear efferents could be found: small neurons located in the lateral superior olive (LSO) and larger ones located bilaterally in the periolivary region. In bats and rats small olivocochlear neurons (OCN) were found only in the ipsilateral LSO. In guinea pigs some small OCN were found also in the contralateral LSO. Large OCN were found in all animals except Rhinolophus. They were organized in a horseshoelike nucleus that extended in a rostrocaudal direction and bent rostrally around the medial superior olive (MSO). This nucleus contains several periolivary nuclei described separately by other authors. In Rhinol. rouxi somata of all olivocochlear efferents are concentrated in a single nucleus between the MSO and LSO, which we therefore call the nucleus olivocochlearis. This nucleus stains for acetylcholinesterase. We consider its neurons to be similar to small OCN, because they are small, associated with the LSO, and only ipsilaterally labeled. This fits well with the fact that Rhinolophus lacks an efferent innervation of outer hair cells (Bishop: Ph.D. Thesis, University of North Carolina, Chapel Hill, '86; Bruns and Schmieszek: Hear. Res. 3:27-43, '80), which are normally innervated by large OCN (Guinan et al: J. Comp. Neurol. 221:358-370, '83).

Topography of projections from the auditory cortex to the inferior colliculus in the rat.

We examined the organization of descending projections from auditory and adjacent cortical areas to the inferior colliculus (IC) in the rat by using the retrograde and anterograde transport of wheat germ agglutinin-horseradish peroxidase. Small tracer injections were placed into cytologically defined subnuclei of the IC. On the basis of the resulting pattern of retrogradely labeled neurons in the cortex, different cortical areas and fields were defined. Two secondary areas located ventrocaudally (Te2) and ventrally (Te3) to the primary auditory area (Te1) were delineated. The primary auditory area was subdivided into a posterior (Te1.p), a medial (Te1.m), and an anterior (Te1.a) auditory field. In addition, we outlined an area located rostrally to the auditory areas comprising a part of the secondary somatosensory cortex, as well as a dorsal belt surrounding dorsally the auditory areas. The following basic patterns of corticocollicular projections are revealed: 1) layers 2 and 3 of the dorsal cortex of the IC (DC2, DC3) are differentially innervated by the primary auditory fields (Te1.p and Te1.a project bilaterally to DC2, while Te1.m projects bilaterally and in topographical order to DC3); cells in Te1.m, arranged in caudal to rostral sequence, project to corresponding loci in DC3 arranged from dorsolateral to ventromedial; 2) the fibrocellular capsule of the IC, comprising layer 1 of the dorsal and external cortex of the IC, receives input from the secondary auditory area Te2; 3) layers 2 and 3 of the external cortex of the IC are only weakly innervated by the primary and secondary auditory cortex; 4) the intercollicular zone receives its major input from the secondary auditory area Te3, the secondary somatosensory cortex, and the dorsal belt; and 5) finally, the central nucleus of the IC receives no input from the temporal cortex at all. Our results demonstrate that the corticocollicular projections are highly organized. These pathways may modulate auditory processing in different functional circuits of the inferior colliculus.

Incidence and prognostic significance of fever following intracerebral hemorrhage.

OBJECTIVE: To investigate the incidence and prognostic significance of fever on presentation and during the subsequent 72 hours in patients with spontaneous supratentorial intracerebral hemorrhage (ICH). METHODS: We analyzed 251 patients. On admission, body temperature, Glasgow Coma Scale (GCS) score, age, sex, blood pressure, blood glucose level, and presumed origin of hemorrhage were analyzed. From the initial CT scan, hematoma volume, location, and presence of intraventricular hemorrhage were determined. From the first 72 hours, hematoma enlargement, duration of increased temperatures, blood pressure, and blood glucose level were determined. Outcome was classified on discharge with the Glasgow Outcome Scale (GOS) score. RESULTS: Outcomes included no symptoms in 23 (9%), moderate disability in 64 (26%), severe disability in 104 (41%), vegetative state in 5 (2%), and death in 55 (22%) patients. Prognostic factors retained from a logistic regression model with a dichotomized GOS scale (GOS score of 1 or 2 versus GOS score of 3 to 5) as response variables were GCS score of 7 or less, age older than 75 years, hematoma volume of more than 60 cm3, ventricular hemorrhage, and presence of a coagulation disorder (p < 0.05). Fever was associated with intraventricular hemorrhage. From 196 patients, data from the first 72 hours were analyzed. A total of 18 patients (9%) had normal temperatures throughout the study. The duration of fever (> or =37.5 degrees C) was less than 24 hours in 66 (34%), 24 to 48 hours in 70 (36%), and more than 48 hours in 42 patients (21%). Independent prognostic factors during the first 72 hours were duration of fever, secondary hemorrhage, GCS score of 7 or less, ventricular hemorrhage, hematoma volume of more than 60 cm3, duration of increased blood pressure of more than 48 hours, and duration of increased blood glucose of more than 48 hours. CONCLUSIONS: The incidence of fever after supratentorial ICH is high, especially in patients with ventricular hemorrhage. In patients surviving the first 72 hours after hospital admission, the duration of fever is associated with poor outcome and seems to be an independent prognostic factor in these patients.

The value of intracranial pressure monitoring in acute hemispheric stroke.

BACKGROUND AND PURPOSE: Persistently elevated intracranial pressure (ICP) has been associated with poor clinical outcome after severe brain injury, such as neurotrauma, intracerebral hemorrhage, and subarachnoidal hemorrhage. Although ICP monitoring is increasingly being used in intensive care treatment of patients with ischemic stroke, its value has not been established. PATIENTS AND METHODS: The clinical course of 48 patients with the clinical signs of increased ICP due to large hemispheric or middle cerebral artery territory infarction defined by CT and subjected to ICP monitoring was prospectively evaluated. Epidural ICP probes were inserted ipsilaterally to the site of primary brain injury in all and also contralaterally in seven patients. Initial clinical presentation was assessed by the Scandinavian Stroke Scale (SSS) and the Glasgow Coma Score (GCS). All patients were treated according to a standardized treatment protocol for elevated ICP. ICP values were correlated with the clinical presentation at the time point of deterioration, with outcome, and with CT findings. Different treatment strategies to lower ICP were analyzed as to their effectiveness. RESULTS: Only nine of the 48 patients survived the infarct (19%). The cause of death was transtentorial herniation with subsequent brain death in all 39 patients. The patients' mean SSS on admission was 20.6 (survivors 21.5 +/- 5.6, nonsurvivors 19.8 +/- 6.5). In all patients clinical signs of herniation preceded the increase in ICP. Patients with ICP values > 35 mm Hg did not survive. CT changes did not always correspond with the measured ICP values. All medical strategies to lower ICP, including osmotherapy, hyperventilation, THAM-buffer, and barbiturates, were initially effective, but only in a minority of patients was ICP control sustained. CONCLUSIONS: ICP monitoring of large hemispheric infarction can predict clinical outcome. Pharmacologic intervention had no sustained effect. ICP monitoring was not helpful in guiding long-term treatment of increased ICP. It remains doubtful that ICP monitoring in acute ischemic stroke has a positive influence on clinical outcome.