Iatrogenic lesions of peripheral nerves.

Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.

Oral diadochokinesis and velocity of narrative speech: a prognostic parameter for the outcome of diffuse axonal injury in severe head trauma.

AIM: To investigate dysarthria in severe traumatic brain injury following an acceleration/deceleration trauma and to correlate results with the severity of head trauma. METHODS: Oral diadochokinesis by testing alternating (/pa/, /ta/and/ka/) and sequential motion rates (/pataka/and/tana/) and contextual speech, which comprises narrative speech and text reading, were examined in 15 patients in the chronic stage after severe closed head trauma with diffuse axonal injury. A possible influence of the severity of brain injury, expressed by the duration of post-traumatic amnesia, was examined. RESULTS: Oral diadochokinesis of alternating motion rates and velocity of narrative speech were significantly reduced in traumatic brain injury. Both parameters correlated highly significantly with each other and correlated with the severity of brain injury described by the duration of post-traumatic amnesia. Reading speed was not comparable with narrative speech. Reading speed did not correlate with diffuse axonal injury but was strongly influenced by parameters that also influenced mental abilities. CONCLUSION: Oral diadochokinetic abilities of alternating motion rates and velocity of narrative speech represent a possible additional prognostic parameter for the outcome of traumatic brain injury in diffuse axonal injury.

Do somatosensory evoked potentials in traumatic brain injury patients indicate brainstem generators for frontally recorded N18, P20 and cervical N13?

PRIMARY OBJECTIVE: To examine the generator of frontal somatosensory evoked potentials by studying patients with traumatic brain injury in the chronic phase. RESEARCH DESIGN: A prospective, non-comparative case series. METHODS AND PROCEDURES: Median nerve somatosensory evoked potentials were performed in 26 survivors of severe traumatic brain injury, which had taken place at a mean of 7 months before. Potentials of short latency somatosensory evoked potentials were recorded simultaneously over the frontal and parietal scalp. MAIN OUTCOMES AND RESULTS: Frontally recorded latencies N18, P20 and N13 recorded from C2 correlated highly significantly with the duration of coma (p<0.01), a history of raised intracranial pressure (p<0.05) and with each other (p<0.01) in traumatic brain injury patients. CONCLUSIONS: These findings indicate that frontally recorded N18, P20 and N13 recorded from C2 are generated in part in the brainstem, which becomes damaged by increased intracranial pressure due to secondary injury in severe traumatic brain injury.

Pediatric care report of spinal cord injury without radiographic abnormality (SCIWORA): case report and literature review.

STUDY DESIGN: Case report of SCIWORA following trivial trauma in childhood and review of the literature. OBJECTIVES: To describe a case of 'spinal cord injuries without radiographic abnormality (SCIWORA)', which was diagnosed 2 years after the event, and define its relevance from a differential diagnostic and medico-legal viewpoint. SETTING: An Austrian neuro-traumatological rehabilitation and workers' insurance appraisal center. METHODS: A 12-year-old patient is presented who suffered an ischemic spinal lesion of unknown origin on her way home from school. The patient was reinvestigated as part of an insurance appraisal 2 years later. The aim of this investigation was to elucidate the origin of the spinal cord lesion, in particular, whether it was because of accidental trauma or because of a preexisting condition (eg vascular malformation). RESULTS: SCIWORA due to a trivial trauma was diagnosed during the reinvestigation. This was of importance for the patient because of accident insurance coverage. CONCLUSION: In children developing a quadroparesis following a minor trauma, spinal cord injury without radiographic abnormality must be considered in the differental diagnosis.

Altitudinal neglect in a patient with occipital infarction.

Visual neglect has been frequently described in a horizontal direction. Altitudinal neglect, however, has rarely been described and has been associated with bilateral lesions in the parieto-occipital or temporo-occipital region. The following case report presents a patient with marked altitudinal neglect of the inferior space which was elicited using a line bisection test. The previously healthy patient had well-defined lesions solely in the occipital cortex following an embolic infarction. The present case report underlines the possibility that bioccipital lesions themselves can be responsible for altitudinal neglect.

Glutathione in the prevention of cisplatin induced toxicities. A prospectively randomized pilot trial in patients with head and neck cancer and non small cell lung cancer.

PURPOSE: Glutathione has been shown to be an effective chemoprotector against cisplatin-induced side effects in patients with ovarian cancer. In view of this fact, we performed a randomized clinical pilot-trial in the management of other solid tumors in order to compare application of Glutathione to intensive hydration in patients undergoing chemotherapy with a regimen including cisplatin. PATIENTS AND METHODS: Twenty patients suffering from advanced non small cell lung cancer (n = 6) or head- and neck cancer (n = 14) were enrolled in the study. All patients received 80 mg/m2 cisplatin along with etoposide or 5-fluorouracil every 4 weeks. Patients randomized to application of Glutathione (n = 11) received 5 g of Glutathione immediately before application of cisplatin followed by 2000 ml of normal saline. Patients in the control group (n = 9) received 2000 ml electrolyte infusion before and 2000 ml of normal saline with forced diuresis after cisplatin. RESULTS: The intensity of hematologic toxicity was significantly less pronounced in patients treated with Glutathione than in the control group (hemoglobin: 10.7 vs 9.5 mg% respectively, p = 0.039; white blood cell count 3.3 vs 2.2 x 103/microliter respectively, p = 0.004; platelets 167 vs 95 x 103/microliter respectively, p = 0.02), whereas in terms of non-hematologic toxicity no difference was observed. Objective remission occurred in 6 out of 11 evaluable patients from the group receiving Glutathione (55%; complete remission: 9%; partial remission: 46%), and in 4 out of 8 evaluable patients from the control group (partial remission: 50%). However, there was no statistical difference in terms of response and overall survival (13.5 months vs. 10.5 months) between the two groups. CONCLUSIONS: Application of Cisplatin and Glutathione seems to be safe and feasible and the antitumoral efficacy of cisplatin is apparently not impaired by the concomitant use of Glutathione in patients with solid tumors.

[Psychosocial sequelae after severe head injury. Interviews with patients and their relatives in comparison]. / Psychosoziale Folgen schwerer Hirnverletzungen. Interviews mit Patienten und Angehörigen im Vergleich.

Head injury patients often suffer from psychosocial sequelae in the long-term. Since patient reports are regarded as little reliable due to lack of awareness, we compared the patients' to the relatives' view of such sequelae. By means of a semi-structured interview, 37 patients and their relatives were investigated on average 4.4 years after severe head injury. Psychosocial and neuropsychological effects were markedly severe in most cases. However, patients' compared to relatives' perspectives differed significantly only regarding report of aggressive-disinhibited behaviour of the patients, which was more often reported on by the relatives than by the patients themselves. This difference was also found in respect of pre-injury behaviour. Surprisingly, in six patients "positive" psychosocial sequelae were reported. For example, a patient said he had become more tender and more serious. Residual morphological findings in these six patients were either rather minor, or marked left-brain lesions. We conclude that the patients' significant other signs should be included in diagnostic and therapeutic efforts of rehabilitation procedures. Since besides neuropsychological factors psychosocial factors seem to influence outcome after brain injury, psychotherapeutic techniques should be more intensively studied in treatment of head injury patients.

Outcome after shunt implantation in severe head injury with post-traumatic hydrocephalus.

OBJECT: Post-traumatic hydrocephalus (PTH) is considered a frequent complication after severe head injury (HI). There is little known about outcome following shunt implantation. METHODS: A hospital-based retrospective cross-over study investigated the outcome of 48 patients after severe HI, who had undergone ventricular shunt implantation due to PTH (40 males, mean age at injury 36 years, mean duration from HI to shunt implantation 27 weeks). Telephone interviews with the patients or with caring family members by means of a detailed questionnaire were performed after a mean observation period of 3.3 years after shunt implantation. Outcome was categorized using the Glasgow Outcome Scale (GOS): I: 12 patients, II: 7, III: 16, IV: 9, V: 4 at follow-up. CONCLUSIONS: 52.1% had a clear-cut benefit from shunt implantation, whereas 47.9% had not. Post-traumatic seizures were observed in 31 of 48 patients. Other complications after shunt implantation occurred in 20) patients. Revision of shunt implantation was performed in 15 patients (nine due to technical failure, three haemorrhage, one delayed primary wound closure, and two unknown). Two patients clearly deteriorated after operation (one severe frontal bleeding, one sepsis). The best predictive parameter for outcome after shunt implantation was the pre-operative status, patients in a better clinical condition (pre-operative GOS score 3-severe disabled vs 4-persistent vegetative state) had a better outcome. Patient's age at injury did not seem to influence the outcome. Clinical and computertomographic findings were of rather moderate predictive value as regards short- and long-term outcome after shunt implantation. Cisternography does not seem to be of additional help in the establishment of definite diagnosis of PTH.

The impact of apolipoprotein E genotypes on age at onset of symptoms and phenotypic expression in Wilson's disease.

Wilson's disease is a disorder of biliary copper excretion that may result in severe neurological symptoms and advanced liver disease. The wide variation of phenotypic disease expression cannot be fully explained by the different mutations of the Wilson disease gene. In neurological disorders, such as Alzheimer's disease, temporal lobe epilepsy and cerebral trauma, the presence of the apolipoprotein E (ApoE) allele epsilon4 is associated with an increased vulnerability of the brain to the effects of the disease, whereas the presence of the ApoE genotype epsilon3/3 appears to provide moderate neuroprotection. We examined whether this hypothesis holds true for the development of neurological symptoms in patients with Wilson's disease. The ApoE genotype and the H1069Q mutation (the most common in Wilson's disease) status were determined by polymerase chain reaction-based mutation assays in 121 well-characterized, symptomatic index patients with Wilson's disease. An investigation profile was established in which the patients were grouped according to the clinical symptoms at presentation, the ApoE genotypes and the status of the H1069Q mutation. Fifty-nine per cent of the 121 patients had the allele combination ApoE epsilon3/3 (21% ApoE epsilon3/4, 19% ApoE epsilon3/2, 1% ApoE epsilon4/2). The distribution of ApoE genotypes did not deviate from known distributions in healthy European subjects. Within the group of 40 H1069Q-homozygous patients, the onset of symptoms was significantly delayed in patients with the ApoE epsilon3/3 genotype (25 +/- 6 years at presentation) compared with patients with the ApoE epsilon3/4 genotype (20 +/- 3 years at presentation). In this study, the ApoE genotype was established as an important factor delaying the onset of neurological and hepatic symptoms, but not modifying phenotypic disease expression in a homogeneous group of patients with Wilson's disease (all H1069Q-homozygotes, similar genetic background). The presence of ApoE epsilon3/3 attenuates clinical manifestations in Wilson's disease by mechanisms which might involve the antioxidant and membrane-stabilizing properties of the ApoE 3 protein.

Hypoplasia, stenosis and other alterations of the vertebral artery: does impaired blood rheology manifest a hidden disease?

OBJECTIVES: The clinical relevance of abnormal vessel findings in the posterior circulation is still a matter of controversy. PATIENTS AND METHODS: We compared 48 patients displaying sonographic abnormalities of one vertebral artery, i.e., vertebral artery hypoplasia in 24 cases, stenosis in 13 cases, plaques in 11 cases, with 25 healthy subjects in terms of whole blood viscoelasticity and plasma viscosity. RESULTS: All patients with stenosis and plaques suffered from clinical signs and symptoms of ischemic cerebrovascular disease, predominantly in the posterior circulation. Free of acute clinical symptoms were 5 of the 24 patients with hypoplasia. Highly statistically significant differences in blood viscoelasticity were found between the patients and the healthy subjects. As regards differences between the groups, whole blood viscoelasticity was most impaired in stenosis, shear resistance was significantly higher in stenosis compared to hypoplasia. Symptom-free patients with one-sided vertebral artery hypoplasia had a significantly better, nearly normal blood rheology at a low shear rate (10/s), compared to clinically symptomatic patients with hypoplasia. CONCLUSION: The results of the present study offer some evidence that altered hemorheology may be associated with symptomatic vertebrobasilar occlusive disease.

[Neurological and psychosocial sequelae 4 and 8 years after severe craniocerebral injury: a catamnestic study]. / Neurologische und psychosoziale Folgen 4 und 8 Jahre nach schwerer Schädelhirnverletzung: eine katamnestische Studie.

Thirty-three patients (29 male, 4 male) were examined 4 and 8 years after severe head injury. The patients underwent a detailed neurological examination. A semistructured interview according to the Glasgow Assessment Schedule was administered to the patients and their relatives. Most frequent neurological features were motor deficits (55%, at both follow-up investigations, mostly monoparesis), dysarthria (39% versus 33%), ataxia (49% versus 39%) and anosmia (46% versus 33%) at 4 and 8 years, respectively. There was a slight, but not significant improvement between the 2 examinations with respect to frequency and severity of neurological impairment. There was no significant improvement in the activities of daily living and 18% remained totally dependent on other people's help. At both follow-ups 85% complained of memory deficits. 67% and 70% respectively, suffered from poor initiative and increasing irritability at the first and second examination. The patients were more socially isolated and more irritable at the second follow-up. Only 12% and 18%, respectively held the same job as they had had before the injury; nearly half of them had retired. Occupational and psychosocial reintegration appeared to be rather poor in many patients. Excessive alcohol intake prior to trauma was identified as a person-related predictive factor. In contrast to other studies we found persistent, although slight neurological deficits. In the long-term, a combination of neurological and neuropsychological deficits seems to contribute to residual handicap.

Psychosocial long-term outcome of severe head injury as perceived by patients, relatives, and professionals.

OBJECTIVE: We systematically compared information on psychosocial outcome of severe head injury (SHI) gathered from different informants. MATERIAL AND METHODS: We evaluated psychosocial outcome in 33 subjects 8.1 +/- 1.4 years after having suffered SHI using data gathered from the patients themselves, caring relatives, and an assessing neurologist. RESULTS: Our data confirm long-lasting negative effects of SHI on psychosocial functioning even in patients with only mild or moderate neurological impairment. Specific problems in social intercourse, stemming from impaired self-control, are regularly reported by the relatives and probably underestimated by the patients and by the doctors. In contrast, we found a remarkable agreement between self-report and professional estimation in other aspects of psychological consequences of SHI such as depressed mood and social withdrawal. CONCLUSIONS: Our results challenge the common view that patients having suffered from severe SHI are altogether unreliable informants. However, SHI patients tend to have difficulties in monitoring their specific problems of control of behaviour in social relationships. Therefore information gathered from the caring relatives should always be included when evaluating psychosocial sequels of severe SHI.

Dopamine D2 receptor binding is reduced in Wilson's disease: correlation of neurological deficits with striatal 123I-iodobenzamide binding.

To visualise and quantify dopamine D2 receptor binding in the corpus striatum of patients with neurological Wilson's disease (WD) 123I-Iodobenzamide (IBZM) binding was measured using single photon emission computer tomography (SPECT). Ratios of striatal to frontal countrates were calculated in 8 patients and in 21 healthy control subjects. We found reduced IBZM binding ratios in all patients with WD in comparison to those in controls (1.48 +/- 0.13 vs. 1.73 +/- 0.09). The reduction in IBZM binding was correlated with the overall severity of neurological deficits and the severity of dysarthria (correlation coefficients -0.86 [p < 0.01] and -0.79 [p < 0.01], respectively). When patients of three different subgroups of neurological WD were compared no differences in IBZM binding were found. We conclude that assessing basal ganglia function in vivo using IBZM-SPECT is a valuable diagnostic tool in WD.

Serial recording of sensory evoked potentials: a noninvasive prognostic indicator in fulminant liver failure.

Sensory evoked potentials are markedly changed in patients with fulminant liver failure. It is unknown, however, whether serial recordings of sensory evoked potentials provide useful prognostic informations for patient management in fulminant liver failure. Ninety recordings of bilateral median nerve-stimulated short- and long-latency sensory evoked potentials were performed in 25 patients with fulminant liver failure (9 patients spontaneously recovered and survived, 8 patients were referred to emergency liver transplantation and 8 patients died). In all nine survivors the cortical long-latency sensory evoked potential N70 peak was constantly detectable between 74 and 162 ms. In all eight patients who subsequently underwent liver transplantation and in seven of eight patients who died, loss of the N70 peak developed during the course of fulminant liver failure. In 4 of 15 patients who were selected for liver transplantation according to the King's College criteria, the N70 peak was constantly detectable. All four transplantation candidates spontaneously recovered and survived without transplantation. In contrast, eight patients never did fulfill the criteria for liver transplantation. Five of them with constantly detectable N70 peak recovered spontaneously. However, in the remaining three patients loss of the N70 peak developed, and they ultimately died. The probability of correct outcome prediction by sensory evoked potentials is superior to that based on clinical criteria alone (0.96 vs. 0.72). Therefore serial recording of sensory evoked potentials may help identify (a) a subgroup among liver transplantation candidates who may spontaneously recover without transplantation and (b) a subgroup of patients with severe brain dysfunction who should undergo early liver transplantation even though they do not fulfill King's College criteria.

Tactile mental imagery in sighted persons and in patients suffering from peripheral blindness early in life.

Patterns of cortical activity as measured by scalp-recorded event-related slow negative DC potential shifts were recorded in 9 early blind and 23 sighted normals while they imagined the feel of textures with the fingertips of one hand. All sighted subjects reported to have concomitant visual imagery as well. Hence, it was not surprising to observe occipital negative shifts, previously described as a sign of occipital visual cortex involvement in visual mental imagery. Though having never had visual perception, the blind, too, had occipital negativities. Their absolute amplitudes were smaller than in the sighted, not only occipitally but also and more pronounced at other areas, particularly frontally where amplitudes were even positive. On the hypothesis that the smaller overall amplitudes in the blind could obscure topographical differences between groups, the relative distribution of negativity across the scalp was assessed, using normalized data. Such normalized parameters significantly differed between groups, indicating that the occipital potentials of the blind were relatively more negative as related to the other scalp areas, than were the occipital potentials of the sighted as related to the other scalp areas. This occipital finding might indicate a participation of the blind's visually deprived occipital cortex in tactile imagery. Second, parietal DC potentials were maximal over the hemisphere contralateral to the imaging hand, possibly indicating involvement of the contralateral parietal association cortex in tactile imagery. Reasons why this was true only for the sighted, are discussed.

Cranial MR imaging and cerebral 99mTc HM-PAO-SPECT in patients with subacute or chronic severe closed head injury and normal CT examinations.

Eighteen patients in the subacute or chronic state following severe closed head injury with normal cranial CT scans were examined by MR and 99mTc HM-PAO SPECT. Correlations were sought between these 2 imaging modalities and the clinical outcome, as defined by the Glasgow Outcome Scale (GOS) score. Both MR and SPECT revealed cerebral damage in all patients examined but structural and functional alterations did not coincide topographically in 64.9% of lesions. Nevertheless, complementary injury patterns suggesting poor recovery were found; cortical contusions and diffuse axonal injury (MR) in conjunction with cortical and thalamic hypoperfusion (SPECT) were noticed in 8 out of 12 patients with unfavorable outcome (GOS = III and IV). The synthesis of MR and SPECT information clearly enhanced the ability both to accurately assess posttraumatic brain damage and to improve patients' outcome prediction.

Posturographic measurement of body sway in survivors of severe closed head injury.

Postural imbalance was measured in 39 survivors of severe closed head injury 7 to 66 months after head injury using a posturographic platform. The results were compared with those derived from age-matched healthy control subjects. Severe postural imbalance, particularly in an anteroposterior direction, was found in 16 patients, whereas 9 patients showed moderate imbalance and 14 patients showed normal results in the posturographic investigation. Low initial Glasgow Coma Scale scores and deep parenchymal brain lesions demonstrated by magnetic resonance imaging were shown to be significant indicators of subsequent severe postural imbalance. The duration of posttraumatic amnesia, the localization and size of cortical contusions and subcortical white matter lesions, on the contrary, were not associated with postural imbalance in the long-term outcome.

Wilson's disease: evidence of subgroups derived from clinical findings and brain lesions.

Using exploratory factor analysis, we prospectively investigated neuropsychiatric symptoms and structural brain lesions of 47 patients with proven Wilson's disease and identified three subgroups. The first subgroup clinically exhibited bradykinesia, rigidity, cognitive impairment, and an organic mood syndrome and by MRI showed a dilatation of the third ventricle. The second subgroup was characterized by ataxia, tremor, reduced functional capacity, and focal thalamic lesions. The third subgroup showed dyskinesia, dysarthria, an organic personality syndrome, and focal lesions in the putamen and in the pallidum.

Different risk factor profiles in young and elderly stroke patients with special reference to cardiac disorders.

The risk factors of ischemic cerebrovascular disorders in 77 young patients (< or = 40 years) were compared to those in 138 older patients (> 40 years). The risk factor profile of patients with juvenile stroke was considerably different from that of older patients. Migrainous headache and mitral valve prolapse occurred more frequently in the younger age group, whereas hypertension, diabetes mellitus, high levels of cholesterol and triglycerides were found more often in older patients with stroke. 65% of the women under the age of 40 took oral contraceptives which compares to the baseline community value of 28% of women in childbearing age in this country. Cardiac disorders such as atrial fibrillation, left ventricular hypertrophy, coronary heart disease including a history of myocardial infarction, as well as mitral valve disease were demonstrated more often in the group of elderly patients. 7 out of 77 younger patients (9.1%), and 59 out of 138 older patients (42.8%) were considered to belong to a group with "high cardiac risk for stroke". The results of this study indicate that electrocardiographic screening is of prime importance for detecting cardiac risk factors. However, echocardiographic examination often yields additional diagnostic information, particularly in younger patients. The conflicting opinions concerning the relevance of certain risk factors for ischemic stroke could partly be explained by the fact that these risk factors are distributed unevenly depending on age.

Behavioural and psychosocial sequelae of severe closed head injury and regional cerebral blood flow: a SPECT study.

Thirty six patients (31 male, 5 female) who had suffered severe closed head injury were re-examined at an average of 39.3 (SD 12.8, range 7-66) months after the injury. Behavioural symptoms were measured using the Giessen test. The relatives' reports were used for data analysis to ensure that results were valid. The neurophysical impairment subscale of the Glasgow assessment schedule was completed by two neurologists, and the number connection test was completed by each patient. The adjective mood scale was completed by each relative. All patients were investigated by single photon emission computerised tomography (SPECT). Exploratory factor analysis using the principal components method was carried out separately for SPECT results and psychological measures and correlations were sought between the resulting factors. Factor analysis of the data from the Giessen test identified social isolation, disinhibition, and aggressive behaviour as major components of post-traumatic personality changes; it indicates that these behavioural features are independent of the level of neurological and neuropsychological impairment, which loaded on a single independent factor. Relatives' psychic health seemed to be relatively resistant to physical and cognitive disability and was mainly affected by disinhibitive behaviour. The highest correlation was between frontal flow indices and disinhibitive behaviour (p less than 0.01): the severity of disinhibition increased with lower frontal flow rates. There was a significant but somewhat weaker correlation (p less than 0.05) between flow indices of the left cerebral hemisphere and social isolation. Low flow values of the right brain regions were related to aggressive behaviour (p less than 0.05). Neurological and cognitive impairment correlated negatively with the thalamus; worse neurological and cognitive performance indicate by raised scores on the neurophysical scale and on the number connection test was associated with low thalamic flow values. The results support the importance of lesion location in the production of post traumatic behavioural disorders.