[Neurological and psychiatric expert assessment of post-COVID syndrome]. / Neurologisch-psychiatrische Begutachtung des Post-COVID-Syndroms.

Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to a multiorgan disease and subsequently to very different clinical manifestations of coronavirus disease 2019 (COVID-19). In addition to acute symptoms, the long-term complaints in the context of the infection, known as long or post-COVID syndrome, are increasingly attracting attention. With respect to social insurance systems, expert opinions of such problems will become more and more important, whereby neurological and psychiatric symptoms are the most frequent complaints. In addition to the legal principles of the medico-legal assessment with a focus on statutory accident insurance, this overview article discusses the principles of expert assessment and presents landmarks for the expert opinion of the most frequent neurological and psychiatric symptoms occurring in the context of post-COVID syndrome.

[Ability to drive with cerebrovascular diseases : Position paper of the German societies DGNB, DGN, DGNC, DGNR, DSG and GNP]. / Fahreignung bei Hirngefäßerkrankungen : Positionspapier der DGNB, DGN, DGNC, DGNR, DSG und GNP.

The regulations for ability to drive with cerebrovascular diseases in the German Driving License Regulations (Fahrerlaubnisverordnung, FeV) and German Guidelines for the Evaluation of Driving Ability of the Federal Highway Research Institute (BASt) are not up to date with the current medical knowledge and are not consistent with comparable regulations regarding cardiovascular diseases. This is particularly true for the assessment of future risks for a sudden loss of control during driving. The present position paper of six medical and neuropsychological societies in Germany presents the current conditions for the assessment of driving ability of patients a cerebrovascular diesease and recommends an estimation of the ability to drive founded on the current state of scientific knowledge. It addresses the following: 1. Physical and mental functional limitations and the possibilities for compensation, which if necessary enable a fitness to drive under conditions or within limits, including the importance of behavioral or personality changes and cognitive deficiencies that interfere with safety. 2. The potential danger due to a sudden loss of control as a result of a transient ischemic attack (TIA) new stroke event, or another cardiovascular event while driving. A summary in the form of a table provides physicians and expert assessors with assistance for the most important cerebrovascular diseases.

[Guideline "Legal evaluation after closed brain injury in adulthood"]. / Leitlinie "Begutachtung nach gedecktem Schädel-Hirntrauma im Erwachsenenalter".

In 2005 and 2013, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Evaluation) together with other societies developed and consented guidelines fort the legal evaluation of patients with closed head injuries and published them trough the National Working Group of Scientific Medical Societies and in this journal. Five years later, a revision was necessary, this was developed on the higher S2 k level of consent through a Delphi conference.

[Principles of evaluating driving ability for neurological and psychiatric diseases]. / Grundlagen der Fahreignungsbeurteilung bei neurologischen und psychischen Erkrankungen.

If attending physicians and psychologists recognize restricted or a lack of driving ability they are obliged to inform their patients appropriately. In Germany the legal basis for assessing driving ability is the "Fahrerlaubnis-Verordnung" (FeV, driving licence act), supplemented by guidelines for evaluating driving ability. In each individual case it has to be clarified whether and to what extent permanent or paroxysmally occurring disorders affect driving ability and whether lack of insight ability or personality defects are a threat to driving safety. In addition, it has to be considered whether compensation opportunities exist that enable restricted driving ability. If an expert opinion is requested by the driving licence authority in Germany the medical expert must have a specific qualification and should not be the attending physician.

[The German guideline "legal evaluation after closed head injury"]. / Die leitlinie "begutachtung nach gedecktem schädel-hirntrauma".

In 2005, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Legal Evaluation) together with other Societies published a guideline for the legal evaluation of patients with closed head injuries. Meanwhile, not only scientific progress in imaging techniques but also in other fields such as neuropsychology has necessitated a revision, which is presented here. In the mean time, the handling of guidelines has been systematised in Germany so that a registration with the Cooperation of German Medical Learned Societies is applied for and publication in the German Guideline Registry is expected.

[Expert opinions in German statutory accident insurance]. / Begutachtung von Unfallfolgen in der gesetzlichen Unfallversicherung.

German statutory accident insurance covers employees and trainees against occupational accidents, employers bear the inherent charges. Expert opinion is obtained, in particular, for discussing causality questions and for rating accidental health disorders. Causality has to be estimated based on the "theory of essential condition", health disorders have to be substantiated without any reasonable doubt. Reduction in earning capacity due to an accident may not consider the individual kind of occupation and has to be rated by an abstract approach.

[Assessment of psychological consequences of trauma]. / Begutachtung psychischer Unfallfolgen.

After accidents psychological consequences are often asserted. This may be due to the traumatic experience itself, the experience of severe physical injury or to the experience of a traumatic hospital treatment. The pivotal point of the medicolegal assessment is the evidence of primary mental or physical damage that has to be documented beyond a reasonable doubt in all areas of law. A medicolegal assessment in five steps is proposed.

[Revision of DEGUM ultrasound criteria for grading internal carotid artery stenoses and transfer to NASCET measurement]. / Ultraschallkriterien zur Graduierung von Stenosen der A. carotis interna - Revision der DEGUM-Kriterien und Transfer in NASCET-Stenosierungsgrade.

Since 1986, German ultrasound criteria for grading carotid stenosis have followed the local diameter reduction percentage consistent with the definition used in the European Carotid Surgery Trial (ECST) definition. To overcome the confusion caused by the coexisting grading method used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET), a German interdisciplinary council on carotid artery stenosis has recommended the implementation of the NASCET grading system (distal diameter reduction percentage) as the standard. The multi-parametric German "DEGUM ultrasound criteria" consisting of combined Doppler and imaging criteria have consequently been revised and transferred to the NASCET definition. In addition, a novel differentiation between main (primary) and additional (secondary) criteria has been proposed. When these ultrasound criteria are combined, vascular sonography allows reliable grading of carotid disease.

[Symptom validity tests in psychiatric assessment: a critical review]. / Kritische Bestandsaufname zum Einsatz von Beschwerdenvalidierungstests in der psychiatrischen Begutachtung.

Neuropsychological symptom validity testing is increasingly used even in psychiatric expert assessment. Low scores on symptom validity tests can only demonstrate exaggerated symptoms. However, symptom validity tests do not address the question of whether the result is intentionally produced or motivated by internal incentives. Therefore, symptom validity tests cannot differentiate between malingering and somatoform disorder. Test results have to be considered carefully in the medicolegal context and require thorough clinical assessment.

A new sensitive method for the quantification of internal carotid stenoses by means of ultrasound Doppler signal processing.

A new way of processing the ultrasound Doppler spectrum is presented. By introducing a Disturbance Index (DI), based on a double Fourier transformation, the quantitative evaluation of blood flow disturbance is possible. The integral value of this index over the whole cardiac cycle can be used to quantify the degree of lower grade internal carotid artery (ICA) stenoses and plaques. In a preliminary study, this new method has been tested in 18 normal and 10 atherosclerotic carotid arteries against Duplex-scan and angiography. The results were compared with 5 alternative methods of processing the Doppler spectrum.

Vascular effects of oxytocin on human middle cerebral artery determined by transcranial Doppler sonography.

Neurohypophysial hormones may exert regulatory influences on cerebral blood flow. This double-blind cross-over study in healthy humans (n = 6) examined effects of oxytocin (OX) on blood flow in the middle cerebral artery (MCA) by transcranial Doppler sonography. Compared to placebo, intravenous infusion of OX (0.5 IU, within 2.5 min via a forearm catheter) reduced blood flow velocity (V) within 10 min after the start of the infusion (P < 0.05). The pulsatility index (PI) was at the same time increased following OX (P < 0.05). The effects of OX were not accompanied by changes in expiratory endtidal pCO2 or blood pressure. But, heart rate was slightly enhanced immediately after infusion of OX (P < 0.05). The changes in MCA blood flow velocity following OX could reflect a vasoconstrictory effect on small cerebral resistance vessels or a vasodilating effect on the large cerebral arteries.

Differentiating subtotal carotid artery stenoses from occlusions by colour-coded duplex sonography.

During a 9-month period the carotid arteries of 2420 consecutive patients were investigated by conventional Doppler and duplex ultrasonography as well as by colour-coded duplex sonography. Of 186 internal carotid arteries showing a diameter reduction at the bifurcation level of 95% or more by conventional techniques, 131 underwent X-ray angiography which revealed a subtotal stenosis in 25 and an occlusion in 106 cases. Using a total of ten criteria for describing the colour-coded duplex findings, the "distal colour filling", a combination of three single criteria, could be found in all subtotal stenoses and none of the occlusions. "Distal colour filling" was diagnosed if a colour signal was present for a length of at least 1.5 cm directly behind an assumed stenosis comprising the whole area between the vessel walls. Our results suggest that non-invasive colour-coded duplex sonography is superior to conventional Doppler and duplex techniques and comparable to invasive X-ray angiography in differentiating extracranial subtotal carotid artery stenoses from occlusions.

Carbon dioxide reactivity and patterns of cerebral infarction in patients with carotid artery occlusion.

A total of 106 patients with 112 internal carotid artery occlusions were investigated by cranial computed tomography and transcranial Doppler ultrasonography (CO2 test), giving a measure of the cerebrovascular reserve capacity. The morphological patterns of the ischaemic lesions were classified into three categories: lacunar, thromboembolic and haemodynamic infarctions. Of 29 patients with an exhausted CO2 reactivity, 19 showed a haemodynamic type of infarction, whereas of 45 cases with a normal CO2 reactivity only 2, and of 38 patients with a diminished CO2 reactivity only 3 had haemodynamically caused infarctions (P less than 0.001). The correlation between an exhausted CO2 reactivity and the presence of haemodynamic infarctions could be of value for therapy in patients with carotid artery occlusions.

Favourable effect of flunarizine on the recovery from hemiparesis in rats with intracerebral hematomas.

In 25 rats, an intracerebral hematoma was created in the foreleg area of the motor cortex by injection of 50 microliters blood. After the lesion, 13 were treated with flunarizine and 12 with the solvent. Neurological testing was performed by measuring the running time on a rotating platform. In animals with hemiparesis, the flunarizine group (n = 7) showed a significantly (P less than 0.05) better recovery than the control group (n = 8). No significant differences occurred in animals without neurological deficits (flunarizine: n = 6, control: n = 4). So the effect of the drug is not due to a non-specific activation; it may partially cure neurological deficits caused by intracerebral hematoma.

Small rosarylike infarctions in the centrum ovale suggest hemodynamic failure.

BACKGROUND AND PURPOSE: Lesions in the centrum ovale may be classified as microangiopathic (lacunar) lesions and hemodynamic infarctions. To distinguish between them, a size of more than 2 cm has been postulated for hemodynamic infarctions. The reliability of this criterion was assessed with MR imaging. METHODS: In 16 patients with unilateral or bilateral occlusion or high-grade stenosis of the internal carotid artery (ICA), CO2 testing revealed an ipsilateral hemodynamic failure. Each hemisphere in these patients was assessed separately for the presence and size of centrum ovale lesions. RESULTS: Five of the 16 patients suffered from large cortical infarctions with a probable embolic pathogenesis. In the remaining 11 patients (22 hemispheres), a hemodynamic failure was found in 15 hemispheres, due to occlusion (13 hemispheres) or high-grade ICA stenosis (two hemispheres). MR imaging revealed centrum ovale infarctions with a size of more than 2 cm in three of the 15 hemispheres. In eight hemispheres, multiple small lesions (< 1.5 cm; three to 30 per hemisphere) could be found with a rosarylike or sickle-shaped distribution. In none of these eight cases did MR images show lacunar infarctions in the typical regions of the brain. CONCLUSION: Our results favor the assumption that the MR finding of multiple small (< 1.5 cm) rosarylike lesions in the centrum ovale seems to be typical in patients with hemodynamic failure due to severe ICA disease.