Embryology, Malformations, and Rare Diseases of the Cochlea. / Embryologie, Fehlbildungen und seltene Erkrankungen der Cochlea.

Despite the low overall prevalence of individual rare diseases, cochlear dysfunction leading to hearing loss represents a symptom in a large proportion. The aim of this work was to provide a clear overview of rare cochlear diseases, taking into account the embryonic development of the cochlea and the systematic presentation of the different disorders. Although rapid biotechnological and bioinformatic advances may facilitate the diagnosis of a rare disease, an interdisciplinary exchange is often required to raise the suspicion of a rare disease. It is important to recognize that the phenotype of rare inner ear diseases can vary greatly not only in non-syndromic but also in syndromic hearing disorders. Finally, it becomes clear that the phenotype of the individual rare diseases cannot be determined exclusively by classical genetics even in monogenetic disorders.

Does severity of cerebral MRI lesions in congenital CMV infection correlates with the outcome of cochlear implantation?

The objective is to investigate whether there is a correlation between the severity of typical brain lesions in congenital cytomegalovirus (cCMV) infection and cochlear implant (CI) outcome. The design of the study is a retrospective single-institutional chart review (2005-2015), performed in a tertiary academic referral center. 23 children with typical signs of cCMV infection on cerebral magnetic resonance imaging (MRI) and bilateral severe-to-profound sensorineural hearing loss were retrospectively evaluated. They were graded in three groups according to the severity of brain involvement. The average implantation age of the first CI is 1.8 years (range 0.6-5.8). Five patients were implanted unilaterally, 18 bilaterally. The average follow-up time after implantation was 3.3 years (range 0.6-6.9). Hearing performance was assessed using the Categories of Auditory Performance (CAP), and speech development was assessed using Speech Intelligibility Rating (SIR). The outcome in each group showed great variation. The majority of children achieved moderate-to-good auditory and speech rehabilitation. The children with severe MRI changes had comparatively better auditory than speech scores. There were children with good auditory performance (CAP ≥6) both in grades II and III, while poor performers (CAP ≤3) were encountered in each group. The severity of brain lesions on its own does not directly correlate with the outcome of cochlear implantation. Despite good retrospective diagnostic evidence of cCMV infection through MRI patterns, this has no predictive role for future hearing and speech rehabilitation.

Langerhans cell histiocytosis involving the temporal bone with destruction and subsequent reossification of the bony labyrinth boundaries.

PURPOSE: With an incidence between 1-9/100 000 per year, Langerhans cell histiocytosis (LCH) is a rather rare disease from the hemato-oncologic disease spectrum (Hayes et al. 2009). The tumorlike disease with proliferation of histiocytic cells may manifest as localized to one organ or disseminated with infiltration of a wide variety of organs. Approximately 25-30 % of these cases show involvement of the temporal bone (Ni et al. 2017). CASE DESCRIPTION: With vertigo persisting for three years, chronic mastoiditis, and acute progressive hearing loss bilaterally (r > l) for three weeks, a 41-year-old woman presented at an emergency department. The DVT showed extensive bony destruction of large parts of the temporal bone on both sides, involving the vestibular organ, the cochlea, and the internal auditory canal. To confirm the suspicion of a systemic inflammatory process, a PE was performed from the mastoid with bioptic confirmation of an LCH. Systemic therapy was initiated. Post-therapeutic imaging showed almost complete remission with reossification of the preexisting defect zones and the internal auditory canal and labyrinth structures again showed bony margins. Clinically, there was an improvement of the vegetative symptoms with remaining bilateral sensorineural hearing loss. DISCUSSION: LCH of the temporal bone is a rare and often misdiagnosed disease due to its nonspecific clinical presentation. Awareness of temporal bone LCH and its occurrence in adults is essential for accurate and consistent diagnosis. KEY POINTS: · LCH is a rather rare disease from the hemato-oncological spectrum. · Affection of the temporal bone, especially such an extensive one (as in this case report), is rather atypical in adulthood. · Use of systemic therapy resulted in remission. · There was complete reossification of the osseous structures post-therapy. · A cochlear implant was able to be implanted to compensate for hearing loss.

A New Methodology for Evaluation of Large Vestibular Aqueduct in CT and MRI Images.

HYPOTHESIS: Development of a new method for large vestibular aqueduct (LVA)/large endolymphatic sac anomaly (LESA) assessment using magnetic resonance imaging (MRI) and computed tomography (CT)/cone beam CT (CBCT) images. The secondary objective was to compare both modalities. BACKGROUND: The gold standard for LVA diagnosis is the analysis of CT images using Valvassori and Clemis or Cincinnati criteria. The previous studies showed inconclusive results regarding the correlation between audiological and radiological data. METHODS: Retrospective analysis of radiological images from 173 patients (315 ears), who were diagnosed with LVA/LESA based on CT/CBCT and/or MRI images of the temporal bone. The images obtained using both techniques were used to measure the following dimensions of vestibular aqueduct (VA)/endolymphatic duct (ED)/intraosseous endolymphatic sac (ES): width of the opening, length, and width at external aperture. In MRI images, the maximal contact diameters of the extraosseous or intraosseous ES and dura mater were measured as well. RESULTS: LVA has been reported to be bilateral in 82% (142 patients) and unilateral in 18% (31 patients) of cases. Comparison of MRI and CT/CBCT measurements showed a moderate correlation (0.64) in external aperture, a moderate correlation (0.57) in the width of the VA opening, and a weak correlation (0.34) in length measurements (p < 0.05). CONCLUSION: We developed a new method to identify the heterogeneous pathology of LVA/LESA using reconstruction along the VA/ED/intraosseous ES axis, three measurements on two planes, and focus on the maximal contact diameter between the extraosseous or intraosseous ES and dura mater.

Quantitative MRI shows cerebral microstructural damage in hemolytic-uremic syndrome patients with severe neurological symptoms but no changes in conventional MRI.

INTRODUCTION: Severe neurological symptoms in Shiga toxin-producing Escherichia coli infection associated hemolytic-uremic syndrome (STEC-HUS) are often accompanied by none or only mild alterations of cerebral magnetic resonance imaging (MRI). This study aims to analyze if quantitative MRI is able to reveal cerebral pathological alterations invisible for conventional MRI. METHODS: In nine patients with STEC-HUS associated severe neurological symptoms but inconspicuous cerebral MRI findings maps of the parameters T2 relaxation time, relative proton density (PD), apparent diffusion coefficient (ADC), and fractional anisotropy (FA) were generated. Quantitative values of these parameters were measured at the basal ganglia, thalamus, and white matter of the frontal and parietal lobe and compared to those of nine age- and sex-matched controls. RESULTS: Significant T2 prolongation (p < 0.01) was found in the basal ganglia of all patients compared to controls. PD and ADC were not significantly altered. A significant reduction of FA in patients was seen at caput nuclei caudati (p < 0.01). CONCLUSION: Prolonged T2 relaxation time indicates cerebral microstructural damages in these patients despite their inconspicuous MRI findings. T2 relaxometry could be used as a complementary tool for the assessment of metabolic-toxic brain syndromes.

Neuroinflammatory disorders of the brain and inner ear: a systematic review of auditory function in patients with migraine, multiple sclerosis, and neurodegeneration to support the idea of an innovative 'window of discovery'.

Background: Hearing can be impaired in many neurological conditions and can even represent a forme fruste of specific disorders. Auditory function can be measured by either subjective or objective tests. Objective tests are more useful in identifying which auditory pathway (superior or inferior) is most affected by disease. The inner ear's perilymphatic fluid communicates with the cerebrospinal fluid (CSF) via the cochlear aqueduct representing a window from which pathological changes in the contents of the CSF due to brain inflammation could, therefore, spread to and cause inflammation in the inner ear, damaging inner hair cells and leading to hearing impairment identifiable on tests of auditory function. Methods: A systematic review of the literature was performed, searching for papers with case-control studies that analyzed the hearing and migraine function in patients with neuro-inflammatory, neurodegenerative disorders. With data extracted from these papers, the risk of patients with neurological distortion product otoacoustic emission (DPOAE) was then calculated. Results: Patients with neurological disorders (headache, Parkinson's disease, and multiple sclerosis) had a higher risk of having peripheral auditory deficits when compared to healthy individuals. Conclusion: Existing data lend credence to the hypothesis that inflammatory mediators transmitted via fluid exchange across this communication window, thereby represents a key pathobiological mechanism capable of culminating in hearing disturbances associated with neuroimmunological and neuroinflammatory disorders of the nervous system.

Radiological diagnosis of incomplete partition type I versus type II: significance for cochlear implantation.

OBJECTIVES: To investigate an extended cohort of patients with incomplete partition (IP) and examine the adequacy of the existing classifications based on radiological criteria and on their implications for cochlear implantation. METHODS: Patients with IP admitted to a tertiary referral centre during the period 2000-2010 were retrospectively examined. The subjects were initially classified into IP-I, IP-II and atypical cases. For cochlear implant recipients relevant aspects were analysed. RESULTS: Eighty-three ears (49 patients) with IP were found, 19 with IP-I, 54 with IP-II and 10 atypical. Thirty-three patients received a cochlear implant (11 with IP-I, 19 with IP-II and three atypical) achieving heterogeneous though mostly promising results. Cerebrospinal fluid gushing was the commonest surgical complication, particularly in cases of IP-I. In general, patients with IP-II performed better than those with IP-I. CONCLUSIONS: Cochlear implantation promises adequate hearing rehabilitation for most patients with IP. As we move from IP-I to IP-II better results and lower risk for gushing shall be expected. Based on radiological findings we suggest a modified classification into IP-I, atypical IP-I (with large vestibular aqueduct (LVA) and better partition), IP-II (Mondini deformity) and atypical IP-IIa (without LVA) and b (without LVA but with semicircular canal dysplasia). KEY POINTS: • Radiological (CT and MR) features are of crucial importance for cochlear implantation • Imaging can identify two types of incomplete cochlear partition and atypical cases • Detailed pre-operative radiological assessment can help predict complications and outcome • A more comprehensive radiological classification of these anomalies is proposed.

The vestibulocochlear nerve: aplasia and hypoplasia in combination with inner ear malformations.

OBJECTIVE: To determine features of hypoplasia and aplasia of the vestibulocochlear nerve (VCN) in combination with inner ear malformations (IEMs). METHODS: Index cases were retrospectively selected from all IEMs collected since 1995. CT and MRI data were reviewed by two neuroradiologists. The number and thickness of visible nerves in the cerebellopontine angle cistern and inside the internal auditory canal (IAC) were analysed. RESULTS: MR images for 176 patients with IEMs were analysed. Labyrinthine aplasia and otocyst deformity showed 100% correlation, and IAC malformations exhibited 92% correlation with VCN aplasia. Cochlear aplasia, complete aplasia of the semicircular canals, severe cochlear hypoplasia, common cavity, incomplete partition type 1 and mild cochlear hypoplasia showed decreasing degrees of correlation with hypoplasia of the VCN. The remaining types of IEM did not demonstrate VCN hypoplasia. CONCLUSIONS: Certain forms of IEM show 100% correlation with hypoplasia or aplasia of the VCN, while others correlate less strongly and some do not usually exhibit VCN hypoplasia. MRI should always be carried out for those forms often correlated with VCN hypoplasia. KEY POINTS: Vestibulocochlear nerve deficiency can be strongly suspected in certain inner ear malformations • Bony cochlear aplasia and cochlear nerve aplasia are strongly correlated • In semicircular canal aplasia, hypoplasia of the vestibular nerve can be found • Before cochlear implantation, the type of any IEM should be fully understood.

Controlling the position and the dislocation of the middle ear transducer with high-resolution computed tomography and digital volume tomography: implications for the transducers' design.

A minimal tip dislocation of the middle ear transducer (MET(®), Otologics Ltd) may result in poor hearing performance. Our objective was to examine if a defined MET dislocation can be diagnosed by high-resolution computed tomography (HRCT) or digital volume tomography (DVT). A human cadaver head was sequentially implanted with different MET tips (incus application) including a ceramic tip (T 1c), a titanium tip (T 1t), a new, thinner titanium tip (T 2), and a spherical titanium tip (Ts). HRCT and DVT studies were performed. Afterward, the tips were pulled back 0.5 mm, so that they were not attached to the incus. HRCT and DVT scans were repeated to identify the dislocation. Using the best plain in HRCT images, the dislocation of the transducer could be measured reliably and reproducibly in half of the cases. In particular, the precise positioning and the dislocation could be identified when T 1t and Ts were implanted, with the Ts showing the best visibility. DVT failed in recognizing the dislocation in all cases. The identification of MET tip's dislocation with HRCT depends on the shape, size, and material of the tip. This knowledge is useful for the design of the implants, as determination of the right position of the middle ear transducer may be proven important for the hearing outcome. In some cases, however, surgical exploration may still be required. Although DVT represents a promising imaging method for the otologists, it can barely help when MET dislocation is suspected.

Bilateral trochlear nerve palsy subsequent to ventriculoperitoneal shunting of normal pressure hydrocephalus.

Misplacement of the ventricular catheters of shunt systems may result in shunt dysfunction or a variety of neurological symptoms. Bilateral fourth nerve palsy has not been reported thus far after shunting. Here, we describe the occurrence of this unusual neurological deficit in a patient who underwent shunting for normal pressure hydrocephalus, and demonstrate its pathoanatomical correlate.

Extracellular Vesicles in Inner Ear Therapies-Pathophysiological, Manufacturing, and Clinical Considerations.

(1) Background: Sensorineural hearing loss is a common and debilitating condition. To date, comprehensive pharmacologic interventions are not available. The complex and diverse molecular pathology that underlies hearing loss may limit our ability to intervene with small molecules. The current review foccusses on the potential for the use of extracellular vesicles in neurotology. (2) Methods: Narrative literature review. (3) Results: Extracellular vesicles provide an opportunity to modulate a wide range of pathologic and physiologic pathways and can be manufactured under GMP conditions allowing for their application in the human inner ear. The role of inflammation in hearing loss with a focus on cochlear implantation is shown. How extracellular vesicles may provide a therapeutic option for complex inflammatory disorders of the inner ear is discussed. Additionally, manufacturing and regulatory issues that need to be addressed to develop EVs as advanced therapy medicinal product for use in the inner ear are outlined. (4) Conclusion: Given the complexities of inner ear injury, novel therapeutics such as extracellular vesicles could provide a means to modulate inflammation, stress pathways and apoptosis in the inner ear.

Persistent petrosquamosal sinus: high incidence in cases of complete aplasia of the semicircular canals.

PURPOSE: To determine the frequency and to describe the morphologic characteristics and associated skull base anomalies of the petrosquamosal sinus (PSS) in cochlear implant candidates with complete aplasia of the semicircular canals (SCCs). MATERIALS AND METHODS: Ethics committee approval was obtained. Index cases were retrospectively selected from an electronic database in which all inner ear malformations observed in patients presenting to a tertiary referral center between 1995 and 2010 were collected. Computed tomography (CT) data were reviewed by neuroradiologists. Clinical consequences of the neuroradiologic findings were analyzed. The Pearson χ(2) test and the Mann-Whitney U test were used to determine significant differences between the number of PSSs observed in cases of complete aplasia of the SCCs and the number observed in cases of other types of inner ear malformations. RESULTS: Inner ear malformations were analyzed in 241 patients. Thirty-one patients (13%) with bilateral SCC aplasia were identified. Among 31 patients, a uni- or bilateral PSS was observed in 25 (81%). In the ears with SCC aplasia, a PSS was observed in 40 (65%) of 62. The three cases in which these PSS occupy the largest area correlate with bilateral absence of the jugular foramen. In seven of eight ears with a PSS, the PSS inhibited surgical exposure or resulted in accidental opening of the PSS during surgery. In all other patients with inner ear malformations, a PSS was observed in 39 (9%) of 412 ears only. CONCLUSION: The PSS presents a risk for cochlear implant surgery that can be detected by the neuroradiologist in advance. Venous CT angiography is advisable in certain cases. The previous assumption that a persistent PSS is encountered more frequently in cases of skull base deformity can be affirmed in the special situation of complete aplasia of the SCCs.

Appearance of hypoplastic cochleae in CT and MRI: a new subclassification.

INTRODUCTION: Hypoplastic cochleae are among the inner ear malformations more frequently encountered by radiologists; little detailed information is available on these, however. We present the first large series of hypoplastic cochleae and document imaging findings to better characterize this anomaly radiologically. METHODS: We used our electronic database to search for inner ear malformations described between 1995 and 2009 and extracted 81 ears (of 47 patients) with hypoplastic cochleae out of 289 patients with inner ear malformations. Two neuroradiologists evaluated the available CT and MRI data. Measurements of all inner ear structures were performed. Accompanying findings were listed. RESULTS: Cochlear hypoplasia (58 ears, 32 patients) often involves not only the apical turn being reduced in size but also the basal turn being smaller in length. Additionally, 11 ears (eight patients) of hypoplastic cochleae with only a basal turn and five ears (four patients) of cochleae with only a small bud were identified. Non-classifiable hypoplastic cochleae (seven ears, five patients) were those with either a rudimentary or an absent basal turn or a "dwarf appearance" with no further partition. CONCLUSIONS: The term "hypoplastic cochlea" is very general; a further division into severe and less severe forms based on the length and existence of cochlea turns is possible and can help enhance the comparison of CI outcome data. Measurements can help the less experienced radiologist to detect them more easily.

Aberrant course of the intracranial facial nerve in cases of atresia of the internal auditory canal (IAC).

INTRODUCTION: The aim of this study is to describe the morphology of the rare malformation that is atresia of the internal auditory canal (IAC) and determine the course of the facial nerve in cases of normal facial nerve function. METHODS: Index cases were retrospectively selected from our electronic database in which all inner ear malformations presenting to a tertiary referral center between 1995 and 2010 are collected. Computed tomography (CT) data and magnetic resonance (MR) images were reviewed by two neuroradiologists. An otolaryngologist analyzed the patients' clinical data. RESULTS: Nine ears of six patients (three bilateral, three unilateral) with atresia of the IAC were identified. All patients presented with sensory neural hearing loss. Two of these unilaterally affected patients had facial nerve palsy. In the other seven cases of complete atresia of the IAC, the facial nerve was dislocated in its cisternal segment close to the trigeminal nerve. Where the nerve fibers enter the Gasserian ganglion, the facial nerve takes a sharp lateral turn and enters a minute canal by which it reaches the geniculate ganglion. In the two ears with facial nerve palsy, this pathway could not be identified. CONCLUSIONS: In atresia of the IAC, the facial nerve takes a ventral and superior course, with its own canal starting at the point where the trigeminal nerve enters the Gasserian ganglion. Facial nerve palsy points to absence of this aberrant temporal facial nerve canal.

On the Intracochlear Location of Straight Electrode Arrays After Cochlear Implantation: How Lateral Are Lateral Wall Electrodes?

OBJECTIVE: Cochlear implants are the gold standard for patients with severe sensorineural hearing loss. A focused electrical stimulation of individual spiral ganglion neurons has not been achieved yet because the scala tympani is a fluid-filled compartment and does not offer a matrix for neuritic outgrowth. Coating of the electrode contacts with swelling hydrogels could fill that gap between the electrode array and the medial wall of the cochlea. Therefore, the exact position of the electrode array within the scala tympani has to be known. STUDY DESIGN: Retrospective analysis of patient data sets. SETTING: Tertiary referral center. A total of 95 patients with cochlear implants from one manufacturer were included in this study. The lateral wall, the modiolar wall, and the cochlear implant electrode were segmented using OsiriX MD. For repositioning and reconstructing the respective contours and measuring distances, files were analyzed in MATLAB. The distances from the edge of each electrode contact to the cochlear walls showed no significant differences. But between the different contacts within each patient, there were significant differences. Around 180 degree insertion, electrodes start to get in contact with the lateral wall. The tip of the electrode array was always facing toward the modiolar wall independent of the length of the electrode. We established a method to analyze the position of electrodes within the cochlea.

Vestibular Aqueduct Size Correlates With the Degree of Cochlear Hydrops in Patients With and Without Menière's Disease.

OBJECTIVE: To correlate the CT imaging findings of the visibility and size of the vestibular aqueduct (VA) with the degree of the cochlear hydrops determined in MRI late imaging of the hydrops. Study Design: Retrospective study. Setting: Tertiary referral center. Patients: A total of 127 patients (62 women, 65 men, average age 55.6 yrs): 86 of these were diagnosed with Menière's disease (American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] criteria; 67 unilateral, 19 bilateral). INTERVENTIONS: Temporal bone CT and hydrops MRI were performed in all patients. MAIN OUTCOME MEASURES: Visibility/width of the VA in temporal bone CT and grade of cochlear hydrops evaluated by MRI. RESULTS: The width of the VA is significantly smaller in patients diagnosed with Menière's disease (30% non-visible VA), compared with the patients who did not fulfill the diagnostic criteria of Menière's disease (12% non-visible VA) (double sided Spearman correlation, p < 0.001). In all ears of patients diagnosed with Menière's disease the width of the VA was significantly correlated with the degree of the cochlear hydrops (in cases of non-visible VA 65% [34/52] ears presented with hydrops grade 3 or 4; 13% [7/52] ears presented with hydrops grade 1 or 2 and 21% [11/52] ears showed no hydrops) (Spearman correlation p = 0.001/p < 0.01). This is also true for all ears that can be summarized as hydrophic ear disease (symptomatic ears that present with a hydrops in MRI). CONCLUSIONS: The results of our study could confirm the importance of the VA in the pathogenesis of the endolymphatic hydrops in vivo.

From labyrinthine aplasia to otocyst deformity.

INTRODUCTION: Inner ear malformations (IEMs) are rare and it is unusual to encounter the rarest of them, namely labyrinthine aplasia (LA) and otocyst deformity. They do, however, provide useful pointers as to the early embryonic development of the ear. LA is characterised as a complete absence of inner ear structures. While some common findings do emerge, a clear definition of the otocyst deformity does not exist. It is often confused with the common cavity first described by Edward Cock. Our purpose was to radiologically characterise LA and otocyst deformity. METHODS: Retrospective analysis of CT and MRI data from four patients with LA or otocyst deformity. Middle and inner ear findings were categorised by two neuroradiologists. RESULTS: The bony carotid canal was found to be absent in all patients. Posterior located cystic structures were found in association with LA and otocyst deformity. In the most severe cases, only soft tissue was present at the medial border of the middle ear cavity. The individuals with otocyst deformity also had hypoplasia of the petrous apex bone. CONCLUSIONS: These cases demonstrate gradual changes in the two most severe IEMs. Clarification of terms was necessary and, based on these findings, we propose defining otocyst deformity as a cystic structure in place of the inner ear, with the cochlea, IAC and carotid canal absent. This condition needs to be differentiated from the common cavity described by Edward Cook. A clear definition of inner ear malformations is essential if outcomes following cochlear implantation are to be compared.

Relations Between Scalar Shift and Insertion Depth in Human Cochlear Implantation.

OBJECTIVE: The intracochlear position of an electrode array may influence the outcome after cochlear implantation. The design of the electrode array can increase the risk of trauma causing penetration of the basilar membrane or shift of the electrode array into the scala vestibuli. The aim of the present study was to identify a scalar shift after implantation of two different electrode arrays developed by one manufacturer. STUDY DESIGN: Retrospective analysis. SETTING: Tertiary referral center. PATIENTS AND INTERVENTION: Cochlear implant recipients implanted between 2010 and 2014 and receiving either a mid-scala (n = 30) or a perimodiolar (n = 30) electrode array. MAIN OUTCOME MEASURE: Occurrence of scalar shift in association with the electrode type. RESULTS: Scalar shift occurred in 26.7% (8 of 30) of the patients implanted with a perimodiolar electrode array and in 6.7% (2 of 30) of the patients implanted with the mid-scala electrode array. The mean insertion depth in the patients experiencing scalar shift after implantation of the mid-scala electrode was much deeper (21.59 ±â€Š0.34 mm) when compared with the mean insertion depth of the patients with scalar shift after implantation with a perimodiolar electrode array (17.85 ±â€Š2.19 mm). There tends to be a correlation between the cochlear length and the occurrence of a scalar shift. However, the number of patients with scalar shift in the mid-scala group is rather small. CONCLUSION: Based on the presented data, more patients implanted with a perimodiolar electrode array have a scalar shift when compared with the midscalar electrode array.

Neurological Sequelae in Adults After E coli O104: H4 Infection-Induced Hemolytic-Uremic Syndrome.

In an outbreak of shiga toxin-producing Escherichia coli infections and associated hemolytic-uremic syndrome (STEC O104:H4) in Germany in the year 2011 neurological complications in adult patients occurred unexpectedly frequent, ranging between 48% and 100% in different patient groups. Few is known about the long-term effects of such complications and so we performed follow-up exams on 44 of the patients treated for STEC-HUS at Hannover Medical Scool in this observational study. Standardized follow-up exams including neurological and neuropsychological assessments, laboratory testing, magnetic resonance imaging (MRI), and EEG were carried out. Subgroups were examined 2 (n = 34), 7 (n = 22), and 19 (n = 23) months after disease onset. Additionally, at the 19-month follow-up, quality of life, sleep quality, and possible fatigue were assessed.Nineteen months after disease onset 31 patients were reassessed, 22 of whom still suffered from symptoms such as fatigue, headache, and attention deficits. In the neuropsychological assessments only 39% of the patients performed normal, whereas 61% scored borderline pathological or lower. Upon reviewal, the follow-up data most prominently showed a secondary decline of cognitive function in about one-quarter of the patients. Outcome was not related to treatment or laboratory data in the acute phase of the disease nor length of hospitalization. Prognosis of STEC-HUS associated brain dysfunction in adults with regard to severity of symptoms is mostly good; some patients however still have not made a full recovery. Patients' caretakers have to be aware of possible secondary decline of brain function as was observed in this study.