Initial free cortisol dynamics following blunt multiple trauma and traumatic brain injury: A clinical study.

OBJECTIVE: To determine free and total cortisol serum concentrations in the first 24 h after trauma and to evaluate the influence of traumatic brain injury (TBI) on their dynamics. METHODS: This prospective cohort study enrolled patients who had experienced multiple trauma and were admitted to a level 1 trauma centre. The patients were divided in two groups based on the presence of TBI according to clinical and radiological findings. Blood was collected initially as well as at 12 h and 24 h after the traumatic injury. Total cortisol, corticosteroid binding globulin (CBG) and free cortisol levels were determined. RESULTS: The study analysed data from 49 patients (36 males and 13 females) with a mean ± SD age of 45.0 ± 16.0 years. Of these, 36 presented with TBI and 13 had multiple injuries without TBI. Patients with TBI showed significantly lower concentrations of total cortisol and free cortisol compared with patients without TBI. Repeated measures analysis revealed different concentration dynamics in patients with TBI, with no increase in cortisol after trauma. CONCLUSION: Multiple trauma patients with TBI are at risk of acute impaired cortisol secretion and show an attenuated stress response as early as 12 h after injury.

[Superior canal dehiscence syndrome : Diagnosis with vestibular evoked myogenic potentials and fremitus nystagmus. German version]. / Dehiszenzsyndrom des oberen Bogengangs : Diagnostik mit vestibulär evozierten myogenen Potenzialen und Fremitusnystagmus.

BACKGROUND: Superior canal dehiscence syndrome (SCDS) is a relatively rare neurotological disorder that is characterized by a heterogeneous clinical picture. Recently, vestibular evoked myogenic potential (VEMP) measurementwas established for the diagnosis of SCDS. In the present study, a case series of patients with SCDS were analyzed, with a focus on VEMP. METHODS: Four patients with SCDS were prospectively examined with ocular VEMP (oVEMP) and cervical VEMP (cVEMP). The clinical features and the standard audiovestibular test battery results are summarized and analyzed. The diagnostic accuracy of VEMP testing is evaluated. RESULTS: The increased oVEMP amplitudes had a specificity of 100% in this patient population. All patients had normal caloric function and head impulse testing. The Tullio sign was observed in two patients. Three patients had autophony. The airbone gap was not greater than 10 dB in any of the patients. Two patients had marked fremitus nystagmus. All patients had a bony dehiscence of the superior semicircular canal on computed tomography imaging. CONCLUSION: The subjective and clinical features in this case series of SCDS patients were heterogeneous. However, objective oVEMP testing had the highest diagnostic value. Furthermore, we describe a new diagnostic clinical sign: fremitus nystagmus.

Superior canal dehiscence syndrome : Diagnosis with vestibular evoked myogenic potentials and fremitus nystagmus.

BACKGROUND: Superior canal dehiscence syndrome (SCDS) is a relatively rare neurotological disorder that is characterized by a heterogeneous clinical picture. Recently, vestibular evoked myogenic potential (VEMP) measurement was established for the diagnosis of SCDS. In the present study, a case series of patients with SCDS were analyzed, with a focus on VEMP. METHODS: Four patients with SCDS were prospectively examined with ocular VEMP (oVEMP) and cervical VEMP (cVEMP). The clinical features and the standard audiovestibular test battery results are summarized and analyzed. The diagnostic accuracy of VEMP testing is evaluated. RESULTS: The increased oVEMP amplitudes had a specificity of 100% in this patient population. All patients had normal caloric function and head impulse testing. The Tullio sign was observed in two patients. Three patients had autophony. The air-bone gap was not greater than 10 dB in any of the patients. Two patients had marked fremitus nystagmus. All patients had a bony dehiscence of the superior semicircular canal on computed tomography imaging. CONCLUSION: The subjective and clinical features in this case series of SCDS patients were heterogeneous. However, objective oVEMP testing had the highest diagnostic value. Furthermore, we describe a new diagnostic clinical sign: fremitus nystagmus.

[Acute posterior dislocation of the sternoclavicular joint: Reduction, fixation by endobutton system and alternative procedures]. / Akute dorsale Sternoklavikulargelenkluxation: Reposition, Fixierung mit Faden-Titanplättchen-System und alternative Techniken.

Acute posterior dislocation of the sternoclavicular (SC) joint is rare but can lead to life-threatening vascular injuries of the mediastinum; however, diagnosis is difficult and the injury can be initially overlooked so that surgical treatment is delayed. Although a variety of different treatment modalities have been published, the ideal fixation technique has not yet been identified. We report the case of a patient suffering from a locked posterior SC joint dislocation caused by a skiing accident. The injury was treated by transarticular endobutton fixation. This article describes the technique and highlights its advantages and disadvantages in comparison to previously published treatment options.

Preoperative Embolization to Improve the Surgical Management and Outcome of Juvenile Nasopharyngeal Angiofibroma (JNA) in a Single Center: 10-Year Experience.

PURPOSE: Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign neoplasm that occurs almost exclusively in the nasopharynx of adolescent male individuals. METHODS: We performed a retrospective study to determine the efficacy and safety of preoperative embolization and the surgical outcome in patients with JNA in a single-center institution. Fifteen cases undergoing embolization and surgical treatment between April 2003 and February 2013 were evaluated retrospectively. The demographic data, clinical presentation, and treatment were reviewed including the kind of preoperative embolization and different surgical approaches performed. The parameters investigated were the amount of blood loss, the tumor stage, and the rates of recurrence. Subsequently, a comparison was made between patients who had undergone Onyx® embolization versus those who had been embolized with the standard approach. RESULTS: In these 15 patients (mean age, 15 years), a total of 27 surgical procedures were performed. One patient was at stage Ia, two were at stage Ib, two were at stage IIa, six were at stage IIb, one was at stage IIc, and three were at stage IIIa based on the Radkowsky classification. All patients underwent preoperative embolization and subsequent surgery. The surgical approach and the embolization technique varied and evolved during time. The embolization procedure decreased the intraoperative blood loss to a minimum of 250 ml, and with the advent of intratumoral embolization, the rate of recurrence diminished. CONCLUSION: Preoperative Onyx® embolization facilitates the shift in the treatment to endoscopic excision in selected patients, which reduces recurrence rates and overall morbidity.

[A Pair of Siblings with a rare R5H-Mutation in Exon 1 of the MAPT-Gene]. / Ein Geschwisterpaar mit einer seltenen Tau-Gen-Mutation (MAPT R5H).

We report on a female patient presenting with primary progressive aphasia (PPA) and her brother presenting with psychosis. Both siblings had an R5H-mutation in exon 1 of the MAPT-gene. The PPA patient presented for the first time at the age of 72 years with a 4-year-history of language impairment. After a progressive course the patient died at the age of 76 years. The R5H-MAPT-gene mutation detected in the siblings has been described only once in 2002 by Hayashi et al. [1]. In this previous case from Japan, a 75-year-old patient initially displayed amnesia and disorientation. He became bedridden, with progressive mutism and rigidity of the upper extremities. Noteworthy are the manifold signs and symptoms in R5H-mutations and the late age of onset. For future trials, the detection of biomarkers for frontotemporal lobar degeneration in presymptomatic cohorts like the genetic frontotemporal dementia initiative (GENFI) is of help for stratifying subjects at risk.

[Combined ac joint dislocation and distal clavicle fracture. Closed reduction and arthroscopically assisted coracoclavicular fixation]. / Kombinierte AC-Gelenk-Luxation und laterale Klavikulafraktur. Geschlossene Reposition und arthroskopisch gestützte korakoklavikuläre Fixierung.

BACKGROUND: A 55-year-old male patient sustained a dislocation of the acromioclavicular (AC) joint in combination with a distal clavicle fracture. METHODS: Following closed reduction of the fractured clavicle, arthroscopically assisted coracoclavicular fixation was performed. DISCUSSION AND CONCLUSION: A combined injury of a complete ac joint dislocation and a distal clavicle fracture is rare and is not included in currently available classification systems; therefore, in this article a classification and assessment of the stability of this injury as well as appropriate treatment options are discussed.

MR volumetric assessment of endolymphatic hydrops.

OBJECTIVES: We aimed to volumetrically quantify endolymph and perilymph spaces of the inner ear in order to establish a methodological basis for further investigations into the pathophysiology and therapeutic monitoring of Menière's disease. METHODS: Sixteen patients (eight females, aged 38-71 years) with definite unilateral Menière's disease were included in this study. Magnetic resonance (MR) cisternography with a T2-SPACE sequence was combined with a Real reconstruction inversion recovery (Real-IR) sequence for delineation of inner ear fluid spaces. Machine learning and automated local thresholding segmentation algorithms were applied for three-dimensional (3D) reconstruction and volumetric quantification of endolymphatic hydrops. Test-retest reliability was assessed by the intra-class coefficient; correlation of cochlear endolymph volume ratio with hearing function was assessed by the Pearson correlation coefficient. RESULTS: Endolymph volume ratios could be reliably measured in all patients, with a mean (range) value of 15% (2-25) for the cochlea and 28% (12-40) for the vestibulum. Test-retest reliability was excellent, with an intra-class coefficient of 0.99. Cochlear endolymphatic hydrops was significantly correlated with hearing loss (r = 0.747, p = 0.001). CONCLUSIONS: MR imaging after local contrast application and image processing, including machine learning and automated local thresholding, enable the volumetric quantification of endolymphatic hydrops. This allows for a quantitative assessment of the effect of therapeutic interventions on endolymphatic hydrops. KEY POINTS: • Endolymphatic hydrops is the pathological hallmark of Menière's disease. • Endolymphatic hydrops can be visualized by locally enhanced ultra-high-resolution MR imaging. • Computer-aided image processing enables quantification of endolymphatic hydrops. • Endolymphatic hydrops correlates with hearing loss in patients with Menière's disease. • Therapeutic trials in Menière's disease can be monitored with this quantitative approach.

[Detection and evaluation of cartilage defects in the canine stifle joint - an ex vivo study using high-field magnetic resonance imaging]. / Ex-vivo-Untersuchungen zum Nachweis von Knorpeldefekten im Kniegelenk des Hundes mit der Hochfeld-Magnetresonanztomographie.

OBJECTIVE: The aim of our study was to implement and test an imaging protocol for the detection and evaluation of standardised cartilage defects using high-field magnetic resonance imaging (MRI) and to determine its limitations. MATERIAL AND METHOD: A total of 84 cartilage defects were created in the femoral condyles of euthanized dogs with a minimum body mass of 25 kg. The cartilage defects had a depth of 0.3 to 1.0 mm and a diameter of 1 to 5 mm. T1-FLASH-3D-WE-sequences with an isotropic voxel size of 0.5 x 0.5 x 0.5 mm and an anisotropic voxel size of 0.3 x 0.3 x 0.8 mm were used. In addition to quantitative evaluation of the cartilage defects, the sig- nal intensities, signal-to-noise ratios and contrast-to-noise ratios of the cartilage were determined. Of special interest were the limita- tions in identifying and delineating the standardised cartilage defects. RESULTS: With the anisotropic voxel size, more cartilage defects were detectable. Our results demonstrated that cartilage defects as small as 3.0 mm in diameter and 0.4 mm in depth were reliably detected using anisotropic settings. Cartilage defects below this size were not reliably detected. CONCLUSION AND CLINICAL RELEVANCE: We found that for optimal delineation of the joint cartilage and associated defects, a higher in-plane resolution with a larger slice thickness should be used, corresponding to the anisotropic settings employed in this study. For the delineation of larger cartilage defects, both the anisotropic and isotropic imaging methods can be used.

Endolymphatic hydrops in patients with vestibular migraine and auditory symptoms.

Vertigo patients exhibiting features of vestibular migraine (VM) and Menière's disease (MD) present a difficult diagnostic challenge to the clinician, and the two entities are likely to overlap. The aim of the present study was to investigate the occurrence of endolymphatic hydrops in patients with VM and auditory symptoms. This was an observatory diagnostic study. At an academic interdisciplinary dizziness centre, nineteen consecutive patients with definite or probable VM and auditory symptoms were examined by locally enhanced inner ear MR imaging. MR images were evaluated for the presence of endolymphatic hydrops. Of the 19 included patients, four patients (21 %) demonstrated evidence of cochlear and vestibular endolymphatic hydrops on locally enhanced inner ear MR imaging (three with "definite VM", one with "probable VM"). Locally enhanced inner ear MR imaging may be useful in the diagnostic evaluation of patients with VM and auditory symptoms, as some of these patients have signs of endolymphatic hydrops. Whether these patients suffer from MD only and are misdiagnosed as VM or suffer from both, VM and MD or whether endolymphatic hydrops is a consequence of inner ear damage due to VM are clinically relevant questions that can be evaluated by application of this technique.

Effect of standard-dose Betahistine on endolymphatic hydrops: an MRI pilot study.

This study aimed to assess whether standard-dose Betahistine (48 mg daily) exerts an effect upon the degree of endolymphatic hydrops in patients with Menière's disease using a retrospective case series in the setting of a tertiary neurotology referral centre. In six patients with definite unilateral Menière's disease, the degree of cochlear and vestibular endolymphatic hydrops was assessed before and after treatment with a standard dose of Betahistine (48 mg daily), using high-resolution 3 T MR imaging after intratympanic contrast medium application. The treatment duration was 3-7 months (mean 5 months), and the patients were followed-up for 6-29 months (mean 11 months). In the study cohort, the standard dose of Betahistine did not have an MR morphologically measurable beneficial effect on the degree of endolymphatic hydrops. The results indicated no effect of standard-dose Betahistine on endolymphatic hydrops found on high-resolution MR imaging. Possible explanations are: (1) insufficient dosage or duration of treatment with betahistine, (2) insufficient resolution of the MR imaging technique, and (3) insufficient length of follow-up. Further studies addressing these issues are warranted.

Lemierre syndrome: a case report.

INTRODUCTION: Lemierre syndrome, also known as postanginal sepsis, is caused by Fusobacterium necrophorum. This rare disease is usually characterized by thrombophlebitis of the jugular vein and septic embolism after a history of sore throat. OBJECTIVE: Here, we discuss a case of Lemierre syndrome in a 22-year-old man with thrombophlebitis of the facial vein and fusobacteria growth in the blood culture but no obvious focus of inflammation. METHOD: Case report. CONCLUSION: Severe facial infection with high fever and a general feeling of malaise after a history of sore throat should raise the diagnostic possibility of facial vein thrombophlebitis due to F. necrophorum infection.

Evaluation of a resectable ultrasound liver phantom for testing of surgical navigation systems.

A formerly developed ultrasound liver phantom for testing of surgical navigation systems and liver resection trainings was evaluated experimentally. The phantom was scanned with CT and the dataset was analyzed with existing segmentation techniques. A virtual 3D model was generated on the basis of the segmentation; it was later used for phantom registration in a surgical assistance navigation system. Within an experiment, ten test persons have tried to touch three tumor models hidden in the phantom with the tip of a resection instrument. In 67% of overall 30 touch trials it was a successful touch at the first go. It means that the developed liver phantom is appropriate for testing of surgical navigation systems, as well as for computer assisted liver resection trainings.

[Incidentaloma of the pancreas]. / Inzidentalome des Pankreas.

The term incidentaloma refers to an asymptomatic mass detected accidentally during a technical examination, mostly by radiological methods, when performed in a patient examined for other conditions or situations. Surgery is the adequate therapy for adrenal incidentalomas with increasing size, a size bigger than 4 cm at detection, hormone-activity or malignant histology. Incidentalomas of the adrenal and thyroid gland are still often dismissed because they are common and mostly benign. Incidentalomas of the pancreas are distinct and less frequent. At present, no evidence-based guidelines exist for the management of asymptomatic pancreatic lesions. Only few clinical studies describe pancreatic incidentalomas, however these studies claim a malignant histology of up to 30 % and of up to 50 % for pre-malignant incidentalomas of the pancreas. Thus, we recommend an early resection of pancreatic incidentalomas with a size of > 2 cm, in younger patients without concomitant diseases or increased operative risk, with a malignant histology, and with mucinous cells and increased tumour markers in blood samples. Organ-saving procedures or radical pancreatectomy are possible while both methods are safe and have a very low complication risk. The surgical resection of pancreatic incidentalomas offers a significant advantage in survival when the total collective of affected individuals is taken into account.

[Volumetric MRI for evaluation of regional pattern and progressin of neocortical degeneration in Alzheimer's disease]. / MR-Volumetrie zur Darstellung von Verteilung und zeitlicher Abfolge neokortikaler Degeneration bei Morbus Alzheimer.

PURPOSE: Volumetric analysis of the corpus callosum and hippocampus using MRI in Alzheimer's disease (AD) to evaluate the regional pattern and progression of neocortical neurodegeneration. METHODS: In subsequent studies we investigated patients with AD and healthy controls. Volumetry was based on MRI-data from a sagittal 3D T1w-gradient echo sequence. The corpus callosum (CC) was measured in a midsagittal slice, and subdivided into 5 subregions. Volumetry of the hippocampus/amygdala-formation (HAF) was performed by segmentation in coronary reoriented slices. RESULTS: In AD patients we found a significant atrophy in the rostrum und splenium of CC. The atrophy was correlated with the severity of dementia, but no correlation was found with the load of white matter lesions. In comparison with (18)FDG-PET, we found a significant correlation of regional CC-atrophy with the regional decline of cortical glucose metabolism. A ROC-analysis demonstrated no significant differences in the diagnostic accuracy of HAF volumetry and regional CC volumetry of the splenium (region C5) even in mild stages of dementia. CONCLUSION: Regional atrophy of CC can be used as a marker of neocortical degeneration even in early stages of dementia in AD.