A retrospective clinical, laboratory and outcome analysis in 43 cases of acute aseptic meningitis.

Forty-three consecutive cases of acute aseptic meningitis (AAM) presenting within a 24-months period were retrospectively analysed with respect to clinical symptomatology, cerebrospinal fluid (CSF) findings, clinical course, treatment and outcome. Nineteen of the 43 AAM cases (44%) were caused by enterovirus, one by HIV (2%), two by Varicella zoster virus (5%), three due to herpes simplex virus I (7%), two due to herpes simplex virus II (5%), one due to Central European encephalitis virus (2%), and in 15 patients (35%) the aetiology of AAM remained unknown. Headache (100%) and fever (93%) were the presenting symptoms in the majority of cases. Signs of preceding infection were predominantly gastrointestinal in the enterovirus subgroup, but were inconsistently observed in the other subgroups. CSF findings at the first lumbar tap on admission generally revealed lymphomonocytic pleocytosis of less than 500 cells per micro l, mild to moderately elevated protein and normal lactate and glucose levels. Initial therapy consisted of an empirical antiviral and antibiotic regimen until a serological diagnosis was available. Acyclovir, effective only in herpes family viruses, was initially administered to all AAM cases. Effective therapy for other viral pathogens are not broadly available and treating AAM of unknown aetiology imposes a particular problem. The average hospitalization time ranged from 16 to 31 days. Patients were either discharged home (72%) or transferred to a rehabilitation centre (28%). The outcome was good (40%) to fair (51%) in the majority of cases.

Reversible segmental cerebral vasoconstriction (Call-Fleming syndrome): are calcium channel inhibitors a potential treatment option?

The Call-Fleming syndrome is characterized by sudden onset of thunderclap-like headache and focal neurological deficits. The pathophysiological correlate is a reversible segmental cerebral vasoconstriction frequently associated with focal cerebral ischaemia. The syndrome has been described in a variety of clinical conditions, and recently an association between the syndrome and exposure to vasoactive drugs was observed. Effective treatment options are not known. A 63-year-old female developed sudden 'worst ever' headache. Initial neurological examination, laboratory blood tests, CSF examination and brain magnetic resonance imaging (MRI) were normal. Previous medical history was unremarkable and she did not take vasoactive drugs. Eleven days after the onset of headache she developed visual field impairment and a right-sided hemiparesis. Brain MRI revealed bilateral posterior and left parietal ischaemic strokes. Cerebral catheter angiography showed segmental arterial vasoconstriction. A vasodilative therapy with calcium channel inhibitors was started and serial transcranial Doppler ultrasonography demonstrated resolution of cerebral arterial vasoconstriction. The present case illustrates that calcium channel inhibitors may be an effective therapy for segmental cerebral arterial vasoconstriction. However, more clinical data are needed to prove this observation.

[Isolated intracerebral cystic echinococcosis. Unusual presentation of a rare disease]. / Isolierte intrazerebrale zystische Echinokokkose - Ungewöhnliche Manifestation einer seltenen Erkrankung -

HISTORY AND CLINICAL FINDINGS: A 46-year-old woman was admitted with a first generalised tonic-clonic seizure. Past medical history was unremarkable. She reported no travels abroad within the past five years. INVESTIGATIONS: Brain MRI demonstrated disseminated cerebral and cerebellar focal lesions. Cerebrospinal fluid analysis showed a mild eosinophilic pleocytosis. Extensive imaging investigations and serological tests revealed no hints for a systemic parasitic disease. A stereotactic brain biopsy detected no pathogenic agent. 10 months following the initial admission, brain MRI showed multiple cystic lesions with ring-like enhancement following Gd-DTPA administration. At that time serological tests were positive for an infection with Echinococcus granulosus. DIAGNOSIS: The diagnosis was based on positive sequential serological tests and the typical MRI findings in conjunction with an eosinophilic cerebrospinal fluid pleocytosis. TREATMENT AND CLINICAL COURSE: An antihelmintic therapy with Albendazole was initiated. Following two-months of oral Albendazole administration, brain MRI revealed a clear reduction in size and number of the hydatid lesions. The patient was free of complaints and the clinical examination was unremarkable. CONCLUSION: Isolated intracerebral manifestation of cystic echinococcosis is very rare. Compared to the typical presentation with a solitary cerebral hydatid cyst, the dissemination of hydatid cysts is quite uncommon in cystic echinococcosis. Diagnosis should be based on the typical MRI findings and serological tests. The present case demonstrates that the later may be negative over a long period within the clinical course of the disease offering a real challenge to the clinician.

[Prolonged non-convulsive status epilepticus as an early clinical manifestation of epilepsy in connection with HIV infection--case report with EEG and MRI follow-up]. / Prolongierter nicht-konvulsiver Status epilepticus als klinische Erstmanifestation einer Epilepsie im Rahmen einer HIV-Infektion-Fallbericht mit EEG- und MRT-Verlauf.

The non-convulsive status epilepticus (NCSE) is a complication of petit mal epilepsy or epilepsy with temporal lobe seizures. Very rarely it is the primary manifestation of a symptomatic epilepsy. This report is on a 30-year old female inpatient with NCSE as the primary manifestation of symptomatic epilepsy, occurring four years after HIV infection (stage B3 according to the CDC classification) through heterosexual contact. After an initial tonic-clonic seizure, the patient suffered from NCSE for four weeks with diminished consciousness and major cognitive deficits. During this whole time period the EEG showed bilateral synchrone 1-2 Hz spike-wave complexes. After several failed treatment attempts, the NCSE was successfully and permanently treated with a combination of valproic acid and ethosuximide. The cerebrospinal fluid, cranial CT and cranial MRI were completely uneventful with regard to a CNS infection by the HI-virus or other infectious agents. 20 days after the initial symptoms, MRI showed bilateral cortical-subcortical and bilateral hippocampal lesions which stood out as focal edema zones, gradually disappeared completely and occurred in combination with the development of a discrete brain and right sided hippocampal atrophy. The EEG continued to show signs of right-temporal epileptic discharges with tendencies to generalise after 3 months but normalised after 6 months. Epileptic seizures are rarely an initial clinical sign of an infection with the HI-Virus even if no signs of encephalitis is detectable in the cerebrospinal fluid or in the cerebral MRI.

Color Doppler imaging of basal cerebral arteries: normal reference values and clinical applications.

Transcranial color-coded duplex ultrasonography is a new diagnostic procedure allowing the visualization of major intracranial vessels. The purpose of this report is to describe this method and to evaluate its practical potential in the routine examination of basal cerebral arteries. The results from the examination of 96 patients are presented. By means of color coding of Doppler frequencies, the major intracranial vessels were identified by nature of their anatomic location with respect to the echogenic brainstem structures in all subjects. The average maximal systolic velocity was, in the middle cerebral artery, 108 +/- 15 cm/s; in the anterior cerebral artery, 96 +/- 15; in the posterior cerebral artery, 76 +/- 16; and in the basilar artery, 59 +/- 17 cm/s. The determination of the angle between the ultrasonic beam and the examined vessel improved the accuracy of flow velocity measurements in comparison with conventional transcranial Doppler ultrasonography. The exact measurement of blood flow velocity in several segments of the visualized vessel proved helpful in the assessment of pathologic findings, especially in differentiation between a stenosis of the intracranial vessel and a vasospasm.

A comparison of the prognostic value of neuron-specific enolase serum levels and somatosensory evoked potentials in 13 reanimated patients.

Thirteen patients resuscitated after circulatory arrest due to cardiopulmonary aetiologies were studied with regard to survival and outcome. Exclusion criteria were known central nervous system disorders or death secondary to cerebrovascular accident. The serum level of neuron-specific enolase (NSE), presumably a reliable marker of neuronal death, was measured by enzyme immunoassay in peripheral blood samples over the course of 4 days at 12 h intervals. On the first and third day post-resuscitation, median nerve somatosensory evoked potentials (SSEPs) were recorded and evaluated for the absence of the cortical potential--presently the standard approach for assessing prognosis in terms of post-resuscitation hypoxaemic brain damage. Absent cortical potentials were found in six patients with NSE levels above 140 micrograms l-1. Five of these patients died; one patient survived with loss of cortical functioning. Five patients had normal SSEP findings, and their NSE maximum levels were below 25 micrograms l-1. All five patients survived without neurological deficits. One patient with a peak NSE level of 36 micrograms l-1 on the second day developed a prolonged delirium (according to DSM III-R criteria) and one patient with a peak level of 76 micrograms l-1 on the fourth day developed an acute respiratory distress syndrome; both patients had preserved cortical potentials. In conclusion, pathological SSEPs and increased NSE levels are of comparable prognostic value. They may well be complementary investigations. The neuron-bound enzyme NSE is a biochemical marker which varies with the extent of neuronal damage, while absence of the cortical potentials may indicate neurophysiological loss of function.

Duplex ultrasonography of vertebral arteries: examination, technique, normal values, and clinical applications.

A technique for the imaging of vertebral arteries at their origins and along the longitudinal extracranial course is described. The results of the examination of 108 normal vertebral arteries are shown. The vertebral artery could be distinguished in the pretransverse and intertransverse segment C5-C6 in 100%. The average diameter of the vessel was 3.81 +/- 0.46 mm on the right and 3.88 +/- 0.47 on the left side. The average maximal systolic velocity was 43.0 +/- 8.9 cm/s on the right and 43.3 +/- 9.6 on the left side. In 81% of the cases the vertebral origin could be located on the right and in 65% of the cases on the left side. The technical quality of visualization, especially of the vertebral origin, was greatly influenced by the depth of the examined structure. Examples of pathologic findings, such as hypoplasia, stenosis, and occlusion, demonstrate the practical possibilities of this noninvasive method.

Efficacy and tolerance of vinpocetine in ambulant patients suffering from mild to moderate organic psychosyndromes.

The efficacy and tolerance of orally administered vinpocetine was investigated in patients suffering from mild to moderate organic psychosyndromes including primary dementia. Two hundred and three patients were included in a placebo-controlled, randomized double-blind, multicentre trial and received every day for 16 weeks either: 3 x 10 mg doses of vinpocetine, 3 x 20 mg doses of vinpocetine, or 3 x placebo. Patients were assessed on ratings of clinical global impression, cognitive performance and on measures of the quality of life including depressive illness. There were no clinically relevant side-effects reported and the frequencies of adverse events between patients treated with vinpocetine (30 mg or 60 mg) and placebo were comparable. Statistically significant improvements were found in favour of both active treatment groups compared to placebo in both confirmatory evaluations of efficacy of treatment: the "Global Improvement" (on the CGI scale) and cognitive performance (SKT). Vinpocetine was also superior to placebo in ratings of the "severity of illness". This study demonstrates the usefulness and efficacy of vinpocetine in the management of patients with moderate organic psychosyndromes. An apparently greater therapeutic efficacy of 3 x 10 mg vinpocetine compared with the higher vinpocetine dosage is statistically not significant.

[Artificial nutrition in neurology--indications and problems]. / Die künstliche Ernährung in der Nervenheilkunde--Indikationsstellungen und Problematiken.

36 patients with severe neurological diseases (craniocerebral trauma, cerebrovascular insufficiency, meningo-encephalitis, polyneuropathy, paraplegia, intoxication etc.) received for more than 3 months monosaccharides and polyols (Triofusin E 1000) and a 10-%-concentration of crystalline amino acids (Aminofusin L10% kohlenhydratfrei) via the parenteral route in combination with / or exclusively a nutrient-defined diet (Biosorb). Exclusive enteral nutrition was given preference if possible. Numerous laboratory parameters, as for example blood counts, "hepatic enzymes", electrolytes, trace elements, plasma proteins, lipids, urea and creatinine were determined once a week. Substitutions and secondary complications were registered in addition. Iron and plasma proteins had to be substituted most frequently. It could be proved that hypoferremia was caused by insufficient iron supply in case of exclusive/prevailing parenteral nutrition, incorrect application of the iron preparations, inflammatory complications with iron moving into the R.E.S., as well as malabsorption syndromes probably induced by bacteria. Inflammatory complications were also the major cause of protein deficiency syndromes (hypoalbuminemia). In case of relatibely often occurring diarrhea, however, it could clearly be proved that it was not induced by nutrition but was produced by a broad-spectrum antibiosis. Chronically persistent diarrhea with colitis-like colonic changes required enteral feeding with an oligopeptide diet (z.B. Peptisorb) via jejunal feeding tube. Nitrogen balances which were determined after more than 3 months of artificial nutrition formed the basis of a nutritional plan differentiated according to diagnostic groups and stages of disease.

[Spontaneous intracerebral hematomas: occipital lobe hemorrhages]. / Spontane intrazerebrale Hämatome: Okzipitallappen-Blutungen.

Spontaneous intracerebral hematomas can be diagnosed immediately and localized exactly by the means of cranial computerized tomography. The occipital lobe is a relatively rare site of hypertensive hematomas which are the most frequent etiologic group. Out of 264 patients with intracerebral hematomas ion cranial computerized tomography we found the occipital lobes affected in 24 cases i.e. 9%. 116 patients with intracerebral hematomas treated in the neurologic clinic demonstrated in 15 cases (13%) occipital localization. In 7 patients bleedings were of hypertensive origin, in 4 cases etiology was unknown, in one case it originated from an arteriovenous angioma and in 3 cases congophilic (amyloid) angiopathy was the basic disease. In smaller occipital hematomas the clinical symptoms are relatively mild, mainly consisting of acute headache and hemianopsia. If the hematoma is limited to the occipital lobe the prognosis is favorable both with or without neurosurgical treatment.

[Parenteral and enteral feeding of neurologic patients in crisis from the viewpoint of long-term intensive therapy]. / Parenterale und enterale Ernährung krisengefährdeter neurologischer Patienten unter dem Aspekt der Langzeit-Intensivtherapie.

32 patients in a neurological intensive-care unit with severe disturbances of conscious or impaired function of the swallowing muscles had to receive artificial nutrition on an average of 164 days. They were nourished either parenterally, with the nutrient defined diet Biosorb in combination with parenteral nutrition, or exclusively via a feeding tube. Enteral nutrition was given preference over parenteral nutrition if justified under the clinical circumstances. A multivariable study was intended to investigate to what extent the respective type of nutrition and its individual components met the actual clinical requirements during such a long period. Moreover, the study was intended to demonstrate to what degree adverse factors influenced the different nutritional regimens and necessitated--in addition to infusion programs and dietetics--supplementary steps which might also be of use under completely optimized circumstances.

[Tracheotomy or intubation? Problems with long-term intensive care patients]. / Tracheotomie oder Intubation? Probleme mit Langzeit-Intensivpatienten.

Three groups of probands were established among 77 long-term intensive care patients. Group I comprised cases intubated for more than 7 days, group II underwent tracheotomy after a variable time of intubation, and group III were tracheotomised immediately. All complications were severalfold more frequent in patients with hypercatabolic underlying disease than in those with less severe underlying disease. Long-term intubation led generally to laryngeal damage after one week and increased frequency of pneumonia after two weeks. Patients with tracheotomy after an interval showed frequent pneumonias only after one month. Inflammatory changes of trachea, bronchi, and tracheostoma with the appropriate consequences were frequent. Lower tracheal stenoses occurred in approximately 10% of cases in group II. The lowest complication rate was observed in patients tracheotomised immediately. Patients with hypercatabolic disease without prospects for improvement in the near future should be tracheotomised as early as possible. Tracheotomy can be postponed for up to three weeks if regression is to be expected in that time. In diseases without rapid physical deterioration the indication for tracheotomy can be postponed for six weeks.

[The course of functional psychoses (author's transl)]. / Verlaufsdarstellung von Funktionspsychosen.

Functional psychoses correspond to a universal reduction of mental and intellectual function which, fundamentally reversible and unspecific, appear as sequelae of disturbances of cerebral function. They are the most common psychoses in medical practice and in hospitals. With the Syndrome Short Test and Functional Psychosis Scale B we now have a mutually equilibrated test system for the measurement of the whole range of severity of functional psychoses. With these two psychopathometric methods a relatively differentiated investigation of cross section and course can be performed, for example in arriving at a diagnosis, checking medical measures, monitoring the effect of drugs and in the prognosis of a disease.

[The "locked-in" syndrome: pseudocoma in thrombosis of the basilar artery (author's transl)]. / Das "Locked-in"-Syndrom: Pseudokoma bei Basilaristhrombose

In pontine lesions with tetraplegia and cranial-nerve disturbances--including trismus--and with speech disability paralytic akinesia and loss of reactivity may be misinterpreted as coma. "Pseudocoma" of this kind may be associated with normal consciousness or relatively mild psychological disorders. This explains the discrepancy between a normal EEG (only minor abnormalities) and presumed unconsciousness. The term "locked-in" expresses the patient's inability to communicate. In typical cases there may be only vertical eye movements and blinking. Using remaining innervation facilities, those examining and treating the patient must try to communicate with him. The locked-in state may be mistaken for coma particularly if there had been a preceding episode of unconsciousness. Moreover, the "locked-in" syndrome often passes into a state of unconsciousness or coma. The degree of communication can markedly differ from hour to hour. Most of the cases of this syndrome are caused by basilar artery thrombosis.