[Telemedical prenotification in acute stroke treatment : Experiences from the Stroke Angel initiative from 2004 until the present]. / Telemedizinische Voranmeldung in der akuten Schlaganfallversorgung : Erfahrungen der Stroke-Angel-Initiative von 2004 bis heute.

OBJECTIVE: The Stroke Angel initiative investigates the implementation of telemedicine for improvement of preclinical communication between emergency medical services (EMS) and stroke units in cases of acute stroke. MATERIAL AND METHODS: Stroke Angel is a technical system for the telemedical prenotification of patients in cases of suspected stroke at a stroke unit by the EMS. Within the framework of an observational study, the team has been investigating the effects of the system on door-to-computed tomography (CT) and door-to-needle times as well as the lysis rate in the neighboring regions of Rhön-Grabfeld and Bad Kissingen since 2005. RESULTS: The system supports the acute treatment of neurological emergencies and functions as a catalyst for the interlinking of medical institutions in the region as well as for communication between emergency physicians/EMS and hospital physicians. The use of a computer-based data collection enables a continuous improvement process leading to an acceleration of internal clinical procedures and an increase of the lysis rate with the mortality rate staying constant. CONCLUSION: Telemedicine is applicable in the preclinical care of acute stroke and, thanks to the computer-based data collection, leads to an increase in process transparency, which helps to improve the internal clinical processes in and around a stroke unit.

[Home-based telerehabilitation after stroke]. / Telerehabilitation nach Schlaganfall im häuslichen Umfeld.

The use of modern information and telecommunication technologies enables telerehabilitation of neurological deficits in the domestic environment. The current state of studies on rehabilitative teletherapy for improvement of motor function and mobility deficits due to stroke is reviewed. Two neurolinguistic proof of concept studies investigating the efficacy of online interactive telespeech therapy are reported, which compared virtual screen to screen interactive telerehabilitation of aphasia after stroke and dysarthrophonia in Parkinson's disease to conventional face to face rehabilitation. The results of the studies indicate that the neurological rehabilitation of motor and communicative deficits in the domestic environment of patients by means of teletherapy is just as efficient as conventional rehabilitation. Under home-based telerehabilitation patient transfer becomes unnecessary. Rehabilitative Teletherapy is a posthospital component of a cross-sector supply chain for patients with handicaps or impairments due to stroke and other neurological diseases.

Incidence and predictors of chronic headache attributed to whiplash injury.

We identified clinical, demographic and psychological predictive factors that may contribute to the development of chronic headache associated with mild to moderate whiplash injury [Quebec Task Force (QTF) ≤ II] and determined the incidence of this chronic pain state. Patients were recruited prospectively from six participating accident and emergency departments. While 4.6% of patients developed chronic headache attributed to whiplash injury according to the International Classification of Headache Disorders, 2nd edn criteria, 15.2% of patients complained about headache lasting > 42 days (QTF criteria). Predictive factors were pre-existing facial pain [odds ratio (OR) 9.7, 95% confidence interval (CI) 2.1, 10.4; P = 0.017], lack of confidence to recover completely (OR 5.5, 95% CI 2.0, 13.2; P = 0.005), sore throat (OR 5.0, 95% CI 1.5, 8.9; P = 0.013), medication overuse (OR 4.2, 95% CI 1.4, 12.3; P = 0.009), high Neck Disability Index (OR 4.0, 95% CI 1.3, 12.6; P = 0.019), hopelessness/anxiety (OR 3.8, 95% CI 1.3, 8.7; P = 0.024), and depression (OR 3.3, 95% CI 1.2, 9.4; P = 0.024). The lack of a control group limits the conclusions that can be drawn from this study. Identified predictors closely resemble those found in chronic primary headache disorders.

[Familial cavernous malformations of the central nervous system. A clinical and genetic study of 15 German families]. / Familiäre Kavernome des Zentralnervensystems. Eine klinische und genetische Studie an 15 deutsche Familien.

In 1928, Hugo Friedrich Kufs reported on a family with cerebral, retinal, and cutaneous cavernous malformations. Since then, more than 300 families with inherited cavernous malformations have been reported. Genetic studies showed three loci, on chromosomes 7q21-q22 (with the gene CCM1), 7p15-p13 (CCM2), and 3q25.2-q27 (CCM3). The gene product of CCM1 is Krit 1 (Krev interaction trapped 1), a protein interacting with angiogenesis by various mechanisms. Recently, CCM2 has also been identified; its product is a protein which might have a function similar to that of Krit 1. However, the CCM3 gene has still not been found. In this study, we present clinical and genetic findings on 15 German families.

Prospective PC-interactive pressure algesimetry of post-traumatic neck pain after whiplash injury.

Cervical pain is a prominent symptom in both acute whiplash injury and late whiplash syndrome. However, no systematic analysis of post-traumatic pain development covering several weeks has yet been performed in whiplash patients. It was the aim of the present study to analyse the duration and course of post-traumatic muscle pain due to whiplash injury in a prospective follow-up examination with short investigation intervals. A recovery of initially increased muscle pain after whiplash injury within 1 month was hypothesized. Pressure pain of the splenius and trapezius muscles was recorded using PC-interactive pressure algesimetry. Whiplash patients were investigated during the acute injury stage and after 3, 4, and 6 weeks and compared with matched controls. We found significantly increased pressure pain of the splenius and trapezius muscles in the acute stage of whiplash injury. After 4 weeks patients' scores of pain parameters were comparable to those of healthy control subjects. Within the patient group the first changes of pressure pain were observed within 3 (splenius) and 4 weeks (trapezius). For most patients the recovery dynamics lasted 4-6 weeks. A minority of patients did not show any improvement after 6 weeks. The present study shows that the dynamics of pressure pain due to whiplash injury can be quantified by means of PC-interactive pressure algesimetry. Our results confirm the clinical experience that the acute post-traumatic cervical syndrome normally subsides within weeks.

Quantification of acute neck pain following whiplash injury by computer-aided pressure algesimetry.

Until now the clinical investigation of cervical pain due to whiplash injury is mainly based on finger palpation. The present study introduces a PC-interactive pressure algesimetry to standardize cervical pain measurement. Pressure pain scores of the splenius and trapezius muscles of 23 patients with an acute cervical syndrome after whiplash injury were compared to those of 24 healthy subjects. The pressure painfulness of neck and shoulder muscles was significantly increased in whiplash patients. The splenii muscles showed an equally increased muscle pain whereas the trapezii muscles showed a left-sided preponderance of painfulness, possibly due to the seat belt position in this group of motor vehicle drivers. The computer-interactive pressure algesimetry enables a standardized and rater-independent quantification of the cervical syndrome with neck and shoulder pain caused by whiplash injury.

Presumed pharmacologically induced change from upbeat- to downbeat nystagmus in a patient with Wernicke's encephalopathy.

A case of Wernicke's encephalopathy due to proven thiamine deficiency suffering from upbeat nystagmus (UN) changing to downbeat nystagmus (DN) after a latency of 1 year is presented. The case was also notable for the finding of positive oligoclonal bands in the CSF. The underlying pathophysiological mechanisms and a possible effect of baclofen treatment are discussed.

Temporal order of nonlinear dynamics in human brain.

In previous spectral analysis investigations, we demonstrated that the spontaneous activity of the alpha EEG is not stationary but rather shows cyclic alterations with a circa 1-min periodicity. Following the conclusion that a power increase in the alpha band implies a neuronal synchronization, and vice versa, an associated decrease of the EEG complexity was postulated. Accordingly, a rhythmic variation, i.e., a temporal order of the nonlinear dynamics with similar period length, was expected. Bipolar 4-min EEG recordings were obtained from 20 awake subjects (mean age: 23.5+/-2.5 years) with eyes closed for the EEG leads C3, C4, Oz, and Fz according to the 10-20 system. For the automatic evaluation of spontaneous alterations of complexity, a sliding computation of the so-called correlation dimension, using an analysis window length of 20 s continuously shifted by 1 s, was performed. The time series of complexity exhibited an oscillatory behavior with a mean period length of 58.7 s; the Friedman test statistic revealed no significant topological differences. For the rejection of the null hypothesis that the observed periodicity is a random one, two-group t-tests and ANOVA with repeated measures were performed, comparing the corresponding amplitudes and period lengths with those derived from 20 pseudo-random signals (taken from a multivariate Gaussian normal distribution). The mean relative change of EEG complexity was highly significantly increased (P<0.0001) compared to that of random data. Likewise, the difference of mean period lengths was also significant (P<0.01). The results indicate that the coupling strength of the neural network of the brain changes periodically, with a cyclic alteration from a central to a parallel processing mode of information, reflecting state transitions from synchronized, low-complex EEG activity to desynchronized high-complex activity, and vice versa. Various neuronal control mechanisms that may be acting as pacemakers responsible for the temporal order of such transients are discussed. A disturbance of the temporal order may be of pathophysiological significance.

Malignant pheochromocytoma with progressive paraparesis in von Hippel-Lindau disease.

Pheochromocytomas are a feature of the von Hippel-Lindau disease spectrum, a multisystem disorder of autosomal dominant inheritance. Pheochromocytomas are, however, observed during life with a lower frequency than other features of this disease, such as retinal angiomas, haemangioblastomas of the CNS, and renal carcinomas. We present the highly unusual case of a patient who required an emergency operation for an intradural extramedullary thoracic tumour which was clinically suggestive initially of neurinoma. We present evidence from NMR, histological and isotope scan investigations of this being a pheochromocytoma metastasis and of an additional right-sided paraganglioma at the same height. A detailed history revealed that this patient had suffered from four other pheochromocytomas and two other paragangliomas, in addition to retinal angiomatosis of von Hippel-Lindau disease. This case is extraordinary due to (i) the unusual site of the metastasis, (ii) the neurological requirement for an emergency operation of pheochromocytoma, (iii) metastasis of pheochromocytoma in von Hippel-Lindau disease (only eight previous cases), and (iv) the number of recurrent pheochromocytomas. It clearly demonstrates the necessity for frequent and life-long follow-up in von Hippel-Lindau disease.

Inverse covariation of spectral density and correlation dimension in cyclic EEG dynamics of the human brain.

The responsiveness or excitability of the central nervous system (CNS) to external or internal stimuli is systematically altered corresponding to transient changes of the EEG background activity, mainly in the alpha range. We hypothesise that a transient alpha power increase is due to an underlying increase in synchronisation or coupling strength between various neuronal elements or cortical networks. Consequently, the 'network' of the CNS may be more ordered and, hence, less complex in the case of high spectral density, and vice versa. The goals of the present paper are (1) to prove the inverse covariation between spectral density and correlation dimension for a set of human EEG data, (2) to falsify the null hypothesis that the observed relationship is a random one, and (3) to propose a neuronal approach which may explain the observed correlations. A sliding computation of the spectral density and correlation dimension [Grassberger P, Procaccia I (1983) Physica D 9:189-208] of mid-occipital EEG recordings derived from eight awake subjects with eyes closed was performed. The similarity between the two time courses was quantified by similarity measures and descriptive correlation coefficients. The temporal pattern of dimensional complexity showed an inverse relationship with simultaneously computed spectral power changes most pronounced in the alpha range. The group means of similarity measures and correlation coefficients were compared with the corresponding means of a sample set established by 20 Gaussian random signals. Statistically significant differences were obtained at the 0.1% level, rejecting the null hypothesis that the observed relationship is a random one. The results support the idea that the dynamics of the EEG signals investigated reflect a chaotic deterministic process with state transitions from 'high-dimensional' to 'low-dimensional' non-linear dynamics, and vice versa. Adequate neuronal models and approaches to interpret the disclosed transients and the inverse covariation between spectral density and dimensional complexity are proposed, giving additional insight into the integrative functioning of the CNS with respect to the strategy of information processing.

Multiple intracerebral metastases of a 17-year-old girl with previously diagnosed neurofibromatosis type I.

We report a case of a 17-year-old girl with multiple intracerebral tumors. Previously, a neurofibroma in the posterior mediastinum and neurofibromatosis had been diagnosed. She developed a spastic tetraparesis with a prominent hemiparesis of the right side within several weeks. On admission we found clinical signs of elevated intracranial pressure. Cranial CT and MRI scans showed multiple space-occupying intracerebral tumors, thought to be multiple meningeoma. The patient was referred to the neurosurgical department, where two of the intracerebral tumors were excised. The histological examination revealed metastases of a neurosarcoma.

[Pain quantification after whiplash trauma using computer-interactive pressure-pain measurement]. / Schmerzquantifizierung nach HWS-Schleudertrauma mittels computerinteraktiver Druckalgesimetrie.

In patients with an acute cervicocephalic pain syndrome following whiplash injury (n = 12), pressure-pain scores for the splenius and the trapezius muscles on both sides, for the fingers on both sides and for the skull were recorded and compared to a control group. A computer-aided pain measurement was applied, which is presented as an improvement of pressure algesimetry. During constant application of pressure stimuli, the patient rated the increasing pain on a visual analogue scale, resulting in a curve of pain intensity against time. Slope and integral of the curve proved to be the most reliable parameters. After whiplash injury, significantly increased pain scores were found for the splenius muscle on both sides, for the left trapezius muscle and for the left finger whereas there was only a tendency of increased pain at the other stimulation sites. The presented method allows quantification of the cervical syndrome with neck and shoulder muscle sprain caused by whiplash injury. This objective and rater-independent method is of great value for diagnostic, therapeutic and medico-legal purposes in the assessment of the disease course and in clinical therapy trials.

Myopathy in two siblings with nephropathic cystinosis.

Nephropathic cystinosis is a hereditary disorder characterized by a specific defect in the transport of cystine across the lysosomal membrane, leading to an accumulation of protein-free cystine in tissues, including conjunctiva, liver, bone marrow and kidney. Renal transplantation is necessary because of renal failure. With improved life-expectancy, neurological complications have been reported, including cases of distal myopathy diagnosed ante- and post-mortem. We report on two further rare cases of two siblings suffering from cystinosis who developed a predominantly distal myopathy, proven electrophysiologically and on biopsy during life. The reported clinical picture of a distal atrophy resembling a neurogenic disease, confirms a picture apparently typical in cystinosis. Possible effects of cysteamine therapy on the course of the myopathy are discussed. Copyright 1998 Lippincott Williams & Wilkins