Recurrent stenosis following carotid artery stenting treated with a drug-eluting balloon: a single-center retrospective analysis.

PURPOSE: Early in-stent restenosis after stent-protected angioplasty of the carotid artery (SPAC) is an infrequent, but potentially harmful condition for patients with carotid artery disease. METHODS: In our retrospective single-center analysis of 176 patients with carotid artery stenting between 2009 and 2015, using duplex ultrasound, we detected 9 patients with high-grade carotid artery in-stent restenosis. All restenosis patients were treated with a drug-eluting balloon (DEB) to prevent recurrent neointimal hyperplasia. One patient had bilateral carotid artery disease with bilateral in-stent restenosis, and 1 patient needed repeated DEB treatment 19 months after the first DEB intervention, so 11 DEB procedures, in total, were performed. RESULTS: The median time-interval between primary carotid artery stenting and first DEB-treatment was 9 months. In 3 of the 11 interventions, the DEB treatment was assisted by an additional stent. One repeat DEB treatment was necessary, and three DEB treatments were followed by a secondary stent. No peri-interventional complications (TIA, stroke, or death) were observed during or after DEB intervention. Therefore, in the entire group, the 1y event-free survival (EFS) was 100%, and the 2y/3y/5y EFS was 83%. CONCLUSION: DEB intervention seems to be an effective and safe treatment for patients with high-grade in-stent restenosis after SPAC.

[Myasthenia gravis should be considered in cases of Parkinson's disease and progressive dysphagia]. / Bei Morbus Parkinson und progredienter Dysphagie an Myasthenia gravis denken.

We report on four consecutive patients with Parkinson's disease, in whom anti-acetylcholine receptor (AChR) antibody positive bulbar myasthenia gravis (MG) turned out to be responsible for progressive dysphagia.

Mechanical Recanalization following i.v. Thrombolysis: A Retrospective Analysis regarding Secondary Hemorrhagic Infarctions and Parenchymal Hematomas.

Introduction. In acute stroke by occlusion of the proximal medial cerebral artery (MCA) or the distal internal carotid artery, intravenous thrombolysis is an established treatment. Another option is mechanical recanalization. It remains unclear if the combination of both methods poses an additional bleeding risk. The aim of this retrospective analysis is to determine the proportion of hemorrhagic infarctions and parenchymal hematomas. Methods. Inclusion criteria were an occlusion of the carotid T or proximal MCA treated with full dose thrombolysis and mechanical recanalization. 31 patients were selected. Devices used were Trevo, Penumbra Aspiration system, Penumbra 3D Retriever, and Revive. The initial control by computed tomography was carried out with a mean delay to intervention of 10.9 hours (SD: 8.5 hours). Results. A slight hemorrhagic infarction (HI1) was observed in 2/31 patients, and a more severe HI2 occurred in two cases. A smaller parenchymal hematoma (PH1) was not seen and a space-occupying PH2 was seen in 2/31 cases. There was no significant difference in the probability of intracranial bleeding after successful (thrombolysis in cerebral infarctions 2b and 3) or unsuccessful recanalization. Conclusion. The proportion of intracranial bleeding using mechanical recanalization following intravenous thrombolysis appears comparable with reports using thrombolysis alone.

Speech motor deficits in cerebellar infarctions.

Functional imaging studies demonstrated cerebellar activation during speech movements in the rostral cerebellar region. Ischemic lesions of this area, which is supplied by the superior cerebellar artery, induce dysarthria.

Central nervous system involvement in adults with epidemic hemolytic uremic syndrome.

Hemolytic uremic syndrome is a multisystem disorder that is caused by infection with Shiga-toxin-producing Escherichia coli. HUS affects mainly children and is rare among adults. This retrospective case series analyzes clinical signs and MR imaging findings of 11 adult patients with HUS associated nervous system involvement during the epidemic EHEC outbreak in northern Europe with its epicenter in Hamburg in May 2011. The most prevalent imaging finding was symmetric pointy vasogenic edema of the brain stem in the acute and subacute phases of the disease (n = 5). One patient exhibited additional symmetric mesiotemporal signal changes mimicking limbic encephalitis. Two patients developed subcortical patchy lesions, and 4 subjects did not present with any signal changes. Remarkably, territorial ischemia, signs of hemorrhage, or blood-brain barrier disruption have not been detected. While brain stem lesions were transient and normalized with clinical recovery, supratentorial lesions did not resolve completely at 2-month follow-up examination.

[Slowly progressive dysarthria in primary lateral sclerosis]. / Langsam progressive Dysarthrophonie bei primärer Lateralsklerose.

Slowly progressive dysarthria over many years may be the only sign of primary lateral sclerosis (PLS). Clinically it presents as pseudobulbar palsy which can be differentiated from amyotrophic lateral sclerosis (ALS) by the longer disease duration (> or =4 years), central pathological magnetic-evoked potentials to the tongue and lack of denervation in EMG. In contrast, hereditary spastic paraplegia (HSP) is characterized by a primary spasticity of the lower limbs, mostly later onset, the fact that other family members are affected and in isolated cases by positive genetic testing for mutations.

[Central positional vertigo due to cerebellar nodular infarction]. / Lagerungsschwindel bei zerebellärem Nodulusinfarkt.

Nodular infarctions are a rare cause of vertigo and may imitate vestibular neuritis. We report on two patients with acute positional vertigo due to nodular infarction, a clinical presentation is not reported so far. High-resolution MR imaging using thin slices is required to identify isolated nodular infarctions.

[Neurolymphomatosis. Subacute sensorimotor polyneuropathy as a first sign of non-Hodgkin's B cell lymphoma]. / Neurolymphomatose. Subakute sensomotorische Polyneuropathie als Erstmanifestation eines Non-Hodgkin-B-Zell-Lymphoms.

We report on a 65-year-old patient with subacute painful sensorimotor polyneuropathy with distal leg muscle palsy and initially presenting with bilateral leg edema. Electrophysiologic testing showed an axonal lesion pattern with acute denervation. Nerve biopsy demonstrated neurolymphomatosis as an initial manifestation of a non-Hodgkin's B cell lymphoma.

Antiamphiphysin-positive stiff-person syndrome associated with small cell lung cancer.

The paraneoplastic amphiphysin(+) stiff-person syndrome (SPS) has so far only been described in women with breast adenocarcinoma. Here, we describe the rare case of a female patient with antiamphiphysin(+) SPS due to small cell cancer of the lung.

Left-hemispheric dominance for articulation: a prospective study on acute ischaemic dysarthria at different localizations.

Dysarthria is a frequent symptom in cerebral ischaemia. However, speech characteristics of these patients have not previously been investigated in relation to lesion site in a prospective study. We investigated the auditory perceptual features in 62 consecutive patients with dysarthria due to a single, non-space-occupying cerebral infarction confirmed by MRI. Standardized speech samples of all patients were stored within 72 h after stroke onset using a digital tape recorder. Speech samples were assessed independently by two experienced speech therapists, who were unaware of the clinical and neuroradiological findings, using an interval scale ranging from 0 to 6. Separately assessed were features of articulation, phonation, prosody, and the global severity for a total of 31 items. Extracerebellar infarctions (85.5%) were located in the lower motor cortex (14.5%), striatocapsular region (46.8%) and base of the pons (24.2%). Isolated cerebellar infarctions were present in 14.5% of patients. There was a strong correlation between the findings of both examiners, showing identical scores, or only minor differences (<1 on the assessment scale) for 80% of all items. The average severity of dysarthria was 2.9 +/- 1.3. Articulatory abnormalities were the predominant deviation characteristics, affecting in particular the production of consonants. However, phonatory and prosodic abnormalities were also frequently observed speech characteristics. As revealed by factor analysis of speech characteristics the total severity of dysarthria was mainly influenced by the impairment of articulation. Speech parameters describing characteristics of articulation and prosody showed significant side-to-side and area differences, while this effect was lacking for any voice parameter. Left cerebral lesions showed a more severe overall impairment of speech and articulation, independent of lesion topography. Thirty-eight of 62 patients were available for follow-up. Speech evaluation showed normal speech within weeks in 15 out of 38 patients (39.5%). In the other 23 patients overall severity of dysarthria was mild. This is the first prospective study which describes speech characteristics of dysarthria due to acute unilateral cerebral infarctions. We could demonstrate that dysarthria in extracerebellar infarctions was more frequently caused by left-sided lesions and that the severity of dysarthria was more pronounced in left-sided lesions independent from lesion topography. All extracerebellar lesions were located along the course of the cortico-bulbar tract fibres. Compatible with a common pathophysiological basis of dysarthria in these patients, none of the 31 speech items differed significantly between subcortical and brainstem lesions.

A topodiagnostic investigation on body lateropulsion in medullary infarcts.

Body lateropulsion may occur without signs of vestibular dysfunction and vestibular nucleus involvement. The authors examined 10 such patients with three-dimensional brainstem mapping. Body lateropulsion without limb ataxia reflected an impairment of vestibulospinal postural control caused by a lesion of the descending lateral vestibulospinal tract, whereas body lateropulsion with limb ataxia was probably the consequence of impaired or absent proprioceptive information caused by a lesion of the ascending dorsal spino-cerebellar tract.

Brainstem reflex circuits revisited.

Our current understanding of brainstem reflex physiology comes chiefly from the classic anatomical-functional correlation studies that traced the central circuits underlying brainstem reflexes and establishing reflex abnormalities as markers for specific areas of lesion. These studies nevertheless had the disadvantage of deriving from post-mortem findings in only a few patients. We developed a voxel-based model of the human brainstem designed to import and normalize MRIs, select groups of patients with or without a given dysfunction, compare their MRIs statistically, and construct three-plane maps showing the statistical probability of lesion. Using this method, we studied 180 patients with focal brainstem infarction. All subjects underwent a dedicated MRI study of the brainstem and the whole series of brainstem tests currently used in clinical neurophysiology: early (R1) and late (R2) blink reflex, early (SP1) and late (SP2) masseter inhibitory reflex, and the jaw jerk to chin tapping. Significance levels were highest for R1, SP1 and R2 afferent abnormalities. Patients with abnormalities in all three reflexes had lesions involving the primary sensory neurons in the ventral pons, before the afferents directed to the respective reflex circuits diverge. Patients with an isolated abnormality of R1 and SP1 responses had lesions that involved the ipsilateral dorsal pons, near the fourth ventricle floor, and lay close to each other. The area with the highest probabilities of lesion for the R2-afferent abnormality was in the ipsilateral dorsal-lateral medulla at the inferior olive level. SP2 abnormalities reached a low level of significance, in the same region as R2. Only few patients had a crossed-type abnormality of SP1, SP2 or R2; that of SP1 reached significance in the median pontine tegmentum rostral to the main trigeminal nucleus. Although abnormal in 38 patients, the jaw jerk appeared to have no cluster location. Because our voxel-based model quantitatively compares lesions in patients with or without a given reflex abnormality, it minimizes the risk that the significant areas depict vascular territories rather than common spots within the territory housing the reflex circuit. By analysing statistical data for a large cohort of patients, it also identifies the most frequent lesion location for each response. The finding of multireflex abnormalities reflects damage of the primary afferent neurons; hence it provides no evidence of an intra-axial lesion. The jaw jerk, perhaps the brainstem reflex most widely used in clinical neurophysiology, had no apparent topodiagnostic value, probably because it depends strongly on peripheral variables, including dental occlusion.

Effects of botulinum toxin type A on vibration induced facilitation of motor evoked potentials in spasmodic torticollis.

BACKGROUND AND AIMS: It has not been clarified if botulinum toxin (BTX) injection leads to muscle spindle dysfunction in man. This study aimed to test the hypothesis that BTX application reduces the facilitation of a magnetic evoked response (MEP). METHODS: We used the vibration induced facilitation of an MEP of the sternocleidomastoid muscle (SCM) as a surrogate marker for muscle spindle function in 20 healthy subjects and 10 patients with idiopathic rotational torticollis in whom BTX was injected unilaterally. RESULTS: The increase in the amplitude and area of the MEPs in the clinically not affected and untreated SCM of the patients did not differ significantly from the controls. At baseline, the vibration induced increase in the affected SCM of the patients was significantly lower than in the control group. Six weeks after BTX application, the observed facilitation decreased significantly (amplitude and area: p<0.001) when compared with baseline values. Twelve weeks after BTX application, facilitation showed an increase in the values of the amplitude (p<0.001), but not of the area when compared with the six week examination. CONCLUSIONS: We demonstrated that the vibration induced MEP facilitation in the SCM of patients with torticollis significantly decreased six weeks after BTX application and again increased after 12 weeks in part when looking at MEP amplitude. This observation is suggestive of denervation and reinnervation of the muscle spindles after BTX injection.

[Paraneoplastic limbic encephalitis in small cell lung carcinoma]. / Paraneoplastische limbische Enzephalitis bei kleinzelligem Bronchialkarzinom.

We report about a 63-year-old male patient who complained of a recent onset of confusion. A mediastinal mass had been detected in his chest X-ray three days before admission to our clinic. Surprisingly, a CT scan of the brain revealed no signs of cerebral masses or oedema. MRI demonstrated bright hyperintens signals in the medial aspect of both temporal lobes. Biopsy by mediastinoscopy showed small cell lung carcinoma (SCLC). No distant metastases were found by staging procedures. Cerebrospinal fluid and serum contained antineuronal antibodies (anti-Hu). The combination of symptoms, MRI findings and paraneoplastic antibodies established the diagnosis of paraneoplastic limbic encephalitis in a patient with SCLC. Chemotherapy combined with immunosuppression by corticosteroids was started immediately. The primary tumour responded to therapy but improvement of cerebral symptoms was unsatisfactory. Severe memory loss and personality changes remained unchanged while there was a slight improvement in confusion and hallucinations.