[Mimikry of herpes encephalitis by glioblastoma multiforme]

Herpes encephalitis (HSE) is an acute illness. Imaging is an important part of the diagnostic work-up of HSE. In early stages one can see a manifestation in the insular cortex as well as in the fornix. These MRI findings are rather typical for HSE. We present three cases treated in our hospital over the past ten years. In these cases the clinical symptoms and signs as well as the morphological findings were compatible with the HSE diagnostic criteria. Later on, a glioblastoma multiforme was found in all three cases.

Diagnostic accuracy of plasma glial fibrillary acidic protein for differentiating intracerebral hemorrhage and cerebral ischemia in patients with symptoms of acute stroke

BACKGROUND

Glial fibrillary acidic protein (GFAP) is a biomarker candidate indicative of intracerebral hemorrhage (ICH) in patients with symptoms of acute stroke. GFAP is released rapidly in the presence of expanding intracerebral bleeding, whereas a more gradual release occurs in ischemic stroke. In this study the diagnostic accuracy of plasma GFAP was determined in a prospective multicenter approach.

METHODS

Within a 1-year recruitment period, patients suspected of having acute (symptom onset<4.5 h before admission) hemispheric stroke were prospectively included into the study in 14 stroke centers in Germany and Switzerland. A blood sample was collected at admission, and plasma GFAP was measured by use of an electrochemiluminometric immunoassay. The final diagnosis, established at hospital discharge, was classified as ICH, ischemic stroke, or stroke mimic.

RESULTS

The study included 205 patients (39 ICH, 163 ischemic stroke, 3 stroke mimic). GFAP concentrations were increased in patients with ICH compared with patients with ischemic stroke [median (interquartile range) 1.91 μg/L (0.41-17.66) vs 0.08 μg/L (0.02-0.14), P<0.001]. Diagnostic accuracy of GFAP for differentiating ICH from ischemic stroke and stroke mimic was high [area under the curve 0.915 (95% CI 0.847-0.982), P<0.001]. A GFAP cutoff of 0.29 μg/L provided diagnostic sensitivity of 84.2% and diagnostic specificity of 96.3% for differentiating ICH from ischemic stroke and stroke mimic.

CONCLUSIONS

Plasma GFAP analysis performed within 4.5 h of symptom onset can differentiate ICH and ischemic stroke. Studies are needed to evaluate a GFAP point-of-care system that may help optimize the prehospital triage and management of patients with symptoms of acute stroke.

Identification and functional analysis of novel THAP1 mutations

Mutations in THAP1 have been associated with dystonia 6 (DYT6). THAP1 encodes a transcription factor that represses the expression of DYT1. To further evaluate the mutational spectrum of THAP1 and its associated phenotype, we sequenced THAP1 in 567 patients with focal (n = 461), segmental (n = 68), or generalized dystonia (n = 38). We identified 10 novel variants, including six missense substitutions within the DNA-binding Thanatos-associated protein domain (Arg13His, Lys16Glu, His23Pro, Lys24Glu, Pro26Leu, Ile80Val), a 1bp-deletion downstream of the nuclear localization signal (Asp191Thrfs*9), and three alterations in the untranslated regions. The effect of the missense variants was assessed using prediction tools and luciferase reporter gene assays. This indicated the Ile80Val substitution as a benign variant. The subcellular localization of Asp191Thrfs*9 suggests a disturbed nuclear import for this mutation. Thus, we consider six of the 10 novel variants as pathogenic mutations accounting for a mutation frequency of 1.1%. Mutation carriers presented mainly with early onset dystonia (<12 years in five of six patients). Symptoms started in an arm or neck and spread to become generalized in three patients or segmental in two patients. Speech was affected in four mutation carriers. In conclusion, THAP1 mutations are rare in unselected dystonia patients and functional analysis is necessary to distinguish between benign variants and pathogenic mutations.

Posterior reversible encephalopathy syndrome: long-term follow-up

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) has been known for more than 10 years. The long-term prognosis of this condition remains unknown.

PATIENTS AND METHODS

In 2006, the authors screened retrospectively the medical records of our department between 1993 and 2006 for PRES. The authors identified 13 patients. Since 2006, another 12 patients have been included prospectively. Since then, follow-up has been performed yearly for all patients. They were investigated in the outpatient clinic or, if they declined to attend, were interviewed by telephone.

RESULTS

The authors identified 25 patients with 27 episodes of PRES. Eighty-four per cent of the patients had generalised seizures. Their mean blood pressure was 167/100 mm Hg. Follow-up was performed for all patients over a mean period of 2250 days (range 59-9396; median 1699). Symptoms resolved, on average, after 7.5 days. Restitution of imaging abnormalities could be shown in 72% of cases. All others showed a clear improvement, but without complete restitution, after a mean duration of 41 days. Recurrence of PRES was observed in two patients (8%), 3 years after complete recovery from their first episode.

CONCLUSION

These data show that PRES has a good short-term and long-term prognosis. Recurrence is infrequent, even though trigger factors for PRES were repeatedly experienced by the patients. Resolution of MRI lesions is slower than clinical recovery.

[Billing based on a case-based lump sum for stroke. Did this lead to discharge of patients in a worse clinical condition?]

BACKGROUND

It has been supposed that the introduction of a new inpatient reimbursement system starting in 2004 in Germany using the German diagnosis-related groups (G-DRG) may lead to false incentives with encouragement of premature hospital discharge of patients. Exploring a large database on stroke patients, we addressed the question whether length of stay (LOS) and discharge in more severe condition were associated with the introduction of the G-DRG. We further examined other factors with probable effect on LOS such as variations of patient characteristics and treatment during the observation period.

PATIENTS AND METHODS

All stroke patients treated in 2003-2006 in the German state of Hesse (6,100,000 inhabitants) were assessed with respect to stroke severity, symptoms on admission and discharge, LOS and stroke-related deficits on discharge. We compared LOS and outcome in 2003 (before introduction of the G-DRG) with 2004 when the G-DRG had recently been introduced and with 2006 when the G-DRG was already well established in the clinical routine. The effects of LOS and treatment year on outcome were assessed using a logistic regression model.

RESULTS

During the observation period, we evaluated 37,396 stroke patients. The length of stay was reduced significantly from 12.2 to 10.4 days (p<0.001). Both severity of stroke on admission and outcome on discharge decreased during the observation period. A multivariate analysis revealed a minor but significant association [odds ratio (OR): 1.020 per day of hospital treatment; 95% confidence interval (CI): 1.016-1.024] of LOS on outcome. Treatment in 2006 compared to 2003 led to good outcome with an OR of 1.378 (95% CI: 1.279-1.485). Subgroup analysis limited to patients with severe stroke revealed that LOS was significantly lower in 2006 compared to 2003 also in this patient subgroup; moreover, the proportion of patients discharged with severe outcome was lower in 2006 compared to 2003.

CONCLUSIONS

This study reveals a significant reduction of LOS during the years after introduction of the G-DRG. However, reduction of LOS was not associated with more severe outcome on discharge, possibly due to changes in stroke treatment implemented during the observational period. Our results do not support the conjecture that changes in the reimbursement system were associated with compromised patient care.

Klinik und Genetik der Gliedergürteldystrophien

Gliedergürtelmuskeldystrophien („limb girdle muscle dystrophies“, LGMD) sind eine klinisch sowie genetisch heterogene Gruppe von Muskelkrankheiten, von denen bis heute 7 dominante (LGMD1A–G) und 15 rezessive Formen (LGMD2A–O) beschrieben sind. Viele davon beginnen im Jugendlichenalter und führen in der Regel über die folgenden 2–4 Jahrzehnte zur Gehunfähigkeit. Die Symptomatik beginnt häufig im Beckengürtel, die Muskeln des Schultergürtels folgen in unterschiedlichem Abstand. Allele Formen der vorgestellten LGMD können auch einen distalen Prädilektionstyp aufweisen, wie die Miyoshi-Myopathie durch Mutationen im Dysferlingen. Die häufigsten Formen aus der Gruppe der rezessiven LGMD sind Calpainopathien (LGMD2A), Dystrophien durch Mutationen im FKRP-Gen (FKRP: „Fukutin-related protein“, LGMD2I) sowie Dysferlinopathien (LGMD2B). Es folgen in der Häufigkeit die Sarkoglykanopathien, die oft bereits im Kindesalter beginnen. Bei vielen Formen führt der Gendefekt zur Störung eines sarkolemmalen Proteins. Wegen der großen Heterogenität folgt die molekulargenetische Analyse in der Regel der Muskelbiopsie mit immunhistologischer Aufarbeitung. Eine spezifische Therapie ist bislang nicht verfügbar. Die Behandlung von Kontrakturen und die Überwachung evtl. begleitender Kardiomyopathien stehen neben der humangenetischen Beratung im Vordergrund.

Screening of ARHSP-TCC patients expands the spectrum of SPG11 mutations and includes a large scale gene deletion

Autosomal recessive spastic paraplegia with thinning of corpus callosum (ARHSP-TCC) is a complex form of HSP initially described in Japan but subsequently reported to have a worldwide distribution with a particular high frequency in multiple families from the Mediterranean basin. We recently showed that ARHSP-TCC is commonly associated with mutations in SPG11/KIAA1840 on chromosome 15q. We have now screened a collection of new patients mainly originating from Italy and Brazil, in order to further ascertain the spectrum of mutations in SPG11, enlarge the ethnic origin of SPG11 patients, determine the relative frequency at the level of single Countries (i.e., Italy), and establish whether there is one or more common mutation. In 25 index cases we identified 32 mutations; 22 are novel, including 9 nonsense, 3 small deletions, 4 insertions, 1 in/del, 1 small duplication, 1 missense, 2 splice-site, and for the first time a large genomic rearrangement. This brings the total number of SPG11 mutated patients in the SPATAX collection to 111 cases in 44 families and in 17 isolated cases, from 16 Countries, all assessed using homogeneous clinical criteria. While expanding the spectrum of mutations in SPG11, this larger series also corroborated the notion that even within apparently homogeneous population a molecular diagnosis cannot be achieved without full gene sequencing.

[Type I neurofibromatosis and megadolichobasilar artery]

Intracranial vascular malformations are rare but tend to appear more frequently than usual in patients with type I neurofibromatosis (NFI). Aneurysms of the basilar artery have been described four times so far. We report two cases of 51- and 62-year-old patients with type I neurofibromatosis who showed long fusiform dilation of the basilar artery. Clinically both patients presented with locked-in syndrome and died 15 and 11 days after admission. The diagnosis was confirmed by autopsy. These are the first published cases of locked-in syndrome following thrombosis of a megadolichobasilar artery in association with neurofibromatosis I. Our results show that cerebral vascular malformations are found more frequently than random chance would predict in patients with NF I.

[Severe encephalitis without correlate in MRI]

Encephalitis could be a life-threatening disease depending on localisation and infectious agent. Neuroimaging, especially MRI, is an important component in the diagnosis. The recent investigations demonstrate that diffusion abnormalities are the first and sensitive signs of viral encephalitis. We describe five patients with severe encephalitis with normal MR imaging. Three of five patients were intermittently mechanically ventilated, two of these longer than 4 weeks. The other two patients suffered from a severe psychosyndrome with seriously limited ability to communicate throughout 6 weeks. At the time of first MRI examination all patients were noticeably ill. Four of five patients had at least one follow-up MRI. The MRI examinations included FLAIR sequences and DWI in four of five patients. Contrast-enhancement was detectable in none of our patients. Follow-up examinations revealed that symptoms of encephalitis were noticeably or completely regressive.