MMPI profiles in post-lumbar puncture headache

From the original material of 300 patients, of whom 37.3% had experienced a post-lumbar puncture headache (PPH), a total of 20 males and 50 females were evaluated with the Minnesota Multiple Personality Inventory (MMPI). The test was administered on average 33 months after the lumbar puncture (range 13-51), at a time when anxiety and depression related to the original investigation for a possible organic neurologic disease were expected to affect the results minimally. In the present material PPH was experienced by 45.7% of the patients, 40% of the males, and 48% of the females. Patients without PPH were used as controls. The selected material was a representative sample of the original material both as to distribution of age, proportion of organic diagnoses, and frequency of PPH. The MMPI disclosed no statistically significant differences between PPH patients and controls regarding personality traits.

Natural evolution of late whiplash syndrome outside the medicolegal context

BACKGROUND

In Lithuania, few car drivers and passengers are covered by insurance and there is little awareness among the general public about the potentially disabling consequences of a whiplash injury. We took this opportunity to study the natural course of head and neck symptoms after rear-end car collisions.

METHODS

In a retrospective questionnaire-based cohort study, 202 individuals (157 men; 45 women) were identified from the records of the traffic police department in Kaunas, Lithuania. These individuals were interviewed 1-3 years after experiencing a rear-end car collision. Neck pain, headache, subjective cognitive dysfunction, psychological disorders, and low back pain in this group were compared with the same complaints in a sex-matched and age-matched control group of uninjured individuals selected randomly from the population register of the same geographic area.

FINDINGS

Neck pain was reported by 71 (35% [95% CI 29-42]) accident victims and 67 (33% [27-40]) controls. Headache was reported by 107 (53% [46-60]) accident victims and 100 (50% [42-57]) controls. Chronic neck pain and chronic headache (more than 7 days per month) were also reported in similar proportions (17 [8.4%; 5-13] vs 14 [6.9%; 4-12] and 19 [9.4%; 6-15] vs 12 [5.9%; 3-10]) by the two groups. Of those who reported chronic neck pain or daily headache after the accident, substantial proportions had had similar symptoms before the accident (7/17 for chronic neck pain; 10/12 for daily headache). There was no significant difference found. No one in the study group had disabling or persistent symptoms as a result of the car accident. There was no relation between the impact severity and degree of pain. A family history of neck pain was the most important risk factor for current neck symptoms in logistic regression analyses.

INTERPRETATION

Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.

[Sleep disorders]

There has been a great development in sleep medicine during the past 20-25 years and the International Classification of Sleep Disorders now lists about 90 relatively well-defined conditions related to sleep. Several of them are severely underdiagnosed. This review considers frequent and/or disabling sleep disorders, in particular disorders for which treatment is available.

Neck pain in the general population

STUDY DESIGN

A randomized cross-sectional questionnaire was used to determine the prevalence of neck pain in Norwegian adults.

OBJECTIVES

The frequency and duration of neck pain were assessed.

SUMMARY OF BACKGROUND DATA

Reliable epidemiologic studies on the prevalence of neck pain in the general population have been sparse.

METHODS

A questionnaire that inquired about neck pain within the last year was sent to a random sample of 10,000 adult Norwegians.

RESULTS

Overall, 34.4% of the responders had experienced neck pain within the last year. A total of 13.8% reported neck pain that lasted for more than 6 months.

CONCLUSIONS

Chronic neck pain is a frequent symptom in the general population, particularly in women. Although reservations have to be taken as to the interpretation, the reported prevalence of persisting pain after whiplash injuries is of the same magnitude as the prevalence of chronic neck pain in the general population.

Do decreased trace metal concentrations in surficial skagerrak sediments over the last 15-30 years indicate decreased pollution?

Varying concentrations of Zn, Pb and Cu over the last 15-30 years (1963-1991) have been found in two undisturbed cores with preserved sediment-water interfaces from the Skagerrak (Station A: 645 m, Station B: 405 m water depth). Mass Accumulation Rates (MAR) in g/m2/year were used to resolve the question of increased or decreased supply. Station A-MAR increased exponentially: Zn from 0.05 to 0.28, Cu from 0.009 to 0.044, and Pb from 0.003 to 0.114 g/m2/year, while concentrations did not show this increase over the last 15-30 years. Station B-MAR increased exponentially: Zn from 0.07 to 0.29, Cu from 0.013 to 0.049, and Pb from 0.014 to 0.114 g/m2/year, while concentrations decreased over the same period. MAR indicated that both stations received similar trace metal flux. Release of trace metals from the sediment to the water column and/or dilution by water and organic matter within the upper few centimeters of the sediment accounted for the concentration decrease at both stations. MAR revealed an increase in trace metal supply, and thus an increase in pollution, over the last 15-30 years, although concentrations indicated the opposite.

[Mononucleosis and neurological manifestations]

Infectious mononucleosis is a relatively common disease. In this paper, three patients with neurological symptoms related to infectious mononucleosis are described. Patient no. 1 had myelitis, one of the most frequent neurological complications. Patient no. 2 had cerebellar symptoms, with ataxia and disturbance of gait. In this case magnetic resonance revealed vermis atrophy, a finding which, to the best of our knowledge, has not been reported before. Patient no. 3 had bilateral optic neuritis. Repeated serologic tests may be necessary to confirm the diagnosis. Infectious mononucleosis should be considered in younger patients with neurological symptoms of uncertain origin.

[Physician's statement concerning whiplash injuries. Significance of supplementary information]

The frequency of insurance cases following traffic accidents involving the whiplash mechanism is increasing in Norway. The economic consequences are obviously great, both for the individual patient and for society. Declarations by medical specialists may be of vital importance when assessing the degree of medical invalidity. We have investigated some of the information provided by 27 patients who were submitted for assessment of medical invalidity after traffic accidents. In eight of these cases, the information in reports from their usual doctor or physiotherapist varied from the case history described by the patient. In all these cases, a previous history of neck pain was found in the health reports, but was not mentioned, and was partly denied, by the patients. Our results underline the importance of supplementary information.

The prevalence of delayed and advanced sleep phase syndromes

To determine the prevalence of the delayed sleep phase syndrome (DSPS) and the contrasting advanced sleep phase syndrome (ASPS), a cross-sectional nationwide epidemiological study was performed in Norway. Screening questionnaires were sent to a random sample of 10,000 adult individuals (18-67 y), of both sexes, taken from the National register of Norway. The response rate was 77%. Diagnoses of DSPS and ASPS were based on International Classification of Sleep Disorders (ICSD) criteria. All individuals suspected of having DSPS or ASPS were requested to fill out a second questionnaire, and a sleep log for four weeks. Subjects for whom the suspicion of DSPS or ASPS could be upheld were contacted by telephone for a final confirmation. Of the 129 possible DSPS cases identified from the screening questionnaires, 17 (9 f; 8 m) remained with the confirmed diagnosis of DSPS. The prevalence was calculated to be 0.17% (95% Confidence Intervals: 0.10-0.28). Thirteen individuals had a mild to moderate DSPS and four had a severe DSPS. The mean age of onset was 15.4 y, and mean duration was 19.2 y. There was no significant correlation between prevalence and age. A sleep phase delay (MSPD) induced by social/environmental or psychological factors was found in 55 subjects (prevalence = 0.72%). Using strict ICSD criteria, no case of ASPS was detected, confirming earlier assumptions of the extreme rarity of this condition.

Palatopharyngoglossoplasty in the treatment of patients with obstructive sleep apnea syndrome

A new technique (palatopharyngoglossoplasty (PPGP)) has been developed for surgical treatment of patients with the obstructive sleep apnea syndrome (OSAS). In 20 operated patients 18 reported immediate marked improvement of daytime sleepiness, alertness and vigilance during the day, and of working capacity. However, polysomnography carried out pre- and postoperatively showed that only 10 patients were "cured", defined as 50% or more reduction in apnea/hypopnea index (AHI). Cephalometric analysis pre- and postoperatively indicated that nonresponders had a long and narrow posterior airway space, and we suggest that during sleep this part of the upper airway collapses before as well as after the operation. The discrepancy between the subjective improvement observed after PPGP and the postoperative reduction in AHI may be due to reduced/eliminated snoring and/or improvement in sleep quality after the operation.

"Hemicrania continua": a clinical review

Hemicrania continua (HC) is a headache entity completely responsive to indomethacin. Since 1984, 18 cases have been described, 15 females and 3 males, i.e. a F:M ratio of 5.0. The finding of a female preponderance, like that in chronic paroxysmal hemicrania, is a new observation. HC is, in general, a unilateral headache in the sense that it sets in on one side and subsequently sticks to this side. In two cases, both sides might possibly be involved, when the pain was at its maximum. In another (somewhat dubious) case the headache was bilateral. The pain was continuous from the beginning in 8 of 18 cases (early stage ratio continuous: non-continuous = 0.8). Over time, the headache developed a continuous character in 16 of the 18 cases, producing a "continuous: non-continuous ratio" of 8:1. The intensity of pain generally was moderate and was not reported as excruciatingly severe by any patient. The autonomic involvement from a clinical point of view, was clearly less pronounced than that of other unilateral headaches, such as cluster headache and chronic paroxysmal hemicrania.

Anterior perforations in lumbar discectomies. A report of four cases of vascular complications and a CT study of the prevertebral lumbar anatomy

Four cases of vascular complications to anterior perforations during discectomy prompted a CT study to measure lumbar disc diameters and to evaluate the prevertebral anatomy. Fifty young adults who had been referred for low-back pain and/or sciatica but had not undergone operation were included. In five additional patients, prone versus supine CT examinations were compared. Six typical configurations of the vascular anatomy could be classified to explain the type of vascular complications occurring at the L3-4 and L4-L5 disc levels. The sagittal diameter of the three lowest lumbar discs varied from 33 to 56 mm, indicating the importance of this parameter as an intraoperative guideline for the spine surgeon. Air-filled intestines were observed anterior to the L5-S1 disc predominantly in the prone position. The possible relationship between this finding and postoperative discitis is discussed.

[Delayed sleep phase syndrome. The most frequent cause of primary chronic insomnia?]

During the past four years the author has seen six cases of chronic persistent insomnia with onset in childhood. Four of these cases had delayed sleep phase syndrome, a disturbance in sleep-wake schedule characterized by the inability to fall asleep, and by continuous sleep of normal length later in the night. The article describes the case histories of two adolescent patients and experience from using chronotherapy. It appeared that chronotherapy was effective, but the demands on the sleep-wake schedule discipline were difficult to accept. It is suggested that delayed sleep phase syndrome may be the most frequent cause of chronic insomnia with onset in childhood.

Subdural hematoma presenting as headache in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) affects the nervous system in 75% of cases (1). A female with several neurological manifestations in the case history presented with severe headache, psychiatric disturbances, and increasing paraparesis. She was found to have bilateral subdural hematomas, and after evacuation her neuropsychiatric symptoms, including headache, disappeared. It is speculated that the reported low incidence of subdural hematomas in SLE may be more apparent than real. On the basis of our case, we recommend repeated neuroradiological investigations to uncover this important, treatable and otherwise potentially fatal cause of headache.

The significance of age, sex, and cerebrospinal fluid pressure in post-lumbar-puncture headache

In this study of 300 neurological inpatients aged between 18 and 60 years the incidence of post-lumbar-puncture headache (PPH) was 37.3%. The more severe the headache, the more frequently it was associated with dizziness, nausea, vomiting, and tinnitus. If PPH occurred during the first day after lumbar puncture (LP), it was more severe, and lasted longer than PPH, which started later. The incidence of PPH and associated symptoms decreased with increasing age, and was much higher in females than males. The sex difference was nearly exclusively explained by a marked preponderance of PPH in females below 40 years of age, i.e. women in the fertile age. Furthermore, there was a decreased incidence of PPH and associated symptoms in patients with an initial higher than average cerebrospinal fluid (CSF) pressure (162 mm H2O). All these differences were statistically significant. Particularly high frequencies of PPH were found in young women with an initial CSF pressure lower than mean.

Post-lumbar-puncture headache: the significance of body posture. A controlled study of 300 patients

In this single-blind, randomized study of post-lumbar-puncture headache (PPH) in 300 neurologic inpatients the significance of body posture after lumbar puncture (LP) was evaluated. Immediate mobilization was compared with bed rest for 6 h (3 h prone followed by 3 h supine posture). Contrary to the widely held belief, this investigation did not show significant differences between recumbent and ambulant patients as to frequency of PPH in the total material (39% versus 35%) or when men (31% versus 29%) and women (48% versus 41%) were evaluated separately. Headache associated with nausea was significantly more frequent in the recumbent than in the ambulant patients both in the total material (23% versus 13%) and in women (35% versus 16%). Thus, immediate mobilization seems to be preferable after LP.

The treatment of accessory symptoms in narcolepsy: a double-blind cross-over study of a selective serotonin re-uptake inhibitor (femoxetine) versus placebo

A randomized, double-blind cross-over trial was carried out in 10 patients with narcolepsy to evaluate the effect of 600 mg femoxetine versus placebo. In comparison to placebo, femoxetine treatment resulted in a significant decrease in both the number and severity score of cataplectic attacks per day. There were also significantly fewer attacks of sleep paralysis, whilst the effects on nightmare and hypnogenic hallucinations were minor. The frequency of sleep attacks decreased slightly during femoxetine treatment, but the overall estimated sleep time during the day and excessive daytime sleepiness remained un-affected. An ambulatory sleep recording for 48 h one week after the start of the femoxetine and placebo period showed that femoxetine treatment resulted in a significant decrease in the total time spent in REM sleep. The side-effects of femoxetine were restricted to transient nausea in 2 patients. It is concluded that femoxetine or other selective serotonin reuptake inhibitors may be a useful alternative for narcoleptic patients who experience troublesome side-effects with tricyclic antidepressants.

Effects of continuously expanding intracranial lesions on vital physiological parameters. An experimental animal study

The work described in this report confirms and extends the results described in a preliminary communication (Löfgren, J. and Zwetnow, N.N., Acta Neurol. Scand. (1970, 625) which examined the effects in cats of an expanding mass, in the form of an intracranial supratentorial balloon, on vital physiological parameters. In the present study, particular emphasis was placed on the possible significance of the rate of expansion of the mass in the range usually encountered in the clinical situation of intracranial haemorrhages. Results from the experiments on 37 cats and 8 dogs showed that changes in vital parameters appeared when the balloon had reached a volume of about 5% of the intracranial volume (the "reaction volume") while respiratory arrest occurred at an intracranial volume of about 10% (the "apnoea volume"). Both threshold volumes were independent of the rate of expansion within the range used. Alterations in EEG, heart rate, respiratory rate and systemic arterial pressure usually occurred simultaneously with the development of a transtentorial pressure gradient. When respiratory arrest occurred, the cerebral perfusion pressure was markedly reduced, usually to a value of about 30 mm Hg, suggesting that brain tissue ischaemia is an important component in the lethal mechanism underlying intracranial expanding lesions. It is proposed that the volume load tolerance of the organism towards an expanding intracranial lesion, as expressed by the reaction volume and the apnoea volume, may represent a biologically useful parameter potentially suitable for quantitative evaluation of adverse agents and therapeutic procedures.

Effects of prolonged supratentorial mass expansion on regional blood flow and cardiovascular parameters during the Cushing response

To clarify the central nervous and the cardiovascular mechanisms mediating the Cushing response (CR) during intracranial hypertension, the effects of continuous and prolonged expansion of an epidural supratentorial balloon was studied in six dogs. Regional cerebral blood flow, cardiac output, extracerebral tissue blood flow and regional vascular resistance were measured with radioactive microspheres before and during the CR while heart rate, arterial blood pressure and ECG were continuously recorded. The results showed that balloon expansion led progressively to cerebrospinal ischemia beginning in the cerebrum and progressing to the pons, medulla oblongata and spinal cord in an orderly rostro-caudal fashion. This progressing ischemia was closely associated with patterned and stereotyped changes in cardiovascular indices. Thus, respiration ceased, heart rate decreased, blood pressure increased and cardiac output fell when the ischemia appeared in the lower pons. Further advancement of the ischemic front to the lower medulla oblongata led to an abrupt switch-over from bradycardia to tachycardia, which persisted until the experiment was terminated. Since bradycardia disappeared when ischemia reached the vagal cardiomotor nucleus, the initial bradycardia appeared to be the result of increased vagal discharge. When ischemia reached the pons, the mean arterial pressure rose to a maximum of 245 mm Hg (+/- 45) but then fell progressively when the ischemia reached the spinal cord. The decrease in cardiac output persisted throughout the CR and was associated with decreased flow in most extracerebral organs. Exceptions were the heart muscle and the adrenal medulla in which blood flow increased considerably. Changes in regional vascular resistance reciprocated the changes in flow. These results suggest that the vasomotor component of the CR is brought about entirely by peripheral vasoconstriction.

Regional cerebral blood flow and CSF pressures during the Cushing response induced by an infratentorial expanding mass

An experimental study was carried out in eight dogs to investigate whether the Cushing response (CR) during intracranial hypertension is due to pressure per se, tissue distortion, or ischemia in the brain stem. To minimize the effects of rostrocaudal displacement, intracranial pressure was raised by an expanding mass lesion located in the posterior fossa. Regional cerebral blood flow (rCBF) was measured with radioactive microspheres and compartmental cerebrospinal fluid (CSF) pressures were recorded during the CR which was induced by the continuous inflation at a constant rate of an infratentorial epidural rubber balloon in two groups of four dogs. In one group (A) rCBF was measured at the onset of the CR and in the other group (B) at the peak of the systemic blood pressure rise. In the animals of group A blood flow in the mesencephalon, pons and upper medulla oblongata was reduced from control values by 32%, 57% and 85% respectively. In group B blood flow in the same areas did not differ significantly from pre-inflation values. In contrast, the recorded balloon volume, which was assumed to be an index of mechanical distortion of the brain stem, varied considerably at the beginning of the blood pressure rise (from 2.5 to 4.7% of the calculated intracranial space). Similarly, CSF pressure in the posterior fossa at the onset of the CR also varied considerably (from 52 to 117 mmHg). Thus, the large quantitative variations meant that both absolute pressure and tissue distortion were poor predictors of the onset of the CR. The findings suggest that ischemia, rather than brain stem distortion per se or pressure by itself, is responsible for the initiation of the CR. The rise in blood pressure elicited during the CR seems capable of restoring blood flow in the brain stem back to control values.

Regional cerebral blood flow and CSF pressures during Cushing response induced by a supratentorial expanding mass

In order to delineate the critical blood flow pattern during the Cushing response in intracranial hypertension, regional cerebral blood flow was measured with radioactive microspheres in 12 anesthetized dogs at respiratory arrest caused either by expansion of an epidural supratentorial balloon or by cisternal infusion. Regional cerebrospinal fluid pressures were recorded and the local cerebral perfusion pressure calculated in various cerebrospinal compartments. In the 8 dogs of the balloon expansion group, the systemic arterial pressure was unmanipulated in 4, while it was kept at a constant low level (48 and 70 mm Hg) in 2 dogs and, in another 2 dogs, at a constant high level (150 and 160 mm Hg) induced by infusion of Aramine. At respiratory arrest, regional cerebral blood flow had a stereotyped pattern and was largely independent of the blood pressure level. In contrast, concomitant pressure gradients between the various cerebrospinal compartments varied markedly in the 3 animal groups, increasing with higher arterial pressure. Flow decreased by 85-100% supratentorially and by 70-100% in the upper brain stem down to the level of the upper pons, while changes in the lower brain stem were minor, on the average 25%. When intracranial pressure was raised by cisternal infusion in 4 dogs, the supratentorial blood flow pattern at respiratory arrest was approximately similar to the flow pattern in the balloon inflation group. However, blood flow decreased markedly (74-85%) also in the lower brain stem. The results constitute another argument in favour of the Cushing response in supratentorial expansion being caused by ischemia in the brain stem. The critical ischemic region seems to be located rostrally to the oblongate medulla, probably in the pons.

Influence of blood pressure on tolerance to an intracranial expanding mass

In 3 groups of 4 dogs with normotensive, induced-hypotensive and induced-hypertensive blood pressure respectively, continuous expansion of an extradural supratentorial balloon led to respiratory arrest at inflation volumes which increased with increasing blood pressure. This positive correlation between the volume tolerance to an expanding lesion and blood pressure was also found in similar experiments on 4 hypotensive and 4 hypertensive cats. Monitoring cerebrospinal fluid pressures in the cerebral lateral ventricles, in the posterior fossa and in the spinal subarachnoid space showed that absolute pressures in the various compartments as well as the intercompartmental pressure gradients at the moment of respiratory arrest were increased in proportion to the level of the systemic arterial pressure in each case. These observations do not support current concepts that brain-stem distortion alone or that stimulation of baroreceptors in the posterior fossa are responsible for eliciting the Cushing response. The fact that the supratentorial perfusion pressure was the only parameter which did not differ significantly under the different experimental conditions suggests that the mechanism responsible for the respiratory arrest is local brain tissue ischemia, probably near the tentorial incisure. The magnitude of gain in volume tolerance, when mean arterial pressure was varied from 60 mmHg to 190 mmHg, was 87% suggesting that the blood pressure may have a critical role in an intracranial lesion. These findings have clinical implications.

Changes of pituitary hormones in brain death

In six patients with clinical and electroencephalographic signs of brain death, pituitary hormones such as prolactin, human growth hormone (GH), luteinizing hormone (LH), and thyrotrophin (TSH) were measured in blood close to the demonstration of intracranial circulatory arrest by angiography. In addition, pituitary hormone releasing tests and an insulin test were carried out in two patients. The results showed that no patient had a general decrease in hormone levels, according to their biological half life times, which suggests there still was some function in the hypothalamus and pituitary. This was supported by the results of the stimulation tests. It is concluded that in brain death some basal parts of the brain may still be perfused despite the fact that angiography indicates circulatory arrest in these areas.

Laminated Diatomaceous Sediments from the Guaymas Basin Slope (Central Gulf of California): 250,000-Year Climate Record

During Deep Sea Drilling Project-International Program of Ocean Drilling leg 64, December 1978 to January 1979, the initial test of the Deep Sea Drilling Project's hydraulic piston corer obtained an almost undisturbed section from a 152-meter hole into the sediments of the oxygen minimum zone at a depth of 655 meters along the Guaymas slope in the central Gulf of California. The section records variations in climate, productivity, and circulation for more than 250,000 years of Late Pleistocene to Holocene history with recordings of seasonal variations in these parameters in the laminated sections.

Multiple sclerosis and narcolepsy/cataplexy in a monozygotic twin

Symptoms of narcolepsy/cataplexy developed in a monozygotic twin at the age of 56 years, 25 years after the onset of multiple sclerosis. The diagnosis of narcolepsy/cataplexy was confirmed by polygraphic recordings demonstrating sleep-onset periods of rapid eye movements (REM), increase in REM time per 24 hours, and disturbed nocturnal sleep. Frequent catapletic attacks were almost completely controlled by clomipramine. These symptoms may constitute one of the paroxysmal syndromes in multiple sclerosis. The discordancy for multiple sclerosis is attributed to a submaximal risk factor in the HLA system and a strong environmental factor in only one of the twins.

The cerebral lesions in a patient with generalized glutathione deficiency and pyroglutamic aciduria (5-oxoprolinuria)

The clinical and pathologic features of a male patient with generalized glutathione deficiency and pyroglutamic aciduria are presented. The patient died at the age of 28 years. He was mentally retarded from infancy and developed progressive tremor, retardation of movement, and ataxia as from the age of 16. Neuropathologic examination of the brain disclosed a selective atrophy of the granule cell layer of the cerebellum and focal lesions in the visual cortex and the thalamus. The type and distribution of the lesions resembled those seen after mercury intoxication. However, in our patient the damage was probably caused by the lack of protection of glutathione against oxidative damage in the brain. Possible treatment of this rare metabolic disorder might include external supply of an antioxidant, e.g., a thiol capable of penetrating the blood brain barrier.

[Demonstration total brain infarct with radioisotope angiography]

In the field of organ transplantation and in brain death patients where intensive-care measures may seem superfluous, the demonstration of cessation of cerebral blood flow by X-ray angiography is generally agreed to be the diagnostic procedure of choice to prove irreversible loss of cerebral function. There are, however, certain drawbacks involved in X-ray angiography. Arterial puncture is necessary. Furthermore, the procedure can be time-consuming, thus making the continuation of adequate intensive-care measures more difficult. At the same time the circulatory condition may worsen causing hypoxic damage to the organ to be transplanted. In the present paper, the authors report on 13 patients with clinical signs of brain death where cessation of cerebral blood flow was demonstrated atraumatically by intravenous radioisotope angiography (RIA) using a multicrystal gammacamera (Baird Atomic) and the bolus-injection technique with 99m Tc-pertechnetate. Nine patients had severe brain injuries, 2 patients had brain tumours, 1 patient had encephalitis and 1 patient had suffered prepartal thrombosis of the sinus sagittalis. In all patients EEG recordings were isoelectric. At the time when the RIA was performed systolic blood pressure had decreased to 62-85 mmHg (x = 71 mmHg), while body temperature had declined to 31-36,5 degrees C (x = 34 degrees). According to the present results, which were all confirmed by subsequent bilateral carotid X-ray angiography, total brain infarction is unequivocal when the following criteria are satisfied using RIA: 1. when the radioisotope bolus flows along the common carotid arteries but does not proceed any further than to the base of the skull or around the scalp structures, 2. when, at the moment when the radioactivity outlines the scalp structures, neither the intracranial arteries nor the capillary bed or the venous sinuses are visible, 3. when the time-activity curves across the hemispheres show simply a plateau of low count rate without the activity peak typical for cerebral tracer circulation and 4. when the activity peak, typical for venous outflow, is missing from the time-activity curves for the cervical areas. In 12 patients with extremely reduced cerebral blood flow it was demonstrated that the RIA findings were clearly different from those obtained at brain death. Moreover, not one of 438 other patients undergoing RIA exhibited the same features which were associated with brain death. The authors conclude that RIA involves the same degree of safety as X-ray angiography in the diagnosis of total brain infarction but is superior to the latter when the diagnostic procedure has to be performed quickly, thus reducing the risk of any further damage to a prospective donor organ.

Nachweis des totalen Hirninfarktes mit der Radio-Isotopen-Angiographie

Bei 13 Patienten mit totalem Hirninfarkt konnte der zerebrale Kreislaufstillstand atraumatisch mit der Radio-Isotopen-Angiographie (RIA) unter Verwendung von 99mTechnetium-Pertechnetat und der Multi-kristall-Kamera innerhalb von 3—4 Minuten sicher nachgewiesen werden.

Aufgrund der bisherigen Befunde, die ausnahmslos mit der angeschlossenen bilateralen Karotiskontrast-angiographie, in drei Fällen auch mit der 133Xe-Gamma-Clearance-Methode bestätigt werden konnten, sind wir der Auffassung, daß die RIA der konventionellen Röntgen-Kontrast-Angiographie bezüglich der Hirntodesdiagnose zumindest gleichwertig, hinsichtlich eines zu sichernden Transplantationserfolges aber überlegen ist, da die schonend und schnell durchzuführende RIA zu keiner weiteren ischämischen Schädigung des zu transplantierenden Organes führt.

Bei weiteren 12 Patienten mit erheblich reduzierter zerebraler Durchblutung (schweres Schädel-Hirn-Trauma, apallisches Syndrom) wurde demonstriert, daß auch diese Zustände von der RIA erfaßt und von dem des totalen Hirninfarktes eindeutig unterschieden werden können.

[A case of Guillain-Barré syndrome following cholera vaccination (author's transl)]

A 45-year-old woman developed bilateral ascending flaccid paralysis after cholera vaccination, 15 days after the first and 1 day after the second injection. The clinical course resulted in nearly complete paralysis of the lower limbs, paresis of the upper limbs and partial involvement of the cranial nerves. There was only slight sensory loss. The CSF revealed no pleocytosis and a protein level of 206 mg/100 ml. Recovery began 2 weeks later and was almost complete after 2 months. Immunological investigations revealed no remarkable changes.