[New aspects of symptomatic MS treatment: Part 6 - cognitive dysfunction and rehabilitation]

The symptomatic treatment of multiple sclerosis (MS) is nowadays of similar importance as immunotherapy within a comprehensive treatment concept of this chronic disease. It makes a considerable contribution to the reduction of disabilities in activities of daily living as well as social and occupational life. Moreover, symptomatic treatment is of great importance for amelioration of the quality of life. Since our last survey of symptomatic MS treatment in 2004 and publication of the guidelines of the German Neurological Society and the Clinical Competence Network Multiple Sclerosis ("Klinisches Kompetenznetz Multiple Sklerose", KKN-MS) in 2014 several developments within the topics of mobility, bladder and sexual function, vision, fatigue, cognition and rehabilitation have taken place. These new findings together with further aspects of disease measurement methods and overall treatment strategies of the respective symptoms, as well as treatment goals are introduced in several individual contributions. In this article the symptoms of cognitive disorders and the growing impact of rehabilitation are discussed.

[New aspects of symptomatic MS treatment: Part 4-sexual dysfunction and eye movement disorders]

The symptomatic treatment of multiple sclerosis (MS) is nowadays of similar importance as immunotherapy within a comprehensive treatment concept of this chronic disease. It makes a considerable contribution to the reduction of disabilities in activities of daily living as well as social and occupational life. Moreover, symptomatic treatment is of great importance for amelioration of the quality of life. Since our last survey of symptomatic MS treatment in 2004 and publication of the guidelines of the German Neurological Society and the Clinical Competence Network Multiple Sclerosis (Klinisches Kompetenznetz Multiple Sklerose, KKNMS) in 2014, several developments within the topics of mobility, bladder and sexual function, vision, fatigue, cognition and rehabilitation have taken place. These new findings together with further aspects of disease measurement methods and overall treatment strategies of the respective symptoms as well as treatment goals are introduced in several individual contributions. In this article the symptoms of sexual dysfunction and eye movement disorders are discussed.

[What is new in symptomatic MS treatment: Part 1-introduction and methodical approach, ataxia and tremor]

The symptomatic treatment of multiple sclerosis (MS) nowadays is of similar importance as immunotherapy within a comprehensive concept of therapy of this chronic disease, since it contributes considerably to the reduction of disabilities in activities of daily living as well as social and occupational life. Moreover, symptomatic treatment is of great importance for amelioration of quality of life. Since our last survey of symptomatic MS treatment in 2004 and publication of the guidelines of the German Neurological Society and the Klinisches Kompetenznetz Multiple Sklerose (KKN‑MS) in 2014 several developments within the topics of mobility, bladder and sexual function, vision, fatigue, cognition and rehabilitation took place. These new findings together with further aspects of disease measures and overall treatment strategies of the respective symptoms, as well as treatment goals are introduced in a series of six individual contributions. Here, the topic will be introduced, the methodical approach will be explained, and the treatment of ataxia and tremor will be discussed.

Evaluation of Study and Patient Characteristics of Clinical Studies in Primary Progressive Multiple Sclerosis: A Systematic Review

Background

So far, clinical studies in primary progressive MS (PPMS) have failed to meet their primary efficacy endpoints. To some extent this might be attributable to the choice of assessments or to the selection of the study population.

Objective

The aim of this study was to identify outcome influencing factors by analyzing the design and methods of previous randomized studies in PPMS patients without restriction to intervention or comparator.

Methods

A systematic literature search was conducted in MEDLINE, EMBASE, BIOSIS and the COCHRANE Central Register of Controlled Trials (inception to February 2015). Keywords included PPMS, primary progressive multiple sclerosis and chronic progressive multiple sclerosis. Randomized, controlled trials of at least one year’s duration were selected if they included only patients with PPMS or if they reported sufficient PPMS subgroup data. No restrictions with respect to intervention or comparator were applied. Study quality was assessed by a biometrics expert. Relevant baseline characteristics and outcomes were extracted and compared.

Results

Of 52 PPMS studies identified, four were selected. Inclusion criteria were notably different among studies with respect to both the definition of PPMS and the requirements for the presence of disability progression at enrolment. Differences between the study populations included the baseline lesion load, pretreatment status and disease duration. The rate of disease progression may also be an important factor, as all but one of the studies included a large proportion of patients with a low progression rate. In addition, the endpoints specified could not detect progression adequately.

Conclusion

Optimal PPMS study methods involve appropriate patient selection, especially regarding the PPMS phenotype and progression rate. Functional composite endpoints might be more sensitive than single endpoints in capturing progression.

Spasticity in patients with multiple sclerosis--clinical characteristics, treatment and quality of life

AIMS

To gain real-life data on demographic and clinical characteristics, treatment patterns, treatment satisfaction and quality-of-life of multiple sclerosis-related spasticity (MSS) in Germany.

MATERIAL AND METHODS

MObility ImproVEment (MOVE 1), a cross-sectional burden-of-disease study, combines retrospective 12-month chart documentation with questionnaires for both, patients and physicians. Data were collected at office-based neurologists, MS outpatient clinics and rehabilitation centres in Germany. Structured documentation forms, questionnaires and validated instruments were used for data collection. Patients with mild to severe MSS were included. Participants documented the clinical characteristics, impact of MSS on daily living, quality-of-life, treatment patterns and satisfaction with available drug treatment stratified by severity of MSS. Severity was assessed by patients and physicians.

RESULTS

Of 419 patients enrolled at 42 centres from 4/2011 to 9/2011, 414 were available for analysis (mean age: 48.5 years; female: 64%). Most disturbing symptoms associated with spasticity reported by physicians and patients were stiffness (74%) and mobility restrictions (66%). Mean EQ-5D score fell from 0.6 to 0.3 with increasing severity of spasticity, while percentage of subjects with spasticity-related impairment of activities every day rose from 10% in patients with mild to 85% in patients with severe spasticity. At time of enrolment, 55% of patients received pharmacotherapy and 78% physiotherapy. These percentages increased with increasing severity (drugs: 39-84%; physiotherapy: 65-86%). Overall, 41% of physicians and 36% of patients were partial dissatisfied or dissatisfied with the effectiveness of available anti-spastic pharmacotherapy.

CONCLUSIONS

Spasticity and its symptoms impair personal well-being and quality-of-life. Treatment of spasticity with drugs and physiotherapy is common, but satisfaction with the currently available anti-spastic pharmacotherapy is low.

[Importance and treatment of spasticity in multiple sclerosis : results of the MOVE 1 study]

BACKGROUND

The impact of spasticity induced by multiple sclerosis (MS) on patients and the applied treatment options have so far been insufficiently studied.

METHODS

This was a multicentre, retrospective, nationwide study of the care situation of MS spasticity in Germany from the perspective of both patients and physicians.

RESULTS

In this study 414 patients (mean age 48.6 years, 64.3 % women) from 42 centres were analyzed: 27 % suffered from mild, 44 % from moderate and 29 % from severe spasticity. The most common comorbidities were depression and anxiety (25.6 %) and 94.9 % suffered from concomitant symptoms (e.g. fatigue and bladder disorders). The severity of spasticity and its consequences were assessed by both patients and physicians and 54.8 % of physicians were dissatisfied with available treatment options. The most frequently cited disadvantages of currently available antispastic treatment were adverse effects (95.2 %) und insufficient effectiveness (88.1 %) and one third of patients sought help by self-medication.

CONCLUSIONS

This initial assessment of MS-induced spasticity in Germany showed that patients experienced severe impairment due to spasticity. Available treatment options were assessed as dissatisfying.

What is new in symptom management?

Many people with MS suffer from severe and disabling symptoms that restrict their social and private lives, and hence affect their quality of life; it is, therefore, essential that any symptoms that they experience are reduced effectively. Symptomatic treatment should also aim to prevent secondary complications that may result from existing disabilities. Since many MS patients are unaware that some of their complaints may be attributable to MS, e.g. fatigue, sexual dysfunction, pain or dysphagia, all patients should be thoroughly questioned about all healthcare issues and the results must be documented. In recent months, several studies about the treatment of important MS symptoms--like spasticity, pain, fatigue, bladder and sexual dysfunction, depression and cognitive impairment--have been published; this article will briefly summarize and discuss some of these treatments.

Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society

Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.

Managing specific symptoms in people with multiple sclerosis

Besides immunomodulation and immunosuppression, symptomatic treatment is an important part of MS therapy. Its goals are the elimination and reduction of symptoms that impair functional ability and quality of life, and also the avoidance of secondary complications. There are many treatment recommendations for MS symptoms, therefore clear and consensually developed therapeutic strategies are needed. This paper reviews some recommendations for the treatment of MS-related spasticity, fatigue, pain and neurogenic bladder dysfunction that have been established by the Multiple Sclerosis Treatment Consensus Group of the German MS Society.

[Therapy of pain syndromes in multiple sclerosis -- an overview with evidence-based recommendations]

While pain is a common problem in multiple sclerosis (MS) patients, it is frequently overlooked and has to be asked for actively. Pain can be classified into 4 diagnostically and therapeutically relevant categories. 1. PAIN DIRECTLY RELATED TO MS: Painful paroxysmal symptoms like trigeminal neuralgia or painful tonic spasms are treated with carbamazepine as first choice, or lamotrigine, gabapentin, oxcarbazepine and other anticonvulsants. Painful "burning" dysaesthesia, the most frequent chronic pain syndrome, are treated with tricyclic antidepressants or carbamazepine, further options include gabapentin or lamotrigine. While escalation therapy may require opioids, the role of cannabinoids in the treatment of pain still has to be determined. 2. PAIN INDIRECTLY RELATED TO MS: Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents like baclofen or tizanidine, alternatively gabapentin. In severe cases botulinum toxin injections or intrathecal baclofen merit consideration. Physiotherapy and physical therapy may ameliorate malposition-induced joint and muscle pain. Moreover, painful pressure lesions should be avoided using optimally adjusted aids. 3. Treatment-related pain can occur with subcutaneous injections of beta interferons or glatiramer acetate and may be reduced by optimizing the injection technique and by local cooling. Systemic side effects of interferons like myalgias can be reduced by paracetamol or ibuprofen. 4. Pain unrelated to MS such as back pain or headache are frequent in MS patients and may be worsened by the disease. Treatment should be follow established guidelines. In summary, a careful analysis of the pain syndrome will allow the design of the appropriate treatment plan using various medical and non-medical options and thus will help to ameliorate the patients' quality of life.

[Status epilepticus late in pregnancy--eclampsia or subarachnoid hemorrhage?]

After a largely inconspicuous pregnancy, a 31-year old primipara suffered from a status epilepticus in the third trimenon. The convulsions could not be terminated by emergency medical services, resulting in aspiration of gastric contents. Assuming eclampsia, an emergency caesarean section was performed immediately in a central hospital. Postoperatively, a pathological pattern of tendon reflexes was noticed. A CT scan revealed subarachnoid haemorrhage. The causal aneurysm of the right A. pericallosa was clipped subsequently. Eclampsia is the leading cause of epileptic seizures during pregnancy. However, a different aetiology should always be considered, especially if medical history does not reveal symptoms of pre-eclampsia.

[Therapy of myasthenia gravis with cholinesterase inhibitors--principles and pharmacologic monitoring]

Cholinesterase inhibitors are still important in the treatment of myasthenic patients. Therapeutic principles, indications and adverse effects are discussed in detail. Methods of pharmacological monitoring had been searched over many years. Besides determination of pyridostigmine plasma concentration, erythrocyte-bound acetylcholinesterase (AChE) activity could provide a possibility to monitor therapy with cholinesterase inhibitors. 88 patients with myasthenia gravis were investigated. The results demonstrated that after pyridostigmine erythrocyte-bound as well as synaptic AChE is inhibited. Moreover, erythrocyte-bound AChE has proven to be a parameter of cholinesterase inhibitor effect. After injection of edrophonium-chloride (Tensilon) inhibition of AChE activity can be demonstrated as well. During steady pyridostigmine doses stable plasma concentrations and AChE inhibition depend on the respective dosage. Higher daily doses result in greater stability of pharmacologic parameters, whereas low daily doses lead to great interindividual differences of AChE inhibition even after equal pyridostigmine doses. Intraindividually there is no strong correlation, too. Therefore estimation of erythrocyte-bound AChE activity is not useful for routine pharmacological monitoring of cholinesterase inhibitor therapy, but may be helpful in some clinical conditions. The method provides some advantages over pyridostigmine plasma concentration, since it is applicable for other cholinesterase inhibitors, too, and since it requires less technical equipment and time.

[Neurocysticercosis]

A 54-year-old female patient with a 10-year history of ventriculoperitoneal shunt resulting from communicating hydrocephalus of undetermined aetiology is reported. Transient gait disturbances and cerebral infarction at the age of 46 did not lead to further insights into the nature of the disease. After many years with only occasional disturbances, a distinct organic brain syndrome developed. Thorough examination led to a tentative diagnosis of neurocysticercosis; this was based on the history, liquor diagnosis and cerebral microcalcifications in CT. Despite the initiation of specific therapy, the patient died of the sequelae of the disease. At autopsy, characteristic cicatricial residues of mainly basal leptomeningitis were found with collapsed parasitic cysts. Additional intracerebral mesenchymal-glial reactions were less conspicuous. Residual ependymitis had caused aqueductal stenosis. Death was due to cachexia, bronchopneumonia and a lung abscess. The clinical course and morphology of neurocysticercosis are discussed. The disease has become rare in our country, but is globally the most important parasitic disease of the central nervous system.

[Coping with illness in myasthenia gravis]

Within the past few years, the introduction of immunosuppressants in the treatment of myasthenia gravis, has turned this severe, chronic and life-threatening disease into a moderate illness with good chances of control or even remission. Of 44 patients whose coping behavior and course of disease we investigated, only seven experienced a significant change in severity of the disease within nine months. This consistency in the course of the disease was also reflected in the forms of coping with the disease: in contrast to the situation two decades ago, today's myasthenia gravis patients are no longer caught up in the dilemma between passive dependency and active resistance, most of them adopting an attitude of calm acceptance. According to the Berne Forms of Coping (BEFO) which we applied, this attitude is expressed as a pattern of passive cooperation, acceptance, distraction and relativization. This coping pattern remained largely intact even in relation to the severity of the disease and the retrospectively assessed course of the disease. We present two cases to illustrate the influence of coping behavior on the course of the disease. Comparison with two other patient groups (rheumatoid arthritis and hip osteo-arthrosis) showed that there is no disease specificity of coping behavior. It can be assumed that there is a basic pattern in coping with chronic diseases, the manifestation of which is dependent on the severity and prognosis of the disease. If depressive reactions to the disease are excluded, the prevalence of longer-term pre-existent psychiatric disorders among MG patients corresponds to the average for the general population, although there is a relatively high incidence of anxiety disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

Coping with myasthenia gravis and implications for psychotherapy

The aim of this study was to investigate psychosocial influences and mechanisms of coping to establish indications for psychotherapy in patients with myasthenia gravis. We investigated clinical symptoms, personality, psychopathology, and coping in 44 patients with myasthenia gravis. The patients' personalities were not characteristically altered, and in 29.5% (13/44) of them, preexistent, long-term psychiatric disturbances (according to International Classification of Diseases criteria) were present, which corresponds to the prevalence in the average population. In general, coping was characterized by an attitude of calmness and acceptance, which is attributable to effective medical treatment and could be considered an unspecific mode of coping with chronic diseases of moderate severity. Four women had undergone psychotherapy because of neurotic symptoms that were unrelated to myasthenia gravis. At the end of psychotherapy, their myasthenic symptoms had greatly improved or disappeared. Psychotherapeutic techniques may be helpful in patients with neurotic or reactive psychiatric symptoms, but there is no general implication for psychotherapy in myasthenic patients, especially if there is adequate "somatic" therapy.

[General anesthesia in two patients with mitochondrial myopathy]

Two patients with mitochondrial myopathy (Kearns-Sayre syndrome) received general anaesthesia. In the first case propofol-alfentanil anaesthesia was carried out; the second patient received propofol-fentanyl anaesthesia. Muscle relaxation was provided with vecuronium. In both cases we observed a short episode of bradycardia (heart rate < 50.min-1), which was successfully treated with atropine. After the propofol infusion had been stopped, both patients rapidly gained consciousness and were extubated after prompt spontaneous ventilation had returned. Reversal of neuromuscular blockade in the second patient was achieved within 5 min by neostigmine. Special anaesthetic problems in patients with mitochondrial myopathies such as myocardial conduction disturbances, postoperative muscle hypotonia, and possible increased susceptibility to malignant hyperthermia can be overcome by the described anaesthetic management.

Acid-base management during hypothermic cardiopulmonary bypass does not affect cerebral metabolism but does affect blood flow and neurological outcome

In order to compare the effects of blood-gas management on cerebral blood flow, metabolism and neurological outcome after hypothermic cardiopulmonary bypass (CPB) we have studied 65 patients undergoing aorto-coronary bypass surgery allocated randomly to either a pH-stat (temperature-corrected blood-gas management) or an alpha-stat (temperature-uncorrected blood-gas management) group. All patients were examined neurologically on the day before and the 7th day after operation. In 20 patients of the pH-stat group and in 15 patients of the alpha-stat group we measured cerebral blood flow (CBF), using the argon washin technique, and also cerebral oxygen (CMRO2) and glucose (CMRg) uptake. Measurements were performed in awake patients, after induction of anaesthesia with fentanyl, midazolam and pancuronium under normothermic conditions, during CPB at a venous blood temperature of 26 degrees C and at the end of surgery. Compared with postinduction values, hypothermia was associated with an 18% reduction in CBF and decreases in CMRO2 and CMRg of 61% and 60%, respectively, in the alpha-stat group. In the pH-stat group, CMRO2 and CMRg decreased also, by 58% and 74%, respectively, whereas CBF increased by 191%, indicating uncoupling of flow and metabolism. As there were no statistically significant differences between the metabolic variables in both groups, we conclude that acid-base management did not affect cerebral metabolism, despite its influence on blood flow. After rewarming, CBF and cerebral metabolism normalized independently of acid-base management during hypothermia. Nevertheless, neurological dysfunction occurred more often in the pH-stat group (P = 0.036).

Familial myopathy with elevated serum angiotensin-converting enzyme, creatine kinase and lactate dehydrogenase isoenzyme 5

A family is reported in which two members presented with proximal myopathy associated with high serum levels of angiotensin-converting enzyme (SACE), creatine kinase (CK), and lactate dehydrogenase isoenzyme 5. Examination of three relatives revealed elevated SACE levels in all of them, but no myopathy. No evidence of sarcoidosis, the most common disease associated with high SACE levels, could be found. Muscle biopsies of the two affected men revealed myopathic features without granuloma formation. Extensive biochemical, metabolic, immunological, and microbiological studies were all non-contributory. Corticosteroid and, in one patient, azathioprine treatment resulted in an improvement of muscle weakness and in a decrease of SACE as well as CK levels.

Factor XIII concentrate for prevention of recurrent subarachnoid hemorrhage: results of a multicenter pilot study. The FISAH Study Group

Rebleeding after aneurysmal subarachnoid hemorrhage (SAH) has been attributed to fibrinolysis of the blood clot surrounding a rupture aneurysm. Since stability of the clot is influenced by the action of coagulation factor XIII (F XIII), high levels of F XIII might be beneficial in preventing recurrent SAH without causing the severe side effects of synthetic antifibrinolytics. We performed an open multicenter pilot study with administration of 10 x 1250 units of F XIII concentrate during the first 15 days after spontaneous SAH. Of 111 patients who were entered within 72 hours after SAH, 48 (43%) were in grades I and II, 33 (30%) were in grade III, and 30 (27%) were in grades IV and V according to Hunt & Hess. Aneurysm rupture was proved in 76 patients (68%) and aneurysm surgery was performed in 50 patients (45%). Overall mortality at four weeks was 27%. There were 11 recurrent hemorrhages in 9 patients (10%), 7 of which were fatal. Cerebral infarction occurred in 22 patients (20%) and hydrocephalus in 8 (7%). No adverse effects of therapy were noted. We conclude that F XIII therapy is a safe and promising new therapeutic approach in the management of SAH. It is currently being investigated in a large prospective, randomized, double-blind, placebo-controlled trial.

Determination of erythrocyte-bound acetylcholinesterase activity for monitoring pyridostigmine therapy in myasthenia gravis

Monitoring of pyridostigmine therapy in patients with myasthenia gravis is not routinely performed, since the daily pyridostigmine doses are adjusted to the patient's actual clinical status rather than to pyridostigmine plasma concentrations (PPC). Moreover, PPC determination is time-consuming and needs much technical equipment. Since pyridostigmine reversible blocks acetylcholinesterase (AChE) at the neuromuscular junction, we studied the correlation between the enzyme's blood activity (erythrocyte-bound AChE) and PPC, on the one hand, and between blood AChE activity and the clinical status of the individual patient, on the other. In five previously untreated patients with myasthenia gravis blood AChE activity decreased in accordance with the actual PPC after a single oral dose of 60 mg pyridostigmine (group A). Amelioration of the clinical status corresponded to the decrease of AChE activity in the same way. In another five patients, who were on stable pyridostigmine medication for at least 1 week, AChE activity and PPC were constant during the day (group B). Since it is easier to perform than PPC, our results suggest that the determination of AChE activity may be superior to measuring PPC for monitoring cholinesterase inhibitor therapy in selected cases.

Early heparin therapy in patients with spontaneous intracerebral haemorrhage

In 68 patients with spontaneous intracerebral haemorrhage the effect of heparin treatment beginning on the second, fourth or tenth day was investigated. Early (day 2) low-dose heparin medication significantly lowered the incidence of pulmonary embolism. An increase in the number of patients with rebleeding was not observed. The results indicate that the early use of heparin in these patients is safe and can be recommended for the prevention of thromboembolic complications.

99mTc-hexamethylpropylene amine oxime SPECT and X-ray CT in acute cerebral ischaemia

Early diagnosis of acute cerebral ischaemia is still unsatisfactory, because X-ray computed tomography (CT) does not reveal the site and extent of hypoperfusion within the first 24 h. Single photon emission computed tomography (SPECT) using 99mTc-hexamethylpropylene amine oxime (HMPAO) may offer earlier information, since the distribution of HMPAO follows the actual cerebral perfusion pattern. We therefore investigated 53 patients suffering from acute cerebral ischaemia (10 with transient ischaemic attacks, 9 with prolonged ischaemic reversible neurological deficits, 34 with completed stroke). SPECT and CT examinations were performed on days 1, 3, and 14. On day 1, SPECT revealed hypoperfused areas in 42 patients, whereas CT showed hypodensities only in 5. The sensitivity of SPECT was higher in cortical compared with subcortical ischaemia. In patients suffering from reversible neurological deficits SPECT normalized in the follow-up, corresponding to clinical improvement. In completed stroke, SPECT demonstrated variable perfusion patterns with hypo-, normo-, and hypoperfused areas on day 3 and especially on day 14. In contrast to CT, HMPAO SPECT leads to early diagnosis of cerebral ischaemia, in particular within the cerebral cortex.

Progressive inflammatory lesions of the brain parenchyma in localized scleroderma of the head

A patient with localized scleroderma of the head, uveitis, and Raynaud's phenomenon presented with generalized seizures, spastic hemiparesis, and local IgG production in the cerebrospinal fluid. Magnetic resonance imaging revealed progressive cortical and subcortical brain parenchymal lesions mainly adjacent to the cutaneous and bony lesions and probably of inflammatory origin.

Cerebral dysfunction following extracorporeal circulation for aortocoronary bypass surgery: no differences in neuropsychological outcome after pulsatile versus nonpulsatile flow

Nonpulsatile perfusion techniques with extracorporeal circulation for open-heart surgery and aortocoronary bypass grafting are widely used; this treatment is often followed by temporary or permanent neurological deficits. Experimental studies suggest that pulsatile flow may be of greater benefit because of its ability to ameliorate cerebral microcirculation. We therefore investigated 22 men who underwent aortocoronary bypass grafting. Patients were randomly divided into either a group undergoing nonpulsatile (n = 14) or pulsatile flow (n = 8). Neurological examinations were done prior to the operation and on the 7th postoperative day. EEG, cerebral blood flow (CBF), and the metabolic rates of O2 (CMR O2) and glucose (CMR Glucose) were measured before anaesthesia and 30 minutes after the start of extracorporeal circulation, when venous blood temperature was 26 degrees C. Postoperative neurological symptoms consisted of cranial nerve palsies, dysfunctions of the visual cortex, cerebellar symptoms, and slight arm paresis, but no differences between the two treatment groups were detected. Moreover, changes in EEG, CBF, and CMR rates during anaesthesia did not differ between the two groups. Our data suggest that pulsatile flow is not superior to the nonpulsatile perfusion technique, but to confirm this larger patient samples are required.

Complications of plasma exchange in patients with neurological diseases

Plasma exchange has proven to be effective in diseases of established or presumed autoimmune etiology as well as in hyperviscosity syndromes and some rare metabolic disorders. Its application is thought to be relatively safe; nevertheless, severe complications may occur. We therefore analyzed the complications of 291 exchanges in 39 patients with neurological diseases. Minor complications developed in 4.8% and major complications in 2.7% of procedures, including one death. Severe infections and technical problems have been the most serious side effects, sometimes followed by organ failure or even death.

The development of an epileptogenic focus. A case study with 99mTc-HMPAO SPECT

A patient is described who developed complex partial seizures with secondary generalization 3 years after a severe viral encephalitis with a CT and EEG identified lesion in the left insular cortex and its surrounding structures. When the seizures first occurred CT and MRI as well as repeated interictal conventional EEG recordings were entirely normal. Single photon emission computed tomography (SPECT), however, revealed an area of increased 99mTc-hexamethyl propyleneamine oxime (HMPAO) uptake in the left insular cortex. After anticonvulsive therapy the seizures and the SPECT findings disappeared. 99mTc-HMPAO SPECT is a highly sensitive method for the demonstration of functional alterations in brain tissue. It can improve diagnosis of epilepsy and may provide additional information to monitor anticonvulsive therapy.

Heparin therapy, deep-vein thrombosis and pulmonary embolism after intracerebral hemorrhage

A prospective randomized pilot study of subcutaneous low-dose heparin in the prevention of deep-vein thrombosis and pulmonary embolism was carried out in patients admitted to hospital after intracerebral hemorrhage. A high incidence of deep-vein thrombosis and lung embolism was detected by phleboscintigraphy and lung perfusion scintigraphy, respectively. There was no significant reduction of deep-vein thrombosis and pulmonary embolism in the therapy group. Heparin did not increase the risk of rebleeding.

[Energy and amino acid metabolism in the human brain under Disoprivan anesthesia with various paCO2 values]

Propofol like thiopental and etomidate, suppresses cortical electrical activity in a dose-related manner, which leads to a 36% decrease in cerebral oxygen uptake and a 51% decrease in cerebral blood flow after an induction dose of 2 mg/kg followed by a maintenance dose of 0.2 mg/kg per min. In this study, the effects of propofol and varying paCO2 values on cerebral energy and amino acid metabolism were examined. METHODS. Eleven male patients between 49 and 63 years of age who were about to undergo coronary artery bypass surgery were studied. Measurements were performed with the patient awake (I), during steady-state maintenance anesthesia after propofol 2 mg/kg as an induction dose with 0.2 mg/kg per min by infusion with normocapnia (paCO2 39.9 +/- 3.1 mm Hg) (II), during hypocapnia (paCO2 29.9 +/- 2.6 mmHg) (III), and during hypercapnia (paCO2 50.6 +/- 3.3 mmHg) (IV). Cerebral blood flow was measured using the argon wash-in technique. A catheter was advanced into the superior bulb of the right internal jugular vein for measurement of cerebral oxygen, glucose, lactate, and amino acid uptake and release, which were calculated by multiplying the arterial-cerebral venous oxygen and substrate difference by the cerebral blood flow. Lactate/glucose index was calculated from the equation. Formula: see text. where a-vD lactate and a-vD glucose represent the arterial-cerebral venous substrate differences in mmol/l. Cerebral electrical activity was recorded by Fourier analysis of the EEG.(ABSTRACT TRUNCATED AT 250 WORDS)

Difficulties in the diagnosis of brain abscesses

The diagnosis of brain abscesses has been improved during the last 10 years because to introduction of computerized tomography (CCT) and improved methods for the analysis of cerebrospinal fluid (CSF). Typical ring-like enhancement in the CT and an elevated CSF cell count combined with disturbances of the blood-brain barrier and elevated CSF lactate are common and confirm preliminary diagnoses. However, in spite of these procedures, brain abscess is still sometimes misdiagnosed because of the lack of pathological CT findings or a misleading case history sometimes causing cerebral affections. We present the case histories of two young patients in whom diagnosis of brain abscess was delayed. We recommend the immediate performance of contrast-enhanced CT and CSF analysis. If these procedures do not exclude a brain abscess, antibiotic treatment should be begun immediately.