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The kidney-brain interaction has been a topic of growing interest. Past studies of the effect of kidney function on intracerebral hemorrhage (ICH) outcomes have yielded inconsistent findings. Although the second, main phase of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) suggests the effectiveness of early intensive blood pressure (BP) lowering in improving functional recovery after ICH, the balance of potential benefits and harms of this treatment in those with decreased kidney function remains uncertain.

Das posteriore reversible Enzephalopathiesyndrom (PRES) stellt ein akut verlaufendes Krankheitsbild dar, das durch eine unspezifische klinische Symptomatik, wie Kopfschmerzen, Sehstörung, Bewusstseinsstörung oder epileptische Anfälle, sowie charakteristische bildgebende Veränderungen im Sinne eines vasogenen Ödems gekennzeichnet ist. Unterschiedliche Pathomechanismen, die zur Ödembildung führen, werden diskutiert. Da ein PRES bei etwa 2 Drittel aller Patienten mit erhöhten Blutdruckwerten assoziiert ist, wird vermutet, dass es im Rahmen einer hypertensiven Entgleisung zur Überschreitung der oberen Autoregulationsgrenze, nachfolgender zerebraler Hyperperfusion und einem Vascular-Leak-Syndrom kommt. Darüber hinaus wird das Auftreten eines PRES auf eine endotheliale Dysfunktion mit Freisetzung von Vasokonstriktoren und Schädigung von interzellulären Adhäsionsmolekülen durch endo- und exogene Noxen, wie Immunsuppressiva, Chemotherapeutika, Präeklampsie, Sepsis oder Autoimmunerkrankungen, zurückgeführt. Diagnostisch wegweisend ist die Konstellation aus klinischer Symptomatik, bildgebendem Nachweis eines vasogenen Ödems, das meist bilateral und parietookzipital betont lokalisiert ist, und eine überwiegende Reversibilität der Veränderungen. Die Therapie der Erkrankung ist symptomorientiert, eine spezifische Behandlung steht derzeit nicht zur Verfügung. Häufig führt eine konsequente antihypertensive Therapie und, wenn möglich, eine Elimination der auslösenden Noxe zu einer Rückbildung der klinischen und bildgebenden Veränderungen. Aufgrund möglicher Komplikationen, wie dem Auftreten eines Status epilepticus, zerebraler Vasokonstriktion, Ischämie oder intrazerebraler Blutung, ist bei etwa 40 % aller Patienten eine intensivmedizinische Behandlung erforderlich. Posterior reversible encephalopathy syndrome refers to a neurological disorder characterized by headache, disorders of consciousness, visual disturbances, epileptic seizures, and subcortical vasogenic edema. About two thirds of patients develop neurological symptoms, which are associated with blood pressure fluctuations. One hypothesis is that hypertensive episodes cause autoregulatory failure, and values above the upper limit of cerebral autoregulation result in a breakthrough followed by hyperperfusion and blood–brain barrier dysfunction. In another hypothesis, endothelial dysfunction triggered by numerous factors including preeclampsia, immunosuppressive agents, chemotherapeutics, sepsis, or autoimmune disorders is thought to be the key pathomechanism. Endo- or exogenic toxic agents including pharmacological substances, cytokines, or bacterial toxins are supposed to trigger endothelial activation and dysfunction resulting in the release of vasoconstrictors, pro-inflammatory mediators, and vascular leakage. Diagnosis is usually based on clinical and neuroimaging findings that frequently show a bilateral, symmetric, and parietooccipital pattern. However, the diagnosis can often only be confirmed during the course of disease after excluding important differential diagnoses. Currently, there is no specific treatment available. Lowering of arterial blood pressure and eliminating the underlying cause usually leads to an improvement of clinical and neuroradiological findings. Admission to a critical care unit is required in about 40 % of patients due to complicating conditions including status epilepticus, cerebral vasoconstriction, ischemia, or intracerebral hemorrhage. Prognosis is favorable; in the majority of patients neurological deficits and imaging findings resolve completely.

Seroprevalences were determined by testing sera of 1607 blood donors from North, East, and South Tyrol. In the Tyrols, the continental divide delimitates areas with high seroprevalences of IgG antibodies against Borrelia burgdorferisensu lato in the North (7.2%) from areas with low seroprevalences in the South (1.5%). To determine Borreliaprevalences in unfed Ixodes ricinusticks, 755 questing ticks were tested by PCR. Prevalences in nymphal and adult ticks were found to be 19.7% (n=132) and 21.5% (n=205) in North Tyrol and 23% (n=43) and 23.7% (n=376) in South Tyrol, respectively. Sequencing of 46 Borrelia-positive ticks yielded 74% Borrelia(B.) afzelii, 11% B. garinii, 7% B. lusitaniae, 7% B. burgdorferisensu stricto, and 2% B. valaisianainfections. Distinct genetic clusters could not be delimitated on either side of the continental divide. This study describes occurrence and geographic dispersion of Borreliaspp. in the Tyrols, discusses possible reasons for significant differences in human seroprevalence, and indicates that prevalence of Borreliain vector ticks is not a direct predictive factor for the local seroprevalence in humans.

Selective amygdalohippocampectomy (AHE) has been associated with postoperative cerebral vasospasm (CVS) in patients with medically intractable temporal lobe epilepsy. The incidence in temporal lobe resection (TLR) is unknown. This retrospective cohort study evaluates the incidence of and risk factors for the development of CVS in patients with TLR and AHE.

Epidemiology, modes of infection, and predisposing factors need to be known in order to diagnose parasitic diseases of the nervous system in time and to allow timely initiation of the specific antiparasitic therapy. In this review, all those parasites, protozoa and helminths, which have the capacity to invade the central nervous system, leading to critical disease, are discussed in terms of their epidemiology, clinical neurological syndromes, their typical course, best diagnostic methods, differential diagnosis and antiparasitic chemotherapy as well as adjunctive therapeutic strategies. It is mainly the timely diagnosis which is based on appropriate history taking and the early recognition of typical syndromes as well as the correct diagnostic work up which allows the appropriate antiparasitic chemotherapy. Intensive care measures in CNS parasitoses include management of increased intracranial pressure, diffuse brain edema, acute obstructive hydrocephalus, multiorgan dysfunction, and early neurosurgical decompressive interventions. In some parasitic diseases of the CNS, steroid therapy is indicated (e. g. neurocysticercosis, trichinosis), in others, steroid therapy may be deleterious (e. g. cerebral malaria). Die Epidemiologie, die Infektionswege, sowie prädisponierende Faktoren müssen ausreichend bekannt sein, um parasitäre Erkrankungen des Nervensystems rechtzeitig zu erkennen und die frühzeitige Einleitung einer spezifischen antiparasitären Therapie zu erlauben. In dieser Übersicht werden alle Parasiten, Protozoen und Helminthen, die imstande sind, das zentrale Nervensystem zu invadieren und damit zu einer potentiell intensivpflichtigen Krankheit zu führen, in bezug auf ihre Epidemiologie, klinisch neurologische Syndrome, ihren typischen Verlauf, die bestmöglichen diagnostischen Schritte, ihre Differenzialdiagnosen sowie die antiparasitären und adjuvanten therapeutischen Strategien dargestellt. Die essentiell notwendige rechtzeitige Diagnose basiert auf eine appropriate Anamneseerhebung, das Erkennen der typischen Symptome, sowie der Einleitung des korrekten diagnostischen Procedere; erst dadurch wird die richtige antiparasitäre Chemotherapie rechtzeitig ermöglicht. Intensivmedizinische Maßnahmen, die bei ZNS-Parasitosen notwendig sein können, inkludieren das Management eines erhöhten intrakraniellen Drucks, eines diffusen Hirnödems, eines akuten obstruktiven Hydrocephalus, vor allem aber Multiorganversagen und die Indikation zur rechtzeitigen/frühen neurochirurgischen Dekompressions- Intervention. Nur bei einigen parasitären Erkrankungen des ZNS ist eine Steroidtherapie indiziert (z. B. Neurozystizerkose oder Trichinose), demgegenüber sind Steroide bei anderen ZNS-Parasitosen (z. B. zerebrale Malaria), wie auch Heparinisierung kontraindiziert.

To determine whether CSF amyloid beta 1-42 (A-42) and tau have predictive value for prognosis after head injury.

Various clinical parameters, neurological examination models, biochemical tests, electrophysiological procedures and neuro-imaging techniques have been studied with respect to the detection of cerebral hypoxia in patients after cardiopulmonary resuscitation.    These parameters were critically evaluated by the members of the Austrian interdisciplinary consensus conference. Based on the results of scientific publications, the consensus meeting identified 26 parameters, which allow the prognostic evaluation of cerebral hypoxia after cardiopulmonary resuscitation. Among these parameters, however, the strength of evidence and the level of recommendation are different. In den letzten Jahren wurden zahlreiche Prognoseparameter zur Beurteilung der cerebralen Hypoxie nach kardiopulmonaler Reanimation untersucht. Diese Parameter umfassen neben klinischen Daten und klinischen Scoresystemen, verschiedene klinisch-neurologische Befunde, biochemische Parameter, elektrophysiologische Untersuchungen und neurodiagnostische bildgebende Verfahren.    Ziel der österreichischen interdisziplinären Konsensuskonferenz war die kritische Evaluierung dieser Parameter und die Empfehlung welche Parameter bzw. diagnostischen Maßnahmen zu welchem Zeitpunkt eine prognostische Aussage über eine potentielle neurologische Rehabilitation nach cerebraler Hypoxie ermöglichen. Aus mehr als 100 unterschiedlichen Parametern wurden 26 Parameter identifiziert, die, basierend auf Ergebnisse wissenschaftlicher Publikationen, eine prognostische Aussage ermöglichen. Diese Parameter müssen jedoch hinsichtlich der Einschätzung der Evidenz und deren Stärkegrad als Grundlage für prognostische Empfehlungen unterschiedlich beurteilt werden.

Central European encephalitis (CEE) may be accompanied by myeloradiculitic symptoms in up to 5 of patients. The authors report six patients with a myelitic form of CEE mimicking acute poliomyelitis with bulbar and arm predominance and a poor prognosis. Three patients died. Of the survivors, only one can perform most activities of daily living, but still needs assisted ventilation at night. Autopsy in one patient showed severe cervicothoracic inflammation with changes almost exclusively in anterior horn cells and roots, as typically seen in poliomyelitis.

To determine the value of vascular endothelial growth factor (VEGF) in CSF as a marker for carcinomatous meningitis (CM).

Zusammenfassung: Bei einer 63jährigen österreichischen Bäuerin wurde eine durch Streptococcus suis verursachte Meningitis diagnostiziert. Nach nunmehr 16 Monaten leidet sie nach wie vor an den Folgeerscheinungen wie Gleichgewichtsstörung, Gangunsicherheit und beidseitiger Schallempfindungsstörung. Die Patientin gehört aufgrund ihres Berufes, wie der Großteil der Infizierten, einer für diese Erkrankung typischen Risikogruppe an. Unseres Wissens wurde bisher in Österreich noch kein Fall einer humanen Infektion mit Streptococcus suis beschrieben. Eine Erklärung für das nunmehrige Auftreten einer Streptococcus-suis-Meningitis kann nicht gegeben werden. Unsere neurophysiologischen Befunde, die eine direkte kochleäre Schädigung in der klinisch floriden Phase der Menigitis nicht nachweisen konnten, stehen im Gegensatz zum Kay'schen Meerschweinchen-Modell einer suppurativen Labyrinthitis. Die vorhandene Literatur wird vor allem in Hinblick auf Neurophysiologie, Pathogenese, Epidemiologie sowie zunehmende Resistenzentwicklung gegen Antibiotika diskutiert.

Patients suffering from severe cranio-cerebral trauma show alterations of the secretory patterns of thyroid stimulating hormone (TSH) and human growth hormone (HGH) which may be of prognostic significance. We studied 10 patients following severe brain injury and prospectively compared a new synthetic human growth hormone releasing factor (HGHRF) test with the thyrotropin releasing hormone (TRH) test. On admission, all patients had a Glasgow Coma Scale score of 3 or 4. All patients had a low T3 syndrome. In the patients who died the TSH response after stimulation with TRH was also absent. In the patients who survived a significant TSH increase was observed (p<0.05). In comparison to the patients who died those who survived showed a significant (p<0.001) HGH increase after HGHRF stimulation. This test might be useful as an additional tool in establishing early prognosis in patients with severe brain injury.

Summary The histories of two patients with spinal epidural abscess are reported. Attention is drawn to the route of infection by means of direct inoculation of pathogens in the wake of paravertebral infiltration of local anaesthetics for relieving lower backpain, furthermore we emphasize the rare occurrence of a relapsing acute spinal epidural abscess. Additionally the diagnostic superiority of nuclear magnetic resonance tomography is described in a patient known to be allergic to commonly used contrast material.

Antibodies against human immunodeficiency virus, other infectious agents and neopterin levels were determined in 253 patients in a rural area of North-West Tanzania. Seroprevalence for HIV was 3.2%. In one case serology was positive for HIV-1 and HIV-2 antibodies and questions whether there was a real double infection or a cross reaction not only concerning core region proteins but also transmembrane protein. The specificity in the diagnosis of HIV-infection is markedly increased with newer serological methods using recombinant peptides but did not improve sensitivity on African sera.Neopterin was determined as a sensitive indirect marker for the activation of T-cells and is therefore correlated with the susceptibility of HIV infection and with progression of disease. High seroprevalence rates for various infectious agents were determined and may explain the high rate of elevated neopterin levels in 80% of the Africans. Neopterin levels were even higher in HIV patients. Viral p24 antigen was found only in two persons, one of whom had no antibodies detectable.

During a three-week period in March/April 1987, the authors examined 253 consecutive patients referred to a rural hospital in northwestern Tanzania. Sera were tested for antibodies to human immunodeficiency virus type 1 (HIV-1), human immunodeficiency virus type 2 (HIV-2), and human T-lymphotropic virus type I (HTLV-I), as well as for various parasites, hepatitis B virus, and Treponema pallidum. Neopterin (urinary and serum) was chosen as the immunologic parameter. In eight of the 253 patients (3.2%), a clinical diagnosis of acquired immunodeficiency syndrome (AIDS) was established. Three of the AIDS patients had HIV-1 antibodies, two had HIV-1 antigen, one had both HIV-1 and HIV-2 antibodies, and in one patient, only HIV-2 antibodies were found. The total HIV-1 and HIV-2 seroprevalence (antibodies plus antigen) was 4.3%; HTLV-I seroprevalence was 9.9%. No correlation could be found between HIV (or HTLV-I) seropositivity and raised levels of antibody to the above pathogens. There was, however, a significantly positive correlation between HIV seropositivity and history of gonorrhea, whereas a history of operations, injections, vaccinations, blood transfusions, or scarification did not influence the level of HIV seropositivity. The most frequently noted epidemiologic association with HIV seropositivity was traveling to or coming from Uganda or Rwanda. Two thirds of the studied Tanzanians had elevated neopterin levels, and all seven HIV-seropositive patients with clinical signs of AIDS had extremely high serum and urinary neopterin levels compared with HIV-seropositive patients without signs of AIDS. Increased neopterin levels reflect a stimulation of the T-cell/macrophage system.

In 15 patients (median age 33 years; range 17–74 years) suffering from acute pneumococcal (10 cases) and meningococcal (five cases) meningitis, cerebral blood flow velocity (CBFV) was measured in the M1– segment of the middle cerebral artery (MCA) by transcranial Doppler sonography, and cerebral perfusion changes were evaluated by 99m‐Tchexamethylpropylene amine oxime single photon emission computed tomography (HMPAO SPECT). The objective of the study was to test whether increased CBFV during the acute phase of purulent meningitis reflects hyperemia, and to evaluate focal perfusion abnormalities and their correlation to CBFV changes.

Summary We present here a prospective study on infections following tickbites in military recruits in the province of Tyrol (Austria). 84 recruits experienced tickbites and underwent clinical and serological examination twice at four-week intervals for signs of tick borne encephalitis (TBE)-virus orBorrelia burgdorferi infections. 56 and 50 recruits could be evaluated for TBE-virus and Borrelia infection, respectively. Whereas no recruit was found with clinical or laboratory evidence of TBE-virus infection, two (4%) recruits showed an erythema chronicum migrans as primary manifestation of aBorrelia burgdorferi infection and 11 (20%) recruits had a significant increase in the titer of anti-Borrelia burgdorferi antibodies. Our results support the predominance of a subclinical course of a tick-transmitted borrelia infection in the population under observation, and shed some light on the epidemiological situation of tick-transmitted diseases in Tyrol.

Abstract

Summary A patient with serologically confirmed infection byBorrelia burgdorferi presenting with painful paresis and atrophy of the proximal muscles of both upper extremities and bilateral facial paresis is described. Electromyography showed a neurogenic and myopathic pattern, and creatine kinase was raised. Muscle biopsy revealed the typical signs of focal myositis. Treatment with i.v. penicillin led to dramatic clinical and serological improvement. Muscle biopsy was repeated 2 months later; neurogenic changes were still present, but no inflammatory signs could be seen anymore. Thus, the presented case may be the first reported of meningopolyneuritis accompanied by focal nodular myositis, in the second stage of Lyme borreliosis.

The rationale for exchange blood transfusion (ET) in severe falciparum malaria is threefold: reduction of parasitaemia, reduction of presumptive ‘toxic’ factors, and improvement of the rheological quality of the blood. We evaluated the records of 61 patients treated with ET to describe the present status of malaria treatment in Germany, Austria and Switzerland and to assess the efficacy of ET. Clinical data of 61 patients treated with ET were compared to data of 63 patients treated in 2 hospitals where ETs were generally not performed. We found that exchange transfusion is applied according to the clinician’s subjective impression rather than strict guidelines. Logistic regression analysis adjusting for the differences in clinical parameters between patients treated with or without ET did not identify treatment as a prognostic indicator (odds ratio for relative risk of death with ET: 1.3; 95% CI: 0.4–4.9). Exchange transfusion did not significantly improve the unfavourable prognosis in cases of severe falciparum malaria. However, failure to reach statistical significance may be due to the retrospective design of the study and therefore non‐systematic approach.

Summary Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. Beside cerebral involvement spinal cord lesions are extremely rare. To our knowledge, aspergillosis initially presenting with acute paraplegia due to mycotic thrombosis of the anterior spinal artery in a formerly healthy patient has, so far, not been reported. Neither a primary focus nor an underlying disease had been detected.

A 35-year-old man presented with the clinical picture of spontaneous subarachnoid hemorrhage. Four weeks after the first symptoms he noticed blurred vision, and ophthalmological examination detected bitemporal hemianopia. At this time cerebral computed tomography and magnetic resonance imaging showed enlargement of the optic chiasm, and visual evoked potentials revealed delayed latencies. In the cerebrospinal fluid cells and protein content were elevated, and angiotensin-converting enzyme was detectable. Under steroid treatment the patient recovered completely and computed tomography, magnetic resonance imaging, visual evoked potentials, and cerebrospinal fluid findings became normal. Although a great variety of neurological symptoms may occur in neurosarcoidosis, to our knowledge spontaneous subarachnoid hemorrhage as the presenting feature has never been reported before.

Computed tomography and magnetic resonance (MR) studies were done in one case of Behcet disease and showed a focal lesion in the upper brain stem. Early institution of therapy was followed by a complete clinical remission and disappearance of the CT and MR changes. Computed tomography and MR are important modalities for the early detection of Behcet disease when reversibility of the pathological changes is still possible.

Summary A previously healthy seventeen-year-old boy developed loss of weight, poor appetite, and aversion to food. Physical examination being normal, anorexia nervosa was suspected. Thirteen months later a CT scan revealed a mass in the third ventricle histologically proven to be a malignant teratoma. To our knowledge anorexia nervosa is only extremely rarely the presenting feature of intracranial germ cell tumors.

Weaning is an important factor in the aetiology of protein energy malnutrition (PEM). In the present study it was shown that the psychological aspects of weaning — i.e. separation from the mother — play a more important role in the development of PEM than do physical factors. Of children suffering from PEM, 80.4% were physically separated from the mother at time of weaning, whereas only 32% of a comparable healthy control group had undergone the trauma of separation.

Zusammenfassung: Ein 47jähriger, männlicher Patient mit dem Vollbild eines Miller-Fisher-Syndroms, wurde mit Plasmapherese und i.v. 7S-Immunglobulinen behandelt. Innerhalb von knapp 2 Wochen zeigte sich keine Besserung der neurologischen Symptomatik. Aus diesem Grunde wurde eine Liquor-cerebrospinalis-Filtration durchgeführt. Das Gesamtliquoreiweiß sowie der IgG-Index normalisierte sich, innerhalb von wenigen Tagen besserten sich die zerebellären Symptome, nach 3 Wochen wurde der Patient aus der stationären Therapie entlassen.

We studied the efficacy and pharmacokinetics of intraventricularly administered vancomycin in three patients with shunt-associated staphylococcal ventriculitis. We instilled 10 mg of the drug intraventricularly every 24 hours. Cerebrospinal fluid (CSF) levels were measured 1 hour after instillation and then every 2 hours. Peak vancomycin levels reached a mean of 292.9 µg/mL. The mean trough levels, measured immediately before readministration of vancomycin, were 7.6 µg/mL; this level has proved to be sufficient for maintaining the necessary steady-state serum concentration of vancomycin. All three patients were cured clinically and bacteriologically, and CSF parameters returned to normal within 5–13 days. No side effects were observed. Our results suggest that intraventricularly administered vancomycin is a valuable therapeutic strategy for treating shuntassociated staphylococcal ventriculitis. In addition, we provide evidence that 10 mg of vancomycin, administered intraventricularly every 24 hours, allows maintenance of therapeutic drug levels in the CSF for at least 24 hours.

Third-generation cephalosporins are presently the agents of choice for the empirical antimicrobial therapy of bacterial meningitis. However, a number of factors associated with these agents, namely the development of resistance by pneumococci, limited activity against some Enterobacteriaceae and Pseudomonas spp., and the possible adverse effects of their bactenolytic mode of action, indicate that newer classes of antimicrobial agents be evaluated for the treatment of bacterial meningitis. Meropenem is a carbapenem antibiotic which is highly active against the major bacterial pathogens causing meningitis, and penetrates well into the cerebrospinal fluid. Two prospective randomised studies in 56 adult bacterial meningitis patients have compared meropenem 40 mg/kg 8-hourly, up to a maximum of 6 g/day (n = 28) with cephalo-sporin treatment, i.e. cefotaxime (n = 17) or ceftriaxone (n = 11). Patients were assessed by neurological examination, Glasgow Coma Score and Herson-Todd score. Clinical cure was observed in all 23 evaluable patients treated with meropenem (100%) and with 17 of the 22 evaluable cephalosporin-treated patients (77%). All pre-treatment isolates were eradicated except one isolate of Staphylococcus aureus in a cefotaxime-treated patient. Neurological sequelae were noted in three meropenem and four cephalosporin-treated patients. No patients in either treatment group experienced seizures after the start of therapy. This was despite the fact that a patient in each group had experienced seizures before therapy, several had underlying CNS disorders, and that doses of 6 g/day of meropenem were given. Hearing impairment was recorded in 11 meropenem and nine cephalosporin treated patients. Three patients in the meropenem group and one in the cephalosporin group died during treatment for reasons unrelated to study therapy. Overall, the results of this study indicate that meropenem is an effective and well-tolerated antibiotic for the treatment of bacterial meningitis in adults.