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Restless legs syndrome (RLS) is a common neurological disease. Studies have shown that RLS is associated with a variety of medical and neurological disorders.Using the example of three associated neurological diseases, the significance for everyday therapy decisions is assessed.A systematic search was carried out in PubMed for all studies with the keyword "RLS" in combination with polyneuropathies (PNP), Parkinson's disease (PD) and multiple sclerosis (MS) and classified according to the methodology in high, medium or low study quality.Of 16 studies on RLS and MS, 10 were rated as "high". The high association frequency of RLS in MS between 13.3% and 65.1% (the variability possibly originates from different methods) prevents further statements about the prevalence. Within 30 studies on Parkinson's disease 17 were classified as having a high quality. In patients with Parkinson disease RLS occurs most frequently during therapy and is related to the duration of dopaminergic treatment. In patients with polyneuropathy, only 5 out of 24 studies were classified as being of high quality and an increased RLS prevalence was detected for acquired polyneuropathies with heterogeneous data for hereditary forms.There is an increased prevalence of association with RLS for the diseases discussed. This prevalence is possibly determined by the pathophysiology of these disorders. These diseases are possibly characterized by genetic predispositions as well, which can hopefully be classified more accurately in the future.

The differential diagnosis of lymphoid lesions in the central nervous system covers a broad spectrum of neoplastic and inflammatory disorders. Complex cases benefit from the combined expertise in the fields of hematopoietic and neuroepithelial tumors as well as neuroimmunology. The Network Lymphomas and Lymphomatoid Lesions in the Nervous System (NLLLN) recommends performing a biopsy prior to any therapeutic intervention as a precise diagnosis was impossible in approximately 50 % of patients pretreated with corticosteroids. This is based on the analysis of approximately 1,000 cases in the past 4 years. In addition to total NLLLN experiences the characteristics, pathogenesis and differential diagnosis of primary lymphoma of the central nervous system are discussed.

The aim of the study was an assessment of the tolerability and efficacy of slow release oxcarbazepine (OXC-MR) versus immediate release OXC (OXC-IR) after forced titration in patients with focal epileptic seizures with and without secondary generalization who had previously not become seizure-free under OXC-IR with or without concomitant antiepileptic drugs. The primary study variable was to assess the maximum tolerated dosage with OXC-MR and OXC-IR.This was designed as a multicenter, randomized, open, controlled, parallel group phase III study. After randomization patients received OXC-MR or OXC-IR for a study period of 26 days. The initial dosage of 900 mg, 1,200 mg or 1,500 mg OXC was increased every 5 days by 300 mg up to a maximum daily dosage of 2,700 mg. In cases of intolerable adverse events dosage could be reduced by 150 mg 2 days after an increase. Adverse events and executive abilities were assessed with the questionnaire "Adverse Event Profile plus" and with the Epitrack® test protocol. Serum concentrations of OXC and its active metabolite were measured in a part of the patient group.The 71 patients (54% male, age: 19-70 years) enrolled in the study were randomized. The maximum mean daily OXC dosage at the end of the study period was 1,950 mg with OXC-MR and thus statistically significantly higher than in OXC-IR group (1,650 mg, p = 0.022). The number of causally related adverse events was lower in the OXC-MR group (n = 104 versus n = 138 with OXC-IR) and CNS-related adverse events such as dizziness, tremor, somnolence and headache occurred significantly less often with OXC-MR (OXC-MR 65.7%, OXC-IR 88.9%, p = 0.01). Fluctuations of serum concentrations of the active metabolite were less pronounced under the OXC-MR regimen.Due to better tolerability OXC-MR allowed higher maintenance dosages to be reached than OXC-IR. In spite of a higher mean daily dosage adverse events and especially CNS-related adverse events occurred less often than with OXC-IR.

Ocular therapy is necessary even during pregnancy but the use of pharmaceutical substances bears the risk of side effects on mother and child. The article reflects current knowledge on how to treat the most important eye diseases during pregnancy and breastfeeding. The review covers the diagnostics (tonometry, mydriasis, angiography) as well as treatment of infections of the eyes, glaucoma, allergies, diabetic retinopathy, pain and inflammation.

Pregnancy may cause ocular changes, for example refractive changes or contact lens intolerance. A number of ocular diseases may deteriorate. Especially preexisting diabetic retinopathy may worsen. Vaginal delivery is nearly always possible. Caesarean section is not required due to myopia, peripheral retinal degenerations or after retinal surgery. Most topically applied drugs usually used in ophthalmology are safe during pregnancy.

Neuroplasticity is the ability of the central nervous system to induce functional and microstructural changes in order to adapt to a new environment. However, so-called maladaptive neuroplasticity can also bring disadvantages, such as reduced inhibition of input signals, one of the suspected causes of chronic pain. With the method of repetitive transcranial magnetic stimulation (rTMS) a technique has been developed that makes it possible to study cortical excitability changes in the human brain non-invasively over a long time. Electrophysiological studies have shown that the application of rTMS over the primary motor cortex induces a facilitatory or inhibitory effect on the corticospinal and cortico-cortical excitability depending on the protocol used. The results of the clinical studies published suggest that rTMS can inhibit pain perception with regard to chronic pain and in experimentally induced pain conditions. An alternative method to induce neuroplastic changes is transcranial direct current stimulation (tDCS). tDCS acts primarily on the membrane potential, by hyper- or depolarizing it. The induced after-effects are NMDA receptor dependent. The effectiveness of tDCS is currently being explored in migraine research as well as experimentally induced and chronic pain conditions. In phase II trials its efficacy has been demonstrated. Ongoing studies are focusing on management of the placebo effect; however, it is easier to control this effect in tDCS compared to rTMS. Phase III trials are currently in preparation.

We present a 31-year-old female patient with primary non-Hodgkin's lymphoma of the CNS after immunosuppressive therapy. Colitis ulcerosa had been diagnosed 2 years previously. Prophylactic therapy with azathioprine over 9 months was stopped after the development of listeria meningitis which was treated successfully with antibiotics. At this time native CCT was normal. Three months later the patient developed an epileptic seizure and multiple cerebral lesions were detected in CCT and MRI. Although antibiotic therapy was started, the cerebral lesions showed no regression. Stereotactic biopsy revealed immunochemical and histologic high-grade malignant B cell lymphoma. The risk of primary CNS lymphoma under azathioprine treatment for an autoimmune disease with a possible congenital immunodeficiency is presented and the literature is reviewed.

Exaggerated caution or even deferment in the treatment of chronically ill mothers-to-be, for example, in the case of epilepsy, hypertension or bronchial asthma, may result in a dramatic worsening of the underlying disease and thus may threaten the further development of the fetus. On the other hand, an inadequate knowledge of the true risks of pharmacological treatment already applied in the early stages of pregnancy, leads to numerous abortions that are inappropriately indicated. As a basic rule, when planning pharmacological treatment in a pregnant woman, well tried and tested substances should be given preference over new drugs. If a pregnant woman has been exposed to an insufficiently tested substance as a result of ignorance of her pregnancy, recognized centers with appropriate data banks (www.reprotox.de) should be consulted.

Patients with severe multiple sclerosis (MS) relapses which do not respond sufficiently to corticosteroids can undergo escalating immunotherapy with plasma exchange. We review the course of 14 apheresis cycles in 13 adult patients and three pediatric cases from our center between 2004 and 2005. Nine cases were due to optic neuritis, five had experienced clinically isolated syndromes, and two suffered from Devic's disease. Of the adult patients, 71% had good or very good outcome. The mean time point of improvement was after the third plasmapheresis session, and early initiation of plasma exchange therapy (within 1 month after begin of relapse) was associated with better outcome. In pediatric MS, two of three patients showed clear improvement. These data argue for a very good therapeutic effect of plasma exchange if performed early and with adequate indication.

The restless legs syndrome (RLS) is a clinical diagnosis based on the four essential criteria defined by the International Restless Legs Syndrome Study Group (IRLSSG). An idiopathic form can be separated from a symptomatic form. Neurophysiological studies have investigated the pathophysiology of the idiopathic RLS or have been used to exclude a symptomatic cause, in particular polyneuropathy. So far cortical excitability changes, corticomotor, somatosensory and auditory pathways, spinal cord excitability, B-wave rhythm and cycling alternating pattern, as well as reflex mechanisms have been investigated by electroencephalography, evoked potentials, Bereitschaftspotentials, nerve conduction and thermal threshold measurements, electromyography, transcranial Doppler sonography, measurements of the spinal flexor reflex as well as neuroimaging techniques. The etiology of the RLS cannot be revealed by these methods, neurophysiological studies in RLS are, however, useful for a better understanding of the pathophysiology and for exclusion of a polyneuropathy or other symptomatic causes. In addition to neurophysiological investigations, small fiber neuropathy, which seems to be a more common finding in RLS patients than expected to date, may need biopsy for confirmation. This review will focus on investigations of the different systems involved with diverse neurophysiological methods.

Pharmacotherapy in pregnancy is often problematic, since both the mother-to-be and her doctor are often concerned about possible risks for the unborn child. On the other hand, we now have sufficient knowledge of a whole range of medications, to enable the recommendation of safe drug treatment in almost any clinical situation. The family doctor, too, is often consulted by pregnant women requiring treatment for internistic problems. These include such pregnancy-unrelated problems as essential hypertension or bronchial asthma, as well as pregnancy-related disorders such as urinary tract infection or gastrointestinal problems.

Trigeminal neuralgia and postherpetic neuralgia are the most relevant neuralgiform facial pain syndromes. Trigeminal neuralgia is characterized by lancinating intensive pain attacks of very short duration, triggered by external cues,whereas postherpetic neuralgia consists predominantly of long-lasting burning pain. Sodium channel blocking drugs are first choice in treatment of trigeminal neuralgia, operative procedures encompass microvascular decompression,thermocoagulation and percutaneous retrogasserian glycerol rhizotomy. In the acute stage postherpetic neuralgia is treated antivirally and analgesically, in the chronic stage by tricyclic antidepressive substances. Other pain syndromes described encompass the Tolosa-Hunt-syndrome, cervicogenic headache, craniomandibular dysfunction syndrome, atypical facial pain and rarer syndromes. Therapeutic recommendations are based on evidence based medicine criteria (EBM).

While the importance of magnetic resonance (MR) spectroscopy, volumetry, and T2-relaxometry for preoperative localization has already been verified, the question arises as to what extent the individual techniques are useful for assessing postoperative prognosis with respect to seizures and neuropsychological outcome. In a prospective comparative study, 26 patients were examined preoperatively with a 1.5 T whole-body scanner. The MR spectroscopy was taken by high resolution 1 H proton spectroscopy, the volumetry with MP rage technique. The postoperative outcome was laid down using Engel's classification. Our results show that the metabolic changes can be divided into three groups using MR spectroscopy: unilateral, slightly bilateral, and severely bilateral to contralateral. In case of bilateral changes, the severity of metabolic changes in the nonoperated, contralateral side was decisive for postoperative outcome. The results from volumetry did not correlate with postoperative outcome.

External cephalic version (ECV) was performed in 524 single pregnancies. The version was successful in 38.4%. Success is mainly influenced by parity, quantity of amniotic fluid and maternal weight. An emergency cesarean section was necessary in 0.6% because of fetal bradycardia. Compared to controls the ECV was not associated with the increase of a premature rupture of membranes, complications with umbilical cord or transfer of the child to the paediatric department. Also there was no difference in the pH or Apgar-ranges. One fetal death was diagnosed 17 days after ECV, the reason therefore remained unclear. There are existing a few other reports with similar cases. We conclude that ECV is a appropriate trial to convert the fetus into cephalic presentation, but because of possible complications precautions must be taken, e.g. that means to carry out the trial under conditions which allow immediate cesarean section and a frequent follow up of the woman until delivery.

600 ethnically heterogeneous patients with various risk factors from outpatient obstetric clinic of the UFK Ulm were screened for gestational diabetes. Incidence with the 100 g oGTT was 21%, with fasting levels having the lowest prognostic value, and one hour levels having the best. After the diagnosis of gestational diabetes was established patients were counselled and put on diet, 7% received insulin additionally. Weight gain was far more acceptable in those patients compared to the group of patients with normal metabolism. We observed no significant differences concerning fetal macrosomia, caesarean section-rates, newborn apgar and ph-values compared to normal pregnant women. We confirmed the known risk factors, personal history, familial disposition and maternal age. A screening based only on these criteria, however, would fail to detect 20% of patients with gestational diabetes. A general screening must be postulated.

Advanced psychophysical tests, performed in 42 patients who have seizures, showed that the widely used antiepileptic drugs, diphenylhydantoin and carbamazepine, can specifically affect retinal function, while valproic acid and the epileptic seizures do not. The Farnsworth-Munsell 100-Hue and Panel D-15 désaturé tests revealed an accumulation of errors along the tritan/tetartan axis and a high total error score. As shown by measurement of the so-called transient tritanopia and by determination of the spectral sensitivity, this blue vision defect is not only due to loss of postreceptoral interaction between long- and short-wavelength-sensitive cones, but is also based on a disturbance in the receptor mechanism itself. The dark adaptation curve was not affected. As determined by cone flicker thresholds during dark adaptation, the inhibitory action of rods on cones is reduced. The results obtained for mesopic vision and especially glare sensitivity measured by nyktometry were markedly affected in these patients compared to the normal population. The psychophysical methods provide a very sensitive test for early detection of drug-induced retinal dysfunction and allow clear differentiation between the loss of a receptor mechanism and a defect in the neuronal interaction between photoreceptors in the human visual system induced by antiepileptics.

Advanced psychophysical tests, performed in 42 epileptic patients, show that the antiepileptic drugs phenytoin and carbamazepine can specifically affect the retinal function, while Valproic Acid and the epileptic seizures do not. The Farnsworth-Munsell 100-Hue and Panel D-15 désaturé tests revealed an accumulation of errors along the tritan/tetartan axis (blue colour vision deficiencies) and a high total error score. The same defect was shown by measurement of the spectral sensitivity functions. The results obtained for mesopic vision and especially glare sensitivity measured by nyktometry were markedly affected in these patients compared to a normal population. The enhanced sensitivity to glare is mainly the only one symptom complained by the patient. We propose a screening method for early detection of phenytoin- and carbamazepine-induced neurotoxicity. The literature of ocular side effects of anticonvulsant drugs is carefully reviewed.

Interleukin 10 (Il-10) was initially discovered on the basis of its ability to suppress cytokine synthesis. Additionally, it can exert immunosuppressive effects on a variety of cell types. Since patients with malignant gliomas present with a general impairment of the immune system, we sought to investigate if IL-10 is expressed in the glioma tissue. Using RT-PCR, IL-10 mRNA levels were determined in 37 glial tumors of different grades including 2 recurrencies, 3 specimens from normal brain tissue and 3 glioblastoma cell lines. Expression of IL-10 mRNA was demonstrable in all tumors as well as in normal brain. High grade tumors and recurrent cases expressed significantly higher amounts of IL-10 specific mRNA compared to low grade tumors, while 2 out of 3 cell lines showed only weak constitutive expression. We suggest, that IL-10 may contribute to the progression of astrocytomas by allowing the tumor cells to attenuate the T-cell immune response and evade immune detection.

A 35-year-old man, previously healthy except for a grade 1 goitre, sustained a spontaneous left pneumothorax treated with a Bülau drain. When the left pneumothorax recurred 2 months later a left thoracotomy was performed. Two bullae at the lung apex were resected and a pleurodesis performed. After the operation the patient noted hypaesthesia of the dorsum of the left upper arm, mild ptosis of the left eyelid as well as reduced sweat secretion over the left half of the face and the left rib cage. The hypaesthesia improved, but the sympathetic nerve deficits remained. There were no other neurological signs. 9 months later, within one minute of eating a sour apple, the patient developed severe sweating over the left half of the face and the left chest. The reaction was confirmed by infra-red thermography which proved that the skin temperature in the sweating region had fallen to 3 degrees C. The likely cause of localized gustatory sweating is intra-operative damage of the stellate ganglion or its preganglionic nerve connections. Treatment is limited to avoidance of the precipitating gustatory stimulus.

A 49-year-old woman who had noted increasing fatigue and found it difficult to concentrate became confused and uncoordinated with rapid speech. Anxious and suffering from insomnia she had for 6 weeks taken a prescription-free bromide-containing drug mixture (daily 0.09 g potassium bromide and 1.8 g sodium bromide), to a total bromide intake of 60 g. The admission diagnosis of chronic bromism was confirmed by a markedly increased serum bromide concentration (325 mg/l). Once she had stopped taking the drug and had increased her salt intake she became symptom-free within 8 days. The case demonstrates that, while chronic bromism has become rare, it should still be included in the differential diagnosis, even after intake of supposedly harmless medication.

In acute attacks of cluster headache (CH), the mainstays of treatment are inhalation of pure oxygen (due to lack of any side effects), ergotamine aerosol, and intranasal application of local anaesthetics. The following treatments have hitherto been recommended for the prevention of attacks: young patient with first manifestation-methysergide; middle aged patient with episodic or chronic CH-steroids; older patient with history of resistance to therapy-lithium. These guidelines have been superceded as a result of the demonstration of the efficacy of several other drugs which have reduced side effects. This increased variety of treatments also reduces the importance of clinical differentiation between episodic and chronic cluster headache. Today, the drugs of first choice for treatment of episodic cluster headache are steroids or calcium channel blockers like verapamil, replacing methysergide which is now drug of second choice. In chronic CH, verapamil and lithium are normally prescribed, steroids-possibly in combination with one of the other drugs-are regarded as drugs of second choice. Another possibility, used with increasing frequency, is valproate acid, and the experimental drug budipine may be a further alternative in therapy resistant patients. There is no convincing role for invasive surgical procedures, particularly in the light of the increased number of effective drugs. The treatment of choice for chronic paroxysmal hemicrania is indometacin, although individual patients may respond to salicylates, naproxene, prednisone and ergotamine.

By means of registration of somatosensory (SSEP) and visual (VEP) evoked potentials under the influence of different magnetic and electromagnetic fields of Magnetic Resonance we investigated the influence of Magnetic Resonance Imaging (MRI) on human nervous system (all measurements with an 1.0 T MR imager are performed outside and inside the static magnetic field, before and after MR imaging). In vivo experiments on 20 healthy volunteers show in SSEP registrations as well as in VEP-registrations no measurable influence on nerve conduction. The measured latencies before and after MR imaging are found inside the standard values which are valid for healthy volunteers. In vivo experiments at field-strengthens up to 1.0 Tesla show no significant changes of the central and peripheral conduction velocity with human beings.

To study antigenicity, persistence of antibody (efficacy) and reactogenicity of a new bivalent influenza subunit vaccine, Sandovac, it was given in two different concentrations (1000 and 2000 IU) to 156 subjects from two epidemiologically destinct areas (119 students from Essen, average age 22 years, 37 residents from Kassel average age 56 years). Serum antibody response was measured by hemagglutination inhibition (HI) and neuraminidase inhibition (NI) tests before, one, two and six months after vaccination. The following results were obtained: 1. Four weeks post vaccination an excellent strain specific and crossreactive (H3 N2 variant-specific) antibody response was observed. Subtype specific (H0, H1 or H2) activity could not be detected. 2. Six months post vaccination a still notably higher antibody level as compared to the preimmunization status could be demonstrated. 3. A difference, however, existed between the immune responses of the Essen student population with an average age of 22 years, and of the Kassel resident population with an average age of 56 years. The immune response being significantly better in younger vaccinees. 4. High and low concentrated vaccines revealed neither objective nor subjective differences in reactogenicity and were very well tolerated. 5. In all immunological parameters tested the double concentrated vaccine (S 2000) proved to be slightly superior to the lower concentrated vaccine (S 1000) that is officially licensed in the German Federal Republic.