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a Neurology, b Phoniatrics and Pedaudiology and c Radiology, Abstract Background: Neuralgic amyotrophy (brachial plexus neuropathy, brachial plexus neuritis, or Parsonage-Turner syndrome) is an uncommon inflammatory condition typically characterized by acute and severe shoulder pain followed by paresis with muscle weakness and atrophy of the upper limb or shoulder girdle. We report an unusual clinical manifestation of neuralgic amyotrophy, namely bilateral phrenic nerve palsy with concomitant laryngeal paresis. Case Report: A 55-year-old male presented with orthopnea and aphonia after an episode of bilateral shoulder pain preceded by an upper respiratory tract infection. Spirometry, chest X-ray and videolaryngoscopy revealed bilateral and simultaneous paresis of the diaphragm and the vocal cords. Clinical examination at admission and at the 2-month follow-up did not show upper limb weakness or atrophy, except for a mild atrophy of the right supraspinatus muscle. An electromyography of the upper limb muscles and nerve conduction studies did not reveal signs of denervation. Analysis of the cerebrospinal fluid and an MRI of the neuraxis were unremarkable. After treatment with prednisolone, vocal cord function markedly improved within 8 weeks, whereas paresis of the diaphragm persisted. Conclusion: Shoulder pain followed by diaphragmatic paralysis with dyspnea and hoarseness may be a manifestation of neuralgic amyotrophy even if upper limb or shoulder girdle palsies are absent.

SummaryInflammation and thrombosis, two processes influencing each other, are involved in the pathogenesis of cerebrovascular disease. We showed that in patients with acute ischaemic stroke circulating platelets are activated and exhausted. To identify whether activated haemostasis might be cause or effect, we investigated the role of leukocyte and platelet activation in patients with severe asymptomatic and symptomatic carotid artery disease. Flow cytometry analysis demonstrated that monocytes from symptomatic (acute stroke aetiology) and asymptomatic patients were highly activated, shown by significantly enhanced presentation of inflammatory markers CD11b and thrombospondin-1 (TSP-1) on the surface. Both correlated positively with monocyte-platelet association rate. However, increased monocyte activation and elevated levels of monocyte-platelet associates in asymptomatic patients were restricted to patients with echo-lucent plaques, providing a close link between monocyte activation and plaque morphology. Circulating single as well as monocyte-bound platelets from symptomatic patients showed significantly enhanced surface expression of P-selectin and TSP-1, whereas platelets from asymptomatic patients were not significantly activated. These results indicate that monocytes activated by inflammation rather than platelets might be the candidates to initiate platelet-monocyte rosetting during the pathogenesis of atherothrombotic cerebral ischaemia and that haemostasis might be activated secondarily by the first occurring inflammation.

The purpose of this study was to compare the proportion of French hospitals meeting criteria for primary (PSC) or comprehensive (CSC) stroke centres, with that of 24 other European countries. We surveyed 121 randomly selected hospitals admitting stroke patients routinely in France and 765 in other European countries. We determined the proportion of hospitals meeting criteria for CSC and PSC according to the EUSI experts definition. The 121 selected hospitals had treated 37,778 patients in 2005 (mean 312), i.e. approximately 25% of all strokes supposed to have occurred in France. Eleven hospitals had an acute stroke care unit, versus 448 of 765 other Hospitals (OR 0.07; 95% CI, OR 0.04-0.13). rt-PA was given to 622 patients (2.2% of ischaemic strokes, versus 3.3% for the other countries). No hospital met criteria for CSC, and only 2 (1.7%) met criteria for PSC. Many facilities considered as necessary by experts were less available, especially personnel, brain CT-scan, ECG monitoring and rt-PA protocols. However, CT angiography 24 h/24, and air ambulance were more often available. Only a few French hospitals offer an optimal level of care for stroke patients. This result contrasts with the high cost of stroke care in France, suggesting an inappropriate use of resources. Conclusions useful for health administrators are: (i) to offer more facilities in reasonably equipped hospitals; (ii) to prevent admission of stroke patients in small under-equipped hospitals; (iii) to promote specific stroke nurse instruction; and (iv) to promote a better organisation of stroke care over the territory.

Due to suspect vascular occlusion characterized by disorders of brainstem function 183 patients were investigated using Doppler sonography of the vertebrobasilary vascular system. Extracranial vascular lesions were diagnosed in 32 patients (basilary steal syndrome, vertebral artery branching stenosis), 11 patients showed bilateral vertebral artery occlusion or basilary thrombosis, nine unilateral intracranial vertebral artery occlusion and 131 patients showed no abnormal findings. The prognostically worse intracranial lesions were all confirmed by angiography. Twenty-five patients with normal Doppler findings were also controlled. Of these, three patients showed macroangiopathy presenting as megadolichobasilary artery and haemodynamically ineffective stenosis of the basilary artery (one patient). In the majority of cases neurological disorders associated with normal Doppler sonography findings were however considered as representative of cerebral microangiopathy, characterized by a favourable prognosis.

42 patients aged up to 35 years who had suffered a stroke were analysed according to etio-pathogenetic and prognostic criteria. The cause of the stroke could be explained with certainty only in ten patients and with high probability in a further eight. In a quarter of the cases the aetiology was completely obscure. Diagnostic gaps exist especially in haemostatic, virological and cardiological areas. Three patients died from the stroke. Follow-up showed that 40% of patients were able to resume their previous occupation. Relapses were observed in cases with disseminated lupus erythematosus and endocarditis. The relatively low rate of clarified cases (42%) is partly due to selection but also to the gaps in diagnostic knowledge. Accordingly, a stepwise diagnostic program was set up, based upon urgency and technical expenditure, that took into account not only the minimal needs for a sound initial diagnosis but also the extensive differential diagnoses for less common causes of stroke.

This report deals with the non-invasive detection of haemodynamically non-significant stenoses of the intracranial part of the vertebrobasilar system. A new Doppler device transmitting pulsed 2 MHz ultrasound was used. Among 67 patients with transient or stable neurological deficits of the posterior circulation area, five were found to have stenoses of the distal vertebral artery or basilar artery, respectively. Transnuchal approach via the foramen magnum was used. The findings were confirmed by angiography. Twelve subjects with normal Doppler findings also underwent angiography. Three of them presented irregularities and plaquing of the vertebrobasilar trunk without circumscribed stenosing lesions. Transcranial pulsed Doppler sonography permits non-invasive detection of intracranially located stenoses of the vertebrobasilar system which, up to now, could not be diagnosed with the help of extracranial conventional continuous-wave Doppler alone. This new method allows early detection of basilar artery occlusive disease. The effectiveness of anticoagulation and fibrinolysis can be assessed non-invasively.

To prove the tissue-protecting effect of mechanical recanalization, we assessed the CT perfusion-based tissue outcome ("TO") and correlated this imaging parameter with the 3-month clinical outcome ("CO").159 patients with large intracranial artery occlusions revealing mechanical recanalization were investigated by CCT, CT angiography (CTA) and CT perfusion (CTP) upon admission. For the final infarct volume, native CCT was repeated after 24 h. The "TO" ("percentage mismatch loss" = %ML) was defined as the difference between initial penumbral tissue on CTP and final infarct volume on follow-up CCT. We monitored the three-month modified Rankin Scale (mRS), age, bleeding occurrence, time to recanalization, TICI score and collateralization grade, infarct growth and final infarct volume. Spearman's correlation and nominal regression analysis were used to evaluate the impact of these parameters on mRS. Significant correlations were found for %ML and mRS (c = 0.48, p 0.001), for final infarct volume and mRS (c = 0.52, p 0.001), for TICI score and mRS (c = - 0.35, p 0.001), for initial infarct core and mRS (c = 0.14, p = 0.039) as well as for age and mRS (c = 0.37, p 0.001). According to the regression analysis, %ML predicted the classification of mRS correctly in 38.5 % of cases. The subclasses mRS 1 and 6 could be predicted by %ML with 86.4 % and 60.9 % reliability, respectively. No correlations were found for time to recanalization and mRS, for collateralization grade and mRS, and for post-interventional bleeding and mRS. Better than the TICI score, CT-based TO predicts the clinical success of mechanical recanalization, showing that not recanalization, but reperfusion should be regarded as a surrogate parameter for stroke therapy.• %ML as well as the final infarct volume can make a direct point about the immediate effect of successful mechanical recanalization.• The clinical outcomes after mechanical recanalization are reliably predicted by %ML, reflecting the benefit of escalation therapy including interventional reopening of parent vessel occlusions.• Not recanalization but rather reperfusion should be regarded as a surrogate parameter for successful stroke therapy.

Purpose: Aim of this prospective study was to investigate the incidence of spontaneous cervical artery dissection (sCAD) and cerebral ischemia in patients with suspected sCAD by using a combined head-neck MR-imaging protocol. Materials and Methods: 51 consecutive patients (24 m, 27 f, mean age 39.5 years, range 18 - 55 yrs) admitted to our stroke unit with suspected sCAD according to clinical criteria and age < 55 years underwent a combined head and neck MR examination within 24 hours of admission (Gyroscan Intera 1.5 T, Philips). Head MRI included ax FLAIR, ax T 1 , ax DWI and TOF angiography (imaging time 12 min). Neck MRI consisted of ax T1w-TSE, T2w-TSE, contrast enhanced T1w-TSE and CE-MRA (imaging time 17 min). Three radiologists assessed both studies in consensus with regard to the presence of sCAD and acute ischemia. Results: One patient had to be excluded because of motion artefacts. In 17 of 50 patients sCAD was diagnosed, and in 20 of 50 patients cerebral ischemia. In 5 patients cerebral ischemia was caused by sCAD. Conclusion: The proposed combined MR protocol allows imaging work-up of patients with suspected sCAD within approximately 30 min, resulting in conclusive information about the status of the extracranial vasculature and the presence of ischemia. The high incidence of patients with definite sCAD and the low incidence of cerebral ischemia indicates the necessity of an early definite diagnosis in order to start timely anticoagulation to prevent development of stroke.

Das angelsachsische Stroke-Unit-Konzept entwickelte sich zunachst als eine rehabilitative Einrichtung mit akutmedizinischer Versorgung, wahrend in Deutschland beim Aufbau der Stroke Units das multimodale Monitoring des Schlaganfallpatienten als neurovaskularer Notfall und die zunehmende Anwendung der Lysetherapie konzeptionell bestimmend waren. In den angelsachsischen Stroke Units wurde die eindrucksvolle Prognoseverbesserung der Schlaganfallpatienten durch die Stroke-Unit-Behandlung evidenzbasiert bewiesen. Dem therapeutischen Erfolg liegen zwei wesentliche Prinzipien zugrunde, (1) die ausschliesliche Behandlung von Schlaganfallpatienten in dieser Einheit und (2) der Team-Approach, d. h. die multiprofessionelle Expertengruppe als Therapeuten. Beide Prinzipien wurden in den deutschen Stroke Units konsequent umgesetzt. Zwei Entwicklungen in Richtung einer Komplettierung und Vereinheitlichung der Stroke-Unit-Behandlung zeichnen sich inzwischen in Europa ab: In England und Skandinavien wird in den Stroke Units zunehmend akzeptiert, dass das multimodale apparative Monitoring notwendig ist und die Prognose zusatzlich verbessert. In den deutschen Stroke Units wird die Schnittstelle zwischen der 3- bis 4-tagigen Stroke-Unit-Behandlung und der nachbehandelnden Allgemeinstation durch Einbeziehung der bereits vorhandenen Ressourcen in eine “erweiterte Stroke Unit” uberwunden. Diese erweiterte Stroke Unit kommt dem britischen Konzept der “Comprehensive Stroke Unit”, d. h. der Akutbehandlung mit fruh einsetzenden Rehabilitationstherapie aus einer Hand, sehr nahe.

Im Rahmen einer fragebogenbasierten prospektiven Studie wurde die Haufigkeit stationarer Krankenhausbehandlungen in Nordrhein-Westfalen wegen Lasionen der Halsarterien im zeitlichen Zusammenhang mit Chirotherapie an der Halswirbelsaule erfasst. Analysiert wurden 15 Falle fur 1997 und 1998 bei 86 befragten neurologischen oder neurochirurgischen Kliniken. In 4 Fallen war die A. carotis betroffen. Das einzige Einschlusskriterium war der zeitliche Zusammenhang von Chirotherapie und stationarer Behandlung wegen neurologischer Symptome ohne oberes zeitliches Limit fur die Latenzphase. Die Problematik des Kausalzusammenhangs zwischen Lasion und Chirotherapie angesichts von Spontandissektionen und die schwierige Bestimmung der tatsachlichen Haufigkeit werden diskutiert.

Der juvenile ischamische Insult (Alter bis 45 Jahre) stellt eine diagnostische und therapeutische Herausforderung unter den Schlaganfallsyndromen dar. Atiologisch kommen eine Vielzahl von z. T. seltenen Krankheiten in Betracht. Vor allem mussen nichtatherosklerotische Arteriopathien — mit der Gefasdissektion als Hauptvertreter —, paradoxe Embolien und Thrombophilien berucksichtigt werden. Bei fluchtigen Insulten ohne Nachweis struktureller Lasionen kann eine Abgrenzung zu nichtvaskularen Krankheiten (sog. Pseudoinsulten) v. a. einer Migraneaura, einem epileptischen Anfall und einer dissoziativen Storung schwierig sein. Daher fuhren juvenile Insulte zu einem erheblichen diagnostischen Mehraufwand, der die evidenzbasierten Mindestanforderungen weit ubersteigt. Zahlreiche Therapiestrategien beruhen nicht auf grosen randomisierten Studien und mussen auf individueller Basis gestaltet werden. Trotz guter Patientencompliance betragt das jahrliche Risiko fur Reinsulte etwa 2–3% und fur Myokardinfarkte etwa 1%.

Das menschliche Gehirn ist zu massiver funktioneller Reorganisation fahig. Anhand von Ergebnissen der eigenen Arbeitsgruppe und einer Literaturubersicht werden die Grundlagen und Mechanismen dieser Plastizitat am Beispiel des somatosensorischen Systems beschrieben. Sensible Bahnen mit ihren Relais-Stationen verlaufen in einander uberlappenden Projektionen von der Peripherie zur Hirnrinde. Durch Veranderung synaptischer Gewichtungen konnen sich funktionelle Hirnkarten umorganisieren und dementsprechend veranderte Wahrnehmungen hervorrufen. Einerseits konnen z.B. nach einer Gliedmasenamputation die benachbarten Reprasentanzen des somatosensorischen Homukulus in den deafferenzierten Kortexabschnitt “einwandern”. Andererseits fuhrt sensomotorisches Training einer Gliedmase zu einer Vergroserung der zugehorigen kortikalen Reprasentation. Diese Plastizitat kann kurzlebig oder anhaltend und damit irreversibel sein. Plastizitat ist daruber hinaus modulierbar. So konnen Schmerzen aber auch Pharmaka zu einer Verstarkung der funktionellen Umorganisation fuhren. Die Kombination von physiotherapeutischem Training und pharmakologischer Modulation kann die Funktionserholung nach Gehirnlasionen steigern.

Die fur Patient und Therapeut gefahrlichen Folgen liegen auf der Hand: Richtige(re) Differentialdiagnosen werden nicht bedacht, d. h. geeignete, fruhzeitige Behandlungsmoglichkeiten verfehlt. Chirotherapie an der HWS wird auch dann durchgefuhrt, wenn kein pathophysiologischer Zusammenhang zwischen manualtherapeutisch behandelbaren Storungen des zervikalen Bewegungsapparats und den Beschwerden des Patienten besteht. Chirotherapeutische Manipulationen werden vor allem bei jungen Menschen durchgefuhrt, wo ein erhohtes Verletzungsrisiko der A. vertebralis vorliegt. Chirotherapie wird u. U. in der Akutphase einer nicht erkannten, spontan aufgetretenen Dissektion der A. vertebralis durchgefuhrt, was zu lebensbedrohlichen Thromboembolien des vertebrobasilaren Kreislaufs fuhren kann.

Generalized muscle weakness in critically ill patients can result in prolonged periods of artificial ventilation and longer stays in the intensive care unit. Both neuropathic (critical illness polyneuropathy) and myopathic (critical illness myopathy) abnormalities seem to play an important role for this prolonged weakness. This article reviews its complex differential diagnosis with special emphasis on the current understanding of the neuromuscular syndromes. An efficient diagnostic plan is necessary for the exclusion of other curable causes of prolonged muscle weakness even in the presence of polyneuromyopathic changes. Psychological support of the patient and prophylaxis of secondary complications of prolonged immobilization are crucial when specific therapy is not possible.

Nachdem bereits in historischen Beschreibungen eine genetische Verursachung der Migrane vermutet worden war, haben epidemiologische und molekularbiologische Forschungen in den letzten Jahren differenzierte Ergebnisse uber genetische Faktoren in der Atiopathogenese der familiaren Migrane geliefert. Aufgrund von Familien- und Segregationsanalysen und von Zwillingsstudien wird dargestellt, das genetische Faktoren mit groster Wahrscheinlichkeit eine Rolle in der Pathogenese der typischen Migrane spielen. Inwieweit extragenetische Faktoren auf die Atiopathogenese der Migrane Einflus nehmen, ist weitgehend offen. Linkageanalysen haben in jungster Zeit gezeigt, das moglicherweise mehrere verschiedene Gene fur diese Erkrankung verantwortlich sind. Fur die Familiare Hemiplegische Migrane (FHM), der einzigen Migraneform, fur die ein autosomal-dominanter Erbgang nachgewiesen ist, konnte ein Genlocus auf Chromosom 19p13 gefunden werden, gleichzeitig wurde aber auch genetische Heterogenitat nachgewiesen. Verschiedene andere Formen der Migrane zeigten keine Linkage zu diesem Locus. Weitere Forschungen sollten neben der Identifizierung des FHM-Gens auch Linkageanalysen fur Kandidatengene und Genomanalysen an grosen informativen Familien zum Ziel haben. Letztlich werden die Ergebnisse genaueren Einblick in die Pathophysiologie der Migrane liefern und damit therapeutisch relevant sein.

Background and Purpose The purpose of this study was the evaluation of intraobserver, interobserver, and intrasubject variability in the Doppler detection of microembolic signals in patients with mechanical prosthetic valves. Simultaneously, the feasibility of automated embolus detection by means of a neuronal network was investigated. Methods From 25 patients with mechanical prosthetic heart valves, single transcranial Doppler monitoring sessions of 30 minutes’ duration were recorded on videotape, randomized, and subsequently analyzed by eight independent trained observers from three centers. Three observers evaluated these tapes on three separate occasions, blinded to their previous results. An additional 48 patients with prosthetic heart valves were repetitively monitored with transcranial Doppler ultrasonography for 30 minutes three times within 1 year to examine the long-term variability in the occurrence of microembolic signals. Finally, in an effort to assess the short-term intrasubject variability, 20 patients were examined for 90 minutes, and the results of the three 30-minute periods were compared. The interobserver, intraobserver, and intrasubject (both short- and long-term) variability was evaluated. Results No significant differences in microembolic signal counts were found among the different observers, between the human observers and the neuronal network, or among the three separate evaluations of stored data by the same observer. The same was true for repeat examinations of the same patient ( P >.05, Student’s two-paired t test and Friedman’s test). Conclusions The detection of microembolic signals in patients with prosthetic cardiac valves is a reproducible technique. The reliable performance of the neuronal network argues for a broader use of this device. The intrasubject stability of the microembolic rate over 1 year supports the concept that the underlying emboligenic process is associated with intrinsic mechanical properties of the valve implant and not due to a thromboembolic process in the heart.

SummaryThe majority of reports on the phenomenon of musical hallucinations suggests that this abnormality is a complication of a progressive peripheral hearing deficit. The present case report and a review of the international literature would, however, indicate that this syndrome may be the result of a dysfunction of the temporal cortex.

The diagnosis of vertebrobasilar insufficiency (VBI) is a clinical challenge because its manifestations are subjective and difficult to quantify. We evaluate 61 patients with the clinical diagnosis of VBI and 30 control patients with other medical problems. We used duplex scanning to study the extracranial carotid, vertebral, and subclavian arteries, and a 2-MHz transcranial Doppler (TCD) to examine the intracranial vertebral and basilar arteries. Extracranial lesions were more common in VBI patients than among controls, including stenosis of the subclavian artery with and without subclavian-vertebral steal and stenosis of the vertebral artery. Intracranial abnormalities identified in the vertebrobasilar circulation included stenosis and occlusion of the intracranial vertebral artery and basilar artery steal. Overall, significant lesions were detected in 32.8% of VBI patients and 3.0% of controls (P less than 0.05). Systolic artery velocity (cm/sec) in the extracranial vertebral artery was higher in controls (65.9 +/- 23.3) than in VBI patients who had no evidence of vertebrobasilar steal (43.0 +/- 17.4, P less than 0.05). Patients with a steal mechanism had an intracranial vertebral artery systolic velocity of 90.0 +/- 38.9, compared with 53.0 +/- 15.0 in controls (2P less than 0.050). Intracranial vertebral artery systolic velocity was higher among VBI patients with significant carotid artery disease (greater than 50%, 76.7 +/- 28.8) than in those with less severe disease (less than 50%, 47.3 +/- 13.8, P less than 0.05). Evaluation and quantitation of the vertebrobasilar circulation using both intra- and extracranial noninvasive studies may afford further insight as to the pathophysiology of vertebrobasilar insufficiency and provide a readily available, direct, and simple method of initial and serial assessment of VBI patients.

Obstructive sleep apnoea (OSA) has previously been described in a large family suffering from Charcot-Marie-Tooth disease type 1 (CMT1). In the present study, we used a case control design to establish whether this suggested link between OSA and CMT1 may also be found when studying genetically non-related patients. 12 patients with CMT1 and 24 control patients matched for age, sex and body mass index (BMI) were included in the study. Neurological disability was graded with a previously established 6 point score. All patients underwent overnight polysomnography. The mean apnoea-hypopnoea index (AHI) of patients with CMT1 was 10.5 (16.3) which was significantly higher than that of the control group (1.5 (1.3)). Five out of 12 patients with CMT1 had an AHI > or =10/h compared with 1 of 24 control patients (p

Recently, transcranial Doppler sonography has been introduced into clinical practice for noninvasive investigation of the large intracranial arteries. To determine its accuracy for detection of stenosing or occluding lesions, 133 consecutive patients were studied by both transcranial Doppler sonography and selective cerebral arteriography. Statistical analysis of findings was done separately for various arterial segments. High values for sensitivity and specificity were found for detecting obstruction of the carotid siphon and main stem of the middle cerebral artery. Diagnostic reliability of transcranial Doppler sonography was also confirmed by the calculation of a chance-corrected measure of agreement (kappa), which was close to + 1 in all subanalyses. Transcranial Doppler sonography seems to be a valuable tool for noninvasive detection of intracranial lesions of the middle cerebral artery and carotid siphon.

The reported sensitivity of neurovascular ultrasound (nUS) for detecting spontaneous cervical artery dissection (sCAD) varies from 80% to 96% in the internal carotid artery (ICA) and from 70% to 86% in the vertebral arteries (VA). The aim of this study was to assess the sensitivity of nUS compared to MRI of the neck and MR angiography for the detection of sCAD. Forty consecutive patients with sCAD proven by 1.5 T MRI were investigated by nUS within 48 hours of admission. A total of 52 cases of sCAD were detected by MRI, equally distributed (n = 26, 50%) in the ICA and VA territories. Two sCADs affecting the ICA (n = 2, 8%) and two sCADs of the VA (n = 2, 8%) had normal initial nUS findings. The sensitivity of nUS in detecting sCAD is high, about 92% for both vascular territories. However, intramural hematomas may be missed either when they are located outside the arterial segments directly visible by nUS or if they are too small to cause hemodynamically significant stenosis.

Der ischamische Schlaganfall ist eine der haufigsten Ursachen fur Behinderung und Tod in Europa. Im Akutstadium ist die korrekte Identifizierung eines Schlaganfalls und die sofortige Einweisung in eine geeignete Einrichtung, moglichst in eine zertifizierte Stroke Unit, entscheidend. Therapeutisch kann durch systemische oder lokale Lysetherapie bis zu 6 h nach dem Insultereignis eine drastische Verbesserung des Outcome erzielt werden. Das breite Ursachenspektrum des Hirninfarkts erfordert eine differenzierte Diagnostik von Hirnparenchym, hirnversorgenden Gefasen, kardialen Funktionen und Blutparametern. Dies ist die notwendige Voraussetzung fur einen gezielten Ressourceneinsatz zur Sekundarpravention. Nur durch Optimierung von Pravention, Akutbehandlung, Rehabilitation und Nachsorge konnen die sozialmedizinischen und gesundheitsokonomischen Folgen des Schlaganfalls beherrscht werden. Dies erfordert eine noch engere Verzahnung von ambulanten und stationaren Institutionen.

Altere und alte Patienten erhalten seltener eine Therapie mit HMG-CoA-Reduktaseinhibitoren (Statinen) als jungere Patienten. Eine geringere Verordnung von Statinen im Alter wird in der Regel mit der schlechten Datenlage fur altere Patienten, der schlechteren Compliance und dem erhohten Risiko fur Nebenwirkungen und Arzneimittelinteraktionen begrundet. Mit einer schlechten Compliance ist vor allem bei dementen oder depressiven Patienten sowie bei Patienten mit symptomarmen Stadien einer kardiovaskularen Erkrankung zu rechnen. Demgegenuber steht die hohe klinische Relevanz der koronaren Herzkrankheit im Alter: 80% der Patienten, die an einer koronaren Herzkrankheit versterben, sind uber 65 Jahre alt. Die durchschnittliche statistische Lebenserwartung alterer und alter Patienten wird haufig unterschatzt. Die HPS und die PROSPER-Studie konnten nachweisen, dass Patienten mit hohem kardiovaskularem Risiko und/oder einer koronaren Herzkrankheit auch im hohen Lebensalter von einer Statintherapie profitieren. Patienten bis 79 Jahre sollten daher nach denselben Richtlinien wie jungere Patienten behandelt werden. Im Sinne einer Konsensusbildung wird fur Patienten ab 80 Jahre eine verringerte Therapiestringenz in Abhangigkeit von Risikofaktorenlast und Lebenserwartung auf der Grundlage einer Extrapolation der Daten empfohlen, da evidenzbasierte Daten fehlen.

A 48-year-old patient with Toxocara canis infection developed severe ataxia, rigor and neuropsychological disturbances. An aetiology was proven by an indirect immunofluorescence test. CT and MRI revealed both diffuse and circumscribed white matter lesions. Angiography showed multiple occlusion of branches of the middle cerebral artery. Anthelminthic treatment was beneficial in the initial stage of the disease, but had no effect on progression of CNS symptoms. Immunosuppressive therapy with prednisolone and azathioprine yielded partial recovery and stabilisation of the patient.

Im mittleren Lebensalter besteht ein fast linearer Zusammenhang zwischen dem Ausmas kognitiver Defizite und der Hohe des systolischen Blutdrucks. Eine fruhe, konsequente und ausreichende Blutdrucksenkung kann chronisch schleichende Gehirnschadigungen effektiv verhindern. Lediglich bei Hochbetagten ist ein sehr niedriger Blutdruck wegen der damit verbundenen intermittierenden Minderdurchblutung des Gehirns als potenziell ungunstig anzusehen.

Fibromuscular dysplasia (FMD) is a rare, non-inflammatory angiopathy, which can affect the brain supplying arteries. Usually, the diagnosis is based on conventional and/or MR angiography. We present a patient with multisegmental stenoses of the internal carotid artery (ICA) where the diagnosis of FMD is based on an eye-catching ultrasound finding.

Background and Purpose —Functional transcranial Doppler ultrasonography (fTCD) can assess event-related changes in cerebral blood flow velocities and, by comparison between sides, can provide a measure of hemispheric perfusional lateralization. It is easily applicable, insensitive to movement artifacts, and can be used in patients with less than perfect cooperation. In the present study we investigated the validity of fTCD in determining the hemispheric dominance for language by direct comparison of fTCD with intracarotid amobarbital anesthesia (Wada test). Methods —fTCD and the Wada test were performed in 19 patients evaluated for epilepsy surgery. By the Wada test, 13 patients were classified as left-hemisphere dominant and 6 as right-hemisphere dominant for language. fTCD was based on the continuous bilateral measurements of blood flow velocities in the middle cerebral arteries and event-related averaging during a cued word generation task previously shown to activate lateralized language areas in normal adults. Results —In 4 patients fTCD assessment was not possible because of lack of an acoustic temporal bone window. In the remaining 15 candidates, determination of language dominance was concordant with the Wada test in every case. Moreover, the correlation of the lateralization measures from both procedures was highly significant ( r =.92, P Conclusions —This strong correlation validates fTCD as a noninvasive and practical tool for the determination of language lateralization that can be applied for clinical and investigative purposes.

The timing of spontaneous recanalization of an embolically occluded intracerebral artery is unknown, as is modification of the size of the infarction and the clinical course by the rapidity and degree of reperfusion. Most recanalized middle cerebral arteries (MCAs), after arterioarterial or cardiogenic embolic occlusions, occur within the first days [3, 5, 7, 12]. Even under favorable conditions, however, severely ischemic brain tissue can not survive longer than several hours [1, 6], and rapid recanalization of the embolically occluded brain arteries at an early time would be expected to be decisive for recovery. The quality of the leptomeningeal anastomoses, particularly during the first hours, is another important factor modifying both the size of infarction and clinical outcome [2, 11].

We evaluated the influence of time of recanalization or degree of initial leptomeningeal collateral blood flow in cardioembolic or arterio-arterial middle cerebral artery (MCA) occlusion on infarct size and clinical outcome in a series of 34 consecutive acute stroke patients with main stem (N = 31) or major branch (N = 3) occlusions using CT, initial cerebral arteriography (N = 21), repetitive close-meshed transcranial Doppler ultrasonography, and a neurologic stroke scale. We treated 15 patients with tissue plasminogen activator intravenously within the first 6 hours. The type and size of infarction depended on the location of the occluding lesions within the MCA trunk. Proximal MCA occlusion always led to infarction involving the striatum and internal capsule. Sixty-five percent of patients showed recanalization of the occluded MCA within 1 week. Following MCA recanalization, hyperperfusion was present in 38 to 44% of cases. There was a marginally significant relation between size of infarction on CT and recanalization time within the first 24 hours. The more rapidly recanalization occurred, the smaller the size of the infarct. When recanalization time was greater than 8 hours, the lesions always extended to the cortex. An additional good leptomeningeal collateral blood flow significantly reduced the size of the infarct and improved clinical outcome after 17 days and after 10 months. Early recanalization of embolic MCA occlusions within up to 8 hours, in conjunction with good transcortical collateralization, has a favorable impact on infarct size and outcome and may constitute the therapeutic window of opportunity.

Perfusion reserve is recruited to balance organ perfusion versus systemic changes in blood pressure. Regionally, recruitment is of special interest since it acts (a) to maintain baseline perfusion (or flow) in decreasing perfusion pressure (e.g., beyond a stenosis) or (b) to meet increased metabolic demands of an organ during exercise or any other stimulus (Buell and Schicha 1990). Cerebral perfusion reserve (CPR) is a complex system, comprising cerebral perfusion or blood flow (CBF), cerebral blood volume, blood thixotrophy, adaptions in peripheral hematocrit (Schmid-Schonbein 1988), oxygen carriage, chemical effects, vascular innervation and tone (Aaslid et al. 1989), and hormonal and endothelial factors. The vascular reaction to CO2, for example, measured with laser Doppler in normal cat brain revealed a 19% increase in pial arteriolar diameter in combination with augmented flow of 70% and flow velocity of 60%. Blood volume increased by 10% (Haberl et al. 1989). In acute or chronic cerebrovascular disease, CPR seems to recruit these determinants in different combinations. For acute disorders, the interactions have been described by Frackowiak and Wise (1983) and, most recently, by Arora et al. (1990). This article considers findings in chronic cerebrovascular disease.

Critically reduced perfusion pressure in the brain arteries may lead to ischemic damage in certain vulnerable areas (Bogousslavsky and Regli 1986; Leblanc et al. 1987; Ringelstein et al. 1983; Yamaguchi et al. 1979; Zulch 1961). The perfusion pressure of the brain cannot, however, be measured directly in man. Indirect parameters are the regional cerebral blood flow (rCBF) versus regional cerebral blood volume (rCBV) ratio (Gibbs et al. 1984), or the oxygen extraction ratio (Gibbs et al. 1984; Kanno et al. 1988; Levine et al. 1988) documented either by SPECT or by PET imaging. Another approach is to measure the reactivity of the cerebral vasculature to vasodilating stimuli (CO2, acetazolamide). This may be done by measuring an increase in blood flow or blood flow velocity by either rCBF techniques or transcranial Doppler sonography (TCD) (Kanno et al. 1988; Norrving et al. 1982; Ringelstein et al. 1988; Wodarz 1980; see also Dahl et al. and Haberl et al. in this volume).

We used single-photon emission computed tomography to measure cerebral blood flow, cerebral blood volume, and cerebral perfusion reserve and transcranial Doppler sonography with CO2 stimulation to assess hemispheric vasomotor reactivity in 37 patients and in normal controls. Computed tomography and magnetic resonance imaging were performed to differentiate morphologically low-flow infarcts (n = 17) from territorial infarcts (n = 20). In patients with either type of infarct, blood flow was decreased and blood volume was increased in the infarcted areas compared with the same areas in the controls. Perfusion reserve and vasomotor reactivity were significantly reduced in patients with territorial infarcts and carotid artery occlusions (n = 12) and even more reduced in patients with low-flow infarcts (p less than 0.001). Both parameters were normal in patients with cardiac embolic territorial infarcts (n = 8). In patients with territorial infarcts, blood flow and perfusion reserve changes were restricted to the infarcted areas, whereas in patients with low-flow infarcts, regions of decreased perfusion reserve considerably exceeded the area of the infarct. Low-flow infarcts are related to the hemodynamic effects of severe extracranial carotid artery disease.

Between June 1988 and February 1990 we examined 44 patients who had suffered acute stroke due to an acute occlusion of the middle cerebral artery (MCA). Only patients who could be investigated within 24 h of the onset of stroke were included. All patients were examined by transcranial Doppler sonography (TCD) at fixed intervals six times during the first 24 h after stroke, and then on days 2, 3,10, and 17. A simultaneous neurological examination was also carried out each time. Angiography was performed in 24 patients during the first 2 h after admission to the hospital.

We assessed the potential of 2-MHz pulsed-wave transorbital Doppler ultrasonography to delineate the role of the ophthalmic artery as a source of collateral cerebral blood supply by comparing oculopneumoplethysmography, transorbital Doppler ultrasonography, periorbital continuous-wave Doppler ultrasonography, and transcranial Doppler ultrasonography in 25 patients with unilateral internal carotid artery occlusion and five controls with 10 normal internal carotid arteries. Systolic ophthalmic artery blood velocity was reduced ipsilateral to an internal carotid artery occlusion (38.2 +/- 10.2 cm/sec) compared with the contralateral and control velocities (46.0 +/- 10.3 and 47.5 +/- 6.8 cm/sec, respectively; p less than 0.05). Ophthalmic systolic pressure measured by oculopneumoplethysmography was 94.7 +/- 13.2 mm Hg ipsilateral to an internal carotid artery occlusion compared with 108.4 +/- 15.3 mm Hg on the contralateral side (p less than 0.01). Transorbital and periorbital Doppler ultrasonography detected reversed ophthalmic artery blood flow ipsilateral to an internal carotid artery occlusion in 44.0% and 40.0% of the patients, respectively. Systolic middle cerebral artery blood velocity was 55.2 +/- 22.3 cm/sec ipsilateral to an internal carotid artery occlusion compared with 79.4 +/- 23.5 cm/sec on the contralateral side (p less than 0.05) and 101.2 +/- 18.9 cm/sec in the controls (p less than 0.05). Reversed ophthalmic artery blood flow was associated with a low middle cerebral artery blood velocity and lack of major intracerebral collaterals. Transorbital Doppler ultrasonography permits noninvasive evaluation of the ophthalmic artery.(ABSTRACT TRUNCATED AT 250 WORDS)

In 15 patients with internal carotid artery (ICA) dissections, patterns of brain infarctions visible on CT were categorized according to a pathogenetically oriented classification system. This differentiated ischemic brain damage due to low flow from thromboembolic infarctions. Simultaneously, cerebral hemodynamic reserve was evaluated by means of both CO2-dependent vasomotor reactivity and HMPAO- and 99 mTc-RBC-SPECT. Six out of 11 patients with ischemic infarctions had the territorial type of brain lesion, suggesting distal embolism. Five patients revealed the pattern of hemodynamically induced low-flow infarctions. Cerebral hemodynamic reserve was significantly decreased only in these latter patients. In ICA dissections the frequencies of hemodynamically and thromboembolically induced brain infarctions is approximately equal. This finding suggests that only half of the patients with symptoms of symptomatic dissections had brain emboli, whereas in the other half the dissections lead to a low-flow effect in terminal supply areas which is so severe that non-embolic brain infarctions occur. This differentiation can help decide whether antithrombotic or hemodynamic treatment should be given.

To the Editor: In their article on functional transcranial Doppler sonography (fTCD), Schmidt et al1 conclude the fTCD can lateralize higher cognitive functions reliably. They suggest that it may be used in patients in the preoperative evaluation before brain surgery. But because “data to validate fTCD…are still lacking,” they caution that fTCD should be cross-checked with well established techniques (presumably the Wada test), particularly with regard to language dominance. Stroke published such a study (“Noninvasive Determination of Hemispheric Language Dominance Using Functional Transcranial Doppler Sonography: A Comparison With the Wada Test”)2 1 year ago. Schmidt et al base their suggestions on group averages. Again, it was this very journal that published a study on the feasibility and reproducibility of single-subject assessment by fTCD.3 A full account of the present state …

The natural history of carotid artery occlusive disease (CAODO is still not known well enough so as to provide reliable information about the risk of stroke in the individual patient (15). Decision making in performing carotid endarterectomy is made particularly difficult in the case of moderate and low-grade carotid artery lesions, since one must weigh out the risk of this invasive procedure on the one hand and the spontaneous course of the lesion on the other hand (1, 7, 10, 11).

Until recently, both the diagnosis of intracranial occlusive disease of the large brain arteries, as well as intracranial flow abnormalities due to extracranial arterial lesions, have been a "blind spot" for ultrasound techniques. With the advent of transcranial Doppler sonography (TCD), however, a broad spectrum of potential clinical and scientific applications of TCD to the intracranial vasculature has been advocated. In order to achieve an informative insonation of vessels and a correct interpretation of findings, knowledge of both anatomical landmarks within the skull and flow characteristics of distinct vessel segments are necessary. This paper presents such data elaborated from 64 carotid and 42 vertebral angiograms, 40 contrast-medium enhanced CT scans demonstrating the circle of Willis, 122 normal sagittal MRI scans of the brainstem, 40 cadaver skulls, 38 fresh cadavers, 106 normal volunteers and 59 patients with subclavian steal mechanisms. The main findings were as follows: The inner internal carotid artery bifurcation, the M1-segment of the middle cerebral artery, the C3-segment of the carotid siphon, the vertebral artery junction and the top of the basilar artery were found at insonation depths of 60.4 +/- 7, 40 +/- 8 to 60.4 +/- 7, 62 +/- 4, 84 +/- 8 and 108 +/- 8 mm, respectively. Normal mean flow velocities within the M1-segment, the posterior cerebral artery, the carotid siphon and the basilar trunk were 58 +/- 15.6, 39 +/- 9.9, 47 +/- 13.8 and 41 +/- 10 cm/s, respectively, and revealed a marked decrease with age. Intraindividual side-to-side differences were low. Vertebrobasilar data from measurements of neuroradiological material closely met in vivo findings in normals and patients. Criteria for the identification of various vessel segments are provided. On the basis of these findings, a topographical orientation within the skull should be possible in order that beginners commence TCD accurately. Normative velocity data are helpful for differentiating normal and pathological flow conditions at different ages.

CO2-dependent vasomotor reactivity (VMR) of the middle cerebral artery (MCA) distribution has been shown to be a reliable predictor of the patient's risk for low-flow strokes. In order to clarify whether various Pulsatility Indices (PIs) of MCA flow signals would be useful to estimate VMR, 222 subjects with various degrees of stenosing internal carotid artery lesions were studied. VMR of the MCA territory was expressed as the percentage changes in mean blood flow velocity during inhalation of CO2 and hyperventilation. Although the correlation coefficients between VMR and PIs were significantly different from zero, these relationships were not strong enough for PI values to accurately predict the individual values of VMR. Furthermore, VMR could convincingly discriminate subgroups of patients with different severities of extracranial occlusive disease, whereas PIs discriminated only weakly or not at all. PIs may give some vague idea of the vasomotor tone, but cannot predict precisely enough whether a patient is at risk for low-flow infarctions.

Profound changes in the protocols for the management of acute stroke patients irrespective of whether ischaemic or haemorrhagic in origin Although the approval of recombinant tissue plasminogen activator (rtPA) for the treatment of acute ischaemic stroke has been based on the primary imaging technique of conventional cerebral computerised tomography (CT),1 newer and more refined magnetic resonance (MR) techniques are unrelentlessly extending into this particular field of emergency medicine, stimulated by the important hope that these new techniques could help to prolong the therapeutic time window beyond the 3 hour limit in selected patients. Several recent papers have clearly demonstrated that the mismatch concept,2 though leading to diagnostic pitfalls in a small number of cases as well, seems to be helpful in …

• We examined 29 patients with strictly subcortical large striatocapsular infarctions. Eight of them had aphasia or neglect. All patients underwent transcranial Doppler ultrasonography or selective carotid angiography, magnetic resonance imaging, and single photon emission tomography for assessment of cerebral blood flow, blood volume, and cerebral perfusion reserve. The signs were compatible with cortical territorial infarctions rather than lacunes. On both magnetic resonance imaging and computed tomographic scans, the lesions corresponded to the territories of the medial and lateral group of the lenticulostriate arteries, Heubner's artery, or the anterior choroidal artery. The infarctions were either due to cerebral embolization into the M1 segment of the middle cerebral artery or due to stenosis at the same site, ie, lesions that acutely and simultaneously occluded the orifices of the lenticulostriate or neighboring arteries. Persistent occlusion of the middle cerebral arteries and a decrease of cortical regional cerebral blood flow were only found in patients with aphasia or neglect. All patients without aphasia or neglect showed a rapid recanalization of the middle cerebral artery occlusion or a stenosis of the M1 segment and no cortical regional cerebral blood flow decrease. Large striatocapsular infarctions occur due to occlusive disease of the middle cerebral artery (large-vessel disease) and not due to a disseminated in situ occlusion of the long penetrating arteries (small-vessel disease), as in lacunes. Neuropsychological deficits can be explained by decreased cortical blood flow due to a persistent occlusive lesion of the middle cerebral artery.

To determine reference ranges for rheologic parameters (hematocrit, plasma viscosity, erythrocyte aggregation, erythrocyte rigidity) a randomized study involving 653 subjects was carried out. Conditions of sampling, transportation and storing of blood specimens were established prior to the survey. Only 283 subjects met the criteria for enrollment in the study; the others were rejected because of inconspicuous history, normal findings in physical and Doppler-sonographic examination and absence of the risk factors hypertension, diabetes mellitus, overweight, rheumatic diseases, and smoking. The reference range for hematocrit was determined by an impedance-measuring device to equal 39–52% for males and 34–50% for females. The reference range for plasma viscosity, measured by a capillary-tube-plasma viscometer, was found to vary from 1.14 mPas to 1.34 mPas. The reference values for the standardized erythrocyte aggregation index was determined with the mini erythrocyte aggregometer to range from 8 to 21. Erythrocytes measured with the selecting-erythrocyte rigidometer showed a rigidity reference range between 0.83 and 1.19. Analysis of the results revealed that the parameters were independent of age (except in young children) and sex (with the exception of hematocrit).