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Hintergrund: Fatigue ist ein haufiges Symptom bei MS-Patienten mit multifaktorieller Genese. Untersucht wurde der Einfluss von Schlafstorungen auf Fatigue bei RRMS(relapsing remitting)-und CIS (Clinical isolated syndrome)-Patienten unter einer Therapie mit Interferon β-1b. Methode: 73 Patienten wurden uber einen Zeitraum von 12 Monaten an 3 Zeitpunkten (0/6/12 Monate) mittels Fragebogen (Fatigue, Schlafqualitat, Restless Legs Beschwerden, Angst und Depression) und ambulanter Polysomnografie beurteilt. Eine vollstandige Analyse war fur 46 Patienten (35 Frauen und 11 Manner, 35,5±7,6 Jahre alt, EDSS 2±1,4) moglich. Ergebnisse: 50% der Patienten beklagten Schlafstorungen. RLS-Beschwerden nahm von 14 in Visite 1 (N=14) zu auf 20 in Visite 3 (N=20). Das Ausmas der Fatigue korrelierte mit Schlafstorungen und RLS-Beschwerden. Schlussfolgerung: Schlafstorungen und eine RLS-Symptomatik sind bei MS haufig aber wenig untersucht. Durch Therapie dieser Symptome ist auch ein kausaler Therapieansatz hinsichtlich der Fatigue denkbar. Studie mit groserer Patientenzahl und Vergleich unterschiedlicher Immunmodulatoren sind notwendig.

Sleep disorders can be diagnosed in approximately 15 % of the population and have been shown to increase with age. The relationship between sleep disorders and neurological disorders, however, is still insufficiently considered in the clinical practice. Sleep disorders can be an early symptom of the disease, such as the presence of rapid eye movement (REM) sleep behavior disorder (RBD) as an early indicator of neurodegeneration. Sleep disorders have also been shown to be a main symptom of various neurological syndromes, such as in restless legs syndrome (RLS), periodic limb movement disorder (PLMD) and narcolepsy. The international classification of sleep disorders 2nd edition (ICSD 2) describes the main diagnoses, insomnia, circadian rhythm sleep disorders, sleep-related breathing disorders and hypersomnia but all of these can also appear as symptoms in various neurological diseases. Parasomnias are largely considered a differential diagnosis to nocturnal epilepsy. In this review, the main sleep disorders are described with a particular focus on how they relate to neurological diseases; in particular, how they influence disease-related symptoms and how they affect the course of the disease.

Ziel der vorliegenden Studie war es, zu untersuchen, ob – und wenn ja wie – Alter, Geschlecht, Dauer der Immobilisierung, eine Veranderung der RLS-Medikation vor und eine Woche nach der Operation, das von der Operation betroffene Korperteil sowie die Art der Anasthesie den perioperativen Schweregrad der Symptomatik bei RLS-Patienten, die sich einer Operation unterzogen haben, beeinflussen. Die Daten wurden in der Course of Restless Legs Syndrome-Study (COR) erhoben, in deren Rahmen im Verlauf von 2 Jahren Informationen per Fragebogen prospektiv gesammelt wurden. Die nach 2 Jahren (t3) durchgefuhrte Datenerhebung umfasste ein Modul zur retrospektiven Erfassung detaillierter Informationen zu Operationen, die in den vorausgegangenen 3 Jahren durchgefuhrt wurden. Zum Zeitpunkt t3 wurden 2490 Fragebogen zuruckgeschickt, was einer Responserate von 92,4 % der ursprunglichen COR-Stichprobe (nach Ausschluss der Verstorbenen) entspricht. Der Anteil der Patienten mit einer Operation in den vorausgegangenen 3 Jahren betrug 1004 (40,3 %). Bei 95,0 % dieser Patienten wurde die RLS-Medikation vor der Operation nicht verandert; in der ersten Woche nach der Operation wurde die Medikation bei 88,8 % der Patienten nicht verandert. 71,4 % der Patienten erhielten eine Vollnarkose, 14,0 % eine regionale (spinale oder peridurale) und 9,9 % eine lokale Anasthesie; fur 4,7 % war die Art der Narkose nicht bekannt. In einer logistischen Regressionsanalyse zeigte sich, dass es verschiedene signifikante Pradiktoren fur eine postoperative Verschlechterung der RLS-Symptomatik gibt: Frauen (OR 3,6; 95 % CI: 1,2–3,7), Patienten mit einer langeren (≥ 2 Tage) Immobilisierungsdauer (OR 2,1; 95 % CI: 1,2–3,6) sowie Patienten mit einer Operation an den Beinen bzw. an der Hufte (OR 1,9; 95 % CI: 1,2–2,9) haben ein signifikant erhohtes Risiko fur das Auftreten einer Symptomverschlechterung. Lokale Anasthesie ist dagegen im Vergleich zu einer Vollnarkose mit einem protektiven Risiko (OR 0,2, 95 % CI: 0,1–0,9) behaftet Die vorgestellten Ergebnisse sollten bei der Beratung und Betreuung von RLS-Patienten, die sich einer Operation unterziehen mussen, berucksichtigt werden.

Daytime sleepiness for any reason leads to impairment of daytime performance and an increased accident rate. The consequences are an increase of illness- and accident-related costs for the health system. Obstructive sleep apnea (OSA) is one of the major reasons for increased daytime sleepiness, especially in professional drivers. The accident frequency in OSA can be significantly reduced by adequate continuous positive airway pressure (CPAP) therapy. Up till now there are no uniform legal regulations about the handling of OSAS patients or patients with daytime sleepiness due to other diseases as far as driving ability is concerned.

Patienten mit erhohter Tagesschlafrigkeit sind in allen beruflichen und sozialen Lebensbereichen beeintrachtigt. Gutachterliche Stellungnahmen werden im Rentenverfahren, zur Beurteilung der Einsatzmoglichkeiten am Arbeitsplatz und zur Fahrtauglichkeit gefordert. Zur Diagnosesicherung stehen nichtapparative und apparative Testverfahren zur Verfugung. Eine Polysomnographie ist zwingend erforderlich. Vor der endgultigen Begutachtung sollten alle schlafmedizinischen Differenzialdiagnosen abgeklart und eine optimale Behandlung angestrebt worden sein. In der aktuellen Fahrerlaubnisverordnung (FeV) wird erstmals von Fahruntauglichkeit bei unbehandelten Schlafstorungen mit Tagesschlafrigkeit ausgegangen. Die Bedeutung der Tagesschlafrigkeit in anderen Berufsgruppen ist arbeitsplatzbezogen zu bewerten. Vor dem Ansprechen einer adaquaten Therapie besteht haufig vorubergehend Arbeitsunfahigkeit. Die arbeitsmedizinische Beurteilung sollte dem Patienten im Hinblick auf Berufswahl und Arbeitsplatzgestaltung mitgeteilt werden. Der Gutachter hat Therapieerfolge zu kontrollieren. Die vorliegende Ubersicht soll gesetzliche Grundlagen und geeignete Untersuchungsverfahren darstellen.

Sleep disorders can be diagnosed in approximately 15 % of the population and have been shown to increase with age. The relationship between sleep disorders and neurological disorders, however, is still insufficiently considered in the clinical practice. Sleep disorders can be an early symptom of the disease, such as the presence of rapid eye movement (REM) sleep behavior disorder (RBD) as an early indicator of neurodegeneration. Sleep disorders have also been shown to be a main symptom of various neurological syndromes, such as in restless legs syndrome (RLS), periodic limb movement disorder (PLMD) and narcolepsy. The international classification of sleep disorders 2nd edition (ICSD 2) describes the main diagnoses, insomnia, circadian rhythm sleep disorders, sleep-related breathing disorders and hypersomnia but all of these can also appear as symptoms in various neurological diseases. Parasomnias are largely considered a differential diagnosis to nocturnal epilepsy. In this review, the main sleep disorders are described with a particular focus on how they relate to neurological diseases; in particular, how they influence disease-related symptoms and how they affect the course of the disease.

Daytime sleepiness for any reason leads to impairment of daytime performance and an increased accident rate. The consequences are an increase of illness- and accident-related costs for the health system. Obstructive sleep apnea (OSA) is one of the major reasons for increased daytime sleepiness, especially in professional drivers. The accident frequency in OSA can be significantly reduced by adequate continuous positive airway pressure (CPAP) therapy. Up till now there are no uniform legal regulations about the handling of OSAS patients or patients with daytime sleepiness due to other diseases as far as driving ability is concerned.

In patients with COPD and isolated night time hypoxemia, oxygen administration has not shown any effects on life expectancy and the development of pulmonal arterial hypertension. The aim of the present pilot study was to investigate the influence of nocturnal oxygen therapy on the quality of life in daytime normoxemic COPD patients with nocturnal oxygen desaturations.19 patients with COPD, in a stable phase of the disease without need for oxygen supplementation under rest (PaO2 62.7 +/- 4.9 mmHg) and nocturnal hypoxemia (t90 = 55.5 +/- 33.4 % of registration time, mean SaO2 89.8 +/- 1.9 %, minimal SaO2 81.1 +/- 4.8 %) were randomly assigned to either oxygen or placebo treatment, both generated by identical concentrator devices. Each treatment period lasted 6 weeks, after six weeks a cross-over was performed by a technician. Quality of life was assessed before and at the end of each treatment period by the SF-36, Nottingham Health Profile and Saint George's Respiratory Questionnaire.Significant differences for the comparison of placebo and verum were only seen for the dimension sleep (NHP), all other dimensions showed no differences between placebo and oxygen. However, both placebo and oxygen improved the majority of the quality of life items significantly.The prescription of supplemental oxygen in COPD patients with isolated nocturnal hypoxemia in the present pilot study is not able to improve the quality of life within 6 weeks after initiation of therapy. It cannot, therefore, be generally recommended, but may be indicated in patients with a documented improvement of sleep quality.

The prevalence of clinically relevant, obstructive sleep apnoea syndrome (OSAS) in the general population is 2% in women and 4% in men. With increasing age and onset of postmenopausal status, the prevalence of OSAS in women becomes comparable to that of males. However, compared to prevalence data, women are under-represented in clinical sleep laboratories. The present overview deals with the potential reasons for clinical under-recognition of OSAS in women. The fact that OSAS frequency is underestimated in women probably derives from the atypical clinical symptoms, dominated by difficulties of initiating and maintaining sleep and by a depressive mood. There are several protecting mechanisms in women that prevent or postpone OSAS development to higher age groups or until the onset of menopause. These factors include craniofacial morphology and function, gender-specific body-fat distribution and hormonal influences on ventilation and dilating muscles in the oropharynx. Physicians should be aware of the presence of sleep-disordered breathing in women and of their special features.

Patients with increased daytime sleepiness are impaired in all areas of their social environment. Expert opinions are recommended for pension proceedings, regarding driving licenses as well as for restrictions at the workplace. All possibilities should be considered in the differential diagnosis of sleep disorders, which have to be treated before an expert opinion is submitted. Statutory regulations on evaluation of sleepiness are contained in the guidelines for assessing a patient's fitness to drive. The importance of daytime sleepiness in other occupations should be assessed according to the respective workplace. The patient should be informed of the appraisal with regard to career choice and workplace design. The expert thus has the responsible task of carrying out interdisciplinary differential diagnosis of pathological sleepiness and monitoring treatment success with appropriate test methods. In the present paper the legal guidelines in Germany and available test methods are presented.

Patients with COPD present with impairments of their cognitive performance. The present study compares intelligence and memory performance as well as different aspects of attention in COPD patients and healthy controls. Additionally, potential factors influencing daytime performance are analyzed.Neuropsychological testing was performed in 32 patients with COPD and 10 normal controls. The following aspects were evaluated: memory, intelligence, simple, selective and divided attention, sustained attention under stress and under monotonous conditions.There were no differences between COPD patients and normals with regard to divided attention, vigilance and memory. Patients with COPD demonstrated significantly worse results in terms of intelligence (p0.01) as well as simple (p0.01), selective (p0.05) and sustained attention (p0.01). No correlation existed between the severity of the disease (lung function, blood gas analysis, nocturnal oxygen saturation) and neuropsychological findings. Merely a relationship between memory function and slow-wave sleep or REM sleep was demonstrated.Impairments of cognitive performance in patients with COPD cannot be predicted on the basis of the severity of the disease. Therefore neuropsychological testing is recommended, especially when impairment of daytime function has to be quantified.

Patients with obstructive sleep apnea (OSA) have an increased accident risk. The German Society of Sleep Research and Sleep Medicine (DGSM) recommends for patients with OSA and daytime sleepiness that their driving ability should be re-established 6 weeks after the initiation of CPAP (continuous positive airway pressure), with documentation of therapeutic effects on daytime symptoms and performance. The present study was conducted to investigate whether an improvement of driving ability can be documented in neuropsychological tests and a simulated driving situation 14 days after the initiation of CPAP.Driving simulation and neuropsychological tests of vigilance were conducted in 36 patients (36 males, aged 54 9 years) with OSAS before and 2 (n=23), 14 (n=18) and 42 days (n=17) after initiation of CPAP.Vigilance tests showed only slight changes under CPAP. Frequency of accidents during driving simulation was reduced after 14 days of CPAP, but a statistically remarkable decrease was achieved only on day 42. In contrast, concentration faults were reduced after 2 and 14 days of CPAP.In OSA-patients improvement of daytime performance in a simulated driving situation can be documented 14 days after initiation of CPAP. There is need for investigating larger cohorts of patients so that current recommendations for driving licensing can be modified and permission to drive can be given earlier.

Patients with obstructive sleep apnoea syndrome (OSAS) have an increased car accident rate. Investigations on accident frequency are based on case history, insurance reports and driving simulator studies. The present study combines neuropsychological testing of different attention aspects engaged in driving a car and driving simulation to evaluate a suitable instrument for assessing therapeutic effects of continuous positive airway pressure (CPAP). Driving simulator investigation and neuropsychological testing of alertness, vigilance and divided attention were performed in 31 patients with polysomnographically confirmed OSAS (apnoea-hypopnoea index 24.8+/-21.5.h(-1)) before, and 2 and 42 days after initiation of CPAP. Divided attention and alertness improved significantly during CPAP, whereas vigilance remained unchanged. However, accident frequency (OSAS before therapy: 2.7+/-2.0; 2 days after CPAP: 1.5+/-1.4; 42 days after CPAP: 0.9+/-1.3) and frequency of concentration faults (OSAS before therapy: 12.4+/-5.1; 2 days after CPAP: 6.5+/-3.9; 42 days after CPAP: 4.9+/-3.3) decreased in the simulated driving situation after 2 and 42 days of therapy. There was no relation between accident frequency, concentration faults and daytime sleepiness, as measured by the Epworth Sleepiness Scale, and polysomnographic or neuropsychological findings, respectively. In conclusion, the present results suggest that driving simulation is a possible benchmark parameter of driving performance in obstructive sleep apnoea syndrome patients.

Patients suffering from multiple sclerosis often complain of fatigue and sleepiness. Patients often cannot distinguish between these symptoms. Daytime sleepiness, attention and concentration deficits affect life quality severely. Usually symptoms of MS are characterized by the Expanded Disability Status Scale (EDSS). In new studies the MSFC proves to be a more sensitive method especially estimating the cognitive deficits.31 RRMS patients (18 women, 13 men, mean age 35.6 +/- 8.3 years) and 19 healthy controls (9 men, 1 woman, age: 55.1 +/- 7.8 years) were assessed by: 1) morning and evening protocols of the German Sleep Society, 2) Epworth Sleepiness Scale (ESS), 3) Extended Disability Status Scale (EDSS), 4) MS Functional Composite (MSFC) based on arm function, ambulation and cognition (paced auditory serial addition test, PASAT), 5) Fatigue Severity Scale (FSS).The EDSS-Score ranged from 1.0 to 6.5 (2.8 +/- 1.4). Mean Z-Score of MSFC was -0.19 +/- 0.63. Most deficits could be shown in the PASAT. Total sleep time correlated with recovery capacity of sleep (r = 0.42, P0.05). The ESS-Score was 6.1 +/- 2.9 (1 - 14). FSS-Score was raised with intraindividual variability (4,33 +/- 1.62, 1.4 - 7). The EDSS failed to correlate with the ESS- or FSS-Score. FSS correlated significantly with arm function (r = 0.465) und ambulation (r = 0.436) in the MSFC (P0.05).MS-Patients are often not able to distinguish between fatigue and sleepiness. By using different scales judging sleepiness and fatigue significant differences could be evaluated. Fatigue is mainly linked to motoric deficits scored by the MSFC. Therefore medication with stimulants seems not to be useful in fatigue therapy.

Daytime sleepiness is a leading symptom of various diseases, and is an important cause of accidents at the workplace and on the road. For the evaluation of accident frequency, the medical history, neurophysiological and neuropsychological tests, and driving simulator performance are applied. The present paper describes these different methods, and assesses their value in predicting accidents. In the last resort, no single test suffices to evaluate the accident risk of patients suffering from daytime sleepiness--rather, a combination of the methods described is needed, in particular when an expert opinion on a patient's ability to drive is required. To date, no controlled studies have been done to compare the predictive value of the methods considered herein. Our results suggest that the nearness of driving simulation to reality makes it a suitable additional test method, in particular for the monitoring of results under treatment.

Patients with obstructive sleep apnea syndrome (OSAS) have an accident rate between two and seven times higher than normals. Investigations on accident frequency are based on case history, insurancy reports, and driving simulator investigations. The present controlled study was planned to test whether an increased accident risk could be demonstrated in patients with OSAS before and on CPAP (continuous positive airway pressure)-therapy using the driving simulator C.A.R. Driving simulator performance was investigated in 31 patients with polysomnographically confirmed OSAS (apnea-hypopnea-index 24.8 +/- 21.5/h) before, 2 and 42 days after initiation of CPAP and was compared to 10 healthy controls in whom OSAS was excluded by polysomnography. Driving simulator performance was significantly worse in OSAS as compared to normals especially in terms of accident frequency (OSAS: 2.7 +/- 2.0, controls: 1.3 +/- 1.5, p0.05) and concentration faults (OSAS: 12.4 +/- 5.1, controls: 7.1 +/- 3.2, p0.01). On CPAP accident frequency (OSAS before therapy: 12.4 +/- 5.1, 2 days CPAP: 1.5 +/- 1.4, p0.01; 42 days CPAP: 0.9 +/- 1.3, p0.001) and frequency of concentration faults (OSAS before therapy: 12.4 +/- 5.1, 2 days CPAP: 6.5 +/- 3.9, p0.001; 42 days CPAP: 4.9 +/- 3.3, p0.001) could be lowered significantly both in the short and medium term of therapy. The driving simulator C.A.R. is an adequate tool for the evaluation of an increased accident risk in OSAS-patients and demonstrates the efficiency of CPAP-therapy.

We report on a 69-year-old woman who presented with myalgia, hearing impairment, fever, night sweats, weight loss, muscular weakness, paresthesia, hypesthesia, and hypalgesia. Sural nerve biopsy showed demyelinative and axonal polyneuropathy due to necrotizing vasculitis with fibrinoid necrosis. A positive test for antineutrophil cytoplasmic antibodies (ANCA) with a perinuclear immunofluorescence pattern directed against myeloperoxidase was more suggestive of microscopic polyangiitis (MPA) than of polyarteritis nodosa (PAN), the possible differential diagnoses. In addition, positive tests for cytomegalovirus (CMV) antibodies (immunoglobulin (Ig)M and IgG) and the detection of CMV-DNA in sputum specimens by polymerase chain reaction (PCR) were indicative of active CMV infection. Treatment with ganciclovir and anti-CMV immunoglobulin in addition to prednisolone medication for 6 months resulted in rapid improvement of the clinical symptoms without relapse. CMV infection has been described to be related to ANCA-associated vasculitis in non-immunocompromized patients and may be either a causative agent or an opportunistic infection. Identification of a viral etiology in patients with atypical ANCA-associated vasculitides may lead to different, less aggressive treatment approaches, including antiviral therapy.

Um beurteilen zu konnen, ob ein zerebraler Krampfanfall mit einem Trauma in Verbindung gebracht werden kann, muss zuerst entschieden werden, ob eine gravierende zerebrale Schadigung vorgelegen hat.

Hemifacial spasm (HFS) presents a frequent movement disorder. It is thought to have an organic origin. It therefore has to be distinguished from other facial involuntary movements, especially psychogenic tics, because the therapeutic approach differs. The present study opted to evaluate the diagnostic value of the postexcitatory inhibition (pI) after transcranial magnetic stimulation (TMS). After stimulating the contralateral hemisphere with the conventional flat coil and recording from the mentalis muscle, in 10 healthy controls and 10 patients postexcitatory inhibition was determined. PI showed no side to side difference in healthy controls (96.9 + 12.7 ms right, 87.9 +/- 10.8 ms left side, interhemispheric difference 6.4 +/- 3.8 ms). In 8 patients with hemifacial spasm, the duration of pI on the non-affected side did not differ from the healthy controls (87.9+/-43.5 ms). During spasm, pI on the affected side shortened increasingly until no inhibition could be induced. Afterwards the spasm pI was prolonged significantly (up to 140 ms longer than opposite side) before returning to normal values. Two patients presented no side differences of pI during the "spasm". An emotional conflict situation could be evaluated, supporting the diagnosis of somatoform disorder. As postexcitatory inhibition is mainly due to cerebral mechanisms, the electrophysiological results of the study pointed to a cortical influence on the hemifacial spasm. TMS seems to be an electrophysiological tool which allows a differentiation between organic and psychogenic spasm and enables a different therapeutic approach.

Recent literature revealed the importance of subjective coping strategies in chronic diseases. Due to the unpredictable course of the disease, multiple sclerosis patients have to integrate the illness into their psychosocial context. The present study examines the connection between coping styles, cognitive attitudes ("locus of control") and course in 20 outpatients with multiple sclerosis. Favourable coping strategies correlated with internal locus of control. Unfavourable coping behaviour on the other hand was correlated with external cognitive attitudes and a worse outcome. Moreover, depressive coping styles and psychopathological depression dominate with a worse course of the disease. Thus coping and cognitive attitudes have to be evaluated in order to strengthen personal resources in dealing with multiple sclerosis.

Patients with obstructive sleep apnoea syndrome (OSAS) commonly complain about daytime sleepiness and a decline of cognitive functions. Several diagnostic tools have been established to judge objectively vigilance and cognitive impairment. Forty OSAS patients aged between 34 and 74 years were examined via several neuropsychological tests (e.g. vigilance test of the Wiener Testsystem, number connection test ("Zahlenverbindungstest-ZVT") to assess working velocity and information processing, d2-test to rate concentration on exertion) before starting continuous positive airway pressure (CPAP) therapy. In addition, visual evoked event-related potentials (ERPs) were recorded; the P3-component was evaluated. All patients subjectively stated daytime sleepiness and cognitive dysfunctions to variable degrees. Each patient showed at least one pathological result in the neuropsychological tests; vigilance impairment could be revealed only in 7 patients. P3-latencies were increased in OSAS patients when compared to age-matched controls (408.1 +/- 44.4 ms versus 373.4 +/- 32.5 ms; p0.03). P3-latencies and concentration on exertion showed a significant correlation with respect to the relative part of the total sleep time in which the patient's oxygen saturation was below 90% (p0.05). Thus it could be demonstrated that cognitive deficits in OSAS patients are a result of chronic intermittent oxyhaemoglobin desaturation rather than of a decline in daytime vigilance. ERPs represent an objective neurophysiological tool in neuropsychological examination. As they are also generated in subcortical cerebral structures they may indicate cognitive dysfunctions which cannot be evaluated by neuropsychological tests. If lead of ERPs is possible in special sleep centres they should be additionally used in the assessment of cognitive functions in OSAS patients.

Possible changes in the organization of the cortex in patients with facial palsy, serving as a model of peripheral motor deefferentation, were investigated by using transcranial magnetic stimulation (TMS) and positron emission tomography (PET). With TMS, the size of the area producing muscle-evoked potentials (MEPs) of the abductor pollicis brevis muscle, the sum of MEP amplitudes within this area, and the volume over the mapping area were compared between both hemispheres in 8 patients. With PET, increases in regional cerebral blood flow, measured with the standard H2(15)O2 bolus injection technique, were compared between 6 patients and 6 healthy volunteers during sequential finger opposition. Patients moved the hand ipsilateral to the facial palsy, the control subjects the right hand. Of 9 patients in total, 5 participated in both experiments. With both methods, an enlargement of the hand field contralateral to the facial palsy was found, extending in a lateral direction, into the site of the presumed face area. The PET data showed that the enlargement of the hand field in the somatosensory cortex (SMC) is part of a widespread cortical reorganization, including the ipsilateral SMC and bilateral secondary motor and sensory areas. We report for the first time, using two different noninvasive methods, that peripheral, mere motor deefferentation is a sufficient stimulus for reorganizational changes in the healthy adult human cortex.

Patients with obstructive sleep apnea syndrome (OSAS) present upper airway obstruction during sleep which can be documented by electromyography. The cause of weakness in oropharyngeal muscles is still unknown. Lesions of pons and medulla oblongata have to be expected. Brainstem auditory evoked potentials (BAEP) may indicate pathological changes in these regions. Several studies described normal BAEP in OSAS-patients. Moderate forms of OSAS as well as central sleep apnea syndromes were investigated, however. In our study 20 patients (17 men, 3 women, mean age 53.9 +/- 2.1 ys) with severe OSAS (apnea/hypopnea-index: 34.2 +/- 14.1/h, part of O2-saturationor = 90% during sleep (SaO2or = 90%): 13.5 +/- 4.2%, minimal nocturnal O2-saturation: 78.0 +/- 2.5%) before starting nCPAP-therapy were investigated. BAEP were elicited after applying clicks 70 dB above threshold to each ear. Means of single wave latencies as well as interpeak latencies (I-V, I-III, III-V) were delayed significantly compared to normal controls. Main prolongations were seen regarding wave latency I (por = 0.001) and-interpeak latency I-V (por = 0.001). Prolongation of interpeak latencies (mean +/- 2.5 SD) of one or two sides could be demonstrated in 12 out of 20 patients. Pontomesencephal lesions (9 patients) dominated. There was no connection with respiratory parameters. As against pathological BAEP changes correlated with the duration of the disease. In conclusion pathological BAEP indicating brainstem lesions were seen in 60% of the examined OSAS-patients. Mesencephal lesions dominated, number of lesions increased with duration of disease. Therefore pathological findings have not to be considered as cause but as a result of hypoxemia in OSAS. Pathological BAEP may reveal a higher risk for cerebrovascular stroke. Therefore these patients should be leaded to further cerebrovascular investigation.

Twenty-three patients (10 men, 13 women; age: from 23 to 81 years, mean 52 years) with Bell's palsy were investigated by magneto-electrical stimulation in order to evaluate the usefulness of this method for prognostication. At each examination the facial nerve was electrically stimulated, and an orbicularis-oculi-reflex was elicited. Follow-up investigations were possible in 13 patients. All patients showed pathological long- and short-latency responses at the first examination. The blink reflex examination revealed a pathological result in all cases. The responses to electrical stimulation were pathological only in 35%. The follow-up examinations revealed that the analysis of the short-latency response did not give a prognostic information. In contrast, maintained elicitation of the long-latency response pointed to a favourable prognosis. In follow-up investigations, the increase of amplitude and the decrease of latency of the long-latency response correlated with a complete recovery, while the decrease of amplitude and the increase of latency correlated with a partial recovery. The improvement of the responses in magnetic stimulation preceded the clinical improvement. By using magnetic stimulation, an early registration and evaluation of the course of Bell's palsy are possible.

Patients with trigeminal neuralgia are usually investigated by elicitation of the orbicularis oculi reflex and trigeminal evoked potentials. These neurophysiological methods do not allow direct judgement of the trigeminal nerve. By transcranial magnetic stimulation, however, non-invasive investigation of the efferent part of the trigeminal nerve is possible. 10 patients (4 men, 6 women, aged from 43 to 73 years) with trigeminal neuralgia affecting the second or third division were examined. In all patients bilateral long-latency responses after stimulation of the tractus corticonuclearis and short-latency responses after stimulation of the proximal part of the trigeminal nerve were registered. 8 patients showed normal short- and long-latency responses, while in one other patient the long-latency responses were delayed on both sides. The remaining patient revealed a significant difference of amplitude compared to the contralateral long-latency response. This patient had a pontine lesion as shown by blink reflex and a pathological trigeminal evoked potential. In both these latter patients multiple sclerosis was diagnosed. Use of transcranial magnetic stimulation may thus prove helpful in the differential diagnosis of neurological disorders presenting with trigeminal neuralgia.

We report on a 57 year-old patient with schizophrenia. After a 30 years course of the disease, he developed previous unknown psychopathological symptoms, and therapeutic interventions (neuroleptic drugs and electroconvulsive therapy) failed. Neurological examination and EEG revealed the diagnosis of complex partial epileptic seizures. MRI showed bitemporal localized cerebral lesions. Discussion focusses on generalization of microseizures in deep brain structures, and "kindling effect" of electroconvulsive therapy in a patient with pre-existing cerebral lesions.

5 patients (3 men, 2 women, aged from 28 to 51 years) with unilateral facial palsy after surgery of a cerebellopontine angle tumour have been investigated by transcranial magnetic stimulation. The purpose was to evaluate the prognostic aspects of this method, which was compared with the electrical stimulation of the facial nerve and the elicitation of an orbicularis-oculi reflex. The components of the blink reflex were absent in all cases. In 3 patients electrical stimulation was possible (compound muscle action potentials were delayed). With transcranial magnetic stimulation ipsilateral short-latency and contralateral long-latency responses (stimulation of the cortex) were elicited and registered from the M. mentalis as well as 3 times from the M. orbicularis oculi. The short-latency response revealed no prognostic aspects. Despite the missing response, a recovery was possible. Long-latency responses could be evoked in all patients. The extent of delay in latency was strongly correlated with clinical improvement of the paresis. Interestingly, this correlation could also be observed in the single rami of the facial nerve when two muscles were investigated in a patient. Transcranial magnetic stimulation is an important improvement in electrophysiological diagnosis of perioperative lesion of facial nerve to prove continuity of the nerve and to evaluate the clinical course.

Within the framework of preventive measures and therapy of chronic illnesses health psychological theories have contributed to improve knowledge. The analysis of health psychological contributions shows the meaning of "locus of control beliefs" in different diseases. Locus of control is understood as a subjective cognition, able to attribute individual action consequences to specific internal or external features. Differences in general or specific locus of control beliefs may be associated with specific courses of illness. This study presents the results of locus of control beliefs in 20 multiple sclerosis patients with a phasic course after three examinations. These showed that increasing externality is linked to an increase of episodes in Multiple Sclerosis. An increase of health specific externality is indicative of an unfavourable course of this disease. The results of this study is corroborate previous studies of chronic diseases that external locus of control beliefs correlate with an unfavourable course of the disease as well as internal locus of control beliefs correlate with a favourable course. Cognitive interventions could therefore be an additional option in out-patient therapy of Multiple Sclerosis.

By means of transcranial magnetic stimulation bilateral compound muscle action potentials of long latency and ipsilateral potentials of short latency can be obtained in muscles supplied by cranial nerves. In this study motor evoked potentials were recorded from the mentalis muscle of 14 patients with traumatic brain lesions. These results were compared with clinical and radiological as well as other neurophysiological examinations. In spite of the absence of paralysis in muscles supplied by the facial nerve, 9 patients showed pathological long-latency responses, which correlated with the localisation of the paralysis of the limbs. In contrast to this, the degree of pathological latencies of motor evoked potentials did not correspond with the degree of paresis in different patients. A prediction concerning the clinical outcome could not be made by the results of motor evoked potentials. The clinical data showed a poor correlation with the structural brain lesions seen in the CT-scan and the results of EEG, BAEP and orbicularis oculi reflex examination. In conclusion, transcranial magnetic stimulation of cranial nerves proved to be a sensitive method for the evaluation of degree and localization of motor deficits following traumatic brain lesion and seems to be superior to the other examinations compared.

In der klinischen Routinediagnostik der Encephalomyelitis disseminata (E. d.) nehmen die afferent evozierten Potentiale heute einen festen Platz ein. Seit der Einfuhrung der transkortikalen Stimulationstechniken wurde von mehreren Untersuchern auch uber einen Einsatz dieser neuartigen Methodik bei E.d.-Patienten berichtet. Innerhalb unseres klinisch diagnostischen Routineprogramms leiteten wir motorisch evozierte Potentiale ab, um zu einer Einschatzung hinsichtlich ihrer diagnostischen Wertigkeit zu gelangen.