Heparin-mediated extracorporeal LDL/fibrinogen precipitation--H.E.L.P.--in coronary and cerebral ischemia

Cerebral and myocardial infarctions share common aspects of pathobiochemistry. The central problem is the oxygen supply of the infarcted region. To maintain this supply, H.E.L.P.-apheresis (Heparin-mediated Extracorporeal LDL/Fibrinogen Precipitation) has already proven beneficial in the prevention and therapy of myocardial infarction. Since H.E.L.P.-apheresis can lower significantly plasma viscosity and erythrocyte aggregation without reducing the oxygen transport capacity, patients with cerebral infarction (stroke) may also benefit from our experiences in myocardial ischemia. The system is designed to remove selectively plasma fibrinogen, LDL-cholesterol and lipoprotein(a) from blood circulation, simultaneously. The removal of the plasma compounds is achieved by extracorporeal precipitation with heparin at low pH. Excess heparin is completely removed by an adsorber before the plasma is given back to the patient. H.E.L.P.-apheresis has proved to be safe in patients with coronary heart disease and allows a controlled reduction of thrombogenic plasma compounds. It is therefore hoped to be effective also in patients with acute ischemic stroke.

[Cerebral ischemia as initial manifestation of neoplastic low-malignancy changes. 2 case reports and review of the literatures]

Thrombembolic events as paraneoplastic complications in malignant disease account for severe morbidity and mortality in these patients. In some cases disturbance in hemostasis is the first manifestation of a neoplastic process. We report the cases of two patients with cerebral and extracerebral vessel occlusions, in whom epithelial tumors of low malignant potential (borderline-tumors) of ovary and peritoneum were diagnosed later on. In one case the removal of the tumor stopped the coagulation problems. The second patient died a few days after the first symptoms with devastating multiple vessel occlusion. In stroke of unknown aetiology a paraneoplastic process should be kept in mind. The diagnosis is more probable with recurrent thrombembolism in different body regions and when warfarin therapy was ineffective. Thoughtful coagulation studies and a tumor search program is recommended in these cases.

Molecular forms of somatostatin-like immunoreactivity in the cerebrospinal fluid of patients with senile dementia of the Alzheimer type

In the cerebrospinal fluid (CSF) of 53 patients with senile dementia of the Alzheimer type (SDAT) and 12 elderly controls, we measured somatostatin (SLI) and its molecular forms: high-molecular weight form (HMV-SST), somatostatin-14 (SST-14), somatostatin-25/28 (SST-28/25), and des-ala-somatostatin (des-ala-SST) using high pressure liquid chromatography (HPLC) and a radioimmunoassay. In SDAT, SLI was significantly decreased (p < 0.05) and correlated with dementia scores (r = -0.65, p < 0.05). HPLC separation showed a marked heterogeneity of SLI in the CSF with a preponderance of SST-14 and SST-25/28. The significant loss of SST-14 (p < 0.05) in SDAT was found to be correlated with dementia scores (r = 0.65). Moreover, qualitative and quantitative changes in the molecular pattern of SLI in SDAT indicated dysregulated synthesis and/or processing of somatostatin relating to the severity of dementia. The long-term administration of neuroleptics in severe cases of SDAT caused a significant increase of SLI (p < 0.05) and influenced the ratio of HMV-SST/SST-14 and SST25/28/SST-14.

Cerebrospinal fluid neuropeptides and monoaminergic transmitters in patients with trigeminal neuralgia

The pathogenesis of trigeminal neuralgia remains largely unknown. "Peripheral" as well as "central" causes have been suggested. To investigate the role of serotonergic, noradrenergic, dopaminergic, and peptidergic systems, we determined the concentrations of epinephrine, norepinephrine, and their breakdown product, vanillylmandelic acid, in the cerebrospinal fluid of 16 patients (55.3 +/- 8.3 years) with trigeminal neuralgia. As a marker for the dopaminergic system, we determined cerebrospinal fluid concentrations of dopamine and its metabolite, homovanillic acid. As a marker for the serotonergic system, we measured cerebrospinal fluid levels of the serotonin metabolite, 5-hydroxyindoleacetic acid. In addition, levels of the neuropeptides, substance P and somatostatin, were determined. The concentration of norepinephrine (P < 0.01) and its metabolite, vanillylmandelic acid, (P < 0.05) were significantly decreased in our patients. The level of the dopamine metabolite, homovanillic acid, was also significantly reduced (P < 0.01). Also significantly decreased was 5-hydroxyindoleacetic acid (P < 0.01). Substance P was significantly elevated (P < 0.05). Somatostatin was significantly decreased (P < 0.05). We hypothesize that the sum of complex neurochemical changes plays a role in the pathogenesis of trigeminal neuralgia. The elevated substance P could support the concept of a neurogenic inflammation in the trigeminovascular system, whereas changes in the monoaminergic transmitters and their metabolites seem to reflect a more central dysfunction possibly due to a longer duration of the disease and an accompanying depression.

[Faulty regulation of the hypothalamo-hypophyseal-adrenal axis and chronobiological manifestations in cluster headache]

Cluster headache is a rare very severe disorder that is clinically well characterized with a relatively poorly understood pathophysiology. Although peripheral structures are postulated to be involved in triggering the pain attacks, chronobiological changes like the cluster period and the complex dysbalance of the sympathetic and parasympathetic nervous system point to a "central" genesis of cluster headache. To check neuroendocrine changes in cluster headache, in 12 patients (43.4 +/- 6.3 years) during the cluster period cortisol and ACTH were determined four-times a day (7.00, 12.00, 17.00, 23.00) in the plasma. To prove the central genesis of cluster headache, in the cerebrospinal fluid (CSF) the neurotransmitters norepinephrine, epinephrine, dopamine and the metabolites 5-hydroxyindolacetic acid (5-HIAA), homovanillic acid (HVA) and vanillymandelic acid (VMA) were determined. The values of cortisol and ACTH were significantly elevated in the morning (p < 0.01, p < 0.05) and at night (p < 0.01, p < 0.01) in comparison to the control patients. The daily mean value of cortisol was significantly increased compared to controls (p < 0.01). In the CSF norepinephrine (p < 0.05), HVA (p < 0.01) and 5-HIAA (p < 0.01) decreased to significant low levels compared to control patients. We found significant correlations between cortisol/ACTH and norepinephrine and 5-HIAA. Moreover, our results indicate that the higher cortisol the longer the duration of the cluster period. The results of this study confirm changes of the hypothalamic-pituitary-adrenal axis due to the chronobiological changes in cluster headache. The reduced values of neurotransmitters in the CSF are compatible with the hypothesis of a central genesis of cluster headache.

CSF substance P somatostatin and monoaminergic transmitter metabolites in patients with narcolepsy

We have measured the concentrations of substance P, somatostatin, homovanillic acid (HVA), vanillyl mandelic acid (VMA) and 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) of six patients suffering from narcolepsy and 12 age- and gender-matched controls using high pressure liquid chromatography (HPLC) and radioimmunoassay (RIA). Substance P and somatostatin were significantly decreased in our patients compared to controls (36.9 +/- 9.1 fmol/ml versus 52.5 +/- 9.9 fmol/ml, P < 0.05 and 30.3 +/- 7.8 fmol/ml versus 43.9 +/- 9.8 fmol/ml, P < 0.05, respectively). 5-HIAA (P < 0.05) and VMA (P < 0.05) were also significantly decreased. HVA was significantly increased (P < 0.01). The CSF concentrations of substance P and somatostatin correlated with the clinical parameters duration of disease (r = -0.68, P < 0.05 and r = -0.72, P < 0.05, respectively) and severity of cataplectic symptoms (r = -0.71, P < 0.05 and r = -0.78, P < 0.01). In addition, substance P correlated with the intensity of sleepiness and the frequency of day-sleep attacks (r = -0.69, P < 0.05 and r = -0.68, P < 0.05, respectively). Substance P affects the amount of dopamine release in the nigra-striatal region, and decreased amounts could contribute to the pathogenesis of narcolepsy. Reduced levels of substance P, which affects serotonin release, may be responsible for diminished release of serotonin which in turn could affect sleep cycles. Because somatostatin affects motor behavior through dopaminergic mechanisms and since the levels of somatostatin correlate with the intensity of cataplectic symptoms, we speculate that an interaction between somatostatin and dopaminergic neurons plays a role in the pathogenesis of narcolepsy.

Autonomic nervous system and neuroendocrine changes in patients with idiopathic trigeminal neuralgia

To investigate sympathetic nervous system and neuroendocrine changes in idiopathic trigeminal neuralgia, we determined the plasma level of the catecholamines norepinephrine and epinephrine, as well as cortisol and ACTH in 16 patients (55.3 +/- 8.3 years) with trigeminal neuralgia at four different times during the day (7.00, 13.00, 17.00 and 23.00). Morning and evening values of plasma norepinephrine as well as the daily mean value (dmv) were significantly higher (p < 0.01) in patients with trigeminal neuralgia than in an age- and gender-matched control group. Moreover, morning, afternoon and dmv epinephrine values were also significantly elevated. The dmv norepinephrine levels correlated with the intensity of the attacks (r = 0.68, p < 0.01), the frequency of the attacks (r = 0.75, p < 0.01) and the duration of the disease (r = 0.78, p < 0.01). In addition to elevated catecholamines, trigeminal neuralgia patients also demonstrated significantly increased morning, evening and daily mean values of plasma cortisol. Thus, patients with trigeminal pain have an increased sympathetic nervous system activity for an extended period of time without a direct link to pain attacks, which suggests that the sympathetic nervous system itself is at least co-activated in trigeminal neuralgia and perhaps plays a role in the induction and maintenance of trigeminal pain. The neuroendocrine changes are similar to cluster headache and point to a central dysregulation of the hypothalamic-pituitary-adrenal axis, possibly due to the cyclic phenomena in idiopathic trigeminal neuralgia.

[Substance P, somatostatin and monoaminergic transmitters in the cerebrospinal fluid of patients with chronic idiopathic trigeminal neuralgia]

The etiology of trigeminal neuralgia is unknown, but both peripheral and central causes have been suggested. To investigate the role of central neurochemical mechanisms we measured epinephrine, norepinephrine and their breakdown product, vanilly mandelic acid (VMA), in the cerebrospinal fluid (CSF) of 16 patients (53.3 +/- 8.3 years) suffering from trigeminal neuralgia. As markers for the dopaminergic system, we determined CSF levels of dopamine and its metabolite homovanillic acid (HVA). As a marker for the serotonergic system, we measured CSF levels of serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA). In addition, levels of the neuropeptides substance P and somatostatin were determined. The concentration of norepinephrine (P < 0.01), VMA (P < 0.05) and HVA (P < 0.05) were significantly decreased in patients with trigeminal neuralgia and correlated with the duration of the disease and depression scores. 5-HIAA was also significantly decreased (P < 0.05) compared to control patients. Whereas substance P was significantly elevated (P < 0.05), somatostatin was significantly decreased (P < 0.05). Various correlations between the classical neurotransmitters and the neuropeptides could be established. We hypothesize than the sum of complex neurochemical changes plays a role in the etiology of trigeminal neuralgia, which can be separated in local and more central proceedings. The increase in substance P, a major nociceptive neuromodulator, supports the concept of a local neurogenic inflammation, possibly located in the trigeminovascular system. Depending on the duration of the disease and depression, the loss of serotonergic, dopaminergic and noradrenergic innervation seems to reflect more central changes, possibly due to alterations in their antinociceptive descending pathways.

[Primary cerebral non-Hodgkin's lymphomas. The results of radiotherapy]

BACKGROUND

In the last years many therapeutic attempts were made to improve the poor prognosis of primary cerebral non Hodgkin's lymphoma. The aim of this study was to report on own experiences concerning this rare disease.

PATIENTS AND METHODS

In 1986 to 1994 26 patients were treated for primary cerebral non Hodgkin's lymphoma. 15% were HIV-positive. High-grade non-Hodgkin's lymphomas were diagnosed in 62%. 46% of all cases showed multiple lesions. 23% of our patients received a dose less than 25.5 Gy, 27% received 37.5 Gy (whole brain) and 39% were treated with 51 Gy (37.5 Gy whole brain and 13.5 Gy boost dose). Radiation technique included regular and irregular fields (single dose: 1.5 Gy).

RESULTS

62% of patients achieved a complete or partial remission directly after irradiation, in 4% no change or progression was seen. 31% could not be examined due to their bad status or death. The mean follow-up time for all patients was 19.6 months, the median survival was 3.6 months. The 1-year-survival rate was 41%, 3-year survival rate was 28%. Patients who received a tumor dose of 51 Gy had better survival times in comparison to patients who received less (p = 0.01). Prognostic parameters (Cox regression analysis) were: tumor dose, grading and local result after irradiation. The Karnofsky performance status was not an independent parameter (p = 0.12). Side effects were low. Long-term survivors had relatively good quality of life.

CONCLUSION

Taking into consideration the small numbers of patients in all studies all results or conclusions have to be made with great reservations. Despite the high proportion of HIV-positive patients our results are in compliance with other authors using similar therapy protocols. Reports dealing with combined radio-chemotherapy have published good results concerning survival time. But long-term morbidity due to these protocols needs further investigation and has to be awaited.

[Intracerebral hemorrhage and multiple brain abscesses caused by Bacillus cereus within the scope of acute lymphatic leukemia]

Multiple hematogenic brain abscesses in immunosuppression are occasionally caused by rare and primary apathogenic causative agents. We report a first case of an isolated CNS infection by Bacillus cereus, which led to death from multiple brain abscesses and an intracerebral hemorrhage, probably caused by the infection, within 4 days. The underlying disease leading to immunosuppression was acute lymphatic leukemia in complete remission. In spite of antibiotic therapy the chemotherapy-induced neutropenia enabled unhindered spreading of the necrotizing infection, which was verified by histological analysis. The production of potent toxins such as hemolysin and cerelolysin by B. cereus leads to rapid and fulminant tissue destruction usually involving the walls of blood vessels.

[The value of various transcranial color doppler tests for determining cerebrovascular reserve capacity]

One of the techniques for the assessment of the cerebrovascular reserve capacity is the so-called "breath-holding" test. In order to minimise haemodynamic changes following deep inspiration the patients should hold their breath at the end of a normal inspiration. We studied three different ways (breath holding following normal inspiration [NI], deep inspiration [DI], hyperventilation [HV]), of performing this test in 20 healthy volunteers. The acetazolamide test was taken as a reference. The mean flow velocity (FVmean) in the middle cerebral artery was recorded continuously using a TCD monitoring system. Blood pressure, cardiac output and heart rate were measured simultaneously. Breath holding after deep inspiration resulted in longer apnoea (DI: 68.1 +/- 24.1 s; NI: 44.8 +/- 18.4 s; p < 0.01), produced the highest increase of FVmean (DI: +72.2 +/- 29.8%; NI: +69.2 +/- 29.0%) and was the least inconvenient to the patients. Following HV apnoea was longest (93.0 +/- 33.5 s; p < 0.01), but resulted in the lowest increase of FVmean were not significant. A significantly lower increase of FVmean (44.2 +/- 13.4%, p < 0.01 resp.) could be observed after intravenous injection of 1 g acetazolamide. There were no significant haemodynamic changes in any case. Thus, this bedside test does not appear to be influenced by variations in breath holding.

Beta-blockade in acute aneurysmal subarachnoid haemorrhage

The effects of beta-blockade to prevent autonomic disorders after acute aneurysmal subarachnoid haemorrhage were prospectively investigated. 11 patients were treated with the beta-1-selective beta-blocker metoprolol (up to 200 mg/die intravenously). 14 patients received standard therapy as controls. Pulse rate, blood pressure and dosage of the additional antihypertensive medication as signs of sympathetic disturbance were registered. The main result was the normalizing of the pulse rate especially during the first two weeks in contrast to the control group. The patients in the beta-blocker group did not need further antihypertensive medication. This was mainly a result of the reduction in sympathetic activation. No severe side-effects were documented and the survival was better in the treated group. Thus, beta-blockade is able to prevent and reduce autonomic disorders, especially activation of the sympathetic tone, in subarachnoid haemorrhage. Metoprolol as a so called cardioselective beta-blocker seems to be one of the suitable agents and is considered superior to the non-selective agents.

Renin activation correlates with blood amount and distribution in subarachnoid haemorrhage

Blood extent and localization visible in CCT predicts complications and prognosis in patients suffering from subarachnoid haemorrhage (SAH). Plasma renin activity (PRA) elevation is one of the hormonal parameters of autonomic disorders after SAH and its prognostic relevance could be confirmed by this study, too. But the correlation of PRA with blood amount and distribution was the main target of this study. Large amounts of blood are connected with higher PRA-levels and more PRA-rises. Even a linear correlation between the amount of blood defined by a CCT-score and PRA in ng ml h-2 could be established. A significant correlation was found between intraventricular, suprasellar blood, ventricular enlargement of the third/lateral ventricles and PRA-elevations. Disorders of hypothalamic and/or medullary centres of sympathetic control are thought to be the underlying cause and to depend on blood extent and distribution.

Absence of elevation of big endothelin in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Endothelin peptides are potent vasoconstrictors and thus are seen as potential cause of cerebral vasospasm after subarachnoid hemorrhage (SAH). Earlier reports showed elevated or normal endothelin levels in plasma and cerebrospinal fluid in patients suffering from SAH. The present study was designed to determine whether endothelin is a causal factor in SAH.

METHODS

We studied 11 patients with acute SAH. Seven of these 11 patients had a proven aneurysm and six had experienced vasospasm. Big endothelin levels were determined by a radioimmunoassay recognizing the C-terminal peptide (normal range, 1-11 fmol/ml).

RESULTS

There were no elevations of big endothelin in the 59 plasma samples and the 17 simultaneously estimated cerebrospinal fluid samples. Differences between plasma and cerebrospinal fluid did not reach significant levels. Big endothelin values between patients with and without vasospasm showed no significant differences.

CONCLUSIONS

Our findings suggest that plasma elevation of the endothelins is not reproducible in SAH and that big endothelin is unlikely to be a causal plasma factor in the complex multifactorial development of vasospasm after SAH.

[Brain metastases as an initial manifestation of tumor disease]

A retrospective study compared a group of 122 patients with brain metastases from unknown primaries with a second group of 121 patients, who developed brain metastases in the course of a known malignant disease. Special attention was paid to the kind of primary cancer, therapeutic influences and prognostic differences. The results pointed to a late occurrence of brain metastases in breast cancer, no patient with this type of cancer being found in group 1. Melanoma and colorectal cancer were also found predominantly in group 2, whereas lung cancer was the most common cause of metastasis in group 1 and the most frequent cancer in both groups. Clinical course, therapy and outcome showed no significant differences between the two groups. Mean survival time was 4.6 (+/- 6) months for the patient series as a whole. Patients with breast cancer had a significantly higher survival rate than those with other forms of cancer. Localisation and degree of malignancy mainly determine the life-prognosis, the type and intensity of therapy being of secondary importance.

[Neurologic complications of malaria infection]

Infections with malaria are increasing in Europe and Northern America and are also spreading in tropical endemic areas. A falciparum variety of malaria known as cerebral malaria is the most well-known neurological complication, caused by Plasmodium falciparum and characterised by a fulminant course with disturbances of consciousness and facultative seizures or focal neurological deficits. 50% of deaths caused by malaria are due to cerebral involvement. Pathologically a disseminated vasculomyelinopathic disorder is seen. Immunological changes, vascular-hypoxic disturbances and metabolic-toxic factors contribute to these pathological findings. Facts on diagnostic, differential diagnostic and therapeutic procedures are presented. Beside the severe and life-threatening cerebral malaria some unspecific cerebral symptoms are seen, such as cerebellar ataxia and chorea. Spinal disease and peripheral nerve involvement, polyradiculitis and especially psychiatric disorders have also been described. Every neurological and psychiatric disorder presented first in tropical areas or malaria-endemic regions requires malaria diagnostic tests. In our geographical region, any previous history of a journey to the tropics is an important pointer; in particular, neurological or psychiatric symptoms can be important pointers to malaria.

Spastic disorder in patients with hereditary multiple exostoses, but without spinal cord compression: a new syndrome?

We describe a 37 year old man with a history of a gait disorder which had been worsening over a period of three years. Clinical examination showed the typical signs of a spastic tetraparesis with increased tone of all the extremities. Sensation, autonomic and cerebellar functions were not disturbed. Multiple exostoses had been present since early childhood, but none had been found in the spine or the cranium to cause the tetraspastic disorder. MRI scan was normal. Pedigree analysis of four generations showed that other family members were affected by both disorders. Chromosomal analysis was normal. We consider this to be a previously unknown hereditary syndrome transmitted as an autosomal dominant and manifesting a combination of spastic tetraparesis and multiple exostoses.

[A personal computer-based system for online monitoring of neurologic intensive care patients]

In the management of neurological intensive care patients with an intracranial space-consuming process the measurement and recording of intracranial pressure together with arterial blood pressure is of special interest. These parameters can be used to monitor the treatment of brain edema and hypertension. Intracranial pressure measurement is also important in the diagnosis of the various subtypes of hydrocephalus. Not only the absolute figures, but also the recognition of specific pressure-patterns is of particular clinical and scientific interest. This new, easily installed and inexpensive system comprises a PC and a conventional monitor, which are connected by an AD-conversion card. Our software, specially developed for this system demonstrates, stores and prints the online-course and the trend of the measurements. In addition it is also possible to view the online-course of conspicuous parts of the trend curve retrospectively and to use these values for statistical analyses. Object-orientated software development techniques were used for flexible graphic output on the screen, printer or to a file. Though developed for this specific purpose, this system is also suitable for recording continuous, longer-term measurements in general.

[Basilar aneurysm in the cerebello-pontine angle. Case report with review of the literature]

The importance of vascular lesions in the cerebello-pontine angle is discussed with reference to a case report of a basilar artery aneurysm with typical clinical signs of cerebello-pontine angle lesion. A review of 29 cases of aneurysms with cerebello-pontine angle syndrome is given. The presented case is the twelfth reported basilar artery aneurysm in this region with the typical clinical syndrome.