[Further therapeutic possibilities with valproic acid (Convulex)]

Valproic acid is used in first case as an antiepileptic; own clinical observance and references from the literature show other indication-fields outside of the group of cerebral fits; so Convulex was employed successfully also in the therapy of perioral dyskinesia of variable etiology and in the medical treatment of therapy-resistant pains within the bounds of Polyneuropathy-Polyneuritis Syndrome. Our own experience is presented by the description of the 10 case histories.

[The cerebral angiogram in patients with complicated migraine]

38 patients (mean age: 29 years) were investigated by means of complete 4-vessel angiography: all of them were suffering from complicated migraine without detectable vascular malformation. Stenoses of the great craniocervical vessels were found in 11 patients (28.9%), but there was not a single case of vascular occlusion. A correlation between the localization of the stenosis, the localization of the headache and the presumed region of the transient cerebral function disturbance was found only in a few patients. Concerning the morphological changes of the small intracranial arterial branches, there was hardly any difference between clinically affected and non-affected territories of the middle cerebral artery. The angiograms of the 38 cases of complicated migraine were compared with the angiograms of 40 patients suffering from strokes in the young and those of 49 patients with transient ischaemic attacks. There were remarkably fewer stenoses or occlusions in the great craniocervical arteries of patients suffering from complicated migraine (28.9%) than in the vessels of cases of stroke in the young (52.5%). However, the incidence was comparable with the results in patients with transient ischaemic attacks (34.7%). The degree of morphological changes in the small intracranial arterial branches is likely to depend primarily on the patient's age and less on the diagnosis. The results suggest that in almost 30% of patients with complicated migraine-even at juvenile age-stenoses of the great craniocervical vessels might be found.(ABSTRACT TRUNCATED AT 250 WORDS)

Apraxia of the left limbs in a case of callosal disconnection: the contribution of medial frontal lobe damage

A 40 year old right-handed woman suffered hemorrhage from an anterior cerebral artery aneurysm. CT scan showed destruction of the anterior two thirds of the corpus callosum, both cingulate gyri, and the white matter underlying the medial frontal lobes. The left limbs displayed apraxia on verbal command, in imitation, and in actual object use. There were antagonistic actions of both hands, and the patient accused her left hand of disobeying her. We interpret the leftsided apraxia as resulting from a lack of interhemispheric transfer combined with a deficit in ipsilateral motor control stemming from damage to the left supplementary motor area. Right frontal lobe damage may have impaired the motor learning capacity of the right hemisphere and thus its ability to compensate for the lack of left hemisphere motor control.

[Cerebral angiography in complicated migraine--reactions, incidents]

Seventy-one patients (ages: 15-58 years) suffering from complicated migraine were investigated by means of cerebral angiography which was not performed during an attack. Angiography was carried out to exclude stenoses or occlusions of the cranio-cervical vessels and above all vascular malformations (arterial aneurysms, arteriovenous angiomas). In 18 cases (25.4%) organic lesions were found, including three vessel malformations (4.2%). Thirty-one patients (43.7%) suffered from headache reactions or other complications during or within 24 h following angiography. In 15 cases (21.1%) attacks of complicated migraine were observed, three patients (4.2%) suffered from headache and bilateral flickering visual disturbances, another 11 patients (15.5%) developed headache and vegetative symptoms requiring therapeutic management. One patient (1.4%) got an epileptic seizure, another patient (1.4%) developed a generalized urticaria exanthema. There were more headache reactions in women than in men. However, the highest percentage of reactions was observed in patients in whom migraine headache had occurred clearly set off from the transient cerebral functional disturbances. Neurological complications (transient functional disturbances) occurred in 16 of 71 patients (22.5%). The neurological complication rate was significantly (P less than 0.001) higher than that in an unselected group of patients (3.0%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Paroxysmal brain stem ischemia in a combination of thoracic outlet syndrome with contralateral subclavian steal syndrome]

Mechanical irritation of the right subclavian artery in the scalenus region and stenosis of the contralateral subclavian artery in combination with hypoplasia of the vertebral artery led to recurrent neurological symptoms in a 41 year-old female patient. Sudden loss of consciousness, episodes of dizziness, vomiting and paraesthesiae occurred as a result of manoeuvres involving turning the head and lifting the right arm. A significant blood pressure difference between both arms and a stenotic bruit were found. Angiography revealed the "subclavian steal syndrome" with stenosis of the left subclavian artery and hypoplasia of the left vertebral artery. On operation of the right scalenus region an atypically angled origin of the right vertebral artery was detected. After dissection of the scalenus anticus muscle and-in a second step-transaxillary resection of the first rib the patient has remained symptom-free for the past 24 months.

[Sarcoidosis of the nervous system. Clinical and diagnostic synopsis based on two cases]

This paper reports two cases of neurosarcoidosis . Initially the clinical picture involved only the nervous system. Later on manifestations pertaining to other systems were detected by interdisciplinary investigations. The resulting diagnostic problems, the value of additional investigations and the therapeutic management are discussed on the basis of the two presented cases.

[Polygraphic registration of spontaneous syncope]

A 29 year-old female patient suffered from a syncopal attack in the early morning hours. During polygraphic registration (ECG, EEG, pulse, breathing, blood pressure) on a tilt table she developed another spontaneous orthostatic syncopal attack, which was triggered off by a lengthy period of standing and was preceded by a drop in the recorded blood pressure. She was asystolic over 21 sec., the EEG did not show any bioelectric activity (with standard attenuation) over 22 sec. Within a short time she recovered fully from the clinical, as well as from the polygraphic point of view. The syncopal attack in this patient is discussed as being of the vagocardial type in connection with vagotonia. The original polygraphic data of the relevant period are presented.

[A chemically induced polyneuropathy in chronic polyarthritis treated with D-penicillamine?]

Polyneuropathy occurring during therapy with D-penicillamine is reported in a 63 year-old women with chronic rheumatoid arthritis. 6 weeks after recommending therapy with 500 mg D-penicillamine/day the patient developed bilateral oculomotor palsy and axonal peripheral neuropathy. The development of clinical symptoms was accompanied by the observation of high levels of antinuclear antibodies and antibodies against native DNA. The appearance of polyneuropathy after repeated administration of penicillamine, the regression of symptoms and the rapid decrease in antinuclear antibodies after discontinuation of the drug plus the absence of signs of a malignant form of rheumatoid arthritis show a remarkable correlation.

[EEG in phenytoin intoxication (author's transl)]

Four patients had Phenytoin intoxications, whereby 3 of them suffered from acute and one from subacute symptoms (in all of them reversible cerebellar symptoms and acute organic brain syndrome and in one of them an axonal polyneuropathy which lasted a bit longer). The clinic-neurologic symptoms, the Phenytoin blood levels and the current EEG changes were compared. Three patients had blood levels in a high toxic range, the fourth one had levels within the therapeutic range. The EEG changes of acute phase of intoxications showed in each case nonspecific mostly diffused slowing of the traces with theta- and delta-activity over the convexity (Tab. 1a, 2c, d). Although the EEG changes were reversible, they lasted longer than the clinical intoxication phase. These EEG changes were already manifest several days before the clinical symptoms. We feel therefore that the EEG examination is indicated especially in doubtful cases because it is easier to execute than the blood level estimation, - even though the changes are nonspecific. One case (Nr. 1), which was more closely explores, did not develop any epileptic fits, instead the fits were retrospectively seen as stemming from a psychogenic origin, which was treated with Phenytoin. The EEG of this patient showed generalised irregular SW-paroxyms (Tab. 1b) as the medication blood level was receding (120 muMol/l). This would be a manifestation of an independent Phenytoin effect in the high toxic dosage respectively in withdrawal.

[Report on the results achieved over the past 10 years in the neuro-orthopaedic out-patient department (author's transl)]

A short abstract of the pathophysiology of pain and its conduction is followed by a discussion of the importance of neurological-orthopaedic cooperation for the diagnosis and the treatment of pain syndromes arising from the locomotor apparatus. The examination of the spine from the functional, i.e. segmental point of view is pointed out. The main reflex answer of the spine to irritation is the restriction of movement or hypermobility. Therefore, neuro-orthopaedic reflex treatment consists of so-called "test treatment" by means of manipulation to overcome the restriction of movement or by local curative anaesthesia, or by a combination of both methods. The results over the past decade of treatment in 1008 patients suffering from various pain syndromes are presented and differentiated.

[Neurological signs in diphenylhydantoin intoxication (case reports and review) (author's transl)]

Five patients who were treated with long-term diphenylhydantoin for epilepsy developed neurological signs of poisoning. In 4 cases the symptoms appeared following treatment of status epilepticus with additional phenytoin medication. All patients had an acute symptomatic psychosis and a diffuse slowing of the curves in the EEG. All 5 patients showed cerebellar signs and two of them complained additionally of objective polyneuropathy, a third case complaining of itching only. An axonal polyneuropathy with minimal reduction in motor nerve conduction and a considerable extension of distal latency and diminution of compound action potential was found. In one case the biopsy showed concentric lamellar bodies coming from the axon, with intact myelin sheaths. All alterations were reversible. The pathogenesis of toxicity is discussed. Cumulation of toxic products in the plasma arising from delayed elimination of DPH metabolites is pointed out. However, one case with cerebellar signs had normal DPH levels.

[Correlation between clinical and angiographic findings in cases of transient cerebral circulatory disturbances (author's transl)]

The results are presented of angiographic investigations in 85 patients suffering from transient ischaemic cerebral circulatory disturbances. Transient ischaemic attacks (TIA) were observed in 45 patients, reversible ischaemic neurological defects of longer duration (PRIND) were diagnosed in 40 patients. The mean age of all patients at the time of angiography was 49.9 years. Transfemoral cerebral panarteriography was performed in all cases, including studies both of the aortic arch and of the cranio-cervical vessels. The mean interval between the first manifestation of cerebrovascular disease and angiographic investigation was approximately 2 years. 10.6% of all patients showed normal angiograms; in 35.3% of all cases diffuse vessel wall alterations were found; 37.6% showed minor stenoses (vessel diameter reduced to 80-34%), whilst 16.5% showed major stenoses (vessel diameter reduced to 33-1%) or occlusions. There was poor correlation between clinical-neurological localization of the ischaemic lesion and the angiographically-verified stenoses or occlusions. The angiographic findings corresponded to the clinically affected regions in only 52.2% of all patients suffering from stenoses of occlusions. A good correlation was found in 71.4% of the cases when only major stenoses and occlusions were evaluated. Consequently, angiographic studies of the aortic arch, as well as of all extra- and intracranial vessels are a precondition for the surgical treatment of the cranio-cervical vessels in every patient. It is possible by these means only to achieve a comprehensive assessment of the haemodynamic processes in the cerebral circulation.

[Clinical experience with daily doses of misonidazole (author's transl)]

In this pilot study daily low doses of misonidazole (in the range of 1 to 2 g) up to cumulative doses between 7 and 19 g/m2 were used. Serum levels were analysed at different times after administration and according to several dose regimens. We related the cumulative doses to the incidence and severity of the observed peripheral neuropathies. The aim was to find an effective daily low-dose schedule of misonidazole with a clinically acceptable incidence of side effects. Some impressive clinical responses were observed.

[Comparative results of neuropsychological investigations, computer tomography and electroencephalography in post-traumatic epilepsy (author's transl)]

Clinical-neurological and neuropsychological investigations, as well as cranial computerized tomography (CT) and electroencephalography (EEG) were performed in 33 patients suffering from verified post-traumatic epilepsy. The purpose of this study was to compare the neuropsychological test scores (dementia, psycho-organic syndrome, decreased vigilance) with the results of CT and EEG. There was no significant correlation between the neuropsychological scores and the EEG results. On the other hand, a significant correlation was found between decreased vigilance (measured by CFF) and the results of CT, both in the case of focal lesions or diffuse brain atrophy.

The value of CT and EEG in cases of posttraumatic epilepsy

The results of the clinical neurological investigation were compared with those of electroencephalography (EEG) and computed tomography (CT) in 64 patients suffering from verified posttraumatic epilepsy. Only 18 patients (28%) showed central neurological features with corresponding focal disorders on CT (15 cases) and EEG (11 cases). The combined application of both methods led to positive results in 94% on the part of at least one accessory examination. The clinical neurological investigation as well as the EEG and CT were normal in only 3 cases, although the traumatic etiology of epilepsy was beyond doubt. In addition to the clinical neurological investigation, EEG and CT are most important accessory examinations for the diagnosis and followup studies in cases of posttraumatic epilepsy.