Zinc and its specific transporters as potential targets in airway disease

The dietary group IIb metal zinc (Zn) plays essential housekeeping roles in cellular metabolism and gene expression. It regulates a number of cellular processes including mitosis, apoptosis, secretion and signal transduction as well as critical events in physiological processes as diverse as insulin release, T cell cytokine production, wound healing, vision and neurotransmission. Critical to these processes are the mechanisms that regulate Zn homeostasis in cells and tissues. The proteins that control Zn uptake and compartmentalization are rapidly being identified and characterized. Recently, the first images of sub-cellular pools of Zn in airway epithelium have been obtained. This review discusses what we currently know about Zn in the airways, both in the normal and inflamed states, and then considers how we might target Zn metabolism by developing strategies to monitor and manipulate airway Zn levels in airway disease.

[Primary loss of consciousness and amnesia in subarachnoid hemorrhage--a quantitative study]

Subarachnoid hemorrhages (SAH) being sudden events affecting the brain in a rather wide-spread fashion are apt to induce loss of consciousness (LOC) and amnesia. The aim of the present study was to collect data on their frequency and extent. To this end we examined 48 patients at a mean of one year post-onset. Two thirds of them reported anterograde and an additional 17% retrograde amnesia; in 40% LOC (median 6 minutes) was observed. The durations were extremely skewed towards shorter times with a median of 2.7 days for anterograde and 1.3 days for retrograde amnesia who--with a single exception--were markedly shorter than anterograde amnesia. Summing up, a significant proportion of all SAH suffered LOC and amnesia occurred in the majority of cases. SAH therefore are events which with respect to LOC and amnesia bear some resemblance with closed head injuries. Exact observation and history taking may disclose important data on their severity and possible sequelae.

Disease latency in Creutzfeldt-Jakob disease via dural grafting: a case report

The case of a 57-year old man is reported who had been operated upon for cerebellar angioblastoma more than 19 years previously. Having received a lyophilized dural patch he developed Creutzfeldt-Jakob disease of which he died 19 months later. This is the longest latency with dura-associated Creutzfeldt-Jakob disease reported so far.

A nonimpact article about nonimpact injury

If reports of this caliber are required to insinuate that significant "brain damage" may ensue from rather mild nonimpact injury, there is some a priori reason to believe that this is not the case. The introduction of security belts, head rests, side-impact protection, and air bags has made driving safer; yet, the incidence of "brain injury" is allegedly rising. To definitely settle this issue, we will have to wait for other, preferably prospective, randomized, double-blind studies yielding a higher class of evidence. So, what do we learn from this study? First, in the United States, it is possible to select a sample of litigants that after a car accident or similar injury behaves and complains the way they did, even if there was no proof of morphological brain damage. Second, reports like this headed by a misleading title should better go unpublished until certain minimal standards of scientific scrutiny are met.

Recognition of familiar handwriting in stroke and dementia

Patients with left stroke (n = 17), right stroke (n = 16), and dementia (n = 17) and healthy controls (n = 15) were asked to recognize familiar handwriting among 10 handwritten texts. All healthy controls and 96% of the left-brain-damaged patients were able to recognize the familiar handwriting, but only 44% of the right-brain-damaged and 41% of the dementia patients (none if Mini-Mental Status Test score was <18, n = 5) were able to do so. The authors conclude that the recognition of handwriting is a special skill that is independent of other verbal and lexical tasks.

New variant or iatrogenic? A response to Streichenberger et al. [Acta Neuropathol (2000) 99:704-708]

Evidence is presented that the reported case may not be a new variant sensu strictiori as suggested but rather a iatrogenic case transmitted by corneal transplant or tonometry.

Ultrasonography for the evaluation of forearm interosseous membrane disruption in a cadaver model

Recognition of interosseous membrane disruption associated with radial head injury and Essex-Lopresti injury is important, especially if radial head excision is contemplated. Because a widely accepted method to diagnose interosseous membrane disruption does not exist, we evaluated the accuracy of ultrasonography to diagnose this injury in a cadaver model. Nine pairs of cadaver forearms were randomized into 2 groups. The central third of the interosseous membrane of forearms of group 1 was cut, whereas it was visualized but not cut in group 2. A dynamic ultrasound examination was performed to determine interosseous membrane integrity, and static images were made. The static images were evaluated by 2 other radiologists and interpretations were recorded. One radiologist incorrectly interpreted 1 pair of forearms; the other 2 radiologists were 100% accurate. The accuracy of ultrasonography in detecting interosseous injuries was 96% with our methods.

[Cerebrovascular circulation from a clinical view. Historical review, physiology, pathophysiology, diagnostic and therapeutic aspects]

Strokes have been known since ancient times. Today, stroke is the second most frequent cause of death and the most frequent cause of invalidity. In about 80% of cases, stroke is caused by cerebral ischemia and in about 20% by intracerebral hemorrhage, subarachnoidal hemorrhage, venous thrombosis and other cerebrovascular diseases. The brain is one of the most richly perfused tissues and depends fundamentally on the supply of oxygen and glucose. In order to assure adequate cerebral blood flow, the brain is capable of autoregulation through the interaction of diverse autoregulatory mechanisms (myogenic, neurogenic and metabolic factors, blood viscosity, renin-angiotensin-system and endothelium). Reduction of cerebral blood flow below the threshold of about 25 ml/100 g x min leads to an impairment of the functional metabolism and later to impairment of the structural metabolism. Pathophysiologically, a large number of isolated pathobiochemical processes (loss of energy, lactate acidosis, excitating amino acid release, ion balance disorders, calcium overload, free radical release, etc.) start to interfere with each other. Delayed edema and inflammation lead to secondary brain damage. Apoptosis is probably induced by ischemia and can cause secondary deterioration. The basic principles in the treatment of ischemia are firstly the rapid restoration of cerebral blood flow (lysis, carotid endarterectomy) and secondly--following infarction--a limitation of brain damage (preservation of ischemic but not necrotic brain tissue, prevention of secondary complications). Stroke treatment requires profound diagnostic and therapeutic expertise and interdisciplinary cooperation of neuroradiologists, neurosurgeons, vascular surgeons and cardiologists. Stroke can best be managed in special "stroke units", which have now been established in nearly all parts of Germany. Beside acute management of stroke and neurological rehabilitative treatment, emphasis has to be laid on primary (public information, education, treatment of risk factors) and secondary prophylaxis (treatment with antiaggregants, anticoagulants, a. o.).

The use of neuroimaging techniques for clinical detection of neurotoxicity: a review

Although toxins exert their impact on a molecular level, they may yield molar effects by affecting areas large enough to be visualized by neuroimaging techniques. Therefore, neuroimaging of the brain may be used to render the macroscopic sequelae of neurotoxins visible. Toxic agents may induce brain edema or atrophy, demyelination, infarctions, calcifications, hemorrhages, or changes of perfusion, metabolism or receptor density. Although they do not readily disclose their nature, clues as to the offending agent may in some instances be gleaned from the pattern, distribution, and appearance of the cerebral changes. Intoxication, however, has always to be proved or substantiated independently by appropriate means. This paper deals with the extent and certainty to which conclusions as to some of the most common offending substances may be drawn from pictures of the brain.

[Olfactory testing with "sniffin' sticks" for clinical diagnosis of Parkinson disease]

Olfactory dysfunction seems to be one of the most frequent symptoms in idiopathic parkinsonian syndrome (IPS). In contrast to the increasing number of studies providing evidence of the usefulness of olfactory tests in the diagnosis of IPS, clinical assessment of olfactory function is rarely performed. This may be due to the lack of an easy-to-use, inexpensive, standardized, and reliable test. In this study, we administered the newly developed "sniffin' sticks" test to a group of 40 nondemented IPS patients and compared the results with 40 healthy controls matched for age, gender, and smoking habits. In all three subtests including odor identification, odor detection threshold, and odor discrimination, the control group scored significantly better than the IPS group, yielding a specificity and sensitivity of 90% each. Our results indicate that olfactory disturbances in IPS can be found at early stages of the disease, appear bilaterally, and do not correlate with the dominant side of parkinsonism. Therefore, we emphasize that olfactory testing may be a useful tool in the diagnosis of IPS.

Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization

OBJECTIVE, PATIENTS, AND METHODS: A severe case of cerebral air embolism after unintentional central venous catheter disconnection was the impetus for a systematic literature review (1975-1998) of the clinical features of 26 patients (including our patient) with cerebral air embolism resulting from central venous catheter complications.

RESULTS

The jugular vein had been punctured in eight patients and the subclavian vein, in 12 patients. Embolism occurred in four patients during insertion, in 14 patients during unintentional disconnection, and in eight patients after removal and other procedures. The total mortality rate was 23%. Two types of neurologic manifestations may be distinguished: group A (n = 14) presented with encephalopathic features leading to a high mortality rate (36%); and group B (n = 12) presented with focal cerebral lesions resulting in hemiparesis or hemianopia affecting mostly the right hemisphere, with a mortality rate as high as 8%. In 75% of patients, an early computed tomography indicated air bubbles, proving cerebral air embolism. Hyperbaric oxygen therapy was performed in only three patients (12%). A cardiac defect, such as a patent foramen ovale was considered the route of right to left shunting in 6 of 15 patients (40%). More often, a pulmonary shunt was assumed (9 of 15 patients; 60%). For the remainder, data were not available.

CONCLUSION

When caring for critically ill patients needing central venous catheterization, nursing staff and physicians should be aware of this potentially lethal complication.

Recall and recognition in Huntington's disease

We assessed 19 patients with Huntington's disease (HD) at early to moderately advanced stages of their disease using memory tests that investigated verbal and visual recall and recognition. In those tests where identical material was subject to recall and recognition the standardized results (z scores) were lower for recognition. Performance was better with pictorial than with verbal material. While recognition bias and savings scores did not differ significantly from controls, all other recognition parameters did so. This is in contrast to the claim that defective retrieval in HD is greatly enhanced by multiple choice recognition. One major reason for maintaining this assumption was apparently the disregard of false-positive responses. Our results indicate that verbal and visual recognition are impaired in HD, and the notion of a salient deficit of free recall is not supported.

Longitudinal study of neurotoxicity with occupational exposure to aluminum dust

Two cross-sectional studies were conducted at a German aluminum (Al) powder plant to evaluate possible nervous system effects from occupational Al exposure. The investigation included biological monitoring, a neuropsychological test battery, and event-related P300 potentials. Neurophysiologic findings in workers chronically exposed to Al dust did not differ from non-Al-exposed controls from the same plant. The authors suggest that chronic exposure to Al dust, at the levels documented in this study, does not induce measurable cognitive decline.

Sesamoiditis of the index finger presenting as acute suppurative flexor tenosynovitis

Sesamoiditis involving the hand is uncommon, usually reported in the thumb, and has not been reported in the index finger. As rare as this clinical entity remains, its presentation simulating an acute suppurative flexor tenosynovitis is even more rare. We report a patient who presented with Kanavel's 4 cardinal signs of acute suppurative tenosynovitis who was subsequently found to have an acute sesamoiditis of the index finger. This finding was supplemented by a cadaveric and radiographic study to better delineate the anatomy of the index sesamoid and further explain the clinical presentation.

[Dementia of the Alzheimer type in women]

Within the different kinds of dementia, Alzheimer's Disease (AD) obviously is the only one showing relevant gender differences, concerning epidemiology, risk factors and cognitive deficits. Women more often suffer from AD, achieve lower Mini Mental Status Test scores when demented and show lower verbal skills. The possibility of using estrogen as a therapeutic agent, either only or as an augmentation to acetylcholinesterase inhibitors, could become more important for clinical practice, as it is said to cause distinct improvements of cognitive skills. Epidemiological studies were able to show that estrogen replacement therapy in menopausal women lowers risk of AD.

Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients

To study the functional outcomes of patients with cervical herniated intervertebral discs with radiculopathy but without signs of cervical myelopathy using a retrospective cohort study design. The patients were retrospectively identified by chart reviews. Inclusion criteria were (a) cervical radiculopathy with defined neurological disturbances (sensory disorder, reflex abnormalities, and motor weakness); (b) a spinal computed tomograph scan or magnetic resonance image demonstrating neuroradiologic abnormalities (soft or hard disc); and (c) completion of conservative physical and pharmacological treatment. Of 119 consecutive patients who were treated at the Departments of Neurology and Neurosurgery, University of Erlangen-Nuremberg, between January 1, 1985, and December 31, 1995, 60 patients met the inclusion criteria and were prospectively assessed, with an average follow-up time of 5.5 years. The patients were interviewed with regard to their daily activities, ability to work, and the surgical treatment they had undergone. A complete neurological examination also was performed. In 88.3%, the onset of disease was acute and in 11.7% subacute or chronic. The most common signs and symptoms were brachialgia (98.3%), neck pain (93.3%), sensory disorders (88.3%), reflex abnormalities (61.7%), and motor weakness (51.7%). The neuroimaging procedures demonstrated a disc prolapse (soft disc) in approximately 90% and spondylotic osteophytes (hard disc) in approximately 10%. During an average follow-up time of 5.5 years (range, 4.6 months-10.6 years) 39 (65%) patients had been treated using only conservative methods (COG = conservatively treated group), and 21 (35%) patients had undergone surgery (ventral discectomy) (SUG = surgically treated group). Brachialgia was completely or essentially improved in 100% of the COG and 95.1% of the SUG. Sensory disorders remitted completely or markedly in 97% of the COG and 75% of the SUG. The reflex abnormalities normalized or improved in 59.2% of the COG and in 53.3% of the SUG. Motor weakness improved in 94.1% of the COG and in 50% of the SUG. Neck pain was difficult to treat. It improved in only 36.1% of the COG and in 20% of the SUG. Occupational capacity was lost in 10% of the COG and in 38.9% of the SUG. In a self-rating scale, 89.7% of patients in the COG did not feel disabled in their everyday activities, compared with 66.7% of the patients in the SUG. Patients with a herniated cervical intervertebral disc with radiculopathy can be treated conservatively with good results, although a residual intermittent neck pain syndrome often persists. The patients in the SUG, who initially showed more severe and long-lasting neurological disturbances, were improved at the time of examination, although with more marked residual disorders. Surgery is indicated only when appropriate conservative treatment for a reasonable time has failed.

Visually guided exploration in Huntington disease

We compared 24 patients in various stages of Huntington disease (HD) with 26 control patients free from cerebral disorders using a simple visual saccadic tracking test. The two groups were well matched in regard to age, sex, verbal IQ and years of schooling. Test results differed widely. On a time versus error plot, sensitivity (96%) and specificity (100%) were high and the results did not depend on age, education, or disease duration, although an influence of disease stage could be observed. This study shows that a simple saccadic tracking task may be useful in detecting visuomotor disturbances in HD.

Palmar (displaced) fracture of the proximal index metacarpal

A patient sustained a fracture of the ulnar side of the proximal end of the second metacarpal. The fragment was completely displaced into the palmar soft tissues. Open reduction was necessary.

A biomechanical study of the ankle syndesmosis after fibular graft harvest

Harvesting the fibula as corticocancellous bone graft is not without complications. Multiple clinical studies chronicled the morbidity at the donor site, both immediately after surgery and at long-term follow-up. To our knowledge, no cadaveric or biomechanical studies addressed the effect that fibular osteotomy has on the ankle syndesmosis. We carried out two experiments by using cadaveric tibias/fibulas to determine the ability of the ankle syndesmosis to resist both lateral and vertical displacement of the intact fibula, as well as lateral and vertical displacement of the distal fibular stump after serial fibular osteotomies had been made at distances of 14, 10, 6, and 4 cm from the tip of the lateral malleolus. The results of this study show that, once the fibula is cut, the syndesmosis provides significantly less resistance to lateral and vertical displacement. Further, although this resistance continues to decrease with each decrease in fibular stump length, the length of the fibular stump does not significantly affect the stability of the syndesmosis.

Creutzfeldt-Jakob disease via dural and corneal transplants

A review of all published cases of iatrogenic Creutzfeldt-Jakob disease (CJD) via dural (N=71) and corneal (N=4) transplants is given. All but three of the dural cases were obviously due to a commercial product recalled in 1996. Two of the corneal grafts were taken from patients who had died of sporadic CJD. These cases differed from CJD due to human growth hormone injections and the new variant. Instead. they were akin to sporadic cases, but memory loss, disorders of higher cerebral functions and extrapyramidal signs were fewer, while cerebellar abnormalities were more frequent. Progressive dysarthria and gait disorder/gait ataxia were prominent signs during the early stages, myocloni the most salient feature later. A nonperiodic EEG did not contradict the diagnosis. Using current diagnostic criteria the disease was underdiagnosed ante mortem. Utmost care is needed in selecting, harvesting and handling dural and corneal grafts to avoid inadvertent transmission of CJD.

Apnea testing guided by continuous transcutaneous monitoring of partial pressure of carbon dioxide

OBJECTIVE

To continuously monitor PCO2 during two different protocols for apnea testing as part of the determination of brain death.

DESIGN

Prospective comparative study using continuous transcutaneous PCO2 (tcPCO2) monitoring in 54 apnea tests with or without artificial CO2 augmentation. Another 53 apnea tests were not continuously monitored.

SETTING

Intensive care wards in Northern Bavaria.

PATIENTS

Ninety-six consecutive patients with suspected brain death.

INTERVENTIONS

Apnea tests guided by transcutaneous monitoring during a PaCO2 of > or = 60 torr (> or = 8 kPa).

MEASUREMENTS AND MAIN RESULTS

The mean of the difference between tcPCO2 and PaCO2 was -0.26 +/- 1.16 (SEM) torr (-0.035 +/- 0.15 kPa). Seventy percent of all transcutaneous measurements were within +/-10% of the PaCO2 values. The individual differences ranged from -25.8 to 16.9 torr (-3.44 to 2.25 kPa).

CONCLUSIONS

While not as precise as could be desired in individual cases, the overall agreement between tcPCO2 and PaCO2 was good. Transcutaneous monitoring aided in effectively reducing the CO2 target overshoot with artificial CO2 augmentation, reduced the necessary number of blood gas checks compared with a former study, using predetermined time-locked evaluations, and prolonged only tests with artificial CO2 augmentation.

Chemosensory event-related potentials in response to trigeminal and olfactory stimulation in idiopathic Parkinson's disease

Decrease of olfactory function in patients with Parkinson's disease (PD) has been reported by several authors. The current study investigated olfaction in PD patients using olfactory event-related potentials (OERPs) as an electrophysiologic correlate of olfactory function in combination with psychophysical testing. A specific focus was the influence of antiparkinsonian drugs. We investigated PD patients treated with antiparkinsonian drugs (n = 13) and PD patients who received no pharmacologic treatment (n = 18). They were compared to age- and sex-matched control subjects (n = 38). To obtain OERPs, stimulants were chosen to stimulate specifically the olfactory nerve (2.1 ppm vanillin, 0.8 ppm H2S). In addition, chemosomatosensory event-related potentials were recorded after trigeminal stimulation with 52% v/v CO2. Moreover, the subjects' ability to identify and to discriminate odorants was tested by means of a "squeeze bottle" technique. The study yielded the following major results: (1) Odor identification was impaired in PD patients. It was not influenced by treatment with antiparkinsonian drugs. (2) The OERP latencies were prolonged in both PD patients taking and not taking antiparkinsonian drugs; however, this effect was more pronounced in PD patients taking antiparkinsonian drugs. (3) The intranasal chemosensory trigeminal system seemingly was neither affected by the neuronal degeneration seen in PD nor by treatment with antiparkinsonian drugs.

Transmission of Creutzfeldt-Jakob disease via a corneal transplant

A 45 year old woman is reported who initially presented with a cerebellar syndrome, severe ataxia, and dysarthria. She rapidly deteriorated to coma vigile with bilateral myoclonic jerks, flexion rigidity, and immobility necessitating complete nursing. Her EEG showed generalised slow activity and periodic biphasic and triphasic waves. The CSF concentration of neuron specific enolase was very high. Consequently the diagnosis of Creutzfeldt-Jakob disease was established. Eight months later she died of respiratory complications. Thirty years earlier the patient had undergone corneal transplantation for keratoconus. Review of the organ donor's hospital records showed that death was caused by intercurrent pneumonia subsequent to subacute spongiform encephalopathy confirmed by necropsy. In view of two previous case reports in the literature it is presumed that the cadaveric cornea was the source of transmission of Creutzfeldt-Jakob disease in this patient.

Blood pressure and heart rate changes during apnoea testing with or without CO2 insufflation

OBJECTIVE

To determine changes of blood pressure and heart rate during apnoea testing for brain death without (A) and with (B) artificial CO2 augmentation.

DESIGN

Prospective, consecutive study.

SETTING

12 intensive care units in six towns in Northern Bavaria.

PATIENTS AND PARTICIPANTS

A total of 55 apnoea tests were performed on 55 consecutive patients as part of the determination of brain death, 27 without and 28 with CO2 augmentation.

INTERVENTIONS

Apnoea tests following oxygenation with 100% O2 either after reduction of ventilatory volume (A) or after insufflation of CO2 during normoventilation (B). In each case, an arterial partial CO2 pressure of at least 8 kPa was documented.

RESULTS

All apnoea tests were without serious adverse effects (hypoxia, newly induced cardiac arrhythmia, cardiac asystole). An increased dopamine infusion rate was deemed necessary in only one case of group (A) because of marked systolic hypotension (< 8 kPa). Individual variation of systolic and diastolic blood pressure (BP) did not exceed + 62 to -46% and + 49 to -52% respectively, in group (A) and + 35 to -57% and + 40 to -48% respectively, in group (B). Variation of heart rate (HR) remained within the range + 24 to -31% in group (A) and + 37 to -22% in group (B).

CONCLUSIONS

HR varied less than BP. The possibility of a marked relative rise of fall of BP in group (A) was equal; in group (B) there was a lower change of rising BP. The chances for a rise or fall in HR were equal for the two groups. There was a tendency for less variation of cardiovascular parameters in group (B).

[Diagnosis of brain death in the admission department of the Neurologic Clinic of Erlangen University from 1984 to 1994]

OBJECTIVE

The reliable diagnosis of brain death is a precondition of organ removal for subsequent transplantation. As demographic data, information on the underlying cause and written consent to organ removal from brain-dead patients are largely unknown; protocols relating to the determination of brain death were analysed to obtain these data.

PATIENTS AND METHODS

The study was based on an examination of the protocols of 547 consecutive and unselected patients who between 1984 and 1994 had been examined for possible brain death by experienced members of the Neurological Department of Erlangen University, in consequence of the establishment of a consultation service for this purpose to hospitals in the region of North Bavaria. The criteria of brain death were those established by the Federal German Doctors' Chamber, all the data in the written protocol being analysed retrospectively.

RESULTS

Brain death was confirmed in 521 patients (319 males, 202 females; mean age 40.1 [1.5 - 84] years). 473 patients (86.5%) had been examined at the Erlangen University Clinic or the Municipal Hospital in Nuremberg, the remainder in regional hospitals. The most common causes were trauma to the head/brain (43.5%), subarachnoid haemorrhage (18.6%), generalised hypoxaemia (9.5%), cerebral infarction (7.3%) or other conditions (4.5%). 33 patients (6%) had committed suicide. Organs were removed in 244 of 413 patients (59.1%) for whom there data on possible organ removal: seven patients had carried donor cards, relatives' consent was obtained in 237. No consent was given in 90 cases (21.8%), while 79 (19.2%) were excluded for medical reasons.

CONCLUSION

If brain death is suspected, an experienced neurological consultant should be called in as soon as possible to assess the patients survival chances and evaluate possible organ removal for subsequent transplantation.

A case of Alzheimer's disease with extensive focal white matter changes

The case of a patient is reported who suffered from disturbed concentration and memory and constructive apraxia. She had only mild neuropsychological deficits at the first examination. T2-weighted MRI presented extensive focal white matter changes. A brain biopsy showed changes typical for Alzheimer's disease (AD). The extent of the white matter lesions was surprising compared to the mild clinical signs she had. This case confirms that AD may result in prominent white matter disease caused by incomplete infarction or demyelination.

Apnea testing by artificial CO2 augmentation

We used artificial augmentation of CO2 at a rate of 1 l/min after preoxygenation with 100% O2 to test for apnea in 34 patients with suspected brain death. Observation time was markedly reduced compared with conventional apneic oxygenation, allowing PaCO2 levels > or = 60 mm Hg to be reached within 2 minutes. Properly administered, CO2-supported apnea testing is quick, requires only simple technical equipment, and does not unduly lower PaO2 or pH. It seems to be a useful alternative in cases where reduction of ventilatory volume is not wanted.

Methodological problems and clinical relevance of structural neuroimaging in dementia research

Structural neuroimaging and dementia are conceptually different being only loosely correlated. Computed tomography or magnetic resonance imaging can never "prove" a clinical syndrome such as dementia, but yield clues as to its cause and the site and extent of pathological changes. Conversely, the type and degree of intellectual deterioration can hardly predict neuroradiological findings. The value of structural neuroimaging lies in detecting or excluding possible causes of dementia and quantifying linear or volumetric parameters of tissue and fluid volume. If based on a presumed or established etiology, however, specific neuropsychological and dementia syndromes may correspond to focal pathological changes seen in well-defined cerebral areas as recent investigations have shown with hippocampal atrophy in Alzheimer's dementia.

Probable Creutzfeldt-Jakob disease after a cadaveric dural graft

A 26-year old female who had received a cervical cadaveric dural graft 7 years earlier developed psychotic behavior and generalized myoclonic jerks. Following rapid deterioration and appearance of high-charge sharp periodic waves on electroencephalography she died within two months. We believe that this patient is the first German who acquired Creutzfeldt-Jakob disease by dural implant.

Intraneural ganglion of the sciatic nerve: detection by ultrasound

Images

[Recognition of familiar handwriting after left hemisphere and right hemisphere brain damage]

The recognition of handwriting is a specific achievement of the brain which need not be connected to understanding the written text itself. The goal of this study was to determine how this ability is impaired in patients with left- or right-sided lesions. Seventeen aphasic patients with lesions in the left hemisphere, 16 patients with lesions in the right hemisphere, and 15 normal controls (without CNS illness or damage) were investigated. They were asked to recognize the handwriting of a person well-known to them among a sample of ten different handwritten texts. The aphasic patients were able to recognize the handwriting of the familiar person either immediately or after some delay in 96%, the non-aphasic patients in only 44%, and the healthy controls in 100% of the cases. Results indicate that the recognition of handwriting represents a specific achievement which is independent of other verbal and lexical tasks. It is a task which involves the recognition of figural, geometric spatial patterns and, thus, an achievement of the non-dominant hemisphere.

Continuous figure recognition in dementia and unilateral cerebral damage

By means of continuous figure recognition (CFR) using visual pictorial, geometric and nonsense material demented patients could easily be distinguished from vascular controls without dementia and healthy subjects. In cases of infarction in the territory of the middle cerebral artery the hemisphere affected was only a minor determinant of overall scores. Within aphasics there was a tendency for the CFR results to reflect the severity of aphasia being most severely impaired in global aphasics. When aphasics and other cerebrally impaired patients, judged clinically to suffer from memory impairment, were considered as a group, CFR performance was lower than in those without apparent memory problems for the pictures only. It is concluded that CFR is a sensitive indicator of defective memory and/or gross brain lesions and that it is relatively independent of linguistic mediation.

Controlled trial of azathioprine and cyclosporin to prevent anti-HLA antibodies due to third-party transfusion

The beneficial effect of elective transfusion on renal allograft survival must be weighed against the risks of sensitisation. We report a randomised controlled trial in which patients in end-stage renal failure who were non-parous and not previously transplanted or transfused, were entered in a transfusion protocol during which one group received no drugs (controls), one received azathioprine, and one received cyclosporin. Each group was given three identical transfusions of leucocyte-enriched fresh blood at 2-3 week intervals. The transfused blood was of known HLA type and donor/recipient pairs were completely mismatched. Sensitisation rates were assessed by T and B cell cross-matches between donor and recipients and by the screening of all sera against lymphocytes from 40 random donors. Fifty-one patients have completed the protocol, 20 in the control group, 12 in the azathioprine group, and 19 in the cyclosporin group. The sensitisation rate in the control group was 30%, occasionally of high titre, and persistent. In the azathioprine group, 25% developed anti-HLA antibodies and reactivity was of high titre and was broadly specific. Sensitisation in the cyclosporin group was 10%, was narrowly specific, reacting with only 10% of a panel, and was transient. There was no difference in graft survival between the groups. We conclude that cyclosporin therapy concurrent with third-party transfusion reduces the incidence, titre, and duration of sensitisation.