Laufbandtherapie bei Patienten nach ischämischem Hirninfarkt

Treadmill training with body weight support was applied in 30 patients who had suffered an ischaemic stroke, with the goal of improving their independence in the activities of daily living (ADL). The following inclusion criteria were used: inability to walk (FAC-score 0 - 2); motor abilities (the ability to sit without support, a palpable muscle function of the hip extensors, abductors and the knee extensors in the affected leg); adequate cooperation, motivation and vigility; absence of muscle contractures which would affect gait; onset of therapy no later than one year after the incident. The average duration of treadmill training was 6,6 weeks. The patients' age was an average 68 years (48 - 82). 87 % of the patients were able to improve their gait within the Functional Ambulation Categories (FAC) scale. 60 % of the patients achieved the ability to walk independently without technical aid. Apart from improving their gait, the patients also attained significantly increased scores in the motor scale of the Rivermead Motor Assessment (gross function) and the motor part of the ADL scale of the Barthel Index (items 2 - 4) and the Functional Independence Measure (items 3 and 4). Treadmill training is establishing itself as an important therapeutic approach in gait rehabilitation with patients with acquired brain damage.

Prognostic value of lower limb motor evoked potentials for motor impairment and disability after 8 weeks of stroke rehabilitation--a prospective investigation of 100 patients

We investigated 100 patients with a one-sided, functionally relevant hemiparesis after stroke. Motor evoked potentials (MEPs) were obtained from the anterior tibial muscle four or more weeks after the insult as well as after an eight week period of inpatient rehabilitation. The MEP results were correlated with motor deficit, walking ability, and activities of daily living (ADLs). Patients with loss of MEP had lower scores on the Motricity Index (MI) both at the beginning and at the end of the rehabilitative treatment (p < 0.001) and also gained fewer points on the MI than patients with preserved MEP. This was the case even when analyzing the lower limb scores alone (p < 0.001 before treatment, p = 0.003 after eight week rehabilitation). When the MEP was preserved, patients were more likely to regain independence in walking (specificity 0.67, positive predictive value 0.96) and stair climbing (specificity 1.0, positive predictive value 1.0). Patients with preserved MEP also scored higher on global outcome scales such as Barthel Index (BI), Functional Independence Measure (FIM) and Glasgow Outcome Scale (GOS). However, these differences did not reach statistical significance (p > 0.05). According to our results, MEPs of the lower extremity are of predictive value for the rehabilitative treatment of patients in the postacute phase after stroke. This is especially true for the extent of the motor impairment and walking ability. The utilization of MEPs for prediction of future levels of disability and handicap is limited and only useful taking into consideration other clinical and diagnostic findings as well as the patients' cognitive, emotional and social state.

[Terson syndrome: a frequently missed ophthalmologic complication in subarachnoid hemorrhage]

The syndrome of intra-vitreous bleeding in association with subarachnoid hemorrhage (SAH) was first described by the French ophthalmologist Albert Terson. In the last 10 years, 31 articles describing 202 cases of Terson's syndrome (TS) were published. Only 3 out of the 31 were printed in non-ophthalmological journals. The findings of our prospective study underline the fact that too little attention is paid to TS in the early treatment of patients with SAH. Between 1/95 and 8/97, 89 patients with spontaneous SAH (7% of all admissions) were transferred to our hospital for post acute phase rehabilitation. Out of these, 13 patients (19 eyes) could be diagnosed with TS. This corresponds to an incidence of 14.6% of all patients with SAH (previous studies: 2-27%). However, only one patient had been correctly diagnosed with TS in the referring clinic. Early recognition of TS is of high importance since diminuation of visual acuity even to functional blindness, complicated in the bilateral case, can hamper the rehabilitative process considerably. Moreover, complications can lead to significant and irreversible damage, i.e. proliferative vitreo-retinopathy (PVR), retinal breaks, traction amotio, and cataract. Suspicion of TS is raised in either cooperative patients complaining of compromised visual acuity or in patients where funduscopy shows vitreous opacity. According to our results, visual evoked potentials (VEP) have only a limited role in diagnosis because of their low sensitivity. Not infrequently, however, VEP may point to accompanying optic nerve atrophy, thereby suggesting conservative treatment. Absolute indications for surgical interventions are PVR and its sequelae; relative indications are subjective visual impairment, impediment of rehabilitation, or lack of spontaneous resorption of the hemorrhage. The surgical procedure of choice is the pars plana vitrectomy (PPV). Rare complications of this operation are retinal damage, endophthalmitis, and reoccurrence of hemorrhage.

[CT-guided manual afterloading with 198-gold seeds in intracerebral tumors]

Interstitial brachytherapy of intracerebral tumours was stimulated through the introduction of computed tomography and afterloading technique. Biopsies for their histologic verification as well as the stereotactic implantation of plastic tubes and adjusted to the extent of the tumour can be carried out with a high degree of exactitude by means of CT-supported localization and puncture. The small-sized 198-gold seeds are then introduced according to the manual afterloading technique and remain in situ until the planned dose in the target volume of 50 Gy is achieved. Report on our manual afterloading brachytherapy in high-grade astrocytomas III and IV and in adenomas of the hypophysis. Indications of the diagnostic and therapeutic procedure, irradiation planning, calculation of the dose and discussion of our tentative clinical experience are explained.

[Traumatic infraclinoid aneurysms]

Traumatic infraclinoidal aneurysms of the internal carotid artery are rare. They can occur after craniocerebral lesions and can lead to life-threatening haemorrhages from the nasopharyngeal space. Frequently it may take months after the accident before the patient experiences single or repeated rupture bleeding and is referred to acute treatment in an ENT ward. Angiography can confirm the diagnosis and is mandatory to clarify the question of collateral flow in cerebral circulation. In case of local inoperability combined with the need for a ligature of the internal carotid artery, the protective application of an extra-intracranial microvascular anastomosis is an improved safeguard against postoperative deficits. During the past five years five patients suffering from an infraclinoidal aneurysm of the carotid artery have been operated on successfully in this manner. Two of these patients suffered from a traumatic aneurysm; these two case reports are presented.

[Cancers of extravesical origin with secondary perforation into the bladder]

The pseudotumorous forms of cystitis, the benign diseases of the adjacent organs, the rare diseases of the urinary bladder as well as the malignomas of extravesical origin are included into the differential diagnosis of tumours of the urinary bladder. In the present report altogether 17 malignomas of extravesical origin with secondary perforation into the urinary bladder are evaluated. Culmination points of diagnostics and therapy are discussed. Apart from the consequent performance of preventive programmes the improvement of the results of treatment presumes a vast diagnostics.