Escalating immunotherapy of multiple sclerosis--new aspects and practical application

Recent clinical studies in multiple sclerosis (MS) provide new data on the treatment of clinically isolated syndromes, on secondary progression, on direct comparison of immunomodulatory treatments and on dosing issues. All these studies have important implications for the optimized care of MS patients. The multiple sclerosis therapy consensus group (MSTCG) critically evaluated the available data and provides recommendations for the application of immunoprophylactic therapies. Initiation of treatment after the first relapse may be indicated if there is clear evidence on MRI for subclinical dissemination of disease. Recent trials show that the efficacy of interferon beta treatment is more likely if patients in the secondary progressive phase of the disease still have superimposed bouts or other indicators of inflammatory disease activity than without having them. There are now data available, which suggest a possible dose-effect relation for recombinant beta-interferons. These studies have to be interpreted with caution, as some potentially important issues in the design of these studies (e. g. maintenance of blinding in the clinical part of the study) were not adequately addressed. A meta-analysis of selected interferon trials has been published challenging the value of recombinant IFN beta in MS. The pitfalls of that report are discussed in the present review as are other issues relevant to treatment including the new definition of MS, the problem of treatment failure and the impact of cost-effectiveness analyses. The MSTCG panel recommends that the new diagnostic criteria proposed by McDonald et al. should be applied if immunoprophylactic treatment is being considered. The use of standardized clinical documentation is now generally proposed to facilitate the systematic evaluation of individual patients over time and to allow retrospective evaluations in different patient cohorts. This in turn may help in formulating recommendations for the application of innovative products to patients and to health care providers. Moreover, in long-term treated patients, secondary treatment failure should be identified by pre-planned follow-up examinations, and other treatment options should then be considered.

Genetic variants in the tumor necrosis factor receptor II gene in patients with multiple sclerosis

Common genetic variants have been shown to influence disease susceptibility, disease course, or both in multiple sclerosis (MS). Several studies have suggested a role for tumor necrosis factor-alpha (TNF-alpha) in the pathogenesis of MS. Recently, it has been reported that the TNF receptor (TNFR) II plays an essential role in the pathology and progression of experimental autoimmune encephalomyelitis, an animal model of MS. To investigate whether TNFR II polymorphisms influence susceptibility and/or clinical progression of MS, genomic DNA of 321 samples of the Austrian Genetics in MS study group and DNA of 174 platelet donors, who served as healthy controls, were genotyped for five polymorphic sites in the TNFR II gene: exon 6 nucleotide (nt) 676*T-->G, exon 6 nt 783*G-->A (both are associated with non-conserved amino acid substitution), exon 10 nt 1663*G-->A, exon 10 nt 1668*T-->G, and exon 10 nt 1690*T-->C (all of which are located in the 3' non-coding region of the gene). We found a significant association between exon 10 nt 1668*T-->G polymorphism and susceptibility to MS. The other investigated nucleotide substitutions were not associated with susceptibility to or clinical parameters in MS.

Factors influencing quality of life in multiple sclerosis patients: disability, depressive mood, fatigue and sleep quality

OBJECTIVES

In a series of 504 patients with multiple sclerosis (MS), quality of life (QOL) and its main clinical and demographic determinants were assessed in comparison with healthy individuals.

MATERIALS AND METHODS

A postal questionnaire with self-completed measures of disability (Expanded Disability Status Scale, EDSS), QOL (Quality of Life Index, QLI), depressive mood (Self-rating Depression Scale, SDS), fatigue severity (Fatigue Severity Scale, FSS) and sleep quality (Pittsburgh Sleep Quality Index, PSQI) was sent to this sample of MS patients.

RESULTS

Most patients were severely disabled; almost half were mildly to severely depressed, suffering from reduced sleep quality and/or fatigue. The multiple sclerosis patients had significantly lower QLI scores than healthy controls. EDSS and SDS scores were found to be predictors of global QLI score. Regarding the different QLI domains, mean SDS scores remained predictive for all QLI items, while mean EDSS, PSQI and FSS scores were only predictive for physical domains.

CONCLUSION

Our study clearly demonstrates that depressive mood is the main factor influencing QOL. The disability status, fatigue and reduced sleep quality have an impact mainly on physical domains of life quality.

Apolipoprotein E epsilon 4 is associated with rapid progression of multiple sclerosis

OBJECTIVE

The apolipoprotein E (APOE) polymorphism is known to impact on various neurologic disorders and has differential effects on the immune system and on CNS repair. Previous findings concerning a possible modulation of the clinical course of MS have been inconsistent, however.

METHODS

In a cross-sectional study, the authors investigated 374 patients with clinically definite MS and a disease duration of at least 3 years and related their clinical and demographic findings to the allelic polymorphism of the APOE gene. The genotype distribution of patients with MS was compared with a cohort of 389 asymptomatic, randomly selected elderly volunteers.

RESULTS

The authors found no significant differences in the distribution of genotypes between patients with MS and controls. However, patients with MS with the epsilon4 allele (n = 85) had a significantly higher progression index of disability (0.46 +/- 0.4 versus 0.33 +/- 0.26; p < 0.004) and a worse ranked MS severity score (5.1 +/- 1.9 versus 5.7 +/- 1.7; p = 0.05) than their non-epsilon4 counterparts, despite significantly more frequent long-term immunotherapy in epsilon4 carriers (74% versus 58%; p < 0.007). The annual relapse rate in epsilon4 carriers (0.87 +/- 0.56) was significantly higher than in patients with MS without an epsilon4 allele (0.71 +/- 0.47; p = 0.03).

CONCLUSIONS

These results suggest no effect of the APOE genotype on susceptibility to MS, but indicate an association of the APOE epsilon4 allele with a more severe course of the disease.

Electrophysiological, neuropsychological and clinical findings in multiple sclerosis patients receiving interferon beta-1b: a 1-year follow-up

We assessed serial event-related potentials (ERPs) as well as neuropsychological and clinical test findings in a group of multiple sclerosis (MS) patients (n = 14) treated with interferon beta-1b (INF-beta-1b) compared to normal controls (n = 14). All investigations were done within 1 week before INF-beta-1b therapy was started and 12 months later. An auditory oddball paradigm was employed. No significant differences in the N100, P200, N200 or P300 latencies between patients and control group were found, but 3 out of 14 MS patients developed abnormal P300 latencies (more than 2 standard errors from the mean) after 1 year of INF-beta-1b therapy. This was not reflected by the respective neurological impairment as assessed by the Expanded Disability Status Scale score. ERPs might be a useful tool in clinical studies in order to evaluate drug effects on cognition, but for a final statement, the analysis of ERPs in a larger group of patients is required.

Apolipoprotein E polymorphism: survival and neurological outcome after cardiopulmonary resuscitation

BACKGROUND AND PURPOSE

The apolipoprotein E 3/3 (apoE 3/3) genotype is associated with a reduced risk of developing Alzheimer's disease and with a favorable neurological outcome after traumatic head injury. In vitro studies suggest that the most common genotype, apoE 3/3, may be involved in neuroprotective and neuroregenerative mechanisms. The aim of this study was to determine whether the apoE 3/3 genotype has an impact on survival and neurological outcome after cardiopulmonary resuscitation.

METHODS

Eighty patients with cardiac arrest were investigated prospectively for their apoE genotype. Epidemiological data were assessed according to recommended guidelines. Patients were divided into 2 groups, ie, with the apoE 3/3 genotype present or absent, and tested for differences in survival and neurological outcome. Further statistical analysis with respect to survival and neurological outcome was performed by using a stepwise logistic regression analysis.

RESULTS

Patients with the apoE 3/3 genotype had a significantly higher survival rate (64% versus 33%, P:=0.007) and more often a favorable neurological outcome (55% versus 27%, P:=0. 013) compared with patients with other apoE genotypes. The apoE 3/3 genotype was shown to be a substantial predictive factor for a favorable neurological outcome (odds ratio 3.2) and was, apart from other essential factors, predictive for survival (odds ratio 4.4) after cardiopulmonary resuscitation.

CONCLUSIONS

These data give evidence that patients with the apoE 3/3 genotype have a better chance of recovery after cardiopulmonary resuscitation than do patients with apoE genotypes other than 3/3.

The impact of apolipoprotein E genotypes on age at onset of symptoms and phenotypic expression in Wilson's disease

Wilson's disease is a disorder of biliary copper excretion that may result in severe neurological symptoms and advanced liver disease. The wide variation of phenotypic disease expression cannot be fully explained by the different mutations of the Wilson disease gene. In neurological disorders, such as Alzheimer's disease, temporal lobe epilepsy and cerebral trauma, the presence of the apolipoprotein E (ApoE) allele epsilon4 is associated with an increased vulnerability of the brain to the effects of the disease, whereas the presence of the ApoE genotype epsilon3/3 appears to provide moderate neuroprotection. We examined whether this hypothesis holds true for the development of neurological symptoms in patients with Wilson's disease. The ApoE genotype and the H1069Q mutation (the most common in Wilson's disease) status were determined by polymerase chain reaction-based mutation assays in 121 well-characterized, symptomatic index patients with Wilson's disease. An investigation profile was established in which the patients were grouped according to the clinical symptoms at presentation, the ApoE genotypes and the status of the H1069Q mutation. Fifty-nine per cent of the 121 patients had the allele combination ApoE epsilon3/3 (21% ApoE epsilon3/4, 19% ApoE epsilon3/2, 1% ApoE epsilon4/2). The distribution of ApoE genotypes did not deviate from known distributions in healthy European subjects. Within the group of 40 H1069Q-homozygous patients, the onset of symptoms was significantly delayed in patients with the ApoE epsilon3/3 genotype (25 +/- 6 years at presentation) compared with patients with the ApoE epsilon3/4 genotype (20 +/- 3 years at presentation). In this study, the ApoE genotype was established as an important factor delaying the onset of neurological and hepatic symptoms, but not modifying phenotypic disease expression in a homogeneous group of patients with Wilson's disease (all H1069Q-homozygotes, similar genetic background). The presence of ApoE epsilon3/3 attenuates clinical manifestations in Wilson's disease by mechanisms which might involve the antioxidant and membrane-stabilizing properties of the ApoE 3 protein.

Vaccinations and steroids in MS: effects on disease progression and mood

OBJECTIVE

To investigate the effects of vaccinations and steroids on disease progression and mood in patients with multiple sclerosis (MS).

MATERIAL AND METHODS

Twenty-three patients with clinically definite MS were questioned with respect to vaccination history and the cumulative dose of steroids given during their life-time. EDSS scores and MRI scans of the brain were obtained and used to quantify clinical and MRI disease progression. Mood was assessed by using a self-estimated adjective mood scale.

RESULTS

The number of vaccinations showed no effect on disease progression or mood. High cumulative steroid doses were associated with rapid MRI disease progression and the number of supratentorial MRI lesions. The absence of band-like MRI lesions was correlated with rapid clinical and MRI disease progression. Self-estimated mood tended to be worse in patients with chronic-progressive MS compared to those with relapsing-remitting MS.

CONCLUSION

Neither clinical nor MRI-documented disease progression nor mood are influenced by the total number of vaccinations whereas high cumulative steroid doses and the absence of band-like MRI lesions indicate rapidly progressive MS. Self-estimated mood tends to be worse in patients with chronic-progressive MS compared to patients with relapsing-remitting MS.

[Urgent diagnostic steps in acute manifestation of intraspinal processes]

Immediate diagnostic clarification is required in patients who develop acute or subacute symptoms suggestive of an intraspinal lesion. In case of symptoms indicating a monoradicular lesion a spinal CT investigation is mostly sufficient. Since polyradicular syndromes are often due to inflammation, examination of the cerebrospinal fluid is the most important diagnostic measure. However, in case of symptoms suggestive of intramedullary lesions, spinal MRT is by far the most effective diagnostic procedure. In patients with symptoms suggestive of a lesion of the cauda equina spinal CT is sufficient in most cases as a first measure, particularly if the lesion can be precisely localized by clinical examination. The decision as to which diagnostic method should be performed first is relevant mainly because of the limited availability of MRT examinations within the daily clinical routine. MRT should thus be used selectively in patients with lesions that cannot be identified by alternative diagnostic methods.

Assessment of neurotoxicity and "neuroprotection"

Coronal brain slices allow the study of neurotoxicity and "neuroprotection" under conditions where the differentiation-state and interrelationships of the neurones and glial cells are closer to those occurring in the intact tissue than is the case for co-cultured cell systems. The involvement of glial cells in the excitotoxicity of kainate and the potentiation of this toxicity by inhibition of glutamine synthase can be demonstrated. Longer-term toxicity of kainate may also be compounded by depletion of glutathione levels resulting from inhibition of gamma-glutamylcysteine synthase. The involvement of nitric oxide formation in the toxicity of N-methyl-D-aspartate can also be shown. The neurotoxicity of 1-methyl-4-phenylpyridinium can be readily demonstrated in coronal slice preparations. Taurine affords protection against this neurotoxicity. The possible mechanisms of these effects are considered in terms of the cyclic interrelationships between the different events which can lead to cell death.

Spinal cord lesions in patients with multiple sclerosis: comparison of MR pulse sequences

PURPOSE

To compare T2-weighted conventional spin-echo (CSE), fast spin-echo (FSE), shorttau inversion recovery (STIR) FSE, and fluid-attenuated inversion recovery (FLAIR) FSE sequences in the assessment of cervical multiple sclerosis plaques.

METHODS

Twenty patients with clinically confirmed multiple sclerosis and signs of cervical cord involvement were examined on a 1.5-T MR system. Sagittal images of T2-weighted and proton density-weighted CSE sequences, T2-weighted FSE sequences with two different sets of sequence parameters, STIR-FSE sequences, and FLAIR-FSE sequences were compared by two independent observers. In addition, contrast-to-noise measurements were obtained.

RESULTS

Spinal multiple sclerosis plaques were seen best on STIR-FSE images, which yielded the highest lesion contrast. Among the T2-weighted sequences, the FSE technique provided better image quality than did the CSE technique, but lesion visibility was improved only with a repetition time/echo time of 2500/90; parameters of 3000/150 provided poor lesion contrast but the best myelographic effect and overall image quality. CSE images were degraded by prominent image noise; FLAIR-FSE images showed poor lesion contrast and strong cerebrospinal fluid pulsation artifacts.

CONCLUSIONS

The STIR-FSE sequence is the best choice for assessment of spinal multiple sclerosis plaques. For T2-weighted FSE sequences, shorter echo times are advantageous for spinal cord imaging, long echo times are superior for extramedullary and extradural disease. FLAIR-FSE sequences do not contribute much to spinal imaging for multiple sclerosis detection.

Dopamine D2 receptor binding is reduced in Wilson's disease: correlation of neurological deficits with striatal 123I-iodobenzamide binding

To visualise and quantify dopamine D2 receptor binding in the corpus striatum of patients with neurological Wilson's disease (WD) 123I-Iodobenzamide (IBZM) binding was measured using single photon emission computer tomography (SPECT). Ratios of striatal to frontal countrates were calculated in 8 patients and in 21 healthy control subjects. We found reduced IBZM binding ratios in all patients with WD in comparison to those in controls (1.48 +/- 0.13 vs. 1.73 +/- 0.09). The reduction in IBZM binding was correlated with the overall severity of neurological deficits and the severity of dysarthria (correlation coefficients -0.86 [p < 0.01] and -0.79 [p < 0.01], respectively). When patients of three different subgroups of neurological WD were compared no differences in IBZM binding were found. We conclude that assessing basal ganglia function in vivo using IBZM-SPECT is a valuable diagnostic tool in WD.

Alteration in the glial cell metabolism of glutamate by kainate and N-methyl-D-aspartate

Incubation of coronal slices of rat brain with neurotoxic concentrations of kainate (300 microM) and N-methyl-D-aspartate (NMDA; 500 microM) for 40 min reduced the activity of the glial enzyme, glutamine synthetase, by 33% and 21%, respectively. The immunoreactivity of the neuronal enzyme, gamma gamma-enolase (neuron-specific enolase), was also decreased, but to a lesser extent than glutamine synthetase. Pre-incubation of the slices with L-methionine-S-sulphoximine (500 microM), an irreversible inhibitor of both glutamine synthetase and gamma-glutamylcysteine synthetase, before addition of either kainate or NMDA produced a supra-additive reduction in the activity of the enzyme in both cases. Neither kainate nor NMDA directly inhibited the activity of glutamine synthetase, but kainate did inhibit gamma-glutamylcysteine synthetase, a rate-limiting enzyme of the gamma-glutamyl cycle, which is responsible for maintaining glutathione levels within cells. Pre-incubation of the slices with L-NG-nitroarginine, a competitive inhibitor of nitric oxide synthase, effectively prevented the NMDA-induced reduction in glutamine synthetase and neuron specific enolase, but did not diminish the kainate-induced decrease in the activity of either enzyme. These results provide evidence that NMDA, as well as kainate, indirectly affects the activity of glutamine synthetase in brain slices, yet does so by a different mechanism from kainate. The results are discussed in terms of the possible mode of action of each toxin in inhibiting the glial cell metabolism of glutamate.

MR of cerebral Whipple disease

A case of cerebral Whipple disease is reported. MR findings of the brain are discussed in relation to neuropathologic lesions reported previously. Repeated MR investigations may serve as a valuable tool to evaluate long-term efficacy of treatment in cerebral Whipple disease.

Posturographic measurement of body sway in survivors of severe closed head injury

Postural imbalance was measured in 39 survivors of severe closed head injury 7 to 66 months after head injury using a posturographic platform. The results were compared with those derived from age-matched healthy control subjects. Severe postural imbalance, particularly in an anteroposterior direction, was found in 16 patients, whereas 9 patients showed moderate imbalance and 14 patients showed normal results in the posturographic investigation. Low initial Glasgow Coma Scale scores and deep parenchymal brain lesions demonstrated by magnetic resonance imaging were shown to be significant indicators of subsequent severe postural imbalance. The duration of posttraumatic amnesia, the localization and size of cortical contusions and subcortical white matter lesions, on the contrary, were not associated with postural imbalance in the long-term outcome.

Reduction of striatal N-methyl-D-aspartate toxicity by inhibition of nitric oxide synthase

Coronal slices of rat brain were incubated for 40 min in 300 microM kainate (KA) or 500 microM N-methyl-D-aspartate (NMDA). Histological examination showed neuronal degeneration accompanied by significant losses in the activity of neuron-specific enolase (NSE; EC 4.2.1.11) (-23% KA; -26% NMDA). The activity of the glial enzyme glutamine synthetase (GS; EC 6.3.1.2) was also reduced (-32% KA; -27% NMDA). Pre-incubation with 100 microM L-NG-nitroarginine (L-N-ARG), an inhibitor of nitric oxide (NO) synthase (EC 1.14.23.-), for 20 min attenuated the toxicity of toxicity of NMDA, but not KA. NSE levels after successive incubation in L-N-ARG and NMDA were 95% of controls incubated in Krebs bicarbonate medium only (GS activity 89% of controls). In contrast, pre-incubation with L-N-ARG prior to the addition of KA resulted in neuronal degeneration and significant reductions in NSE levels and GS activities. These observations suggest that the unrestricted function of NO synthase is significant in mediating NMDA neurotoxicity whereas KA toxicity is associated with alternative mechanisms not linked to NO production.

Wilson's disease: evidence of subgroups derived from clinical findings and brain lesions

Using exploratory factor analysis, we prospectively investigated neuropsychiatric symptoms and structural brain lesions of 47 patients with proven Wilson's disease and identified three subgroups. The first subgroup clinically exhibited bradykinesia, rigidity, cognitive impairment, and an organic mood syndrome and by MRI showed a dilatation of the third ventricle. The second subgroup was characterized by ataxia, tremor, reduced functional capacity, and focal thalamic lesions. The third subgroup showed dyskinesia, dysarthria, an organic personality syndrome, and focal lesions in the putamen and in the pallidum.

Different risk factor profiles in young and elderly stroke patients with special reference to cardiac disorders

The risk factors of ischemic cerebrovascular disorders in 77 young patients (< or = 40 years) were compared to those in 138 older patients (> 40 years). The risk factor profile of patients with juvenile stroke was considerably different from that of older patients. Migrainous headache and mitral valve prolapse occurred more frequently in the younger age group, whereas hypertension, diabetes mellitus, high levels of cholesterol and triglycerides were found more often in older patients with stroke. 65% of the women under the age of 40 took oral contraceptives which compares to the baseline community value of 28% of women in childbearing age in this country. Cardiac disorders such as atrial fibrillation, left ventricular hypertrophy, coronary heart disease including a history of myocardial infarction, as well as mitral valve disease were demonstrated more often in the group of elderly patients. 7 out of 77 younger patients (9.1%), and 59 out of 138 older patients (42.8%) were considered to belong to a group with "high cardiac risk for stroke". The results of this study indicate that electrocardiographic screening is of prime importance for detecting cardiac risk factors. However, echocardiographic examination often yields additional diagnostic information, particularly in younger patients. The conflicting opinions concerning the relevance of certain risk factors for ischemic stroke could partly be explained by the fact that these risk factors are distributed unevenly depending on age.

[Neurological complications in 95 patients with HIV infection. A retrospective analysis of anamnestic and clinical data]

This retrospective investigation of neurological deficits in 95 consecutive patients (77 men, mean age 35 years; 18 women, mean age 28 years) infected by the human immunodeficiency virus showed that 61% of the female and 47% of the male patients exhibited neurological deficits. In 18% of the total population neurological deficits were the initial sign of acquired immunodeficiency. In addition, we found that a history of headaches and the clinical finding of mental impairment as well as internistic symptoms were significantly correlated with neurological deficits. Patients suffering from cerebral toxoplasmosis developed mental impairment significantly more often than patients with central nervous symptoms of other etiogenesis. Furthermore, it was found that HIV-infected women manifested peripheral neuropathies more often than HIV-infected men. The overall mortality rate over the investigation period of 30 months was 28%. The results of our retrospective investigation indicate that HIV-infected patients have a high risk of developing lesions of the central and peripheral nervous system during the course of the disease. Various reasons might be responsible for these findings: neurotropy and metamorphosis of the human immunodeficiency virus, opportunistic infections and tumors, vitamin deficiencies, and a variety of diseases prior to HIV-infection.

Spontaneous body sway as a function of sex, age, and vision: posturographic study in 30 healthy adults

Detailed neurological examinations and body sway measurements with a stable force measuring platform were carried out on 30 healthy adults between 21 and 63 years of age. The results were analyzed for sex- and age-associated changes with regard to three different sway components (total sway, anterio-posterior sway, lateral sway) and two different conditions (eyes open, eyes closed). Sex-associated differences were highly significant for all sway components in the oldest age group (51-65 years) in which men exhibited more spontaneous postural sway than women in the condition eyes open. With eyes closed these differences increased. Middle-aged men (36-50 years) also exhibited significantly more postural sway than women of the same age. In the condition eyes open especially total sway and anterioposterior sway were increased, whereas in the condition eyes closed total sway and lateral sway were predominantly higher in men than in women. In the youngest age group (21-35 years) no sex-related differences in postural sway were found. Age-associated differences were significant for anterioposterior sway (eyes open) in men, increasing continuously from the young to the middle-aged, and again from the middle-aged to the older age group. Anterioposterior sway in women, on the contrary, did not change with age. Age-associated differences in women were found for total sway (eyes open) and lateral sway (eyes closed). However, the highest values for total sway and lateral sway within the female group were obtained from young women in both conditions eyes open and eyes closed.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution of ischemic cerebrovascular events in cardiac embolism

Distribution and number of ischemic cerebrovascular events were studied in 57 patients who suffered from heart disorders with proven or highly probable source of cardiac embolism and compared to 39 patients with ulcerations of the craniocervical vessels. Patients with coexisting lesions were excluded from the present study. Out of the 57 patients with cardiac disorders, a single episode of cerebral embolism occurred in 33 patients. Of the 24 patients with recurrent ischemic episodes, different vascular territories were involved in only six cases. There was no evidence of a distinct distribution of vascular territories involved in cerebral embolism. The left middle cerebral artery was affected in 42.9%, the right middle cerebral artery in 23.8%, the vertebrobasilar territory in 19%, and the ophthalmic arteries in 14.2%. Statistical analysis revealed no significant differences in lesion localization between the group with a cardiac source of embolism and the group with ulcerations of the craniocervical vessels. There was a high frequency of patients with recurrent cardiogenic emboli in the ophthalmic (6 of 9 patients) as well as in the vertebrobasilar (6 of 12 patients) circulation who experienced a delayed initiation of cardiac assessment. The possibility of cardiac embolism should be considered in any patient with cerebral ischemia, independently of the vascular territory affected.

The inhibition of glutamine synthetase in rat corpus striatum in vitro by methionine sulfoximine increases the neurotoxic effects of kainate and N-methyl-D-aspartate

Coronal slices of rat brain were incubated in Krebs bicarbonate medium containing kainate (300 microM), or N-methyl-D-aspartate (500 microM). Degeneration of striatal neurons by both these toxins was apparent after 40 min incubation, and was accompanied by a 33% (kainate) and 21% (N-methyl-D-aspartate) reduction in striatal glutamine synthetase activity. Pre-incubation of the slices with 500 microM L-methionine sulfoximine, an inhibitor of glutamine synthetase, for 20 min prior to the exposure to either kainate or N-methyl-D-aspartate, again showed extensive degeneration of striatal neurons, and a supra-additive reduction in glutamine synthetase activity in the tissue. The activity of the neuronal marker enzyme, neuron-specific enolase, was also reduced by pre-incubation of the slices with L-methionine sulfoximine before the addition of kainate or N-methyl-D-aspartate, but to a much lesser extent than glutamine synthetase. The results are discussed in terms of a possible mechanism of interaction between either kainate or N-methyl-D-aspartate, and glial cell metabolism.

Atypical vertebral artery in a patient with an intra-and extraspinal cervical neurenteric cyst

A 15 year old girl experienced Horner's syndrome on the right side, paraesthesia of the right arm and meningitis. CT and MRI showed a cystic lesion on the right side of the cervical spine at C3/C4 which descended with an extraspinal portion down to C6. Histology revealed a complex neurenteric cyst. The ipsilateral vertebral artery showed an atypical course. This abnormal artery besides a partial fusion of the vertebrae C2/C3/C4 suggest a complex malformation at the site of the cyst. Disturbed developmental relationships in this case indicate that pathological blood vessels may represent a risk factor in the surgical treatment of neurenteric cysts.

Neurological and neuropsychiatric spectrum of Wilson's disease: a prospective study of 45 cases

Forty-five patients with Wilson's disease (WD) were prospectively studied: 27 had neurological deficits, 12 hepatic signs, and 6 were asymptomatic. Kayser-Fleischer rings occurred in 23 of the neurological patients and in only 4 of the hepatic patients. Neurological features were extremely variable with respect to frequency and severity. Most frequent were dysdiadochokinesis (25 patients), dysarthria (23), bradykinesia (17), and posture tremor (14). Fifteen, mainly long-term treated patients, presented with rather discrete neurological abnormalities which predominantly consisted of dysarthria and various forms of tremor. Eight patients had a parkinsonian type of neurological WD associated with signs of an organic mood syndrome. Three patients were predominantly hyperkinetic, presenting with dystonic and choreatic movements. In 1 patient, ataxia was the predominant neurological feature. There was a clear-cut correlation between the severity of neurological impairment and the restriction in functional capacity. Nine patients were not able to engage in salaried employment or were retired. Psychiatric symptoms and behavioural disorders were common, varying from mild personality and psychological disturbances to severe psychiatric illness resembling psychotic disorders and major depressive syndromes. Significant mental deterioration was not found in the patients. Disturbances of mood were observed in 12 patients, all of whom had neurological abnormalities. There was a history of an attempted suicide in 7 patients, and a history of an organic delusional syndrome in 3.

[Prognosis after transient ischemic attacks]

Transient ischemic attacks (TIAs) are reversible neurological deficits due to cerebral ischemia in a vascular territory lasting less than 24 hours, usually less than one hour. The natural course of TIAs is variable. One third of the patients suffer from a subsequent completed stroke with lasting disability, one third of the patients continues to experience TIAs and in one third no further symptoms are encountered. TIAs are a warning symptom of a generalized vascular process, myocardial infarction being the most common cause of mortality and ischemic brain infarction being the most common cause of morbidity. Clinical parameters--besides age--seem to be of minor prognostic relevance. Vascular risk factors should be evaluated in all TIA patients; especially, a cardiac work up including 2D-echocardiography and an exercise stress test should be performed. Duplex sonography of craniocervical vessels shows atherosclerotic lesions in a considerable proportion of patients with TIA; however, localization of these lesions does not always correspond to clinical symptomatology. Some angiographic features are of prognostic relevance. Computed tomography (CT) and magnetic resonance imaging (MRI) show ischemic lesions in a considerable proportion of patients, which connects TIAs directly to ischemic brain infarcts. The extent and localization of these lesions are of some prognostic relevance. Blow flow studies on single photon emission computed tomography (SPECT) and studies of brain metabolism on positron emission tomography (PET) are abnormal in many TIA patients for prolonged periods and also have some prognostic impact. TIA patients probably are a heterogeneous group with a common symptom. A detailed diagnostic work-up may have implications on a more specific and efficient therapy.

Subarachnoid hemorrhage of unknown etiology: early prognostic factors for long-term functional capacity

Forty-one patients suffering subarachnoid hemorrhage (SAH) of unknown etiology were re-investigated at an average of 91 months after the bleed to determine functional capacity. Nineteen patients were performing at their previous level of work, five were employed part-time, and four could not work due to the SAH. Five patients showed a moderate disability in activities of daily living but were not dependent on help, one patient was severely disabled, and two had died. There was one rebleed. Early prognosis of an unfavorable outcome was possible on the basis of three clinical variables on admission: a history of hypertension, a Hunt and Hess grade of greater than II, and the presence of focal neurological deficits. In addition, the presence of an organic mental syndrome at discharge was identified as a predictive factor for reduced functional capacity later on. Other clinical variables in the acute stage, including sex, age, history of headache, interval between SAH and admission, impaired consciousness, and cognitive deficits, were not related to a limited functional level. Residual neurological deficits and the Glasgow Outcome Scale score on discharge were also not predictive of restrictions in global functions evaluated by means of the Karnofsky Performance Scale status at follow-up review.

[AIDS of the central nervous system]

The central nervous system of nearly every HIV-positive patient becomes affected by the AIDS virus itself or by one of the associated diseases during the course of the illness. Early diagnosis of lesions which demand therapeutic consequences is of the most importance concerning prolongation of life and improvement in its quality. In spite of the frequent underestimation of cerebral involvement by imaging methods and their unspecific findings they are often the only diagnostic means which permit-timely diagnosis and, at least in some diseases, therapeutic monitoring. Indications for cranial computed tomography (CCT) or magnetic resonance tomography (MRT) are already present with mild or transient neurological or psychiatric symptoms or the extracerebral manifestation of neurotropic organisms or tumours which metastasize to the brain, even in patients without subjective complaints.

[Use of nicotine--a risk factor for stroke?]

The results of studies on cigarette smoking as a risk factor for stroke are more controversial than for cardiovascular disease. The CO-induced increase in the corpuscular elements of blood (erythrocytes), the influence on other parameters (such as RBC volume, haemoglobin, haematocrit, blood and plasma viscosity, tendency of erythrocytes and platelets to aggregate, fibrinogen level etc.), as well as the increase in catecholamine level are taken to be reversible. On the other hand, the association between cigarette smoking and probably irreversible morphological changes in the craniocervical vessels--possibly via lipid metabolism--is well documented. The following possible explanations for discrepant results in the literature are discussed: different extent of daily cigarette smoking, inhomogeneous populations, difficulties in diagnosing stroke, especially before the introduction of computed tomography and the common failure to consider other risk factors.

Subarachnoid haemorrhage: prognostic factors as related to working capacity

Seventy-two adult patients suffering spontaneous subarachnoid haemorrhage (SAH) were investigated concerning early mortality. Five patients died within 3 weeks after the onset of clinical symptoms. A demonstrable bleeding source and a Hunt-Hess score greater than 2 were found to be powerful predictive factors for early mortality. Sixty-seven survivors of SAH were examined at an average of 85 months after their first bleeding with regard to working capacity. Various clinical variables and different rating scales during the acute and subacute stage of SAH were identified retrospectively, and their prognostic value for working capacity was investigated. We found that all clinical features at the acute stage of SAH were not predictive of limited working capacity. At the time of discharge, however, organic brain syndrome, focal neurological deficits and a low Barthel Index proved to be significantly related to impaired working capacity. A Hunt-Hess score greater than 2 on admission, and a demonstrable bleeding source, were powerful predictors for early death, but not for impaired working capacity of survivors of SAH.

Stabilizing and destabilizing effects of vision and foot position on body sway of healthy young subjects: a posturographic study

A total of 800 posturographic measurements--each characterized by four values (sway path, sway area, anteroposterior sway and lateral sway)--was carried out for this study. Eight different conditions (interfoot distances of 0, 4, 10 and 20 cm, each with eyes open and eyes closed) were compared by statistical means. All sway values were diminished by vision in small interfoot distances. At large interfoot distances, however, the presence of visual control resulted in an increase of lateral sway. Comparing the different foot positions, an increase of anteroposterior sway and a decrease of all other components were found at large interfoot distances no matter whether the eyes were open or closed.

Neuroborreliosis in morphea and lichen sclerosus et atrophicus

Nine cases of different types of morphea and two of lichen sclerosus et atrophicus were investigated for the presence of neurologic symptoms. The Borrelia origin of morphea and lichen sclerosus et atrophicus was verified by the presence of antibodies against Borrelia burgdorferi and by the visualization of spirochetes on histologic sections by immunohistochemical methods. One patient had intrathecally synthesized IgG antibodies against B. burgdorferi that indicated intrathecal infection. A second patient had an elevated cell count and oligoclonal bands of unknown specificity in cerebrospinal fluid. In another patient a disturbance of the blood-brain barrier was detected. Seven patients had signs of peripheral neural involvement, mostly lesional dysesthesias. Our findings indicate frequent neural involvement in morphea and lichen sclerosus et atrophicus, suggesting the necessity of adequate antibiotic treatment in these diseases.

[Neuro-AIDS]

Various findings prove the neurotropism of the human immune deficiency virus (HIV). Besides an aseptic meningitis at the time of seroconversion and polyradiculoneuropathies clinical and neuropathological studies focus on subacute encephalitis leading to dementia and focal neurological complications. Therapeutic strategies, various considerations concerning the pathogenesis of other subacute, chronic and slow virus infections of the nervous system as well as prophylactic implications become more and more important.

[Initial clinical experiences in a large Austrian patient sample with immunodeficiency syndrome (AIDS): I. Type and course of encountered infections]

This study presents a report on the first clinical experiences gained in 68 hospitalized HIV antibody-positive patients from Austria, covering a period of twelve months. 36 patients (52.9%) belonged to risk group I or Ib (homo- or bisexual), whereas 26 (38.2%) patients were i.v. drug abusers (risk group II). 5 (7.4%) patients fulfilled the criteria of stage II of the CDC classification of HIV-associated clinical symptoms, 10 (14.7%) were classified as stage III and the remaining 53 patients (78%) as stage IV. The most frequent and also the most serious problem was the development of opportunistic infections. Multiple infections were found in 45.7% of all cases. Kaposi's sarcoma was found in 9 patients who all belonged to risk group I. During the entire observation period 10 patients died as a consequence of HIV-1-induced immunodeficiency and the resulting opportunistic infections and/or neoplasms.

Adult coeliac disease and brainstem encephalitis

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[Possibilities of early diagnosis of intracranial meningioma based on clinical symptoms]

In a retrospective study, 56 patients with intracranial meningiomas were investigated. The diagnosis was verified by computer tomography with subsequent selective cerebral angiography in all cases. At the time of admission, 62.5% of the patients had functional losses affecting the cranial nerves, 44% functional losses involving the long nerve tracts and 23.2% had cerebellar symptoms. Nonspecific clinical symptoms found comprised headaches in 61% of the patients; these were already present almost three and a half years before the final diagnosis. There was a marked organic psychological disorder in 50% of the patients which had already been present retrospectively for an average of 10 months. Cerebral convulsive attacks were present in 27% of the patients with partial convulsions (mainly of the "temporal lobe type") which had already been present for an average of 40 months before diagnosis; in the general tonic-clonic convulsions, the diagnosis was already made an average of six weeks after the first attack. These data show that nonspecific symptoms such as headaches, organic psychological disorders and cerebral convulsions may be early indicators for the presence of an intracranial space occupation and should be investigated further without delay.

CSF cytology of a patient with conversion of an acute lymphatic leukemia to an acute eosinophilic leukemia

The course of leukemic disease in a male adolescent with meningeal leukemia is described. The bone marrow aspirates showed a conversion from an acute lymphatic leukemia to an eosinophilic leukemia. Four weeks after the peripheral shift of phenotype two different cell clones were detected in one CSF smear. While under ultrahigh dose araC therapy the patient died 3 months after conversion. Possible explanation for the shift of phenotype and the peculiar leptomeningeal infiltration are discussed.