[Dehydration. Ethical standards finding in the social controversy]

Three case histories are presented, in which terminal hydration was omitted. Two patients were in the terminal phase of a menigiosis carcinomatosa and Creutzfeldt-Jacob disease, the third was completely aphasic and hemiplegic after ischemic stroke. All three died peacefully without signs of suffering or thirst. The psychological aspects of therapeutic-palliative change and the archetypical horror of death are considered. The moral justification is discussed in relation to the "Principles for Physicians Accompanying the Dying" of the German chamber of physicians. The respect of the patient's will is the guiding principle. These ethical controversies should be discussed sincerely and frankly so that the society is enabled to follow.

Non-convulsive status epilepticus in two patients receiving tiagabine add-on treatment

We report two patients with epileptic syndromes who developed non-convulsive status epilepticus under adjunctive antiepileptic therapy with tiagabine. The paradoxical effect may be the result of a difference in effects between GABAA and GABAB receptors, or between GABA receptors in different regions of the brain.

Phenomenological diversity of spinal reflexes in brain death

In brain death, spinal reflexes and automatisms are observed which may cause irritation and even doubt in the diagnosis. In the literature there are no dedicated descriptions of the diversity and of neuroanatomical considerations. In 278 examinations of 235 patients for the determination of brain death, on 42 occasions obvious spinal reflexes and/or spinal automatisms were observed in 27 brain dead bodies. Because they were not systematically searched for, minute forms have probably been missed. The reflexes (R) and automatisms (A) are described according to the time of observation in relation to the development of brain death, the presumable spinal localization and the possible phylogenetical interpretation. Especially disquieting examples are discussed in more detail, e.g. monophasic EndotrachealSuction-ThoracicContraction-R supposedly switched in segments C2-6 or TrapeziusPinch-ShoulderProtrusion-R conveyed by the accessory nerve (terminology according to the scheme: for the reflexes, Trigger-Response-R: for the automatisms, Movement-A). After these experiences a more thorough examination showed frequent observations of rather minute forms of spinal reflexes, as well as automatisms and even the Lazarus sign (in possibly more than two thirds of the examinations). An estimation of the factual frequency would necessitate special attention to those much more frequent but less obvious minute spinal reflexes and automatisms.

[Disorders of consciousness: the basis for ethical assessment]

During the past few years there is an ethical debate about neurological disease entities that are characterised by a) prolongation of life owing to medical treatment, b) limited chances of cure, and c) impaired to unbearable life quality: akinetic mutism, vegetative state ("Wachkoma", apallic syndrome), and locked-in syndrome. These are compared to typical coma and brain death. According to Gerstenbrand (1967) [34] the vegetative state is differentiated into the transitional state following typical coma, the variations of typical and incomplete vegetative state, the remission state and the "Durchgangssyndrom" (characterized by preserved wakefulness with affective lability, disorientation, and amnesia). With regard to pathogenesis we differentiate posttraumatic and posthypoxic origin and variable lesions in cerebral cortex, thalamus or mesencephalic reticular formation. Uncertainty of prognosis is stressed. In respect of brain death we compare a) neocortical death, b) brain stem death, and c) whole brain death, and discuss problems of difficult delimitation and uncertainty of diagnosis. These syndromes are compared to anencephaly and hydranencephaly. Regarding the locked-in syndrome, typical, incomplete and complete (total) forms are distinguished. The differential diagnosis between the complete locked-in syndrome and brain stem death seems problematic. Difficulties in decisions limiting therapeutic effort stem from a) essentially intuitive judgement about observations, b) variability of syndromes and courses, c) uncertainty of prognosis, and d) differences in understanding and valuation throughout society. Emphasis is on a trustful and open colloquy among the persons concerned.

Perfusion CT of the brain: diagnostic approach for early detection of ischemic stroke

PURPOSE

To determine the value of perfusion computed tomography (CT) in a clinical study of patients with stroke and compare the results with single photon emission CT (SPECT) findings.

MATERIALS AND METHODS

Perfusion CT was performed within 6 hours of symptom onset in 32 patients with possible stroke. Cerebral blood volume (CBV), cerebral blood flow (CBF), and time to peak contrast material enhancement were calculated on the basis of the CT results. Cerebral SPECT was also performed in a subgroup of 18 patients. Perfusion CT and SPECT findings were compared in a lesion-by-lesion analysis. Perfusion CT results were compared with follow-up CT and magnetic resonance imaging findings.

RESULTS

Areas of reduced CBF were detected with the aid of perfusion CT in 25 of 28 patients with a proved infarct (sensitivity, 89%). The results of the CBF maps corresponded well to SPECT findings in 13 (81%) of 16 patients, but ischemia was located outside the scanning level in the other three patients and was therefore missed. Perfusion CT revealed various changes in CBF, CBV, and time to peak enhancement in ischemic territories.

CONCLUSION

Perfusion CT not only allows early detection of cerebral ischemia but also yields valuable information about the extent of perfusion disturbances.

[Quantifying pathological disorders of consciousness. Reliability criteria, aims, feasibility]

Within a survey of coma scales we distinguish scales of clinical findings (Glasgow Coma Scale [GCS], Glasgow Liège Scale [GLS], Innsbruck Coma Scale [ICS], Comprehensive Level of Consciousness Scale [CLOCS]), grading tests (Vigilance Scale [VS], Funktionspsychose-Skala-B [FPBS-B]) and level-scales (Reaction-Level-Scale [RLS-85], Munich Coma Scale [MCS]). With regard to the purpose we differentiate a classification of depth, the prediction of prognosis and the monitoring of changes. For the purpose of classification of depth, the RLS-85 because of its superior objectivity is preferable, but the GCS is of comparable validity and more widely used. The GLS differentiates the deeper states of coma better than either of these because brainstem-reflexes in cranio-caudal order are added. Within the prediction of prognosis all coma-scales have only limited validity and for the purpose of resource economy require additional criteria in the individual case. For the purpose of monitoring changes the level-scales primarily do not fit, the GCS is not sensitive enough. The Glasgow-Cologne-List is better suited; it is more than one-dimensional, but can be expressed through the GCS numbers for comparative purposes. The ICS is not widely used and the prognostic validity has not been proven to the same extent. The Glasgow-Cologne-List could be amplified for the less severe disturbances of consciousness according to Price (32,33), and for the lower levels according to the GLS (2,3,4). In both cases the expense is slightly higher.(ABSTRACT TRUNCATED AT 250 WORDS)

[The concept of consciousness from the neuropsychiatric and interdisciplinary viewpoint]

In German neuropsychiatric literature there is an established tradition of viewing the disturbance of consciousness as a leading symptom of the acute, potentially reversible organic psychoses. Following the late H. H. Wieck acute organic psychoses which are characterized by a disturbance of wakefulness (syndromes of somnolence, sopor, coma), have to be distinguished from those with preserved wakefulness, which he called 'Durchgangssyndrom' (e.g. amnesic syndrome with affective lability). These two syndromes have found their way into textbooks and everyday language in medicine as 'disturbance of consciousness'. But neurology and psychiatry are developing in different directions. Furthermore classical phenomenological psychopathology is not a numerative science and consciousness is still under the persisting eliminative verdict of behaviorism. During the last decades consciousness and the psychopathology of acute organic psychoses have been subject to methodological reflection only with the aim of elaborating quantitative scales. In philosophy and psychology there has been a development towards a new impartiality about consciousness during the same time. The biological sciences have acquired more knowledge about cerebral functions with respect to conscious mental processes and between these sciences a fruitful cooperation has evolved from this. The different views of consciousness in relevant neighbouring sciences are looked at from two main points of view. Following classical descriptive tradition are: philosophy (Bunge, Seifert, Hastedt), philosophically oriented psychiatry (Jaspers, Ey), descriptive psychology (Deleay/Pichot), and the post-behaviorist psychology (Hilgard, Mandler, Natsoulas). On the other hand the neurobiologically oriented sciences: clinical neuropsychology (Mesulam, Kolb/Wishaw, Poeck, Stuss, Shallice), neurophysiology (Brain, Goldman-Rakic, Creutzfeldt, Roland), and neurophilosophy (Churchland, Oeser). These more recent developments can contribute to a more actual sight of psychopathology of consciousness in neurology and psychiatry.

[Diagnosis of brain death: limitations of angiography after osteoclastic trepanation]

A 50-year-old man sustained severe skull-brain trauma with intracerebral bleeding, cortical contusion foci and fracture of the petrosal bone. He went into coma a few hours after the accident. Three days after surgical removal of an intracerebral bleeding via a frontoparietal osteoclastic trepanation (removal of a 4 x 5 cm piece of bone) there occurred complete brainstem areflexia, respiratory arrest and drop in temperature; the encephalogram was isoelectric. There was thus no clinical-neurological doubt of brain death. But cranial digital subtraction angiography, generally considered to give the most reliable evidence of irreversible loss of cerebral functions, showed contrast medium in the branches of the left cerebral artery. The diagnostic criteria of brain death, as proposed by the Federal German Chamber of Physicians (Bundesärztekammer), were thus not exactly met, and despite the clinically obvious brain death a contemplated removal of organs for transplantation was therefore not undertaken. The patient died 6 hours after the angiography. This case shows that the value of angiography for the diagnosis of brain death may sometimes be limited, at least in those cases in which osteoclastic trepanation has been performed or there are other causes for a skull defect, because they can prevent the rise of intracranial pressure which brings about the cerebral circulatory arrest.