C. R. Hornig

Space-occupying cerebellar infarction. Clinical course and prognosis.

Background and Purpose Because the timing and strategy of surgical intervention in massive cerebellar infarction remains controversial, we report our experience with the management of 52 such patients. Methods Case records, computed tomographic scans, surgical reports, and angiograms of 52 patients with space-occupying cerebellar infarction defined by computed tomographic criteria were reevaluated with regard to clinical course, etiology, therapeutic management, mortality, and functional outcome. Results In most cases clinical deterioration started on the third day after stroke, and a comatose state was reached within 24 hours. Sixteen patients were treated medically, and 30 by suboccipital craniectomy (22 plus ventriculostomy, 12 plus tonsillectomy). Ten patients primarily had ventriculostomy, which in 4 patients was supplemented by craniotomy because of continuing deterioration. Twenty-nine patients made a good recovery, 15 remained disabled, and 8 died. Even comatose patients had a 38% chance of a good recovery with decompressive surgery. Age older than 60 years (P=.0043) and probably initial brain stem signs (P=.0816) and a late clinical stage (P=.0893) were linked with a fatal or disabling outcome. Conclusions Decompressive surgery should be the treatment of choice for massive cerebellar infarction causing progressive brain stem signs or impairment of consciousness. (Stroke. 1994;25-372-374.)

Hemorrhagic transformation in cardioembolic cerebral infarction.

Background and Purpose Because the frequency of hemorrhagic transformation of cerebral infarcts is still a matter of controversy, we performed a prospective magnetic resonance imaging study in a series of consecutive patients with cardioembolic stroke. Summary of Review Among 200 consecutive patients with transient ischemic attack or ischemic stroke, 41 were identified with a computed tomographically proven supratentorial infarct due to cardiogenic embolism. Magnetic resonance imaging (T1-weighted) was performed 3 weeks after the stroke in 35 of these 41 patients. Eight patients received anticoagulants. Magnetic resonance images showed hemorrhagic transformation in 68.6% (24) of the 35 infarcts, always without clinical deterioration. In a stepwise forward logistic regression analysis only the volume of infarction edema on the initial computed tomogram was linked significantly with the risk of hemorrhagic transformation (p=0.037). Hemorrhages were a regular finding on magnetic resonance images of infarcts exceeding a volume of 10 cm3 (94.4%, 17 of 18). Conclusions Hemorrhagic transformation is a regular finding in medium-sized and large cardioembolic infarcts. Thus, in therapeutic and preventive studies of acute stroke the severity, not the frequency, of hemorrhages into brain infarcts should be the matter of interest.

Specific cardiological evaluation after focal cerebral ischemia

Purpose of this study was to define a subgroup of TIA/stroke patients who should be examined by transthoracal and transesophageal echocardiography or Holter‐electrocardiography to identify those with cardiogenic brain embolism reliably; 300 consecutive patients with acute focal brain ischemia underwent a standardized diagnostic protocol for the evaluation of the etiology including, clinical examination by a cardiologist and routine electrocardiography, Holter‐electrocardiography, transthoracal and transesophageal echocardiography. 188 patients had a potential cardiac source of embolism. In particular echocardiography was diagnostic in 163 patients, and Holter‐electrocardiography 10; 159 of these 188 patients (84.6%) had competitive etiologies, predominantly large vessel atherosclerosis. In 136 patients cardiogenic brain embolism was assumed as quite definite or possible. To identify these patients reliably, transthoracal and transesophageal echocardiography would have been necessary in 89% of the entire group of patients (all with clinically cardiological abnormalities, pathological routine ECG, without vascular risk factors, or no atherosclerosis in duplex sonography), and Holter‐electrocardiography in 54%.

Long-term prognosis of infratentorial transient ischemic attacks and minor strokes.

This study was performed to gather information about long-term prognosis after infratentorial transient ischemic attacks and minor strokes and about the factors influencing it. Methods We included 226 patients with transient ischemia and 169 patients with a minor stroke of the brain stem/cerebellum consecutively admitted to a neurological department. Medical records and the findings of computed tomography, Doppler ultrasonography, and angiography were evaluated retrospectively. Follow-up information was gathered from the patients and their physicians by questionnaires. Complete follow-up information was available for 381 patients. Results During a mean follow-up of 3.9 years, 15.7% of the 381 patients suffered a stroke and 6.8% a myocardial infarction; 15% died. Kaplan-Meier estimates revealed a cumulative stroke rate of 5.1% within the first year and a risk of stroke, myocardial infarction, or death of any cause of 9.8%. In a proportional hazards model, the time-dependent risk of stroke was significantly increased by increasing age (p=0.018), minor stroke (p=0.0005), hypertension (p=0.022), previous stroke (p=0.0006), and carotid artery occlusive disease (p=0.0065). The probability of stroke, myocardial infarction, or death was influenced by age (p=0.0001), minor stroke (p=0.006), diabetes (p=0.015), previous stroke (p=0.002), infarct on a computed tomogram (p=0.041), and carotid artery disease (p=0.032). Conclusions Long-term prognosis after brain stem/cerebellar transient ischemic attacks and minor strokes is significantly influenced by age, diabetes, hypertension, previous stroke, and concomitant carotid artery disease. Patients with transient ischemic attacks have a better prognosis than those with minor stroke.

Changes in CSF blood-brain barrier parameters in ischaemic cerebral infarction

SummaryTotal CSF protein and CSF/serum albumin and α2-macroglobulin ratios as indicators of a disturbed blood-brain barrier were determined in 39 cases of ischaemic cerebral infarction proved by computed tomography (CT). About 50% of the patients had a barrier disturbance, whereat the CSF serum albumin ratio was shown to be the most sensitive parameter. A disturbed blood-brain barrier was more often found in cases of large infarction, as shown by CT, and occurred most frequently in the first 2 weeks of illness. No correlation was seen between enhancement in CT and disturbance of the blood-brain barrier.ZusammenfassungGesamteiweiß, Liquor/Serum Albumin-Quotient und Liquor/Serum α2-Makroglobulin-Quotient als Parameter einer gestörten Blut-Hirn-Schrankenfunktion wurden bei 39 Patienten mit computertomographisch gesicherten ischämischen Hirninfarkten bestimmt. Mehr als die Hälfte hatten eine Schrankenstörung, wobei sich der Liquor/Serum Albumin-Quotient als empfindlichster Parameter erwies. Eine Schrankenstörung war bei ausgedehnten Infarkten häufiger. Sie trat hauptsächlich in den ersten beiden Krankheitswochen auf. Ein Zusammenhang mit dem Kontrastmittel-Enhancement im CT war nicht nachweisbar.

Early outcome and recurrences after cardiogenic brain embolism

Functional outcome and recurrence rate were evaluated retrospectively in a series of 566 consecutive patients with a cardioembolic TIA or stroke. Seventy‐five patients had a TIA/RIND, 163 a minor stroke, 238 a major deficit, and 90 a fatal event. In a logistic regression analysis the probability of a disabling or fatal outcome was significantly influenced by age (p = 0.0023), a previous stroke (p = 0.0262), concomitant carotid artery disease in Doppler sonography (p = 0.0210), and the underlying heart disease (p = 0.0001). Fatal or major strokes predominated among patients with nonvalvular atrial fibrillation, prosthetic heart valves, acute or chronic myocardial infarction. Kaplan‐Meier estimates revealed a cumulative risk of recurrent cerebral embolism of 2.9% within three weeks. In a proportional hazards model only the underlying heart disease was significantly linked with the risk of recurrent embolism (p = 0.021).

CSF cyclic AMP and CSF adenylate kinase in cerebral ischaemic infarction

SummaryThe severity of neurological deficits, size of hypodense zone on CT, concentration of cAMP and activity of adenylate kinase in cerebrospinal fluid (CSF) were evaluated at predefined intervals in the acute stage of supratentorial cerebral ischaemic infarction in 52 patients. Patients with cerebral infarction had raised activities of adenylate kinase CSF as compared with normal persons. Patients with marked neurological deficits, only slight improvement of neurological signs and large infarction zones on CT had higher average activities of adenylate kinase and lower concentration of cAMP in CSF. Alterations of CSF adenylate kinase and CSF cAMP values were most distinct on the 3rd day after the stroke. Reasons for the changes may be metabolic disorders following brain ischaemia.

Charakteristische Liquorbefunde und Klinik der lymphozytären Meningoradikulitis

SummaryClinical data and Cerebrospinal fluid (CSF) findings of 20 patients suffering from a meningoradiculitis were analyzed. Most patients had a tick bite or an erythema migrans before neurological symptoms occurred. All suffered from severe radicular pain. Predominant neurological symptoms were peripheral palsies of the facial nerve followed by motor paresis of the trunk and the extremities of mostly asymmetric distribution. Predominant CSF alterations were a long lasting inflammatory cellular reaction and an impairment of the blood-CSF barrier. In contrast to the CSF of 17 patients suffering from a polyradiculitis Guillain Barré with a similar total protein content, an intrathecal immunoglobulin IgG synthesis could be confirmed for the majority of the patients. CSF finding would be compatible to a viral as well as a borrelia etiology.

Die Bedeutung der Liquorlaktatbestimmung bei neurologischen Krankheiten

SummaryLactic acid concentration has been determined in the cerebrospinal fluid (CSF) of 715 patients suffering from various neurological diseases. It was found to be most often elevated in cases of ischemic cerebral infarction, cerebral contusion, arteriosclerotic dementia, metastatic encephalitis, bacterial meningitis, menigiosis carcinomatosa and after epileptic seizures. In fewer cases lactate levels were increased with brain tumors, encephalitis, viral meningitis and radiculitis. Diagnostic relevance of CSF lactic acid determination is discussed with regard to ischemic cerebral disorders, differential diagnosis of viral and bacterial meningitis and for the confirmation of epileptic seizures.Lactic acid concentration has been determined in the cerebrospinal fluid (CSF) of 715 patients suffering from various neurological diseases. It was found to be most often elevated in cases of ischemic cerebral infarction, cerebral contusion, arteriosclerotic dementia, metastatic encephalitis, bacterial meningitis, menigiosis carcinomatosa and after epileptic seizures. In fewer cases lactate levels were increased with brain tumors, encephalitis, viral meningitis and radiculitis. Diagnostic relevance of CSF lactic acid determination is discussed with regard to ischemic cerebral disorders, differential diagnosis of viral and bacterial meningitis and for the confirmation of epileptic seizures.

Protein pattern of cerebrospinal fluid in various neurological diseases

SummaryCSF/serum albumin and immunoglobulin G ratios were determined in 520 patients suffering from various neurological diseases. Blood-brain barrier impairment was detectable in most cases of spinal tumour, meningitis, Guillain-Barré syndrome and in two-thirds of the patients with cerebral infarctions. A local IgG formation in the CNS has to be assumed for some cases of meningitis considering the course of the protein dysequilibrium. Autochthonous IgG production together with a barrier dysfunction was found in patients with encephalitis, meningoradiculitis and neurosyphilis. In cases of multiple sclerosis local IgG formation in the CNS was the pre-dominant finding.ZusammenfassungDie Liquor/Serum-Konzentrationsquotienten für Albumin und Immunglobulin G wurden bei 520 Patienten mit unterschiedlichen neurologischen Erkrankungen bestimmt. Eine Störung der Blut-Liquor Schranke hatten die meisten Patienten mit spinalen Tumoren, Meningitiden, Polyradiculitiden und zwei Drittel der Fälle mit Hirninfarkten. Eine lokale IgG-Synthese im Zentralnervensystem muß für einen Teil der Patienten mit Meningitiden angenommen werden. Eine autochthone IgG Bildung zusammen mit einer Blut-Liquorschrankenstörung fanden wir bei Enzephalitiden, Meningoradiculitiden und der Lues cerebrospinalis. Die lokale IgG Produktion war der vorherrschende Befund bei der multiplen Sklerose.