Charly Gaul

Telemedicine in Emergency Evaluation of Acute Stroke: Interrater Agreement in Remote Video Examination With a Novel Multimedia System

Background and Purpose— In acute stroke care, rapid but careful evaluation of patients is mandatory but requires an experienced stroke neurologist. Telemedicine offers the possibility of bringing such expertise quickly to more patients. This study tested for the first time whether remote video examination is feasible and reliable when applied in emergency stroke care using the National Institutes of Health Stroke Scale (NIHSS). Methods— We used a novel multimedia telesupport system for transfer of real-time video sequences and audio data. The remote examiner could direct the set-top camera and zoom from distant overviews to close-ups from the personal computer in his office. Acute stroke patients admitted to our stroke unit were examined on admission in the emergency room. Standardized examination was performed by use of the NIHSS (German version) via telemedicine and compared with bedside application. Results— In this pilot study, 41 patients were examined. Total examination time was 11.4 minutes on average (range, 8 to 18 minutes). None of the examinations had to be stopped or interrupted for technical reasons, although minor problems (brightness, audio quality) with influence on the examination process occurred in 2 sessions. Unweighted &kgr; coefficients ranged from 0.44 to 0.89; weighted &kgr; coefficients, from 0.85 to 0.99. Conclusions— Remote examination of acute stroke patients with a computer-based telesupport system is feasible and reliable when applied in the emergency room; interrater agreement was good to excellent in all items. For more widespread use, some problems that emerge from details like brightness, optimal camera position, and audio quality should be solved.

Neurological Symptoms in Type A Aortic Dissections

Background and Purpose— Aortic dissection typically presents with severe chest or back pain. Neurological symptoms may occur because of occlusion of supplying vessels or general hypotension. Especially in pain-free dissections diagnosis can be difficult and delayed. The purpose of this study is to analyze the association between type A aortic dissection and neurological symptoms. Methods— Clinical records of 102 consecutive patients with aortic dissection (63% male, median age 58 years) over 7.5 years were analyzed for medical history, preoperative clinical characteristics, treatment and outcome with main emphasis on neurological symptoms. Results— Thirty patients showed initial neurological symptoms (29%). Only two-thirds of them reported chest pain, and most patients without initial neurological symptoms experienced pain (94%). Neurological symptoms were attributable to ischemic stroke (16%), spinal cord ischemia (1%), ischemic neuropathy (11%), and hypoxic encephalopathy (2%). Other frequent symptoms were syncopes (6%) and seizures (3%). In half of the patients, neurological symptoms were transient. Postoperatively, neurological symptoms were found in 48% of all patients encompassing ischemic stroke (14%), spinal cord ischemia (4%), ischemic neuropathy (3%), hypoxic encephalopathy (8%), nerve compression (7%), and postoperative delirium (15%). Overall mortality was 23% and did not significantly differ between patients with and without initial neurological symptoms or complications. Conclusion— Aortic dissections might be missed in patients with neurological symptoms but without pain. Neurological findings in elderly hypertensive patients with asymmetrical pulses or cardiac murmur suggest dissection. Especially in patients considered for thrombolytic therapy in acute stroke further diagnostics is essential. Neurological symptoms are not necessarily associated with increased mortality.

Iatrogenic (para-) spinal abscesses and meningitis following injection therapy for low back pain.

&NA; Low back pain is often treated with paraspinal injections of analgesics and steroids. Infectious complications of these techniques are rare but they can potentially hold high risks for the patients. History and clinical data of all patients admitted to a neurological unit suffering from community acquired purulent meningitis were prospectively analyzed during an 8 year interval (1992 and 2000) with special regard to the previous medical history. One hundred and twenty eight patients were included in the study. Eight out of 128 patients (6.25%) had a history of single or repeated paravertebral (4/8), facet‐joint (2/8), peridural (1/8) or spinal (1/8) injections 2–21 days before admission to the hospital. In six out of eight patients either Staphylococcus aureus (4/8) or coagulase‐negative staphylococci (2/8) were found in the cerebro spinal fluid (CSF), in two patients no causative organism was detected. One patient died, three survived with sequel. Repeated paraspinal, peridural or spinal injections with analgesic drugs in combination with corticosteroids hold a risk for parameningeal inoculation of bacteria resulting in paraspinal, spinal, and epidural abscesses or meningitis. The absolute frequency of these complications may be rare but they are responsible for a considerable proportion of community acquired purulent CNS infections.

Does Lumbar Cerebrospinal Fluid Reflect Ventricular Cerebrospinal Fluid? A Prospective Study in Patients with External Ventricular Drainage

Ventriculitis may sometimes occur after an external ventricular drain has been removed, and diagnosis has to be made by lumbar puncture. But are the lumbar findings comparable to previously obtained ventricular results? In a prospective study, sample pairs of ventricular and lumbar cerebrospinal fluid (CSF) were obtained at an interval of <30 min in 25 patients with increased intracranial pressure suffering from cerebral hemorrhage (n = 15), meningitis/encephalitis (n = 6), cerebral infarction (n = 3), and meningeosis carcinomatosa (n = 1). CSF was analyzed for protein, albumin, IgG, IgA, IgM, glucose, lactate, and leukocytes including cytological differentiation. A significant ventriculo-lumbar increase was observed for protein, albumin, and the immunoglobulins. Lactate was distributed equally in ventricular and lumbar CSF, as well as glucose in the cerebral hemorrhage subgroup (n = 15). Cell count failed to show a clear ventriculo-lumbar ratio. Cytological distribution was comparable in lumbar and ventricular CSF, except for macrophages showing a significant rostrocaudal decrease. In conclusion, in cases of clinically suspected bacterial central nervous system infection after removal of an external ventricular drain, lumbar CSF lactate, glucose, and cytology are comparable to previously determined ventricular values, and thus may help physicians to choose the best treatment.

Intravascular lymphomatosis mimicking disseminated encephalomyelitis and encephalomyelopathy

Intravascular lymphomatosis is characterized by the presence of large lymphoma cells predominantly within small vessels. This report presents two patients with diagnostically misleading neurological manifestation of this disease. Case 1, a 63-year-old man, developed a sensorimotor transverse spinal cord syndrome and encephalopathy. Lumbar puncture revealed albuminocytological dissociation. Magnetic resonance imaging (MRI) showed progression of multifocal infarct-like lesions in the brain, the thoracic cord and the medullary cone. Autoimmune inflammation was suspected, and the patient received immunosuppressive therapy with immunoglobulins, steroids and azathioprine. He died 18 months after the onset of symptoms. Case 2, a 68-year-old man, showed fluctuating aphasia, disorientation, and fever for several months. Brain MRI-scan, electroencephalography (EEG) and cerebrospinal fluid (CSF) cytology were inconclusive. Premortal biopsy of lesions in liver and right suprarenal gland showed no further characterized malignancy. He died 6 months after the first occurrence of symptoms. Autopsy of both cases revealed an intravascular lymphomatosis. Tumour cells were seen disseminated in extranodal sites including heart, lung, adrenal gland, spleen, thyroid gland and brain. An intravascular lymphomatosis should be considered when a meningoencephalitic symptomatology is unclear. A biopsy of different organs including the brain and leptomeninges should not be delayed to ensure ante mortem diagnosis and to initiate chemotherapy.