Jens P. Regel

Secretion of sHLA-G molecules in malignancies.

Our clinical studies revealed significantly increased soluble HLA-G (sHLA-G) plasma levels in patients suffering from malignant melanoma, glioma, breast and ovarian cancer. Specific ELISpot assays demonstrate that sHLA-G molecules expressing intron-4 sequences are preferentially secreted by peripheral blood monocytes. In vitro, the sHLA-G secretion of monocytes and tumor cells was strongly enhanced by TH1 cytokines like IFN-alpha, -beta, -gamma whereas TH2 cytokines (e.g. IL-4, -10) had minor effects. As sHLA-G can inhibit the functions of T and NK cells high concentration of these molecules should systemically or at the tumor side reduce the immune surveillance and thus favour the progression of cancer.

Flow Void of Cerebrospinal Fluid in Idiopathic Normal Pressure Hydrocephalus of the Elderly: Can It Predict Outcome after Shunting?

OBJECTIVE We investigate the predictive value of cerebrospinal fluid (CSF) flow void on outcome after shunting in a prospective series of patients with idiopathic normal pressure hydrocephalus (NPH). METHODS The degree and extension of CSF flow void were examined on T2-weighted magnetic resonance imaging scans of 37 elderly patients with idiopathic NPH who underwent subsequent shunting. The degree of flow void was assessed in comparison with the signal of large cerebral arteries. The extension was evaluated via the calculation of sum scores for the occurrence of flow void in different locations of the ventricular system. Those parameters were not considered in the decision to perform shunting. CSF flow void in the aqueduct and the adjacent third and fourth ventricles of the 37 patients with idiopathic NPH was compared with that of 37 age-matched control patients. CSF flow void scores in patients with idiopathic NPH were investigated for correlations between postoperative outcome scores and ventricular width indices. RESULTS No difference was found between the occurrence of aqueductal CSF flow void in patients with idiopathic NPH and the control group. A significant difference, however, was noted for the extension of the CSF flow void, which was greater in the NPH group. Postoperative improvement was found in 33 of 37 patients with idiopathic NPH at a mean follow-up of 15.6 months. Only small, statistically not significant correlations were found between CSF flow void and postoperative outcome. Flow void sum scores, however, correlated significantly with ventricular width indices. CONCLUSION The degree and extension of CSF flow void on T2-weighted magnetic resonance imaging scans have little predictive value for outcome after shunting in patients with idiopathic NPH. The greater extension of the CSF flow void in patients with NPH is most likely related to increased ventricular width. It is not useful to consider CSF flow void findings on conventional magnetic resonance imaging scans in making the decision to offer shunting in patients with idiopathic NPH.

White matter lesions in patients with idiopathic normal pressure hydrocephalus and in an age-matched control group : A comparative study

OBJECTIVE To compare the occurrence of periventricular lesions (PVLs) and deep white matter lesions (DWMLs) in elderly patients with idiopathic normal pressure hydrocephalus (NPH) and in an age-matched control group. METHODS PVLs and DWMLs were evaluated using T2-weighted magnetic resonance scans of 37 patients with idiopathic NPH and 35 participants from an age-matched control group. All patients with idiopathic NPH included in this study improved after shunting. The control group consisted of 16 healthy elderly persons and 19 patients with depression. To allow quantitative assessment and comparison, scores for PVLs and DWMLs were calculated. Furthermore, possible correlations between white matter lesion scores, ventricular width, and age were investigated. RESULTS There was a significantly higher incidence of PVLs and DWMLs in patients with idiopathic NPH. The mean total PVL was 12.1 (range, 2-24) in the NPH group and 3.9 (range, 0-10) in the control group (P < 0.001). The mean total DWML score was 12.9 (range, 3-24) in the NPH group and 4.5 (range, 0-16) in the control group (P < 0.001). There were significant correlations between the severity of PVL and DWML scores in both groups. Only a weak positive correlation between the severity of DWMLs and age was found in the NPH group, whereas this correlation was significant in the control group. There was a significant negative correlation between the width of the anterior horns and the severity of both PVLs and DWMLs in patients with NPH; however, positive correlations were found in the control group. CONCLUSION Elderly patients with idiopathic NPH have more frequent and more severe PVLs and DWMLs than people in age-matched control groups. Our data suggest a frequent co-occurrence of idiopathic NPH and vascular subcortical encephalopathy; however, they do not support a direct causal relationship.

Analysis of intrathecal interleukin-6 as a potential predictive factor for vasospasm in subarachnoid hemorrhage

OBJECTIVEInflammatory response seems to be one of the relevant pathophysiological aspects for developing vasospasm in subarachnoid hemorrhage. The probable diagnostic value of intrathecal proinflammatory markers is still unclear and is assessed in this study. METHODSWe analyzed daily clinical data and laboratory tests of the cerebrospinal fluid (CSF) of 64 patients with mostly poor-grade subarachnoid hemorrhage during a period of 14 days. Special attention was given to the relationship between the development of vasospasm and the time course of the intrathecal interleukin (IL)-6 concentrations in CSF (IL-6CSF). The potential power of IL-6CSF for predicting vasospasm was studied. RESULTSVasospasm developed in 28.1% of the patients, with a mean onset of 6.4 days after bleeding, and was detected by conventional methods. Patients with vasospasm demonstrated statistically significant higher median values of IL-6CSF on Days 4 and 5 (P < 0.05). Most importantly, the increase of IL-6CSF preceded the conventional signs of vasospasm. A cut-off value of IL-6CSF of at least 2000 pg/ml on Day 4 yielded an 11.72-fold higher relative risk (95% confidence interval, 2.93–46.60) of developing vasospasm, predicting vasospasm with a sensitivity of 88.9% and a specificity of 78.3%. We found a statistically significant correlation between IL-6CSF and delayed cerebral ischemia for Day 7 (P = 0.03). However, there was no correlation with IL-6CSF on any other day and outcome. CONCLUSIONIL-6CSF seems to be a reliable early marker for predicting vasospasm after subarachnoid hemorrhage on Days 4 and 5 before clinical onset.

Intraspinal migration of a Kirschner wire 3 months after clavicular fracture fixation

Abstract. The authors describe a patient who had Kirschner (K-) wire osteosynthesis of a right lateral clavicular fracture and developed a tetraparesis after 3 months. Plain X-ray and CT scan showed an intraspinal migration of one K-wire through the intervertebral foramen of C5/6. The K-wire was pulled out through an opening of the wound over the right clavicle. No CSF fistula was seen. The patient recovered without any postoperative neurological deficit. Patients with K-wire osteosynthesis should be informed about the risk of dislocation and wandering and should regularly be seen in the outpatient clinic. Regular X-rays should be performed. The K-wires must be sufficiently bent at the distal end to prevent wandering into the proximal direction. The K-wires should be removed soon after 6 weeks and, in cases of dislocation and migration, as early as possible.

Reliability and validity of ICARS in focal cerebellar lesions

To evaluate the therapies for cerebellar diseases appropriate neurological assessment methods to measure severity of ataxia are required. Reliability and validity of the semiquantitative International Cooperative Ataxia Rating Scale (ICARS) has recently been examined in patients with degenerative ataxias. We evaluated reliability (internal consistency), criterion‐related validity and internal construct validity of ICARS for the first time in patients with focal cerebellar lesions (68 patients with surgical lesions and 68 patients with ischemic lesions). For comparison 45 patients with degenerative cerebellar ataxia were included. We found an excellent Cronbachs α as a measurement for internal consistency which was independent from underlying disease. Criterion‐related validity was high. Total ICARS score mirrored clearly the immediate postsurgical worsening and the improvement during the first 3 months after focal surgical and ischemic lesions, whereas in chronic state of focal and degenerative cerebellar disorders ICARS score remained nearly unchanged. Principal component analysis in patients with focal lesions revealed five distinct and clinically meaningful factors which corresponded to the four ICARS subscores and reflected the laterality of kinetic functions. In degenerative disorders, however, the items for the subscore “kinetic function” loaded to more than one factor. Total ICARS score seems to be a useful and valid measurement to describe the time course of ataxia in patients with focal and degenerative disorders affecting primarily the cerebellum. Validity of subscores however is good in focal, but not in degenerative disorders.

Extended long-term (> 5 years) outcome of cerebrospinal fluid shunting in idiopathic normal pressure hydrocephalus.

BACKGROUNDShunt surgery has been established as the only durable and effective treatment for idiopathic normal pressure hydrocephalus. OBJECTIVEWe evaluated the “extended” long-term follow-up (> 5 years) in a prospective study cohort who underwent shunting between 1990 and 1995. A secondary objective was to determine the cause of death in these patients. METHODSFifty-one patients were included after confirmation of the diagnosis by extensive clinical and diagnostic investigations. Surgery included ventriculoatrial or ventriculoperitoneal shunting with differential pressure valves in the majority of patients. For each of the cardinal symptoms, postoperative outcome was assessed separately with the Krauss Improvement Index, yielding a value between 0 (no benefit) and 1 (optimal benefit) for the overall outcome. RESULTSMean age at surgery was 70.2 years (range, 50–87 years). Thirty patients were women, and 21 were men. Short-term (18.8 ± 16.6 months) follow-up was available for 50 patients. The Krauss Improvement Index was 0.66 ± 0.28. Long-term (80.9 ± 51.6 months) follow-up was available for 34 patients. The Krauss Improvement Index was 0.64 ±0.33. Twenty-nine patients died during the long-term follow-up at a mean age of 75.8 years (range, 55–95 years). The major causes of death were cardiovascular disorders: cardiac failure (n = 7) and cerebral ischemia (n = 12). Other causes were pneumonia (n = 2), acute respiratory distress syndrome (n = 1), pulmonary embolism (n = 1), cancer (n = 2), renal failure (n = 1), and unknown (n = 3). There was no shunt-related mortality. CONCLUSIONIdiopathic normal pressure hydrocephalus patients may benefit from shunting over the long term when rigorous selection criteria are applied. Shunt-related mortality is negligible. The main cause of death is vascular comorbidity.

Epiduralhämatom nach Entlastung eines akuten Subduralhämatoms

ZusammenfassungSubduralhämatome sind häufig Folge eines Schädel-Hirn-Traumas (SHT) und stellen vielfach eine dringliche Operationsindikation dar. Die Patienten werden postoperativ mittels Sedierung und Relaxierung abgeschirmt. Trotz intensivmedizinischer Maßnahmen sind computertomographische Kontrolluntersuchungen unerlässlich. Anhand einer ungewöhnlichen Kasuistik eines Patienten mit akutem Subduralhämatom und nachfolgendem Epiduralhämatom soll dies nochmals veranschaulicht werden. Darüber hinaus soll der Stellenwert der konventionellen Röntgenaufnahme des Schädels im Rahmen der Primärdiagnostik und die Anlage einer intrakraniellen Druckmessung diskutiert werden.AbstractSubdural haematomas as a consequence of severe head injury often constitute the indication for operative evacuation. Despite intensive care management postoperative computed tomography scans are essential. This is illustrated by an unusual case report of a patient suffering from an epidural haematoma after operation of an subdural haematoma. In addition, the importance of the skull X-ray in the emergency setting and intracranial pressure monitoring are discussed.

Epidural haematoma after operative evacuation of an acute subdural haematoma. Discussion of primary treatment illustrated by an unusual case

ZusammenfassungSubduralhämatome sind häufig Folge eines Schädel-Hirn-Traumas (SHT) und stellen vielfach eine dringliche Operationsindikation dar. Die Patienten werden postoperativ mittels Sedierung und Relaxierung abgeschirmt. Trotz intensivmedizinischer Maßnahmen sind computertomographische Kontrolluntersuchungen unerlässlich. Anhand einer ungewöhnlichen Kasuistik eines Patienten mit akutem Subduralhämatom und nachfolgendem Epiduralhämatom soll dies nochmals veranschaulicht werden. Darüber hinaus soll der Stellenwert der konventionellen Röntgenaufnahme des Schädels im Rahmen der Primärdiagnostik und die Anlage einer intrakraniellen Druckmessung diskutiert werden.AbstractSubdural haematomas as a consequence of severe head injury often constitute the indication for operative evacuation. Despite intensive care management postoperative computed tomography scans are essential. This is illustrated by an unusual case report of a patient suffering from an epidural haematoma after operation of an subdural haematoma. In addition, the importance of the skull X-ray in the emergency setting and intracranial pressure monitoring are discussed.