Udo Patzold

Mollaret's meningitis: CSF-immunocytological examinations

SummaryMollarets meningitis is a rare clinical entity consisting of recurrent attacks of meningeal irritation, which, after a sudden onset, last for a few days. The prognosis appears to be excellent, although the aetiology has not been established. In the CSF so-called endothelial cells are a typical finding, but their classification is not yet clear. In the present case immunocytological examination of CSF cells revealed that the so-called Mollaret cells are monocytes. The time course of changes in helper/suppressor ratio is similar to that in other infectious diseases of the central nervous system.

Immune complexes in multiple sclerosis

SummaryUsing a C1q binding test, circulating immune complexes (IC) were detected in 33.3% of sera from 138 patients and in 19.4% of 124 spinal fluid samles from patients with multiple sclerosis. Most often they occur in sera alone. As a rule their detectable amount is small in sera as well as in spinal fluids. IC were observed with equal frequency during acute exacerbations and in stable phases of the disease. In patients with early MS of less than 3 months duration, IC were detected only rarely, whereas their frequency increased up to 50% in patients with longer standing disease. Immunosuppressive therapy has no influence on IC formation. Patients with immune complexes exhibited a more rapid clinical deterioration if compared as a group with IC-negativ ones. No correlations were found between immune complex formation and the CSF-IgG index or the rate of pleocytosis in spinal fluids. Neither the complement factors C3, C4, C3A nor total hemolytic complement activities (CH 50) in serum were significantly decreased in patients with IC formation in serum as compared with the IC-negative group. The results demonstrate that IC formation probably is of no importance in the pathogenesis of multiple sclerosis.ZusammenfassungZirkulierende Immunkomplexe ließen sich mit Hilfe des C1q-Bindungstestes bei 33,3% von 138 Multiple-Sklerose-Kranken im Serum und bei 19,4% von 124 Multiple-Sklerose-Kranken im Liquor nachweisen. Sie traten zumeist im Serum allein auf. Ihre nachweisbare Menge war sowohl im Serum als auch im Liquor häufig nur gering.Sie traten in akuten Stadien der Erkrankung ebenso häufig auf wie in relativ stabilen Phasen. Bei frisch Erkrankten mit einer Krankheitsdauer von maximal 3 Monaten sind sie sehr selten. Bei längerer Krankheitsdauer lassen sie sich dann bei 40–50% der erkrankten Personen nachweisen, auch noch nach jahre- oder jahrzehntelangem Verlauf. Bei einer zweijährigen Verlaufsbeobachtung zeigte sich, daß bei Personen mit zirkulierenden Immunkomplexen die Multiple Sklerose rascher fortschreitet. Eine immunsuppressive Behandlung ist ohne Einfluß auf die Bildung der Immunkomplexe. Ihre Entstehung ist auch unabhängig von der Immunglobulin G-Erhöhung im Liquor und dem Ausmaß der Pleozytose. Eine Verminderung einzelner Komplementfraktionen (CH 50, C3, C4, C3A) war bei Personen mit zirkulierenden Immunkomplexen nicht festzustellen.Die Untersuchung macht deutlich, daß Immunkomplexe wahrscheinlich keine entscheidende Rolle in der Pathogenese der Multiplen Sklerose spielen.

Aphasia and Non-Verbal Intelligence in Brain Tumour Patients

SummaryPatients with primary brain tumours were investigated using the Aachen Aphasia Test and subtests of the Wechsler Adult Intelligence Scale (WAIS). The statistical evaluation of the data from 43 patients indicated that: (1) Aphasia was an amnestic aphasia, independent of the localization of the tumour within the dominant hemisphere; (2) aphasics have no more intellectual impairment than non-aphasics with similar brain lesions; (3) the severity of the aphasic syndrome does not correlate with the WAIS; (4) with right-sided tumours, there was correlation between the speech reception subtest and the WAIS. We conjecture that this subtest tested visuocognitive abilities in patients with right-sided brain lesions.Zusammenfassung43 Kranke mit Hirntumoren unterschiedlicher Lokalisation und Art wurden mit dem Aachener Aphasie Test untersucht. Bei den meisten Personen wurde zur gleichen Zeit der Handlungsintelligenzquotient mit Hilfe des Hamburg-Wechsler-Intelligenz-Testes ermittelt. Die Untersuchung hat folgendes ergeben:1.Sprachstörungen bei Hirntumorkranken sind in der Regel amnestische Aphasien, unabhängig vom prä- oder postsylvischen Sitz der Geschwülste.2.Personen mit Aphasie haben keine größere Intelligenzstörung als nicht aphasische mit gleicher Hirnschädigung.3.Die Schwere der Aphasie korreliert nicht mit dem Handlungsintelligenzquotienten.4.Bei rechtshirnigen Geschwulstträgern korrelieren die Leistungen in dem Untertest Sprachverständnis des Aachener Aphasie Tests mit dem Handlungs-IQ. Dies läßt vermuten, daß dieser Untertest auch visuo-cognitive Fähigkeiten prüft.

Reactivity of sera and isolated monoclonal IgM from patients with waldenström's macroglobulinaemia with peripheral nerve myelin

SummarySera of 23 patients with Waldenströms macroglobulinaemia and six monoclonal IgM paraproteins, which had been isolated from these sera, were examined for reactivity against peripheral nerve tissue. Of theser 23 patients, 12 had clinical signs of peripheral polyneuropathy (PN). Using an indirect immunofluorescence method, all sera and monoclonal IgM preparations reacted with peripheral nerve structures, displaying a distinct granular fluorescence pattern with anti-IgM sera. The Waldenström sera reacted mainly with structures at the border of the myelin sheath, as well as between myelin and axon, and occasionally with the axon itself. There was no difference between sera of patients with PN and those without. Negative results were obtained in a complement fixation assay. Of the 23 sera, 15 reacted in an antibody-dependent lymphocyte-mediated cytotoxicity reaction (ADLC) with peripheral nerve myelin, and to a much lesser extent with myelin basic protein from CNS. Five of the six isolated monoclonal IgM preparations also gave positive ADLC reactions. These results constitute additional evidence for an immunological mechanism in the pathogenesis of PN in Waldenströms macroglobulinaemia.

Liquorcytologischer Nachweis von primären und sekundären Geschwülsten des Zentralnervensystems

SummaryIn the routine cytological examination of the lumbar CSF of 4000 patients, the diagnosis of a tumour was made in 46 cases, most being metastases to the CNS, 20 having meningeal carcinomatosis. There were 9 malignant cerebral tumours of neuroepithelial origin, 2 spinal meningioma and 1 spinal neurinomas. Autochtonous cerebral tumours rarely exfoliate or become differentiated so are more difficult to identify and especially to distinguish from the nonspecific CSF irritation syndrome. On the other hand metastases are morphologically distuinguishable by cell type and the large number of mitoses. Cytological study of the CSF is of great diagnostic value and, in some cases is the only way to make the correct diagnosis.ZusammenfassungBei routinemäßiger cytologischer Untersuchung von 4000 Liquores wurde 45mal der Verdacht auf einen Tumor geäußert. 12 primäre Hirntumoren waren 9mal intrakraniell und nur 3mal intraspinal lokalisiert; letztere waren ausnahmslos gutartig (2 Meningeome, 1 Neurinom). Bei den anderen handelte es sich ausnahmslos um sekundäre Geschwülste des Zentralnervensystems, 20mal um diffuse oder umschriebene Meningeal-carcinosen mit oder ohne Abtropfmetastasen längs der Hirnnerven oder Wurzeln. Autochthone Hirntumoren sind durch geringe Exfoliationsfreudigkeit und wenig ausgeprägte Zellatypien cytologisch viel schwerer und somit seltener zu erfassen und nicht leicht gegen unspezifische Liquorreizsyndrome abzugrenzen. Metastasen dagegen bieten ein auffallendes Zellbild mit oft reichlich atypischen Mitosen. Bei den primären und den intracerebralen sekundären Tumoren des ZNS bestätigt der liquorcytologische Befund im allgemeinen lediglich die Ergebnisse anderer Untersuchungsmethoden. Vor allem aber bei den sog. Meningealcarcinosen stellt er jedoch oft die einzige wegweisende Untersuchungsmethode dar.In the routine cytological examination of the lumbar CSF of 4000 patients, the diagnosis of a tumour was made in 46 cases, most being metastases to the CNS, 20 having meningeal carcinomatosis. There were 9 malignant cerebral tumours of neuroepithelial origin, 2 spinal meningioma and 1 spinal neurinomas. Autochtonous cerebral tumours rarely exfoliate or become differentiated so are more difficult to identify and especially to distinguish from the nonspecific CSF irritation syndrome. On the other hand metastases are morphologically distuinguishable by cell type and the large number of mitoses. Cytological study of the CSF is of great diagnostic value and, in some cases is the only way to make the correct diagnosis.

Epileptische Anfälle bei Hirngeschwülsten

SummaryAfter our work on the diagnostic value of epileptic seizures for location and morphology of brain tumors, the records of the same 946 patients were reviewed for any diagnostic value of the type of convulsive seizures. Again IBM computer 360/67 (program “Paula”) was used for the data processing.The type of convulsive seizures depends on the location of the tumor. Grand mal occurs most often with tumors of the frontal lobe but quite frequently with tumors in other locations. Occasionally they are seen with tumors expanding into the temporal or occipital lobe only. If Jacksonian epilepsy occurs, the tumor may be located in the frontoparietal or parieto-occipital area but is most often in the parietal area only. If the patient suffers from psychomotor epilepsy, the tumor is usually expanding into the temporal lobe or the frontotemporal or temporo-occipital area.The combination of grand mal with Jacksonian epilepsy is most often seen with tumors of the frontal and the parietal lobe, while grand mal and psychomotor epilepsy frequently occur together with tumors of frontal and temporal lobe. Expansion into subcortical regions often favors the manifestation of both combinations. Psychomotor epilepsy alone is frequently found with temporal tumors and Jacksonian epilepsy alone with parietal tumors, whereas the occurrence of isolated grand mal is independent of the location of the tumor.However, the type of the seizures also depends on the type of the tumor. Isolated psychomotor epilepsy is most often seen with astrozytomas of the frontal or temporal lobe. In addition, the combination of psychomotor and Jacksonian epilepsy and the combination of all three types of convulsions only occur in astrozytomas of the temporal lobe. If grand mal and psychomotor epilepsy appear, the tumor is most often an oligodendroglioma situated either in the frontotemporal lobe or in the temporo-occipital area. This combination is also often seen in astrozytomas of the temporal lobe. Grand mal and Jacksonian epilepsy are frequently found with frontal or parietal meningeomas, oligodendrogliomas or astrozytomas. If Jacksonian epilepsy occurs alone, the tumor is likely to be a meningeoma, metastasis, glioblastoma or astrozytoma of the parietal lobe. Isolated grand mal has no diagnostic value for the morphology.ZusammenfassungIn Ergänzung zu den jüngst in dieser Zeitschrift mitgeteilten ersten Ergebnissen unserer Untersuchung über die „Tumorepilepsie“ wurde der diagnostische Wert verschiedener Anfallsformen für Topik und Morphologie intrakranieller Blastome geprüft. Hierbei hat sich ergeben:1.Der Anfallstyp wird, wie zu erwarten war, von der Geschwulstlokalisation bestimmt. Grand mal werden am häufigsten von Stirnhirngeschwülsten hervorgerufen. Sie kommen jedoch überzufällig häufig auch bei anders lokalisierten Geschwülsten vor, nur nicht bei solchen, die isoliert im Temporal- oder Occipitallappen gelegen sind. Das Auftreten fokal-motorischer Anfälle ist an einen Geschwulstsitz in der Zentroparietalregion oder den angrenzenden Hirnregionen geknüpft. Psychomotorische Anfälle weisen auf einen frontotemporalen, temporalen oder temporooccipitalen Geschwulstsitz hin.2.Darüber hinaus läßt sich nachweisen, daß die Häufigkeit der verschiedenen Anfallsformen auch von der Morphologie der Geschwülste abhängt. Offensichtlich ebnen die einzelnen Geschwülste verschiedenen Anfallsarten den Weg. Bemerkenswert ist, daß isolierte psychomotorische Anfälle nur bei frontal oder temporal ausgebreiteten Astrocytomen überzufällig häufig zur Beobachtung gelangen.3.Die im einzelnen aufgezeigten Beziehungen machen wahrscheinlich, daß die phylogenetisch jüngsten und ontogenetisch spätentwickeltsten Hirnanteile die niedrigste Krampfschwelle und die geringste Fähigkeit zur Eingrenzung einer einmal entstandenen Krampfaktivität haben.

Myelomnachweis mittels Liquorcytologie

SummaryMyeloma cells in CSF have been described by Spaar and Argyrakis in a case of an unusual type of plasocytoma which involved the cerebrospinal leptomeninges and subarachnoid spaces mainly.In addition to this paper a case of myeloma is reported, in which the diagnosis of this disease could only be verified by specific cytologic evaluation of the CSF too.

Zur Problematik der Früherkennung von Hirngeschwülsten, die als einziges Symptom epileptische Anfälle hervorrufen

SummaryThe diagnosis of brain tumour could not be made in 91 cases at the first investigation in a group of 1155 brain tumours. Slowly growing gliomas causing only epileptic fits and no other symptoms are especially difficult to diagnose.Of 21 personal observations of tumour seizures, in which the diagnosis of the neoplasm was missed at the first investigation in hospital, 9 were oligodendrogliomas, 5 astrocytomas, 3 glioblastomas, 2 spongioblastomas, 1 gangliocytoma and 1 a metastasis. They were all located in the frontal or centroparietal region. In most cases the seizures appeared during the third or fourth decade. The average interval between the first epileptic fit and the tumour diagnosis was 8.2 years in cases of oligodendrogliomas and 2.2 years in astrocytomas.5 patients had major seizures, 2 had psychomotor attacks and all the others suffered from partial epilepsy. Anticonvulsive therapy was often successfull; either the frequency of the fits diminished or, in 2 cases, the character of the seizures changed.18 patients had a normal neurostatus at time of the first investigation. Only 3 patients had a slight difference of physiological reflexes, but no other pathological signs. In none of the patients did investigation of the CSF, skull X-rays, brain scanning, pneumencephalography or cerebral angiography first lead to the diagnosis of a brain tumour. The EEG alone showed focal signs corresponding to the location of the tumour in about 50% of the cases.ZusammenfassungVon 1155 Hirngeschwülsten war in 91 Fällen die Diagnose bei der ersten stationären Durchuntersuchung in einer neurologischen Klinik nicht gestellt worden. Insbesondere langsam wachsende Gliome, die zunächst lediglich epileptische Anfälle hervorrufen, entziehen sich leicht dem Nachweis.An Hand von 21 eigene Beobachtungen, bei denen sich die zugrundeliegende Geschwulst zunächst nicht hat fassen lassen, werden die bei der Früherkennung der Tumorepilepsie anstehenden Probleme besprochen.The diagnosis of brain tumour could not be made in 91 cases at the first investigation in a group of 1155 brain tumours. Slowly growing gliomas causing only epileptic fits and no other symptoms are especially difficult to diagnose. Of 21 personal observations of tumour seizures, in which the diagnosis of the neoplasm was missed at the first investigation in hospital, 9 were oligodendrogliomas, 5 astrocytomas, 3 glioblastomas, 2 spongioblastomas, 1 gangliocytoma and 1 a metastasis. They were all located in the frontal or centroparietal region. In most cases the seizures appeared during the third or fourth decade. The average interval between the first epileptic fit and the tumour diagnosis was 8.2 years in cases of oligodendrogliomas and 2.2 years in astrocytomas. 5 patients had major seizures, 2 had psychomotor attacks and all the others suffered from partial epilepsy. Anticonvulsive therapy was often successfull; either the frequency of the fits diminished or, in 2 cases, the character of the seizures changed. 18 patients had a normal neurostatus at time of the first investigation. Only 3 patients had a slight difference of physiological reflexes, but no other pathological signs. In none of the patients did investigation of the CSF, skull X-rays, brain scanning, pneumencephalography or cerebral angiography first lead to the diagnosis of a brain tumour. The EEG alone showed focal signs corresponding to the location of the tumour in about 50% of the cases.