904 sure, loss of endothelium-dependent vasodilatation due to acetylcholin, discrete morphological lesions in the endothelium and vascular musculature and a disruption of the brain-blood barrier permitting leakage of fluids and plasma proteins; in addition, vascular dilatation is modulated by biochemical mediators; superoxyde-anion radicals, which form during acute hypertension. An accelerated arachidonic acid metabolism may play a primary role . Moreover, several authors have demonstrated dysfunction of the blood-brain barrier in animal experiments of induced acute hypertension. Auer found diffuse distension of arterioles in which he interpreted as overstretching of the muscular vascular wall due to high intraluminal pressure. Blood flow autoregulation occurs primarily in precapillary arterioles. In addition, activation of the sympathicus constricts larger extraparenchymatous vessels, which protects the dependent pathways, especially when the upper limits of cerebral autoregulation are exceeded. Clinical symptoms of acute hypertensive encephalopathy are headache, qualitative and quantitative impairments in vigilance, epileptic seizures, visual impairment or focal Introduction

The aim of the present prospective study was to investigate whether hyperglycemia influences the clinical outcome or the infarct size after intravenous thrombolysis of focal cerebral ischemia. A consecutive series of hyperglycemic (n = 14) and normoglycemic patients (n = 17) with acute focal cerebral ischemia (<3 h) in the middle cerebral artery (MCA) territory received rtPA (0.9 mg/kg body weight) intravenously. Clinical outcome was measured using the NIH Stroke Score on admission and was followed up until day 28. Infarct volume was measured by diffusion-weighted MR imaging on admission, on days 3 and 7. There was a significantly better neurological outcome on day 28 in the normoglycemic patients than in the hyperglycemic group (NIH SS 4.0 versus 7.4; p < 0.05). The infarction volume increased significantly in the hyperglycemic patients Δ = 39.9 ± 17.4% compared to normoglycemic patients Δ = 27.1 ± 14.1% (p < 0.05). The present study suggests that hyperglycemia in patients with a focal MCA ischemia can cause a worse clinical outcome despite recanalization of the occluded vessel by thrombolysis therapy. This correlates with a markedly larger increase of the infarction volume in the hyperglycemic group. These results may be explained by an accentuated lactate accumulation and pH decrease by elevated energy levels which cannot be compensated by restoration of blood flow alone.

The development of non-invasive diagnostic methods is a matter of great importance. This paper describes Motion Sensitized Single Shot RARE Sequences (MoSeSS) as a new, non-invasive diagnostic method in CSF-flow disturbances. The range of applications and clinical validity are examined. The strongly T2-weighted RARE-sequence displays selectively unbound water. The addition of flowencoding gradients shows moving spins flow-dependently as a signal reduction. ECG-triggering enablesthe registration of present flow phases, and the CSF-flow can be observed as cine-mode in quasi real-time. Thirty healthy subjects and 137 patients from subcollectives with diverse CSF-flow disturbances were investigated. The MoSeSS RARE-sequence provides reliable information in occlusion or stenoses of the inner CSF-spaces and in ventriculocisternostomies. Indirect signs of shunt dysfunction are CSF turbulences which correlate in degree with the increase in CSF pressure. Determination of localization and degree of dural impairment in traumatic or postoperative pseudomeningoceles is dependent on the activity of the CSF-flow at the leak. Depending on the stage of NPH, a variably marked active flow oscillation in the aqueduct and in the third ventricle is shown. Liquorrhoea has no definable flow detectable with the MoSeSS RARE-sequence. Vascular pulsation can make differentiation of the CSF-flow from artefacts difficult near larger vessels. The MoSeSS-RARE-Sequence is a fast, non-invasive and radiation-free method, which yields valid clinical information on circulation disturbances in the inner CSF-spaces. With the cine-mode technique, CSF movements can be observed in quasi real-time. Positive enhancement of the CSF is necessary in assessing processes with an undefined, non-detectable flow.

The capability of magnetic resonance imaging (MRI) to differentiate and simultaneously depict osseous, discoligamentary, muscular, neural structures and CSF cavities has attained a specific degree of importance, particularly in functional diagnostic of the spinal column (SC), and even more especially in the cervical spine (CS). The examination process is, however, influenced by the apparatus-technical conditions such that the diagnostic value is considerably limited. Except for a few trials with open, low field equipment with limited resolution, which performed functional examination of the CS in upright position, this is usually performed in a closed system on the supine patient.Examination in the supine position are highly problematic for the assessment of functional defects in the cervical spine. The supporting mat leads to a passive compliance of the cervical structures, the possible artificially simplified movement in this position causes loss of the effect of all functional mechanisms.Therefore examination in the upright position appears to be mandatory. A neutral, self-controlled upright position, in which the gravitational force is actively balanced should be the starting point for motional examinations. At the same time high spatial and temporal resolution are necessary to study the detailed motional displacement of the relevant structures.An optimized MR-system for such examinations will therefore require a magnetic field strenght of at least 1 T. Technically such a concept can be realized by a superconductive magnet with a vertical bore. Apart from the technical system specifications, appropriate devices for patient positionig and standardized motional excursions have to be realized in order to permit functional diagnostic of the CS appropriate to the real physiological situation.

Zusammenfassung Die Inzidenz der Sinus- und Hirnvenenthrombosen (SVT) wurde 1936 mit 0,1% (9) und 1973 mit 9% (24) angegeben. Die eigenen Erfahrungen der letzten 10 Jahre deuten jedoch darauf hin, daß die Prozentzahl noch weiter nach oben korrigiert werden muß. Für diese Entwicklung wesentliche Faktoren sind: a) Die Vorteile einer frühzeitigen Behandlung einer SVT gegenüber einer nicht oder spät behandelten SVT wecken zunehmend das Interesse der Kliniker an ihrer Diagnostik. b) Durch die Verfügbarkeit und technische Entwicklung der diagnostischen Verfahren werden klinische Verdachtsdiagnosen einer SVT häufiger bestätigt werden als noch vor ca. zehn Jahren. c) In den letzten zwanzig Jahren sind zusätzliche Noxen wie Alkohol und Zigaretten, Drogen, Pilleneinnahme, die eine SVT begünstigen, mit steigender Frequenz zu verzeichnen. d) Die längeren Überlebenszeiten bei diversen Krankheiten, die in unterschiedlichen Stadien eine SVT als Komplikation induzieren. Ätiologisch unterscheidet man infektiös-septische Thrombosen nach eitrigen Entzündungen des Ohrs oder der Nasennebenhöhlen, nach Meningitiden oder nach septischer Streuung von den häufigeren blanden Thrombosen. Letztere kommen postpartal, bei exogener Hormonzufuhr, bei hämatologischen Störungen, posttraumatisch und auch ohne erkennbare Ursache vor. Kinder und Neugeborene können allein infolge einer Dehydratation oder Unterernährung an einer Hirnvenen- und Sinusvenenthrombose erkranken.

This case report emphasizes the importance of central nervous system infections for the differential diagnosis of psychiatric symptoms. We report on a patient with progressive depressive symptoms culminating in delirium. The results of cerebrospinal fluid examination (lymphomonocytic pleocytosis with markedly increased protein and reduced glucose quotient) and magnetic resonance imaging (pronounced enhancement of the basal leptomeninges, diffuse brain oedema, and marked hydrocephalus) suggested a diagnosis of neurotuberculosis. An extensive search for an infectious agent was negative, apart from a weakly positive polymerase chain reaction indicating tuberculi in the cerebrospinal fluid. Upon treatment with combination anti-tuberculous therapy, the cerebrospinal fluid and magnetic resonance imaging abnormalities resolved and the patient's psychiatric and neurologic symptoms dissipated. The patient's clinical course and the exclusion of other etiologies support the diagnosis of tuberculous meningoencephalitis. This case report illustrates the occurrence of the often poorly described psychopatilological changes as the presenting manifestations of tuberculous meningoencephalitis and the importance of initiating empiric anti-tuberculous therapy if tuberculosis is suspected, whereas cultures for tuberculosis remain negative.

A newborn male child was admitted with hypoxemia, high output failure, hypertrophic right lower limb with a segmental pink naevus flammeus, lymphatic edema, subcutaneous varices and multiple arteriovenous fistulae (AVF) spinal and pelvine; findings of the Klippel-Trenaunay- / Parkes-Weber-Overlap Syndrom (KTW). Because of a threatening right heart insufficiency caused by the shuntvolume, the child was embolized as early as 5 months of age. In the course of 5 years, a total of 17 spinal and pelvic feeding arteries were occluded in 6 sessions using Histoacryl, Platincoils or Ethibloc. The low weight of the child's body (4.3 kg) and cardiac insufficiency (CI) limited the amount of contrast agent and fluid. To reduce the amount of contrast agent used for diagnostic purposes we analyzed the pathological hemodynamics by magnetic resonance angiography (MRA). Within 5 years normal bodily development took place with no sings of exponential growth of the affected leg. We understand the “newly formed” fistulae in the current angiography as a local hemodynamic activation of persistent primitive arteriovenous communication caused by mesodermal disturbances, the degree of which correlate with the prognosis.

Since the introduction of CT and MRI as diagnostic aids, it has been possible to obtain direct images of neoplastic meningiosis. After more than ten years experience, the combination of MRI with the administration of a paramagnetic contrast medium is now accepted as the method of choice for the sensitive detection of meningeal diseases and for monitoring their treatment. The almost uniform character of leptomeningeal or pachymeningeal enhancement in the presence of infective, inflammatory, neoplastic, vascular or reactive changes is the reason for the restricted specificity of MRI, so that with the imaging process alone only very limited information about the etiology is available. Clinical data, laboratory findings, examination of the CSF and histopathological examination are therefore essential for interpreting the meningeal changes and making a differential diagnosis. Various pathophysiological processes can lead to a single meningeal enhancement visualizable with MRI: 1. a genuine disturbance of the blood-brain barrier is found in the presence of infection or inflammation, 2. leptomeningeal structures can be directly infiltrated by sheets or nodules of tumors, the blood vessels of which possess no intact blood-brain barrier, 3. physical or chemical irritants may produce of local inflammatory reaction with vascular proliferation and its corresponding enhancement, a 4. a pseudoenhancement may follow reactive dilatation of the vessels. In the present article the various appearances of neoplastic invasion of the meninges in MRI and their differential diagnosis will be described.

In a prospective series of symptomatic adult hydrocephalus characterized by gait disturbance, cognitive impairment, and/or urinary incontinence, 88 of 118 patients (75%) had additional akinetic, tremulous, hypertonic, or hyperkinetic movement disorders. Their prevalence was highest in patients with idiopathic normal pressure hydrocephalus (NPH) of the elderly (56/65 patients, 86%), and they were less frequent in patients with secondary NPH (10/15, 66%), with nonhydrodynamic atrophic/other hydrocephalus (20/33, 61%), and with obstructive hydrocephalus/aqueductal stenosis (2/5, 40%). Akinetic symptoms were found in 73 of 118 patients (62%), and the most frequent movement disorder was upper extremity bradykinesia (55%). Akinetic, tremulous, hypertonic, and hyperkinetic movement disorders were exclusively secondary to causes not related to hydrocephalus in 24 of 118 patients (20%). The proportion of patients with movement disorders not attributable to only such causes was highest in the idiopathic NPH group (44/65, 68%). Thirteen of 118 patients (11%) presented with a parkinsonian syndrome. There was evidence for coexistent Parkinson's disease in four of these patients. Parkinsonism was found to be secondary to NPH in five patients and was found improved after shunting. Akinetic symptoms in patients with NPH generally responded favorably to CSF diversion, which was evident in 80% of a subset of this group. Various other movement disorders did not show definite improvement. The high prevalence of bradykinesia and other akinetic symptoms in NPH and the beneficial effect of shunting on such symptoms suggest that NPH may cause a more generalized disorder of motor function.