Biomedical subjects
Publications and source records attributed to A Lozano.
Two patients with movement disorders associated with syringomyelia are described, one of whom developed unusual torticollis, and the other had choreoathetoid-dystonic movements of the hand and arm. In each case, the movements resolved with decompression of the syrinx. The literature is reviewed and possible mechanisms explored.
We report two cases of transient epileptic foci in humans associated with placement of intracranial electrodes. The abnormalities consisted of restricted areas of active, almost continuous, rhythmic spiking, intermittently evolving into electrographic seizure activity, which resolved spontaneously within 3-4 days. The first occurred after placement of a subdural electrode grid and the second following insertion of epidural peg electrodes. Neuroimaging demonstrated a small subdural hematoma overlying the grid and a focal intraparenchymal hemorrhage underlying the affected epidural electrodes. The insertion of intracranial electrodes may be complicated by the induction of transient epileptic foci unrelated to a patient's typical epileptic generator.
Primary central nervous system lymphoma (PCNSL) is a relatively uncommon disease in which spontaneous remission is exceedingly rare. We are reporting three cases of primary CNS lymphoma with spontaneous regression in two to eight weeks, from the time of the initial diagnosis. The remission lasted for four years in the first case, two years in the second, and one year in the third case. Tissue diagnosis was made in the first two cases after relapse, and in the third case a biopsy was done at the initial presentation. The literature and the possible pathophysiological mechanisms of this interesting phenomenon are discussed.
A rigorous characterization of the dynamic regimes underlying human seizures is needed to understand, and possibly control, the transition to seizure. Intra- or extracranial brain electrical activity was recorded in five patients with partial epilepsy, and the interictal and ictal activity analysed to determine the dynamics of seizures. We constructed first-return one-dimensional maps by fitting the scatter plots of interpeak intervals. The features of the mapping indicated that type III intermittency is the dynamic characteristic of the ictal events. This was confirmed using histograms of the durations of the regular phases during seizures. The intermittent regime explains the abrupt transitions observed during ictal events in terms of transient stabilization of the unstable steady state.
BACKGROUND: The prognostic significance of epileptiform activity (EA) recorded intraoperatively at electrocorticography (ECOG) in patients with lesion-related frontal lobe epilepsy (FLE) is unknown. METHODS: The results of ECOG performed in 22 patients with intractable FLE and a circumscribed frontal lobe structural lesion were compared with postoperative seizure control. Three patients underwent re-operation for a total of 25 cases, 23/25 with post-resection ECOG. Lesions were neoplasms (12), hamartomas (6) and arteriovenous malformations (4). RESULTS: Outcomes were 15/25 Class I, 5/25 Class III and 5/25 Class IV (Engel classification). Class I outcome was associated with pre-excision EA recorded from < or = 2 gyri (p < 0.05) and absence of EA, or EA limited to the resection border, at post-excision ECOG (p < 0.01). Complete lesion excision was highly correlated with Class I outcome (p < 0.001). The most significant correlations were seen when ECOG and lesionectomy variables were considered together: all 12 cases with complete lesionectomy and absent post-excision EA distant to the resection border had Class I outcome (p < 0.00015) and all 13 cases with complete lesionectomy and pre-excision EA recorded from < or = 2 gyri had Class I outcome (p < 0.00005). CONCLUSIONS: Postoperative seizure control in lesion-related FLE is assured in the setting of complete lesion resection with pre-excision EA recorded from < or 2 gyri and no post-excision EA distant to the resection border; complete lesion excision is of paramount importance.
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Galanin can normally be detected only in a few dorsal root ganglion (DRG) neurons, but it is dramatically upregulated after peripheral nerve injury in both rat and monkey. Galanin is stored in large dense core vesicles, which after axotomy are often found close to the membrane of afferent nerve endings in the dorsal horn. In the monkey there is an increase in galanin in many nerve terminals in the superficial dorsal horn after axotomy, but such an increase is more difficult to detect in the rat. Galanin is also present in local dorsal horn neurons, where it is upregulated by peripheral inflammation. Both galanin-R1 and galanin-R2 receptor mRNAs are expressed in rat DRGs, mainly in, respectively, large and small DRG neurons. Galanin-R1 receptor mRNA is downregulated in DRG neurons after axotomy, and a small decrease in galanin-R2 receptor mRNA levels can also be seen. After peripheral tissue inflammation galanin-R1 receptor mRNA levels decrease and galanin-R2 receptor mRNA levels increase. The present results show that galanin and galanin receptors are present in sensory and local dorsal horn neurons and are regulated by nerve injury and inflammation. Galanin may therefore be involved in processing of pain information, primarily exerting analgesic effects. Whereas local dorsal horn neurons represent a defense system against inflammatory pain, we have proposed that a second defense system, against neuropathic pain, is intrinsic to DRG neurons.
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OBJECTIVE: To evaluate, in a double-blind fashion, the efficacy of deep brain stimulation of the internal segment of the globus pallidus (GPi) contralateral to a previous unilateral medial pallidotomy (MP). METHODS: This pilot study involved 4 patients with a previous MP and one previously unoperated patient unable to tolerate any antiparkinsonian drugs. One of the patients with a prior unilateral MP had two electrodes implanted in the contralateral side, one in GPi and one in Vim thalamus. Detailed neurologic assessments were performed after overnight drug withdrawal and in the drug "on" state at baseline, 1 week and 3 months (in all), and 9 and 12 months (one) with patients and evaluators blinded to the status of stimulation. RESULTS: GPi stimulation resulted in improvements in "off-period" contralateral bradykinesia, rigidity and tremor in all patients. Dyskinesias and freezing episodes were ameliorated in one patient each but dyskinesias were transiently induced in another. The patient with GPi + Vim electrodes had complete resolution of contralateral tremor with thalamic stimulation but less benefit from acute GPi stimulation. One patient experienced a single seizure one week post-op and no other surgical complications were observed. CONCLUSIONS: Deep brain stimulation can be applied safely and effectively in patients who have already had a pallidotomy on the contralateral side. The effect of stimulation at different sites on different symptom profiles and levodopa-induced dyskinesias requires further evaluation.
BACKGROUND: Hepatitis C virus (HCV) infection in a population of haemodialysed patients was studied over a 3-year follow-up period in order to evaluate the changes in viral RNA, diversity of genotypes, and serological response to synthetic HCV peptides. METHODS: Twenty-eight (32.9%) patients with anti-HCV antibodies from a total of 85 patients assigned to a haemodialysis unit were studied. The serological response to immunopeptides was evaluated by immunoblotting, viral RNA in serum was detected using the polymerase chain reaction (RT-PCR), and genotyping was carried out by hybridization with probes fixed to nitrocellulose paper. RESULTS: Of the 28 haemodialysis patients who had anti-HCV antibodies, three (10.7%) were always RNA negative, six (21.4%) were always RNA positive, and 19 (67.8%) were variable RNA. There was an incomplete antibody response to non structural antigens in non-viraemic patients. Genotype was determined in 23 patients, and the other two could not be genotyped. The most common genotype was 1b (69.4%), followed by 1a (17.4%), and 2a, 3a, and 4a (each 4.4%). CONCLUSIONS: Haemodialysis patients, when followed up for a long time, frequently show an intermittent HCV viraemia state, suggesting that HCV cannot be evaluated adequately by isolated RNA determinations.
The immediate motor effects of stimulation through electrodes chronically implanted in the globus pallidus internus (GPI) were studied in 9 subjects with Parkinson's disease. Single stimuli (at >>0.4 Hz) produced short latency facilitation of voluntarily activated contralateral muscles in all subjects. The latency and distribution of the facilitation, its probably monosynaptic nature, and the short chronaxie and refractory period of the activated neural elements suggest that the facilitation results from the direct excitation of the fast conducting corticospinal pathway. The facilitation of motoneurons followed high frequency (e.g. 200 Hz) stimulation without decrement and occurred at stimulus intensities well below those required to produce a visible muscle contraction. We conclude that, while there may be other effects, GPI stimulation through electrodes may activate the corticospinal tract, even when the stimuli are below the threshold for a visible muscle contraction, and that continuous stimulation may do so continuously. This may be an unwanted side effect, but possible therapeutic actions are considered. The reproducible short latency facilitation enabled us to estimate current spread from the quadripolar electrodes used for deep brain stimulation. When the current is sufficient to excite large myelinated fibers near one of the quadripolar electrodes, an additional 1-mA current will activate similar fibers at an additional distance of 1.8 mm with bipolar stimulation and at a distance of 5.7 mm with monopolar stimulation.
OBJECT: Many neurosurgeons routinely obtain computerized tomography (CT) scans to rule out hemorrhage in patients after stereotactic procedures. In the present prospective study, the authors investigated the rate of silent hemorrhage and delayed deterioration after stereotactic biopsy sampling and the role of postbiopsy CT scanning. METHODS: A subset of patients (the last 102 of approximately 800 patients) who underwent stereotactic brain biopsies at the Toronto Hospital prospectively underwent routine postoperative CT scanning within hours of the biopsy procedure. Their medical charts and CT scans were then reviewed. A postoperative CT scan was obtained in 102 patients (aged 17-87 years) who underwent stereotactic biopsy between June 1994 and September 1996. Sixty-one patients (59.8%) exhibited hemorrhages, mostly intracerebral (54.9%), on the immediate postoperative scan. Only six of these patients were clinically suspected to have suffered a hemorrhage based on immediate postoperative neurological deficit: in the remaining 55 (53.9%) of 102 patients, the hemorrhage was clinically silent and unsuspected. Among the clinically silent intracerebral hemorrhages, 22 measured less than 5 mm. 20 between 5 and 10 mm, five between 10 and 30 mm, and four between 30 and 40 mm. Of the 55 patients with clinically silent hemorrhages, only three demonstrated a delayed neurological deficit (one case of seizure and two cases of progressive loss of consciousness) and these all occurred within the first 2 postoperative days. Of the neurologically well patients in whom no hemorrhage was demonstrated on initial postoperative CT scan, none experienced delayed deterioration. CONCLUSIONS: Clinically silent hemorrhage after stereotactic biopsy is very common. However, the authors did not find that knowledge of its existence ultimately affected individual patient management or outcome. The authors, therefore, suggest that the most important role of postoperative CT scanning is to screen for those neurologically well patients with no hemorrhage. These patients could safely be discharged on the same day they underwent biopsy.
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Growing evidence suggests an involvement of brain membrane phospholipid metabolism in a variety of neurodegenerative and psychiatric conditions. This has prompted the use of drugs (e.g., CDPcholine) aimed at elevating the rate of neural membrane synthesis. However, no information is available regarding the human brain enzymes of phospholipid synthesis which these drugs affect. Thus, the objective of our study was to characterize the enzymes involved, in particular, whether differences existed in the relative affinity of substrates for the enzymes of phosphatidylethanolamine (PE) compared to those of phosphatidylcholine (PC) synthesis. The concentration of choline in rapidly frozen human brain biopsies ranged from 32-186 nmol/g tissue, a concentration similar to that determined previously for ethanolamine. Since human brain ethanolamine kinase possessed a much lower affinity for ethanolamine (Km = 460 microM) than choline kinase did for choline (Km = 17 microM), the activity of ethanolamine kinase in vivo may be more dependent on substrate availability than that of choline kinase. In addition, whereas ethanolamine kinase was inhibited by choline, and to a lesser extent by phosphocholine, choline kinase activity was unaffected by the presence of ethanolamine, or phosphoethanolamine, and only weakly inhibited by phosphocholine. Phosphoethanolamine cytidylyltransferase (PECT) and phosphocholine cytidylyltransferase (PCCT) also displayed dissimilar characteristics, with PECT and PCCT being located predominantly in the cytosolic and particulate fractions, respectively. Both PECT and PCCT exhibited a low affinity for CTP (Km approximately 1.2 mM), suggesting that the activities of these enzymes, and by implication, the rate of phospholipid synthesis, are highly dependent upon the cellular concentration of CTP. In conclusion our data indicate different regulatory properties of PE and PC synthesis in human brain, and suggest that the rate of PE synthesis may be more dependent upon substrate (ethanolamine) availability than that of PC synthesis.
BACKGROUND: Pallidotomy helps parkinsonian symptoms. We tested the hypothesis that this might be due to changes in inhibition in the motor cortex. METHODS: We examined 15 patients with parkinsonism before and after posteroventral pallidotomy. Magnetic stimuli were delivered over the motor cortex, while subjects maintained a 30% maximum voluntary contraction of the contralateral first dorsal interosseus (FDI). RESULTS: Weak stimuli inhibited voluntary muscle activity, while slightly stronger stimuli caused short latency facilitation from activation of the corticospinal neurons. After pallidotomy magnetic stimulation, at the threshold for the short latency facilitation, resulted in more inhibition than before. CONCLUSION: Pallidotomy increases cortical inhibition. This may be associated with improved control of movements.
This study was conducted to determine the safety and efficacy of multilevel anterior cervical corpectomy and stabilization using fibular allograft in patients with cervical myelopathy. Thirty-six patients underwent this procedure for cervical myelopathy caused by spondylosis (20 patients), ossified posterior longitudinal ligament (four patients), trauma (one patient), or a combination of lesions (11 patients). The mean age (+/- standard deviation) of the patients was 58 +/- 10 years and 30 of the patients were men. The mean duration of symptoms before surgery was 30 +/- 6 months and 11 patients had undergone previous surgery. Prior to surgery, the mean Nurick grade of the myelopathy was 3.1 +/- 1.4. Seventeen patients also had cervicobrachial pain. Four vertebrae were removed in six patients, three in 19, and two in 11 patients. Instrumentation was used in 15 cases. The operative mortality rate was 3% (one patient) and two patients died 2 months postoperatively. Postoperative complications included early graft displacement requiring reoperation (three patients), transient dysphagia (two patients), cerebrospinal fluid leak treated by lumbar drainage (three patients), myocardial infarction (two patients), and late graft fracture (one patient). One patient developed transient worsening of myelopathy and three developed new, temporary radiculopathies. All patients achieved stable bone union and the mean Nurick grade at an average of 31 +/- 20 months (range 0-79 months) postoperatively was 2.4 +/- 1.6 (p < 0.05, t-test). Cervicobrachial pain improved in 10 (59%) of the 17 patients who had preoperative pain and myelopathy improved at least one grade in 17 patients (47%; p < 0.05). Twenty-six surviving patients (72%) were followed for more than 24 months and stable, osseous union occurred in 97%. These results show that extensive, multilevel anterior decompression and stabilization using fibular allograft can be achieved with a perioperative mortality and major morbidity rate of 22% and with significant improvement in pain and myelopathy.
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