Amantadine may reverse punding in Parkinson's disease--observation in a patient

Punding, complex stereotyped behavior, sometimes occurs in patients with Parkinson's disease under dopaminergic replacement therapy. Reduction of dopaminergic drugs may reduce the problem but risks enhancing motor impairment. We report a patient with Parkinson's disease presenting disabling punding, which was reversed by amantadine without aggravating motor function. Amantadine may reduce punding by blocking NMDA receptors, in the same manner as in levodopa-induced dyskinesias.

Pramipexole Safely Replaces Ergot Dopamine Agonists with either Rapid or Slow Switching

This prospective, open-label, multicentre study examined the efficacy and safety of rapidly (overnight) or slowly (after 2 weeks of concomitant usage) switching patients with Parkinson's disease (PD) from conventional ergot dopamine agonists (DAs) to the non-ergot DA, pramipexole. Fifty-nine early-to-advanced PD patients with motor symptoms that were inadequately controlled by ergot DAs were enrolled. Patients were switched from ergot derivatives to pramipexole and evaluated every 2 weeks for 12 weeks by Hoehn and Yahr staging, Unified Parkinson's Disease Rating Scale (UPDRS) and a modified Epworth Sleepiness Scale (mESS). The UPDRS III subscores and total UPDRS scores significantly improved, independent of switching method. Adverse events, all of which were mild, occurred in 29.2% of patients. No sudden onset of excessive daytime sleepiness or significant worsening in mESS was seen. Switching patients with PD from ergot DA to pramipexole, using either a slow or rapid switching method, appeared to be well tolerated and effective, although further dose adjustment may be necessary in some patients after the switch.

Weight loss in Parkinson's disease

Weight loss is frequent in patients with Parkinson's disease (PD). Reduced energy intake and/or increased energy expenditure have been postulated as the cause. Dysphagia, anorexia, and gastrointestinal dysfunction may be possible causes of reduced energy intake; whereas, rigidity, tremor, and levodopa-induced dyskinesia may increase energy expenditure. Levodopa may enhance glucose metabolism resulting in enhanced energy expenditure. Depression, anti-parkinsonian drugs, and medical complications such as pneumonia and malignancies also may facilitate weight loss in PD. Combinations of various degrees of these factors, especially in advanced PD, may produce weight loss. Such weight loss is associated with malnutrition which may precipitate infection and decubitis; accelerate motor, behavioral, and autonomic impairment; consequently spoiling one's quality of life. Attention must be paid as well to motor symptoms to prevent or reverse weight loss in PD patients.

Dropped head syndrome in Parkinson's disease

We determined the frequency of dropped head syndrome in Parkinson's disease (PD) in Japan and evaluated its clinical correlates. A total of 252 consecutive patients with PD who visited our hospital were studied. Dropped head syndrome was found in 15 patients (6.0%) (3 men, 12 women; mean age at onset of PD, 62.8 +/- 11.5 years). The interval before emergence of dropped head after disease onset was 5.4 +/- 4.3 years (-0.5 to 15 years). The Hoehn-Yahr score at the on stage was 3.2 +/- 0.7; at the off stage 3.5 +/- 0.8. Of those 15 patients, 8 had major symptoms of rigidity and akinesia. In 2 patients, administration of a dopamine agonist appeared to evoke dropped head syndrome. An increase in and/or the addition of antiparkinsonian drugs alleviated head drop in 4 patients and reduced head drop in 7 patients. Any medication was not effective for 4 patients. Dropped head syndrome in PD is not rare in Japan. It is more often observed in women and is associated with patients who primarily suffer rigidity and akinesia. Dropped head syndrome in these patients appears to be produced by disproportionate tonus of the neck muscles. It is modulated by antiparkinsonian drugs and is considered to be a type of dystonia.

Reduced cardiac uptake and enhanced washout of 123I-MIBG in pure autonomic failure occurs conjointly with Parkinson's disease and dementia with Lewy bodies

The purpose of this study was to investigate myocardial uptake of 123I-metaiodobenzylguanidine (MIBG) in patients with pure autonomic failure (PAF), which has pathologic features in common with idiopathic Parkinson's disease (IPD) and dementia with Lewy bodies (DLB).

METHODS

Six patients with PAF, 130 with IPD, 21 with DLB, 9 with corticobasal degeneration (CBD), 11 with progressive supranuclear palsy (PSP), and 11 with multiple-system atrophy (MSA) underwent myocardial 123I-MIBG scintigraphy, as did 16 control patients.

RESULTS

Resulting heart-to-mediastinum (H/M) ratios were significantly lower in patients with PAF, IPD, or DLB than in patients with CBD, PSP, or MSA and in the controls. H/M ratios were lower for delayed images than for early ones in patients with PAF, IPD, or DLB, whereas the ratios were higher for delayed images in patients with CBD and in the controls.

CONCLUSION

Cardiac sympathetic denervation and enhanced washout of 123I-MIBG from sympathetic nerve terminals may develop in parallel in patients with PAF, IPD, or DLB.

[Psychoses in patients with Parkinson's disease; their frequency, phenomenology, and clinical correlates]

The frequency, phenomenology, and risk factors of hallucinations and delusions were investigated in 64 consecutive inpatients with Parkinson's disease. Fifty patients were admitted to our hospital with symptoms related to Parkinson's disease: psychiatric problems 27 (psychosis 22; anxiety 2; depression 2; mania 1): motor symptoms, 20 (wearing-off 5; akinesia 4; freezing 4; postural instability 4; dyskinesia 2; tremor 2; dystonia 1), and sensory symptoms, 3. Fourteen patients were admitted with other medical problems (pneumonia 4; cerebral infarction 3; bone fracture 3; lumbago 2; seizure 1; cat bite 1). Totally 49 patients had psychiatric problems. Psychosis was present in 43 patients, dementia in 10, depression in 8, mania in 1, anxiety in 10, agitation in 6, stereotypy in 2, and hypersexuality in 2. Of the 43 patients with psychoses, 40 presented with visual hallucinations, 18 with auditory hallucinations, and 23 with delusions. To determine what the clinical correlates with the severity of psychosis were, we divided the patients into 3 groups: the severe group, 22 patients admitted because of psychotic symptoms; the mild group, 21 patients admitted because of problems other than psychosis but presenting psychotic symptoms; and the control group, 21 patients who had no psychotic symptoms. Incidences of auditory hallucinations and delusions were higher in the severe group as compared to the mild group. Patients in the severe group had higher Hoehn-Yahr stages, lower Mini-Mental State Examination scores, decreased H/M ratios of cardiac 123I-MIBG uptake, and lower frequencies of background activity on electroencephalograms. There were no differences in age at admission, age at onset of Parkinson's disease, duration of illness, amounts of levodopa and dopamine agonists received, Hamilton's depression rating scores, and brain MR findings, including atrophy and ischemic changes. Emergence of psychotic symptoms in parkinsonian patients appears to be clearly associated with impaired cognitive function. Therefore, it may be associated with the disease process itself. Terms such as dopaminomimetic or levodopa-induced psychosis may not be appropriate when describing psychosis in Parkinson's disease.

[Behavioral impairments in Parkinson's disease]

Behavioral impairments in parkinsonian patients include agitation, hypersexuality, stereotypic movement, pathological gambling, abuse of antiparkinsonian drugs, REM sleep behavioral disorder, and restless legs syndrome. Dementia, psychoses, and emotional disorders, such as depression and anxiety/panic disorder, also impair behavior. Symptoms may be produced by dysfunction of the central nervous system, medication, and/or the psychosocial problems associated with Parkinson's disease. Treatment therefore should be based on the cause of the symptoms seen. In some cases, the reduction or change of antiparkinsonian drugs, or both, may be effective. Treatment of the motor symptoms of Parkinson's disease, including motor fluctuations, may reduce the risk of panic attacks being evoked in the 'off' period. Use of antidepressants, sedatives, and neuroleptics may often be effective. Physicians should identify the causes of the symptoms of behavioral impairment and select appropriate treatments.

Bezold-Jarisch Reflex Blunts Arterial Baroreflex via the Shift of Neural Arc toward Lower Sympathetic Nerve Activity

Although the Bezold-Jarisch (BJ) reflex is potentially evoked during acute myocardial ischemia or infarction, its effects on the static characteristics of the arterial baroreflex remain to be analyzed in terms of an equilibrium diagram between the neural and peripheral arcs. The neural arc represents the static input-output relationship between baroreceptor pressure input and efferent sympathetic nerve activity (SNA), whereas the peripheral arc represents that between SNA and arterial pressure (AP). In 8 anesthetized rabbits, we increased carotid sinus pressure stepwise from 40 to 160 mmHg in increments of 20 mmHg at one-minute intervals while measuring renal SNA and AP under control conditions and during the activation of the BJ reflex by intravenous administration of phenylbiguanide (PBG, 100 microg.kg(-1).min(-1)). The neural arc approximated a sigmoid curve whereas the peripheral arc approximated a straight line. PBG decreased AP at the operating point from -91.3 +/- 2.4 to -71.7 +/- 3.1 mmHg (P < 0.01), and attenuated the total loop gain at the operating point from -1.31 +/- 0.44 to -0.51 +/- 0.14 (P < 0.05). The equilibrium diagram indicated that PBG caused a parallel shift of the neural arc toward lower SNA such that the maximum SNA was reduced to approximately 60% of control. PBG decreased neural and peripheral arc gains at the operating point to approximately 43% and 77%, respectively. In conclusion, the BJ reflex blunts arterial baroreflex via the shift of the neural arc toward lower SNA.

The retention indices of 201Tl-SPECT in brain tumors

OBJECTIVE

The aim of this study was to assess the utility of 201Tl SPECT in the differential diagnosis of intracranial tumors and to determine the relationship between 201Tl uptake and histological types.

METHODS

Thirty-eight patients (19 males and 19 females) with thirty-eight brain tumors were evaluated with 201Tl-SPECT. The early and delayed 201Tl uptake ratio was calculated, and the retention index (RI) was applied as follows; RI = delayed uptake ratio/early uptake ratio.

RESULTS

The RI of malignant tumors was higher (0.72 +/- 0.18) than that of benign tumors (0.50 +/- 0.16) and the difference was statistically significant (p = 0.00045). The difference between high-grade glioma (0.80 +/- 0.15) and metastatic tumors (0.64 +/- 0.19) was statistically significant (p = 0.039).

CONCLUSION

201Tl-SPECT may add useful biochemical information and could differentiate malignant brain tumors from benign lesions, but the RI of metastatic tumors varied depending on the organs with the primary lesion and histological types.

Benign adult familial myoclonic epilepsy (BAFME) with night blindness

This is the first report of benign adult familial myoclonic epilepsy (BAFME) with night blindness. Our cases of BAFME (mother, son, and daughter) demonstrated night blindness with a reduced b-wave response on electroretinography (ERG) suggesting an alteration in calcium-mediated neurotransmitter release from photoreceptors in response to light. Several familial epilepsies have been shown to be due to a channelopathy. On the other hand, the mutation of a calcium-channel gene in Xp11.23 was recently reported in incomplete X-linked congenital stationary night blindness (CSNB). Although the gene locus of BAFME was recently assigned to 8q23.3-q24.1, the causative gene has yet to be identified. The present familial case suggests that BAFME may also be a disease of the calcium channel that is present in the retina and the central nervous system (CNS).

Effects of short- and long-acting dopamine agonists on sensitized dopaminergic neurotransmission in rats with unilateral 6-OHDA lesions

The effects of short and long-acting dopamine agonists on sensitized dopaminergic transmission in an animal model of Parkinson's disease were investigated. Rats with 6-hydroxydopamine (6-OHDA) lesions of the left nigrostriatal dopaminergic pathway were pre-exposed i.p. to 50 mg/kg methyl levodopa for 10 days. After a 7-day withdrawal period, these animals were treated with saline i.p., 0.05 mg/kg apomorphine s.c., or 0.5 mg/kg cabergoline i.p., once daily for 7 days. On the 8th day, rats in each treatment group received a challenge dose of 0.05 mg/kg apomorphine or saline s.c. The temporal changes in the number of rotations away from the 6-OHDA lesion side were evaluated after the challenge. The apomorphine challenge increased the number of rotations more markedly in the apomorphine pretreated rats than in the other pretreatment groups. In cabergoline pretreated rats, the number of rotations was significantly lower than that of saline-pretreated animals. Pretreatment with saline did not alter the apomorphine sensitivity of rotational behavior. These findings suggest that the repeated administration of long-acting dopamine agonists may reduce sensitized dopaminergic transmission in dopamine-depleted rats, whereas short-acting ones may further enhance sensitization of the transmission process.

Fractal dimension analysis of static stabilometry in Parkinson's disease and spinocerebellar ataxia

The static stabilometry patterns associated with Parkinson's disease (PD, n = 15) and spinocerebellar ataxia (SCA, n = 15) were compared with those of normal control (n = 15) by measuring the fractal dimensions. Fractal dimensions were estimated using the modified pixel dilation (mPD) method. The fractal dimensions with closed eyes showed a significant correlation with Environmental area for SCA group (p < 0.05). The fractal dimension for SCA group was significantly higher with closed eyes than that with open eyes (p < 0.05). The fractal dimension with closed eyes was significantly higher in PD and SCA groups than that in normal group (p < 0.05). The fractal dimension with closed eyes was higher when the clinical stage was more severe with PD and SCA group while Environmental and Longitude/Environmental areas were not. These findings suggest that the fractal dimension is more sensitive than traditional stabilometric analysis in an evaluation of postural instability in PD and SCA.

Inflammatory demyelinating polyradiculoneuropathy associated with interstitial lung disease

A 58-year-old woman presented with inflammatory demyelinating polyradiculoneuropathy accompanied by sensory and motor disturbance and interstitial lung disease. Corticosteroid therapy led to a marked amelioration of both the neuropathy and the lung disease. We suggest that a demyelinating neuropathy is associated with an interstitial lung disease.

Diagnostic significance of tau protein in cerebrospinal fluid from patients with corticobasal degeneration or progressive supranuclear palsy

Distinguishing corticobasal degeneration (CBD) from progressive supranuclear palsy (PSP) is clinically and pathologically difficult, and a useful biological marker to discriminative these two diseases has been a subject of clinical interest. In the present study, we assessed tau protein levels in cerebrospinal fluids by sandwich ELISA to distinguish CBD from PSP. The subjects consisted of 27 cases of CBD, 30 cases of PSP, and 36 healthy controls (CTL). The tau values in CBD were significantly higher than those in PSP (P<0.001) and those in CTL (P<0.001). The assay of CSF tau provided diagnostic sensitivity of 81.5% and specificity of 80.0% between CBD and PSP according to receiver-operating characteristic (ROC) curve analysis. When values were compared separately with respect to stage of the disease, differences in the values for moderate CBD vs. moderate PSP had the greatest significance (P<0.001 sensitivity 92.3%, specificity 100.0%), followed by cases of mild CBD and PSP (P<0.005, sensitivity 100.0%, specificity 87.5%). The values in severe CBD and PSP were not significantly different (P=0.07, sensitivity 100%, specificity 75.0%). Using data obtained from a larger number of disease cases, we confirmed our previous findings that tau protein levels in cerebrospinal fluids in patients with CBD are significantly higher than those in patients with PSP. Because tau protein levels in cerebrospinal fluids are significantly higher in early CBD cases than in early PSP cases, measurement of tau protein levels in cerberospinal fluids may be useful for the differential diagnosis of early CBD from early PSP.

Glutamate enhances DNA fragmentation in cultured spinal motor neurons of rat

The role of glutamate in the mechanism of spinal motor neuron death is not fully understood. With addition of glutamate to primary culture of 11-day-old rat spinal cord, terminal deoxynucleotidyl transferase-mediated dUTP-biotin in situ nick end labeling (TUNEL) positive nuclei were found in spinal large motor neurons from 24 h, and the number of TUNEL positive large motor neurons greatly increased at 48 h. In contrast, only a small number of large motor neurons became TUNEL positive at 48 h with addition of vehicle to the primary spinal cord culture. The present results show that excessive amount of glutamate enhances DNA fragmentation in developing large motor neuron of cultured spinal cord by involving in apoptotic process of the neurons.

Effects of repeated methyl levodopa administration on apomorphine sensitivity of rotational behavior and striatal Fos expression of rats with unilateral 6-OHDA lesions

This study was designed to elucidate the mechanism to develop levodopa-induced dyskinesia in patients with Parkinson's disease. For this purpose, we administered methyl levodopa repeatedly to a rat model of Parkinson's disease with unilateral 6-hydroxydopamine (6-OHDA)-induced lesion of the nigrostriatal dopamine pathway. After a washout period, we measured apomorphine sensitivity of contralateral rotation and made parallel determination of Fos expression in the caudate-putamen and globus pallidus of the same animal. Once daily, i.p. injection of methyl levodopa plus benserazide for 10 days increased the number of rotations over time. A challenge dose of apomorphine showed enhanced rotational response in rats pretreated with methyl levodopa. Repeated administration of methyl levodopa resulted in diminished apomorphine sensitivity of Fos expression in the dopamine depleted caudate-putamen and in enhanced sensitivity in the globus pallidus of the same side. Present results may add evidence to the idea that repeated administration of levodopa develops dopaminergic sensitization mediated by augmented activation of pallidal neurons involved in D2-responsive pallidal output pathway.

[A case of neuro-Behçet's disease with HLA B54 and predominant cerebral white matter lesions]

We report a 55-year-old woman with neuro-Behçet's disease with HLA B54 and predominant cerebral white matter lesions. She showed a cryptogenic high fever and cerebral cortical symptoms such as perseveration, limbkinetic apraxia and dementia. CSF study showed an increase of cell count and protein and a decrease of sugar. MRI showed diffuse T2-high signal intensity mainly in the subcortical white matter of left parieto-occipital lobes and basal ganglia. Her clinical signs greatly improved after administration of prednisolone. Her HLA type was not B51 but B54. Though our patient did not completely satisfy clinical criteria for neither neuro-Behçet's disease nor Sweet's syndrome, she showed partial features of both Behçet's disease and Sweet's syndrome.

A case of spinocerebellar ataxia accompanied by severe involvement of the motor neuron system

We report a sporadic case of spinocerebellar ataxia accompanied by later but severe involvement of the motor neuron system. A 72-year-old man began to show ataxia and dysarthria at age 66 years. Neurological examinations revealed saccadic eye movement, slurred speech, truncal ataxia, pyramidal sign, and urinary disturbance. Neither history of alcoholism nor hereditary factors were found. He developed muscular atrophy of the lower and upper extremities and limb ataxia within three years. Superficial and deep sensations were diminished in both feet four years after onset. Thus, he presented with cerebellar ataxia, bulbar sign, upper and lower motor neuron symptoms, sensory disturbance, and autonomic sign after six years at age 72. The level of serum, creatine phosphokinase (CPK) was increased, and muscle biopsy showed marked neurogenic change. Magnetic resonance imaging (MRI) revealed mild cerebellar and pontine atrophy. Although the combination of spinocerebellar ataxia and motor neuron disease is very rare, the present case suggests the inter-relation of the spinocerebellar and motor neuron systems, and presents peripheral neuropathy as a subtype of multisystem atrophy.

Temporal profile of CRE DNA-binding activity in the rat hippocampus following a kindling stimulation

This study was designed to establish a role for cAMP-responsive element (CRE) binding protein (CREB) in signal transduction cascade in the hippocampus associated with kindling. Male Sprague-Dawley rats were kindled from the left amygdala until they exhibited Racine's class 5 generalized seizures [Racine (1972). EMBO J. 11, 3337-3346] Nuclear proteins were extracted from dorsal hippocampi obtained from 0 to 24 h after final kindling stimulation. From these, we evaluated the temporal pattern of CRE DNA-binding activity by use of a gel mobility-shift assay with a 32P-labeled CREB oligonucleotide probe. CRE-binding activity in the hippocampus was enhanced significantly at 2 h and returned to baseline level within 4 h after the stimulation. Our results suggest that CREB may be involved in the hippocampal signal transduction pathway of rats activated in response to a kindling stimulation to the amygdala. However, the transient elevation of CRE-binding activity following a seizure in a kindled animal also suggests that persistent activation of CREB may not be required for maintenance of the kindling phenomenon.

Sjögren's syndrome with acute transverse myelopathy as the initial manifestation

This is the first report of a patient with acute transverse myelopathy as the initial manifestation of primary Sjögren's syndrome (SS). The patient developed tetraparesis and sensory disturbance within 6 days of onset. Spinal MRI showed an extensive intraparenchymal lesion with high T2-weighted signal intensity, gadolinium enhancement, and cord swelling. Although the patient did not show clinical sicca symptoms, primary SS was diagnosed on the basis of clinical tests on lacrimal and salivary glands which showed high levels of autoantibodies. Treatment with prednisone improved motor and sensory symptoms and resulted in improvement of MRI findings. The present case suggests that acute transverse myelopathy can occur as an initial symptom of SS.

Temporal changes in expression of neuronal nitric oxide synthase mRNA in the rat hippocampus associated with kainate-induced seizures

We studied the temporal changes in expression of neuronal nitric oxide (NO) synthase (nNOS) mRNA in the hippocampus of rats treated with kainic acid by use of in situ hybridization technique. Intraperitoneal injection of 10 mg kg-1 kainic acid decreased expression of nNOS mRNAs in the dentate gyrus and CA3 region of the hippocampus at 3 h and 8 h and increased it in the dentate gyrus and CA1 at one week after treatment. Although our previous study indicated that administration of kainic acid increased NO generation in the rat hippocampus, present results suggest that the injection of kainic acid results in differential regulation of nNOS mRNA and NO formation in the rat hippocampus.

Myositis as a manifestation of chronic graft-versus-host disease

We report a 22-year-old man who had myositis in the course of chronic graft-versus-host disease after bone marrow transplantation for acute monocytic leukemia. The distribution of muscular involvement was different from idiopathic polymyositis. Muscular atrophy and weakness were noted in the distal muscles as well as in the proximal muscles of the upper extremities but there was little weakness in the proximal muscles of the lower extremities. However, histological and immunohistochemical study of the biceps brachii muscle showed findings similar to those of idiopathic polymyositis. It was suggested that myositis can be a manifestation of chronic GVHD caused by a cellular immune reaction by donor T cells.

Isolated oculomotor nerve palsy in lymphoma

We report a patient with non-Hodgkin's lymphoma who developed a unilateral left oculomotor nerve palsy. Only eyelid lifting and vertical gaze were involved. Lateral gaze or sizes and light reactions of pupils were not involved. Magnetic resonance imaging revealed an enhancement of an upper part of left cavernous sinus and the posterior clinoid process. It was conceivable that lymphoma invaded the upper branch of oculomotor nerve. Such neurological symptoms in cases of oculomotor nerve palsy by lymphoma have not been reported previously. Because cranial neuropathy could occur as the first sign of lymphoma, lymphoma is an important differential diagnosis for the partial oculomotor palsy such as our present case.

An MR image of spinal cord sarcoidosis

We present a case of spinal cord sarcoidosis with a unique magnetic resonance imaging (MRI) finding. MRI of the cervical spine revealed an unusual lesion of low signal intensity on T2-weighted image at the core of the lesion surrounded by high signal intensity. T1-weighted gadolinium enhanced image showed a high signal at the core lesion. Low signal intensity on T2-weighted image in the case was suggested to be due to hemosiderin deposition. Steroid therapy dramatically improved clinical symptoms with a marked reduction of peripheral T2 high intensity area and the core lesion size detected by gadolinium enhancement.

D1/D2 receptor synergism on CREB DNA-binding activities in the caudate-putamen of rat

Cyclic AMP-responsive element-binding protein (CREB) is a transcription factor that is activated by cyclic AMP-dependent protein kinase and regulates the induction of fos. In order to elucidate the cellular pathway of D1/D2 dopamine receptor synergism, the effect of D1 and D2 agonists on CREB DNA-binding activities was studied in the caudate-putamen of rats with an ipsilateral 6-hydroxydopamine-lesion of the medial forebrain bundle. Combined administration of D1 (SKF38393) and D2 (bromocriptine or quinpirole) agonists resulted in enhanced CREB-binding activities at a dose that did not enhance it when given separately. These results suggest that D1/D2 dopamine receptors play synergistic role in inducing CREB DNA-binding activities in the dopamine-depleted caudate-putamen of rats.

Motor neglect following left thalamic hemorrhage: a case report

We present a report on a patient who developed unilateral motor neglect of the right hemibody after a left thalamic hemorrhage. He presented with pure motor neglect without aphasia, ideomotor apraxia, or unilateral spatial neglect due to a lesion in the centromedian parafascicular (CMPF) and ventrolateral (VL) nuclei of the left thalamus. Although unilateral motor neglect is usually associated with right hemispheric lesions, a left thalamic lesion may also result in isolated motor neglect.

Cochlear implantation for symptomatic hereditary deafness

Recently, the effectiveness of cochlear implantation for hereditary deafness has been reported. We performed cochlear implantation for two patients with symptomatic hereditary deafness. Deafness in one patient was thought to be a result of albinism-deafness syndrome and in the other patient, a result of chronic progressive external ophthalmoplegia syndrome. Since their speech perception abilities improved dramatically, we believe that cochlear implantation should be actively performed for these two syndromes.

Laminar cortical necrosis in central nervous system lupus: sequential changes in MR images

A 44-year-old woman with systemic lupus erythematosus developed central nervous system lupus presenting with headache, fever, cloudiness of consciousness, and psychotic symptoms. T1-weighted and proton MR images showed laminar high intensity lesions in the parietal and temporal cortex bilaterally. T2-weighted images of the lesions showed low signal intensity. Treatment with corticosteroids alleviated the clinical symptoms within 7 months. The low T2 and high T1 signal abnormalities disappeared in a year and in 5 years, respectively. The laminar cortical lesions on MR images were suggested to represent cortical necrosis associated with central nervous system lupus.

[Huntington's disease: clinical and molecular genetics]

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder characterized by motor, cognitive, and psychiatric symptoms. An unstable CAG trinucleotide repeat expansion within the first exon of the responsible gene "IT15", encoding huntingtin, was identified. The clinical phenotype strongly correlates with the number of CAG repeat. The mutant huntingtin is expressed ubiquitously as same as the wild-type huntingtin, suggesting a toxic gain of function of the mutant huntingtin. The identification of huntingtin-interacting proteins and intranuclear aggregates containing a fragment of mutant huntingtin provide new insights into the pathophysiological mechanisms underlying HD. Moreover, the progress in transgenic animal models for HD will be critical for understanding the development of HD and for the testing of new therapeutics.

Enhanced Fos expression in rat lumbar spinal cord cultured with cerebrospinal fluid from patients with amyotrophic lateral sclerosis

The etiology of amyotrophic lateral sclerosis (ALS) remains unknown although an existence of neurotoxic substances in cerebrospinal fluid (CSF) from ALS patients have been postulated. In order to investigate a possible effect of CSF from ALS patients on cellular signaling in spinal neurons, we compared Fos-like immunoreactivity (Fos-LI) in organotypic cultures of rat lumbar spinal cord after addition of CSF from ALS patients or another neurologic disease. Fos-LI was normally present predominantly in dorsal horn neurons, whereas only a few ventral horn neurons were positive for Fos-LI. The number of Fos-LI positive neurons significantly increased in dorsal horn with addition of CSF from ALS patients as well as glutamate at 100 microM. However, the increase was not observed with addition of CSF from other neurologic diseases. The increase in Fos-LI positive neurons in dorsal horn was reversed by a further supplement of MK801, an N-methyl-D-aspartate (NMDA) receptor antagonist, but not of CNQX, an alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)/kainate antagonist. These results indicate that there may be substances in CSF from ALS patients that stimulate Fos expression in certain populations of spinal neurons via the NMDA receptors.

Differential regulation of AP-1 DNA-binding activity by D1 and D2 dopamine receptor antagonists in the rat caudate-putamen and globus pallidus following a unilateral 6-OHDA lesion of the medial forebrain bundle

The effect of D1 and D2 dopamine receptor antagonists on the DNA-binding activity of the AP-1 transcription factor was studied in the rat caudate-putamen and globus pallidus following a unilateral 6-OHDA lesion of the medial forebrain bundle. In the caudate-putamen, vehicle-treated rats showed increased AP-1 DNA-binding activity, which appeared to be reversed completely by treatment with the D1 receptor antagonist SCH23390 (1 mg kg-1 i.p.) and partially by the D2 antagonist sulpiride (50 mg kg-1 i.p.). In the globus pallidus, vehicle and sulpiride did not induce AP-1, while SCH23390 increased it significantly. This induction was much more prominent in the 6-OHDA-lesioned hemisphere than in the intact hemisphere. The present study suggests that in the caudate-putamen, dopamine-depletion induces long-lasting enhancement of AP-1 DNA-binding activity via activation of D1 receptors and the simultaneous activation of D2 receptors facilitate it. However, in the globus pallidus of the 6-OHDA-lesioned hemisphere, D1 but not D2 antagonism induces AP-1 in certain cell populations which may be distinct from those expressing AP-1 upon stimulation of D2 receptors.

Circadian rhythm sleep disorder associated with pontine lesion

A 55-year-old man presented with excessive daytime sleepiness and a circadian rhythm sleep disorder. Magnetic resonance imaging of the brain revealed a pontine lesion distinguishable from major cerebrovascular disease, demyelination and neoplasm. Benzodiazepines, antidepressants, methylcobalamine and thyroxine failed to synchronize the circadian rhythm. Antiepileptic drugs aggravated the condition, while melatonin and protireline partially relieved the patient from poorly controlled sleep disorder. A pontine lesion appeared to be related to the circadian rhythm sleep disorder of the patient.

Enhanced AP-1 binding in brain induced by D1 and D2 agonists in methamphetamine-sensitized rats

The activator protein-1 (AP-1) binding activities induced by a separate challenge with SKF38393 and quinpirole after 1 weeks' abstinence from chronic methamphetamine (4 mg/kg/day, 14 days) were increased significantly in the striatum, nucleus accumbens and cingulate cortex compared with the saline-treated controls. Quinpirole-, but not SKF38393-induced AP-1 binding activities were still significantly higher after a 4-week abstinence period in the chronic methamphetamine group than in the chronic saline control group. Downward sniffing, which occurred following a quinpirole-challenge, was significantly intensified after both a 1 and 4 weeks' abstinence from chronic methamphetamine. These results indicate that chronic administration of methamphetamine induces alterations of the interactions of dopamine D1 and D2 receptors which are reflected as enhanced AP-1 binding activities.

Kainic acid may enhance hippocampal NO generation of awake rats in a seizure stage-related fashion

Temporal changes in kainate-induced seizure activity and hippocampal NO generation were evaluated simultaneously in conscious rats by using in vivo microdialysis and by determining the concentrations of nitrite and nitrate in perfusates. Intraperitoneal injection of kainic acid produced 'wet dog shake', focal seizure of the limbs and neck, hypersalivation, or generalized convulsion. These behavioral changes peaked at 120 min after the drug challenge and lasted for about 100 min. In contrast, the concentrations of NO metabolites, nitrite and nitrate, in the hippocampal perfusates increased rapidly and reached a plateau level at 40 min after the injection, and the level remained high for over 220 min. The increase was more marked in animals presenting severe seizures than those presenting mild ones. Pre-treatment with 25 mg/kg N(G)-nitro-L-arginine methyl ester promoted the severity of kainate-induced seizures, but it suppressed the increase in NO metabolites. These results suggest that kainic acid enhances hippocampal NO generation in a severity-related manner of the induced seizures. The enhanced NO generation upon kainate challenge appears mainly to be involved in seizure suppression.

Radiation Complications Following Breast Conserving Therapy

BACKGROUND: Breast conserving therapy is being established as a standard therapeutic procedure for early breast cancer in Japan. However, the indications of radiotherapy and a standardized therapeutic procedure have not been established yet. In this study, complications following radiotherapy were evaluated in patients who had previously undergone breast conserving therapy at Tokushima University Hospital. METHODS From October 1989 to March 1996, 60 women with stage I or II breast cancer underwent radiation therapy after breast conserving surgery, and all patients were followed-up for a median of 27 months. Radiation morbidity scoring of the breast and adjacent organs was performed using the toxity criteria of the Radiation Therapy Oncology Group (RTOG) and European Organization for Research andTreatment of Cancer (EORTC). RESULTS: Only 1 patient developed local recurrence, and no distant metastasisor death was observed. The cause of recurrence in 1 case was considered to be due to extended intraductal component. Although transient dermal reaction was induced by irradiation of the breast, no side effects that may cause cosmetic problems were found. No serious radiation complications were found in the lungs, ribs, heart or other adjacent organs. CONCLUSION: The adverse reactions caused by irradiation does not reduce the merit of combined use of radiation therapy in breast conserving therapy, and therefore, are not the hesitation factor in application of radiotherapy.

Reversible pitch perception deficit due to carbamazepine

Carbamazepine (CBZ) is a drug frequently used to treat variety of neurological diseases or symptoms. Among its adverse effects, auditory disturbance is described rarely. In the present report, we describe an 18-year-old girl who noted false lowering of perceived pitch after starting CBZ treatment for epilepsy, and review the literature reporting CBZ-associated abnormal pitch perception.

Presumed venous infarction in spinal decompression sickness

We describe the serial MR imaging findings in a patient with spinal decompression sickness. In the acute phase, the spinal cord was swollen, with increased T2 signal in the posterior part of the column; 1 month later, marked contrast enhancement was noted in the same location; and 2 months later, the swelling and T2 signal had decreased. MR imaging may facilitate the early diagnosis of spinal decompression sickness.

L-DOPA does not facilitate nitric oxide production in the rat striatum and substantia nigra: in vivo microdialysis study

Using in vivo microdialysis and flow-injection, we evaluated the production of nitric oxide (NO) in the striatum and substantia nigra of freely moving rats in response to challenge doses of L-dihydroxyphenylalanine (L-DOPA) by measuring the NO metabolite levels of nitrate and nitrite. The dopamine and 3,4-dihydroxyphenylacetic acid (DOPAC) concentrations also were determined in the same perfusates. Intraperitoneal injection of L-DOPA produced a significant, dose-dependent increase in the extracellular levels of dopamine and DOPAC in these areas, but did not modify the extracellular levels of the NO metabolites. An acute dose of L-DOPA does not appear to facilitate NO production in the rat striatum and substantia nigra.

Hyperintense basal ganglia on T1-weighted MR images in a patient with central nervous system lupus and chorea

We describe a patient with central nervous system lupus and choreatic movements in whom both basal ganglia showed high signal intensity on T1-weighted MR images, while the signal on T2-weighted images remained low. Within 8 months after onset, the choreatic movements had disappeared, with a corresponding decrease in the hyperintense T1 signal. The emergence of the choreatic movement disorder in this patient might have been related to the T1 hyperintensity of the basal ganglia, which, in turn, might have resulted from a vascular insult associated with central nervous system lupus.

Temporal pattern of AP-1 DNA-binding activity in the rat hippocampus following a kindled seizure

DNA binding by transcripton factor AP-1 was enhanced remarkably following kindling stimulation in rat amygdala. Maximum increase occurred 2 h after stimulation with return to baseline within 24 h. Supershift and western analyses revealed that 38,000 mol. wt Fos-related antigen and JunD were the main components of the evoked AP-1 complexes at the time their induction reached maximum. AP-1 induction 2 h after the last kindling stimulation was more prominent in samples from previously kindled rats than in those from non-kindled rats. This study sought to establish the role of AP-1 in plastic changes of the hippocampus associated with kindling. Male Sprague-Dawley rats were kindled from the left amygdala until they exhibited Racine15 class 5 generalized seizures. Nuclear proteins were extracted from dorsal hippocampi obtained from 0 to 24 h after final stimulations. From these, we evaluated the temporal pattern of DNA binding by AP-1 using a gel mobility-shift assay with a 32P-labelled AP-1 probe. Supershift and western analyses were added to investigate components of the seizure-evoked AP-1 complexes. Our results suggest that the basal level of AP-1 complexes is not associated with the seizure susceptibility in kindling. However, development of kindling appears to facilitate stimulus-evoked AP-1 induction, probably via plastic changes in the central nervous system. AP-1 may mediate such changes by regulating expression of certain genes.

[A man with systemic lupus erythematosus presenting with spastic paraplegia]

We report a 38-year-old man systemic lupus erythematosus who presented with an acute onset of paraplegia and urinary retention. The man had a 12-year history of nodular cutaneous mucinosis and arthralgia. In 1994, he was admitted to our hospital with a sudden onset of weakness and numbness of the right leg followed by an emergence of similar symptoms in the left leg. His elder sister had died at 16 years of age after suffering from systemic lupus erythematosus for 6 years. On examination, the patient had skin rash on his chest, back, head, forehead, and extremities. The neurological examination revealed that his tongue deviated to the right on protrusion. The muscle power was reduced to 2-3/5 in the right leg and to 4/5 in the left leg. The sensory disturbance was noted in the lower extremities with predominant involvement of the right leg. Reflexes were increased in the right biceps, triceps, both patellas, and Achilles tendons. Babinski sign was noted bilaterally. Urinary retention and constipation were also noted. The results of the blood cell count and hepatic and renal function tests were normal. Serum levels of C-reactive protein and complements (C3, C4, CH50) were also normal. Serological examinations showed increased anti-DNA antibody (14 U/ml, [normal, < 6]). Antinuclear antibody was positive at a titer of 1:1380. CSF study showed an increased protein concentration of 83 mg/dl and an IgG level of 14 mg/dl with a normal number of cells. MR images revealed a T1-low, T2-high signal lesion at the upper part of the left ventral medulla. MR images of the brain and spinal cord were normal. The patient was diagnosed as having SLE. High-dose intravenous methylprednisolone (1 g/day) pulse treatment that was started 25 days after the onset of neurological symptoms, produced partial relief. Our case presented with paraplegia with a focal lesion in the left upper ventral part of the medulla on MR images. The incidence of male SLE is low, and paraplegia is a rare complication of SLE. Thus, the medullary lesion in SLE observed in our case appears to be rare. SLE should be considered as a cause of acute onset paraplegia or myelopathy.

Noninsulin-dependent diabetes mellitus-related encephalopathy presenting with amnesia, personality change, and autonomic seizure

We describe a patient with noninsulin-dependent diabetes mellitus presenting with an amnestic disorder, personality change, and autonomic seizure. Magnetic resonance images of the brain showed T2-high signal lesion in the hippocampi bilaterally and nonspecific white matter disease, while single photon emission computed tomography revealed a diffuse reduction of cerebral blood flow. Sensory and auditory evoked potentials revealed delayed impulse conduction velocities in the central nervous system. Degenerative changes caused by a microvascular angiopathy related to noninsulin-dependent diabetes mellitus may underlie the central nervous system manifestations in our patient.