Neurophysiology of myoclonus

Myoclonus may be generated by any area in the central nervous system. Finding its generator is helpful in the diagnostic process. Although clinical features have to be carefully analyzed as they may give a first idea, neurophysiologic study of myoclonus provides the most important clues for the determination of the generator. Surface electromyography (EMG) allows analyzing the recruitment order in generalized myoclonus, thereby suggesting either a cortical, brainstem, or spinal origin. It also reveals whether myoclonus is positive (jerks that are caused by muscle activation) or negative (jerks that are caused by brief muscle inhibition). In non-generalized myoclonus the EMG burst duration gives an idea of the level of the generator. Repetitive peripheral nerve stimulation is required to record somatosensory evoked potentials (SEPs) as well as long latency reflexes (LLR), especially the C reflex. The presence of giant cortical SEPs is an indirect argument for cortical myoclonus. Similarly the existence of LLR at rest orientates towards cortical reflex (sensitive to sensory stimuli) myoclonus. Finally EEG-EMG polygraphy is the only test which is able to prove directly the cortical origin of myoclonus. This is the case when focal cortical events precede myoclonus with a fixed delay. These premyoclonic cortical potentials may either be seen directly on raw recordings or require the use of jerk-locked back averaging (JLBA). This technique allows the averaging of the EEG prior to myoclonus onset (as determined by EMG) in order to reveal a premyoclonic spike that otherwise would remain undetected in the global EEG.

Involvement of 5-HT(2) serotonergic receptors of the nucleus raphe magnus and nucleus reticularis gigantocellularis/paragigantocellularis complex neural networks in the antinociceptive phenomenon that follows the post-ictal immobility syndrome

The post-ictal immobility syndrome is followed by a significant increase in the nociceptive thresholds in animals and men. In this interesting post-ictal behavioral response, endogenous opioid peptides-mediated mechanisms, as well as cholinergic-mediated antinociceptive processes, have been suggested. However, considering that many serotonergic descending pathways have been implicated in antinociceptive reactions, the aim of the present work is to investigate the involvement of 5-HT(2)-serotonergic receptor subfamily in the post-ictal antinociception. The analgesia was measured by the tail-flick test in seven or eight Wistar rats per group. Convulsions were followed by statistically significant increase in the tail-flick latencies (TFL), at least for 120 min of the post-ictal period. Male Wistar rats were submitted to stereotaxic surgery for introduction of a guide-cannula in the rhombencephalon, aiming either the nucleus raphe magnus (NRM) or the gigantocellularis complex. In independent groups of animals, these nuclei were neurochemically lesioned with a unilateral microinjection of ibotenic acid (1.0 microg/0.2 microL). The neuronal damage of either the NRM or nucleus reticularis gigantocellularis/paragigantocellularis complex decreased the post-ictal analgesia. Also, in other independent groups, central administration of ritanserin (5.0 microg/0.2 microL) or physiological saline into each of the reticular formation nuclei studied caused a statistically significant decrease in the TFL of seizing animals, as compared to controls, in all post-ictal periods studied. These results indicate that serotonin input-connected neurons of the pontine and medullarly reticular nuclei may be involved in the post-ictal analgesia.

Increased brainstem volume in panic disorder: a voxel-based morphometric study

Neurocircuitry models of panic disorder have hypothesized that the panic attack itself stems from loci in the brainstem including the ascending reticular system and respiratory and cardiovascular control centers. Voxel-based morphometry with acobian modulation was used to examine gray matter volume changes in 10 panic disorder patients and 23 healthy controls. The panic disorder patients had a relatively increased gray matter volume in the midbrain and rostral pons of the brainstem. Increased ventral hippocampal and decreased regional prefrontal cortex volumes were also noted at a lower significance threshold. This finding has implications for pathophysiologic models of panic disorder, and provides structural evidence for the role of the brainstem in neurocircuitry models of panic disorder.

Consciousness, coma, and caring for the brain-injured patient

In this article, a preliminary conceptual framework is presented for exploring nursing interventions and research aimed at improving care of the unconscious brain-injured patient during the early subacute phase of brain injury. The cue-response framework presented is derived from multidisciplinary sources and has specific clinical relevance to critical care nurses caring for unconscious brain-injured patients. A key aspect of this framework is the attention focused on the timing of nursing interventions in response to how nurses interpret the physical, physiological, and secondary cues they observe when caring for comatose patients. A case exemplar is used to present one example of how this framework may be used in the clinical setting.

Anterior cingulate cortex contributes to the descending facilitatory modulation of pain via dorsal reticular nucleus

Supraspinal centres biphasically modulate spinal nociceptive transmission, including descending inhibition and facilitation. Recent studies have revealed that descending facilitatory modulation is a key mechanism underlying induction and maintenance of neuropathic and inflammatory pain. The anterior cingulate cortex (ACC) is not only involved in the transmission of pain sensation but also plays a role in processing pain-related emotion. The ACC also widely connects with relevant regions of the descending modulation system. Here we used electrophysiological and behavioural techniques to study the possible pathways behind the modulation of spinal nociceptive transmission from the ACC. C-fibre-evoked field potentials in the spinal dorsal horn were produced by electrical stimulation of the sciatic nerve at an intensity high enough to excite C fibres, and paw withdrawal latencies (PWLs) to noxious heating were recorded. The results showed that high-frequency tetanic electrical stimulation of the ACC both unilaterally enhanced the C-fibre-evoked field potentials in the spinal dorsal horn and bilaterally shortened PWLs, indicating a facilitation of spinal nociception. A similar effect was observed after microinjection of N-methyl-d-aspartic acid (NMDA; 10 nm, 1 microL) or homocysteic acid (HCA; 0.1 m, 1 microL) into the ACC. When the dorsal reticular nucleus (DRt) was electrolytically lesioned, ACC-induced facilitation of spinal nociception was blocked. These results imply that: (i) activation of the ACC may facilitate spinal nociception; (ii) NMDA receptors in the ACC may be involved in descending facilitation; and (iii) the DRt plays a crucial role in mediating ACC-induced facilitation of spinal nociception.

Pontine reticular formation neurons are implicated in the neuronal network for generalized clonic seizures which is intensified by audiogenic kindling

The caudal pontine reticular formation nucleus (cPRF) is implicated in seizure propagation to the spinal cord in several forms of generalized convulsive seizures, including audiogenic seizures (AGS). Focal microinjection studies implicate cPRF as a requisite neuronal network site subserving generalized AGS in the moderate severity substrain of genetically epilepsy-prone rats (GEPR-3s). AGS in GEPR-3s culminate in generalized clonus, but daily repetition of AGS (AGS kindling) results in an additional seizure behavior, facial and forelimb (F and F) clonus, not seen prior to kindling. This study examined cPRF neuronal firing changes and seizure behaviors during AGS in GEPR-3s. We examined extracellular cPRF neuronal responses to acoustic stimuli (12 kHz) and observed neuronal firing during AGS. cPRF neurons exhibited onset responses to acoustic stimuli before and after AGS kindling. After AGS kindling, increased neuronal firing occurred, and response latencies were prolonged. Tonic neuronal firing occurred during generalized clonus, which changed to burst firing after AGS kindling. Burst firing also occurred during F and F clonus. Increased neuronal firing and the change from tonic to burst firing suggest that AGS kindling involves increased cPRF excitability. These data support an important role for cPRF neurons in generation of generalized clonus in unkindled GEPR-3s, which is increased by AGS kindling. The increased cPRF response latency might reflect a greater role of rostral components of the AGS neuronal network in transmission of acoustic responses to cPRF. This study also suggests that cPRF neurons may be involved in F and F clonus, which was unexpected since F and F clonus is thought to originate primarily in forebrain structures.

Ventrolateral medullary compression in hypertensive patients with hemifacial spasm

In a patient-controlled study, the authors demonstrated a significantly higher prevalence of rostral ventrolateral medulla (VLM) compression in hypertensive patients with hemifacial spasm (HFS) compared with age-, sex-, race-, disease duration-, and disease severity-matched normotensive patients with HFS (p = 0.02). Hypertensive HFS patients were more likely to have a greater severity of neurovascular compression at the VLM compared with normotensive HFS patients (p = 0.008). VLM compression is associated with risk of hypertension in this study population.

Chronic administration of olmesartan attenuates the exaggerated pressor response to glutamate in the rostral ventrolateral medulla of SHR

It has been shown that the pressor responses to microinjection of L-glutamate in the rostral ventrolateral medulla (RVLM) are augmented in spontaneously hypertensive rats (SHR), and that these augmented responses are not altered by chronic conventional antihypertensive treatment. The aim of the present study was to determine the effect of chronic oral treatment with a new angiotensin II type 1 (AT(1)) receptor antagonist, RNH-6270 (the active form of olmesartan medoxomil), on cardiovascular responses to excitatory amino acids in the RVLM of SHR. SHR (12 weeks old) were treated with RNH-6270 (30 mg/kg/day) or vehicle for 4 weeks. At 16 weeks of age, L-glutamate (2 nmol), N-methyl-D-aspartate (NMDA; an ionotropic glutamate receptor agonist (20 pmol)), or (1S,3R)-1-aminocyclopentane-1,3-dicarboxylic acid ((1S,3R)-ACPD; a metabotropic glutamate receptor agonist (1 nmol)) was microinjected into the RVLM of rats. The pressor responses to microinjection of L-glutamate or NMDA in the RNH-6270-treated SHR (+28.3 +/- 1.0 and +48.3 +/- 2.5 mm Hg, respectively) were significantly smaller than those in untreated SHR (+45.7 +/- 2.2 and +69.4 +/- 7.0 mm Hg, respectively, P < 0.05 each); however, they were still greater than those in the Wistar-Kyoto rats (+21.7 +/- 1.0 and +28.6 +/- 3.3 mm Hg, respectively, P < 0.05 each). In contrast, the augmented pressor responses to microinjection of (1S,3R)-ACPD in SHR were not affected by the RNH-6270 treatment. These results demonstrated that chronic oral treatment with RNH-6270, an AT(1) receptor antagonist, partly normalizes the pressor responses to L-glutamate or NMDA, but not (1S,3R)-ACPD, in the RVLM of SHR, suggesting that endogenous angiotensin II may be involved in the exaggerated pressor response to l-glutamate, probably through its ionotropic glutamate receptors.

Differential Effects of Sleep Deprivation on Saccadic Eye Movements

STUDY OBJECTIVES

This study was designed to show the influence of sleep deprivation on different types of saccadic eye movements.

DESIGN

Performance of saccadic eye movements was compared after normal sleep and sleep deprivation in a randomized, within-subjects paradigm. Parameters of voluntary and reflexive saccades were measured before and after experimental nights and after a night of recovery sleep. Additionally, subjects spent 1 adaptation night in the laboratory before the experiments.

SETTING

Experiments took place under controlled laboratory conditions.

PARTICIPANTS

Fifteen healthy male volunteers (aged 19-30 years).

INTERVENTIONS

Each subject participated in 1 night of sleep deprivation followed by a night of recovery sleep and, on another occasion, in 2 successive nights of undisturbed sleep.

MEASUREMENTS AND RESULTS

Horizontal prosaccades, antisaccades, and memory-guided saccades were recorded by means of electrooculography. They were analysed semiautomatically with respect to accuracy, peak velocity, and latency. Peak velocity was significantly reduced in all saccade tasks after 1 night of sleep deprivation but recovered after another night of sleep. Latency was prolonged after sleep deprivation only for memory-guided saccades; accuracy showed a decrease after 1 night without sleep only for prosaccades.

CONCLUSIONS

Sleep deprivation has a general impairing effect on the peak velocity of saccades, reflecting possible dysfunction at the level of the brainstem reticular formation. Deficits of accuracy and latency point to dysfunction of specific brain sites such as the supplementary eye field and cerebellum, whereas the cardinal functions of the frontal and parietal eye fields were not affected. These results suggest the possibility of measuring fatigue by means of saccadic parameters, especially saccadic peak velocity.

Cortical/subcortical BOLD changes associated with epileptic discharges: An EEG-fMRI study at 3 T

BACKGROUND

Malformations of cortical development have characteristic interictal discharges, yet the mechanisms of generation of these discharges are not known in humans. Interictal discharges in malformations of cortical development were studied with EEG-fMRI.

METHODS

Six subjects with malformations of cortical development and seizures were studied using spike-triggered fMRI at 3 T. The blood oxygen level-dependent (BOLD) signal changes associated with interictal discharges were measured.

RESULTS

All subjects showed spike-related BOLD signal changes. In four subjects, the signal increases were seen in the lesion, and in four subjects, decreases were seen surrounding the lesion. Five subjects had BOLD signal changes at distant cortical sites and three had subcortical changes (basal ganglia, reticular formation, or thalamic).

CONCLUSION

BOLD signal changes may be directly correlated with overall synaptic activity. Changes were found in and around the lesion of malformations of cortical development and in distant cortical and subcortical structures. The results suggest that EEG-fMRI studies might help elucidate the mechanisms of epileptic discharges in humans.

Understanding and Managing Coma Stimulation

The incidence of people surviving with traumatic brain injury is rising at a remarkable pace. Unfortunately, patients also experience some form of coma and significant deficits (ie, cognitive, functional, etc). The focus is shifting from saving these patients to trying to figure out what else can be done for them? In the past, patients were medically maintained, stabilized, and then sent to rehabilitation centers for coma stimulation, in the hope of waking up their reticular activating system. Today, healthcare professionals are being encouraged to research and explore the possibility of implementing structured coma stimulation programs as early as 72 hours postinjury in the intensive care unit. Starting early is of paramount importance to a patient's survival, quality of life, and overall long-term prognosis. The goal of this article is to educate healthcare professionals (in the hospital setting) about managing and implementing structured sensory stimulation sessions.

Spinocerebellar ataxias types 2 and 3: degeneration of the pre-cerebellar nuclei isolates the three phylogenetically defined regions of the cerebellum

The pre-cerebellar nuclei act as a gate for the entire neocortical, brainstem and spinal cord afferent input destined for the cerebellum. Since no pathoanatomical studies of these nuclei had yet been performed in spinocerebellar ataxia type 2 (SCA2) or type 3 (SCA3), we carried out a detailed postmortem study of the pre-cerebellar nuclei in six SCA2 and seven SCA3 patients in order to further characterize the extent of brainstem degeneration in these ataxic disorders. By means of unconventionally thick serial sections through the brainstem stained for lipofuscin pigment and Nissl material, we could show that all of the pre-cerebellar nuclei (red, pontine, arcuate, prepositus hypoglossal, superior vestibular, lateral vestibular, medial vestibular, interstitial vestibular, spinal vestibular, vermiform, lateral reticular, external cuneate, subventricular, paramedian reticular, intercalate, interfascicular hypoglossal, and conterminal nuclei, pontobulbar body, reticulotegmental nucleus of the pons, inferior olive, and nucleus of Roller) are among the targets of both of the degenerative processes underlying SCA2 and SCA3. These novel findings are in contrast to the current neuropathological literature, which assumes that only a subset of pre-cerebellar nuclei in SCA2 and SCA3 may undergo neurodegeneration. Widespread damage to the pre-cerebellar nuclei separates all three phylogenetically and functionally defined regions of the cerebellum, impairs their physiological functions and thus explains the occurrence of gait, stance, limb and truncal ataxia, dysarthria, truncal and postural instability with disequilibrium, impairments of the vestibulo-ocular reaction and optokinetic nystagmus, slowed and saccadic smooth pursuits, dysmetrical horizontal saccades, and gaze-evoked nystagmus during SCA2 and SCA3.

Syncope: facts and fiction

According to the current state-of-art on the brainstem functional anatomy and reticular formation, authors believe that nucleus tractus solitarii (NTS) is the neural structure, which meets all the conditions of the hypothetical syncope generating, reflex centre. The afferent branch of this reflex arc represents information from different visceral sources including the brain itself. The efferent branch of this reflex arc is reticular activating system (RAS). The executive mechanism of syncope is deactivation of RAS done with the active engagement of NTS through solitarioreticular pathway (SRT) and parabrachial nuclear complex (PBC). The biological purpose of syncope would be resetting of the NTS in case of an unbearable vegetative input, which is code for triggering the mechanism described.

Convulsive seizures induced by α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid microinjection into the mesencephalic reticular formation in rats

Effects of microinjections of a single 2 or 10 nmol dose of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) into the unilateral mesencephalic reticular formation (MRF) on behavior and on the electroencephalogram were examined in rats (n=30) over a 15-min period (Exp. 1); subsequent effects of sound stimulation with key jingling applied at 15, 30, and 45 min after the injection were observed (Exp. 2). The microinjections of a 2 nmol dose of AMPA (n=15) induced hyperactivity (15 of 15 rats) and running/circling (10 of 15 rats) in Exp. 1, and hyperactivity (5 of 15 rats) in Exp. 2. Moreover, the microinjections of a 10 nmol dose of AMPA (n=15) induced hyperactivity (15 of 15 rats), running/circling (13 of 15 rats), generalized tonic-clonic seizures (GTCS) (4 of 15 rats), and amygdala kindling-like seizures (AMKS) (8 of 15 rats) in Exp. 1; electroencephalographic seizure discharges were predominantly observed in the MRF during hyperactivity, running/circling and GTCS, while those predominantly observed in the amygdala were during AMKS. In Exp. 2, hyperactivity (15 of 15 rats), running/circling (14 of 15 rats) and GTCS (6 of 15 rats) were elicited by sound stimulation, although AMKS were not. The control group of rats (n=15) which received a single dose of saline microinjection into the unilateral MRF showed no behavioral or electroencephalographic changes in both Exp. 1 and 2. These findings suggest that potentiation of excitatory amino acid neurotransmission induced by AMPA injection into the MRF plays an important role not only in the development of hyperactivity, running/circling, GTCS and AMKS, but also in the development of audiogenic seizures.

[A psychoneurophysiological evaluation of non-specific cerebral systems in patients with permanent autonomic disorders of psychogenic etiology during therapy]

Fifteen patients with permanent vegetative disorders combined with a pronounced anxiety were examined before and after treatment by the Nott drug. The clinical-and-neurological technique, psychometric evaluation of cognitive functions and the neurophysiological method of acoustic cognitive induced potentials P300 were made use of. Before treatment, pronounced vegetative anxiety-related and cognitive disorders were observed in patients. A reliably decreased amplitude of the P300 peak was noted in patients versus healthy subjects while registering the cognitive induced potentials. After treatment, there was a reliably decreased severity of vegetative, anxious and cognitive disorders in patients; the P300 amplitude went up reliably. Supposedly, the changed P300 amplitude, as observed in patients with permanent vegetative disorders; denotes the malfunction in non-specific limbic-reticular brain structures. A growing P300-peak amplitude combined with the arrest of psychovegetative and anxious disorders and with an improvement of cognitive functions in patients due to therapy are indicative of a lower degree of the functional disintegration in the non-specific limbic-reticular brain structures. Finally, the method of endogenous induced P300 potentials can be used as a diagnostic tool in the objective evaluation of a condition of non-specific brain systems in patients with the psychovegetative syndrome; it can also be an objective criterion in the efficiency assessment of a conducted therapy.

Arousal mechanisms related to posture and locomotion: 2. Ascending modulation

An intrinsic function of the reticular activating system (RAS) is its participation in fight vs. flight responses such that alerting stimuli simultaneously activate thalamocortical systems, as well as postural and locomotor systems, in order to enable an appropriate response. The P50 midlatency auditory-evoked potential appears to be an ascending manifestation of the cholinergic arm of the RAS in eliciting changes in arousal state. Abnormalities in the manifestation of the P50 potential are present in disorders which include: (1) dysregulation of sleep-wake cycles; (2) abnormalities in reflex/postural, especially, startle, responses; and (3) malfunctions in flight vs. flight responses. In general, the P50 potential appears to be upregulated (increased amplitude and/or decreased sensory gating) in disorders which are marked by upregulation of RAS outputs (hypervigilance), and downregulated in disorders characterized by decreased RAS outputs (hypovigilance). Many of the disorders discussed have a developmental etiology and a postpubertal age of onset.

[Neurobiology of trigeminal pain]

The brainstem trigeminal complex integrates somatosensory inputs from orofacial areas and meninges. Recent studies have shown the existence of a double representation of pain within the brainstem, at the level of both caudalis and oralis subnuclei. Noxious messages are mainly conveyed by C-fibers that activate the subnucleus caudalis neurons. These neurons in turn activate the subnucleus oralis whose neurons share similar features with the deep spinal dorsal horn neurons. In contrast with the nearness of the laminar organization of the dorsal horn, the vertical organization of the trigeminal complex offers an easier access for the study of segmental mechanisms of nociceptive processing. This model allowed us to show the existence of subtle NMDA-related mechanisms of segmental nocious processing. The trigeminal complex conveys nociceptive messages to several brainstem and thalamic relays that activate a number of cortical areas responsible for pain sensations and reactions. Cortical processing is sustained by reciprocal interactions with thalamic areas and also by a direct modulation of their pre-thalamic relays. The dysfunction of these multiple modulatory mechanisms probably plays a key role in the pathophysiology of chronic trigeminal pain.

[Motion sickness exemplified by seasickness]

The knowledge of seasickness is as old as seafaring itself. In ancient times the Babylonians already reported on this malaise and on possible therapeutical measurements. The Babylonians, the advice of old sailors and modern pharmaceuticals have one thing in common. They have not been able to find a complete cure for motion disease. The interactions of the relevant cerebral structures are so complex that no drug is available which can interrupt this process definitively. The most important preventive measure is to develop strategies which lead to a quicker adaptation to movement.

Cardiovascular and respiratory consequences of bilateral involvement of the medullary intermediate reticular formation in syringobulbia

We studied five patients with clinical and radiological evidence of syringobulbia (SB) to determine whether the distribution of lesions in relationship to the cardiorespiratory control networks in the medullary intermediate reticular zone (IRt) correlates with the presence of abnormalities in autonomic cardiovascular and respiratory control in these patients. All patients underwent high resolution MRI to characterize the size, volume and distribution of the SB lesions, cardiovascular autonomic function testing and polysomnography. One patient with bilateral IRt involvement at both the rostral and caudal medulla had orthostatic hypotension (OH), absent HR(DB), abnormal Valsalva ratio, exaggerated fall of BP during phase II and absent phase IV during VM, and a dramatic fall of BP during head up tilt; this patient also had severe obstructive sleep apnea (OSA) and exhibited BP drops during each respiratory effort. A second patient, with bilateral IRt involvement restricted to the caudal medulla, had less severe cardiovascular autonomic dysfunction but also exhibited severe OSA. The other three patients had small SB cavities sparing the IRt and had sleep apnea but no autonomic dysfunction. Autonomic dysfunction could not be related to the size of the syrinx or the degree of atrophy in the cervical spinal cord in any of the five patients. Bilateral involvement of the IRt by SB produces cardiovascular autonomic failure and sleep apnea. In patients with more restricted lesions, autonomic and respiratory dysfunction may be dissociated. Clinico-radiological correlations using high resolution MRI assessment of medullary lesions can provide insight into the central organization of cardiovascular and respiratory control in humans.

The integrative role of the rat medullary subnucleus reticularis dorsalis in nociception

Neurons within the medullary subnucleus reticularis dorsalis (SRD) of the rat convey selectively nociceptive information from all parts of the body. We have sought to define the neuronal networks that convey information from widespread noxious stimuli to the diffuse thalamocortical system and also modulate spinal outflow. The experiments, which were performed in rats, were designed to determine whether efferents from the SRD issue collaterals to the thalamus and spinal cord. Injections of the tracers fluorogold and tetramethylrhodamine-labelled dextran were centred stereotaxically in two areas that receive dense projections from the SRD: the cervical spinal cord and the lateral ventromedial thalamus (VMl), respectively. In other experimental series, SRD neurons were characterized electrophysiologically and individually labelled in a Golgi-like manner following juxtacellular iontophoresis of biotin-dextran. More than half reticulothalamic neurons within the SRD provided monosynaptic connections to the spinal cord. SRD neurons that responded to Adelta- or Adelta- and C-fibre activation from any area of the body had axons that gave both ascending and descending collaterals. Because the SRD innervates several areas involved in motor processing and receives strong, direct influences from several cortical regions, it could provide a structural basis for the processing of nociceptive and motor activities.