Polyneuropathy associated with IgA monoclonal gammopathy: a hypothesis of its pathogenesis

We describe three patients with chronic progressive polyneuropathy associated with IgA monoclonal gammopathy. Two patients had a prominent sensory neuropathy and one had a prominent motor neuropathy. Sural nerve biopsies showed axonal degeneration in all cases. In immunocytochemical studies patients' IgG immunostained axons. By Western immunoblot a band of IgG reactivity with an axonal protein of 66 kDa was found. No band of IgA and IgM were found. We suggest the possibility that the IgA monoclonal protein may act as a stimulating factor of preexisting B cell clones eliciting an immune reaction against nerve antigens.

Morphological and functional evaluation of peripheral nerve regeneration in the rat using an expanded polytetrafluoroethylene (PTFE) microprosthesis

The aim of our study was to evaluate in the rat the ability of a polytetrafluoroethylene microprosthesis (PTFE), to guide the peripheral nerve regeneration between the two extremities of a transected sciatic nerve. In 15 adult male Wistar rats, weighing 200 g, a segment of the right sciatic nerve was resected, leaving a gap of about 1 cm, bridged with microprosthesis, using our original microsurgical technique. Neurophysiological evaluations were performed at 6 and 9 months post-operatively to study the distal motor latency either in the right sciatic nerve or in the unoperated control side. In all the rats myoelectrical responses with an increased latency of the operated side were produced from the interosseous muscle of the foot. The animals were sacrificed 9 months post surgery. Histological sections at the level of the graft were done in all the rats, and in 10 animals biopsies of the tibialis anterior muscle (TA) of each side were performed. An active process of axonal regeneration was documented inside the graft, with no infiltration of nerve fibers through the wall of the prosthesis. A connective fibrous reaction was present around the external wall of the graft. Muscle biopsies showed definite signs of muscle reinnervation, with residual features of variable degree of denervation. These findings stress and confirm the ability of the PTFE graft to allow effective regeneration in a peripheral nerve gap in the rat.

Axonal neuropathy with monoclonal IgG kappa that binds to a neurofilament protein

We report a 74-year-old woman with a slowly progressive sensory motor axonal neuropathy and a monoclonal IgG-kappa that bound to a 68-kd axonal protein identified as the low molecular weight neurofilament protein. The sera of control subjects and disease controls did not bind to neurofilament protein.

Evolution of neuropsychological changes after partial callosotomy in intractable epilepsy

Early neuropsychological changes following partial anterior callosotomy were evaluated in 15 patients with epilepsy (10 secondary generalized and 5 Lennox-Gastaut syndromes) by comparing their performances 1 month before surgery and then 15-20 and 90-100 days postoperatively without modifying the anticonvulsant treatment. The following neuropsychological and motor functions were tested: memory, attention, visuo-motor ability, posture, motor dexterity, language, praxis and gnosis. Social behaviour was also investigated. The main results are as follows: (i) most cognitive functions showed no significant variation; (ii) motor organization was still slightly impaired at the second check-up after the surgery; (iii) improvements in social behaviour and posture were frequently observed at the final evaluation. The analysis of individual cases highlights the influence of the extent of commissurotomy, lesions related to the surgical procedure and preoperative brain damage in determining the post-surgical profile. On this basis, the short-term neuropsychological cost of partial callosotomy appears to be low and seems to depend mostly on surgical parameters and brain conditions before the operation.

Callosotomy for the treatment of drug resistant generalized seizures

Fifteen patients have been followed for more than one year following callosotomy having presented with long standing epilepsy, no well defined focus amenable to radical excision, and severely incapacitating atonic seizures that were refractory to anticonvulsant therapy. Atonic fits have been reduced by more than 80% in thirteen patients, with two patients suffering long term sequelae (slight dysarthria in one, and dyslexia with mild visuo-spatial disturbances in another). Anticonvulsant therapy was still required post-operatively.

Callosotomy for the management of intractable non-focal epilepsy: a preliminary personal assessment

After reviewing the data of the literature, the authors report their personal series composed of twelve cases. In evaluating the results of surgical treatment only the first ten patients are taken into account. As previously stressed in the literature, callosotomy (total in two cases and anterior in the remainder) has proved effective in abolishing or significantly reducing atonic seizures. Tonico-clonic seizures have also benefitted in some cases, while in complex partial and partial seizures the effects of callosotomy have been so far unpredictable, albeit in some patients all kinds of seizures have been abolished or definitely reduced. The most impressive EEG and neuropsychological features after callosotomy are briefly summarized. Anterior callosotomy seems to be a relatively safe procedure, its results appear to be, on the whole, gratifying even though in patients with severe mental retardation and Lennox-Gastaut syndromes remain controversial.

Functions of the corpus callosum: observations from callosotomy performed for intractable epilepsy

The effects of complete and partial corpus callosotomy in 6 patients are reported. Only the 2 cases undergoing total callosotomy showed evidence of impaired interhemispheric sensory transfer, related to sectioning of the splenium. Only mild long-lasting neuropsychological deficits were detected. Post-commissurotomy mutism and akinesia appeared in 4 cases, 2 with total, and 2 with partial anterior callosotomy. The short-and long-term effects of corpus callosotomy appear to be related to the extent of the section the creation of lesions during the surgical procedure, and a peculiar organization of cognitive functions in chronic epileptic patients.

Cryoglobulinaemic neuropathy. A clinical, morphological and immunocytochemical study of 8 cases

Clinical, pathological and immunocytochemical studies are described for 8 patients with cryoglobulinaemia and peripheral neuropathy: 5 had essential cryoglobulinaemia and 3 secondary cryoglobulinaemia. The cryoglobulins in 2 cases were type II (mixed cryoglobulins with a monoclonal component), type III (mixed polyclonal cryoglobulins) in 2 others, and were not characterized in 4. In all patients the neuropathy had an acute or subacute onset and in 7 it was initially asymmetric but, during the illness, in 3 it gradually progressed to a symmetric sensorimotor polyneuropathy. All patients had sural nerve biopsies. In 4 there was widespread vasculitis with necrosis of vessel walls and perivascular inflammatory cells. In another 2, thickening of vessel walls and luminal narrowing without inflammatory cell infiltration, together with loss of myelinated fibres from single fascicles or focally within fascicles, suggested that the neuropathy was of vascular origin. In all patients the main pathological damage was axonal degeneration. Signs of axonal regeneration were rare. The total number of myelinated fibres was reduced in all cases, from 24 to 95% below the lower limit of normal control values. Large diameter fibres were lost preferentially in 7 patients, being below 16.5% of the total number. Several possible pathogenetic mechanisms have been suggested for cryoglobulinaemic neuropathy, including immunologically mediated demyelination and ischaemic injury due to intravascular deposits of cryoglobulins or vasculitis. Our observations therefore confirm a major role for ischaemic factors, secondary to inflammatory vascular destruction, in the pathogenesis of peripheral neuropathy in most cases of types II and III cryoglobulinaemia.

Neuropsychological changes after callosotomy in drug-resistant epilepsy: a study of the short-term evolution

With the increasing interest in callosotomy as treatment for intractable epilepsy, it seems to be important to define the neuropsychological consequences of the related surgical operation. 8 patients suffering from drug-resistant seizures underwent section of the corpus callosum, 6 in the anterior part only and 2 undergoing complete two-stage commissurotomy including the posterior part. Before the callosotomy the patients were studied using a cognitive, affective and behavioural battery which was repeated 15 and 90-100 days after the operation. The patients with sufficient I.Q. were described in more detail using the cognitive parameters; the social and motor behaviour of Lennox-Gastaut subjects are accurately reported. No disconnection syndrome was ever observed after the partial commissurotomy while it occurred in one of the two complete callosotomies. The patients showed longer reaction times and a mild impairment of linguistic, praxic, memory and motor functions in the former evaluation (15 days), but there was consistent improvement in the latter check up. At the 90-100 day follow-up the Lennox-Gastaut patients responded more readily to the environmental stimulations and their postural, motor and behavioural functions were unchanged or improved, with respect to presurgical performances. The social and emotional behaviour of all the patients had always improved by the time the long-term evaluation (90 days) was performed. Finally, by limiting the callosotomy to the anterior part only, the neurological and psychological consequences seem to be limited.(ABSTRACT TRUNCATED AT 250 WORDS)

Ichthyosis accompanied by neurological symptoms with special reference to epilepsy

5 patients with ichthyosis had a neurological accompaniment: epilepsy in 4, congenital palpebral ptosis, facial pain and neurosis in 1. In one patient epilepsy was combined with multiple malformations (normal dwarfism, prematurely old face, skeletal abnormalities) and oligophrenia. There was considerable variability genetically: 2 sporadic cases, 1 with X-linked transmission, 1 with autosomal dominant and 1 with apparent autosomal recessive heredity. In one case the co-existence of glucose-6-phosphate dehydrogenase deficiency provided proof of X-linked transmission. Further study of larger case-series is needed for a better definition of the nosographic and genetic aspects of non blastomatous neuroectodermatoses in which ichthyosis figures.

[Neurological complications in drug dependence with special reference to the development of epileptic syndromes]

33 drug abusers were examined and all of them were addicts to several drugs and always to heroin. Neurological complications occurred rather frequently. One patient had subarachnoid hemorrhage and angiography showed no arteriovenous malformations nor other pathology. Polyneuropathy has been found in one case. 7 patients (21,2%) developed psychotic episodes. Epileptic attacks were found in 5 cases (15,1%). Latency between the onset of drug-abusing and occurrence of the attacks was found to be at least 1 year in two cases and 3 years in the other three. 4 cases suffered from partial complex seizures with secondary generalization and one patient had generalized tonic-clonic attacks. Fits occurred rarely in all cases; one patient had two episodes of partial status. Further research is required because there are few clinical reports in comparison with the experimental ones.

[Clinical and CT aspects of muscular dystonias]

Clinical, EMG, genetic and CT investigations were performed on 16 subjects suffering from Torsion Dystonia. We obtained the following results: i) genetically most cases were sporadic, only two could be considered autosomic dominant; ii) one of the pedigrees, with many patients, confirmed that spasmodic torticollis is not a distinct form from that of Dystonia Muscolorum Deformans; the two forms must be included in one disease called "Torsion Dystonia", as maintained by some Authors; iii) we found that the various drugs employed, rarely produced improvement, although benzodiaze4pines have given some benefit; iv) CT findings were not specific, though useful for differential diagnosis.

CT and EEG investigations in 100 patients with multiple sclerosis (MS)

100 MS patients were followed up for an average of 5 years. We considered age at onset, duration of the disease, number of attacks, neurological and psychic status, CT and EEG findings and tried correlating the last two with all the previous factors. In remission the most frequent CT abnormality was diffuse atrophy. In acute exacerbations there were 3 possibilities: normality, hypodensity and, much more rarely, hyperdensity with pseudotumoral patterns. A normal CT and short duration of disease were positively correlated with a small number of attacks. There were no positive correlations between CT findings, age at onset and neurological and psychic status. EEG, like CT, may show no changes in a high percentage of cases but there is scant correlation between the two.

[Genetic, polyphysiographic, CT and therapeutic aspects (author's transl)]

Genetic, clinical, polyphysiographic and therapeutical aspects were investigated in a 37 year old patient suffering from: sporadic and localized segmentary myoclonia (present during rest and increasing slightly during movement), cerebellar syndrome, marked hypoacusia, hyper-reflexia of the lower limbs, spike and polyspike EEG discharges and massive myoclonia during photostimulation. A dominant autosomic inheritance of this syndrome was suggested by the occurrence of a more serious and rapid, yet similar, illness in the mother and by EEG alterations in an 8 year old son. The Authors suggest that, from the clinical point of view, they are dealing with an atypical Ramsay-Hunt syndrome (MCD) with signs of Pierre-Marie Heredoataxia. This supports the possibility, however rare, of intermediate forms between MCD and Heredoataxia. The patient underwent polyphysiographic investigations under the following conditions: i) without therapy; ii) with diphenylhydantoin; iii) with phenobarbital; iv) with sodium dipropyl-acetate; v) with clonazepam. The above investigations confirmed the previously described alterations, during wakefulness or sleep, observed in cases of Unverricht-Lundborg syndrome (PME) and Ramsay-Hunt syndrome (MCD). Clonazepam was found to be the most effective drug in attenuating myoclonia, in reducing the EEG spike activity and in reorganizing the phases and cycles of sleep.

[The problem of private insurance for patients with epilepsy (author's transl)]

324 epileptics were questioned about their approach to private insurance. Only 9,26% of them were covered by a life or accident insurance policy: 3,70% had life insurance, 3,70% accident insurance and 1,86% both. None of the patients had declared his disability to the insurance company. In 6,17% of the 324 epileptic cases an insurance policy had been taken out by their parents. In comparison about 35% of the Italian population in general are insured. A questionnaire was sent to 20 insurance companies; only 5 of them replied, saying that as far as accidents were concerned, they considered epileptics uninsurable. As for life insurance, policies can be contracted at increased premiums, according to the individual case (including the severity of the illness). Physicians must give epileptics fuller information about their insurance plans because, if their illness is detected after an accident, they will find themselves not covered by insurance. Government intervention is called for with the setting-up of special funds for this purpose.

[Epileptic patients: work and entailing risks (author's transl)]

We made a survey of 450 epileptic patients to find out how their disability affected their jobs and what risks were involved. 60% of the patients questioned had jobs. Those who did not work had frequent attacks and neurological and/or psychiatric handicaps. About 50% of the working epileptic patients were self-employed against a figure of 35% for the self-employed population in our region. In 6.6% of the cases, accidents had occurred at work because of attacks. In half of these cases the accident was not serious and in the other of no account. There is little difference between the Italian population in general and the epileptic when we consider the risks involved at work. This may be attributed to the prudence and common sense the patients show in their choice of work (when this is possible) and in the way they perform their work. Italian law on civil disability limits the work for which epileptics may be employed. For this reason they very often hide their illness from their employer and co-workers.

[The driving license and epilepsy (author's transl)]

Italy is one of the few countries in Europe with no legislation specifically concerning driving licenses and epilepsy. We made a survey of 321 epileptics all over 18 years of age; 80,4% of them had epilepsy (temporal lobe). 47,7% of the 321 had a driving license, 2,8% had their license withdrawn because of epilepsy. The frequency of attacks among those with licenses was as follows: 52,9% rarely had attacks (1 every 2 years or even less often), 17,7% had attacks yearly and 29,4% had frequent attacks (1 a month, 1 a week or even daily). About 2% of the patients examined had had accidents because of attacks; none of the accidents were very serious. In spite of the lack of legislation, a high number of patients has driving license. However our investigations have shown that they were careful in their driving and scrupulous about treatment and medical check-ups. The main problem is that epileptics with a driving license may encounter serious difficulties with insurance companies if they have a car accident. It is to be hoped that in Italy appropriate measures are taken parallel to those of other European Countries.

[Institutionalized epileptic patients in the "Marche" region (preliminary data) (author's transl)]

The purpose of this survey was to gather information about long stay epileptic patients in 16 institutions of the "Marche" region. The 203 institutionalized subjects were examined and the information fed into computer. All the patients, in addition to epilepsy, had psychiatric and or neurological handicaps, which were often more disabling than their epilepsy (with difficult social adjustment in most cases). The socio-economic level of the families was usually rather low. Ths survey showed satisfactory as well as unsatisfactory aspects of rehabilitation facilities, equipment, medical and para-medical staff, in these institutions. The deficiencies were mostly caused by the lack of coordination and programming at regional level. Each institution, in effect, acted independently.

[Efficacy and side-effects of long term L-dopa therapy in Parkinsonian syndromes (evaluated by CT scan as well) (author's transl)]

The evolution of symptoms and therapeutic response in a group of have been followed parkinsonian patients 81 for a period of 4 years. Hoehn and Yahr, and Webster's scales have been used. In addition CT scan, EEG, ECG, blood and urine analyses have been carried out. Treatment was carried out with L-Dopa and decarboxylase inhibitor (benserazide for 50% of cases and carbidopa for the other 50%). Anticholinergics (esp. metixene) were often required. The initial response was satisfactory for all patients except one who had hydrocephalus (with normal pressure). Four years later, the initial improvement diminished by about 1/3. Side effects occurred in 80.24% of cases in the beginning, and in 82.50% of cases after 4 years. Dyskinesias, confusional state and "on-off" phenomenon increased with time, whereas gastric trouble diminished. CT scan were obtained in all patients and atrophic changes were found in 82.7%. There were no correlations between localization and severity of anatomical lesions on the one hand, and therapeutic response and side-effects on the other. It is suggested that the severity of the disease depends mainly on the degree of neurochemical integrity in the affected area rather then to the extent of anatomical lesions.

[Bromocriptine in Parkinsonian syndromes. Results obtained in a group of patients treated for 8 months]

Antiparkinsonian treatment with L-Dopa gives rise to a number of problems: I) lack of initial response in a few cases; II) side-effects; III) becoming less effective after the first few years of treatment. Consequently, various drugs have been tried to replace, or combine with, L-Dopa. Among those drugs bromocriptine has been described the most effective. Twelve patients suffering from severe parkinsonism, all being intolerant to L-Dopa, have been treated with Bromocriptine. They fell into stage V of the Hoehn and Yahr's scale after 8 days of complete withdrawal of therapy with L-Dopa. Benefit and side-effects have been assessed as follows: a) L-Dopa alone; b) bromocriptine alone; c) combination of a and b. A daily dose of 30 mg of bromocriptine was given for 4 months. This was then reduced to 15 mg with the addition of L-Dopa for another 4 months. The results were: I) bromocriptine scored higher in all patients except one; II) bromocriptine has been consistently less effective than L-Dopa; III) side-effects were similar to those of L-Dopa but less frequent; IV) the combined effect of the two drugs was superior to each drug given alone.

Quantitative data on cell loss and cellular atrophy of intralaminar nuclei following cortical and subcortical lesions

Morphological changes in the intralaminar nuclei centralis medialis, paracentralis and centralis lateralis of the thalamus of adult cats after cortical excisions have been determined by means of a quantitative method. The number and size of the remaining neurons on the operated side have been compared with those of the normal side. The differences between the normal and the operated side have been compared to those found between the two sides in the control animals. The most important result is the demonstration that after cortical ablations the intralaminar nuclei show not only chromatolytic or atrophic changes of their cells but also a true cell loss. These reactions are qualitatively similar to those observed in the specific nuclei of the thalamus, the only difference being a quantitative one. As a consequence it can be suggested that some intralaminar nuclei project to certain areas of the cerebral cortex which also receive projections from one or other specific thalamic nucleus. A large essential connection of the intralaminar nuclei, in particular the nucleus centralis medialis, with subcortical structures is confirmed.

[Therapeutic effects of taurine in epilepsy: a clinical and polyphysiographic study (author's transl)]

A study was carried out after i.v. administration of 200 mg/Kg of taurine on 37 epileptic patients in whom frequency and duration of seizures was considerable. Twenty-two subjects were given taurine for 15 consecutive days and then, once a week for a period of 6 weeks. In 5 control cases, the daily dosage wascontinued up to the 30th day; in 5 more, up to the 45th day and finally, in 5 up to the 60th day. Out of 37 patients 15 had temporal lobe epilepsy, 10 were cases of Lennox-Gastaut syndrome, 5 had generalised epilepsy, either convulsive or non-convulsive, 4 had H.H.E. syndrome and three brothers had myoclonic familial progressive epilepsy. In each group the results were similar and may be summarised as follows: I) both interictal activity and electroclinical seizures were reduced by about 30% within the first 10 days of administration; II) between the 30th and 45th day the ictal and interictal activity returned to its initial values; III) after this period, on the 60th day, values were similar to the initial ones; IV) as far as interictal activity is concerned, the same effect was found during nocturnal sleep; V) no significant changes were noticed in nocturnal sleep cycles and stages; VI) there was no apparent evidence that any phase of sleep might facilitate any improvement. Improvement was observed in about 50% of the cases (21) both physically and psychologically. The physical improvement was noticed above all in the appearence of the skin while the psychological improvement was mostly related to both attention and memory. Any pathological aspect of personality did not appear to be modified.