Heterogeneity of neurological syndromes in survivors of grade 3 and 4 periventricular haemorrhage

To evaluate the topographical neurological distribution, patterns of abnormal tone and related functional neuromotor impairment after grade 3 and grade 4 intraventricular/periventricular haemorrhage (IPVH), 33 children with previous grade 3 or 4 IPVH of mean gestational age 30.9 weeks (range 25-40 weeks) and mean birth weight 1743 g (range 866-3600 g) were examined neurologically at 4.7 years (range 0.75-10.8 years). Neurological signs were absent in 10/33 cases which were equally distributed between the grade 3 and grade 4 IPVH groups. The largest single topographical neurological distribution was hemiparesis in 8/23, followed jointly by diplegia (cerebral paraplegia) in 6/23 and triplegia in 6/23 cases and finally quadriplegia in 3/23 cases. Grade 4 IPVH tended to result in asymmetrical syndromes, accounting for 7/8 cases of hemiparesis and 5/6 cases of triplegia, whereas all 3/3 cases of quadriplegia followed grade 3 IPVH. The 6/23 cases of diplegia were shared between the grade 3 and grade 4 IPVH groups. Tone was normal in 7/8 of the hemiparetic subjects. Dystonia was the commonest tone abnormality, affecting 8/23 children with neurological disturbance, followed by ataxia/hypotonia in 4/23 and mixed dystonia/hypotonia in 3/23. Only 1/23 cases had signs of spasticity. Spasticity is rare following severe IPVH. Diplegic children had a better functional neuromotor grade than hemiparetic children, who in turn did better than triplegic children. Ataxia hypotonia resulted in better functional outcome than dystronia, which in turn was more favourable than mixed tone patterns. Cranial imaging by ultrasound (US) or computed tomographic (CT) scanning proved an unreliable prognostic indicator except in the case of hemiparesis, for which US scans correctly predicted the affected side in 5/7 cases. The neurological syndromes following severe IPVH differ from the classical encephalopathy of prematurity, and this should lead to a re-appraisal of the trends in the prevalence of cerebral palsy. Caution should be exercised in the interpretation of cranial imaging with regard to pessimistic prognoses in the presence of changes or undue optimism in their absence.

A comparison of the mechanogram of the ankle jerk in men and women: observations using an adjustable dorsiflexing torque, high inertia mechanical filter and automatic readout system

An instrument of new design has been constructed to measure the contractions of the calf musculature resulting from a tap on the Achilles tendon. The instrument provides a predetermined and adjustable dorsiflexing torque from a printed motor, but the contractions are virtually isometric as the system is one of high inertia. Peak force, half-contraction time and half-relaxation time are monitored by electronic circuits equipped with digital output meters. Observations have been made on fifty-two male and forty-five female medical students. There were no significant differences in the peak torques generated by the contractions between the men and women students and no difference in the half-contraction times. The half-relaxation times of the women were, however, significantly longer than those of the men (P = 0.0001). In another group of students the EMG discharges following a tendon tap were recorded, there was no significant difference in the duration of the activity in men and women. Observations have also been made on twenty-three male and seventy female subjects whose mean ages were in the mid-sixties. The peak torques generated by the contractions were significantly higher in the women (P = 0.03). There was no difference in the half-contraction times, but the half-relaxation times of the women were significantly longer (P = 0.001). Possible reasons for the differences are discussed.

Peripheral and central mechanisms of hindfoot equinus in childhood hemiplegia

A detailed clinical examination of 24 hemiplegic children at a mean age of 9.9 years showed that nine had an obligate toe-strike when walking at a self-selected speed and this was maintained throughout stance. None of the 24 children had a fixed equinus. No association could be found between this pattern of gait equinus and lower-limb atrophy, reduced ankle-joint range, muscle extensibilite, power of dorsiflexors and plantarflexors or actual muscle imbalance at the ankle joint. Gait equinus was independent of reduced compliance of the calf muscles, of a clinical diagnosis of tonic spasticity, of fine-motor dexterity of the toes, and of the side of the hemiplegia. Gait equinus cannot be explained merely in terms of a central paralytic foot-drop. A developmental model of equinus is advanced.

Neurological outcome following neonatal post-haemorrhagic hydrocephalus: the effects of maximum raised intracranial pressure and ventriculo-peritoneal shunting

The neuromotor outcome of 33 survivors of grade 3 or 4 neonatal post-haemorrhagic hydrocephalus born between 1975 and 1988 was assessed at a mean age of 4.7 years (9 months to 13 years). Two outcomes were determined: 12 patients were either normal (10 or had neurological signs without functional impairments (2), while 21/33 were moderately (16), severely (2), or profoundly impaired (3). Intracranial pressure (ICP) was measured in 26/33 patients (4-40 mm Hg): 2 had normal pressures (< 5.6 mm Hg) and were normal. Raised ICP was not significantly different between outcome groups. Twenty-seven children were shunted; 10/27 had five or more operations (up to 14) and all of these had abnormal neurological outcomes, whereas the number of children with 1-4 shunt procedures was equal in both outcome groups. The rise in morbidity after the fourth shunt procedure may be associated with the ventriculitis suffered by 9 of the 10 patients with more than four shunts (P < 0.01): this compares with 4/14 cases of ventriculitis in the children with 2-4 shunts and no cases of infection in the 3/27 who were shunted once. Outcome was independent of antenatal and perinatal factors including the age at or mode of presentation, and was unrelated to grade of intraventricular haemorrhage or parenchymal changes on ultrasound or CT scanning.

CONCLUSION

for these small numbers, adverse outcome is statistically related to more than four shunt procedures and ventriculitis but independent of maximum ICP or other perinatal factors.

Effects of mutations in glycosylation sites and disulphide bonds on processing, CD4-binding and fusion activity of human immunodeficiency virus envelope glycoproteins

Site-directed mutagenesis was used to study the biological significance of a disulphide bridge and two N-linked oligosaccharides in the CD4-binding region of the envelope glycoproteins of human immunodeficiency virus type 1. Mutagenesis was performed in a phage M13 system at sites corresponding to the cysteine residue (amino acid 402) and the asparagine residues (390 and 447) of the env gene. The mutated env gene was inserted into a recombinant vaccinia virus under the control of the vaccinia virus 7.5K promoter and the expression of mutated env proteins was analysed by SDS-PAGE, a conventional indirect immunofluorescence assay and by a fluorescence-activated cell sorter. Cysteine 402 was found to be essential for the specific cleavage of gp160 into gp120 and gp41, and for intracellular transport of the protein to the cell surface. CD4-binding and syncytium formation assays demonstrated that the disulphide bridge of cysteine 402 stabilized a conformation essential for receptor binding as well as syncytium formation by CD4+ cells. No altered biological activity compared to that of the wild-type proteins could be detected for the mutant proteins lacking the N-glycosylation sites. These data show that the two conserved glycans attached to asparagine residues 390 and 447 do not play any active role in the formation of the disulphide bridge involving cysteine 402 or in the maintenance of an active conformation of the protein, despite their location within the functionally important CD4-binding region.

Four-channel Ti:LiNbO(3) wavelength division multiplexer for 1.3-microm wavelength operation

A four-channel Ti:LiNbO(3) wavelength division multiplexer (WDM) that uses cascaded two-mode-interference dual-channel WDM waveguide structures was demonstrated. Its implementation in integrated-optic form affords ease of fabrication, voltage tunability, and the potential for combining other devices for different functions on the same chip. The device was operated in the wavelength region of 1.3 microm. The channel spacings ranged from 12 to 15 nm. The channel wavelengths can be electro-optically tuned at the rate of 1 nm/V. The cross talk was measured to be less than -20 dB.

Treatment of disseminated Mycobacterium avium complex infection of beige mice with liposome-encapsulated aminoglycosides

Free and liposome-encapsulated amikacin are active in vitro against intracellular Mycobacterium avium complex (MAC). To examine whether liposome-encapsulated aminoglycosides might kill intracellular MAC more effectively in vivo, beige mice were infected with MAC strain 101 (serotype 1) and after 1 week were treated intravenously every other day (5 doses total) with amikacin liposomes (0.2, 1, or 4 mg/dose), amikacin solution (0.2, 1, or 2 mg), gentamicin liposomes or gentamicin solution (0.2 or 1 mg), placebo liposomes (without aminoglycosides), or buffer. Amikacin and gentamicin liposomes significantly reduced bacterial counts in blood, liver, and spleen (98.5%, 92.7%, and 92.8%, respectively, for the 1-mg dose of amikacin and 92.8%, 99.7%, and 99.4% for gentamicin; 95.7%, 69.7%, and 89.1%, respectively, for the 0.2-mg dose of amikacin and 49.9%, 76.7%, and 89.1% for gentamicin) compared with placebo liposomes and buffer. Equivalent doses of free drug were not associated with significant decreases in viable bacteria. Thus, aminoglycoside liposomes improved bactericidal effects over conventional treatment in disseminated MAC infection, offering potential application in treating MAC infection in humans.

Successful treatment using gentamicin liposomes of Salmonella dublin infections in mice

Gentamicin entrapped within stable multilamellar liposomes was used to treat mice after they were infected per os with Salmonella dublin. Of 10 mice, 8 survived after a single intravenous (i.v.) injection of 2 mg of gentamicin liposomes per kg compared with 0 of 10 treated with the same amount of free gentamicin. All mice survived after treatment with a single i.v. or intraperitoneal injection of 20 mg of gentamicin liposomes per kg, whereas that dose of free drug was completely ineffective and caused neuromuscular paralysis when injected rapidly i.v. In mice treated with gentamicin liposomes, there was a steady decrease in the number of salmonellae in spleens for 2 weeks after treatment. High concentrations of gentamicin were present in the spleen for at least 10 days after treatment. Although gentamicin was not detected in the mesenteric lymph nodes of mice treated with gentamicin liposomes, bacterial counts in the nodes also decreased over time. Small numbers of bacteria remained viable in the mesenteric lymph nodes and Peyer's patches but not in the spleens of mice treated with 20 to 80 mg/kg. Mice treated with doses of gentamicin liposomes as high as 80 mg/kg showed only a transient increase in blood urea nitrogen and no rise in serum creatinine. These results confirm that gentamicin in liposomes is less toxic in mice than is free gentamicin and is extremely effective therapy for disseminated Salmonella infections in mice.

Characterization of noncholinergic nicotine receptors on human granulocytes

The noncholinergic nicotine receptor on leukocytes identified earlier [Davies et al., Molec. Cell. Biochem. 44, 23 (1982)] was further characterized. Structure-activity relationships showed that a pyrrolidine ring containing a basic N atom is an important structural feature for ligands that bind to the receptor. Accordingly, the carcinogenic component of tobacco smoke, N-nitrosonornicotine, does not bind to the receptor. The stereoselectivity for the d-isomer, which was confirmed using [3H]d-nicotine as a ligand, together with the absolute configurational relationship between d-nicotine and L-proline, suggested that basic peptides containing proline as the N-terminal amino acid would bind to the receptor. The finding that Pro-Lys-Pro-Arg, which has been reported to inhibit granulocyte phagocytosis, bound to the receptor with an IC50 value of 3.5 microM is compatible with this idea. An increase in receptor binding, which was observed in the presence of plasma, could be ascribed to bicarbonate. The presence of bicarbonate in the binding assay, even when the pH of the buffer was carefully controlled, resulted in an increase (approximately 2-fold) in the apparent number of receptors without affecting the Kd value significantly. Increasing the pH of the buffer in the absence of bicarbonate also increased receptor binding, suggesting that bicarbonate may increase receptor binding by its known ability to increase intracellular pH at constant extracellular pH. Preincubation of cells with d-nicotine under certain conditions reduced the subsequent binding of [3H]d-nicotine to the receptor.

First position wobble in codon-anticodon pairing: amber suppression by a yeast glutamine tRNA

A 2.4-kb fragment of DNA isolated from the Saccharomyces cerevisiae genome was found to suppress amber mutations when its carrier plasmid was present in high copy number. A 1.2-kb subclone of this fragment was sufficient to confer suppressor activity. Sequencing has established that this fragment carries a normal glutamine tRNA gene. Deletion of this tRNA gene from the subclone resulted in the loss of suppressor activity. The tRNAGln has the anticodon CUG that normally recognizes the glutamine codon CAG. We propose that suppression occurs via an inefficient readthrough of the UAG amber stop codons during translation. Such readthrough requires wobble in the first position of the codon.

CT of thrombosed arteriovenous malformations in children

Thrombosed arteriovenous malformations (AVMs) in children are rare lesions that may present with headaches or a seizure disorder. Thirteen patients (4 months to 21 years of age) with this lesion were examined with computed tomography (CT). In 11 patients surgical confirmation was obtained, and the other two patients were examined with follow-up CT scans. Angiography either showed an avascular mass (7/13) or was negative (6/13). CT showed a lobulated lesion (8/13), peripheral location (11/13), and minimal surrounding edema (8/13). All of the lesions were hyperdense prior to the administration of contrast material and all enhanced either slightly or not at all following contrast material administration. It is concluded that these characteristic CT features aid in making the diagnosis of thrombosed AVM. The major differential diagnosis is small intracerebral neoplasm.

Computed tomography of the asymptomatic postsurgical lumbar spine: analysis of the physiologic scar

Computed tomography (CT) has been shown to be an effective noninvasive means of imaging the lumbar spine in patients with suspected disk disease. The clinical and radiographic evaluation, however, of patients with new or recurrent symptoms after surgery for disk disease is fraught with difficulty. This report describes CT changes seen in seven asymptomatic volunteers scanned at various intervals after disk surgery and discusses the implications of these findings.

Pitfalls in the computed tomographic evaluation of the lumbar spine in disc disease

Computed tomography (CT) is an effective non-invasive method of evaluating the lumbar spine in cases of suspected disc disease. In over a 3-year period in a high volume neuroradiologic practice we have observed a number of pitfalls in the diagnosis of herniated nucleus pulposus which may lead to erroneous conclusions and therefore, decrease the overall accuracy of the examination. These pitfalls, and their implications are presented and discussed.

Intravenous digital subtraction angiography in the investigation of intracranial disease

Eighty-six patients who presented with a variety of intracranial lesions were examined with intravenous digital subtraction angiography (IV-DSA). A grading system was used to evaluate the ability of IV-DSA to answer specific diagnostic questions regarding intracranial tumors, vasospasm following subarachnoid hemorrhage, lesions of the sella, dural sinus occlusion, and post-therapeutic embolization. Eighty-four per cent of the examinations provided clinically useful information. In 15% of the cases limited but useful information was obtained; only 1% of the examinations provided no useful information. We conclude that IV-DSA can routinely provide useful information in the evaluation of the variety of intracranial lesions described above.

Vasospasm secondary to ruptured aneurysm: assessment by digital intravenous angiography

Digital intravenous angiography was used for the documentation and evaluation of cerebral vasospasm secondary to acute ruptured aneurysm. Attenuation of vessel caliber and/or generalized poor visualization of intracranial arteries and prolongation of circulation time were observed in seven patients with the acute clinical diagnosis of cerebral vasospasm. Posttreatment intravenous angiography demonstrated improvement in both arterial caliber and circulation time in six patients who responded to medical therapy for vasospasm. Digital intravenous angiography allowed repeat investigations of the intracranial vasculature safely and quickly without undue risk to the critically ill patient.

Evidence for a noncholinergic nicotine receptor on human phagocytic leukocytes

A noncholinergic nicotine receptor on human phagocytic leukocytes has been characterized using the binding of 3H-(d,1)-nicotine. The average affinity +/- standard deviation of (d,1)-nicotine for the receptor on neutrophils is 36 +/- 18 nM (n = 6). The binding is saturable with an average of 8.7 x 10(4) sites per neutrophil. Monocytes and to a lesser extent lymphocytes but not erythrocytes also display specific binding. Bound nicotine is dissociable from the receptor and is not metabolized. Only close structural analogs of nicotine bind to the receptor, which is stereoselective for the (d)-isomer. The receptor can be occupied by (1)-nicotine at concentrations present in the blood of smokers. It is suggested that some of the adverse effects of smoking on leukocyte functions may be mediated by a specific nicotine receptor.

The value of routine cranial computed tomography in neurologically intact patients with primary carcinoma of the lung

The most common cerebral metastatic lesion is from carcinoma of the lung. Preoperative cranial computed tomography (CCT) with contrast enhancement was performed in 55 neurologically intact patients with a diagnosis of bronchogenic carcinoma; 3 patients (5%) demonstrated cerebral metastasis. CCT could spare a significant number of such patients from unnecessary surgery, with a net saving substantially greater than its cost.

Pseudoaneurysm formation secondary to spontaneous thrombosis of a massive cerebral arteriovenous malformation

A case of a large cerebral arteriovenous malformation (AVM) with spontaneous partial thrombosis and intracerebral hematoma is reported. The unusual and unique features of the radionuclide brain scan and cerebral angiogram are described. The characteristic angiographic features of residual tortuosity and dilatation or pseudoaneurysm formation at the bifurcations of the feeding arteries in a partially thrombosed cerebral AVM have not been described previously in the literature.

Computed tomography in herpes simplex encephalitis

Nine patients with herpes simplex encephalitis examined by CT scan were reviewed. A total of 15 satisfactory scans was analyzed. The majority of our cases had CT scan abnormalities: lucency 63% (5 of 8, one case with suboptimal scan), mass effect 50% (4 of 8), abnormal contrast enhancement 57% (4 of 7). The earliest CT scan finding was lucency, presented in two out of three cases studied within 48 hours following onset of symptoms. The primary role of CT scan is to support the suspected diagnosis of herpes simplex encephalitis as well as to indicate the best site for brain biopsy and to permit early effective treatment with adenine arabinoside.

The choroidal artery to the fourth ventricle and its radiological significance

The choroidal artery to the fourth ventricle has been studied in 25 brain specimens and 100 normal posterior fossa angiograms, including 25 angiotomograms. Its variable origin, course and radiological significance have been stressed.

Some aspects of the computed tomography of the head

Computed tomography demonstrates intracranial neoplasms so clearly that nearly all early work in this field was limited to descriptions of the appearance of various lesions. Only recently have investigators directed their attention to the medical implications of the physical and pathophysiologic phenonmena that characterize this remarkable new technique. This paper will discuss recent work in these two areas and its clinical implications, and will examine the application of computed tomography to the evaluation of the postsurgical and postradiation patient.

Positive and negative contrast myelography in spinal trauma

The myelograms of 60 acutely injured patients were reviewed. Positive contrast material (Pantopaque) was preferred in cervical and thoracic trauma manifesting bony deformity, in cervical trauma without bony deformity (in the prone position), in delineating the thoracic spinal cord in the frontal projection, and in lumbar spinal injuries. Negative contrast material (air) was preferred in cervical trauma without bony deformity, to delineate the thoracic spinal cord in the lateral projection and in chronic trauma to demonstrate cord atrophy. An experimental, water-soluble positive contrast material (Amipaque) may show the spinal cord advantageously in both the anteroposterior and lateral projections and may be more extensively used. A protocol has been devised, based on the analysis of the myelographic findings.