An MR protocol for presurgical evaluation of patients with complex partial seizures of temporal lobe origin

PURPOSE

To find an optimal diagnostic protocol for the presurgical MR evaluation of patients with temporal lobe epilepsy.

METHODS

MR imaging in 14 healthy subjects and 25 consecutive patients with temporal lobe epilepsy was performed in paracoronal sections perpendicular to the hippocampi with T1-weighted inversion recovery and T2 weighting. Volume measurements of the hippocampus/amygdala complex were performed and a multiecho sequence yielded T2-calculated images.

RESULTS

Hippocampal disease was seen in 22 of 25 temporal lobe epilepsy patients on paracoronal T1-weighted inversion recovery images. Four had bilateral abnormalities. Characteristic for hippocampal disease were features such as volume loss, decreased signal, and loss of internal morphology. Only 17 of 25 patients demonstrated hippocampal pathology on T2-weighted images, and in one patient this was bilateral. Patients with only minimal structural loss on T1-weighted inversion recovery had normal T2-weighted images. T2 calculation was no more sensitive than visual assessment on the T2-weighted images. Volume measurements were normal in one patient and misleading in two patients. Lateralization, as compared with clinical and electroencephalographic findings, was most confidently done with paracoronal T1-weighted inversion recovery images and volume measurements.

CONCLUSIONS

An optimum MR protocol for temporal lobe epilepsy patients is proposed. Its essential feature is that the hippocampus be evaluated by paracoronal T1-weighted inversion recovery images and volume measurements. T2-weighted imaging can be omitted.

Haemodilution study in major orthopaedic surgery experience as a technique of blood conservation

Haemodilution and auto-transfusion were carried out in 103 consecutive patients having major orthopaedic surgery. The records of 99 patients were available for retrospective assessment of this technique. Fifty-six per cent of the patients did not require any homologous blood transfusion. Homologous blood transfusion was given to 44% of the patients, who used up 99 units of blood in their entire hospital stay. There was no morbidity such as transfusion reaction, infection, decrease in platelets or re-operation for bleeding associated with the procedure, although there was one death secondary to myocardial infarction. This technique offered an alternative method to reduce the use of homologous blood transfusion in major orthopaedic operations.

Clinical and neurophysiological correlations in patients with refractory partial epilepsy and intracranial structural lesions

Twenty patients (13 males, 7 females), who presented with refractory partial epilepsy and a CT and/or MR detected intracranial intra-axial structural lesion were admitted to the University of Gent Epilepsy Monitoring Unit. Mean duration of the epilepsy was 17 years (2-47 years). All patients were enrolled in a comprehensive presurgical protocol including neurological examination, video-scalp-EEG monitoring with prolonged interictal and ictal recording, neuropsychological assessment and positron emission tomography (PET). Intracranial EEG monitoring was performed in 5 patients in whom discrepancies between different tests were found during the non-invasive evaluation. Clinical neurological examination was normal in 16 patients; 4 patients had a mild contralateral hemiparesis. Lesions were mainly located in the temporal lobe (55%). Most patients presented with complex partial seizures (90%). Clinical seizure characteristics correlated well with the lesion location in 55% of patients. Interictal EEG showed focal epileptic activity and focal slowing in respectively 85% and 30% of patients. Interictal EEG lateralization was congruent with the side of the lesion in 17 patients (85%). Interictal EEG localization was congruent with the lobe of the lesion in 13 patients (65%). Ictal EEG lateralized correctly in 14 patients (70%) and localized correctly in 10 patients (50%). Neuropsychological assessment lateralized and localized congruently in respectively 8/17 (47%) and 7/17 (41%) of patients. Interictal PET showed focal interictal hypometabolism, congruent with the lesion, in 13/16 (81%) of patients. Intracranial EEG was congruent with the lesion location in 3 patients but non-congruent in 2 patients. All patients underwent surgical procedures: average follow-up was 14 months (6-24 months). Complete surgical removal of the lesion with free margins resulted in a more than 90% reduction of seizures without postoperative neurological deficit in 12/13 patients.

Long-term video-EEG monitoring revisited. The value of interictal and ictal video-EEG recording, a follow-up study

Between October 1990 and November 1992, 100 patients were monitored at the University of Gent Epilepsy Monitoring Unit. Sixty-three patients were referred for refractory epilepsy, 38 of whom were entered in the epilepsy surgery protocol. Thirty-seven patients were evaluated for the diagnosis of attacks of uncertain origin. Average duration of monitoring was 3.5 days (2-15 days). Prolonged interictal EEG was recorded in all patients. Ictal EEG was obtained in 63 patients; the average number of recorded episodes was 3 (1-15). Pre-monitoring tentative seizure diagnosis was available in 81 patients, 59 of whom had clinical attacks. Premonitoring diagnosis was confirmed in 31 patients and revised in 28 patients. As a result of the monitoring session, anticonvulsant medication was started in 10 patients, changed in 47, stopped in 5 and left unchanged in 23 patients. Twelve patients underwent surgery. Average follow-up after monitoring was 17 months (4-30 months). Four patients were lost to follow-up; 2 patients died of an underlying disease. In the nonsurgical group (85 patients), 60 patients became seizure-free or experienced significant reduction in seizure frequency. Outcome was unrelated to the availability of ictal recording. While prolonged interictal EEG monitoring is mandatory in the successful management of patients with refractory epilepsy, ictal video-EEG monitoring is very helpful but not indispensable, except in patients enrolled for epilepsy surgery or suspected of having pseudoseizures.

Neurotropin treatment of brain edema accompanying acute middle cerebral artery infarction

The present study is a second analysis of a randomized double-blind controlled trial on the efficacy of neurotropin on brain edema in a subgroup of patients with acute middle cerebral artery infarct treated within 24 hours. Neurotropin is a biological extract that specifically inhibits the release of bradykinin. The mortality rate was significantly lower in the neurotropin than in the placebo group. In the surviving patients the neurological deficit decreased to a significantly greater extent by neurotropin therapy after 15 days. The CT scan findings in the brain of the neurotropin-treated patients demonstrated a significant reduction in the size of the infarct and of the edematous area. Patients with middle cerebral artery infarct, which is prone to give rise to fatal intracranial hypertension, may derive great benefit from treatment of brain edema with neurotropin.

A positron emission tomography study of patients with acute carbon monoxide poisoning treated by hyperbaric oxygen

Seven patients with an acute and severe carbon monoxide intoxication were treated with hyperbaric oxygen and underwent a positron emission tomographic examination 2-5 days after the acute event. Although the final clinical outcome was good in all patients, ischaemic changes were observed. Three patients with temporary sequelae after hyperbaric oxygen treatment showed the most severe changes, mainly in striatum and thalamus. Although positron emission tomographic examination cannot predict the final outcome, it can show the regions at risk for development of late complications following carbon monoxide poisoning.

Brain abscess after esophageal dilatation for stenosis

The case is presented of a 28-year-old female with a brain abscess after esophageal dilatation for stricture, secondary to an acute necrotizing esophagitis. Other causes of brain abscess were excluded. To our knowledge this is the first documented case of brain abscess after dilatation for esophageal stricture in adult life. Some reports in the pediatric literature have been published previously.

Controllable and uncontrollable footshock and monoaminergic activity in the frontal cortex of male and female rats

Effects of controllable and uncontrollable footshock on monoaminergic activity in the frontal cortex and plasma corticosterone levels were studied in male and female rats. Subjects were exposed to a shuttle-box procedure for a period of either 30 min (60 shocks) or 90 min (180 shocks). A shuttle response ended shock presentation for escape subjects, whereas their yoked, same-sex, counterparts were unable to escape from shock presentation. A third group was exposed to the experimental environment, but did not receive any shocks. Concentrations of noradrenaline, serotonin and dopamine and their major metabolites were measured in the frontal cortex by high performance liquid chromatography with electrochemical detection. Plasma corticosterone was measured by radioimmunoassay. Results of this experiment show that: (1) exposure to the experimental environment without shock already increased the activity of all 3 transmitter systems. In particular, serotonin was very responsive to mere confinement to the shuttle-box. Changes induced by exposure to the experimental environment were similar for males and females. (2) Presentation of footshocks further increased transmitter activity. The activation of noradrenaline and dopamine was larger after uncontrollable shock than after controllable shock. Moreover, uncontrollable shock resulted in higher serotonin levels than controllable shock. (3) Sex-dependent effects of controllability were found for noradrenaline and dopamine, but not for serotonin. Differences in catecholaminergic activity between controllable and uncontrollable shock were larger in females than in males. (4) In both males and females, corticosterone levels in plasma were increased by exposure to the experimental environment. A further elevation was found in response to footshock presentation, which was independent of the controllability of shock.

A carbohydrate-directed heterobifunctional cross-linking reagent for the synthesis of immunoconjugates

A novel, highly water-soluble, heterobifunctional cross-linking reagent, S-(2-thiopyridyl)-L-cysteine hydrazide (TPCH), was synthesized which contains a hydrazide moiety for coupling to aldehyde groups generated in the carbohydrate residues of antibodies by mild periodate oxidation, and a pyridyl disulfide moiety for coupling to molecules with a free sulfhydryl group. Since the carbohydrate moieties are distal to the antigen binding region of antibodies, derivatization with this cross-linker minimizes impairment of the antigen binding function. Derivatization of the human monoclonal IgM antibody 16-88 against human colon carcinoma cells with as many as 16 TPCH cross-linker molecules did not impair its antigen binding capability. Using mild oxidation conditions for antibody derivatization, sialic acid residues were identified as attachment sites for the cross-linker molecules, since after desialylation of antibody 16-88 by neuraminidase virtually no cross-linker molecules could be incorporated. Comparison of TPCH with S-(2-thiopyridyl)mercaptopropionic acid hydrazide and S-(2-thiopyridyl)-L-cysteine, two related cross-linking reagents, revealed that TPCH is most efficiently incorporated into periodate-treated antibody. Based on the structural differences of the cross-linkers, the more efficient incorporation of TPCH appears to be a function of the presence of a hydrazide moiety with an adjacent amino group. When three to four molecules of pyridyl disulfide-derivatized barley toxin were coupled to TPCH-derivatized antibody 16-88, the antigen binding capability remained uncompromised. In addition, no significant impairment of toxin activity upon coupling to the antibody was observed. Based on these data, TPCH may be very useful for the synthesis of immuno-conjugates with no or only minimal impairment of the antigen binding function.

Pancreatic encephalopathy. A case report and review of the literature

Pancreatic encephalopathy is an uncommon condition found in patients with acute pancreatitis. The present report shows the interest of MRI in the diagnosis of this disorder. Patchy white matter signal abnormalities, resembling plaques seen in multiple sclerosis, may reflect the lesions that are found in the cerebral white matter of post-mortem confirmed cases.

Villaret's syndrome due to thrombosis of the jugular vein

Villaret's syndrome is an extremely uncommon condition in which the four lower cranial nerves and the cervical sympathetic are selectively affected. Most cases described thus far have been attributed to either trauma or space-occupying lesions in the posterior retroparotid space. This report demonstrates a first case of "pure" Villaret's syndrome caused by jugular vein thrombosis secondary to previous mastoiditis.

Sex differences in passive avoidance depend on the integrity of the central serotonergic system

Effects of the neurotoxin para-chloroamphetamine (PCA) on sex differences in passive avoidance were studied. Seven days prior to passive avoidance training and testing, male and female rats were injected with PCA (5 mg/kg) or physiological saline (SAL). Treatment effects on brain monoamines levels were evaluated in brains collected shortly after the passive avoidance test. Compared to SAL-treated control groups PCA severely reduced both serotonin (5-HT) and 5-hydroxyindole-acetic acid (5-HIAA) in the frontal cortex of males and females. Levels of dopamine (DA) and homovanillic acid (HVA) in the frontal cortex were not affected. These data are indicative of a strong and selective depression of the central 5-HT activity. PCA- and SAL-treated male and female rats were trained and tested in a two-compartment step-through passive avoidance apparatus. Sex differences in passive avoidance were clearly observed in the SAL-treated control groups; a higher number of males did not enter either compartment within the maximum test duration. After PCA treatment sex differences in passive avoidance were abolished, mainly resulting from an increase in the number of PCA-males reentering. Irrespective of sex or treatment subjects seldom failed to choose the nonshock compartment when entering during the passive avoidance test, indicating that disturbance of memory or learning cannot explain for the present results. Rather, the data are discussed in terms of a sex-specific role of central 5-HT in punishment-induced behavioral suppression.