Infektionen

Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus.

National Institute on Aging-Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease: a practical approach

We present a practical guide for the implementation of recently revised National Institute on Aging-Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease (AD). Major revisions from previous consensus criteria are: (1) recognition that AD neuropathologic changes may occur in the apparent absence of cognitive impairment, (2) an "ABC" score for AD neuropathologic change that incorporates histopathologic assessments of amyloid β deposits (A), staging of neurofibrillary tangles (B), and scoring of neuritic plaques (C), and (3) more detailed approaches for assessing commonly co-morbid conditions such as Lewy body disease, vascular brain injury, hippocampal sclerosis, and TAR DNA binding protein (TDP)-43 immunoreactive inclusions. Recommendations also are made for the minimum sampling of brain, preferred staining methods with acceptable alternatives, reporting of results, and clinico-pathologic correlations.

A sound sleep

Benzodiazepine is a commonly encountered agent of poisoning, which is readily diagnosed by a pertinent history of drug ingestion and the clinical scenario. In the absence of a proper drug history, the diagnosis becomes challenging. Proper clinical assessment, urine assays and imaging play a very important role in reaching the diagnosis. We present a case of acute benzodiazepine poisoning without a history of drug intake. The key pointers toward diagnosis were an unarousable state with obstructive apnea. Magnetic resonance imaging (MRI) of the brain revealed peculiar symmetrical isolated globus pallidus T2 hyperintensity. We believe this to be the first report of isolated bilateral basal ganglia T2-weighted hyperintensity in MRI in the setting of acute benzodiazepine poisoning from India.

Dementia due to Meningovascular Syphilis in Medial Temporal Lobe and Cognitive Rehabilitation

The temporal lobe is essential in saving declarative memory and plays an important role along with the cerebral neocortex in creating and maintaining long-term memory. Damage to the temporal lobe is expected to result in cognitive impairment or dementia, which has characteristic symptoms such as cognitive and behavioral dysfunction and decreasing self-reliance in activities of daily living. We report on a patient, who suffered from dementia due to meningovascular syphilis affecting the medial temporal lobe, and on the outcome of cognitive rehabilitation.

Comparing the validity of the Modified Modified Ashworth Scale (MMAS) and the Modified Tardieu Scale (MTS) in the assessment of wrist flexor spasticity in patients with stroke: protocol for a neurophysiological study

INTRODUCTION

Reliable and valid tools must be used to assess spasticity in clinical practise and research settings. There is a paucity of literature regarding the validity of the Modified Modified Ashworth Scale (MMAS) and the Modified Tardieu Scale (MTS). No study, to date, has been performed to compare the validity of the MMAS and the MTS. This neurophysiological study protocol will compare the validity of the MMAS and the MTS in the assessment of poststroke wrist flexor spasticity.

METHODS AND ANALYSIS

Thirty-two patients with stroke from the University Rehabilitation clinics will be recruited to participate in this cross-sectional, non-interventional study. All measurements will be taken in the Physical Medicine and Rehabilitation Department of Shafa University Hospital in Tehran, Iran. First, wrist flexor spasticity will be assessed clinically using the MMAS and MTS. The tests will be applied randomly. For the MTS, the components of R1, R2, R2-R1 and quality of muscle reaction will be measured. Second, neurophysiological measures of H-reflex latency, H(max)/M(max) ratio, H(slp) and H(slp)/M(slp) ratio will be collected from the affected side. The results will be analysed using Spearman's ρ test or Pearson's correlation test to determine the validity of the MMAS and the MTS as well as to compare the validity between the MMAS and the MTS.

ETHICS AND DISSEMINATION

The Research Council, School of Rehabilitation and the Ethics Committee of Tehran University of Medical Sciences (TUMS) approved the study protocol.  The study results will be disseminated in peer-reviewed publications and presented at international congresses.

Familial amyloidotic polyneuropathy and transthyretin

There has been much progress in our understanding of transthyretin (TTR)-related amyloidosis including familial amyloidotic polyneuropathy (FAP), senile systemic amyloidosis and its related disorders from many clinical and experimental aspects. FAP is an inherited severe systemic amyloidosis caused by mutated TTR, and characterized by amyloid deposition mainly in the peripheral nervous system and the heart. Liver transplantation is the only available treatment for the disease. FAP is now recognized not to be a rare disease, and to have many variations based on genetical and biochemical variations of TTR. This chapter covers the recent advances in the clinical and pathological aspects of, and therapeutic approaches to FAP, and the trend as to the molecular pathogenesis of TTR.

Peptidoglycan: a critical activator of the mammalian immune system during infection and homeostasis

Peptidoglycan is a conserved structural component of the bacterial cell wall with molecular motifs unique to bacteria. The mammalian immune system takes advantage of these properties and has evolved to recognize this microbial associated molecular pattern. Mammals have four secreted peptidoglycan recognition proteins, PGLYRP-1-4, as well as two intracellular sensors of peptidoglycan, Nod1 and Nod2. Recognition of peptidoglycan is important in initiating and shaping the immune response under both homeostatic and infection conditions. During infection, peptidoglycan recognition drives both cell-autonomous and whole-organism defense responses. Here, we examine recent advances in the understanding of how peptidoglycan recognition shapes mammalian immune responses in these diverse contexts.

Computed tomographic pattern of physiological intracranial calcifications in a city in central Africa

Objective:

Intracranial calcifications underlie certain brain diseases which may be de novo or systemic. But calclfications un-connected to pathologies are classified physiological.

Aim:

To evaluate physiological intracranial calcifications in Douala with establishment of earliest age range of detection.

Materials and Methods:

Prospective study of brain computed tomograms was done from April to October 2009 using Schumadzu CT Scan machine. Axial, reconstructed and bone window images as well Hounsfield unit measurements were used for final evaluations. Results were analysed with SSPS 3.

Results:

132 patients with 75 males and 57 females were studied and 163 separate calcifications were identified due to co-existent calcifications. The highest calcification was in choroid plexi, constituiting 56.82% of the studied population. This was followed by pineal gland. Both were commonly co-existent with advancing age. These calcifications were first seen at 10-19years. No type of physiological intracranial calcification was seen below age 10. The least calcification of 0.76% of population was in dentate nucleus.

Conclusion:

No intra-cranial physiological calcifications started earlier than 9years in Douala, a city in Cameroon, Central Africa.

A nationwide survey of the prevalence of multiple sclerosis in immigrant populations of Sweden

BACKGROUND

In 2008, immigrants constituted 14% of the population of Sweden, a high-risk area for multiple sclerosis (MS). We investigated the largest Swedish immigrant populations for the prevalence of MS.

METHOD

Data on foreign-born MS patients were retrieved from Swedish national health and population registers. We calculated observed versus expected numbers of MS patients and gender- and age-specific prevalence ratios (PR) between immigrant populations and the general population of Sweden and, where possible, of the countries of birth.

RESULTS

The 19 largest immigrant populations included 1327 MS patients. The global variation in MS prevalence was reflected in Sweden. The prevalence in immigrant populations who had moved to Sweden from countries with a lower MS risk was however higher than in their countries of birth. Notably, the MS prevalence in the population born in Iran was at least as high as in the general population of Sweden (men: PR = 1.10, 95% CI 0.81-1.46, p = 0.537, women: PR = 1.18, 95% CI 0.97-1.44, p = 0.855) and more than twice as high as in Isfahan, Iran (men: PR = 3.06 (95% CI 2.26-4.06), p <0.001, women: PR = 2.21 (95% CI 1.81-2.68), p <0.001).

CONCLUSIONS

The MS prevalence increased in migrants who moved to Sweden from countries with a lower MS risk. In the Iranian immigrant population the prevalence exceeded that in the general population of Sweden. This indicates that Iranians carry genetic factors that contribute to a higher MS risk when environmental-lifestyle MS risk factors change.

Depression, strokes and dementia: new biological insights into an unfortunate pathway

The literature emphasizes the risk of depression after a stroke. Less well known is the fact that depression may be as big a risk factor for strokes as hypertension, particularly in the older age group. This article reviews the risk for stroke and cognitive impairment consequent to depression, and describes the cardiovascular and immunological mechanisms that would appear to link depression to its cerebrovascular consequences. As well, the article refers to the brain imaging signatures that may allow prediction of impending brain injury. Finally, some questions that might be explored by future research are suggested, and some practical means to identify and help those at risk for the development of depression-associated vascular disease of the brain are suggested.

Randomized controlled trial on the effects of a combined sleep hygiene education and behavioral approach program on sleep quality in workers with insomnia

To evaluate the effects of a combined sleep hygiene education and behavioral approach program on sleep quality in workers with insomnia, we conducted a randomized controlled trial at a design engineering unit in Japan. Employees evaluated for insomnia by the Athens Insomnia Scale (≥6 points) were divided into an intervention and control group. The intervention group received a short-term intervention (30 min) program that included sleep hygiene education and behavioral approaches (relaxation training, stimulus control, and sleep restriction) performed by occupational health professionals. We calculated differences in change in Pittsburgh Sleep Quality Index (PSQI) scores between the two groups from baseline to three months after the start of intervention after adjusting for gender, age, job title, job category, average number of hours of overtime during the study period, marital status, smoking habit, average number of days of alcohol consumption per week, exercise habits, K6 score, and baseline PSQI score. Results showed that the average PSQI score decreased by 1.0 in the intervention group but increased by 0.9 in the control group. Additionally, the difference in variation between the two groups was 1.9 (95% confidence interval: 0.6 to 3.4), which was significant. Taken together, these results indicate that the intervention program significantly improved the sleep quality of workers with insomnia.

Guillain-Barre syndrome: first description of a snake envenomation aetiology

BACKGROUND

Guillain-Barre syndrome (GBS) is considered as an acute, immune-mediated polyradiculoneuropathy with different clinical phenotypes arising after viral or bacterial infections, vaccination or surgery. However, in 40% of GBS patients the aetiology remains unknown. In this manuscript, we report the occurrence of GBS in a patient bitten by a snake (Vipera aspis) for which a cross-reaction was shown between GM2 ganglioside and glycosidic epitopes of venom proteins.

METHODS

The venom of the snake implied in the patient's envenomation was collected. Its composition was characterised by ELISA and SELDI-TOF MS. Cross-reactivities between venom proteins and GM2 gangliosides were identified by Western blot after immunoabsorption of patient's serum with increasing amounts of purified GM2. Enzymatic deglycosylation of the venom was performed to determine the specificity of the patient's serum cross-reaction.

FINDINGS

We proved the absence of neurotoxicity of the viper venom. The patient's serum presented specific cross-reactions with several glycosylated venom proteins. After deglycolysation of these proteins, the patient's serum cross-reactivity was abolished. Furthermore, we compared the immune response to venom proteins of sera from two groups of patients. The first group showed IgM reactivity against GM2 ganglioside associated with GBS, and cross-reacted with venom proteins. The second group presented an IgM reactivity against CMV, without neurological disorders, and reacted with neither venom proteins nor gangliosides.

INTERPRETATION

Our study proved the auto-immunological aetiology of GBS in our patient based on molecular mimicry mechanisms between venom proteins and GM2 ganglioside.

Type I IFN promotes IL-10 production from T cells to suppress Th17 cells and Th17-associated autoimmune inflammation

Whereas the immune system is essential for host defense against pathogen infection or endogenous danger signals, dysregulated innate and adaptive immune cells may facilitate harmful inflammatory or autoimmune responses. In the CNS, chronic inflammation plays an important role in the pathogenesis of neurodegenerative diseases such as multiple sclerosis (MS). Our previous study has demonstrated a critical role for the type I IFN induction and signaling pathways in constraining Th17-mediated experimental autoimmune encephalomyelitis (EAE), an animal model of human MS. However, it remains unknown if self-reactive Th17 cells can be reprogrammed to have less encephalitogenic activities or even have regulatory effects through modulation of innate pathways. In this study, we investigated the direct effects of type I IFN on Th17 cells. Our data show that IFNβ treatment of T cells cultured under Th17 polarizing conditions resulted in reduced production of IL-17, but increased production of IL-10. We also found that IFNβ induced IL-10 production by antigen specific T cells derived from immunized mice. Furthermore, IFNβ treatment could suppress the encephalitogenic activity of myelin-specific T cells, and ameliorate clinical symptoms of EAE in an adoptive transfer model. Together, results from this study suggest that IFNβ may induce antigen-specific T cells to produce IL-10, which in turn negatively regulate Th17-mediate inflammatory and autoimmune response.

[Absence of the musculocutaneous nerve and its distribution from median nerve: About two cases and literature review]

Musculocutaneous nerve arises mostly from the lateral cord of brachial plexus. Nevertheless, variations have been reported and, among them: the total absence of musculocutaneous nerve (from 1.4 to 15%), the absence of its passage through the coracobrachial muscle, its variable level of penetration as measured from the tip of the coracoid process, and its communicating branches with the median nerve. We report two cases of unilateral musculocutaneous nerve absence in a 66-year-old male and a 95-year-old female cadavers, on the right and the left side, respectively. The nerve fibers normally coming from musculocutaneous nerve emerged from the median nerve. The knowledge of this anatomical variation is important specially when performing plexus bloc or Latarjet's procedure.

Stress proteins and glial cell functions during chronic aluminium exposures: protective role of curcumin

Involved in the ongoing debate is the speculation that aluminium is somehow toxic for neurons. Glial cells cope up to protect neurons from this toxic insult by maintaining the glutathione homeostasis. Of late newer and newer roles of glial cells have been depicted. The present work looks into the other regulatory mechanisms that show the glial cells response to pro-oxidant effects of aluminium exposure. In the present investigation we have evaluated the inflammatory responses of the glial cells as well as HSP70-induction during aluminium exposure. Further, the protective role of curcumin is also evaluated. Aluminium was administered by oral gavage at a dose level of 100 mg/kg b.wt/day for a period of 8 weeks. Curcumin was administered i.p. at a dose of 50 mg/kg b.wt./day on alternate days. Enhanced gene and protein expression of HSP70 in the glial fractions of the aluminium exposed animals as compared to the corresponding neuronal population. Aluminium exposure resulted in a significant increase in the NF-κB and TNF-α expression suggesting inflammatory responses. In the conjunctive treatment group of aluminium and curcumin exposure marked reduction in the gene and protein expression of NF-κB and TNF-α was observed. This was further reflected in histopathological studies showing no evidence of inflammation in conjunctive group as compared to aluminium treatment. From the present study, it can be concluded that curcumin has a potential anti-inflammatory action and can be exploited in other toxicological conditions also.

Current Status of Intravenous Thrombolysis for Acute Ischemic Stroke in Asia

Background

Data regarding thrombolysis for acute ischemic stroke in Asia are scarce and only a small percentage of patients are thrombolysed. The dose of intravenous tissue plasminogen activator (IV-tPA) in Asia remains controversial. Case-controlled observation studies in Asia included only Japanese patients and suggested the clinical efficacy and safety of low-dose IV-tPA (0·6 mg/kg body weight; max 60 mg) comparable to standard dose (0·9 mg/kg body weight; max. 90 mg). Reduced treatment cost, lower symptomatic intracerebral hemorrhage risk and comparable efficacy encouraged many Asian centers to adopt low-dose or even variable-dose IV-tPA regimens. We evaluated various Asian thrombolysis studies and compared with SITS-MOST registry and NINDS trial.

Methods

We included the published studies on acute ischemic stroke thrombolysis in Asia. Unadjusted relative risks and 95% Confidence intervals were calculated for each study. Pooled estimates from random effects models were used because the tests for heterogeneity were significant.

Results

We found only 18 publications regarding acute ischemic stroke thrombolysis in Asia that included total of 9300 patients. Owing to ethnic differences, stroke severity, small number of cases in individual reports, outcome measures and tPA dose regimes, it is difficult to compare these studies. Functional outcomes were almost similar (to Japanese studies) when lower-dose IV-tPA was used in non-Japanese populations across Asia. Interestingly, with standard dose IV-tPA, considerably better functional outcomes were observed, without increasing symptomatic intracerebral hemorrhage rates.

Conclusions

Variable dose regimens of IV-tPA are used across Asia without any reliable or established evidence. Establishing a uniform IV-tPA regimen is essential since the rapid improvements in health-care facilities and public awareness are expected to increase the rates of thrombolysis in Asia.

Current therapies in ischemic stroke. Part A. Recent developments in acute stroke treatment and in stroke prevention

Stroke is the third leading cause of death with an increasing prevalence. In previous years many important achievements and new therapeutic strategies have been established. This article provides an overview on recent developments and is an update to the article of Green et al. that was published in 2004. As this article is a comprehensive review we divided it in two parts. In this Part A of our review, recent developments in acute stroke treatment and in stroke prevention are described. In Part B we will reflect on neuroprotection.

An epidemiological study of dementia among the habitants of eastern Uttar Pradesh, India

Dementia is one of the most serious health problems of the elderly and their caregivers.

Longitudinal extensive transverse myelitis--it's not all neuromyelitis optica

Longitudinal extensive transverse myelitis (LETM) is defined as a spinal cord lesion that extends over three or more vertebrae, as seen on MRI of the spine. The clinical presentation of a patient with LETM is often dramatic and can consist of paraparesis or tetraparesis, sensory disturbances, and gait, bladder, bowel and/or sexual dysfunction. LETM is a characteristic feature of neuromyelitis optica, but such spinal lesions can also occur in various other autoimmune and inflammatory diseases that involve the CNS--such as multiple sclerosis, sarcoidosis or Sjögren syndrome--or in infectious diseases with CNS involvement. Patients with a neoplastic disorder or traumatic spinal cord injury can also present with longitudinal spinal lesions. In this Review, the signs and symptoms that suggest various etiologies and differential diagnoses of LETM are described, and illustrated by educational case studies. The best therapeutic options for patients with each diagnosis are also discussed.

Idiopathic hypertrophic cranial pachymeningitis: Three biopsy-proven cases including one case with abdominal pseudotumor and review of the literature

Hypertrophic pachymeningitis (HP) is a rare disorder of diverse etiology. It presents with headaches, cranial neuropathies and ataxia occurring alone or in combination. Dural biopsy is essential to exclude secondary causes of pachymeningitis. There is paucity of data on biopsied cases of HP. We report three biopsy-proven cases of idiopathic hypertrophic cranial pachymeningitis. All our patients had headaches and multiple cranial neuropathies; ataxia was seen in one patient. One patient had recurrent anterior and posterior cranial neuropathies, while one each had recurrent anterior and posterior cranial neuropathies. Two patients had profound irreversible mono-ocular visual loss. All of them showed prominent pachymeningeal thickening on imaging. Infarcts were seen in one patient, which have rarely been documented. All patients showed biopsy evidence of meningeal thickening and nonspecific chronic inflammation of the dura. The disease may have a remitting and relapsing course, and usually responds to steroids. Clinical improvement was excellent in two patients and modest in one on steroid therapy. All our patients required azathioprine during the course of therapy. Early institution and long-term maintenance of steroid therapy prevents neurologic sequelae. Occurrence of abdominal inflammatory pseudotumor in a patient of HP possibly as part of multifocal fibrosclerosis has not been described earlier.

Dengue-associated transient muscle dysfunction: clinical, electromyography and histopathological changes

BACKGROUND

Dengue is commonly associated with myalgia, but there is paucity of studies on the frequency, severity, and basis of muscle involvement. The aim of this study was to document the clinical, electromyographic, and histological changes in dengue-associated muscle dysfunction.

MATERIALS AND METHODS

Seropositive dengue patients admitted to the neurology ward during 2010 were enrolled in this study. Detailed medical history, including bleeding diathesis and organomegaly, were noted. Muscle power on a 0-5 scale, muscle tone, reflex, sensations and coordination were tested. Blood counts, hemoglobin, and serum chemistry, including creatine kinase (CK) evaluations, were carried out. Concentric needle electromyography (EMG) and muscle biopsy were performed when clinical conditions were suitable.

RESULTS

The study cohort comprised 39 patients with dengue, with a median age of 28 years. Of these, 31 patients showed evidence of muscle involvement-16 with clinical and 15 with subclinical muscle involvement. Eight of these patients had severe weakness and five had hyporeflexia. Thrombocytopenia was present in 26 patients, elevated serum creatinine in three patients and liver dysfunction in 31 patients. The median CK level was 837 (range 194-3,832) U/L. The EMG revealed polyphasic normal to short duration motor unit potentials, but spontaneous activity was absent. Muscle biopsy in three patients revealed interstitial hemorrhage with occasional necrosis and myophagocytosis. There was no vasculitis, but subtle inflammatory changes were present in one patient. The severity of muscle weakness correlated with the platelet count and CK level. All patients improved by 15 days of treatment initiation.

CONCLUSION

Dengue commonly results in benign and self-limiting transient muscle dysfunction.

Detection of rabies virus nucleoprotein-RNA in several organs outside the Central Nervous System in naturally-infected vampire bats

Rabies is a neurological disease, but the rabies virus spread to several organs outside the central nervous system (CNS). The rabies virus antigen or RNA has been identified from the salivary glands, the lungs, the kidneys, the heart and the liver. This work aimed to identify the presence of the rabies virus in non-neuronal organs from naturally-infected vampire bats and to study the rabies virus in the salivary glands of healthy vampire bats. Out of the five bats that were positive for rabies in the CNS, by fluorescent antibody test (FAT), viral isolation in N2A cells and reverse transcription - polymerase chain reaction (RT-PCR), 100% (5/5) were positive for rabies in samples of the tongue and the heart, 80% (4/5) in the kidneys, 40% (2/5) in samples of the salivary glands and the lungs, and 20% (1/5) in the liver by RT-PCR test. All the nine bats that were negative for rabies in the CNS, by FAT, viral isolation and RT-PCR were negative for rabies in the salivary glands by RT-PCR test. Possible consequences for rabies epidemiology and pathogenesis are discussed in this work.

Probing ischemic tissue fate with BOLD fMRI of brief oxygen challenge

It has been recently shown that at-risk tissue exhibits exaggerated T(2)⁎-weighted MRI signal increases during transient oxygen challenge (OC), suggesting that the tissue is still metabolically active. This study further characterized the effects of transient OC on T(2)⁎-weighted MRI in permanent focal stroke rats (N=8) using additional quantitative measures. The major findings were: i) the ischemic core cluster showed no significant response, whereas the mismatch cluster showed markedly higher percent changes relative to normal tissue in the acute phase. ii) Many of the mismatch pixels showed exaggerated OC responses which became hyperintense on T(2)-weighted MRI at 24h. The area with exaggerated OC responses was larger than the mismatch, suggesting that some tissue with reduced diffusion were potentially at risk. iii) Basal T(2)⁎-weighted intensities on the perfusion-diffusion contourplot were high in normal tissue and low in the core, with a sharp transition in the mismatch. iv) OC-induced changes on the perfusion-diffusion contourplot dropped as perfusion and diffusion values fell below their respective viability thresholds. v) Basal T(1) increased slightly in the ischemic core (P<0.05). OC decreased T(1) in normal (P<0.05) but not in mismatch and core pixels. vi) OC decreased CBF in normal (P<0.05) but not in mismatch and core pixels. T(2)⁎-weighted MRI of OC has the potential to offer unique clinically relevant data.

Role of glial cells in innate immunity and their role in CNS demyelination

The adaptive and innate arms of the immune system are the two pillars of host defense against environmental pathogens. Multiple sclerosis (MS) is an inflammatory demyelinating disease of the CNS which is considered to be autoimmune and is thought to result from breakdown in the usual checks and balances of the adaptive immune response. The major pathological outcome of the disease is "the MS plaque" a unique feature of CNS demyelination characterized by the destruction of oligodendrocytes with loss of myelin and underlying axons. The MS plaque is not seen in other inflammatory disorders of the CNS. The prevailing opinion suggests that MS is mediated by the activation of an adaptive immune response which targets neural antigens. Currently, the role of an innate immune in the development of the lesions in MS has remained unclear. We explore the potential cellular elements of the innate immune system and in particular glial cells, which are likely candidates in inducing the specific pathological picture that is evident in MS. Activated microglia and the release of molecules which are detrimental to oligodendrocyte have been suggested as mechanisms by which innate immunity causes demyelination in MS. However a microglia/macrophage centric model does not explain the specificity of lesion development in MS. We propose that activation pathways of receptors of the innate immune system present on oligodendrocytes and astrocytes rather than microglia are central to the pathogenesis of demyelination seen in MS.

Pituitary apoplexy

Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.

Fibrodysplasia ossificans progressiva: report of a case and review of articles

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder, characterized by painful swelling of muscles and connective tissue in the early years of life, consequently leading to ossification at a mean age of 4-5 years. We report FOP in a 2-year-old boy with palpable masses in the frontal and lower cervical paraspinal and left periscapular muscles.He was born with hallux valgus. Despite this hallmark, he was referred to the hospital with the primary diagnosis of hematoma, but further investigation indicated FOP. The patient was discharged from the hospital with non steroidal anti-inflammatory drugs (NSAID) and education of the parents. The importance of this case was that in spite of the early occurrence of the typical presentation of FOP for more than one year and the fact that the patient's mother was a physician who had consulted with many specialists, the diagnosis had been missed.This indicates that the general physicians, radiologists and other specialists' awareness and knowledge of FOP is insufficient.

Hospital-based management of acute ischemic stroke following intravenous thrombolysis

Timely administration of proven therapies remains the primary goal in acute stroke care. Following reperfusion therapy with intravenous thrombolysis, medical and neurological complications may develop in the hospitalized patient with acute ischemic stroke. Medical complications may include deep venous thrombosis, pulmonary embolism, aspiration, systemic infections and neuropsychiatric disturbances. Neurologic complications may include symptomatic intracranial hemorrhage, cerebral edema with elevated intracranial pressure, and post-stroke seizures. Early initiation of preventative strategies and proper management of common complications may improve both short-term and long-term outcomes. Here we review evidence-based management strategies for hospitalized acute ischemic stroke patients following intravenous thrombolysis.

Lesion detection at seven Tesla in multiple sclerosis using magnetisation prepared 3D-FLAIR and 3D-DIR

Objectives

To examine the feasibility and value of 7 T 3D T2-weighted Fluid Attenuated Inversion Recovery (FLAIR) and Double Inversion Recovery (DIR) MR sequences for lesion detection in multiple sclerosis (MS).

Methods

High-resolution 3D-FLAIR and 3D-DIR MR sequences at 7 T were obtained using magnetisation preparation (MP), and compared with 2D-T2-weighted and 3D-T1-weighted sequences in 10 MS patients and five healthy controls. We determined contrast ratios and counted lesions according to anatomical location.

Results

MR imaging at 7 T was safe and allowed multi-contrast imaging within clinically acceptable imaging times. Lesion to white matter (WM) and grey matter (GM) contrast ratios were higher in 3D-MP-FLAIR and 3D-MP-DIR compared with 2D-T2 and 3D-T1. Cortical (mixed+intra-cortical) and total lesion counts were 97/592 on 3D-MP-FLAIR and 100/558 on 3D-MP-DIR compared with 84/384 on 2D-T2 and 42/442 on 3D-T1. More juxta-cortical lesions were seen with 3D-MP-FLAIR (205) and 3D-MP-DIR (133) than with 2D-T2 (125) and 3D-T1 (70). Finally, higher numbers of lesions were found for deep WM lesions: 176 for 3D-MP-FLAIR and 196 for 3D-MP-DIR vs. 155 for 2D-T2 and 131 for 3D-T1.

Conclusions

Near isotropic 3D-MP-FLAIR and 3D-MP-DIR allows high quality T2-weighted MR imaging in MS at 7 T, improving (cortical) lesion detection.

Key Points

• Magnetization prepared 3D-FLAIR and 3D-DIR 7 T MRI provide high quality isotropic images.

• MS lesions are well demonstrated by 3D-MP-FLAIR and 3D-MP-DIR at 7 T MRI.

• 3D-MP-FLAIR and 3D-MP-DIR at 7 T MRI show many more Virchov-Robin spaces.

Challenges to clinical trials in multiple sclerosis: outcome measures in the era of disease-modifying drugs

PURPOSE OF REVIEW

This review summarizes standard and evolving outcome measures in multiple sclerosis (MS) clinical trials.

RECENT FINDINGS

Progress in the development of MS treatments has led to an increasing number of clinical trials and a need for sensitive, timely, and clinically relevant outcome measures. Relapse rate and the Expanded Disability Status Scale remain the standard clinical outcome measures, but the MS Functional Composite continues to gain additional validation as a meaningful outcome measure. The uncertain relationship between MRI outcome measures and clinical disability has been a persistent challenge in MS clinical trials, but there is increasing evidence supporting a correlation between MRI changes and disability in relapsing-remitting MS patients. Additionally, new imaging techniques are being developed to further increase the sensitivity of MRI as a tool in MS clinical trials. Optical coherence tomography is another outcome measure gaining influence in clinical trials. Some of the greatest challenges remain in the subset of primary progressive MS clinical trials in which brain atrophy appears to be the most promising imaging outcome measure, but the optimal clinical measures and study durations are still uncertain.

SUMMARY

Progress in MS clinical trials requires critical evaluation of existing and future outcome measures and their relationships to one another.

Identification of the direction of the neural network activation with a cellular resolution by fast two-photon imaging

Spatiotemporal activity patterns in local neural networks are fundamental to understanding how information is processed and stored in brain microcircuits. Currently, imaging techniques are able to map the directional activation of macronetworks across brain areas; however, these strategies still fail to resolve the activation direction for fine microcircuits with cellular spatial resolution. Here, we show the capability to identify the activation direction of a multicell network with a cellular resolution and millisecond precision by using fast two-photon microscopy and cross correlation procedures. As an example, we characterized a directional neuronal network in an epilepsy brain slice to provide different initiation delay among multiple neurons defined at a millisecond scale.

Hyperammonemic encephalopathy related to valproate, phenobarbital, and topiramate synergism

We present a woman with epilepsy secondary to a lesion in the left frontal lobe. She developed episodes of disorientation and behavioral changes. She was taking valproic acid (1500 mg/day), topiramate (200 mg/day), and phenobarbital (100 mg/day). During an episode, the EEG revealed moderate encephalopathy and ammonia levels were increased (195 μg/dL, reference range: 11-60 μg/dL). Episodes ceased after withdrawal of valproic acid.

Irish Medicines Board safety warnings: do they affect prescribing rates in primary care?

PURPOSE

To examine the impact of safety warnings issued between 2005 and 2007 by the Irish Medicines Board (IMB) on the rate of prescribing of clopidogrel, co-amoxiclav, celecoxib and haloperidol by primary care physicians in the General Medical Services (GMS) scheme across Ireland.

METHODS

This study was performed using the Irish Health Service Executive-Primary Care Reimbursement Services national prescribing database. Rate of prescribing per 1000 GMS population was calculated for each of the 12 months before and after the IMB warnings were issued to physicians. A segmented regression analysis was used to examine the change in level and trend in prescribing rates before and after the IMB warnings. Regression coefficients are presented with SEs. Significance at p < 0.05 was assumed. SPSS 16 and SAS were used for statistical analysis.

RESULTS

Prescribing of clopidogrel continued to rise in both genders following the warning. This increase was slightly higher in male patients. The prescribing of co-amoxiclav showed seasonal variation with significant autocorrelation. The rate of prescribing of celecoxib declined approximately 4  months prior to the IMB warning. A significant decrease in the level and trend of the rate of prescribing of celecoxib was observed with evident discontinuity. The IMB warning had no significant effect on the level of trend in the prescribing of haloperidol, suggesting no discontinuity.

CONCLUSIONS

Results indicate that the IMB safety warnings had inconsistent effects on the rate of prescribing of drugs considered.

Incidence of dementia in a Kashmiri migrant population

Background:

Mishriwala is one of five exclusive clusters of Kashmiri migrants established in 1990 to accommodate Kashmiri Pandit families who left Kashmir valley in the wake of militancy. Mishriwala migrant camp has seen minimal immigration and out-migration since its establishment. In an earlier study we reported on the prevalence of dementia amongst a Kashmiri migrant population. That study was conducted in the migrant camp at Mishriwala, 12 km west of Jammu city, the winter capital of Jammu and Kashmir State. We have developed standardized study methods and instruments for use in the Kashmiri-speaking population, which we used for screening for dementia during the prevalence study. We now report the results of a 1-year prospective study carried out to find out the incidence of dementia in the same population.

Aim:

To ascertain the incidence of dementiain the Kashmiri Pandit population aged 60 years and above.

Materials and Methods:

A 1-year, prospective, epidemiological study of 186 subjects aged 60 years and above, using cognitive and functional ability screening and clinical evaluation.

Results:

The incidence of dementia in this population was 5.34 cases per 1000 person-years.