Stroke-Related Visceral Alterations: A Voxel-Based Neuroanatomic Localization Study

OBJECTIVE

Functional and morphologic changes in extracranial organs can occur after acute brain injury. The neuroanatomic correlates of such changes are not fully known. Herein, we tested the hypothesis that brain infarcts are associated with cardiac and systemic abnormalities (CSAs) in a regionally specific manner.

METHODS

We generated voxelwise p value maps of brain infarcts for poststroke plasma cardiac troponin T (cTnT) elevation, QTc prolongation, in-hospital infection, and acute stress hyperglycemia (ASH) in 1,208 acute ischemic stroke patients prospectively recruited into the Heart-Brain Interactions Study. We examined the relationship between infarct location and CSAs using a permutation-based approach and identified clusters of contiguous voxels associated with p < 0.05.

RESULTS

cTnT elevation not attributable to a known cardiac reason was detected in 5.5%, QTc prolongation in the absence of a known provoker in 21.2%, ASH in 33.9%, and poststroke infection in 13.6%. We identified significant, spatially segregated voxel clusters for each CSA. The clusters for troponin elevation and QTc prolongation mapped to the right hemisphere. There were 3 clusters for ASH, the largest of which was in the left hemisphere. We found 2 clusters for poststroke infection, one associated with pneumonia in the left and one with urinary tract infection in the right hemisphere. The relationship between infarct location and CSAs persisted after adjusting for infarct volume.

INTERPRETATION

Our results show that there are discrete regions of brain infarcts associated with CSAs. This information could be used to bootstrap toward new markers for better differentiation between neurogenic and non-neurogenic mechanisms of poststroke CSAs. ANN NEUROL 2023;94:1155-1163.

Dosimetric Parameters Correlate with Taste Alterations in Head and Neck Radiotherapy

PURPOSE/OBJECTIVE(S)

Dysgeusia is an acute and chronic side effect of head and neck chemoradiation, with persistent taste dysfunction 1-2 years post radiotherapy occurring in 23-50% of patients. Several head and neck clinical trials set oral cavity mean doses between 30 to 40 Gy, however, there are no set guidelines accurately defining the composite structure and anatomic boundaries for the oral cavity or separating the tongue into specific quadrants. In this single institution cross sectional study, we sought to determine the effects of radiation doses to specific regions of the oral cavity and tongue on patient-reported long term dysgeusia. We hypothesize that radiation Dose to specific structures in the oral cavity will correlate with long-term dysgeusia in patients who have received head and neck radiotherapy.

MATERIALS/METHODS

Patients with primary head and neck cancer receiving definitive intensity modulated radiation therapy (RT) completed quality of life assessments that included patient-reported gustatory function, 1 year post RT. Dosimetric data from RT plans were collected for specific regions and organs at risk within the oral cavity. These structures included the anterior, posterior, superior and inferior tongue (OT), pharyngeal constrictors (as a surrogate for the corda-tympani) and the oral cavity. A forward binary logistic regression model was performed using these data points with scoring from the QLQ-H&N43 questionnaire subsection on taste (Q45) to determine the most predictive values for dysgeusia and the OR for moderate/severe alterations in taste.

RESULTS

A total of 78 patients were included in this study, of these patients, 63 had dosimetric data for the pharyngeal constrictors. The Oral Cavity Volume percentage receiving 50Gy (OC V50) and Pharyngeal Constrictors Volume percentage receiving 55Gy (PC V55) were the most predictive constraints for dysgeusia. (0.042, p = 0.011 and 0.041, p = 0.033). Holding all other variables constant in a forward binary logistic regression including 78 patients, the odds of having moderate to severe taste alterations increased by 56% (OR 1.045, 95% CI 1.012-1.079) for a 1% increase in OCV50. When analyzing the 68 patients with available pharyngeal constrictors data, taste alteration increased 20% for every 1% increase in PCV55 (OR 1.042, 95% CI 1.003-1.082). There was no correlation with taste alterations in any of the dose parameters tested (Dmax, mean and V50 up to V70) for superior, inferior, anterior or posterior regions of the tongue.

CONCLUSION

Dosimetric parameters for the oral cavity (OC V50) and pharyngeal constrictors (PC V55) were positively correlated with taste alterations, however, no other specific regions within the oral tongue predicted taste disfunction. Normal tissue complication probability modeling curves to identify OC V50 and PC V55 constraints for dysgeusia are needed.

Feasibility and acute toxicities of radioimmunoguided prostate brachytherapy

PURPOSE

We present a technique that fuses pelvic CT scans and ProstaScint images to localize areas of disease within the prostate gland to customize prostate implants. Additionally, the acute toxicity results from the first 43 patients treated with this technique are reviewed.

METHODS AND MATERIALS

Between 2/97 and 8/98, 43 patients with clinical stage II prostate adenocarcinoma received ultrasound-guided transperineal implantation of I-125 or Pd-103 seeds. The median patient age was 70 years (range 49-79). Prior to treatment, the median Gleason score and prostate-specific antigen (PSA) were 6 (range 3-8) and 7.5 (range 1.8-16.6 ng/mL), respectively. The median follow-up was 10 months (range 2.9-20.4 months).

RESULTS

The median PSA value at 10 months is 0.7 ng/mL. Significant acute complications within the first month following implantation included 13 Grade I urinary symptoms, 24 Grade II urinary symptoms, 6 Grade III symptoms, and no Grade IV complications. Beyond 4 months, complications included 12 Grade I urinary symptoms, 17 Grade II urinary symptoms, 1 Grade III, and 1 Grade IV complications.

CONCLUSIONS

The image fusion of the pelvic CT scan and ProstaScint scans helped identify regions within the prostate at high risk of local failure, which were targeted with additional seeds during implantation.

Prostate cancer and prostate bed SPECT imaging with ProstaScint: semiquantitative correlation with prostatic biopsy results

BACKGROUND

ProstaScint (Cytogen Corporation, Princeton, NJ) murine monoclonal antibody imaging is FDA-approved for imaging of prostate cancer patients at high risk for metastatic disease and patients postprostatectomy with a rising serum prostate-specific antigen (PSA) level. ProstaScint is a murine monoclonal antibody which targets prostate-specific membrane antigen (PSMA). PSMA expression is upregulated in primary and metastatic prostate cancer. FDA Cytogen (Princeton, NJ) protocol studies using 111indium-labeled ProstaScint revealed correlation between areas of increased concentration in the prostate and biopsy-proven tumors in patients imaged pretherapy.

METHODS

In our study, four transverse, single-photon emission tomography (SPECT) images were isolated and regions of interest were selected and correlated with pretherapy prostate biopsy results. Prostate cancer and normal tissue prostate/muscle background (P/M) ratios were derived, so that postprostatectomy/radiation therapy patients could be evaluated for the presence of residual prostate cancer. Twenty-three pretherapy prostate cancer patients with quadrant/sextant biopsies had SPECT 96-hr 111indium ProstaScint pelvic images. The four transverse 1-cm slices above the midline penile blood pool were chosen, and four to six 27-30-pixel regions of interest were placed over the prostate bed. The background muscle region of interest was placed over the external obturator muscle region. The P/M ratio was calculated and compared to the quadrant/sextant prostatic biopsy result. The same procedure was applied to 17 posttherapy prostate cancer patients with rising PSA.

RESULTS

In the 23 pretherapy prostate cancer patients, there was a correlation between the P/M ratio of at least 3.0 in 32 of 35 prostatic cancer biopsy regions, and there was correlation with P/M ratios less than 3.0 in 82 of 89 negative biopsy regions. Seventeen posttherapy patients underwent ProstaScint studies. Six underwent biopsy, with typically one biopsy site per patient. All 6 had P/M ratios greater than 3.0 in the biopsied region. Five out of six biopsies revealed residual prostate cancer.

CONCLUSIONS

A prostate/muscle ratio was developed from 111indium ProstaScint regions of interest obtained on 1-cm SPECT transverse slices through the prostate bed in 23 patients preprostatic cancer therapy. A P/M ratio above 3.0 correlated in the majority of positive cases, and a P/M ratio below 3.0 was demonstrated in negative prostatic biopsy cases. The P/M ratio of above 3.0 or below 3.0 also separated those posttherapy prostate cancer patients with rising PSA who had residual prostate carcinoma in the prostate bed.

Long-term outcomes of therapeutic pelvic lymphadenectomy for stage I endometrial adenocarcinoma

OBJECTIVE

The treatment of patients with stage I endometrial adenocarcinoma is often shorter and less expensive if total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and therapeutic lymphadenectomy are used rather than TAH, BSO, pelvic lymph node sampling, and pelvic external beam radiation. We studied whether the survival and morbidity of patients treated with therapeutic lymphadenectomy are equal to or better than with these alternative treatments.

METHODS

We reviewed the medical records of patients with stage I endometrial adenocarcinoma who were enrolled in the MetroHealth Medical Center tumor registry between 1970 and 1993 after undergoing full pelvic lymph node dissection, in addition to total abdominal hysterectomy, bilateral salpingo-oophorectomy, and vaginal brachytherapy. The mean number of resected nodes was 33 (median, 31; interquartile range, 19). Patients were followed for 1. 6-20 years (median, 8 years; interquartile range, 5.8 years). Morbidity and survival rates were compared to published series using similar treatment strategies and to those from studies using pelvic external beam radiation and pelvic lymph node sampling rather than lymphadenectomy.

RESULTS

Of 192 patients with pathologic stage I (FIGO 1988) endometrial adenocarcinoma, 178 patients had full pelvic lymph node dissection; 159 patients were evaluable. The 15-year overall survival was 98%; 10- and 15- year disease-free survivals were 96 and 94%, respectively. Overall morbidity was 18% (29/159), and moderate-to-severe morbidity was 13% (21/159). Recurrences were seen in 4.4% (7/159) of patients. Grade and myometrial invasion were not significant predictors of disease-free survival after full pelvic lymph node dissection (grade, P = 0.42; stage, P = 0.67). The results compare favorably with those of similar studies and with studies of pelvic external beam radiation.

CONCLUSIONS

Primary surgical management with total abdominal hysterectomy, bilateral salpingo-oophorectomy, therapeutic pelvic lymphadenectomy, and vaginal brachytherapy is a viable and possibly preferable option for patients with stage I endometrial adenocarcinoma.

Comparison of laser phacovaporization using the Er-YAG and the Er-YSGG laser

OBJECTIVE

To study the interaction of the erbium (Er)-YAG (2.94 microns) and the Er-YSGG (2.79 microns) lasers with the human crystalline lens tissue.

METHODS

Fresh human crystalline lens sections were used to measure the photovaporization threshold, rate, and damage zone of the two lasers.

RESULTS

We found the photovaporization threshold for the Er-YAG and the Er-YSGG lasers to be 1.4 J/cm2 and 5.5 J/cm2, respectively. At 10 J/cm2, the photovaporization rate is 67.9 microns per pulse for the Er-YAG laser and 18.4 microns per pulse for the Er-YSGG laser. The increased rate of photovaporization as a function of radiant energy for the Er-YAG laser is almost twice that for the Er-YSGG. Damage zones for the Er-YAG laser ranged from 4 to 9 microns compared with 10 to 22 microns for the Er-YSGG.

CONCLUSIONS

It is apparent that both lasers can adequately photovaporize human crystalline lens tissue and should be further studied for this purpose.

Neurally induced cardiac damage. Definition of the problem

Sudden unexpected death is a problem of major importance, but very little is known about its cause. Electrocardiographic abnormalities have been known to occur in the context of neurologic disease for a long time. This article discusses the neuroanatomy of the heart and lungs and neurogenic lung and heart disease. The four classes of causes of these abnormalities are catecholamine infusion, stress plus or minus steroids, nervous system stimulation, and reperfusion. These classes are tied together by a common thread, the essential feature of which is sympathetic overactivity with secondary catecholamine toxicity. A unifying hypothesis is proposed to explain all of the forms of sudden death based on the anatomic connection between the nervous system and the heart and lungs.

A practical approach to coma diagnosis in the unresponsive patient

Diagnosis of coma in the unresponsive patient can be done in a relatively short time by making key observations that will confirm disease of either the brain stem or the hemispheres, the two locations in which coma originates. Determining the location of the lesion is the primary goal in early assessment of the unresponsive patient. Examination of the patient's eyes is the single most important step in understanding coma.

Cerebral toxoplasmosis in patients with AIDS

Toxoplasma gondii, a previously rare cause of central nervous system infection, has become a major cause of encephalitis in patients with acquired immunodeficiency syndrome. The diagnosis of cerebral toxoplasmosis should be kept in mind when neurologic signs and symptoms develop in patients with AIDS. Patients with positive serology and characteristic lesions on computed tomographic scans should receive two weeks of antitoxoplasma therapy. Biopsy is recommended for patients with atypical presentation, negative serology, progressive clinical deterioration or differential response of lesions to empiric therapy.

Parkinsonian symptoms in a patient with AIDS and cerebral toxoplasmosis

Images

Cerebral toxoplasmosis in the acquired immune deficiency syndrome

We examined the clinical and pathological features of 26 patients who presented with a diagnosis of CNS toxoplasmosis. Patient data was analyzed with respect to demographics, clinical presentation, treatment course and pathology. Patients presented with a wide variety of signs and symptoms. All patients had positive serum antitoxoplasma IgG; ring enhancing lesion(s) were present on all but one brain CT scans. A series of guidelines in the management of CNS toxoplasmosis in AIDS patients are presented. Prior to biopsy, patients with positive serology and characteristic CT scans should receive two weeks of treatment. Biopsy is indicated in those cases with negative serology, atypical presentation, progressive clinical deterioration, or differential response of lesions to empiric therapy.

Sensory form of acute polyneuritis

A patient presented with severe sensory loss and ataxia with total arreflexia, and elevation of CSF protein with pleocytosis. At autopsy there was extensive lymphocytic infiltration of nerves and posterior roots, sparing the anterior roots. Teased fiber preparation of nerve showed a demyelinating lesion. There were no abnormalities in the CNS. The condition appears to be an acute sensory polyneuritis bearing a close relationship to acute Guillain-Barré syndrome.

Neurogenic heart disease: a unifying hypothesis

Electrocardiographic abnormalities have been known to occur in the context of neurologic disease for a long time. These changes fall into 2 categories: arrhythmias and repolarization abnormalities. However, until relatively recently these changes were believed to represent purely electrophysiologic alterations and not real heart disease. It is now clear that some patients with neurogenic electrocardiographic changes show cardiac enzyme release and myofibrillar degeneration at autopsy. There are 4 major methods for producing myofibrillar degeneration (i.e., contraction band necrosis or coagulative myocytolysis): catecholamine infusion, stress-steroid, nervous system stimulation and reperfusion. The common thread connecting these 4 methods is the opening of receptor-operated calcium channels, resulting in intense contraction of cardiac muscle. Thus, neurogenic influence over cardiac function may represent a continuum. In the mild reversible circumstance, only the electrocardiographic change will be seen, whereas in the severe, irreversible situation, myofibrillar degeneration will ensue with release of cardiac enzymes. Cardiac cell death may be caused by oxygen free radicals produced by metabolism of catecholamines or reperfusion or both, after variable periods of ischemia. This concept represents a unifying hypothesis, tying together the clinical, physiologic, biochemical and pathologic findings in neurogenic heart disease.

Myocardial contraction band lesions in patients with fatal asthma: possible neurocardiologic mechanisms

Myocardial contraction band necrosis (MCBN) occurs in catecholamine infusion, central nervous system stimulation, stress, and transient myocardial ischemia with reperfusion. In 4 of 13 children who died with asthma, MCBN was present, suggesting that this cardiac lesion may contribute to the deaths of some asthmatic patients. Two of the 4 patients who had MCBN had not received sympathomimetics intravenously or by an intracardiac route. Therefore, mechanisms other than infusions of large doses of catecholamines are probably involved in production of this cardiac lesion in asthmatics.

Multiple simultaneous intracerebral hematomas. Clinical, radiologic, and pathologic findings in two patients

The simultaneous occurrence of two intracerebral hematomas in different arterial territories of the brain is rare. We report the clinical, radiologic, and post-mortem findings in two such cases. The absence of readily identifiable vascular disease in such patients suggests that a subtle degenerative process may be active in the pathogenesis of this condition.

Clinical exercise trial for stroke patients

This investigation evaluated the effectiveness of the traditional and facilitation approaches to therapeutic exercise in stroke patients. A total of 42 adults (24 men and 18 women) with a mean age of 61.6 years (SD = 21) were selected from a larger population of hospitalized stroke victims. Stroke patients were classified by CT scan information and judged medically fit to participate in a nonrestrictive program by neurologic examinations and laboratory tests. The Barthel Index and the manual muscle test were administered at admission and discharge. Both facilitation and traditional exercise therapies improved functional and motor performance, but there were no significant differences between these approaches. The lack of differences between the facilitation and traditional exercise therapies may be due to heterogeneity of the stroke population, the small sample size, and the measurements used. The study demonstrates the need for a measurement instrument capable of reliably assessing the facilitation approach. Future investigations should incorporate lesion type, site, and side along with global measurements in evaluating differences among motor remediation approaches.