Baron Larrey at the Dawn of Correlative Neuroanatomy

In 1820, a young soldier was accidentally injured by a splinter of a fencing sword that penetrated through the right orbit into the brain. Examination by the French military surgeon Baron D.-J. Larrey revealed nominal aphasia, right hemiplegia, and monocular temporal hemianopia with an altitudinal component in the right eye only. In this paper, we aimed to reconstruct Larrey's contribution to neurology in the eve of correlative neuroanatomy. Larrey predicted that the blade passed from the roof of the right orbit to graze the root of the right optic nerve at the chiasm and from there, into the vicinity of the left Sylvian fissure. This course was verified posthumously 3 months later. Larrey's previous experience with galvanic currents enabled the adoption of Samuel von Sömmering's idea of regarding the brain as a telegraphing system made of a multitude of galvanic piles sending and receiving messages from distant points. Larrey's description is a very early diligent study of the tracks of penetrating head injuries. It correlates the symptoms with the injured cerebral tissues together with autopsy verification. Here are the beginnings of the construction of human correlative neuroanatomy, which lingered until flourishing in the first decades of the 20th century.

[Young man with gunshot wound (GSW)--what killed Ernst vom Rath?]

On the morning of November 7, 1938 vom Rath, a diplomat at the German embassy in Paris, was shot by Herschel Grynzspan, a Jewish teenager. Of the 5 shots fired, 2 hit vom Rath, one in the right shoulder and one in the abdomen. He was rushed to Alma Women's Hospital near the embassy, where emergency surgery was undertaken. Two days later his condition deteriorated rapidly and succumbed 55 hours after the shooting. It is believed that the assassination triggered the "Kristallnacht"--the organized Nazi pogrom against Jews across Germany. Based on the Alma hospital registry, autopsy findings and articles from recent years, the course of his condition and possible cause of his death are discussed. The possibility of malpractice, and even medical fraud, which led to his death are also mentioned.

The neurologist lipman halpern-author of the oath of the hebrew physician

Lipman Halpern was born in 1902 into a family of Grand Rabbis who lived in Bialystok from the mid-nineteenth century. Inspired by his son's decision to study medicine, Halpern's father authored a comprehensive and innovative book on medicine according to Rabbinic Law. After completing his initial medical studies in Königsberg, Halpern went on to specialize in neuropsychiatry in Berlin and then in Zurich. In 1934, Halpern immigrated to Eretz-Israel (then Palestine), where he founded and expanded the Department of Neurology at the Hadassah University Hospital in Jerusalem. Under his guidance, the department became a leader in clinical neurology, clinical and basic neurological research, and teaching. For the graduation of the first class of the Faculty of Medicine of the Hebrew University of Jerusalem in 1952, he authored the "Oath of the Hebrew Physician," which went on to become the official oath for all new physicians graduating from Israeli faculties of medicine. Halpern authored many clinical and research articles in English, German, French, and Hebrew. His studies on the relationship between the vestibular, cerebellar, and visual systems resulted in the description of the phenomenon of "monocular disequilibrium" and the "sensorimotor induction syndrome," also known as "Halpern's syndrome." In 1953 he became the first Israel Prize laureate in Medicine. Halpern died in 1968 while serving his second term as Dean of the Faculty of Medicine at Hebrew University.

Moritz schiff (1823-1896): a physiologist in exile

Moritz Schiff was one of the pioneers of modern experimental physiology. His involvement in the liberal movement forced him out of Germany, and, because of his adherence to proper physiological research, he had to flee Italy, his first refuge. The number and importance of his contributions are outstanding. The aim of this paper is to raise interest in his biography and to present a yet unreported field of research that is regarded as the root of functional imaging of the brain.

Chapter 4: neurology in the Bible and the Talmud

The Bible, a major pillar of Western Civilization consists of Hebrew Scriptures, assembled over a millennium and accepted as of divine origin. The Talmud is a compendium of Jewish laws, covering every possible aspect of life, analyzed in depth from 200 BCE to 600 CE, becoming the foundation of Jewish existence. The all-encompassing character of the books provides numerous medical problems and observations that appear in various connotations. When in need to clarify various legal dilemmas, the Talmudic sages displayed astoundingly accurate anatomical knowledge and were pioneers in clinical-pathological correlations. The descriptions of "neurological" events in the Bible are very precise but show no evidence of neurological knowledge. Those reported in the various tractates of the Talmud are evidence of a substantial medical knowledge, marked by Hellenistic influence. Subjects such as head and spinal injuries, epilepsy, handedness neuralgias aphasia tinnitus and tremor were discussed in depth. This chapter is an updated collection of the studies, extracting observations and discussions of neurological manifestations from the ancient texts.

Hyperbaric oxygen pretreatment according to the gas micronuclei denucleation hypothesis reduces neurologic deficit in decompression sickness in rats

During sudden or too rapid decompression, gas is released within supersaturated tissues in the form of bubbles, the cause of decompression sickness. It is widely accepted that these bubbles originate in the tissue from preexisting gas micronuclei. Pretreatment with hyperbaric oxygen (HBO) has been hypothesized to shrink the gas micronuclei, thus reducing the number of emerging bubbles. The effectiveness of a new HBO pretreatment protocol on neurologic outcome was studied in rats. This protocol was found to carry the least danger of oxygen toxicity. Somatosensory evoked potentials (SSEPs) were chosen to serve as a measure of neurologic damage. SSEPs in rats given HBO pretreatment before a dive were compared with SSEPs from rats not given HBO pretreatment and SSEPs from non-dived rats. The incidence of abnormal SSEPs in the animals subjected to decompression without pretreatment (1,013 kPa for 32 min followed by decompression) was 78%. In the pretreatment group (HBO at 304 kPa for 20 min followed by exposure to 1,013 kPa for 33 min and decompression) this was significantly reduced to 44%. These results call for further study of the pretreatment protocol in higher animals.

Pituitary Apoplexy and CABG: Should We Change Our Strategy?

Patients with pituitary adenoma that had coronary artery bypass grafting with cardiopulmonary bypass had pituitary apoplexy develop with neurologic deficits and even death. Four patients with pituitary adenoma underwent coronary artery bypass grafting operations (3 patients had coronary artery bypass grafting on bypass, 1 of them with known pituitary adenoma. All of them had pituitary apoplexy develop with neurologic deficits). One patient with known pituitary adenoma who had a coronary artery bypass grafting operation off pump was neurologically intact. Our recommendation is to consider operating on patients with pituitary adenoma who need coronary artery bypass grafting operation off pump, and to prevent pituitary apoplexy that cardiopulmonary bypass may cause.

Hyperbaric oxygen pretreatment reduces the incidence of decompression sickness in rats

We have previously hypothesised that the number of bubbles evolving during decompression from a dive, and therefore the incidence of decompression sickness (DCS), might be reduced by pretreatment with hyperbaric oxygen (HBO). The inert gas in the gas micronuclei would be replaced by oxygen, which would subsequently be consumed by the mitochondria. This has been demonstrated in the transparent prawn. To investigate whether our hypothesis holds for mammals, we pretreated rats with HBO at 304, 405, or 507 kPa for 20 min, after which they were exposed to air at 1,013 kPa for 33 min and decompressed at 202 kPa/min. Twenty control rats were exposed to air at 1,013 kPa for 32 min, without HBO pretreatment. On reaching the surface, the rat was immediately placed in a rotating cage for 30 min. The animal's behaviour enabled us to make an early diagnosis of DCS according to accepted symptoms. Rats were examined again after 2 and 24 h. After 2 h, 65% of the control rats had suffered DCS (45% were dead), whereas 35% had no DCS. HBO pretreatment at 304, 405 and 507 kPa significantly reduced the incidence of DCS at 2 h to 40, 40 and 35%, respectively. Compared with the 45% mortality rate in the control group after 24 h, in all of the pretreated groups this was 15%. HBO pretreatment is equally effective at 304, 405 or 507 kPa, bringing about a significant reduction in the incidence of DCS in rats decompressed from 1,013 kPa.

[Dr. Henry Wigderson--the first neurosurgeon in Eretz-Israel]

The vision of Hadassah Medical Organization and the Hebrew University in Jerusalem was to establish a University Hospital where clinical excellence and high academic level will be the hallmark of its departments. More than seventy years ago, guided by this spirit, the leaders of the two institutions attempted to establish a department of neurosurgery, which, at the time in only a few countries, was making its initial steps as an independent discipline. It was only during World War II that Hadassah could bring over a specialist in neurosurgery who worked for nearly three years in the Hadassah Hospital on Mount Scopus. This article describes the way Dr. Henry Wigderson was selected to be the first neurosurgeon in Eretz-Israel, his activities and the incorporation of the idea, in spite of the disappointment caused by his departure, that even at times of distress, neurosurgery is not a luxury but an indispensable part of an forward-looking medical institution.

Evaluation of the apoptosis-related proteins of the BCL-2 family in the traumatic penumbra area of the rat model of cerebral contusion, treated by hyperbaric oxygen therapy: a quantitative immunohistochemical study

The growth and progression of traumatic brain injury (TBI) lesions depend significantly on developments in the traumatic penumbra area, perilesional region, where delayed neuronal death occurs. Recent data supports the important role of apoptosis in delayed cell death in TBI. Previously we demonstrated a significant reduction of apoptosis in traumatic penumbra in animals treated by hyperbaric oxygen (HBO). In this study we evaluate the expression of apoptosis-related proteins of the Bcl-2 family (Bcl-2, Bax and Bcl-xL) in the traumatic penumbra area in correlation with the extent of apoptosis in the rat model of focal cerebral contusion, treated by HBO. Sprague-Dawley rats underwent cortical dynamic deformation, some with subsequent hypoxemia. A group of both hypoxemic and non-hypoxemic animals was treated by HBO. The pathological study was based on immunohistochemical staining of the brain sections for Bcl-2, Bax and Bcl-xL with quantitative evaluation of staining by image analysis. The expression of Bcl-2 in hypoxemic animals was lower than in non-hypoxemic animals, but a significant increase in Bcl-2 expression was seen in both groups after HBO treatment. Bcl-xL also demonstrated an increase after HBO treatment but less significant. Staining for Bax protein did not demonstrate significant change after treatment. These data correlate well with the reduction of TUNEL-positive cells in traumatic penumbra after HBO treatment. We concluded that the apoptotic mechanisms are important in delayed cell death in TBI and that post-traumatic hypoxemia increases the intensity of apoptosis, probably through a decrease in Bcl-2 and Bcl-xL expression which normally repress apoptosis. The beneficial effect of HBO treatment in our model of brain contusion correlates well with the increased expression of anti-apoptotic proteins (Bcl-2 and Bcl-xL) following treatment and the appropriate decrease in the extent of apoptosis. In light of these results, the usage of HBO is justified as neuroprotective treatment in TBI.

Antidepressant effects of different schedules of repetitive transcranial magnetic stimulation vs. clomipramine in patients with major depression: relationship to changes in cortical excitability

The antidepressant effects of repetitive transcranial magnetic stimulation (rTMS) that have been demonstrated in recent studies could be related to its ability to modulate cortical excitability. Yet, the relationship between stimulus location and frequency and treatment outcome has not been established. The aim of the present study was to compare efficacy of rTMS in various configurations and clomipramine treatment in patients with major depression (MD) and to evaluate the relationship between clinical outcome and changes in cortical excitability. Fifty-nine MD patients were randomized to receive (1) left (n = 12) or right (n = 12) 3 Hz rTMS with placebo medication; (2) left (n = 10) or right (n = 9) 10 Hz rTMS with placebo medication; (3) active medication (clomipramine) with sham rTMS (n = 16). Both 3 Hz and 10 Hz rTMS were administered to the prefrontal cortex by a circular coil at an intensity of 110% and 100% of the resting motor threshold (rMT) respectively. Measurements of cortical excitability were performed prior to and 24 h after completion of 2 wk of daily rTMS or pharmacological treatments. These included the rMT, silent period threshold (SPT), inter-threshold difference (ITD), MEP/M-wave amplitude ratio and silent period duration (SPD). Severity of depression was blindly assessed by the Hamilton Depression Rating Scale (HDRS). The best improvement scores were seen in patients who received left 3 Hz rTMS. The 10 Hz rTMS treatment was less tolerated resulting in a significantly higher dropout rate. A significant increase of the MEP/M wave amplitude ratio accompanied by a shortening of the SPD was evidenced in patients who showed marked clinical improvement (reduction in HDRS by 50% or more) following left rTMS regardless of stimulation frequency. Our results suggest that 3 Hz left rTMS has a higher therapeutic efficacy and tolerability in patients with MD. The enhancement of cortical excitability may be related to the antidepressant action of rTMS.

Evidence for cortical hyperexcitability of the affected limb representation area in CRPS: a psychophysical and transcranial magnetic stimulation study

Functional alterations in noxious, sensory and motor circuits within the central nervous system may play an important role in the pathophysiology of complex regional pain syndrome (CRPS). The aim of the present study was to search for further evidence of hyperexcitability in the hemisphere contralateral to the affected limb in patients with CRPS by employing both psychophysical and transcranial magnetic stimulation (TMS) methods. Twelve patients with CRPS type I, confined to the distal part of a limb (six in an upper-limb and six in a lower-limb), were enrolled in the study. The quantitative thermal, mechanical and 'wind-up' like pain testing was performed at the most painful site in the affected limb and in the ipsilateral limb. Results were then compared to those found at mirror sites in the contralateral limbs. TMS was used to assess the inter-hemispheric difference in parameters of corticospinal excitability, intracortical inhibition, and intracortical facilitation. The quantitative thermal and mechanical testing showed significant differences in cold, heat and mechanical pain thresholds, as well as in the first and last 'wind-up' stimuli between the affected and the contralateral limbs of the CRPS patients. No significant differences between the ipsilateral unaffected limbs and their contralateral pair limbs were found. A significant reduction in the short intracortical inhibition associated with a significant increase of the I-wave facilitation was found in the hemisphere contralateral to the affected side in the upper-limb CRPS group. No significant inter-hemispheric asymmetry between the affected and the non-affected sides was revealed in the lower-limb CRPS group. Taken together, these results suggest that in patients with well-localized CRPS, there is evidence for sensory and motor CNS hyperexcitability, though it seems to involve only corresponding regions within the CNS rather than the entire hemisphere.

Effect of electroconvulsive therapy on cortical excitability in patients with major depression: a transcranial magnetic stimulation study

OBJECTIVE

The antidepressant action of electro-convulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) may be related to their ability to modulate cortical excitability. The aim of this study was to investigate changes in cortical excitability following ECT in patients with major depression (MD) and to compare therapeutic efficacy of ECT combined with rTMS to that of ECT alone.

METHODS

Twenty-two patients with MD were assigned to receive ECT and right prefrontal 1 Hz rTMS (n=12) or ECT with sham rTMS (n=10). ECT was given twice weekly and rTMS was applied on the remaining 4 days, throughout 3 weeks. The resting motor threshold (rMT) and motor evoked potential (MEP)/M-wave area ratio were evaluated before and 6 h after the first, third and sixth ECT session. The active motor threshold (aMT), intra-cortical inhibition (ICI) and intra-cortical facilitation (ICF) were measured at baseline and 24 h after the last ECT.

RESULTS

There were no significant differences in the degree of clinical improvement and measures of cortical excitability in the ECT+active rTMS group as compared to the ECT+sham rTMS group. Marked clinical improvement observed in 19 out of the 22 patients was associated with a significant increase of the MEP/M-wave area ratio, decrease of the aMT and reduction of the ICI in the left hemisphere.

CONCLUSIONS

The antidepressant effect of ECT was associated with an enhancement of left hemispheric excitability. rTMS did not add to the beneficial effect of ECT. However, the small sample size and the robust effect of ECT might have obscured a potential therapeutic effect of rTMS.

SIGNIFICANCE

Measures of cortical excitability may provide insight to our understanding of the mechanism of action of ECT and might be useful for the assessment of treatment response.

The value of motor and somatosensory evoked potentials in evaluation of cervical myelopathy in the presence of peripheral neuropathy

STUDY DESIGN

Patterns and rates of motor-evoked potential (MEP) and somatosensory-evoked potential (SEP) abnormalities were evaluated in 9 patients with combined cervical cord compression and diabetic neuropathy and 15 patients with asymptomatic cervical cord compression. The results were compared with those of 8 patients with pure cervical myelopathy and 7 patients with pure diabetic neuropathy.

OBJECTIVE

To assess the efficacy of MEPs and SEPs in the evaluation of cervical myelopathy in the presence of peripheral neuropathy.

SUMMARY OF BACKGROUND DATA

Previous studies have demonstrated a high sensitivity of MEPs and SEPs in documenting a functional involvement of motor and somatosensory pathways in pure or preclinical cervical myelopathy. However, there have been no detailed reports on MEPs and SEPs in cervical cord compression associated with peripheral neuropathy.

METHODS

Central somatosensory conduction was assessed by median and tibial SEPs using peak-to-peak and onset-to-onset methods. Central motor conduction was measured by MEPs and F-waves elicited from upper and lower limb muscles in response to transcranial magnetic stimulation, magnetic stimulation of cervical motor roots, and electrical stimulation of peripheral nerves.

RESULTS

MEPs were more sensitive than SEPs in detecting central conduction impairments in patients with either pure or preclinical or combined forms of cervical myelopathy. The rate of MEP abnormalities suggesting the corticospinal tract involvement in the combined cervical cord compression-neuropathy group did not differ significantly from that in the asymptomatic cervical cord compression group but was lower than in the pure cervical myelopathy group. Combined MEP and SEP analysis improved the test sensitivity in detecting clinically "silent" cervical cord dysfunctions.

CONCLUSIONS

MEPs associated with SEPs are a valuable tool for assessing the presence and severity of cervical cord involvement in combined cervical cord compression and peripheral neuropathy lesions.

Hyperbaric oxygen therapy for reduction of secondary brain damage in head injury: an animal model of brain contusion

Cerebral contusions are one the most frequent traumatic lesions and the most common indication for secondary surgical decompression. The purpose of this study was to investigate the physiology of perilesional secondary brain damage and evaluate the value of hyperbaric oxygen therapy (HBOT) in the treatment of these lesions. Five groups of five Sprague-Dawley rats each were submitted to dynamic cortical deformation (DCD) induced by negative pressure applied to the cortex. Cerebral lesions produced by DCD at the vacuum site proved to be reproducible. The study protocol entailed the following: (1) DCD alone, (2) DCD and HBOT, (3) DCD and post-operative hypoxia and HBOT, (4) DCD, post-operative hypoxia and HBOT, and (5) DCD and normobaric hyperoxia. Animals were sacrificed after 4 days. Histological sections showed localized gross tissue loss in the cortex at injury site, along with hemorrhage. In all cases, the severity of secondary brain damage was assessed by counting the number of terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) and caspase 3-positive cells in successive perilesional layers, each 0.5 mm thick. Perilesional TUNEL positive cells suggested the involvement of apoptosis in group 1 (12.24% of positive cells in layer 1). These findings were significantly enhanced by post-operative hypoxia (31.75%, p < 0.001). HBOT significantly reduced the severity and extent of secondary brain damage expressed by the number of TUNEL positive cells in each layer and the volume of the lesion (4.7% and 9% of TUNEL positive cells in layer 1 in groups 2 and 4 respectively, p < 0.0001 and p < 0.003). Normobaric hyperoxia also proved to be beneficial although in a lesser extent. This study demonstrates that the vacuum model of brain injury is a reproducible model of cerebral contusion. The current findings also suggest that HBOT may limit the growth of cerebral contusions and justify further experimental studies.

[Indirect traumatic optic neuropathy--problems and challenges in diagnosis and uncertainty in treatment]

Traumatic optic neuropathy is one of the many facets of head injuries and a major cause of devastating permanent visual loss due to head injuries. Indirect traumatic optic neuropathy (ITON) occurs when blunt trauma to the forehead results in a transmission of force through the cranium to the confined portion of the optic nerve within the bony optic canal. The physics of the injuring forces that induced anatomical and histological effects on the optic nerve were thoroughly studied but the recognition of ITON in the acute stage still poses a diagnostic challenge. The accuracy of diagnosis still varies ten-fold among different centers. The use of Visual Evoked Potentials (VEP) in the evaluation of patients at risk of ITON will improve the diagnostic abilities. The clinical course varies between immediate and permanent visual loss of varied severity, delayed deterioration and spontaneous recovery. No clinical technique, however, proved to provide predictive abilities. None of the current forms of treatment--conservative, high dose steroids and surgical decompression of optic nerve, were found to be superior, and the patient series are still too small. The reviewers recommend establishing a national registry of ITON that will facilitate the improvement of the diagnosis and will contribute to the adoption of an evidence-based therapeutic approach.

Unlocking the brain: attempts to improve mental function of microcephalic retarded children by "craniotomy"

"Is it sufficient glory to don a white apron and swing a carbolized knife and is therein a sufficient indication to let daylight into a deformed cranium and on top of a hopelessly defective brain, and to proclaim success because the victim consented not to die of the assault? Such rash feats of indiscriminate surgery, if continued, moreover in the presence of fourteen deaths in thirty-three cases, are stains on your hands and sins on your souls. No ocean of soap and water will cleanse those hands, no power of corrosive sublimate will disinfect the souls." These passionate words, delivered by Abraham Jacobi, the father of American pediatrics, at the International Congress in Rome in 1893, and later in the article "Non nocere" (42), epitomize the growing antagonism to the attempts by many prominent surgeons to improve the gloomy fate of severely retarded, microcephalic children by "liberating" their brains from their presumed bony chains by "linear craniotomy." This article portrays how the fallacious 19th-century concepts of the relationship between the capacity of the cranial cavity and intelligence, backed by "scientific racism" together with the changing attitude toward retarded and malformed children, generated a surgical solution for microcephalic idiocy. It describes how hopeful surgeons, neurologists, and pediatricians, encouraged by the advances in anesthesia and asepsis, lost their judgment and disregarded logic and evidence. They generated a wave of enthusiasm and hope that soared from the United States and France through the British Isles, Europe, and as far as Ceylon and Australia to end in a ripple of bitter disgrace under caustic criticism, leaving a scar on the recently budding field of neurological surgery.

[Gunshot brain injury--Rishon-le-Zion 1913]

Dr. Leon Pochovski (1869-1965), the first fully trained surgeon to settle in Eretz-Israel, was summoned in 1913 from Jaffa to Rishon-le-Zion to treat a patient who sustained a tangential gunshot injury of the brain from a bullet shot at nearly point blank range, in the right occipital region. As the patient's condition deteriorated intracranial bleeding was diagnosed. Dr. Pochovski did not hesitate to operate and successfully removed an intracerebral hematoma. At first there were no visual symptoms, but on the 11th day there was hemianopia due to dysfunction of the initially uninvolved left hemisphere. It became progressed and then cleared. The hemianopia was associated with diplopia and created hallucinations in the blind field. The mode of treatment and the learned discussion of the uncommon symptomatology demonstrate that the practicing physicians were providing clinical service that did not differ in the technical standards and academic level from that of their colleagues overseas.

Non invasive local cerebral oxygenation monitoring using a combination of light and ultrasound

OBJECTIVES

We present a new imaging technology that will allow to obtain three-dimensional maps of oxygen saturation in the brain tissues. This technology is not invasive and not ionizing, and can lead to small, portable device that can be brought to bedside.

METHODS

The technology uses a combination of near-infrared laser light and ultrasound. Like for other near-infrared spectroscopy techniques, light gives the information on the hemoglobin species present in the tissues. However, since tissues are turbid media, light alone cannot give precise local information. In the technique that we demonstrate, localization is obtained using a focussed ultrasound that locally shifts the laser wavelength, similarly to laser doppler techniques. The frequency-shifted light can be precisely detected and attributed without ambiguities to a specific location. By scanning the ultrasound focus, we can obtain a mapping of the oxygen saturation.

RESULTS

We present preliminary results on a phantom showing the detection of an absorbing object buried more than two centimeters within the phantom. Scanning the ultrasound on the phantom allows to determine precisely the object position and absorption. Scattering and absorption parameters of the phantom are similar to the brain's. The probe works in the reflection mode, meaning that no transillumination is needed. The ultrasound frequency is 1.25 MHz, ensuring relatively good ultrasound penetration within the skull.

CONCLUSIONS

The method is very promising for brain imaging of trauma or tumors. It is particularly suited for monitoring, since the use of the ultrasound removes the well-recognized problem of light propagation in the CSF.

[The amputated leg--a tale of scientific curiosity--1792]

In 1792 the young military surgeon Dominique Jean Larrey (later Baron de l'empire) had to amputate a soldier's leg. His scholarly knowledge combined with intellectual curiosity turned a common event into an innovative scientific experiment, after he used the severed leg to affirm in the human being the recent observations made by Galvani on frogs. The possibility of inducing muscular contractions by galvanic current led him to foretell, much ahead of his time, that this mode would facilitate rehabilitation of the paralyzed.

Basilar vasospasm following spontaneous and traumatic subarachnoid haemorrhage: clinical implications

BACKGROUND

Cerebral vasospasm has been commonly described following subarachnoid haemorrhage (SAH) though its impact on neurological outcome, especially in head trauma, has not been yet elucidated. The purpose of this study was to monitor and correlate neurological condition and flow velocities (FVs) in the arteries of the brain after SAH and more particularly to investigate the influence of basilar artery (BA) vasospasm on neurological outcome.

METHODS

Daily transcranial Doppler (TCD) evaluations were conducted in 116 consecutive patients with subarachnoid haemorrhage. SAH was of traumatic origin (tSAH) in 59 patients and spontaneous (sSAH) in 57 patients. Vasospasm in the MCA and ACA was defined by a mean FV exceeding 120 cm/s and three times the mean FV of the ipsilateral ICA. Basilar artery (BA) vasospasm was defined as moderate whenever the FV was higher than 60 cm/s and severe above 85 cm/s.

FINDINGS

Sixty-two patients (53.4%) had elevated FVs in the BA, among these 34 (29.3%) had FVs above 85 cm/s. Basilar vasospasm was significantly more common in tSAH (59.7%) than in sSAH (40.3%, P=0.041). In patients with moderate and severe BA vasospasm, FVs in the BA increased on the third day after admission and remained elevated for a week before returning to normal value by the end of the second week. This elevation in BA FVs in patients with BA vasospasm was followed by a significant and progressive worsening in the neurological condition at the end of the first week. Permanent neurological deficit was associated with elevated BA FVs consistent with moderate BA vasospasm whereas patients who remained in persistent vegetative state, had FVs consistent with severe BA vasospasm (P=0.00019).

INTERPRETATION

The present results further support that BA vasospasm may act as an independent factor of ischaemic brain damage following SAH, especially in head trauma.

A flask full of jelly: the first in vitro model of concussive head injury--1830

IN 1830, THE French Military Surgeon Jean-Pierre Gama reported an experiment planned to unravel the mechanical events caused by head injury. His model was a round glass flask with a long neck filled with a gelatinous substance that resembled the consistency of the brain. Thumping the walls of the flask caused the movement of thin wires embedded in the "brain-like" material, thought to represent the spread of forces within the brain. Gama thought that he could thus observe oscillatory and vibratory movements of the wires representing the effects of concussion without visible structural brain lesions. Although it was crudely constructed, entirely subjective as to evaluation of results, and lacking the essential instrumentation that only modern technology can provide, this hypothesis-driven pioneer experiment should be regarded as the first to use the novel approach of physical modeling of the brain. Even today, this approach has not been fully exploited.

Neuropsychological effects of prefrontal slow rTMS in normal volunteers: a double-blind sham-controlled study

Recent reports have suggested that repetitive transcranial magnetic stimulation (rTMS) is effective in major depression. Unlike ECT, rTMS does not involve a seizure and is associated with minimal side-effects, including cognitive difficulties. However, the effect of rTMS on cognitive functioning has not been systematically evaluated. This study was designed to examine the neuropsychological effects of slow rTMS in normal volunteers. Forty-six normal volunteers were randomly assigned to receive one session of right (N = 16) or left prefrontal (N = 15), or sham (N = 15) rTMS at 1 HZ. Patients were assessed before and after stimulation by a computerized neurospychological battery. All three groups showed significant improvement over time in processing speed (reaction time) and efficiency (correct responses per unit of time). However, no time by group interaction was found for any of the neuropsychological tests. These findings suggest that a single session of slow rTMS does not interfere with neurospychological functioning in normal volunteers, supporting clinical reports of no adverse cognitive effects.

Excitatory and inhibitory corticospinal responses to transcranial magnetic stimulation in patients with minor to moderate head injury

OBJECTIVES

The changes in excitatory and inhibitory responses to transcranial magnetic stimulation (TMS), as attested by motor evoked potential (MEP) and silent period (SP) parameters, were compared in patients who sustained minor to moderate head injury.

METHODS

A total of 38 patients with brain concussion, and diffuse, focal, and combined brain injury and 20 healthy volunteers were examined. The MEPs and SPs were recorded from the abductor pollicis brevis muscle after single pulse TMS 2 weeks after head trauma. The parameters assessed were the MEP resting threshold, the MEP/M wave amplitude ratio, the central motor conduction time (CMCT), the SP threshold, the interthreshold difference (ITD), and the SP duration (SPD).

RESULTS

The main finding was an increase in the ITD in patients with mild and moderate head injury due to the relatively greater augmentation of the MEP threshold. This was associated with a reduction of the MEP/M wave amplitude ratio. The degree of MEP and SP changes depended on severity of head injury and was not related to the type of brain lesions. The SPD did not differ significantly in brain concussion, or diffuse, focal and combined brain injury groups compared with the control group. The CMCT was prolonged in patients with diffuse and combined brain lesions. Among subjective complaints only fatigue was significantly related to ITD, MEP, and SP threshold abnormalities.

CONCLUSIONS

The results suggest that mechanisms involved in MEP and SP generation are differently affected in head injury, the first being impaired more severely. The increase of the ITD accompanied by reduction of the MEP/M wave amplitude ratio may reflect a dissociated impairment of inhibitory and excitatory components of central motor control in head trauma.

Leeches for the unfortunate locksmith: self-inflicted posttraumatic transient cerebral blindness--mode of treatment and underlying mechanism (1826)

In 1826, Jean-Pierre Gama, a French military surgeon, treated a young locksmith who had self-inflicted posttraumatic transient cortical blindness. This may be the earliest detailed, firsthand description of this condition by a medically and scientifically trained observer. Gama's report sheds light on the concept of the mechanism of coup-contrecoup of cerebral concussion and its treatment in the early 19th century and on the germinating discipline of cerebral localization.

Classification of brain-stem trigeminal evoked potentials in multiple sclerosis, minor head injuries and post-concussion syndrome pathologies by similarity measurements

In this study measurements obtained from brain-stem trigeminal evoked potentials (BTEP) are applied to the problem of diagnosing Multiple Sclerosis (MS) and Post-concussion syndrome (PCS). We present a simplistic model that depicts the BTEP waveform as the linear combination of a set of filters excited by a short stimulus. The relation between the BTEP latencies and the 1st to 4th harmonic components is shown. The performance of a fuzzy similarity measure based classifier is compared with that of human experts. The efficiency of the proposed classifier in conjunction with delay time and amplitude features is examined. Using this novel approach, a classification rate of 93.55% and 84.1% for MS and PCS pathologies, respectively, was achieved. This performance compares favorably to the classification rates of 84.28% for MS and 70.47% for PCS pathologies achieved by human experts.

Preliminary evidence for a beneficial effect of low-frequency, repetitive transcranial magnetic stimulation in patients with major depression and schizophrenia

OBJECTIVE

This study was designed to evaluate the potential efficacy of repetitive transcranial magnetic stimulation (rTMS) at low-frequency in patients with major depression and schizophrenia.

EXPERIMENTAL DESIGN

We investigated the therapeutic effect of a course of 10 rTMS sessions in 14 subjects with major depression (MD) and 10 with schizophrenia.

PRINCIPAL OBSERVATIONS

Seven of the depressed patients reported significant improvement in depressive symptomatology, and seven of the schizophrenic subjects reported amelioration of anxiety and restlessness.

CONCLUSIONS

These preliminary results suggest that low-frequency rTMS may be beneficial mainly in MD and to some extent in schizophrenia, and support the need for controlled studies to further validate its therapeutic potential.

The blind beautiful eye

Master Jehan Yperman, a medieval surgeon, observed that when the optic nerve is injured, the eye becomes blind and beautiful. This is an attempt to trace the footsteps of this forgotten surgeon and to track the history of the cosmetic use of the belladonna herb, as well as the concept of amaurotic mydriasis.

[Favorable outcome of hyperacute epidural hematoma in an octogenarian]

Acute epidural hematoma is very rare in the elderly after head injury. It is usually associated with extremely high mortality or severe disability. In an 87-year-old woman a large, hyperacute, epidural hematoma was diagnosed. She was treated promptly and enjoyed an uneventful, complete recovery. This exceptional case should encourage an intensive approach even in seemingly minor head trauma in the elderly.

Brain natriuretic peptide and cerebral vasospasm in subarachnoid hemorrhage. Clinical and TCD correlations

BACKGROUND AND PURPOSE

Hyponatremia has been shown in association with cerebral vasospasm (CVS) following aneurysmal subarachnoid hemorrhage (SAH). In the past few years there has been increasing evidence that brain natriuretic peptide (BNP) is responsible for natriuresis after SAH. The purpose of the present study was to investigate the relationship between BNP plasma concentrations and CVS after aneurysmal SAH.

METHODS

BNP plasma concentrations were assessed at 4 different time periods (1 to 3 days, 4 to 6 days, 7 to 9 days, and 10 to 12 days) in 19 patients with spontaneous SAH. BNP plasma levels were investigated with respect to neurological condition, SAH severity on CT, and flow velocities measured by means of transcranial Doppler.

RESULTS

Thirteen patients had Doppler evidence of CVS; 7 of these had nonsymptomatic CVS. In 6 patients, CVS was severe and symptomatic, with delayed ischemic lesion on CT in 5 of these. CVS was severe and symptomatic in 6 patients, and delayed ischemic lesions were revealed on CT in 5 of these. BNP levels were found to be significantly elevated in SAH patients compared with control subjects (P=0.024). However, in patients without CVS or with nonsymptomatic CVS, BNP concentrations decreased throughout the 4 time periods, whereas a 6-fold increase was observed in patients with severe symptomatic CVS between the first and the third periods (P=0.0096). A similar trend in BNP plasma levels was found in patients with severe SAH compared with those with nonvisible or moderate SAH (P=0.015).

CONCLUSIONS

In conclusion, our results show that BNP plasma levels are elevated shortly after SAH, although they increase markedly during the first week in patients with symptomatic CVS. The present findings suggest that secretion of BNP secretion after spontaneous SAH may exacerbate blood flow reduction due to arterial vasospasm.

Right prefrontal slow repetitive transcranial magnetic stimulation in schizophrenia: a double-blind sham-controlled pilot study

BACKGROUND

The aim of this study was to extend our previous work on the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) in major depression to patients with schizophrenia.

METHODS

Thirty-five inpatients with schizophrenia were randomly assigned to either right prefrontal rTMS or sham treatment and were rated before and after treatment for positive, negative, and depressive symptoms.

RESULTS

Thirty-one subjects (rTMS = 16, sham = 15) completed a 2-week treatment protocol. No serious adverse effects were reported; however, rTMS was not superior to sham treatment on any of the clinical ratings.

CONCLUSIONS

In contrast to our previous positive findings in major depression, right prefrontal slow rTMS does not appear to have a beneficial effect for actively psychotic patients with schizophrenia.

Penetrating head injuries caused by a new weapon, the side dome

The "side dome" is a mix of high and low explosives with a multitude of small metal balls molded within a specially designed half-sphere that directs the explosion wave and the projectiles in one direction to augment the harm. This weapon, originally designed by guerrilla and terrorist groups, is now used by regular armies. This report presents one craniocervical and eight cranial injuries caused by this new weapon and discusses the cases' various clinical features, the paucity of intracerebral cavitation damage along the missile track, the need for only minimally aggressive surgery, and the relatively favorable outcome. In all cases, the helmet offered good protection and the entry of the projectiles was just below its rim in an upward direction.

Dissociation of somatosensory and motor evoked potentials in non-comatose patients after head injury

OBJECTIVES

This study was performed to evaluate the clinical value of combined use of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) in patients with different brain lesions after head trauma.

METHODS

A total of 64 patients with minor and moderate head injury were investigated by means of SEPs recorded over the parietal and frontal areas and MEPs following single-pulse transcranial magnetic stimulation (sTMS) and slow-rate repetitive transcranial magnetic stimulation (rTMS).

RESULTS

In almost 50% of the patients, a dissociated impairment of somatosensory and motor evoked potentials was found. This dissociation was related to different distribution of SEP and MEP abnormalities in head injury subgroups. The higher threshold to sTMS and increased variability of the MEP amplitude during slow-rate rTMS were the most prominent features in patients with focal brain contusions, suggesting impairment of the cortical excitability. SEP abnormalities, as well as central conduction impairments, were more noticeable in patients with diffuse brain injury.

CONCLUSIONS

A combined analysis of SEPs and MEPs may improve the assessment of cortical dysfunctions and central conduction abnormalities in non-comatose patients with head injury. A slow-rate rTMS may be considered as a complementary technique to the evaluation of the threshold in assessment of the excitability of the motor cortex in minor and moderate head injury.

Therapeutic efficacy of right prefrontal slow repetitive transcranial magnetic stimulation in major depression: a double-blind controlled study

BACKGROUND

Transcranial magnetic stimulation (TMS), a noninvasive technique for stimulation of the brain, has recently been suggested to be effective for the treatment of major depression. We conducted a double-blind, placebo-controlled study to assess the efficacy of slow repetitive TMS (rTMS) in patients with major depression.

METHODS

Seventy patients with major depression (53 women, 17 men; mean age, 58.7 years; SD, 17.2 years) were randomly assigned to receive rTMS or sham rTMS in a double-blind design. Treatment was administered in 10 daily sessions during a 2-week period. Severity of depression was blindly assessed before, during, and after completion of the treatment protocol.

RESULTS

All patients completed the first week of treatment and 67 completed the entire protocol. Patients who received rTMS had a significantly greater improvement in depression scores compared with those who received sham treatment. At the end of 2 weeks, 17 of 35 patients in the rTMS group, but only 8 of 32 in the sham-treated group, had an improvement of greater than 50% in their depression ratings.

CONCLUSIONS

This controlled study provides evidence for the short-term efficacy of slow rTMS in patients with recurrent major depression. Additional studies will be necessary to assess the efficacy of rTMS as compared with electroconvulsive therapy as well as the long-term outcome of this treatment in major depression and possibly other psychiatric disorders.

[Exhaustion of motor cortex after head injury--revealed by transcranial magnetic stimulation]

We evaluated the pattern of motor evoked potentials elicited by single-pulse and slow-rate (1 Hz) repetitive, transcranial, magnetic stimulation (RTMS) in minor head injuries. The motor response to a single magnetic stimulus in patients with minor head injury was characterized by a significantly higher threshold than in healthy subjects. However, central and peripheral motor conduction was normal in all patients. A stable pattern of MEP throughout the RTMS session was the most prominent feature in the control group. A progressive decrease in MEP amplitude and irregular alternation of large and very small MEPs over the course of RTMS was observed in minor head injury. The higher threshold of the motor response and the abnormal patterns of MEP behavior revealed by RTMS may reflect impaired excitability and enhanced exhaustion of the motor cortex in patients with minor head injuries, which improve with time.

[The surgeon and the Emperor--a humanitarian on the battlefield]

The Baron Dominique-Jean Larrey, one of the greatest names in military surgery, participated as Chief Surgeon in all the Napoleonic campaigns. He developed the concept of early evacuation from the battlefield, and of immediate treatment of the wounded, even under fire. He implemented improved surgical techniques and improved wound care that were followed by surgeons all over Europe. His devotion to wounded soldiers crossed national boundaries and became a way of life. Here is an account of Larrey's involvement in the aftermath of the Battles of Lutzen and Bautzen (May-June 1813), when many soldiers were accused of self-mutilation and were about to be executed. He dared to oppose, singlehanded, the Emperor, the highest military authorities and their concurring physicians and surgeons, armed only by his undisputed honesty, professional authority and exceptional reputation won over years of devotion to wounded soldiers. Larrey saved the lives of many soldiers and set an example of unbent ethical integrity.