Chronic inflammatory demyelinating polyradiculoneuropathy: can a diagnosis be made in patients not fulfilling electrodiagnostic criteria?

BACKGROUND AND PURPOSE

The aim was to identify the clinical and diagnostic investigations that may help to support a diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in patients not fulfilling the European Federation of Neurological Societies and Peripheral Nerve Society (EFNS/PNS) electrodiagnostic criteria.

METHODS

The data from patients with a clinical diagnosis of CIDP included in a national database were retrospectively reviewed.

RESULTS

In all, 535 patients with a diagnosis of CIDP were included. This diagnosis fulfilled the EFNS/PNS criteria in 468 patients (87.2%) (definite in 430, probable in 33, possible in three, while two had chronic immune sensory polyradiculopathy). Sixty-seven patients had a medical history and clinical signs compatible with CIDP but electrodiagnostic studies did not fulfill the EFNS/PNS criteria for CIDP. These patients had similar clinical features and frequency of abnormal supportive criteria for the diagnosis of CIDP compared to patients fulfilling EFNS/PNS criteria. Two or more abnormal supportive criteria were present in 40 (61.2%) patients rising to 54 (80.6%) if a history of a relapsing course as a possible supportive criterion was also included. Increased cerebrospinal fluid proteins and response to immune therapy most frequently helped in supporting the diagnosis of CIDP. Response to therapy was similarly frequent in patients fulfilling or not EFNS/PNS criteria (87.3% vs. 85.9%).

CONCLUSIONS

Patients with a clinical diagnosis of CIDP had similar clinical findings, frequency of abnormal supportive criteria and response to therapy compared to patients fulfilling EFNS/PNS criteria. The presence of abnormal supportive criteria may help in supporting the diagnosis of CIDP in patients with a medical history and clinical signs compatible with this diagnosis but non-diagnostic nerve conduction studies.

Comparative study of the radiobiological effects induced on adherent vs suspended cells by BNCT, neutrons and gamma rays treatments

The present work is part of a preclinical in vitro study to assess the efficacy of BNCT applied to liver or lung coloncarcinoma metastases and to limb osteosarcoma. Adherent growing cell lines can be irradiated as adherent to the culture flasks or as cell suspensions, differences in radio-sensitivity of the two modalities of radiation exposure have been investigated. Dose related cell survival and cell cycle perturbation results evidenced that the radiosensitivity of adherent cells is higher than that of the suspended ones.

A rare association of early-onset inclusion body myositis, rheumatoid arthritis and autoimmune thyroiditis: a case report and literature review

Sporadic inclusion body myositis (sIBM) is a slowly progressive, red-rimmed vacuolar myopathy leading to muscular atrophy and progressive weakness; it predominantly affects males older than fifty years, and is resistant to immunotherapy. It has been described in association with immuno-mediated thrombocytopenic purpura, multiple sclerosis, connective tissue disorders and, occasionally, rheumatoid arthritis. A 37-year-old man with longstanding rheumatoid arthritis and autoimmune thyroiditis with hypothyroidism was referred to us with slowly progressive, diffuse muscle weakness and wasting, which had initially involved the volar finger flexors, and subsequently also the ankle dorsiflexors and knee extensors. Needle electromyography showed typical myopathic motor unit potentials, fibrillation and positive sharp waves with normal nerve conduction studies. Quadriceps muscle biopsy was suggestive of sIBM. Considering data published in the literature, this case may be classified as an early-onset form. The patient was treated with long-term intravenous immunoglobulin and obtained a substantial stabilization of his muscle strength.

Cell death following BNCT: a theoretical approach based on Monte Carlo simulations

In parallel to boron measurements and animal studies, investigations on radiation-induced cell death are also in progress in Pavia, with the aim of better characterisation of the effects of a BNCT treatment down to the cellular level. Such studies are being carried out not only experimentally but also theoretically, based on a mechanistic model and a Monte Carlo code. Such model assumes that: (1) only clustered DNA strand breaks can lead to chromosome aberrations; (2) only chromosome fragments within a certain threshold distance can undergo misrejoining; (3) the so-called "lethal aberrations" (dicentrics, rings and large deletions) lead to cell death. After applying the model to normal cells exposed to monochromatic fields of different radiation types, the irradiation section of the code was purposely extended to mimic the cell exposure to a mixed radiation field produced by the (10)B(n,α) (7)Li reaction, which gives rise to alpha particles and Li ions of short range and high biological effectiveness, and by the (14)N(n,p)(14)C reaction, which produces 0.58 MeV protons. Very good agreement between model predictions and literature data was found for human and animal cells exposed to X- or gamma-rays, protons and alpha particles, thus allowing to validate the model for cell death induced by monochromatic radiation fields. The model predictions showed good agreement also with experimental data obtained by our group exposing DHD cells to thermal neutrons in the TRIGA Mark II reactor of the University of Pavia; this allowed to validate the model also for a BNCT exposure scenario, providing a useful predictive tool to bridge the gap between irradiation and cell death.

1H and 10B NMR and MRI investigation of boron- and gadolinium-boron compounds in boron neutron capture therapy

(10)B molecular compounds suitable for Boron Neutron Capture Therapy (BNCT) are tagged with a Gd(III) paramagnetic ion. The newly synthesized molecule, Gd-BPA, is investigated as contrast agent in Magnetic Resonance Imaging (MRI) with the final aim of mapping the boron distribution in tissues. Preliminary Nuclear Magnetic Resonance (NMR) measurements, which include (1)H and (10)B relaxometry in animal tissues, proton relaxivity of the paramagnetic Gd-BPA molecule in water and its absorption in tumoral living cells, are reported.

From radiation-induced chromosome damage to cell death: modelling basic mechanisms and applications to boron neutron capture therapy

Cell death is a crucial endpoint in radiation-induced biological damage: on one side, cell death is a reference endpoint to characterise the action of radiation in biological targets; on the other side, any cancer therapy aims to kill tumour cells. Starting from Lea's target theory, many models have been proposed to interpret radiation-induced cell killing; after briefly discussing some of these models, in this paper, a mechanistic approach based on an experimentally observed link between chromosome aberrations and cell death was presented. More specifically, a model and a Monte Carlo code originally developed for chromosome aberrations were extended to simulate radiation-induced cell death applying an experimentally observed one-to-one relationship between the average number of 'lethal aberrations' (dicentrics, rings and deletions) per cell and -ln S, S being the fraction of surviving cells. Although such observation was related to X rays, in the present work, the approach was also applied to protons and alpha particles. A good agreement between simulation outcomes and literature data provided a model validation for different radiation types. The same approach was then successfully applied to simulate the survival of cells enriched with boron and irradiated with thermal neutrons at the Triga Mark II reactor in Pavia, to mimic a typical treatment for boron neutron capture therapy.

In vitro and in vivo studies of boron neutron capture therapy: boron uptake/washout and cell death

Boron neutron capture therapy (BNCT) is a binary radiotherapy based on thermal-neutron irradiation of cells enriched with (10)B, which produces α particles and (7)Li ions of short range and high biological effectiveness. The selective uptake of boron by tumor cells is a crucial issue for BNCT, and studies of boron uptake and washout associated with cell survival studies can be of great help in developing clinical applications. In this work, boron uptake and washout were characterized both in vitro for the DHDK12TRb (DHD) rat colon carcinoma cell line and in vivo using rats bearing liver metastases from DHD cells. Despite a remarkable uptake, a large boron release was observed after removal of the boron-enriched medium from in vitro cell cultures. However, analysis of boron washout after rat liver perfusion in vivo did not show a significant boron release, suggesting that organ perfusion does not limit the therapeutic effectiveness of the treatment. The survival of boron-loaded cells exposed to thermal neutrons was also assessed; the results indicated that the removal of extracellular boron does not limit treatment effectiveness if adequate amounts of boron are delivered and if the cells are kept at low temperature. Cell survival was also investigated theoretically using a mechanistic model/Monte Carlo code originally developed for radiation-induced chromosome aberrations and extended here to cell death; good agreement between simulation outcomes and experimental data was obtained.

Selective uptake of p-boronophenylalanine by osteosarcoma cells for boron neutron capture therapy

Osteosarcoma is the most common non-hematologic primary cancer type that develops in bone. Current osteosarcoma treatments combine multiagent chemotherapy with extensive surgical resection, which in some cases makes necessary the amputation of the entire limb. Nevertheless its infiltrative growth leads to a high incidence of local and distant recurrences that reduce the percentage of cured patients to less than 60%. These poor data required to set up a new therapeutic approach aimed to restrict the surgical removal meanwhile performing a radical treatment. Boron neutron capture therapy (BNCT), a particular radiotherapy based on the nuclear capture and fission reactions by atoms of (10)B, when irradiated with thermal neutrons, could be a valid alternative or integrative option in case of osteosarcoma management, thanks to its peculiarity in selectively destroying neoplastic cells without damaging normal tissues. Aim of the present work is to investigate the feasibility of employing BNCT to treat the limb osteosarcoma. Boronophenylalanine (BPA) is used to carry (10)B inside the neoplastic cells. As a first step the endocellular BPA uptake is tested in vitro on the UMR-106 osteosarcoma cell line. The results show an adequate accumulation capability. For the in vivo experiments, an animal tumor model is developed in Sprague-Dawley rats by means of an intrafemoral injection of UMR-106 cells at the condyle site. The absolute amounts of boron loading and the tumor to normal tissue (10)B ratio are evaluated 2 h after the i.v. administration of BPA. The boron uptake by the neoplastic tissue is almost twice the normal one. However, higher values of boron concentration in tumor are requested before upholding BNCT as a valid therapeutic option in the treatment of osteosarcoma.

Spontaneous intracranial hypotension: case report

Spontaneous intracranial hypotension is a well defined entity, however it is characterised by a relevant clinical heterogeneity. The main feature is orthostatic headache, often accompanied by other symptoms. The diagnosis is easily made in the presence of orthostatic headache, excluding an obvious aetiology of low cerebrospinal fluid (CSF) pressure, and often there is no evidence of direct or indirect CSF leak.

Proximal nerve conduction by high-voltage electrical stimulation in S1 radiculopathies and acquired demyelinating neuropathies

OBJECTIVE

To evaluate the reliability and sensitivity of the high-voltage electrical stimulation for studying proximal conduction of peripheral motor axons in normal subjects, S(1) radiculopathies and acquired demyelinating neuropathies.

METHODS

Twelve patients with compressive S(1) radiculopathy, 22 patients with acquired demyelinating neuropathy and 29 healthy volunteers were examined. The conduction of peripheral motor axons between lumbosacral roots and the sciatic nerve at the gluteal fold was investigated by high-voltage electrical stimulation delivered percutaneously.

RESULTS

The main electrophysiological finding in S(1) radiculopathy was an abnormal side to side difference in the amplitude of the compound motor action potential by proximal stimulation. Overall, the frequency of abnormalities detected by using high-voltage electrical stimulation was similar to that found with conventional EMG studies, and the two methods showed electrophysiological alterations in the same patients. In all patients with acquired demyelinating neuropathy, the proximal motor nerve conduction velocity from lumbosacral roots to the sciatic nerve at the gluteal fold was reduced; proximal stimulation of the motor axons revealed electrophysiological abnormalities more often than when using other electrophysiological techniques (F wave and H reflex).

CONCLUSIONS

High-voltage electrical stimulation of peripheral motor axons shows high sensitivity in detecting proximal neuropathies; it can also define the site and relevance of proximal lesions in the peripheral nervous system better than other conventional techniques.

Pelizaeus-Merzbacher disease: electrophysiological study of two sibs with the classic form and of their relatives

We examined two sibs with the classic form of Pelizaeus-Merzbacher disease (PMD) and their relatives. Electromyographic-electroneurographic studies and magnetic stimulation of motor pathways were performed. In both patients we found an absence of compound motor action potential (cMAP) after stimulation of the motor cortex and a normal conduction time by stimulating the cervical roots. Despite reported sparing of the peripheral nervous system in PMD, our conduction study of the tibial nerve revealed a slightly decreased motor nerve conduction velocity in one patient. In both patients the EMG study showed neurogenic findings. The elder sister showed a prolonged central motor conduction time. This study demonstrates abnormalities of motor corticospinal pathways also in PMD relatives suggesting that magnetic stimulation could be useful in detecting "subclinical" abnormalities in this dysmyelinating condition. Furthermore, in accordance with previous studies, we suggest that a slight involvement of the peripheral nervous system could be observed in PMD.

Unilateral headaches and their relationship with cervicogenic headache

The concept of headache originating/starting in the neck is revised and considered in the light of previous descriptions of syndromes and entities and with reference to the current diagnostic systems for the classification of headache and other head pain. Cervicogenic headache (CEH), a clinical picture recently described by Sjaastad and coworkers and listed in the International Association for the Study of Pain (IASP) Classification, is analyzed, also taking into consideration its diagnostic criteria in terms of sensitivity and specificity. The problem of a differential diagnosis with migraine, tension headache and other well defined forms of unilateral headaches is discussed with reference to a case series of 114 patients who were selected based on their adherence to two fundamental criteria: (i) side-locked unilaterality of pain; and (ii) pain starting in the neck and spreading to the fronto-orbital area. Based on the results, these simple criteria can contribute to a preliminary identification of possible CEH cases that may then undergo a sequence of clinical and instrumental procedures in order to confirm the diagnosis and, possibly, to localize the level(s) of dysfunction in the cervical spine which may be the target for therapeutic investigations, whether invasive or non-invasive.