Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment

BACKGROUND

The aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment.

METHODS

Consecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05).

RESULTS

In the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA.

CONCLUSION

Preoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.

Experience of a multidisciplinary task force with exome sequencing for Mendelian disorders

BACKGROUND

In order to optimally integrate the use of high-throughput sequencing (HTS) as a tool in clinical diagnostics of likely monogenic disorders, we have created a multidisciplinary "Genome Clinic Task Force" at the University Hospitals of Geneva, which is composed of clinical and molecular geneticists, bioinformaticians, technicians, bioethicists, and a coordinator.

METHODS AND RESULTS

We have implemented whole exome sequencing (WES) with subsequent targeted bioinformatics analysis of gene lists for specific disorders. Clinical cases of heterogeneous Mendelian disorders that could potentially benefit from HTS are presented and discussed during the sessions of the task force. Debate concerning the interpretation of identified variants and the content of the final report constitutes a major part of the task force's work. Furthermore, issues related to bioethics, genetic counseling, quality control, and reimbursement are also addressed.

CONCLUSIONS

This multidisciplinary task force has enabled us to create a platform for regular exchanges between all involved experts in order to deal with the multiple complex issues related to HTS in clinical practice and to continuously improve the diagnostic use of HTS. In addition, this task force was instrumental to formally approve the reimbursement of HTS for molecular diagnosis of Mendelian disorders in Switzerland.

Problems associated with long-term treatment with selective serotonin reuptake inhibitors

Although the selective serotonin reuptake inhibitors (SSRIs), which are now widely used as a first-line treatment for depression and many other psychiatric conditions, are generally well tolerated, they are not devoid of side effects. Most short-term treatment-related side effects of SSRIs are transient and disappear after a few days or weeks. However, following long-term treatment with the SSRIs, some serious adverse events may occur. Some of them can be difficult to recognise because they can resemble residual symptoms of depression. The most serious can be life threatening. They all have a negative influence on the patient's quality of life and are frequently a prime reason for a lack of long-term compliance with the associated increased risk of recurrence of a depressive episode. This article is an overview of the more common adverse events, which are seen with non-acute treatment with the SSRIs.

[Germ-cell tumors of the central nervous system in childhood: retrospective study of 13 patients]

BACKGROUND AND PURPOSE

Germ cell tumors (GCT) of the central nervous system are rare (2% of all brain tumors in children). Although originating from germ cells, GCT cover a spectrum of different tumors with different management and prognosis, depending on whether they secrete tumor markers or not. The aim of this study is to present a series of children with GCT and comment on overall management practices.

METHODS

We retrospectively reviewed 13 children under the age of 18 years (nine boys and four girls), treated in the same institution between 1986 and 2006 for one or more primitive GCT of the central nervous system.

RESULTS

Median age at diagnosis is 12.9 years (7-17 years). Tumor markers (alpha foetoprotein [alphaFP], human chorionic gonadotrophin [betaHCG]) were assessed 11 times in blood as well as cerebrospinal fluid (CSF). Tumors were located as follows: pineal region (10 cases), hypothalamus (eight cases), basal ganglia (one case) and corpus callosum (one case). Six were bifocal (pineal region and hypothalamus). Clinical signs were mostly dominated by diabetes insipidus and intracranial hypertension. Seven children required surgery for hydrocephalus. Tumor markers were positive in three cases and these children subsequently received chemotherapy followed by radiotherapy, except one child. Eventually, the three patients with positive markers required surgery because of a residual lesion. The eight other patients had a stereotactic biopsy for diagnosis. At the end of follow-up, treatment morbidity appears to be low and neither death nor recurrence was observed. Mean follow-up is 8.85 years (2-20 years).

CONCLUSIONS

The prognosis of cerebral GCTs in children is excellent because of their pronounced chemo- and radiosensitivity. Surgery is crucial for diagnosis in the event of negative markers, or if there is evidence of residual tumor with normalization of tumor markers at the end of chemotherapy. Tumor markers must be monitored to check the diagnosis and for follow-up. The place of tumor biopsy during endoscopic third ventriculostomy (performed if hydrocephalus is present) is still debated.

[Complete bed rest prescription in an internal medicine ward: a dangerous treatment?]

A general knowledge led to the assumption that bed rest is beneficial for most illnesses and bed rest is prescribed in a large number of medical conditions. However, evidence from randomised studies and systematic reviews suggest a potentially harmful effect of bed rest. This review article discusses the utility of bed rest in some frequent medical pathologies such as myocardial infarction, pulmonary embolism, community acquired-pneumonia, and low back pain.

[Imaging follow-up of post-traumatic myelomalacia]

The authors report a case of secondary worsening of neurological symptoms in a patient 2 months after cord injury at T5 causing paraplegia. The MRI showed myeolomalacia, which appears as cord oedema, located in the grey matter, extending increasingly from the initial lesion (eighth thoracic vertebra) to the bulb. This cord lesion known as grey matter cytotoxic oedema, evolved into a syringomyelic cavity.

[Risks and responsibilities in diagnostic and interventional radiology. Ethical and medicolegal considerations]

Medical risk management has one main purpose: to ensure the safety of care. The law of March 2002 has generated a true cultural revolution. The radiologist is involved with new and difficult areas of medical liability due to technical advances, the increasing number of imaging techniques, the increasing complexity of imaging techniques, their efficiency and the need for multidisciplinary approach. Imaging recommendations requiring increasing levels of technical and clinical skills. The radiologist is liable with regards to the indications of imaging studies, and also with regards to informed consent. The prevention of medicolegal problems is achieved by competency, which must be combined to good liability insurance and ongoing vigilance supported by appropriate continuous medical education.

Individualized treatment of craniopharyngioma in children: ways and means

BACKGROUND

Medium- and long-term prognosis of craniopharyngioma is overwhelmed by the risks of hypothalamic and visual impairment. This problem has been underestimated for a long time because the major concern for the neurosurgeon was the risk of recurrences, their best prevention being thought to be complete tumour resection. Today, we know that radical surgery not only is not an absolute guarantee against recurrences but also can cause hypothalamic and visual complications.

METHODS

The authors suggest that instead of complete removal, the first choice treatment should be, when possible, a less aggressive, multistaged and personalized treatment. In this perspective they focus on other therapeutic methods: endocavity treatment of cysts with rhenium-186, triconformational radiotherapy, radiosurgery, and widespread use of the trans-sphenoidal approach.

CONCLUSIONS

These simple methods should reduce the risks of visual aggravation and metabolic syndrome.

[Thrombus of the left lateral sinus spreading to the internal jugular vein]

Cerebral venous thrombosis is an uncommon event which presents a wide spectrum of sometimes extraneurological signs different from the classical clinical presentation. We report the cases of two middle-aged women who developed thrombosis of the left lateral sinus spread-ing to the internal jugular vein from the sigmoid sinus. The time course of the symptoms suggested that intracranial thrombosis occurred first. No infectious or neoplastic local disease could be found but both women were taking oral contraceptives. Medical treatment led to good reperfusion of the intracranial sinuses but occlusion of the jugular vein persisted despite prolonged oral anticoagulants. Long-term outcome was favorable with residual benign epilepsy in one patient, and occurrence of an arteriovenous fistula in the other.

Where are the new therapies for anxiety and obsessive-compulsive disorders?

The benzodiazepines have monopolized the acute anxiety market for about 40 years, but their potential for tolerance and dependency has stimulated an interest in alternative anxiolytics. Until recently, however, attention has focused on existing drugs such as monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors. The 5-HT1A partial agonist, buspirone (Bristol-Myers-Squibb), is one of the few compounds developed principally as an anxiolytic since the benzodiazepines. The challenge for the future is not only to find efficacious treatments with a rapid onset of action and an acceptable side effect profile but also to determine the optimal compounds for each of the different anxiety disorders.

The possible role of 5-HT(1B/D) receptors in psychiatric disorders and their potential as a target for therapy

Serotonin (5-hydroxytryptamine, 5-HT) is implicated in several psychiatric diseases. Is this also true for 5-HT(1B/D) receptors? These receptors are found in high density in substantia nigra, globus pallidus, striatum and basal ganglia and in other brain regions. This ubiquity makes 5-HT(1B/D) receptors responsible for many physiological and behavioural functions. This review focuses on the role of 5-HT(1B) receptors in the regulation of 5-HT release and synthesis. Microdialysis experiments performed on freely moving animals are an interesting in vivo model to study the function of the terminal 5-HT(1B) autoreceptor. Synthesis of 5-HT, estimated by the measurement of the accumulation of 5-hydroxytryptophan (5-HTP) ex vivo or in vitro, is modulated by the 5-HT(1B) autoreceptors. Many reports have shown that chronic administration with selective serotonin reuptake inhibitors leads to the desensitisation of the terminal 5-HT(1B) autoreceptors. With the help of some animal models of depression and anxiety and with some data from clinical studies it has been hypothesised that 5-HT(1B) receptors may be supersensitive in depression, anxiety and obsessive compulsive disorder. Thus, since the dysfunction of 5-HT(1B) receptors may be involved in some pathological states, particularly in the psychiatric field, these receptors represent important potential targets for drugs to treat mental diseases.

[Radioanatomy of the cerebral cortex. Practical guide of identification]

Cerebral sulci identification process is based on several formal rules: it consists a series of steps allowing the identification of the major sulci. The process may be variable for each of us and we propose to read the images in certain order starting with the frontal lobe and its superior frontal gyrus than precentral and central gyri followed by the lateral fissure. Then the insular, lateral parietal and medial hemispheric regions. Finally the major sulci within the temporal and occipital lobes are described in the frontal plane. This presentation indicates the principal rules of cerebral lobes'identification, the basis of variability perception and the localization of small lesions allowing an accurate correlation with clinical findings and a suitable therapeutic procedure.

[Diffusion imaging in asymptomatic focal vasospasm. Apropos of a case]

We report a case of an asymptomatic vasospasm with a focal, reversible apparent diffusion coefficient (ADC) decrease after a middle cerebral artery aneurysm rupture. This isolated decrease of ADC has not yet been reported in this pathological situation. It could be interesting to predict the risk of ischemic delayed complications of vasospasm.

[Dysembryoplastic neuroepithelial tumors. Analysis of 16 cases]

OBJECTIVES

We report on 16 cases of dysembryoplastic Neuroepithelial tumor (DNT) treated in the Nancy University Hospital from 1987 to 1997.

PATIENTS AND METHODS

There were 9 males and 7 females. Mean age at onset of symptoms was 9.5 years (range: 3 months to 29 years) and the mean age at surgery was 16 years. Nine patients experienced partial complex seizures, 5 patients generalized seizures, 1 patient partial seizures with secondary generalization and one patient ataxia. The diagnosis of DNT was made under consideration of clinical, radiological and neuropathological features. All patients underwent surgery.

RESULTS

Removal of the tumor was complete for 10 patients, subtotal or partial for 6 patients. Histological examination revealed that 7 cases were specific forms of DNT due to the presence of the specific glioneuronal element. For the 9 remained cases, the diagnosis of DNT could only be made with the consideration of clinical and radiological features. Mean post-surgical follow-up was 3.5 years (range: 1-8 years). Eight patients were seizures-free, 7 had a significative reduction in seizures frequency with minimal anti-convulsivant treatment. The patient with ataxia remained unchanged. For the patients with partial resection of the tumor, follow-up MRI and CT scan showed no significant growth of the remnant and the remaining patients have had no recurrence to date.

CONCLUSION

The recognition of this surgically curable entity is mandatory. Knowledge of the good prognosis associated with the DNT is essential to avoid deleterious side effects of overtreatment by radiotherapy and/or chemotherapy.

Five-year outcome in patients with isolated proximal left anterior descending coronary artery stenosis treated by angioplasty or left internal mammary artery grafting. A prospective trial

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) improve the clinical status of patients with isolated proximal left anterior descending coronary artery stenosis. At 2 years, only additional revascularization was more frequently required after PTCA.

METHODS AND RESULTS

We monitored 134 patients randomized to PTCA (n=68) or CABG (n=66) for </=5 years. End points were death, myocardial infarction, need for additional revascularization, clinical status, and medical treatment. At 5 years, 6 patients (9%) had died in the PTCA group versus 2 (3%) in the CABG group (P=0.12). One patient in each group died of a cardiac cause. Myocardial infarction was more frequent after PTCA (15% versus 4%; P=0.0001), but Q-wave infarction was not (6% in the PTCA group versus 3% in the CABG group; P=0.8). Additional revascularization was required in 38% of patients in the PTCA group versus 9% in the CABG group (P=0.0001). Functional status was comparable, with 6% of patients after PTCA and 3% after CABG in functional class III or IV. Finally, after PTCA or CABG, 62% and 91% of patients, respectively, were free of events (P=0.0001).

CONCLUSIONS

The 5-year prognosis of patients with isolated proximal left anterior descending coronary artery stenosis is good. Both PTCA and CABG improve clinical status, but revascularization was needed more frequently after PTCA. There is an excess incidence of non-Q-wave myocardial infarction in the PTCA group that does not affect the vital or symptomatic outcome.

[Percutaneous versus surgical revascularization of isolated lesions of the proximal anterior interventricular artery. Five-year follow-up of a prospective randomized study]

The authors report the results of 5 years follow-up of 134 patients who benefited from percutaneous transluminal coronary angioplasty 5PTCA) or surgical intervention with implantation of the internal mammary artery as treatment of an isolated lesions of the proximal left anterior descending artery with normal left ventricular function. Sixty-eight patients underwent PTCA (group 1) and 66 had surgical bypass (group 2). The demographic data of the two groups was comparable. The incidence of the following events was analysed: death, myocardial infarction, indication for further revascularisation and functional class. At 5 years, the global mortality was 6% (8% in group 1 and 2% in group 2) but cardiac mortality was only 1% (1 patient in each group). The cumulative incidence of myocardial infarction was higher after angioplasty (15% vs 5%) but was mainly related to acute occlusions or acute coronary syndromes during angioplasty. However, the incidence of Q wave infarction was similar in the two groups. During follow-up, 32 patients (26 in group 1 and 6 in group 2) required one or more additional revascularisation procedures of the left anterior descending or of another artery. The proportion of asymptomatic patients at 5 years was high and similar in both groups. Finally, the proportion of patients without events during follow-up was 56% in group 1 and 86% in group 2. Despite the risk of restenosis and reoperation associated with angioplasty, this technique is an acceptable therapeutic alternative to surgical revascularisation in patients with isolated stenosis of the left anterior descending artery. Therefore, the therapeutic decision depends on the individual case, the availability of treatment and the patient's preference during consultation.

[MRI aspects of spinal cord abscesses. Report of 5 cases and review of the literature]

The spinal canal is an uncommon site for abscess formation resulting from bloodstream disseminated infection. Prognosis is often unfavorable. Rapid treatment is essential for satisfactory neurological recovery. Abscesses within the spinal canal are thus diagnostic and therapeutic emergencies. The neuro-infectious and inflammatory manifestations and laboratory findings vary considerably and are insufficient for diagnosis. MRI plays a decisive role. The most commonly reported signs are the presence of an intramedullary collection giving a low-intensity signal on T1-weighted images and a high-intensity signal on T2-weighted images with peripheral contrast uptake and generally extended adjacent medullary edema. We report here five cases of spinal canal abscesses diagnoses with MRI at different stages of development (pre-suppurative myelitis in two cases, constituted abscess in three cases). For each case we reviewed the clinical course and describe the details of the imaging findings. In our series, the collected abscesses presented as round lesions within the canal with contrast uptake. It is noteworthy that the periependymal gray matter adjacent to the lesion also took up the contrast agent in all patients with a collected abscess. This sign has not been described previously and appears to be a going argument orienting the diagnosis towards an infectious rather than tumoral formation.

5-HT1B receptor antagonist properties of novel arylpiperazide derivatives of 1-naphthylpiperazine

A new series of arylpiperazide derivatives of 1-naphthylpiperazine of general formula 4 has been prepared and evaluated as 5-HT1B antagonists. Binding experiments at cloned human 5-HT1A, 5-HT1B, and 5-HT1D receptors show that these derivatives are potent and selective ligands for 5-HT1B/1D subtypes with increased binding selectivity versus the 5-HT1A receptor when compared to 1-naphthylpiperazine (1-NP). Studies of inhibition of the forskolin-stimulated cAMP formation mediated by the human 5-HT1B receptor demonstrate that the nature of the arylpiperazide substituent modulates the intrinsic activity of these 1-NP derivatives. Among them, 2-[[8-(4-methylpiperazin-1-yl)naphthalen-2-yl]oxy] -1-(4-o-tolylpiperazin-1-yl)ethanone (4a) was identified as a potent neutral 5-HT1B antagonist able to antagonize the inhibition of 5-HT release induced by 5-CT (5-carbamoyltryptamine) in guinea pig hypothalamus slices. Moreover, 4a was found to potently antagonize the hypothermia induced by a selective 5-HT1B/1D agonist in vivo in the guinea pig following oral administration (ED50 = 0.13 mg/kg).

5-HT autoreceptors in the regulation of 5-HT release from guinea pig raphe nucleus and hypothalamus

5-HT autoreceptors involved in the regulation of 5-HT release in the guinea pig dorsal raphe nucleus have been studied in comparison with those in the hypothalamus. In vitro release was measured in slices of raphe and hypothalamus prelabelled with [3H]5-HT, superfused with Krebs solution and depolarized electrically. The non-selective 5-HT receptor agonist, 5-carboxamidotryptamine (5-CT) (0.1-10 nM for raphe: 1-100 nM for hypothalamus) and antagonist, methiothepin (10-1000nM), decreased and increased, respectively, the release of [3H]5-HT evoked by electrical stimulation in either of these regions when given alone. The selective 5-HT1B/D receptor antagonist, GR127935 (100-1000 nM), and the 5-HT1D receptor antagonist, ketanserin (300-1000 nM), had no significant effect on this release in either of these regions. Methiothepin and GR127935 (100-1000 nM) shifted to the right the concentration-effect curve of 5-CT in both the raphe and the hypothalamus. At 300 nM, ketanserin shifted to the right the concentration-effect curve of 5-CT in the raphe but did not modify the 5-CT curve in the hypothalamus. In microdialysis experiments ketanserin, applied locally at 10 microM, increased the extracellular levels of 5-HT in the dorsal raphe nucleus of the freely moving guinea pig, whereas 5-HT levels were unchanged in the hypothalamus. Ketanserin at 1 microM did not affect the decrease in 5-HT output induced by the selective 5-HT1B/D receptor agonist, naratriptan (used at 10 microM in raphe and 0.1 microM in hypothalamus), in the raphe or the hypothalamus. In the raphe, WAY100635, a 5-HT1A receptor antagonist, at 1 microM, did not prevent naratriptan (10 microM) from reducing the extracellular levels of 5-HT. These results suggest that, in the conditions used in this study, the release of 5-HT in the dorsal raphe nucleus is possibly modulated in part by 5-HT1B receptors but essentially the control is through 5-HT receptors whose subtype is still to be determined. In the hypothalamus, however, it is clear that only 5-HT1B receptors are involved in the modulation of 5-HT neurotransmission.

[Unusual facial clefts]

After briefly review facial morphogenesis, the authors define facial clefts, distinguishing primary clefts, secondary clefts, and residual clefts. They discuss the uncertainties surrounding the embryology and clinical features of palpebral colobomas. The various pathogenetic concepts are analysed: amniotic hypothesis, vascular hypothesis, fusion defect. The various classifications of rare facial clefts are reviewed, with particular emphasis on Tessier's classification and the so-called Milan classification. The general principles of surgical treatment are described together with the various skeletal and soft tissues procedures.

Effects of milnacipran and pindolol on extracellular noradrenaline and serotonin levels in guinea pig hypothalamus

Milnacipran, a dual noradrenaline (NA) and serotonin (5-hydroxytryptamine, 5-HT) uptake inhibitor, increased extracellular levels of NA and 5-HT in hypothalamus of freely moving guinea pigs as measured by microdialysis. The basal levels of both monoamines, which were tetrodotoxin sensitive, were increased in a dose-dependent manner and to a similar extent after the intraperitoneal administration of milnacipran (10 and 40 mg/ kg i.p.). Levels of the NA metabolite 4-hydroxy-3-methoxyphenylglycol (MHPG) were decreased by milnacipran at 10 and 40 mg/kg i.p., whereas those of the 5-HT metabolite 5-hydroxyindoleacetic acid (5-HIAA) showed no effect. Subcutaneous injection of 5-HT1A and beta-adrenergic receptor antagonist (-)-pindolol alone, at 10 mg/kg, had no effect on the extracellular levels of NA or 5-HT. The concomitant administration of (-)-pindolol (10 mg/kg s.c.) with milnacipran (10 mg/kg i.p.) increased severalfold the effect of milnacipran on the extracellular levels of NA and 5-HT. These results indicate that milnacipran, by blocking the uptake of NA and 5-HT, increases virtually equipotently the extracellular levels of NA and 5-HT, confirming previous in vitro studies. In addition, the antagonism of 5-HT1A autoreceptors by (-)-pindolol potentiates the action of milnacipran on both NA and 5-HT systems, without modifying the ratio of these activities.

Autoradiographic localization of 5-HT1E and 5-HT1F binding sites in rat brain: effect of serotonergic lesioning

5-carboxamidotryptamine (5-CT)-insensitive binding sites labelled by [3H]5-hydroxytryptamine (5-HT) in the presence of 100 nM 5-CT and 100 nM mesulergine, were examined by semi-quantitative autoradiography in rat brain. Under these conditions most of the labelled sites correspond to 5-HT1E and 5-HT1F sites. The 5-CT-insensitive binding is located mainly in cortical layer V, caudate-putamen, interpeduncular nucleus and claustrum. In cortex and caudate-putamen, a large proportion of 5-CT-insensitive sites is displaced by 250 nM sumatriptan and can be attributed to the presence of 5-HT1F receptors. A low, but significant, level of displacement by sumatriptan was observed in the choroid plexus. Lesions of serotonergic neurones by intracerebroventricular 5,7-dihydroxytryptamine injection does not significantly modify the densities of 5-HT1E or 5-HT1F binding sites. Our findings suggest that the 5-HT1F receptor has a limited distribution in rat brain, mainly located on non-serotonergic neurones.

Ex vivo inhibitory effect of the 5-HT uptake blocker citalopram on 5-HT synthesis

Serotonin (5-hydroxytryptamine, 5-HT) synthesis was determined in vivo by measuring the accumulation of 5-hydroxytryptophan (5-HTP) in rat frontal cortex after inhibition of aromatic amino acid decarboxylase by administrative of m-hydroxybenzylhydrazine (NSD 1015) (100 mg/kg, i.p.). The selective 5-HT reuptake inhibitor, citalopram, the 5-HT1A agonists, (+/-) 8-hydroxy-2-(di-n-propylamino)-tetralin (8-OH-DPAT), ipsapirone, gepirone and the 5-HT1A/B agonist, 7-trifluoromethyl-4(4-methyl-1-piperazinyl-pyrolo[1,2-a]-quinox ali ne (CGS 12066B), the 5-HT1A/B ligands and beta-adrenoceptor antagonists, (+/-) pindolol and (+/-) alprenolol, and the non-selective 5-HT ligands, m-chlorophenylpiperazine (mCPP) and metergoline, all inhibited the synthesis of 5-HT. The 5-HT1A/5-HT2 antagonist, spiperone, alone, had no effect on basal 5-HT synthesis, however it attenuated the effect of 8-OH-DPAT by 56% and CGS 12066B by 39% but only barely that of citalopram by 17%. The selective 5-HT1A antagonist, WAY 100635, which did not modify by itself 5-HT synthesis, had no effect on citalopram-induced reduction of 5-HT synthesis. Neither the 5-HT2 agonist, (+/-)1-(2,5-dimethoxy-4-indophenyl)-2-aminopropane (DOI) nor the 5-HT2 antagonist, ritanserin, had any effect on the synthesis of 5-HT. In addition, ritanserin did not modify the inhibitory effect of citalopram. Methiothepin was the only compound to increase 5-HT synthesis. These results suggest that the effect of citalopram on the synthesis of 5-HT is not mediated by 5-HT1A or 5-HT2 receptors and that other receptors may be involved.

Preclinical pharmacology of milnacipran

Milnacipran (Ixel) is a new antidepressant which has been developed for its selective inhibition of both serotonin and noradrenaline reuptake and its lack of affinity for neurotransmitter receptors. It inhibits virtually equipotently the reuptake of serotonin and noradrenaline both in vitro and in vivo, as demonstrated by the antagonism of centrally acting monoamine displacers. It has no effect on dopamine reuptake. In addition, milnacipran has been shown by intracerebral microdialysis to increase the extracellular levels of both serotonin and noradrenaline after acute administration. Milnacipran is devoid of interactions at any known neurotransmitter receptor or ion channel. In particular, and unlike tricyclic antidepressants, it does not act at noradrenergic, muscarinic or histaminergic receptors. Contrary to tricyclic antidepressants, chronic administration of milnacipran does not modify beta-adrenoceptor binding or second messenger function. Milnacipran is active on various animal models of depression such as the forced swimming test in the mouse, learned helplessness in the rat and the olfactory bulbectomized rat model. This pharmacological profile, associated with an excellent bioavailability in man, was predicted to be that required for a powerful and well-tolerated antidepressant. Subsequent clinical development has shown this prediction to be well founded.

Effects of acute and repeated administration of citalopram on extracellular levels of serotonin in rat brain

The effects of acute (2 days) and repeated (21 days) administration (50 mg/kg in the diet) of the selective serotonin (5-HT, 5-hydroxytryptamine) reuptake inhibitor, citalopram, on extracellular levels of 5-HT and their modulation by terminal autoreceptors in the hypothalamus of freely moving rats were compared in vivo by microdialysis. When studied without washout, extracellular levels of 5-HT were increased by both acute and repeated citalopram administration. In rats treated repeatedly, extracellular 5-HT levels were 43% (but not significantly) greater than in those treated acutely. Extracellular levels of 5-HT in control and citalopram-treated rats were similar when measured after 24 h washout. The enhancing effect of non-selective serotonergic autoreceptor antagonists, methiothepin (100 microM) or 1-(1-naphthyl)piperazine (NP) (10 microM), administered through the microdialysis probe, after 24 h washout, was similar in both control and chronically treated groups. These results suggest that repeated administration of citalopram followed by a washout of 24 h does not lead to desensitization of the terminal autoreceptor as measured in vivo in contrast to the effects we have shown previously in vitro. In rats treated chronically with citalopram without washout, methiothepin had a greater maximal effect on 5-HT outflow in comparison to rats receiving acute citalopram treatment. This finding suggests that a 5-HT autoreceptor antagonist or a combination of such a drug with a 5-HT uptake inhibitor would produce a greater increase of extracellular levels of 5-HT in hyposerotonergic states such as depression.

[The anatomy and the MRI anatomy of the interhemispheric cerebral commissures]

Correlation of myelin-stained or cryotomic sections of human brain with inversion-recovery MR images can display the cerebral commissures as white-matter tracts (in hypersignal on MRI), crossing the mid-line. MRI shows routinely in three orthogonal planes a) the corpus callosum stretched above the supra-tentorial ventricles, it's four portions (rostrum, genu, body and splenium) and connections with the Deep Grey Nuclei b) the fornix, intralimbic commissure joining anteriorly the mammillary bodies (through it's columns) to the alveus posteriorly and inferiorly (via it's two crura), arcing around the thalamus and lying over the hippocampus and the dentate gyrus as shown on the frontal sections c) the anterior commissure, white-matter tract connecting the two temporal lobes. In axial view, the anterior commissure has the shape of bicycle handlebars, coursing posteriorly, inferiorly and laterally behind the head of the caudate nucleus and passes into the lateral nucleus of the globus pallidus into the inferior and middle temporal gyri. Because the anterior commissure is easily recognisable in all planes, it's appears to be a important landmark for identification of the lateral and medial nuclei of the globus pallidus on axial and sagittal planes d) at least, the posterior commissure, anterior margin of the pineal region, closely related to the superior colliculi, acquire a major importance in the AC-PC line delineation becoming a reference landmark for stereotatical procedures.

Effect of mefenorex on 5-HT release: studies in vitro on rat hypothalamic slices and in vivo by microdialysis

Mefenorex, used for 20 years as an anorexic drug, has not been studied so far with regard to its central mechanism of action, although its chemical structure suggests a serotonergic mechanism. In the present study, the effect of mefenorex on serotonin (5-HT) release was investigated both in vitro, on rat hypothalamic slices and in vivo, using microdialysis in the paraventricular (PVN)-ventromedian (VMH) hypothalamic area while mefenorex was applied locally by means of counterdialysis. In vitro, mefenorex increased the spontaneous release of 3H 5-HT from hypothalamic slices but not the electrically evoked release. This suggests a 5-HT releasing action of mefenorex not mediated through the terminal autoreceptor. The in vivo study confirmed the enhanced release and provided additional information. The delayed and modest increase of the 5-HT intracellular metabolite 5-HIAA may be indicative of an inhibition of reuptake. The dopaminergic system was also, but more modestly, activated by mefenorex. The increase in 5-HT release together with the inhibition of its reuptake may represent the main mechanism of action of mefenorex, and the secondary activation of the dopaminergic system may contribute in its anorexigenic effect at the level of the PVN-VMH area.

In vitro and in vivo activity of 1-(1-naphthyl)piperazine at terminal 5-HT autoreceptors in guinea-pig brain

The effect of 1-(1-naphthyl)piperazine (NP) on the 5-HT terminal autoreceptor modulating 5-HT release was investigated in vitro and in vivo. In vitro 5-HT release was measured in slices of guinea-pig substantia nigra and hypothalamus prelabelled with 3H-5-HT, superfused with Krebs solution and depolarized electrically. NP, at 0.1 and 1 mumol/l, did not modify the calcium-dependent release of 3H-5-HT elicited by electrical stimulation using a frequency of 5 Hz, however at 0.1 mumol/l NP shifted to the right the inhibition curve of the non-selective autoreceptor agonist, 5-carboxamidotryptamine, in both regions. In hypothalamus when using lower frequencies (1 Hz or 0.2 Hz) or under pseudo-one-pulse stimulation, NP decreased the release of 3H-5-HT at 1 mumol/l. In vivo microdialysis was used to measure extracellular levels of endogenous 5-HT in the substantia nigra of freely moving guinea-pigs. The endogenous release of 5-HT was tetrodotoxin (TTX)-sensitive, indicating a neuronal origin of this efflux. NP, administered through the microdialysis probe (1-100 mumol/l), increased the levels of extracellular 5-HT in concentration-dependent and TTX-sensitive manner. These results suggest that in vitro NP acts as a 5-HT autoreceptor partial (ant)agonist in the substantia nigra and hypothalamus of guinea-pigs, and as a full antagonist in vivo. However, NP administered systemically at 10 mg/kg i.p., did not modify the levels of extracellular 5-HT in the substantia nigra. This lack of systemic effect of NP probably results from its interaction at other receptors that modify 5-HT neurotransmission.(ABSTRACT TRUNCATED AT 250 WORDS)

Autoradiographic characterization of binding sites for [3H]milnacipran, a new antidepressant drug, and their relationship to the serotonin transporter in rat brain

Milnacipran is a new antidepressant drug and an equipotent inhibitor of the uptake of serotonin and noradrenaline. Quantitative autoradiography and radioligand binding studies were used to characterize recognition sites of [3H]milnacipran in rat brain. [3H]Milnacipran demonstrated saturable, reversible and nanomolar affinity binding. The binding was Na(+)-dependent, potently displaced by serotonin uptake inhibitors in all structures and moderately or weakly displaced by catecholamine uptake inhibitors (order of potency: paroxetine > fluoxetine > mazindol > desipramine > nomifensine > maprotiline). High density of recognition sites were found in structures dense in serotonergic innervation (raphe, basal ganglia, colliculi, cortex). The autoradiographic pattern of [3H]milnacipran recognition sites resembled that of [3H]paroxetine, but their distribution did not correlate well in some structures. Selective lesioning of serotonergic neurons by intracerebral injection of 5,7-dihydroxytryptamine caused a large decrease of [3H]milnacipran binding in various regions (septum, caudate, hippocampus, thalamus, ventral and dorsal hypothalamus), but in other structures, the [3H]milnacipran binding was partially affected (putamen) or even unchanged (amygdala, lateral hypothalamus). In contrast, lesion of noradrenergic neurons by intraperitoneal administration of [N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine] did not affect the binding of [3H]milnacipran in any region. These results show that [3H]milnacipran mainly binds to the serotonin transporter and does not recognize the catecholamine transporters under the conditions used. In addition, [3H]milnacipran might also bind to other sites, serotonin transporter localized on non-serotonergic neurons or serotonergic neurons insensitive to 5,7-DHT neurotoxicity.

Effect of milnacipran and desipramine on noradrenergic alpha 2-autoreceptor sensitivity

1. The effects of chronic administration with milnacipran and desipramine on the noradrenergic alpha 2-autoreceptor sensitivity in the rat hypothalamus were compared. 2. Rats were administered, in their diet, milnacipran (50 mg/kg/day for 21 days, 24 h wash-out), desipramine (35 mg/kg/day for 21 days, 24 h wash out) or desipramine (14 mg/kg/day for 21 days, 41 h wash-out). Hypothalamic slices were incubated with [3H]noradrenaline, superfused and stimulated electrically. 3. Chronic administration with milnacipran did not modify basal or electrically induced release of [3H]noradrenaline, tissue incorporation of [3H]noradrenaline or the sensitivity of the alpha 2-autoreceptor assessed by the inhibition of the stimulation-evoked release of [3H]noradrenaline by the alpha 2-adrenoceptor agonist, guanabenz, in comparison to controls. After chronic desipramine (35 mg/kg), basal and evoked release of [3H]noradrenaline were increased, tissue incorporation of [3H]noradrenaline decreased and the inhibitory effect of guanabenz was diminished. At the lower dose (14 mg/kg), chronic desipramine increased only the evoked release of noradrenaline but did not modify the sensitivity of the alpha 2-autoreceptor. 4. Desipramine at 35 mg/kg remains in the tissue after 24 h wash out, causing a reduction of uptake and complicating the interpretation of the data.

Present status of computerized tomography and angiography in the diagnosis of cerebral thrombophlebitis cavernous sinus thrombosis excluded

In order to evaluate the contribution of computerized tomography (CT) to the diagnosis of cerebral thrombophlebitis, a series of 28 cases was reviewed and compared with data from the literature. In an examination carried out 4 to 5 days of its constitution the thrombus may be directly visualized as a spontaneous hyperdensity. This early but very transient sign, called "cord sign", can easily be overlooked, which explains why it was found in only 5 of our 28 cases and in 2% of the largest series of the literature. The thrombus thereafter becomes hypodense and can be intensified by peripheral contrast enhancement which produces the classical "delta sign". This sign is more frequent: 13/28 in our series and 16 to 30% in published cases. It is usually found in the superior sagittal sinus and must be distinguished from anatomical variations which are common at that level. These two direct signs acquire a greater value when associated with such indirect signs as diffuse or localized cerebral oedema (12 to 52%) and venous ischaemia (22 to 59%). Venous ischaemia is characterized by its strong bleeding potential (more than 50% of the cases) and by its usually favourable course; these two elements and its site differentiate it from arterial ischaemia. Finally, venous stasis is responsible, in 5 to 19% of the cases, for intense enhancement of the tentorium cerebelli; this sign is not specific but easy to evidence and of great value when associated with a direct sign. Dilatation of cortical veins, found in 4 of our 28 cases, also seems to be an interesting sign which, to our knowledge, has not yet been mentioned in the literature. Since in 3.6 to 26% of the cerebral thrombophlebitis the CT scan is normal, a negative CT examination does not rule out this disease, and in many cases the exploration must be rapidly completed by angiography or MRI. Because it is non-invasive and very sensitive to flows, MRI has become the key examination to assert the diagnosis. Angiography is now restricted to those cases where cases where MRI cannot be performed promptly or to certain, purely cortical thrombophlebitis which might pass unnoticed at MRI. When carried out and interpreted cautiously, angiography always shows the venous thrombosis, its exact size and its suppletive network. The results of this study show that MRI alone can diagnose cerebral thrombophlebitis in most patients, that CT well done and interpreted often provides useful but seldom sufficient indices, and that angiography should be reserved for difficult cases.

[Pericranial sinus]

This study concerns four cases of sinus pericranii observed at the Neurological Department of Nancy. Sinus pericranii is a direct communication between the outer surface of the skull and the intracranial venous sinuses. It may be congenital, acquired or traumatic. This abnormality, usually located in the midline and often in the frontal region, is usually symptomless, but some patients complain of headache, nausea and vertigo. Sinus pericranii shows as a fluctuating non pulsatile mass of reddish or bluish colour, expanding when the patient bends his head down. Radiography usually shows one or several bone defects opposite the lesion found at CT bone window. On soft tissue window the mass is not calcified and usually enhanced by contrast injection. It is sometimes possible to visualize the vascular communication between the extracranial region and the underlying dural sinus. When visualization is blurred, or CT shows intracerebral abnormalities, MRI examination is required. Angiography with subtraction in venous phase (40 to 60 seconds after the injection), sometimes aided by films taken in head down position. It is of interest only in cases where CT and MRI have shown associated vascular abnormalities. Otherwise, direct injection of contrast medium into the malformation makes it possible to assert the diagnosis of sinus pericranii and to determine the flow rate within the malformation, which to some extent commands the the therapeutic technique. In patients with small and asymptomatic sinus pericranii absention is the rule. When the sinus is of moderate size, and the flow rate not rapid and when there is no significant communication with the cerebral veins, endovascular sclerosis may be advocated. In all other cases, surgical removal is recommended and is usually easy.

Neuropharmacology of 5-hydroxytryptamine1B/D receptor ligands

In spite of a lack of compounds acting selectively at the 5-hydroxytryptamine (5-HT)1B and 5-HT1D receptor subtypes, by cross-relating the available data, this review attempts to tentatively assign behavioural and other in vivo correlates of these receptor subtypes. In addition, a summary of data from microdialysis studies is included to develop an integrated view. Finally, a suggestion is made as to the possible pathophysiological consequences of 5-HT1D receptor dysfunction in man.

Quantitative autoradiography of 5-HT1E binding sites in rodent brains: effect of lesion of serotonergic neurones

Binding sites corresponding to 5-HT1E receptors were labelled in mouse, rat, and guinea-pig brains by using [3H]5-hydroxytryptamine ([3H]5-HT) in the presence of 5-carboxamidotryptamine (5-CT) (0.1 microM), and their distribution within the brain was studied by quantitative autoradiography. The results obtained with mouse brain show that 5-HT1E binding sites are particularly present in the cortex, caudate-putamen and claustrum, where they showed the highest density. Lower densities were measured in other regions. Saturation experiments showed that the affinity of [3H]5-HT for 5-HT1E binding sites (nanomolar range) was very similar in the different structures. The distribution of 5-HT1E binding sites was similar in rat and guinea-pig brains. In rat brain, selective lesioning of serotonergic fibres by intracerebroventricular injection of 5,7-dihydroxytryptamine (5,7-DHT), a specific 5-HT neurotoxin, did not affect the density of 5-HT1E binding, indicating that these receptors are mainly localized on non-serotonergic neurones.

Neurobiological mechanisms involved in antidepressant therapies

Selective serotonin reuptake inhibitors (SSRIs) are effective in alleviating the symptoms of depression. However, clinical improvement is only obtained after several weeks of treatment. SSRIs, when administered acutely to animals, have little effect on synaptic levels of serotonin. This suggests the existence of one or more regulatory mechanisms controlling serotonergic neurotransmission. The firing rate of dorsal raphe serotonergic neurons is under the control of somatodendritic 5-hydroxytryptamine 1A (5-HT1A) autoreceptors, the release of serotonin from nerve terminals is under the control of 5-HT autoreceptors (5-HT1B subtype in rodents, 5-HT1D in other species), whereas the control of the activity of tryptophan hydroxylase, the rate-limiting enzyme of serotonin synthesis, is complex, involving 5-HT1A but possibly other 5-HT receptors including the 5-HT1B/D subtype. During prolonged administration with a SSRI, these three feedback systems become desensitized and their regulatory effects on serotonergic neurotransmission are weakened or lost. This has the effect of allowing the synaptic levels of serotonin to rise with a consequently increased stimulation of one or more types of postsynaptic 5-HT receptor. Thus, it is only after prolonged administration that the pharmacological activity of SSRI is fully expressed in terms of synaptic serotonin levels. This may explain the latency of antidepressant action seen with these drugs in humans. Various other classes of antidepressant therapies (tricyclic antidepressants and monoamine oxidase inhibitor drugs, electroconvulsive therapy) have long-term effects on one or more of the feedback mechanisms such that an increase in synaptic concentrations of serotonin may be a common mechanism of many antidepressant therapies.

Does 5-carboxamidotryptamine-induced turning in guinea-pigs involve 5-HT1D autoreceptors?

Contralateral turning induced by unilateral injection of 5-carboxamidotryptamine (5-CT) into guinea-pig substantia nigra could result from unilaterally reduced inhibition of the dopaminergic pathway as a consequence of a decreased release of inhibitory 5-hydroxytryptamine (5-HT) through stimulation of 5-HT1D autoreceptors. This hypothesis was tested by administering 5-CT unilaterally to freely moving guinea pigs through a microdialysis probe, and simultaneously measuring extracellular 5-HT in the dialysate and rotation. A concentration of 250 mN 5-CT was required to produce significant turning. This also induced a massive increase in extracellular 5-HT, introduced as an impurity of the 5-CT. The presence of high concentrations of extracellular 5-HT makes it unlikely that 5-CT-induced rotation is mediated through decreased 5-HT release resulting from 5-HT1D autoreceptor stimulation.

The unique effect of methiothepin on the terminal serotonin autoreceptor in the rat hypothalamus could be an example of inverse agonism

Slices of rat hypothalamus were pre-incubated with [(3)H] 5-hydroxytryptamine ([(3)H ] 5-HT), then superfused continuously and twice stimulated electrically. The effects of methiothepin, metergoline and alprenolol, all considered to be terminal 5-HT autoreceptor antagonists (although they also act at a number of other receptors), were studied. The stimulation-evoked overflow of tritium was increased by methiothepin in a concentration- dependent manner. The slight enhancing effect of alprenolol was not concentration dependent and metergoline, at concentrations which did not modify spontaneous outflow, was devoid of effect on evoked tritium overflow. The concentration-dependent inhibition by the terminal 5-HT autoreceptor agonist, lysergic acid diethylamide (LSD), of the electrically induced release of [(3)H] 5-HT was antagonized by methiothepin, alprenolol and metergoline. The stimulatory effect of methiothepin on tritium release was diminished by metergoline and by alprenolol at a concentration which slightly enhanced the evoked overflow of [(3)H ] 5-HT when given alone. Thus methiothepin induced an effect opposite to that of an agonist, in contrast to alprenolol and metergoline which under our conditions had no effect by themselves but reduced the effect of an agonist. In addition, the stimulating effect of methiothepin on release was reversed by two terminal 5-HT autoreceptor antagonists, alprenolol and metergoline. These results are consistent with methiothepin being an inverse agonist at the terminal 5-HT autoreceptor.

Effect of antidepressant drugs on monoamine synthesis in brain in vivo

The activity of tryptophan and tyrosine hydroxylase were estimated in vivo by measuring the accumulation during 30 min of 5-hydroxytryptophan (5-HTP) and 3,4-dihydroxyphenylalanine (DOPA), respectively, after inhibition of aromatic amino acid decarboxylase by administration of m-hydroxybenzylhydrazine (NSD 1015) (100 mg/kg, i.p.). Whereas the activity of tyrosine hydroxylase in the dopamine-rich striatum was sensitive to haloperidol, which caused a significant increase in accumulation of DOPA, there was no effect of haloperidol in the predominantly noradrenergic frontoparietal cortex, confirming that the activity of tyrosine hydroxylase, measured in the frontoparietal cortex, is essentially localized in noradrenergic neurones. In the frontoparietal cortex of the rat the in vivo activity of tryptophan and tyrosine hydroxylase were equipotently attenuated by imipramine, while the selective blocker of the uptake of noradrenaline, desipramine and the selective blocker of the uptake of serotonin, citalopram, reduced only tyrosine or tyrosine hydroxylase respectively. Milnacipran, an antidepressant which inhibits the uptake of both monoamines to a similar extent, decreased the synthesis of both monoamines equipotently. The monoamine oxidase inhibitor, clorgyline, also reduced the synthesis of both monoamines. Thus, the in vivo inhibition of the synthesis of monoamines would appear to be mediated by an increase in synaptic concentration of monoamines, resulting from the inhibition of the uptake or catabolism of monoamines. Chronic administration of citalopram led to a significant increase of the basal synthesis of 5-hydroxytryptamine (5-HT). Milnacipran, given chronically, significantly enhanced the basal synthesis of both 5-HT and noradrenaline (NA).(ABSTRACT TRUNCATED AT 250 WORDS)