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Correa DD, Kryza-Lacombe M, Zhou X, Baser RE, Beattie BJ, Beiene Z, Humm J, DeAngelis LM, Orlow I, Weber W, Osborne J. A pilot study of neuropsychological functions, APOE and amyloid imaging in patients with gliomas. J Neurooncol 2017; 136:613-622. [PMID: 29168082 PMCID: PMC5807139 DOI: 10.1007/s11060-017-2692-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 11/18/2017] [Indexed: 12/27/2022]
Abstract
Brain tumor patients treated with radiotherapy (RT) often develop cognitive dysfunction, and recent studies suggest that the APOE ε-4 allele may influence cognitive outcome. The ε-4 allele is known to promote beta (β) amyloid deposition in the cortex, and preliminary evidence suggests that RT may be associated with this process. However, it is unknown whether β-amyloid accumulation contributes to treatment neurotoxicity. In this pilot study, we assessed neuropsychological functions and β-amyloid retention using 18F-florbetaben (FBB) PET in a subset of brain tumor patients who participated in our study of APOE polymorphisms and cognitive functions. Twenty glioma patients treated with conformal RT ± chemotherapy participated in the study: 6 were APOE ε-4 carriers and 14 were non-ε-4 carriers. Patients completed a neuropsychological re-evaluation (mean time interval = 5 years, SD = 0.83) and brain MRI and FBB PET scans. Wilcoxon signed-rank test comparisons between prior and current neuropsychological assessments showed a significant decline in attention (Brief Test of Attention, p = 0.018), and a near significant decline in verbal learning (Hopkins Verbal learning Test-Learning, p = 0.07). Comparisons by APOE status showed significant differences over time in attention/working memory (WAIS-III digits forward, p = 0.028 and digits backward, p = 0.032), with a decline among APOE ε-4 carriers. There were no significant differences in any of the FBB PET analyses between APOE ε-4 carriers and non-ε-4 carriers. The findings suggest that glioma patients may experience worsening in attention and executive functions several years after treatment, and that the APOE ε-4 allele may modulate cognitive decline, but independent of increased β-amyloid deposition.
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Affiliation(s)
- D D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10021, USA. .,Department of Neurology, Weill Cornell Medical College, New York, NY, USA.
| | - M Kryza-Lacombe
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - X Zhou
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - R E Baser
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - B J Beattie
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Z Beiene
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - J Humm
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - L M DeAngelis
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10021, USA.,Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - I Orlow
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - W Weber
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | - J Osborne
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Radiology, Weill Cornell Medical College, New York, NY, USA
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Correa DD, Wang Y, West JD, Peck KK, Root JC, Baser RE, Thaler HT, Shore TB, Jakubowski A, Saykin AJ, Relkin N. Prospective assessment of white matter integrity in adult stem cell transplant recipients. Brain Imaging Behav 2016; 10:486-96. [PMID: 26153467 PMCID: PMC4706509 DOI: 10.1007/s11682-015-9423-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is often used in the treatment of hematologic disorders. Although it can be curative, the pre-transplant conditioning regimen can be associated with neurotoxicity. In this prospective study, we examined white matter (WM) integrity with diffusion tensor imaging (DTI) and neuropsychological functioning before and one year after HSCT in twenty-two patients with hematologic disorders and ten healthy controls evaluated at similar intervals. Eighteen patients received conditioning treatment with high-dose (HD) chemotherapy, and four had full dose total body irradiation (fTBI) and HD chemotherapy prior to undergoing an allogeneic or autologous HSCT. The results showed a significant decrease in mean diffusivity (MD) and axial diffusivity (AD) in diffuse WM regions one year after HSCT (p-corrected <0.05) in the patient group compared to healthy controls. At baseline, patients treated with allogeneic HSCT had higher MD and AD in the left hemisphere WM than autologous HSCT patients (p-corrected <0.05). One year post-transplant, patients treated with allogeneic HSCT had lower fractional anisotropy (FA) and higher radial diffusivity (RD) in the right hemisphere and left frontal WM compared to patients treated with autologous HSCT (p-corrected <0.05).There were modest but significant correlations between MD values and cognitive test scores, and these were greatest for timed tests and in projection tracts. Patients showed a trend toward a decline in working memory, and had lower cognitive test scores than healthy controls at the one-year assessment. The findings suggest a relatively diffuse pattern of alterations in WM integrity in adult survivors of HSCT.
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Affiliation(s)
- D D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Y Wang
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J D West
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - K K Peck
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, Brooklyn, NY, USA
| | - J C Root
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - R E Baser
- Department of Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - H T Thaler
- Department of Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - T B Shore
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - A Jakubowski
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - A J Saykin
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - N Relkin
- Department ofNeurology, Weill Cornell Medical College, New York, NY, USA
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Correa DD, Root JC, Baser R, Moore D, Peck KK, Lis E, Shore TB, Thaler HT, Jakubowski A, Relkin N. A prospective evaluation of changes in brain structure and cognitive functions in adult stem cell transplant recipients. Brain Imaging Behav 2014; 7:478-90. [PMID: 23329358 DOI: 10.1007/s11682-013-9221-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is an efficacious treatment for many hematologic malignancies. However, the conditioning regimen of high-dose (HD) chemotherapy with or without total body irradiation (TBI) can be associated with neurotoxicity. In this prospective study, we used quantitative neuroimaging techniques to examine regional gray matter and ventricular volumes, and standardized neuropsychological tests to assess cognitive function before and 1 year after HSCT in 28 patients with hematologic malignancies and in ten healthy controls evaluated at similar intervals. Nineteen patients received conditioning treatment with HD chemotherapy alone and nine had both TBI and HD chemotherapy. There was a significant reduction in gray matter volume in the middle frontal gyrus bilaterally and in the left caudate nucleus in the patient group (all patients combined) but not among healthy controls over the 1-year follow-up period. There was a significant increase in left lateral ventricle volume and in total ventricle volume in the patient group, relative to healthy controls. Similar brain structural changes were seen for patients treated with HD chemotherapy alone. The neuropsychological results showed that 21% of patients could be classified as impaired at baseline. The Reliable Change Index suggested no significantly different rates of cognitive decline between patients and healthy controls. The findings suggest that HSCT patients may be at an increased risk for developing regional brain volume loss, and that subgroups may experience cognitive dysfunction prior to and 1 year following the transplant.
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Affiliation(s)
- D D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA,
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Gonzalez JDSR, Eduardo O, Salvador A, de la Mora Alejandra P, Peiffer AM, Leyrer CM, Greene-Schloesser D, Kearns WT, Hinson WH, Tatter SB, Rapp SR, Robbins ME, Shaw EG, Chan MD, de Groot M, Douw L, Sizoo EM, Bosma I, Froklage FE, Heimans JJ, Postma T, Reijneveld JC, Klein M, Froklage FE, Sizoo EM, de Groot M, Postma TJ, Taphoorn MJ, Bosma I, Oosterbaan L, Reijneveld JC, Heimans JJ, Douw L, Klein M, Wefel JS, Armstrong TS, Wang M, Won M, Bottomley A, Mendoza TR, Coens C, Werner-Wasik M, Brachman DG, Choucair AK, Mehta MP, Gilbert MR, Otten M, Mikell CB, Youngerman BE, Small SA, McKhann G, Slavc I, Leiss U, Dressler A, Peyrl A, Dieckmann K, Czech T, Correa DD, Baser R, Beal K, Sasan K, Lisa D, Panageas K, Barradas R, Statucka M, Abrey L, Gutin P, Omuro A, Robben R, Uitdehaag BMJ, Fagel SSAA, Taphoorn MJB, Postma TJ, Heimans JJ, Klein M, Gehring K, Sawyer AM, Etzel CJ, Lang FF, Wefel JS, Gehring K, Sawyer AM, Etzel CJ, Lang FF, Wefel JS. NEURO-COGNITIVE. Neuro Oncol 2011. [DOI: 10.1093/neuonc/nor166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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O'Neil SH, Azoff J, Buranahirun C, Dhall G, Panigrahy A, Borchert M, Khatua S, Ji L, Sposto R, Finlay J, Gong X, Schwartz P, Linskey M, Bota DA, Wefel JS, Patwardhan SY, Strange C, Emily F, Celine A, Penelope K, Anne-Sophie C, Rolando DM, Michael P, Correa DD, Shi W, Abrey L, DeAngelis L, Thaler H, Habets EJ, Walchenbach R, Kloet A, Zwinkels H, Klein M, Vecht CJ, Taphoorn MJ, Ambachtsheer N, van Nieuwenhuizen D, Heimans JJ, Reijneveld JC, Peerdeman SM, Klein M, van Nieuwenhuizen D, Lagemaat C, Heimans JJ, Peerdeman SM, Klein M, Reijneveld JC, Peters KB, Reardon DA, Vredenburgh JJ, Desjardins A, Friedman HS, Driever PH, Koustenis E, Henze G, De Sonneville L, Rueckriegel SM, Mok K, Klein D, Del Maestro R, Petrecca K, Olivier A, Schanker BD, Curry WT, Edelstein K, Spiegler BJ, Fung S, Panzarella T, Hodgson DC, Mabbott DJ, Laperriere N, Tabori U, Bouffet E, Mason WP. Neuro-cognitive. Neuro Oncol 2010. [DOI: 10.1093/neuonc/noq116.s7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Correa DD, Maron L, Harder H, Klein M, Armstrong CL, Calabrese P, Bromberg JEC, Abrey LE, Batchelor TT, Schiff D. Cognitive functions in primary central nervous system lymphoma: literature review and assessment guidelines. Ann Oncol 2007; 18:1145-51. [PMID: 17284616 DOI: 10.1093/annonc/mdl464] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment-related neurotoxicity has been recognized as a significant problem in patients with primary central nervous system lymphoma (PCNSL) as effective treatment has increased survival rates. There is, however, a paucity of research on cognitive functions in this population. DESIGN In a review of the literature, a total of 17 articles that described cognitive outcome in adult PCNSL patients were identified. RESULTS The studies that assessed cognitive functions after whole-brain radiotherapy combined with chemotherapy reported cognitive impairment in most patients. Patients treated with chemotherapy alone had either stable or improved cognitive performance in most studies. Methodological problems, however, limited the ability to ascertain the specific contribution of disease and various treatment interventions to cognitive outcome. On the basis of the literature review, a battery of cognitive and quality-of-life (QoL) measures to be used in prospective clinical trials was proposed. The battery is composed of five standardized neuropsychological tests, covering four domains sensitive to disease and treatment effects (attention, executive functions, memory, psychomotor speed), and QoL questionnaires, and meets criteria for use in collaborative trials. CONCLUSION The incorporation of formal and systematic cognitive evaluations in PCNSL studies will improve our understanding of treatment-related neurotoxicity in this population.
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Affiliation(s)
- D D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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El Kamar FG, Deangelis LM, Yahalom J, Correa DD, Grant BW, Larocca RV, Raizer JJ, Schiff D, Abrey LE. Combined immunochemotherapy with reduced dose whole brain radiotherapy (WBRT) for newly diagnosed patients with primary CNS lymphoma (PCNSL). J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.1518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- F. G. El Kamar
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - L. M. Deangelis
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - J. Yahalom
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - D. D. Correa
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - B. W. Grant
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - R. V. Larocca
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - J. J. Raizer
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - D. Schiff
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
| | - L. E. Abrey
- Memorial Sloan-Kettering Cancer Center, New York, NY; University of Vermont, Burlington, VT; Kentuckiana Cancer Inst PLLC, Louisville, KY; Northwestern University, Feinberg School of Medicine, Chicago, IL; University of Virginia Medical Ctr, Dept of Neurology, Charlottesville, VA
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Abstract
BACKGROUND The standard treatment for primary CNS lymphoma (PCNSL) involves high-dose methotrexate-based (MTX) chemotherapy and whole brain radiotherapy (WBRT). This combined regimen prolongs patient survival, but also carries a substantial risk for delayed neurotoxicity particularly in the elderly. However, cognitive outcome evaluations have not been included in most clinical trials. OBJECTIVE To assess cognitive functioning and quality of life in PCNSL survivors treated either with WBRT +/- MTX-based chemotherapy or chemotherapy alone. METHODS Twenty-eight PCNSL patients in disease remission received a post-treatment baseline neuropsychological evaluation, and a subset of patients were available for an 8-month follow-up evaluation. Assessment of quality of life and extent of white matter disease on MRI were also performed. RESULTS Patients displayed mild to moderate impairments across several cognitive domains. These were of sufficient severity to reduce quality of life in half of the patient sample. Comparisons according to treatment type revealed more pronounced cognitive impairment, particularly in the memory and attention/executive domains, among patients treated with WBRT +/- chemotherapy. Extent of white matter disease correlated with attention/executive, memory, and language impairment. CONCLUSIONS PCNSL survivors treated with WBRT +/- chemotherapy displayed more pronounced cognitive dysfunction than patients treated with MTX-based chemotherapy alone.
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Affiliation(s)
- D D Correa
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York 10021, USA.
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Hirsch J, Ruge MI, Kim KH, Correa DD, Victor JD, Relkin NR, Labar DR, Krol G, Bilsky MH, Souweidane MM, DeAngelis LM, Gutin PH. An integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions. Neurosurgery 2000; 47:711-21; discussion 721-2. [PMID: 10981759 DOI: 10.1097/00006123-200009000-00037] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate an integrated battery of preoperative functional magnetic resonance imaging (fMRI) tasks developed to identify cortical areas associated with tactile, motor, language, and visual functions. METHODS Sensitivity of each task was determined by the probability that a targeted region was activated for both healthy volunteers (n = 63) and surgical patients with lesions in these critical areas (n = 125). Accuracy of each task was determined by the correspondence between the fMRI maps and intraoperative electrophysiological measurements, including somatosensory evoked potentials (n = 16), direct cortical stimulation (n = 9), and language mapping (n = 5), and by preoperative Wada tests (n = 13) and visual field examinations (n = 6). RESULTS For healthy volunteers, the overall sensitivity was 100% for identification of the central sulcus, visual cortex, and putative Wernicke's area, and 93% for the putative Broca's area (dominant hemisphere). For patients with tumors affecting these regions of interest, task sensitivity was 97% for identification of the central sulcus, 100% for the visual cortex, 91% for the putative Wernicke's area, and 77% for the putative Broca's area. These sensitivities were enhanced by the use of multiple tasks to target related functions. Concordance of the fMRI maps and intraoperative electrophysiological measurements was observed whenever both techniques yielded maps and Wada and visual field examinations were consistent with fMRI results. CONCLUSION This integrated fMRI task battery offers standardized and noninvasive preoperative maps of multiple critical functions to facilitate assessment of surgical risk, planning of surgical routes, and direction of conventional, intraoperative electrophysiological procedures. Thus, a greater range of structural and functional relationships is brought to bear in the service of optimal outcomes for neurosurgery.
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Affiliation(s)
- J Hirsch
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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Ruge MI, Victor J, Hosain S, Correa DD, Relkin NR, Tabar V, Brennan C, Gutin PH, Hirsch J. Concordance between functional magnetic resonance imaging and intraoperative language mapping. Stereotact Funct Neurosurg 2000; 72:95-102. [PMID: 10853058 DOI: 10.1159/000029706] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although the correspondence between functional-magnetic resonance imaging (fMRI) representations of the sensorimotor cortex and intraoperative electrophysiology (including somatosensory evoked potential, SSEP, recordings and direct cortical stimulation) has been reported, a similar correspondence between fMRI and intraoperative localization of the language-sensitive cortex is not as well established. The aim of the present study was to evaluate the concordance between fMRI and intraoperative electrophysiology with respect to the localization of the language-sensitive and sensorimotor cortices. We present the results of 21 patients who underwent language and sensorimotor mapping by fMRI and intraoperative electrophysiology including SSEP recordings (n = 21), direct cortical stimulation of motor cortex (n = 15) and direct cortical stimulation of Broca's and Wernicke's area (n = 5). When responses were obtained with both methods, localization of function concurred in all cases. These observations suggest that fMRI represents a reliable preoperative tool for the identification of language-sensitive areas.
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Affiliation(s)
- M I Ruge
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY, USA.
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Abstract
Bismuth subsalicylate preparations are over-the-counter products for gastrointestinal complaints. Bismuth toxicity causes delirium, psychosis, ataxia, myoclonus, and seizures and is reversible over several weeks or months, when bismuth intake is stopped. We report a 54-year-old man with a 6-week history of progressive confusion and memory difficulty and a 2-3-week history of involuntary movements and gait impairment. His encephalopathy was further characterized by marked multifocal myoclonic jerks, coarse postural tremors, postural instability, and gait ataxia. He gradually improved. Extensive toxic, metabolic, and infectious workup demonstrated bismuth toxicity. Spinal tap and brain magnetic resonance scan were normal. Electroencephalography showed bihemispheric slowing. As his encephalopathy cleared, he reported using bismuth subsalicylate long term (daily intake of 8 oz). Bismuth levels 5 weeks after cessation of bismuth were elevated and normalized after 12 weeks. He followed a typical course for bismuth toxicity with subacute progressive encephalopathy and gradual recovery. Creutzfeldt-Jakob was strongly considered due to his rapidly progressive encephalopathy, multifocal myoclonus, and ataxia. Due to its rarity, bismuth toxicity is often overlooked. We hope this presentation will increase recognition of bismuth toxicity. We believe more detailed labeling of bismuth products is needed to avoid similar toxicity from this readily available product.
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Affiliation(s)
- M F Gordon
- Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, NY 11042, USA
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