Neuromyelitis optica after a spinal anaesthesia with bupivacaine

We report the case of a 53-year old woman who developed a neuromyelitis optica (NMO or Devic’s syndrome) after a spinal anaesthesia with bupivacaine. To our knowledge, the use of bupivacaine in human has not been associated to neurological complications like myelitis or NMO. The patho genesis of this complication will be discussed.

[Paucisymptomatic and reversible myelinolysis after an anaphylactic shock]

Myelinolysis is characterized by a non inflammatory demyelination, affecting the central portion of the pons. Clinical features usually reflect damage to the descending motor tracts and include spastic tetraparesis, pseudobulbar paralysis, and the locked-in syndrome. We describe the case of a 58-year-old man, who developed a pontine and extrapontine myelinolysis, without hyponatremia, after an anaphylactic shock. Follow up demonstrated improvement of the clinical signs after a few days and the normalization of the MRI three months later. Our observation shows that a paucisymptomatic and spontaneously regressive myelinolysis can be the consequence of a state of shock.

[Subjective blockage in Parkinson's disease]

Akinetic symptoms or off-period motor signs in patients with Parkinson's disease and motor fluctuations can be associated with subjective symptoms. A systematic interview was conducted in a series of 24 patients. Sixteen out of 24 (67 p. cent) experienced these subjective symptoms as on-off non motor symptoms that were classified in three groups: energy lost consistent with a severe asthenia, perceptive and cognitive alterations, and emotional troubles such as panic and depression. These phenomenons could be combined in some patients and were sometimes asynchron to akinesia. In some patients (six cases reported), they occurred without any akinesia but could totally inhibit patients daily activities, and so could be described as subjective off-period . Frequently, the patients did not distinguish them from motor disability. Their persistence, after subthalamic nucleus stimulation or intrastriatal transplant, could interfere with functional results, even though akinetic symptoms had disappeared.

CONCLUSION

subjective phenomenons during off-periods are frequent. Their frequency is underestimated due to a non-targeted examination. Subjective off-periods are symptoms of Parkinson's disease, partly independent from off motor symptoms, and important to consider in evaluation of therapeutics, especially surgery.

Central nervous system disease in patients with macrophagic myofasciitis

Macrophagic myofasciitis (MMF), a condition newly recognized in France, is manifested by diffuse myalgias and characterized by highly specific myopathological alterations which have recently been shown to represent an unusually persistent local reaction to intramuscular injections of aluminium-containing vaccines. Among 92 MMF patients recognized so far, eight of them, which included the seven patients reported here, had a symptomatic demyelinating CNS disorder. CNS manifestations included hemisensory or sensorimotor symptoms (four out of seven), bilateral pyramidal signs (six out of seven), cerebellar signs (four out of seven), visual loss (two out of seven), cognitive and behavioural disorders (one out of seven) and bladder dysfunction (one out of seven). Brain T(2)-weighted MRI showed single (two out of seven) or multiple (four out of seven) supratentorial white matter hyperintense signals and corpus callosum atrophy (one out of seven). Evoked potentials were abnormal in four out of six patients and CSF in four out of seven. According to Poser's criteria for multiple sclerosis, the diagnosis was clinically definite (five out of seven) or clinically probable multiple sclerosis (two out of seven). Six out of seven patients had diffuse myalgias. Deltoid muscle biopsy showed stereotypical accumulations of PAS (periodic acid-Schiff)-positive macrophages, sparse CD8+ T cells and minimal myofibre damage. Aluminium-containing vaccines had been administered 3-78 months (median = 33 months) before muscle biopsy (hepatitis B virus: four out of seven, tetanus toxoid: one out of seven, both hepatitis B virus and tetanus toxoid: two out of seven). The association between MMF and multiple sclerosis-like disorders may give new insights into the controversial issues surrounding vaccinations and demyelinating CNS disorders. Deltoid muscle biopsy searching for myopathological alterations of MMF should be performed in multiple sclerosis patients with diffuse myalgias.

Retest effects and cognitive decline in longitudinal follow-up of patients with early HD

OBJECTIVE

To assess the natural progression of cognitive impairment in Huntington's disease (HD) and to reveal factors that may mask this progression.

BACKGROUND

Although numerous cross-sectional studies reported cognitive deterioration at different stages of the disease, progressive cognitive deterioration has been, up to now, difficult to demonstrate in neuropsychological longitudinal studies.

METHODS

The authors assessed 22 patients in early stages of HD at yearly intervals for 2 to 4 years (average, 31.2 +/- 10 months), using a comprehensive neuropsychological battery based on the Core Assessment Program for Intracerebral Transplantation in Huntington's Disease (CAPIT-HD).

RESULTS

The authors observed a significant decline in different cognitive functions over time: these involved primarily attention and executive functions but also involved language comprehension, and visuospatial immediate memory. Episodic memory impairment that was already present at the time of enrollment did not show significant decline. The authors found a significant retest effect at the second assessment in many tasks.

CONCLUSION

Many attention and executive tasks adequately assess the progression of the disease at an early stage. For other functions, the overlapping of retest effects and disease progression may confuse the results. High interindividual and intraindividual variability seem to be hallmarks of the disease.

[Toe phasic posture reflex: description and distribution among patients with neurological disease and in the general population]

A clinical sign is described consisting of a brief extension of the toes after upward tapping of the plantar surface of their terminal phalanges. Electrological data support the hypothesis of a long loop reflex, which we call the "toe phasic posture reflex" (TPPR). In a preliminary study, this sign was observed in patients with central nervous system disease, especially in subcortical brain disorders regardless of etiology. In Parkinson's disease, it was seen mostly in severe and postural forms. Among 237 healthy subjects, it was observed in none of those under 70 years old (n=116), and in 10p. cent of those over 69 years and doing no sport (n=132), but in none of those doing regularly gymnastics or swimming (n=29). TPPR could thus be a sign of motor and especially postural aging.

Motor and cognitive improvements in patients with Huntington's disease after neural transplantation

BACKGROUND

Huntington's disease is a neurodegenerative disease of genetic origin that mainly affects the striatum. It has severe motor and cognitive consequences and, up to now, no treatment. Motor and cognitive functions can be restored in experimental animal models by means of intrastriatal transplantation of fetal striatal neuroblasts. We explored whether grafts of human fetal striatal tissue could survive and have detectable effects in five patients with mild to moderate Huntington's disease.

METHODS

After 2 years of preoperative assessment, patients were grafted with human fetal neuroblasts into the right striatum then, after a year, the left striatum. Final results were assessed 1 year later on the basis of neurological, neuropsychological, neurophysiological, and psychiatric tests. The results obtained were compared with those of a cohort of 22 untreated patients at similar stages of the disease who were followed up in parallel. Repeated magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning with fluorine-18-labelled fluorodeoxyglucose was also done to assess metabolic activity.

FINDINGS

The final PET-scan assessment showed increased metabolic activity in various subnuclei of the striatum in three of five patients, contrasting with the progressive decline recorded in the two other patients in the series, as seen in patients with untreated Huntington's disease. Small areas of even higher metabolic activity, coregistering with spherical hyposignals on MRI were also present in the same three patients, suggesting that grafts were functional. Accordingly, motor and cognitive functions were improved or maintained within the normal range, and functional benefits were seen in daily-life activities in these three patients, but not in the other two.

INTERPRETATION

Fetal neural allografts could be associated with functional, motor, and cognitive improvements in patients with Huntington's disease.

Dissociation between distal and proximal left limb agraphia and agraphesthesia in a patient with a callosal disconnection syndrome

A few neuropsychological studies have suggested the existence of bilateral hemispheric representations for the proximal parts of the limbs in humans. We report the case of a patient who presented with a callosal disconnection syndrome, which at a later stage of disease became restricted to left agraphia, left agraphesthesia and left auditory extinction. The anomic character of the agraphesthesia was demonstrated. Tactile naming was normal, which allows us to conclude that separate callosal pathways related to the left language areas transmit information for graphesthesia and tactile naming. Agraphia and agraphesthesia were not observed when the proximal part of the left upper limb was utilized. These observations support the conclusion that writing and graphesthesia with the proximal part of the limb can be mediated by the ipsilateral cortex.

[Right parietal lesions, spatial neglect and egocentric reference]

Using a proprioceptive "straight-ahead" pointing task, we determined the position of the subjective sagittal middle in thirty unselected patients with unilateral vascular lesions in the right hemisphere and twenty-two normal controls. Patients with extensive right parietal damage (n = 16) showed an ipsilesional (rightward) deviation of their egocentric reference, whereas patients with lesions that substantially spared the right parietal lobe (n = 14) showed a contralesional (leftward) deviation. No significant correlation emerged between the position of the egocentric reference and the performance on a neglect battery. These results can help explain some dissociations between left neglect signs and ipsilesional deviation of the egocentric reference, and raise some questions about the links among lesion location, neglect signs and egocentric frame of reference.

Safety and tolerability assessment of intrastriatal neural allografts in five patients with Huntington's disease

This study describes issues related to the safety and tolerability of fetal striatal neural allografts as assessed in five patients with Huntington's disease. Huntington's disease (HD) is characterized by motor, cognitive, and behavioral disturbances. The latter include psychological disturbances and, as a consequence, we took particular care to analyze behavioral changes, in addition to the usual "safety" follow-up. We conducted multidisciplinary follow-up at least 2 years before and 1 year after grafting. Psychological care extended to close relatives. The grafting procedure itself was altogether safe and uneventful, and there were no apparent clinical deleterious effects for 1 year. The immunosuppressive treatment, however, was complicated by various problems (irregular compliance, errors of handling, side effects). Direct psychological consequences of the transplantation procedure were rare and not worrisome, although mood alteration requiring treatment was observed in one patient. Indirectly, however, the procedure required patients and relatives to accept constraints that tended to complicate familial situations already marred by aggressivity and depression. All patients and close relatives expressed major expectations, in spite of our strong and repeated cautioning. It is clearly important to be aware of these particular conditions since they may eventually translate into psychological difficulties in coping with the long-term clinical outcome of the procedure, if not beneficial. Despite an overall good tolerance, therefore, this follow-up calls for caution regarding the involvement of HD patients in experimental surgical protocols.

Primary somatosensory cortex activation is not altered in patients with ventroposterior thalamic lesions: a PET study

BACKGROUND AND PURPOSE

We know remarkably little about the mechanisms underlying cortical activation. Such mechanisms might be better understood by studying the effect of well-localized lesions on the cortical activations in simple paradigms.

METHODS

We used H(2)(15)O and positron emission tomography to measure regional cerebral blood flow (rCBF) at rest and during hand vibration in 7 patients with unilateral thalamic lesion involving the ventroposterior (VP) somatosensory thalamic relay nuclei. We compared the results with those obtained in 6 patients with thalamic lesions sparing the VP nuclei and 6 healthy controls.

RESULTS

The patients with VP lesions had a selective hypoperfusion at rest in the ipsilesional primary sensorimotor cortex (SM1). This hypoperfusion was significantly correlated with the degree of contralateral somatosensory deficit. This abnormality may reflect the deafferentation of SM1 from its somatosensory thalamic input. Despite this deafferentation, the ipsilesional SM1 was normally activated by the vibration of the hypoesthetic hand.

CONCLUSIONS

The fact that a lesion of the somatosensory thalamic relay nuclei alters the rCBF at rest in SM1 but not its activation by hand vibration indicates that the mechanism of cortical activation is complex, even in the case of simple sensory stimulation. In addition, a dissociation may occur between obvious neurological deficits and apparently normal activation patterns, which suggests that activation studies should be interpreted cautiously in patients with focal brain lesions.

Peripheral injections of Freund's adjuvant in mice provoke leakage of serum proteins through the blood-brain barrier without inducing reactive gliosis

Breakdown of the blood-brain barrier (BBB) and ensuing gliosis are common events following physical trauma to the central nervous system (CNS) or during autoimmune diseases such as experimental allergic encephalomyelitis (EAE). Some studies of EAE in rodents report that peripheral injections of complete Freund's adjuvant (CFA), which contains heat-inactivated Mycobacterium to provoke peripheral inflammation without adversely affecting the CNS, can itself lead to increased BBB permeability to small tracer molecules and certain serum proteins. To study the equivocal relationship between serum protein extravasation and reactive gliosis, we injected C57BL/6 mice with CFA and histologically assessed the permeability of various serum proteins and the reactivity of proximal microglia and astrocytes in the uninjured brainstem and spinal cord enlargements after 1-4 weeks. Our results confirm that CFA injections induce progressive increases in the perivascular extravasation of serum IgG, albumin, IgM, and exogenous horseradish peroxidase, all to varying degrees, most prominently in the brainstem and cervical spinal cord after 2-3 weeks. More importantly, neither microglial cells nor astrocytes in regions of focal serum protein leakage appeared morphologically reactive based on immunoreactivity for CR3 receptors (Mac-1) or glial fibrillary acidic protein (GFAP), respectively. Because we found no evidence of T cell infiltration accompanying the exudates, our results indicate that in the absence of physical trauma or inflammatory cells resident CNS neuroglia remain quiescent upon exposure to extravasated serum proteins.

Neurological complications of neurofibromatosis type 1 in adulthood

Neurofibromatosis type 1 (NF1) is a genetic disease with a wide range of neurological manifestations. To examine these, and to evaluate neurological morbidity in adulthood of patients with NF1, we studied a hospital-based series of 158 patients that included 138 adult patients aged >18 years and 20 children. NF1 evaluation included a multidisciplinary clinical and a clinically oriented radiological investigation. Neurological events occurring during childhood (in both children and adults of the series) and adulthood were recorded. One or several neurological manifestations have been observed in 55% of patients (adults and children) (n = 87). These included: headache (28 patients); hydrocephalus (7); epilepsy (5); lacunar stroke (1); white matter disease (1); intraspinal neurofibroma (3); facial palsy (1); radiculopathy (5); and polyneuropathy (2). Tumours included: optic pathway tumours (20); meningioma (2); cerebral glioma (3); and malignant peripheral nerve sheath tumours (6). Life-threatening complications were observed in five adults and included four malignant peripheral nerve sheath tumours and one meningioma. Pain was the leading symptom in 11 adults and was related to malignant peripheral nerve sheath tumours, complications of intraspinal neurofibromas, subcutaneous neurofibromas and peripheral nerve neurofibromas. NF1 in adults was not associated with other disabling or life-threatening neurological complications. Symptomatic optic pathway tumours, cerebral gliomas, symptomatic aqueductal stenosis and spinal compression due to intraspinal NF were observed exclusively during childhood. In this series, the predominant neurological features of adults with NF1 were chronic pain and malignant peripheral nerve sheath tumours.

Somatosensory cortical activations are suppressed in patients with tactile extinction: a PET study

OBJECTIVE

To investigate whether tactile extinction alters the cortical somatosensory activations induced by hand vibration.

BACKGROUND

Tactile extinction occurs mainly after right-brain lesions and consists of the inability to perceive a contralesional cutaneous stimulation when a similar stimulus is applied to the mirror region of the ipsilesional hemibody. The pathophysiology of tactile extinction is poorly understood, but it is considered to be a deficit of selective attention of somatosensory stimuli. Although other theories have been proposed, our understanding of the pathophysiology of tactile extinction may benefit from functional imaging studies.

METHODS

We selected three patients with pure tactile extinction and a mainly subcortical right-brain lesion that spared the primary sensorimotor cortex (SM1). We used PET to investigate the responses to unilateral and bilateral hand vibration in SM1 and the secondary somatosensory cortical area (SII).

RESULTS

During bilateral hand vibration, activation was normal in the left SM1, suppressed in the right SM1, and markedly decreased in both SII, which was consistent with the extinction of the left-hand stimulus. During unilateral left-hand vibration, the activation of the right SM1 was still markedly impaired, but the activation of both SII was normal.

CONCLUSIONS

We found marked changes in the activation of cortical somatosensory areas induced by hand vibration in patients with tactile extinction. The role of selective attention in cortical activation is also examined.

Right-side neglect in Alzheimer's disease

Unilateral neglect--the inability to pay attention to events occurring on one side of space--usually occurs for left-side events after focal right-hemisphere damage. We report a 73-year-old woman with probable AD and no evidence of focal brain lesions who showed signs of right-side neglect and extinction. Neglect was more severe after 1 year. Neuroimaging techniques demonstrated an asymmetry of cortical involvement, with cortical atrophy and hypoperfusion predominant in the left posterior regions. Unilateral neglect should be assessed systematically in AD.

Inversion superiority in visual agnosia may be common to a variety of orientation polarised objects besides faces

Selective impairment in recognition of faces (prosopagnosia) resulting from certain localized cortical lesions has been advanced as an argument for a face specific brain module. The argument is claimed to be strengthened by the discovery of an inversion superiority effect in the recognition of faces by a prosopagnosic patient (Farah et al., Vis Res 1995b;35:2089-2093). The present paper reports an inversion superiority effect in the recognition of faces and shoes in a visual agnosic patient. The finding raises the possibility that several classes of orientationally polarized objects, of which shoes and faces are examples, will exhibit inversion superiority.

[Pointing and its object: towards the neuropsychology of objectivation]

We describe a disorder similar to body-image agnosia or autotopagnosia characterized by the inability to designate targets situated outside the body. This disorder, which we have termed allotopagnosia, occurs exclusively in subjects with a lesion involving the posterior region of the left parietal lobe. The most common manifestation is the designation of parts of the body of another person as being part of the patient's own body (heterotopagnosia with self-designation). This disorder cannot be explained by aphasia, apraxia, or visuomotor dysfunction nor by an inability to identify parts of the body as self. Patient's expression of the confusion between their own body with that of others and the gestures they use to designate indicate a relationship with reality (non-self and target) confined to the human species. The disorder appears in children at the same time as language acquisition. This suggests the hypothesis that allotopagnosia results from a deficit or dysfunction of the left parietal lobe where outside elements are attributed to situations and identities independent of self.

Multiple-domain dissociation between impaired visual perception and preserved mental imagery in a patient with bilateral extrastriate lesions

A brain-damaged patient is described whose pattern of performance provides insight into both the functional mechanisms and the neural structures involved in visual mental imagery. The patient became severely agnosic, alexic, achromatopsic and prosopagnosic following bilateral brain lesions in the temporo-occipital cortex. However, her mental imagery for the same visual entities that she could not perceive was perfectly preserved. This clear-cut dissociation held across all the major domains of high-level vision: object recognition, reading, colour and face processing. Our findings, together with other reports on domain-specific dissociations and functional brain imaging studies, provide evidence to support the view that visual perception and visual mental imagery are subserved by independent functional mechanisms, which do not share the same cortical implementation. In particular, our results suggest that mental imagery abilities need not be mediated by early visual cortices.

Circulating transforming growth factor beta 1 (TGF-beta1) in Guillain-Barré syndrome: decreased concentrations in the early course and increase with motor function

OBJECTIVE

To delineate the possible implication of the immunosuppressive cytokine transforming growth factor beta 1 (TGF-beta1) in the pathogenesis of Guillain-Barré syndrome. Guillain-Barré syndrome is a disorder that may implicate cytokines in its pathogenesis. TGF-beta1 is a potent anti-inflammatory cytokine occasionally shown to be regulated in the course of demyelinating disorders.

METHODS

The study measured circulating proinflammatory and anti-inflammatory cytokines from the progressing phase to early recovery in patients with Guillain-Barré syndrome. Plasma concentrations of TNF-alpha, IL-beta1, IL-2, IL-4, IL-6, IL-10, and TGF-beta1 were prospectively evaluated in 15 patients with Guillain-Barré syndrome every three days for the first 15 days after admission to hospital, and in 15 controls with non-inflammatory neurological diseases.

RESULTS

Concentrations of TGF-beta1 in plasma were decreased in 13115 patients (87 %) at day 1, remained low during progression and the plateau of paralysis (days 1-10), and then progressively increased up to control concentrations during early recovery (days 12-15). Concentrations of plasma TGF-beta1 correlated positively with motor function, the lowest values being e found in the most disabled patients. Concentrations of plasma TGF-beta1 were decreased before any treatment, and during treatment by either plasma exchange or intravenous immunoglobulins, plasma exchange being associated with a more pronounced decrease in TGF-beta1 at day 7. Circulating TNF-alpha concentrations were raised, as previously reported, when other cytokines were either randomly increased (IL-2, IL-6), or undetectable (IL-1, IL-4, IL-7, IL-10).

CONCLUSIONS

Down regulation of TGF-beta1 in the early course of Guillain-Barré syndrome could participate in neural inflammation.

Disruption of residual reading capacity in a pure alexic patient after a mirror-image right-hemispheric lesion

A 74-year-old woman became a letter-by-letter reader after the occurrence of a left occipito-temporal hematoma. Seven months later, she suffered a second, mirror-image hematoma in the right hemisphere. After this second lesion, her residual reading capacity deteriorated dramatically in terms of both accuracy and reading latencies for words and isolated letters. Our findings support the hypothesis that the right hemisphere contributes to the residual reading capacities of pure alexic patients.

All-trans retinoic acid in relapsing malignant gliomas: clinical and radiological stabilization associated with the appearance of intratumoral calcifications

PURPOSE

To evaluate the therapeutic effect of all-trans retinoic acid (ATRA) with and without cytosine arabinoside in relapsing malignant gliomas.

PATIENTS AND METHODS

9 patients (8 male, 1 female, age 53.9 +/- 11.2) with relapsing malignant gliomas (grade IV:6; grade III:3) were treated by ATRA 1 to 21 months after the end of their initial treatment. ATRA was given unceasingly during 2 to 17 months at 90 mg/d. In 6 patients it was associated to cytosine arabinoside (4 g/course, 1 to 9 courses every 4 weeks).

RESULTS

4 non-responder patients died 2.5 to 4 months after starting therapy. One patient who had been reoperated before receiving ATRA and cytosine arabinoside (5 course) had no sign of tumor recurrence after 17 months of treatment. In 4 responder patients (2 glioblastoma and 2 anaplastic astrocytoma) a clinical and radiological stabilization (time to progression) during 9 +/- 2.5 months was observed. This stabilization was associated in 3 of them with the appearance of intra tumoral calcifications visualized on repeated CT scans and confirmed in one patient by post-mortem examination. All of them had received cytosine arabinoside (1 to 9 courses) with ATRA; however small calcifications were also observed in one non-responder patient who did not receive aracytine.

CONCLUSION

These results suggest: a) a therapeutic effect of ATRA in combination with cytosine arabinoside in patients with relapsing malignant gliomas b) that intratumoral calcifications are related to the effects of ATRA on differentiation and/or on endothelial t-PA production and that these effects explain the tumor progression arrest in responder patients. The transient efficiency is probably related to the pharmacokinetics of ATRA or to changes of cellular mechanisms that modulate the cell response to the drug and is a critical issue for this therapy.

Improvement of severe postural cerebellar tremor in multiple sclerosis by chronic thalamic stimulation

Tremor can be particularly disabling in patients with multiple sclerosis (MS) and is mildly improved by drug treatment. The efficiency of stereotactic thalamotomy has been reported in a small number of patients but was counterbalanced by severe postoperative complications. Stimulation of the thalamic ventral intermediate nucleus, which is a less aggressive surgical method, is efficient in essential and in parkinsonian tremors. We report here the results of thalamic stimulation in 13 patients with MS with tremor. All patients were subjected to clinical examination, videorecording, and quantification of the functional disability before surgery and 3 months postoperatively. The surgical intervention was well tolerated in all cases. A clear improvement of the tremor was observed in 69.2% of the patients. Functional improvement was more varied and depended on the severity of tremor and coexistence of other neurological symptoms. Of the eight most severely affected patients, seven recovered the possibility to easily catch an object and use it. The results indicate that thalamic stimulation may be useful in the treatment of severe postural cerebellar tremor in MS.

All-trans-retinoic acid in POEMS syndrome. Therapeutic effect associated with decreased circulating levels of proinflammatory cytokines

Chronically elevated serum levels of proinflammatory cytokines is a feature of the syndrome known as POEMS (plasma cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, monoclonal [M] protein, skin changes). A patient had a POEMS syndrome with thrombocytosis and biclonal gammopathy and was treated as follows: all-trans-retinoic acid (tretinoin) at 90 mg/day for 50 days, no treatment for 70 days, readministration of tretinoin at 75 mg/day for 180 days. Focal bone lesion irradiation was performed from day 26 to day 50. Serum levels of interleukin-6 (IL-6), tumor necrosis factor alpha (TNF alpha), and IL-1 beta normalized within 7 days after the first administration of tretinoin, transiently increased at the time of radiotherapy, increased again after withdrawal of the tretinoin, and decreased again after its reintroduction. The platelet count and gammopathy paralleled the changes in the cytokine levels. This study documents in vivo the ability of all-trans-retinoic acid to down-regulate the release of IL-6, IL-1 beta, and TNF alpha, and illustrates its potential as a therapeutic agent in conditions associated with chronic overproduction of proinflammatory cytokines.

[Neuropsychological testing of 5 patients with Parkinson's disease before and after neuron graft]

Five patients with idiopathic PD were followed by neuropsychological tests after brain fetal neuronal transplantation. The following tests were used in order to assess memory as well as visuospatial and frontal functions: MMSE, Mattis Scale, Wisconsin Card Sorting Test, Stroop task, word fluency tasks, 15-objects test, WAIS-R (Digit span, Arithmetic, Block design, Pictures completion, Pictures arrangement), learning of 15 words of Rey, WMS-R (Logical memory) and Visual memory of L. Israël. The same tests were performed before, then one year following the transplantation. Pooled data did not show any significant difference between pre and post-operative tests. Individual results varied among patients: 2 remained unchanged, 1 had a pathological deterioration which increased after one year, 1 had some frontal symptoms whereas the last patient improved. Our data confirm that this surgical procedure do not induce permanent neuropsychological deficits, but do not indicate at the present time any clear effect of dopamine reinnervation on cognitive functions.

Overproduction of proinflammatory cytokines imbalanced by their antagonists in POEMS syndrome

The polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes (POEMS) syndrome is a rare multisystem disorder of obscure pathogenesis associated with osteosclerotic myeloma. Circulating levels of proinflammatory cytokines (tumor necrosis factor-alpha (TNF-alpha) interleukin-1 beta [IL-1 beta], IL-2, IL-6, and interferon-gamma [IFN-gamma]), anti-inflammatory cytokines (transforming growth factor beta 1 [TGF beta 1], IL-4, IL-10, and IL-13), the cytokine carrier protein alpha 2 macroglobulin, IL-1 receptor antagonist (IL-1ra), soluble TNF receptors (sTNFr) p55 and p75, and soluble IL-6 receptor (sIL-6r) were determined in 15 patients with POEMS syndrome and 15 with multiple myeloma. Patients with POEMS syndrome had higher serum levels of IL-1 beta, TNF-alpha, and IL-6 and lower serum levels of TGF beta 1 than did patients with multiple myeloma. Serum levels of IL-2, IL-4, IL-10, IL-13, IFN-gamma, alpha 2 macroglobulin, and sIL-6r were similar in both groups. IL-1ra and sTNFrs were increased in POEMS syndrome, but out of proportion to the increase of IL-1 beta and TNF-alpha. Serial evaluations in 1 patient showed that proinflammatory cytokine serum levels paralleled disease activity assessed by platelet count and neurologic involvement. Our results suggest that the manifestations of POEMS syndrome might be regarded as the result of a marked activation of the proinflammatory cytokine network (IL-1 beta, IL-6, and TNF-alpha) associated with a weak or even decreased (TGF beta 1) antagonistic reaction insufficient to counteract the noxious effects of cytokines.

Long-term outcome of unilaterally transplanted parkinsonian patients. I. Clinical approach

Five patients with Parkinson's disease, unilaterally transplanted with foetal mesencephalic cells into putamen (n=1) or putamen and caudate (n=4), were followed throughout a period of 15-36 months after surgery, according to the recommendations of the core assessment programme for intracerebral transplantations (CAPIT). All these patients exhibited an increase in the fluorodopa uptake in the grafted putamen, which was most significant in the first and last patient of the series. Long-term bilateral improvement of skilled hand movements was observed, starting between the third and sixth month after grafting, and confirmed by the statistical analysis of CAPIT timed tests. A mild to moderate effect on the amount of 'off' time and 'on-off' fluctuations was observed, whereas, apart from one case, no other clear effect on gait, walking and speech was found. One patient included in the study, already suffering slight cognitive impairment, clearly exhibited progression of a dementia process after surgery. Daily living activities were clearly improved in only one of the other four patients. At the end of the study period, all patients needed L-dopa therapy at a similar or higher dose than before grafting, but, in most of them, other dopaminergic drugs were reduced or stopped. All patients exhibited bilateral dyskinesias before grafting that were greatly decreased in intensity a few months after surgery. Delayed asymmetrical dyskinesias, occurring on the side displaying the better motor improvement, i.e. contralateral to the graft, were observed in three patients. These results suggest that neural transplants may influence two central mechanisms involved in motor function and the onset of dyskinesias. These effects are likely to occur through complex interactions with the post-synaptic dopaminergic receptors. The occurrence of dyskinesias might simply reflect increased presynaptic storage and release of dopamine. Alternatively, it might, in part, represent some other long-term deleterious effect of the graft. Since PET-scan data indicate that the reinnervation obtained is sub-optimal, it will be of interest to obtain a larger and denser reinnervation of the host striatum and to try, thereafter, to reduce the dose of L-dopa.

Thalamic stimulation for severe action tremor after lesion of the superior cerebellar peduncle

Images

Diphtheritic neuropathy

A 29-year-old Haitian man had a sore throat with a marked tonsillar exudate followed by the onset of increasingly blurred vision with swallowing difficulties and, then, a diffuse acute demyelinating neuropathy. Cerebrospinal fluid showed moderate pleiocytosis and elevated protein content. Serological testing for diphtheria, but not for tetanus and poliomyelitis, was markedly positive. Other tests including HIV1 and 2, HTLV1 and Lyme disease were negative. Diphtheritic neuropathy should be considered in the differential diagnosis of Guillain-Barré syndrome in nonvaccinated patients.

Striatal dopaminergic denervation in pallidopyramidal disease demonstrated by positron emission tomography

Pallidopyramidal disease is a rare disease of young patients in which they manifest a parkinsonian syndrome and pyramidal signs. Pallidopyramidal disease has been attributed to a degeneration of the pallidum and the pyramidal tract, although only 1 patient has been studied postmortem. In the present report, [18F]fluorodopa positron emission tomography in 2 patients showed a marked dopaminergic denervation of the striatum, suggesting that this disease corresponds more to a nigropallidopyramidal dysfunction.

Sporadic lower limb hypertrophy and exercise induced myalgia in a woman with dystrophin gene deletion

A 25 year old woman, without family history of muscular dystrophy, had had an isolated lower limb hypertrophy since infancy and later experienced exercise-induced myalgia. Genomic DNA analysis showed a deletion of exons 45 to 52 of the dystrophin gene. Uncommon phenotypes of dystrophinopathies and consequences in genetic counselling in women are emphasised.

Creutzfeldt-Jakob disease after liver transplantation

We report a 57-year-old woman who died from Creutzfeldt-Jakob disease 2 years after a liver transplantation. The liver donor had no history of neurological disease. In one albumin donor, possible Creutzfeldt-Jakob disease developed 3 years later. The patient initially had cerebellar symptoms. Neuropathology included "Kuru-type" plaques and prion protein (PrP) deposits involving the cerebellum predominantly. The patient was homozygote valine at codon 129 of the PrP gene while the liver was homozygote methionine. This observation raises the possibility of transmission of Creutzfeldt-Jakob disease by the graft itself or the associated albumin transfusions and, on a wider extent, by nonneural tissue.

Methylprednisolone infusion during acute exacerbation of MS: plasma and CSF concentrations

Plasma and CSF concentrations of methylprednisolone (MP), after a high-dose intravenous administration (1,500 mg) prescribed to patients presenting acute exacerbation of multiple sclerosis, were measured. A plasma pharmacokinetic study with 1 CSF sample was performed in 9 patients and 4 other patients had a single plasma sample at the time of lumbar puncture. MP plasma kinetics were similar between patients. Pharmacokinetic parameters were very close to previous published values obtained in normal volunteers or patients with rheumatoid disease. Passage of MP into the CSF was delayed since mean plasma/CSF ratio dropped dramatically from 150 at the 2nd h to 25 at the 3rd h after starting infusion. CSF concentrations of MP were high with a mean reaching 522 micrograms/l at the 6th h. The high levels of CSF concentrations suggest that MP may have powerful pharmacological effects within the CNS. No correlation was found between CSF concentration and the clinical response to steroid therapy. The issues related to previous data on clinical, biological and radiological effects of high-dose intravenous MP are discussed in the light of our results.

Rest tremor and extrapyramidal symptoms after midbrain haemorrhage: clinical and 18F-dopa PET evaluation

A 25 year old man had an acute subarachnoid haemorrhage due to the rupture of a right peduncular subthalamic arteriovenous malformation. Seven months later he developed a left rest tremor associated with mild bilateral extrapyramidal symptoms and responsive to levodopa treatment. Surface EMG recording showed synchronous activity of agonist and antagonist muscles in the left limbs. A PET 18F-dopa study showed a large decrease of the Ki value in the right striatum. One year after the stroke a persistent postural component developed in the tremor.

Creutzfeldt-Jakob disease and cerebral amyloid angiopathy

An 83-year-old female with no personal or familial neurological history developed progressive gait and speech disturbance and left motor deficit. She suffered intractable seizures and died 3 months after the onset of neurological signs. Neuropathology showed severe spongiosis and gliosis in the cortex and basal ganglia, and diffuse cerebral amyloid angiopathy. Immunostaining for prion protein (PrP) showed intense PrP positivity in areas of confluent spongiosis and some granular staining in astrocytes. The cortical vessel walls stained positively for beta/A4 amyloid but not for PrP amyloid. Both types of amyloid were only observed in pericapillary parenchyma, in areas with severe spongiosis. There were only a few tangles and neuritic plaques in the temporal cortex; amyloid plaques were not present either by silver stains or immunostains. There was neither arteriopathic leukoencephalopathy nor cerebral hemorrhage. Immunoblot analysis of brain extracts revealed an abnormal proteinase K-resistant isoform of PrP. Association of Creutzfeldt-Jakob disease and Cerebral amyloid angiopathy in the absence of Alzheimer changes in unusual. The association of PrP and beta/A4 amyloid deposits could have been fortuitous in an 83-year-old patient. An etiopathogenic relationship between beta/A4 amyloid deposition and PrP accumulation may also be considered.

Elevated levels of interleukin-1 beta (IL-1 beta) and IL-6 in serum and increased production of IL-1 beta mRNA in lymph nodes of patients with polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (POEMS) syndrome

To evaluate a possible implication of cytokines in the pathogenesis of polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (POEMS) syndrome, we studied five consecutive patients with this condition, of which four had sclerotic bone lesions and four had multicentric Castleman's disease. Interleukin-1 beta (IL-1 beta) and IL-6 serum levels were determined in these patients (13 serum samples) and in patients with multiple myeloma (5) and Waldenström's macroglobulinemia (5). In situ hybridization of the relevant mRNAs was performed on lymph node specimens of two patients with POEMS syndrome who had Castleman's disease. Elevated serum levels of IL-1 beta (13/13 samples), and IL-6 (7/13 samples) were found in patients with POEMS syndrome. In the other patients, serum IL-1 beta was undetectable or slightly increased and IL-6 was elevated in a single patient with Waldenström's macroglobulinemia. Abundant IL-1 beta mRNA-producing cells were present in interfollicular spaces in the two tested patients, while IL-6 mRNA-producing cells were rare. We conclude that IL-1 beta and IL-6 serum levels may be chronically elevated in patients with POEMS syndrome, and that lymph node may be one site of IL-1 beta overproduction. These results are in keeping with the hypothesis that cytokines mediate systemic manifestations of POEMS syndrome.

Early weight loss and high serum tumor necrosis factor-alpha levels in polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes syndrome

We studied tumor necrosis factor-alpha (TNF-alpha) levels in serial serum samples from 3 consecutive patients who had a complete form of POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes) syndrome and early weight loss. Serum TNF-alpha levels were compared with those of 10 patients with multiple myeloma (5) or Waldenström's macroglobulinemia (5). Elevated serum levels of TNF-alpha were found in the patients with POEMS syndrome (two- to eightfold increase in 10 of 11 samples) and not in those with other malignant plasma cell dyscrasias. These results are in keeping with the hypothesis of a role for nonimmunoglobulinic mediators in the pathogenesis of the POEMS syndrome, and are consistent with previous reports of TNF-alpha overproduction in inflammatory demyelinating neuropathies and cachectic states.

Selective deficit of visual size perception: two cases of hemimicropsia

Hemimicropsia is a rare disorder of visual perception characterized by an apparent reduction of the size of objects when presented in one hemifield. We report two cases of hemimicropsia resulting from focal brain lesions. The first patient was an art teacher and could accurately depict his abnormal visual perception. He subsequently died and his brain was examined post mortem. In the second patient, micropsia was assessed by a quantified size comparison task. The size of a given object is normally perceived as constant across any spatial position. Hemimicropsia may thus be considered a limited violation of the size constancy principle. Behavioural and anatomical data are discussed in relation to the neural basis of visual object perception in humans.

Severe frontal syndrome associated with infarcts of the left anterior cingulate gyrus and the head of the right caudate nucleus. A clinico-pathological case

The clinicopathological findings in a patient who presented a severe frontal syndrome and who had ischaemic lesions in the left anterior cingulate gyrus and in the head of the right caudate nucleus are reported. The clinical features included complex disorders such as distractibility, docility, emotional unconcern, manual grasping, prehension and utilization behaviour, perseverations and anterograde amnesia. They are closely similar to those previously described in a patient with bilateral lesions involving the anterior cingulate gyri. These findings suggest that (i) in the presence of a lesion of the anterior cingulate gyrus on one side, a lesion of the head of the contralateral caudate nucleus may be equivalent to a lesion of the anterior cingulate gyrus, the anterior cingulate gyrus--caudate complex working as a single functional unit; (ii) the anterior cingulate gyri (and anterior cingulate gyrus--caudate complexes) play a crucial role in the expression of frontal lobe functions; (iii) they are necessary for sustained goal-oriented responses to (emotionally or not) discriminated stimuli.

Concentric MR patterns in multiple sclerosis. Report of two cases

We report two cases of multiple sclerosis with concentric patterns of demyelinated foci on MR images. These were compared with the pathological data of Balò's disease. The T2-weighted MR images displayed alternating high and low signal areas which probably corresponded to the concentric type of demyelination. Our two cases were characterized by their acute onset and their regression following corticosteroid therapy. This suggests that Balò's disease may be a transient disease and not always associated with a fatal course.