F. Pinto

Monitoring of somatosensory evoked potentials during carotid endarterectomy

SummarySomatosensory evoked potentials (SEPs) were monitored in the course of 368 carotid endarterectomies (CEAs) carried out in 312 patients. In an initial group of 26 patients the shunt was used routinely while in a second group, involving 342 CEAs, it was applied selectively on the basis of modifications which the SEP underwent during clamping. The criterion for shunting was the progressive reduction, up to 50%, of the N20-P25 amplitude. New postoperative neurological deficits appeared in 6 patients, all of whom displayed a transitory SEP flattening. The SEPs of 2 of these returned to normal by the time they awoke and both showed a clinical deficit homolateral to the operated side. In only 2 cases did the deficit fail to regress completely and their postoperative CT scans revealed ischaemic lesions. A positive relationship emerged between SEP changes and back pressure values; nonetheless, as many as 75% of the patients with low residual back pressure values (< 25 mm Hg) tolerated the clamping. SEP monitoring appears to provide a reliable basis for selectively applying a shunt when there is a high risk of haemodynamic ischaemia during clamping.

Cytokine pattern in the cerebrospinal fluid from patients with GBS and CIDP

Macrophage-colony stimulating factor (M-CSF) and, less frequently, IL-1 beta and IL-6 were detected in the cerebrospinal fluid (SF) from Guillain-Barré syndrome (GBS) patients. IL-1 alpha, IL-2, IL-10, TNF alpha, and IFN gamma were not found. Detectable cytokine levels were not observed in chronic inflammatory demyelinating polyneuropathy (CIDP) SF nor in any of the sera studied. These findings suggest a prominent intrathecal activation of cells of the monocyte/macrophage lineage (Mø) in GBS, and further support the hypothesis of a crucial role for Mø in GBS immunopathology.

Continuous EEG-SEP monitoring of severely brain injured patients in NICU: methods and feasibility.

AIMS To evaluate the feasibility of a continuous neurophysiologic monitoring (electroencephalography (EEG)-somatosensory evoked potentials (SEPs)) in the neuro-intensive care unit (NICU), taking into account both the technical and medical aspects that are specific of this environment. METHODS We used an extension of the recording software that is routinely used in our unit of clinical neurophysiology. It performs cycles of alternate EEG and SEP recordings. Raw traces and trends are simultaneously displayed. Patient head and stimulator box are placed behind the bed and linked to the ICU monitoring terminal through optic fibers. The NICU staff has been trained to note directly clinical events, main artefacts and therapeutic changes. The hospital local area network (LAN) enables remote monitoring survey. RESULTS Continuous EEG (CEEG)-SEP monitoring was performed in 44 patients. Problems of needle detachment were seldomly encountered, thanks to the use of a sterile plastic dressing, which covers needles. We never had infection or skin lesions due to needles or the electrical stimulator. The frequent administration of sedative at high doses prevented us from having a clinically valuable EEG in several cases but SEPs were always monitorable, independently of the level of EEG suppression. The diagnosis of seizures and non-epileptic status was based on raw EEG, while quantitative EEG (QEEG) was used to quantify ictal activity as a guide to treatment. CONCLUSIONS EEG and EP waveforms collected in NICU were of comparable quality to routine clinical measurements and contained the same clinical information. A continuous SEP monitoring in a comatose and sedated patient in NICU is not technically more difficult and potentially less useful than in operating room. This monitoring appears to be feasible provided the observance of some requirement regarding setting, electrodes, montages, personnel integration, consulting and software.

A synthetic glycopeptide of human myelin oligodendrocyte glycoprotein to detect antibody responses in multiple sclerosis and other neurological diseases

Glycopeptides of hMOG(30-50) containing a glucosyl moiety on the side-chains of Asn, Ser or Hyp at position 31 were synthesised. Antibody titres to hMOG(30-50) and to its glucoderivatives were measured by ELISA in sera of patients affected by different neurological diseases. Anti-hMOG(30-50) antibodies were detected only using the glycopeptide [Asn31(N-Glc)]hMOG(30-50).

Spatial analysis reveals alterations of parvalbumin- and calbindin-positive local circuit neurons in the cerebral cortex of mutant mdx mice

The aim of the present study was to investigate the spatial organization of selected populations of local circuit neurons in the cerebral cortex of the mutant mdx mouse, an acknowledged model of Duchenne Muscular Dystrophy. To this purpose, we quantified and compared the distribution of parvalbumin- and calbindin-positive neurons in the motor, somatosensory, visual, and anterior cingulate cortices of wild-type and mdx mice. The methodological approach was based on generation of two-dimensional Voronoi polygons from digital charts of the cell populations visualized immunohistochemically. Polygon areas were then analyzed and the derived coefficients of variation were statistically compared. Using this strategy, we were able to reveal, in mdx mice, changes involving both the above populations of interneurons. These changes were evident in the motor and anterior cingulate cortices but not in the somatosensory and visual cortices. In addition, the changes of coefficients of variation were area-specific in the cortex of mdx mice. The values increased in the motor cortex and decreased in the anterior cingulate cortex with respect to the corresponding values of wild-type animals. The present findings point out widespread alterations in the mdx cortex involving also areas not primarily related to sensorimotor integration. In addition, we demonstrate that cortical alterations of the local circuit machinery are characterized in mdx mice by individual regional differences.

Prognostic value of somatosensory evoked potentials in comatose children: a systematic literature review

PurposeTo review the predictive powers of SEPs in comatose children after acute brain injury.MethodsMEDLINE, EMBASE, OVID, ISI Web of Knowledge, BIOMED Central and the Cochrane Library (1981–2007) were searched. First, predictive values were calculated for each primary study. Second, we analysed effects of different factors on the SEP diagnostic odds ratio by meta-regression. Third, we compared SEP predictive values in children and in adults.ResultsWe selected 14 studies covering 732 patients; analysis was conducted in 11, while the other 3 were used for simple qualitative examination. In individual papers, the presence of SEP predicted favourable outcomes as shown by the area under both sROC curves being 0.958. The same value was shown by SEP absence for predicting unfavourable outcomes. All covariates showed no significant effects on diagnostic accuracy, but only a slight non-significant trend. For SEP grading, a simple sub-group analysis showed a high predictive value for non-awakening for absence of SEPs (PPV 97.0%) and a high prognostic power to predict awakening for normal SEPs (PPV 92.2%). Pathological SEPs did not show reliable predictivity. In children, the presence of SEPs showed a high prognostic power similar to that in adults.ConclusionThis study supports the use of SEPs in the integrated process of outcome prediction after acute brain injury in children. Caution is recommended in predicting unfavourable outcomes in patients with an absence of SEPs in both TBI and HIE comas. Future studies are needed to resolve the issue of the effect of aetiology and age on SEPs predictive power.

Cortical and brainstem neurons containing calcium‐binding proteins in a murine model of Duchenne's muscular dystrophy: Selective changes in the sensorimotor cortex

In the muscular dystrophic (mdx) mouse, which is characterized by deficient dystrophin expression and provides a model of Duchennes muscular dystrophy, we previously demonstrated marked central nervous system alterations and in particular a quantitative reduction of corticospinal and rubrospinal neurons and pathologic changes of these cells. Prompted by these findings and in view of the relations between calcium ions and dystrophin, we analyzed with immunohistochemistry the neurons containing the calcium‐binding proteins parvalbumin, calbindin D28k, and calretinin in cortical areas and brainstem nuclei of mdx mice. In the sensorimotor cortex, parvalbumin‐positive and calbindin‐positive neurons, which represent a subset of cortical interneurons, were significantly more numerous in mdx mice than in wild‐type ones. In addition, the laminar distribution of parvalbumin‐positive neurons in the motor and somatosensory cortical areas of mdx mice was altered with respect to wild‐type animals. No alterations in the number and distribution were found in the parvalbumin‐ or calbindin‐expressing cell populations of the visual and anterior cingulate cortices of mdx mice. The pattern of calretinin immunoreactivity was normal in all investigated cortical areas. The cell populations containing either calcium‐binding protein were similar in brainstem nuclei of mdx and wild‐type mice. The present findings demonstrated selective changes of subsets of interneurons in the motor and somatosensory cortical areas of mdx mice. Therefore, the data showed that, in the cortices of these mutant animals, the previously demonstrated pathologic changes of corticospinal cell populations are accompanied by marked alterations in the local circuitry. J. Comp. Neurol. 456:48–59, 2003.

Abnormal projection of corticospinal tracts in a patient with congenital mirror movements

A 31 year-old woman with familial congenital mirror movements not associated with other neurological defects underwent a detailed neurophysiological evaluation including: voluntary electromyographic activity recorded from upper limbs in response to acoustic stimuli, motor evoked potentials from the thenar muscles to focal transcranial magnetic stimulation, F waves from upper extremities, scalp somatosensory evoked potentials and long-latency responses from thenar muscles to electric stimulation of the median nerve. The results were consistent with the presence of fast-conducting pathways connecting each hand motor cortex with both contra- and ipsilateral spinal motoneurones.

The organisation of spinal projecting brainstem neurons in an animal model of muscular dystrophy: A retrograde tracing study on mdx mutant mice

Previous studies we performed on the mdx mouse demonstrated marked central nervous system alterations in this model of human Duchenne muscular dystrophy, such as reduction in number and pathological changes of cortico-spinal neurons. Prompted by these findings we extended the survey of the mdx brain to the major brainstem-descending pathways: the rubro-, vestibulo-, reticulo-, and raphe-spinal projections. Horseradish peroxidase microinjections were performed in the cervical spinal cord of mdx and control mice. The rubro-spinal neurons were found to be significantly reduced in mutants compared to controls. The vestibulo-spinal, reticulo-spinal, and raphe-spinal cell populations, though less numerous in mdx than in control mice, were instead substantially spared. Our data further unveil the selective nature of mdx brain damage indicating a marked and selective involvement of the highest centers for motor control.

Anti-ganglioside antibodies and elevated CSF IgG levels in Guillain-Barré syndrome

Anti‐ganglioside antibody production and dysfunction of blood‐cerebrospinal fluid (CSF) barrier (BCB) are frequent findings in dysimmune neuropathy patients, whereas intrathecal synthesis of immunoglobulins is still a matter of debate. We examined the CSF, immunological and electrophysiological characteristics from a cohort of patients with Guillain‐Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP), and from patients with other neurological diseases as control. Thirty‐eight percent of GBS patients and 28% of CIDP patients had detectable serum titers of anti‐ganglioside antibodies, which were associated with a high incidence of motor conduction block and increased F wave latencies. In GBS patients, but not in CIDP or control patients, there was an association between anti‐ganglioside antibodies and increased CSF immunoglobulin‐G (IgG) levels as determined by the IgG index. However, none of the GBS patients had CSF oligoclonal bands (OBs) or indications of intrathecal anti‐ganglioside antibody synthesis. The possibility of an abnormal CSF concentration of immunoglobulins from serum through dysfunctional BCB or damaged nerve roots, and the role of serum anti‐ganglioside reactivity in this process are discussed.