Vincenzo Branca

Intraoperative subcortical language tract mapping guides surgical removal of gliomas involving speech areas

OBJECTIVESubcortical stimulation can be used to identify functional language tracts during resection of gliomas located close to or within language areas or pathways. The objective of the present study was to investigate the feasibility of the routine use of subcortical stimulation for identification of language tracts in a large series of patients with gliomas and to determine the influence that subcortical language tract identification exerted on the extent of surgery and on the appearance of immediate and definitive postoperative deficits. METHODSSubcortical stimulation for language tract identification was systematically used during surgical removal of 88 gliomas (44 high-grade and 44 low-grade gliomas) involving language pathways. Procedures were performed during asleep/awake craniotomy. Subcortical stimulation was continuously alternated with surgical resection in a back-and-forth fashion. Language performances were tested by neuropsychological language evaluation preoperatively and at 3, 30, and 90 days after surgery. RESULTSLanguage tracts were identified in 59% of patients, with differences according to tumor location but not according to histological grade. Language tract identification influenced the ability to reach a complete tumor removal in low-grade gliomas, in which tracts were documented inside the peripheral mass of the tumor. Identification of language tracts was associated with a higher occurrence of transient postoperative deficits (67.3% of cases), but a low occurrence of definitive morbidity (2.3% of cases). A pattern of typical language disturbances related to the phonological and semantic system can be identified according to tumor location, with preservation being important for the maintenance of language integrity. CONCLUSIONOur study supports the routine use of subcortical stimulation for language tract identification as a reliable tool for guiding surgical removal of gliomas in or in close proximity to language areas or pathways.

Schilder's disease: non-invasive diagnosis? :A case report and review.

Schilder’s disease, or myelinoclastic diffuse sclerosis, is a rare disorder characterised by an inflammatory white matter plaque of demyelination. Clinical signs and symptoms might be atypical for early multiple sclerosis and at imaging the lesion is easily taken for a brain tumour. Regardless of the use of Poser’s criteria for clinical diagnosis of Schilder’s disease proposed in 1986, diagnostic difficulties are still present, as evidenced by the many reported cases in the English literature revised (Pubmed indexed, period 1998–2008). It clearly emerges that neuroradiological features, observable in additional magnetic resonance sequences are crucial, besides the consideration of Poser’s criteria, in differentiating between demyelinating lesions and brain tumours. A 29-year-old female patient is presented, where a careful evaluation of both the clinical and radiological features, which might have been at a first glance misleadingly suggestive for a brain tumour, allowed non-invasive diagnosis of Schilder’s disease.

Pediatric mercury poisoning, brain MRI, and white matter hyperintensities

-weighted MRimages of the brain, Benz et al. [1] describe a 4-year-oldgirl with a nonfatal percutaneous inorganic mercuryintoxication due to topical application of mercury-containing skin lightening cream. The authors are to becommended on their case report as they also provide anexcellent discussion of the effects of chelation therapy with2,3-dimercapto-1-propanesulfonic acid. In the “Introductionsection” of their case report, Benz et al. state that, “Dataabout magnetic resonance imaging (MRI) findings inintoxication from inorganic Hg did not exist up to now” [1].We wonder if they are aware that diffuse and punctiformsubcortical WMLs on T

Cerebellum Enlargement and Corpus Callosum Agenesis: A Longitudinal Case Report

Macrocerebellum, a neuroradiological and clinical entity of unknown etiology characterized by an isolated, disproportionately large cerebellum, has to date been reported in only a few cases. It has been suggested that the condition could represent a marker for disturbed cerebral development, however, longitudinal reports are lacking. We describe a 19-month-old patient with agenesis of the corpus callosum, who developed enlargement of the cerebellum without clinical signs of cerebellar impairment, a picture that has not been previously described.

BMD, fMRI study and brain hypoactivity

(FMS). The review by Klossika et al. is concerned with modulation of pain by emotional states. My review notes that this is a two-way interaction but emphasizes activation of central circuits for stress reactions and emotional processing by nociceptive input. The obvious elicitation of emotions by pain makes it difficult to understand Knapp s point of contention. Why would he reject evidence, new or old, for a peripheral contribution to FMS pain and associated emotions? Probably it is because the originating condition for FMS pain is not detectable by standard clinical examination, in contrast to many focal pain conditions. This frustrating diagnostic problem has frequently led to adoption of the emotional disorder hypothesis for FMS. However, there is a very big difference between modulation of pain, as proposed by Klossika et al., and the possibility of de novo creation of a specific type of pain (e.g., the muscular pain of FMS) by an emotional state. In addition, a correlation between pain and an emotional disorder does not permit assignment of causality. Simply noting that pain is associated with depression (or vice versa) does not permit conclusions that a patient s depression causes pain or even that their pain causes depression. A patient might be depressed because his or her activities are restricted by the FMS condition (including pain, fatigue and loss of sleep), and a brain image of this patient should reveal activity in areas involved in emotional and pain processing. Additional evidence is required to identify neurobiological mechanisms for the pain and the depression. These points of interpretation have important implications for development of effective treatments for FMS. Depression is a common accompaniment of chronic pain, and antidepressants are frequently prescribed for FMS and other pain conditions. Antidepressant medication helps patients cope with their condition, but attenuation of FMS pain is so minimal, if present, that it is difficult to document (Goldenberg, 1989). The emotional disorder hypothesis appears not to be the whole story. An alternative approach is to reduce the pain and see if depression falls away. In order to test this possibility, treatments based on mechanistic evidence are needed (Woolf et al., 1998). Rapidly increasing knowledge concerning autonomic regulation and peripheral mechanisms of muscular pain offers considerable promise in this regard.

Aspergillosis, maxillary foreign body, and mercury amalgam

With reference to the recent short communication by Burnam and Bridle1 about a 49-year-old man with a maxillary spergilloma caused by retained amalgam in his right maxilary antrum after complications of extraction of a tooth, we ould like to make the following points: The authors provide no details of the cultured fungal olonies. Were any microbiological tests done? Although in general a specimen that grew a pathogen is ot necessary for diagnosis, it would be interesting to know he results of microbiological testing for Aspergillus species r that for other fungi associated with retention of amalgam n the maxillary antrum.2 We also wonder how the patient was treated during the revious 2 years. It would be useful to know whether he was iven long-term inhaled or nasal steroids, or both for chronic inusitis.3