Neurological Disorders

This 33-year-old man presented with one-year history of intermittent left orbital pain and diplopia after was diagnosed as HIV infection for 6 months. He had limited movement of the left eye with impairment of nearly all gaze direction. RAPD was positive on the left. He had no weakness or sensory disturbance. MRI showed a well efined mass in the left cavernous sinus with post-gadolinium enhancement. Suprasellar extension with dural tail on the left side was noted with mild pressure effect to the left prechiasmatic optic nerve

A 73 year-old man with past medical history of atrial fibrillation, not on warfarin, severe peripheral vascular disease, coronary artery disease, hypertension, dyslipidemia was speaking with a co-worker and suddenly lost consciousness, dropping to the floor.

Viral vector gene transfer is an important tool for studying protein function in vivo. Recombinant adeno-associated virus (AAV) is advantageous for gene transfer to the central nervous system. Over the past few years it has been shown that an intravenous vector delivery can transduce neurons throughout the central nervous system [1-3]. The images are of rats administered AAV serotype 9 vector encoding green fluorescent protein (GFP). The rats were injected intravenously on post-natal day one and imaged for GFP expression 4-12 weeks later. There is robust expression in the spinal cord and dorsal root ganglia and the cerebellum (Figures 1-3). We have been exploiting the efficient spinal cord transduction to study a spinal cord disease, amyotrophic lateral sclerosis [2-4].

Connectome matrices are increasingly instructive in the evaluation of human brain neuroanatomy. Data collected for the human brain connectome reveals elaborate intricacies of the human brain and what makes us unique and diverse. White matter density differences, for instance, can be correlated with quantity of information flowing through a particular brain region, which, in turn, may suggest potential neuroanatomical correlations with cognitive ability.

Interleukin-2 (IL-2) has been implicated in neurological disorders including multiple sclerosis and Alzheimer’s disease. Peripheral IL-2 deficiency in gene-deleted mice results in T cell mediated autoimmunity that begins to develop slowly after weaning and progressively increases through adulthood. Loss of brain-derived IL-2 results in neurobiological and behavioral abnormalities, and may contribute to the development of CNS autoimmunity by modifying the neuroimmunological milieu of the brain. We have shown previously that IL-2 knockout (KO) mice have altered learning acquisition in the Morris water-maze. Hypothesizing that the learning acquisition deficits in IL-2KO would be associated largely with the loss of brain-derived IL-2, the present study sought to determine if these cognitive alterations are due to the loss the IL-2 gene in the brain and/or autoimmunity resulting from loss of the gene in the peripheral immune system. We found that SCID congenic mice (mice free of IL-2 deficiency induced peripheral autoimmunity) without brain IL-2 (two IL-2KO alleles) did not differ from SCID congenic mice with normal brain IL-2 (two WT IL-2 alleles); thus, contrary to our hypothesis, loss of brain-derived IL-2 did not affect learning acquisition in the water-maze. Compared to adult WT littermates (9 weeks), adult IL-2KO mice with autoimmunity exhibited alterations in learning acquisition in the Morris water-maze whereas younger pre-autoimmune IL-2KO mice (5 weeks) had performance comparable to younger WT littermates, suggesting that the water-maze learning deficits in IL-2KO mice were associated with the development of peripheral autoimmunity. As IL-2KO mice have cytoarchitectural alterations in the dentate gyrus, circuitry involved in the differentiation of contexts (versus places), we also compared IL-2KO mice and littermates in a contextual fear discrimination paradigm. IL-2KO mice were found to have reduced conditioned fear discrimination that was not related to age-associated autoimmunity. Together, these findings suggest that complex interactions between IL-2 deficiency in the brain and immune system may modify brain processes involved in different modalities of learning and memory.

The rate of critically ill older patients being admitted to intensive care units (ICU) continues to rise. Multiple factors influence the complexity of treatment strategies and create challenges for optimizing patient care while avoiding unwanted adverse effects. These factors include Pharmacokinetic (PK) and Pharmacodynamics (PD) changes that are compounded by both age and critical illnesses and may heighten the risk of suboptimal treatment strategies and adverse drug events, including neurotoxicity, to the patient. Medications that increase the risk for adverse drug events, drug-drug interactions, and drug-disease interactions may be classified as a potentially inappropriate medications based on risk versus benefit of use in older adults. However, many times these agents are needed for treatment of critically ill patients and must be dosed and monitored appropriately to avoid complications, such as delirium, which is associated with increased morbidity and mortality in the older population. Unfortunately, clinical pharmacotherapy and outcome studies with extreme age considerations for pharmacotherapy are lacking. This article reviews the pharmacotherapy challenges in older critically ill patients, and provides medication considerations for avoiding adverse drug events that may complicate patient care.

Idiopathic hypertrophic pachymeningitis is a rare entity, posing challenge to the radiologist for a confident prospective diagnosis. The same is of prime importance as in the absence of a definitive treatment, the clinician has to initiate a presumptive therapy based on radiological diagnosis, histopathology not being the pragmatic option in most cases. We present a case which is interesting not only by virtue of the rarity of this disease but also due to the extent of cranial nerves involved and the drastic response to therapy initiated once suspected on MRI. The emphasize of this report is on being mindful of the possibility and early recognition of signs differentiating it from other close and commoner mimickers.

This article is about specificity of schizophrenia care with the evolution of these last years and the help of Cognitive Remediation to improve the quality of life and the insertion of these patients. First, we describe the criteria of international classifications (DSM V and ICD 10) and the fact that they are not completely the same. To illustrate this limit, we define the frequent case of brief psychosis, it can be an isolate episode in a life or not. Sometimes, the evolution is the chronic illness. Then, the cognitive approach is a new definition of psychotic disorders. The question is how to help these patients to adapt their cognition with the society and how to help them to compensate their deficits. Here, are described more precisely IPT, CRT, RECOS, REHACOM® and RC2S programs with the necessity of a personal accompaniment. Explain them the trouble is essential and depend of the singularity of each subject in his own culture and family history. Randomized studies show that Cognitive Remediation, new medications and psychotherapies are supplementary to cure schizophrenia and psychosis as an illness like any other.

The five universally accepted tastes, sweet, salty, sour, bitter, and umami (a savory sensation elicited by monosodium glutamate) have specific receptors in oral, pharyngeal and laryngeal regions [1]. The most credited candidates to the function of human primary taste cortex are the frontal operculum and the anterior insula; while the opercular cortex and the orbitofrontal cortex are thought to code for secondary gustatory functions, while the amygdale and the dorsolateral prefrontal cortex are involved as hierarchically superior processing units [2]. Conversely, more is known on the peripheral pathway of taste, including the molecular dynamics of many receptors [3].

Background: Wernicke encephalopathy after bariatric surgery is rare and difficult to recognize. The severity of the disease and the preventable but irreversible long-term implications lead us to emphasize the importance of timely and correct diagnosis and treatment. Nonalcoholic Wernicke encephalopathy often manifests atypical clinical presentation and disease progression that makes it prone to be underestimated.
Clinical case: We report the medical history of a 48-year old lady after bariatric surgery. It is a case of possible Wernicke encephalopathy. The patient presents with a constellation of physical features that may represent a complex clinical situation due to longer existing vision problems or an as yet uncharacterized Wernicke encephalopathy. We discuss diagnosis, underlying pathology, metabolic mechanism and common therapeutic approach.
Conclusion: With the ongoing global epidemic of obesity the need for obesity surgery will increase, thus leading to increased occurrence of Wernicke encephalopathy. This emphasizes the importance of awareness of this clinical entity and the need for early detection and prevention.

Introduction: Dural injuries are encountered generally as trauma, spinal tumor excision or postop complications. It is a major problem leads to cerebrospinal fluid leakage meningitis. The method used often in repair is applying the watertight suture to the damaged area with appropriate measures of fascia and dural grafts. The used grafts can be ranged as bovine pericardium, synthetic collagen matrices, fibrin tissue adhesive, vicryl, and polydioxanone graft. In the studies, it is observed that there is still no significant difference between grafts and fascia.
Material-Methods: In our study, 60 Spraque Dawley rats whose weights are ranging from 200-250 gr were used. The solution consists of the ketamine hydrochloride (60 mg/kg) and xylazine (12 mg/kg) was injected intraperitoneally to the subjects and the subjects were taken into anesthesia. The subjects were divided into 5 groups. In the first group no extra action was taken, in the second group, fibrin tissue adhesive was applied on the dural injury and in the third group collagen matrix was applied on the dural injury, in the fourth group bovine pericardium was applied on the dural injury, in the fifth group subcutaneous fascia (autogenetic graft) was applied on the dural injury.
Surgical Operation: After providing the sterile conditions and operating the anesthesia agents, the experimental animals were laid down on the operating table in the prone position for surgical operation. Following the local area cleaning and environment isolation, subcutaneous incision was applied. Fascia was opened and paravertebral muscles were scarred subperiostally. After applying L1-4 laminectomy, approximately 2 cm linear incision was made with bistoury and cerebrospinal fluid leakage was observed from the dural injury. Analgesia was applied with 10 mg/kg paracetamol on the subjects which survived approximately 6 weeks after the operation. On the 7th day (early group) after the operation, 6 animals from each group and 6 animals from each group after 6 weeks from the operation were injected 100 mg/kg phenobarbital intraperitoneally and scarification operation was completed. Former incision was opened and spinal cord under the laminectomy area was removed with the dural graft as a block and histopathological findings was provided.
Histopathological findings: The incisions from this area were stained with Hematoxylin Eosin and Masson Trichrome. In the examination, collagen, vascular diagenesis and necrosis from histopathological findings were examined in early period (first week) and late period (sixth) week. It was observed that in the groups.

Objectives: The present study aims to assess the results of extended Transforaminal Lumbar Interbody Fusion (TLIF) for a two-surgeon, single institution series.
Methods: 57 cases of extended TLIF with bilateral decompression were performed. Pain, ASIA scores, patient demographics, BMI, perioperative indices and radiographic measurements were recorded and analysed.
Results: 57 operations were performed between February 2011 and January 2014, there were 38 female and 19 male patients. Mean patient age was 62.86 years, mean BMI was 30.31 kg/m2. In 49 patients spondylolisthesis was the primary indication. The mean intraoperative time was 284.65 min, this decreased as the series progressed. The median length of stay was 5 days, ranging from 2 to 9 days. The surgical complication rate was 22.8%. Two patients died from cardiopulmonary complications. 78.9% of the cohort had single-level TLIF, L4/5 was the most commonly fused level. Significant pain reduction was achieved from a mean Pre-operative VAS of 8.28 +/- 1.39 to post-op VAS of 1.50+/-1.05 at 12 months. No patients deteriorated neurologically. Spondylolisthesis was significantly corrected from a pre-operative mean of 6.82 mm to 2.80 mm post-operatively. There is a learning curve associated with the procedure.
Discussion: TLIF with bilateral facet joint removal and decompression appeared to be a safe and effective alternative to other fusion techniques, and is comparable to other published case series. Stabilisation and correction of spinal deformity reduces pain, aids neurologic recovery and improves quality of life.

The objective of this study was to present a case of a solitary fourth intraventricular schwannoma with a review of the literature, and to analyzing the current theories of its origin and application of trancerebellomedullary fissure approach. The authors presented a primary intraventricle schwannoma occurring in the lateral recess of the fourth ventricle in a 53-year-old female. She presented with severe headache, dysphagia, horizontal nystagmus, ataxia and quadriparesis were detected on initial examination. Imaging studies showed a large mass in the fourth ventricle and a marked hydrocephalus. The tumor was removed by microsurgical dissection using the cerebellomedullary fissure approach at our Institution. Complete removal was achieved and no reccurrence was noted follow-up period of 8 months after surgery. To our knowledge, this is the ninth reported case schwannoma of fourth intraventricule in the literature, which is unrelated to the cranial nerves and cerebellar hemisphere parenchyma, blood vessel or to the dura, is extremely rare. The etiology and natural history of intraventricular schwannomas is not well understood. The presenting clinical, radiological and pathological features of this tumor are summarized. We have discussed the effectiveness of this approach for removal of bulky tumors of the fourth ventricle, the other cases reported in the literature are reviewed and the benefits and potential hazards of trancerebellomedullary fissure (T-CMF) approach. Intraventricular schwannomas are benign tumours that are amenable to complete surgical removal, having a good prognosis without the need of adjuvant therapy.

The subdural hematoma (SDH) could be a serious complication of the spontaneous intracranial hypotension (SIH) that is a rare but well-known entity. We reported four illustrative cases of subdural hematomas revealing SIH. Three women and a man with mean age of 58.5 years. In three cases we noted sudden headaches, progressive and postural in one. CT scan has diagnosed the subdural hematomas that were thin and bilateral in three cases. Magnetic resonance imaging (MRI) confirmed the diagnosis of associated SIH. None has undergone an invasive exploration. Two patients were operated for clinical worsening. All of our patients were treated by epidural lumbar blood patch with very good outcome. author highlights the strategy of diagnosis and management of this underestimated pathology by showing different practical situations.

We determined whether cyclooxygenase-2 (COX-2) gene polymorphisms were involved in the aggravation of migraines due to the overuse of medication. Polymorphisms in the COX-2 (rs20417, rs689466) gene were examined. Forty-seven patients with migraine (6 males and 41 females; 5 with migraines with aura (MA), 36 with migraines without aura (MO), 6 with MA + MO; 1 with MA and 21 with MO; 36.4 ± 10.3 years) and 22 patients with medication overuse headache (MOH) (1 male and 21 females; 39.6 ± 9.9 years) who had migraines participated in this study. The genotypes of each polymorphism were analyzed by polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) methods. No significant differences were observed in the genotypic distributions of rs20417 (C/C + G/C vs. G/G, p=0.220) between migraine patients and MOH patients. The frequencies of the rs689466 G/G genotype were significantly higher in patients with MOH than in patients with migraines (G/G vs. A/A+A/G, p=0.008). Furthermore, the frequencies of the rs689466 G/G genotype were significantly higher in patients with MOH who had migraines without aura (MO) than in patients with MO (G/G vs. A/A+A/G, p=0.001). The results of this study showed that the COX-2 polymorphism (rs689466) was independently related with the complication of MOH in patients with MO.

Onyx Liquid Embolic System (LES) embolization of highly vascular lesions is becoming more frequently used as an adjuvant therapy prior to surgical resection. The authors present a case of a successful pre-operative embolization of a glomus jugulare tumor using Onyx LES. The patient returned for scheduled operative resection one week later. Immediately following the surgery, the patient experienced new onset left hemiplegia. Full radiological workup revealed a fragment of Onyx LES occluding the middle cerebral artery (MCA). All indications are that the fragment became dislodged during the operation. To our knowledge, there have been no other reported cases where complications of tumor embolization with Onyx LES occurred during surgical resection.