Depression in secondary epilepsy: relation to lesion laterality.

Patients with epilepsy often have depressive disorders. This association may be particularly prominent in secondary epilepsy from a left hemisphere lesion. Among 1611 outpatients with epilepsy 272 patients were identified whose seizures originated from a structural brain lesion other than mesial temporal sclerosis. Sustained depressive disorders had occurred in 25 (9%) of these patients with secondary epilepsy. The depressed patients were compared with the remaining patients without depression with regard to location of lesion laterality and seizure variables. The only group difference was unilateral left hemisphere lesions in 58% of the patients with depression compared with only 21% of the non-depressed patients (chi 2 = 10.4, p = 0.006). This finding supports the idea of a relation of depression with epileptogenic lesions in the left hemisphere.     

Eyelid closing and opening disorders in patients with unilateral brain lesions: A case report with video neuroimage and a systematic review of the literature

Eyelid closing or opening disorders have been only sporadically described in patients with focal brain lesions over the last decades. Furthermore, the restricted number of reports and the lack of uniform clinical assessment of affected individuals did not allow to define more in depth the clinical features and the underlying neural correlates of these uncommon clinical disorders. Here we report an 89-years old woman with a right hemispheric lesion who showed a contralesional defect of eyelid closure. We also include a video neuroimage of this case and a review of eyelid closing and opening disorders in patients with focal unilateral lesions. In this review we found a correlation between right hemisphere and eyelid motor control, particularly for apraxia of eyelid closure affecting only the contralesional eye. The right parietal lobe was most frequently affected in this unilateral form of eyelid closing disorders, whereas putamen and other subcortical structures were more involved in eyelid opening than in eyelid closing disorders. The relations between unilateral eyelid closing disorders and other forms of motor-intentional defects are shortly discussed.     

Lesion therapy for Parkinson's disease and other movement disorders: update and controversies.

An analysis of the international literature on lesioning for movement disorders was undertaken to review lesion therapy for Parkinson's disease (PD) and other movement disorders and to highlight important controversies surrounding this surgical technique. Lesions have been placed throughout the neuraxis with varying approaches and success. Our understanding of the pathophysiological basis underlying the development of PD and other movement disorders has led to a better understanding of why lesioning certain portions of the nervous system should improve motor function. Advances in imaging technology and electrophysiological techniques used for localization of brain structures, such as microelectrode mapping, have improved the ability to accurately identify and lesion target structures deep in the brain. This improvement has led to an increase in the degree and consistency of clinical benefit. The major controversies in lesion therapy include: (1) which target for which disorder; (2) determination of the optimal lesion site and whether the external globus pallidus (GPe) should be included in the pallidotomy lesion for PD; (3) determination of the size of the lesion; (4) whether bilateral lesions can be placed without the high incidence of side effects reported by some investigators; (5) whether microelectrodes aid in the ability to improve clinical outcomes or increase the risk of side effects by making multiple microelectrode penetrations; (6) whether the subthalamic nucleus (STN) should be explored further as a lesioning target; and (7) whether lesioning should be abandoned entirely in favor of deep brain stimulation (DBS). Many important questions and controversies regarding lesion therapy remain unanswered. It is unlikely given the pro-DBS environment that these questions will be answered in the near future. We should, however, be careful not to abandon an effective therapy before fully exploring through randomized trials the relative effect of different surgical approaches for the treatment of patients with movement disorders.     

Somatoparaphrenia: A Case Report

A patient with a severe organic schizophrenif orm illness is described in whom the bizarre psychotic features were related to a non-dominant parietal lobe lesion. This case is a severe and unusual form of the neuro-psychiatric disorder, soma toparaphrenia. The relationship of this condition to other disorders of parietal lobe function is discussed.     

Some anatomo-clinical aspects of phonemic and semantic comprehension disorders in aphasia

60 aphasic patients, affected by localized lesions of the left hemisphere and classed as Broca's, Global, Conduction, Amnestic or Wernicke's aphasia received 1 phoneme discrimination test and 3 semantic-lexical discrimination tests. The aim of the study consisted in investigating the relationships between phoneme and semantic-lexical discrimination disorders, the clinical form of aphasia and the anatomic locus of the cerebral lesion.
The results were not consistent with the claim that comprehension disorders of Wernicke's aphasic patients can be traced back to a phoneme discrimination disorder, since Wernicke's aphasics were not more impaired than other aphasic groups and since patients with lesions localized in the temporal lobe performed quite well in the phoneme discrimination test.
Semantic discrimination disorders were very frequent and severe in patients classified as Wernicke's, Amnesic or Global aphasia, whereas they were much less relevant in patients classified as Broca's or Conduction aphasia.
As for the locus of the lesion, left temporal damage severely impaired semantic-lexical discrimination without affecting phoneme discrimination (a finding which supports the assumption of a selective involvement of the temporal lobe in semantic-lexical memory).
On the other hand, patients with damage localized in the left frontal lobe, obtained poor scores both on semantic-lexical discrimination tasks and on phoneme discrimination tests.     

伴有精神症状癫痫的立体定向手术治疗

目的探讨立体定向技术对伴有精神症状癫痫的治疗效果。方法采用立体定向技术,运用多元化定位和多靶点组合,射频热凝治疗伴有精神症状的癫痫病人13例。采用癫痫的国内疗效评定标准和全国精神外科疗效评定标准进行疗效评定。结果手术治疗1年后,13例病人中,癫痫症状基本控制,9例癫痫未再发作,4例发作次数减少50%以上;11例精神病症状基本消失,2例部分症状存在。结论双侧杏仁核、双侧内侧隔区及单侧Forel-H区多靶点组合治疗,对伴有精神症状癫痫的治疗有明显效果。     

Predictors of thermal response and lesion size in patients undergoing magnetic resonance-guided focused ultrasound thalamotomy

Magnetic resonance-guided focused ultrasound (MRgFUS) is being increasingly utilized in the treatment of movement disorders such as essential tremor (ET) and Parkinson’s disease (PD). Whilst skull density ratio (SDR) has previously been correlated with achieving lesional temperature rises, other patient factors such as brain and cerebrospinal fluid (CSF) volume have not previously been investigated. We aimed to investigate the effect of brain and CSF volumes on lesional temperature rises, as well as the effect of brain and CSF volumes and SDR on post-treatment lesion sizes. Fifty-four consecutive patients were studied with patient and treatment-related variables collected along with post-treatment lesion sizes. Linear regression analysis identified that SDR alone was associated with lesional temperatures. Both SDR and brain atrophy were associated with post-treatment lesion sizes on linear regression analysis. On multiple linear regression analysis SDR was significantly associated with post-treatment lesion size, and the association between brain atrophy and lesion sizes approached significance, a finding that warrants further investigation.     

Lesions in the central tegmental tract in autopsy cases of developmental brain disorders

We retrospectively analyzed central tegmental tract (CTT) lesions in 120 consecutive autopsy cases of developmental brain disorders to investigate the significance of symmetrical CTT lesions. Magnetic resonance imaging (MRI) findings of CTT lesions have been sporadically reported in various cases of child neurological diseases. In this study, symmetrical CTT lesions were observed in 25 (20.8%) among 120 cases of developmental brain disorders. These 25 cases were classified into three groups (groups I-III) in decreasing order of the severity of the lesion. Compared to five cases of group I in which CTT lesions were accompanied by diffuse tegmental damage, 20 cases of groups II or III developed relatively selective CTT lesions in which the medial longitudinal fasciculus and/or medial or lateral lemniscus were preserved. The causes of brain disorders in all three groups seemed to be different, and lysosomal disorders and congenital brain anomalies were frequently seen in cases in groups II and III, respectively. The dentato-rubro-olivary system is known to be involved in palatal myoclonus, and five out of 13 cases in group II showed myoclonic epilepsy. Compared with 95 cases without the CTT lesion, the changes in the pontine reticular formation were more closely associated with the CTT lesion than those in the inferior olivary nucleus. In conclusion, in cases of developmental brain disorders, the neuropathology of the symmetrical CTT lesion should be investigated.     

The crossed upgoing toe sign: A clinical study

We compared the crossed upgoing toe sign with the plantar response as an indicator of pyramidal tract dysfunction in 125 normal subjects and 192 patients with neurological disorders. A positive crossed upgoing toe sign was associated significantly with a partial pyramidal tract lesion in the contralateral cerebral hemisphere with a frequency similar to that of Babinski's sign. Unlike Babinski's sign, however, the positive crossed upgoing toe sign was lost when pyramidal weakness was severe enough to produce paralysis of voluntary dorsiflexion of the great toe, and it was found only rarely with pyramidal tract lesions of the spinal cord. The crossed upgoing toe sign has little value as a sensitive indicator of a pyramidal tract lesion. It is potentially of limited value as an aid in determining the level of a pyramidal tract lesion (cerebral hemisphere versus spinal cord), but its usefulness is seriously impaired by the high frequency of false positive signs in normal subjects and patients with other neurological disorders.     

Hematoma of the pyramidal muscle. A complication of anticoagulant treatment

A patient developed a hematoma of the pyramidal muscle as a complication of anticoagulant treatment. The lesion provoked an entrapment neuropathy due to the compression between the muscle and the iliac spine of the great sciatic, inferior gluteal and pudendal nerves. Hyperalgic paralysis of the leg and buttock was associated with bladder sphincter disorders and impotence, a remarkable finding in view of the unilateral disturbance in nervous control. Pain, and urinary and sexual disorders were reversed dramatically by an early neurolysis. A CT scan enables the identification of the lesion.     

New onset of idiopathic bilateral ear tics in an adult

Tic disorders are commonly considered to be childhood syndromes. Newly presenting tic disorders during adulthood are uncommon and mostly described in relation to an acquired brain lesion or as incidental tics, particularly in context with other neurological or psychiatric diseases. Tic disorder involving the ears is extremely uncommon with only few studies in English literature. In the present case, we describe an adult patient with new-onset idiopathic tics disorder involving both ears, causing social embarrassment. In addition, our patient had recent onset of the tics without any childhood or family history of tic disorders. The single most important component of management is an accurate diagnosis. At the same time, tics should be differentiated from other movement disorders such as chorea, stereotypy, and dystonias.     

Brainstem infarcts presented medial longitudinal fasciculus (MLF) syndrome and cerebellar ataxia--report of three cases

Vascular disorders of the brainstem manifest characteristic neurologic symptoms according to their localization. The medial longitudinal fasciculus (MLF) lies in the paramedian portion of the upper brainstem tegmentum, and the lesion in this fasciculus shows specific abnormality of the eye movement pattern which is known as the MLF syndrome. Although the MLF syndrome was reported frequently to be accompanied by varieties of other neurologic deficits according to the lesion extending into the adjacent structures in the brainstem, the combination of MLF syndrome and cerebellar ataxia has attracted less attention of neurologists. Recently we experienced three cases of cerebellar ataxia arisen simultaneously with MLF syndrome. Magnetic resonance imaging (MRI) tomography or X-ray computed tomography visualized lacunar lesion(s) in the upper brainstem tegmentum in all of three cases. It was obvious that the lesion included the MLF and caused the MLF syndrome in these cases. It was speculated that ventro-caudal extension of the lesion involved the decussation of the superior cerebellar peduncle, and was responsible for the association of cerebellar ataxia with MLF syndrome. According to the recent discussion about the feeding arteries in the brainstem, we decided that the damage of the paramedian branches diverging from the basilar tip resulted in the lacunar lesion(s). The development of diagnostic procedures especially MRI enables the diagnosis of the vascular disorders in the brainstem with considerable accuracy.     

Prevalence of psychologic disorders after surgical treatment of seizures

To investigate whether surgical treatment of refractory epilepsy is associated with increased risk for serious psychopathology, 25 treated patients were compared with 25 current candidates for surgery matched on demographic and neuroepileptic characteristics. Diagnoses were made by the National Institute of Mental Health Diagnostic Interview Schedule. No differences between groups in lifetime or point prevalence rates were significant. The rate of psychosis in the postoperative group (8%) approximated the lower estimates in previous studies. Thus, surgical treatment of seizures did not increase the risk for psychopathology. However, patients with temporal lobe electroencephalogram foci or tumor as the epileptogenic lesion were more likely to have serious disorders than other patients. Also, anxiety disorders were more prevalent in our patient groups than in the general population.     

Neuroanatomy of pseudobulbar affect

Pseudobulbar affect (PBA) is defined as episodes of involuntary crying, laughing, or both in the absence of a matching subjective mood state. This neuropsychiatric syndrome can be found in a number of neurological disorders including multiple sclerosis (MS). The aim of this study was to identify neuroanatomical correlates of PBA in multiple sclerosis (MS) using a case-control 1.5T MRI study. MS patients with (n = 14) and without (n = 14) PBA were matched on demographic, disease course, and disability variables. Comorbid psychiatric disorders including depressive and anxiety disorders were absent. Hypo- and hyperintense lesion volumes plus measurements of atrophy were obtained and localized anatomically according to parcellated brain regions. Between-group statistical comparisons were undertaken with alpha set at 0.01 for the primary analysis. Discrete differences in lesion volume were noted in six regions: Brainstem hypointense lesions, bilateral inferior parietal and medial inferior frontal hyperintense lesions, and right medial superior frontal hyperintense lesions were all significantly higher in the PBA group. A logistic regression model identified four of these variables (brainstem hypointense, left inferior parietal hyperintense, and left and right medial inferior frontal hyperintense lesion volumes) that accounted for 70% of the variance when it came to explaining the presence of PBA. In conclusion, MS patients with PBA have a distinct distribution of brain lesions when compared to a matched MS sample without PBA. The lesion data support a widely-dispersed neural network involving frontal, parietal, and brainstem regions in the pathophysiology of PBA.     

Arithmetic skills in patients with unilateral cerebral lesions

In this paper we describe the construction of a Graded Difficulty Arithmetic test (GDA) consisting of 12 additions and 12 subtractions which are orally presented. The test was administered to a control group of 100 volunteer subjects with extra-cerebral neurological disorders and to two experimental groups of patients with unilateral cerebral lesions of the left and right hemisphere. In the control group performance on the GDA was found to correlate highly with other measures of verbal intelligence, namely the National Adult Reading Test, the WAIS Arithmetic subtest and the WAIS Digit Span subtest. Between group analysis showed a significant groups effect on the GDA, the left hemisphere lesion group showing greater impairment compared to the right hemisphere lesion group and the controls. Using "cut-off" scores the left hemisphere lesion group's performance was shown to be significantly worse than that of the right hemisphere lesion group, who in turn were not significantly worse than the control group.     

Seizure-induced transient brain edema in the medial temporal lobe]

We reported a patient with sudden onset seizure resulting in prolonged amnesia. MRI revealed a T2 high signal lesion with swelling in the right medial temporal lobe. Because the MRI lesion remained to be the same in size for two months, biopsy specimens were obtained under informed consent to rule out the brain tumor. Based on histological findings showing brain edema without specific abnormal findings (malignancy, inflammation etc), we concluded that the temporal lesion was the edema induced by the seizure attack. In Japan, many papers on non-herpetic acute limbic encephalitis (NHALE) have recently been published. In their reports, seizures were frequently observed as a preceding symptom; moreover, clinical courses and MRI findings are similar to those of seizure-induced brain edema. The secondary brain edema induced by the seizure must be considered in patients with NHALE and other CNS disorders, especially if the patient has a history of the recent seizure.     

Computed tomography and pure motor hemiparesis

Computed tomography (CT) was abnormal in 75% of 33 patients with pure motor hemiparesis (PMH). In 13 cases, lesions were detected in the capsular region; 10 were consistent with infarction, and 3 were of increased density consistent with hemorrhage. Seven had other vascular disorders, and four had nonvascular conditions. Of 20 patients with PMH with normal electroencephalogram (EEG), isotope scan, and cerebrospinal fluid, 11 had CT evidence of a lesion in the internal capsule-corona radiata region. In patients with PMH with normal CT, recovery was more complete and rapid than in those with CT evidence of a vascular lesion. In 5 cases, CT showed a capsular lesion, although the patients had never had any neurologic deficit.     

丘脑结节动脉梗死的神经心理学障碍

目的探讨丘脑结节动脉梗死的神经心理学障碍及其机制。方法回顾性分析9例丘脑结节动脉梗死患者的临床资料。结果9例患者主要临床表现为:意志缺乏和行为障碍、丘脑性失语和左侧空间忽视及视空间功能障碍、记忆障碍,而均无脑神经损害及运动、感觉障碍。结论丘脑结节动脉梗死患者的临床表现主要为神经心理学障碍。     

Neuronal cell death--what we can see and what we cannot]

Recently several responsible genes for hereditary neurodegenerative disorders were identified. In some of them the gene products were found to be aggregated. In the case of Alzheimer disease beta protein and apolipoprotein E accumulated in senile plaques. In CAG repeat diseases the polyglutamine aggregates in neuronal nuclei. More recently alpha synuclein accumulates in Lewy bodies in Parkinson disease and tau protein accumulates in NFT of hereditary frontotemporal dementia with tau mutation. Those results suggested that the responsible gene products accumulates in the lesion which the products involve in. However, presenilin which is one of the genes for familial Alzheimer disease accumulates in NFT and on the other hand its mutation changes the production ratio of beta 1-42/40, suggesting that the abnormal gene products not simply accumulate the lesion that it involved. The gene products accumulate in different lesions such as in nuclei of polyglutamine diseases, extracellular plaque and cytoplasm of prion disease and extracellular plaques in Alzheimer disease. Some of them are ubiquitinated and some of them are not. Thus the accumulating process in these disorders seems apparently same but is essentially different. We should study more precisely each pathological process of those disorders.     

Psychiatric disorders in temporal lobe gliomas

The rate of temporal lobe gliomas among all hemispheric glial tumors is up to 30%. Psychiatric disorders are typical for temporal lesions and could be even single manifestation of the disease. There is a rich variety of different psychopathologic and epileptic signs exactly in cases of temporal gliomas in comparison to tumors of other localizations. In our study we investigated psychiatric disorders on statistically significant group of patients (140 cases) with temporal lobe tumors with considerations of side, localization, histology of lesion and functional asymmetry of patients. We revealed psychiatric disorders in 72% of patients, mainly in glioblastoma. Seizures were more typical for WHO Grade I and II gliomas. Psychopathologic symptoms were more typical for left side lesions. Lefthanders had psychiatric disorders significantly more frequently than righthanders (p < 0.05). After surgical removal of tumor the rate of psychiatric disorders didn't differ statistically (p < 0.05) by 2 years follow-up. Complete regress of seizures was observe in 56% of cases.