Changes in the management and outcome of central nervous system involvement from ovarian cancer since 1994

Objective

To identify differences in the management and outcome of patients with central nervous system metastases from epithelial ovarian cancer.

Methods

The clinical and pathologic characteristics, treatment, and outcome of 23 patients with brain metastases from epithelial ovarian cancer who were treated during 1982-1994 were compared with those of 20 patients treated during 1995-2010 at the same center.

Results

No differences were found in terms of primary tumor characteristics, time interval from ovarian cancer diagnosis to brain involvement diagnosis, sites of metastasis, and presence of extracranial disease. The main difference between the 2 groups was the therapeutic approach. During 1982-1994, most patients received radiotherapy only, whereas most patients during 1995-2010 underwent surgical resection followed by radiotherapy and/or chemotherapy. The duration of survival during 1982-1994 was 5 months, which was significantly shorter than the duration of survival (18 months) during 1995-2010.

Conclusion

An aggressive multimodal treatment approach might prolong the survival of patients with brain involvement from ovarian cancer.     

Our clinical experience about prenatal diagnosis and neonatal outcomes of fetal central nervous system anomalies

Objective.?To present a retrospective analysis of the prenatal diagnosis and the outcome of fetuses diagnosed with central nervous system (CNS) anomalies.

Materials and methods.?We reviewed the medical records and ultrasound data of 69 cases diagnosed with CNS anomalies from 2007 to 2008. We described the prenatal diagnosis, associated findings, and outcome of these patients.

Results.?Sixty-nine patients were diagnosed with CNS anomalies. Of these, 31 had ventriculomegaly + hydrocephaly, 14 had spina bifida + meningomyelosel, 5 had choroid plexus cyst, 5 had Dandy Walker malformation, 3 had sacrocoxigeal teratoma, 2 had encephalosel, 1 had microcephaly, and 1 had Arnold Chiari malformation. Eight amniocentesis, three cord blood sampling, and two fetal reduction procedure were performed. Nine pregnancy termination and 36 delivery were performed. Neurosurgical correction was performed for neonates with spina bifida, hydrocephaly and sacrocoxigeal teratoma. Twenty-one neonates were discharged with cure, 4 neonates with follow-up, 7 neonates with paraplegia, and 13 neonates died.

Conclusion.?The outcome of fetuses with CNS anomalies was shown to depend mainly on the degree of neural tube defect and the associated anomalies were the most important factors in surviving.     

Extended-release formulations of oxybutynin and tolterodine exhibit similar central nervous system tolerability profiles: a subanalysis of data from the OPERA trial

OBJECTIVE: This study was undertaken to compare the central nervous system (CNS) tolerability profiles of the extended-release formulations of oxybutynin chloride and tolterodine tartrate in the treatment of women with overactive bladder (OAB), as observed in the OPERA (Overactive bladder: Performance of Extended Release Agents) trial. STUDY DESIGN: The OPERA trial was a randomized, double-blind, active-control comparison of the efficacy and safety of extended-release oxybutynin (10 mg/d) and extended-release tolterodine (4 mg/d) given to 790 women with OAB for 12 weeks. The incidence of reported CNS events was compared between the treatment groups by using the Fisher exact test. RESULTS: The incidence of CNS adverse events was 9% and 8% for the oxybutynin and tolterodine treatment groups, respectively. The difference between groups was not statistically significant. All reported CNS adverse events were rated as mild or moderate in severity. There were no serious treatment-related adverse events in either group, and discontinuation because of a CNS adverse event was infrequent. CONCLUSION: The extended-release formulations of oxybutynin and tolterodine were observed to be associated with a similar low incidence of CNS adverse events, which were mostly mild or moderate in severity.     

Ultrasound of the fetal central nervous system

Current ultrasound equipment allows the antenatal identification of many central nervous system anomalies from early gestation. In selected cases, special techniques (transvaginal sonography, three-dimensional ultrasound, colour Doppler) may enhance the diagnostic potential. Diagnostic accuracy, however, remains heavily dependent upon the expertise of the sonologist. Fetal ultrasound is effective in identifying neural tube defects, although alpha-fetoprotein screening seems to yield a greater sensitivity. The sensitivity in the diagnosis of central nervous system malformations other than neural tube defects remains unclear because of the ascertainment biases of the few large prospective studies that have been carried out so far. Magnetic resonance imaging may play a major role in the evaluation of cases with suboptimal ultrasound visualization, or when specific anomalies are suspected, such as intracranial haemorrhage or migrational disorders.     

Three-dimensional sonographic features of fetal central nervous system anomaly

OBJECTIVE: To visualize an intracranial structure of the fetal central nervous system (CNS) anomaly using transabdominal three-dimensional (3D) sonography. METHODS: A total of 12 cases with fetal CNS anomalies (one unilateral ventriculomegaly; three hydrocephalus; three anencephaly; three holoprosencephaly; one Dandy-Walker cyst; and one enlarged cisterna magna) from 17 to 37 weeks of gestation were studied with transabdominal 3D sonography (3.5 MHz). RESULTS: In unilateral ventriculomegaly, insight view of dilated lateral ventricle, especially dilated atrium was depicted. In hydrocephalus, severely dilated bilateral ventricles and thin brain mantle were very clearly shown. In anencephalus, an absence of the brain and defect of the vault of the skull was clearly noted. In holoprosencephaly, absent interhemispheric fissure, common ventricle, and the extent of thalamic fusion were evident. In Dandy-Walker cyst, cerebellar hemisphere was clearly depicted due to the agenesis of cerebellar vermis. In enlarged cisterna magna, posterior intracranial view of the fetus showed a large space of cisterna magna. Although the diagnosis of each CNS anomaly was made using conventional two-dimensional sonography, 3D sonography proved most helpful delineating the exact nature and anatomic level of the anomaly. CONCLUSIONS: These results suggest that 3D sonography provides a novel means of visualizing fetal CNS anomalies in utero. However, it should be noted that our 3D sonography cannot depict intracranial brain structures in normal fetuses or some CNS anomaly such as intracranial tumor.     

Epidemiology of stillbirth and fetal central nervous system injury

The epidemiology of stillbirth and fetal central nervous system (CNS) injury is described with some emphasis on maternal and feto-placental risk factors. To maximize utility of the discussion and because it also represents the classical manifestation of fetal CNS injury, we have selected cerebral palsy (CP) to illustrate the epidemiologic aspects of injury to the fetal CNS in general. While trends in stillbirth rates have modestly decreased over time, those of CP seem to be increasing. Interestingly, both stillbirth and CP share traditional as well as emerging risk factors lending credence to the hypothesis that fetuses that would previously have been stillborn are increasingly surviving albeit with some form of morbidity. The existence of shared risk factors also suggests that in some cases of stillbirth fetal CNS injury precedes the in utero fetal demise. Pregnant women bearing these risk indicators represent potential candidates for appropriate and tailored protocols for antenatal fetal testing.     

Behavioral parameters assessing human fetal development

Fetal behaviors gradually integrate into more complex movements in relation to each other along with functional central nervous system development. Investigating the ontogenesis of fetal behavior made it possible to allow prenatal localization of functional brain impairment, however, it is still difficult to deduce higher brain function in human fetuses.

Fetal learning has the potential to be a new parameter to deduce higher brain function in the human fetus. We investigated fetal learning from a behavioral development perspective assessed by a conventional parameter, i.e. eye movement patterns. After at least 32 weeks of gestation, the fetuses presented habituation to vibro-accoustic stimulation. Fetuses less developed required significantly more trials to show habituation than developed fetuses from a behavioral standpoint even at the same gestational age. Three- or four-dimensional ultrasound evaluation also provides new findings in fetal behaviors in early gestation.

These methods could be new parameters to assess fetal brain function, however, it is necessary to choose appropriate parameters and to develop easy and ubiquitous criteria, which cover higher brain function throughout the entire gestational stage.     

Transvaginal sonographic evaluation of the fetal central nervous system.

This article describes the sonographic appearance of the central nervous system (CNS) from about 6 weeks to term. Highlights of CNS development and the chronologic appearance of sonographically detected new structures throughout gestation are presented.     

The antenatal development of fetal behavioral patterns assessed by four-dimensional sonography

The investigation of fetal intrauterine activities has been enabled by the development of two-dimensional ultrasound. It has been shown that the earliest signs of fetal motor activity can be in the late embryonic period, and that the characteristics of fetal motor patterns change constantly throughout gestation. During the first trimester of pregnancy, the repertoire and frequency fetal movement patterns constantly expand, whereas the second and third trimesters are characterized by the progressive organization of fetal activities into complex and clearly distinct behavioral patterns. The comparison of real time ultrasonic studies of fetal behavior with the morphological studies of fetal brains has revealed that the appearance of new behavioral patterns or the transition of existing patterns directly reflect the complex neurodevelopment processes. It has been suggested that the assessment of fetal behavioral patterns could give us insight into the integrity of fetal central nervous system and enable the early detection of cerebral dysfunctions. The development of a new ultrasonic technique, four dimensional sonography, could represent a significant improvement in the assessment of fetal behavior. According to the preliminary results, this new technique could open a new perspective for the investigations of fetal behavioral patterns and contribute significantly to our better understanding of complex neurodevelopmental events. The most important neurodevelopmental events, the basic technology of 4D ultrasound and its application in the assessment of functional development of fetal central nervous system will be the subject of this review.     

Developmental sequence of fetal behavior and the functional development of the fetal central nervous system

The development of central nervous system (CNS) is the latest among the various fetal organs and is on the way to mature even at birth. Because behavior is the phenotype of the CNS function, the behavioral pattern significantly changes with the developmental stage of CNS throughout the whole fetal period. The purpose of this study is to clarify the developmental sequence of fetal behavior and to discuss the functional development of the fetal CNS. For the first step of this study, thirty-one normal pregnant women, between 20 and 41 weeks of gestation, were examined for 60 minutes by using four ultrasonographic machines, which were employed simultaneously for observing four parts of each fetus: head, trunk, upper and lower extremities. All fetal movements were categorized according to the moving parts of the body and the peculiarities of movement. Trunk movements include six types i.e. flexion, stretch, rolling, startle, jumping (stepping), and writhing. The peak incidences of flexion and stretch were in 28-31 weeks of gestation. The incidence of rolling movements was high in 24-27 weeks, thereafter lowered gradually with gestational age, and then showed the significant increase in 40-41 weeks. The incidences of startle and jumping movements were high before 28 weeks, and then decreased significantly. Writhing movements were often observed after 28 weeks. The other movements showed the respective patterns of the changes in the incidence. Secondly, animal experiments were performed to obtain the basic data on fetal behavior which could not be given by the ultrasonographic observation of human fetuses. Fetal goats were incubated under the physiological condition in artificial amniotic fluid by using extracorporeal membrane oxygenation (ECMO) system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fetal magnetic resonance imaging in prenatal diagnosis of central nervous system abnormalities: 3-year experience

Objective: To evaluate the comparative merits of ultrasound and fetal magnetic resonance imaging (MRI) in the correct antenatal diagnosis of suspected central nervous system abnormalities. Methods: A retrospective review of 27 consecutive pregnancies referred for fetal MRI for suspected central nervous system abnormalities between July 1998 and July 2001. Women were referred for the MRI examination when further anatomical and/or pathological clarification of the ultrasound scan findings was needed. Antenatal ultrasound scan and MRI were reviewed in relation to the findings on postpartum investigations. Results: Data were complete for 26 pregnancies. The median gestational age at the time of the ultrasound examination was 26 weeks (95% CI 24 weeks 2 days to 28 weeks 1 day). The median gestational age at the time of magnetic resonance imaging was 27 weeks' gestation (95% CI 26 weeks 1 day to 29 weeks 2 days). Eight fetuses had associated skeletal, renal and/or cardiac abnormalities previously noted on ultrasound examination. MRI confirmed the ultrasound diagnosis in 15/26 cases (58%). It changed the diagnosis to the correct one in 7/26 (27%) and misdiagnosed four cases (15%). Three of the four cases that were misdiagnosed on MRI occurred in the first 18 months of our 36-month experience. Conclusion: Ultrasound remains the primary imaging modality for prenatal diagnosis. Fetal MRI appears to be a useful adjunct to ultrasound to confirm or exclude certain abnormalities; this will consequently help in the counselling of parents and assist in planning further management. However, like any imaging technique, the sensitivity and specificity of the test are likely to improve with experience.     

Autonomic nervous system activity in the late luteal phase of eumenorrheic women with premenstrual symptomatology

The majority of women of reproductive age experience a regular recurrence of various symptoms in the premenstrual phase. The etiopathogenesis of premenstrual symptomatology, however, remains inconclusive. The present study was proposed to evaluate whether the activity of the autonomic nervous system (ANS), which largely contributes to the relative stability of a human's internal environment, is altered during the menstrual cycle of women with premenstrual symptomatology. Thirty eumenorrheic young women participated in this study. All subjects were investigated during the follicular and late luteal phases. The ANS activity was assessed by means of heart rate variability power spectral analysis during supine rest. No intramenstrual cycle differences in the ANS activity were found in women experiencing no or small increases in premenstrual symptoms. In contrast, the sympathetic nervous system (SNS) activity significantly increased and the parasympathetic nervous system (PNS) activity apparently decreased in the late luteal phase in subjects whose premenstrual symptomatology was not unbearable, but substantially increased (>20%) compared to the symptom-free follicular phase. The women with greater degrees of premenstrual distress possessed higher SNS activity and lower PNS activity in the late luteal phase than the women with less symptomatology. The ANS activity in the follicular phase did not differ among the subjects regardless of their premenstrual symptoms. Although causes and consequences continue to elude, the present study provides additional intriguing evidence that the altered functioning of ANS in the late luteal phase could be associated with diverse psychosomatic or behavioral symptoms appearing premenstrually.     

Magnetic resonance signal intensity measurements in the diagnosis of fetal central nervous system anomalies

Objectives: To evaluate the possible role of Magnetic Resonance (MR) signal intensity measurements in diagnosing Central Nervous System (CNS) anomalies antenatally. Methods: MR images of 110 fetal brains between 18 and 38 weeks were studied. Nine were excluded due to destroyed brain. 50 had CNS anomalies. 51 had normal CNS and were used as controls. Regions of interest (ROI) cursors were placed in Vitreous, cerebellar vermis, thalamus, frontal white matter, corona radiata, periventricular region and grey matter. The lateral ventricle diameters were also obtained. Signal intensity ratio (SIR) was calculated by the signal intensity of each of the above regions to that of the vitreous. SIR in controls were compared with fetuses having: (1) Hydrocephalus. (2) Arnold Chiari type-2 Malformation (ACM-2) (3) Non-progressive ventriculomegaly (4) Miscellaneous CNS anomalies. The correlation of the normalcy or abnormalcy of the brain was based on Clinical/Physical examination in 51, Ultrasound in 20, MRI in 2 and autopsy in 28. Results: In hydrocephalus and ACM-2, the SIR of vermis and periventricular region were higher than controls whereas in non-progressive ventriculomegaly and miscellaneous CNS anomalies there was no significant difference. Conclusion: Signal intensity measurements are useful to differentiate physiological and non-progressive ventriculomegaly from hydrocephalus and ACM-2.     

Magnetic resonance imaging and ultrasound in the assessment of the fetal central nervous system

Ultrasound is the screening modality of choice for evaluation of the fetal central nervous system (CNS). However, in cases of difficult diagnosis further fetal investigation is desirable. Due to ultrafast magnetic resonance imaging (MRI) techniques artifacts from fetal motions are minimized. MRI involves no exposure to radiation and hence appears to be safe. Due to the better soft tissue contrast, additional investigation by MRI may extend the sonographic diagnosis of fetal CNS-anomalies. Ultrasound and MRI are complementary imaging methods in the evaluation of the fetal CNS. The most important indications for ultrasound are screening for CNS anomalies and serial assessment of the dynamic of the disorder. The most important indications for fetal MRI are the "second opinion" and investigation by fetal MRI instead of postpartum MRI (especially in cases of planned postpartum intervention). In this article the indications and limitations of ultrasound and magnetic resonance imaging in the evaluation of the fetal CNS are discussed.     

Randomized controlled trial of prenatal zinc supplementation and the development of fetal heart rate

OBJECTIVES: This study was undertaken to evaluate whether prenatal zinc supplementation affects maturation of fetal cardiac patterns. STUDY DESIGN: A randomized double-blind controlled trial among 242 low-income Peruvian women was performed. Beginning at 10 to 16 weeks' gestation, women received supplements containing 60 mg iron, 250 microg folic acid with or without 25 mg zinc. Fetal heart rate (mean FHR, variability [HRV], number of accelerations) and movements (number and amplitude of movement bouts, time spent moving) were electronically monitored monthly from 20 weeks' gestation. Developmental trends were evaluated by supplement type among 195 women who completed the trial and had no serious complications of pregnancy. RESULTS: Zinc supplementation was associated with lower FHR, greater number of accelerations, and greater HRV. Supplementation effects on HRV and accelerations were more pronounced after 28 weeks' gestation. No differences in motor activity were observed. CONCLUSION: Prenatal supplementation of zinc-deficient mothers may be beneficial to fetal neurobehavioral development.     

血浆置换治疗儿童难治性神经系统疾病1例

目的 观察分析治疗性血浆置换用于儿童难治性神经系统免疫障碍性疾病的疗效.方法 选取本院2019年收治的1例难治性神经系统免疫障碍性疾病患儿应用治疗性血浆置换治疗.分析疗效与安全性.结果 治疗后患儿临床症状明显改善,10 d后撤体外膜肺氧合机,15 d顺利撤呼吸机,肌力治疗后恢复正常,能行走锻炼.期间出现皮疹并发症,给予...