Are two leads always better than one: an emerging case for unilateral subthalamic deep brain stimulation in Parkinson's disease

Bilateral subthalamic (STN) deep brain stimulation (DBS) provides significant symptom relief for the majority of well-screened patients suffering with Parkinson's disease (PD). Implantation of stimulating electrodes bilaterally in a single session has become standard in most operating theaters worldwide. There is, however, limited evidence-based support for this approach. Although bilateral surgical procedures have been shown, using standardized clinical ratings, to provide greater motor benefits compared to unilateral procedures, bilateral procedures are more likely to be associated with increased acute and long-term complications including post-operative confusion, speech difficulties and cognitive dysfunction. Unilateral stimulation has been shown to provide significant benefits for appendicular and axial symptoms. The relative benefit of implanting one versus two sides and whether the degree of benefit associated with the second side is worth the potential risk of doing so have not been examined systematically. The relative magnitude of benefit associated with unilateral versus bilateral procedures is likely to vary from patient to patient, particularly in those patients with asymmetric symptomatology. As such, there are likely subsets of patients who do not require and therefore should not be exposed to the potential complications associated with bilateral simultaneous implantation. This review and commentary will outline our current understanding of the benefits associated with unilateral and bilateral STN DBS and discuss the role of unilateral or staged unilateral procedures as an alternative surgical approach for patients with advanced PD.     

Experimental induction of an abnormal ipsilateral visual field representation in the geniculocortical pathway of normally pigmented cats

In the normally pigmented neonatal cat, many ganglion cells in temporal retina project to the contralateral dorsal lateral geniculate nucleus (LGNd) and medial interlaminar nucleus (MIN). Most of these cells are eliminated during postnatal development. If one optic tract is sectioned at birth, much of this exuberant projection from the contralateral temporal retina is stabilized (Leventhal et al., 1988b). To determine how the abnormal projection from the contralateral temporal retina is accommodated in the central visual pathways, neuronal activity was recorded in the visual thalamus and cortex of adult cats whose optic tracts were sectioned as neonates. The recordings showed that up to 20 degrees of the ipsilateral hemifield is represented in the LGNd and MIN. Recordings from areas 17 and 18 of the intact visual cortex showed that up to 20 degrees of the ipsilateral visual field is also represented and that the ipsilateral representation is organized as in a Boston Siamese cat (Hubel and Wiesel, 1971; Shatz, 1977; Cooper and Blasdel, 1980) or a heterozygous albino cat (Leventhal et al., 1985b). The extent of the ipsilateral visual field representation was greater in area 18 than in area 17; the extent of the ipsilateral hemifield representation in areas 17 and 18 varied with elevation, increasing with distance from the horizontal meridian. The receptive fields of cells in the LGNd and visual cortex subserving contralateral temporal retina were abnormally large. Otherwise, their receptive field properties seemed normal. In the same animals studied physiologically, HRP was injected into the ipsilateral hemifield representation in the LGNd and MIN of the intact hemisphere. The topographic distribution of the alpha and beta cells, respectively, labeled by these injections correlated with the elevation-related changes in the ipsilateral visual field representation in areas 18 and 17. Our results indicate that the retinotopic organization of the mature geniculocortical pathway reflects the abnormal pattern of central projections of ganglion cells in neonatally optic tract sectioned cats. Thus, if they do not die, retinal ganglion cells normally eliminated during development are capable of making seemingly normal, functional connections. The finding that an albino-like representation of the ipsilateral hemifield can be induced in the visual cortex of normally pigmented cats suggests that the well-documented defects in the geniculocortical pathways of albinos are secondary to the initial misrouting of ganglion cells at the optic chiasm (Kliot and Shatz, 1985) and not a result of albinism per se.     

Deep brain stimulation: how does it work?

Deep brain stimulation has significantly improved the motor symptoms in patients with Parkinson's disease (PD) and other movement disorders. The mechanisms responsible for these improvements continue to be explored. Inhibition at the site of stimulation has been the prevailing explanation for the symptom improvement observed with deep brain stimulation. Research using microelectrode recording during deep brain stimulation in the MPTP monkey model of PD has helped clarify how electrical stimulation of structures within the basal ganglia-thalamocortical circuit improves motor symptoms, and suggests that activation of output and the resultant change in pattern of neuronal activity that permeates throughout the basal ganglia motor circuit is the mechanism responsible for symptom improvement.     

Amantadine induced reversible corneal edema

Amantadine is becoming more commonly used for Parkinson’s disease (PD), particularly for its efficacy in treating the drug-induced dyskinesias. Corneal edema is a known but unusual side effect of amantadine therapy, rarely reported in the neurological literature. We report amantadine-induced reversible corneal edema in a patient with advanced PD.     

Congenital chylothorax: from foetal life to adolescence

Aim: To analyse the main prenatal and postnatal features of congenital chylothorax (CC), and the outcome including mid‐term follow‐up. Methods: We searched our databases for CC diagnosed between 1990 and 2006. Data of 29 cases were retrieved and analysed. Follow‐up until 3 years of age was available for all patients. Results: Most patients were diagnosed prenatally (94%) and most cases were complicated by foetal hydrops (66.7%). The overall survival rate at 3 years was 56%. A significantly poorer outcome was observed when foetal hydrops, preterm birth < 34 weeks, large effusions and/or early‐onset pneumothorax were present. An important but not significant improvement in the survival rate was observed through the study period; while in 1990–1998, the survival rate was 41.7%, from 1999 to 2006 it was 66.7% (p = 0.19). In the mid‐term follow‐up, we did not observe any recurrence of CC and most infants remain asymptomatic. However, 27% of survivors were diagnosed as having asthma in early infancy. Conclusion: CC still carries a significant risk of perinatal mortality. However, continuous advances in foetal and neonatal medicine are improving the prognosis of these patients, and nowadays most of them are likely to survive. Beyond the neonatal period, most survivors have an uneventful outcome.     

Evaluation of preanalytical stability of the sample for complete blood count

ObjectiveTo evaluate the effect of time of incubation on complete blood count (CBC) by using HmX analyzer.MethodsA cross sectional study was conducted at Manipal Acunova Limited, Bangalore. Ten blood samples which were stored at room temperature for CBC and differential count by using HmX analyzer were analyzed within one hour of draw and on 24, 48 and 72 hours of draw.ResultsDifferential count measured in an automated instrument changed over time.ConclusionsThe finding of this study shows that some of CBC parameters can be changed with the incubation, therefore it is better to perform on a fresh sample.     

Preradiation intracarotid cisplatin treatment of newly diagnosed anaplastic gliomas. The CNS Cancer Consortium.

PURPOSE: This phase II study was performed to assess the response of patients with newly diagnosed, untreated malignant gliomas (anaplastic astrocytoma [AA] and glioblastoma multiforme [GBM]) to intracarotid (IC) cisplatin. PATIENTS AND METHODS: Eligibility criteria included surgical intervention limited to biopsy only, measurable contrast-enhancing tumor, and unilateral tumor location within the vascular territory of one internal carotid artery. Patients were scheduled to receive four infusions of IC cisplatin (75 mg/m2 every 4 weeks) before beginning standard radiotherapy. Twenty-six patients were treated, and 22 were assessable for response. RESULTS: Ten patients (45%) showed a greater than 25% decrease in the enhancing tumor area before radiotherapy with stabilization or improvement of neurologic deficits, and three patients (14%) had a greater than 70% decrease in tumor area. The likelihood of response to IC cisplatin was not clearly linked to patient age, tumor histology, or pretreatment tumor size. Myelosuppression, nephrotoxicity, and ototoxicity were mild. Optic neuropathy occurred in one patient, seizures in two, and fatal postinfusion cerebral edema in one. CONCLUSION: This study design, which permits assessment of the drug sensitivity of the untreated glioma, has shown definite antitumor activity of IC cisplatin in newly diagnosed malignant glioma patients.     

500-element ultrasound phased array system for noninvasive focal surgery of the brain: a preliminary rabbit study with ex vivo human skulls.

The aim of this study was to test a prototype MRI-compatible focused ultrasound phased array system for trans-skull brain tissue ablation. Rabbit thigh muscle and brain were sonicated with a prototype, hemispherical 500-element ultrasound phased array operating at frequencies of 700-800 kHz. An ex vivo human skull sample was placed between the array and the animal tissue. The temperature elevation during 20-30-sec sonications was monitored using MRI thermometry. The induced focal lesions were observed in T2 and contrast-enhanced T1-weighted fast spin echo images. Whole brain histology evaluation was performed after the sonications. The results showed that sharp temperature elevations can be produced both in the thigh muscle and in the brain. High-power sonications (600-1080 W) produced peak temperatures up to 55 degrees C and focal lesions that were consistent with thermal tissue damage. The lesion size was found to increase with increasing peak temperature. The device was then modified to operate in the orientation that will be used in the clinic and successfully tested in phantom experiments. As a conclusion, this study demonstrates that it is possible to create ultrasound-induced lesions in vivo through a human skull under MRI guidance with this large-scale phased array.