Magnetic resonance imaging after corpus callosotomy

Assessment of gadolinium leakage into traumatic spinal cord lesion using magnet resonance imaging

STUDY DESIGN

Exploratory study in patients with acute spinal cord trauma using magnetic resonance imaging (MRI).

OBJECTIVE

The aim of this study was to assess the leakage of Gd-DTPA into traumatic lesions of the human spinal cord using MRI.

SUMMARY OF BACKGROUND DATA

While MRI of acute spinal cord trauma is a routine type of clinical investigation, the time course of Gd-DTPA enhancement in traumatic spinal cord injury is not known.

METHODS

In early stage after spinal cord injury (<24 hours) and at follow-up on day 4, 7, 14, 21, 28, and 84, the accumulation of Gd-DTPA within 30 minutes after bolus injection was investigated in sagittal and axial T2-weighted images and T1-weighted images.

RESULTS

In 4 men aged between 23 and 55 years with severe paraparesis, the traumatic spinal cord lesion had a maximum of spatial extent after 7 days. Gd-enhancement was first detected on day 4 in T1-weighted images, was most pronounced between day 7 and 28 but absent on day 84. The Gd-enhancement progressively increased in intensity after intravenous injection between 5 and 10 minutes when a maximum was reached, which remained stable for up to 30 minutes.

CONCLUSION

We used MRI to study the dynamics of post-traumatic Gd-DTPA leakage into the injured spinal cord. This appears as a promising approach for monitoring the local secondary lesion changes.

Amantadine-induced multiple spike waves on an electroencephalogram of a schizophrenic patient

Although amantadine is relatively free of side effects compared with levodopa, the incidence and severity of unwanted effects, such as hallucinations, insomnia and dizziness, markedly increase when the daily dose exceeds 200 mg. A 63-year-old schizophrenic female developed the Pisa syndrome following neuroleptic medication. She was started on a regimen of amantadine, 200 mg per day, on September 4, and the electroencephalogram (EEG) on September 11 was within normal limits. The dosage was increased to 300 mg on September 18 because there was no improvement and no side effects. Two days later a generalised convulsion occurred and an EEG revealed frequent multiple spikes or sharp waves with slow waves. No epileptic seizure has been observed since the amantadine was discontinued. The EEG on September 27 was again within normal limits. To our knowledge, the EEG of a patient with convulsion induced by amantadine has not been described previously. The epileptic mechanisms of amantadine have not been elucidated; however, it may be related to a modulating role of dopamine in the central nervous system.

MRI signal changes in the white matter after corpus callosotomy

Magnetic resonance imaging (MRI) changes reported after corpus callosotomy include hyperintensity in the corpus callosum, perifalcine hyperintensity caused by surgical retraction, and acute changes associated with surgical complications. The authors have observed MRI signal changes in the cerebral white matter of corpus callosotomy patients that are separate from the sectioned callosum and not clearly related to surgical manipulation or injury. Brain MRI scans were retrospectively reviewed in 25 of 38 patients who underwent anterior, posterior, or total callosotomy for refractory seizures between 1988 and 1995. Nine patients had signal changes in the cerebral white matter on postoperative MRI. Six of these patients had preoperative MRI studies available for comparison, and none of the white matter signal abnormalities were evident preoperatively. T2 prolongation or hyperintensity on proton-density images was observed in areas including the centrum semiovale, forceps major, and forceps minor. Three patients had signal changes that had distinct borders extending only to the posterior limit of the callosotomy. MRI signal changes in the cerebral white matter after corpus callosotomy have not been previously reported and may represent distant effects of callosal section. Wallerian degeneration occurring in the neuronal processes cut during surgery could account for the signal changes.

The role of dopamine in epilepsy

The clinical benefits of dopamine agonists in the management of epilepsy can be traced back over a century, whilst the introduction of neuroleptics into psychiatry practice 40 years ago witnessed the emergence of fits as a side effect of dopamine receptor blockade. Epidemiologists noticed a reciprocal relationship between the supposed dopaminergic overactivity syndrome of schizophrenia and epilepsy, which came to be regarded as a dopamine underactivity condition. Early pharmacological studies of epilepsy employed nonselective drugs, that often did not permit dopamine's antiepileptic action to be clearly dissociated from that of other monoamines. Likewise, the biochemical search for genetic abnormalities in brain dopamine function, as predeterminants of spontaneous epilepsy, proved largely inconclusive. The discovery of multiple dopamine receptor families (D1 and D2), mediating opposing influences on neuronal excitability, heralded a new era of dopamine-epilepsy research. The traditional anticonvulsant action of dopamine was attributed to D2 receptor stimulation in the forebrain, while the advent of selective D1 agonists with proconvulsant properties revealed for the first time that dopamine could also lower the seizure threshold from the midbrain. Whilst there is no immediate prospect of developing D2 agonists or D1 antagonists as clinically useful antiepileptics, there is a growing awareness that seizures might be precipitated as a consequence of treating other neurological disorders with D2 antagonists (schizophrenia) or D1 agonists (parkinsonism).

Corpus callosotomy: a quantitative study of the extent of resection, seizure control, and neuropsychological outcome

Corpus callosotomy is valuable for controlling medically intractable generalized seizures in appropriate patients, but postoperative development of language disorders, neuropsychological impairment, and motor dysfunction have all been noted. The extent of callosum resection has been implicated as a possible determinant of outcome, but this hypothesis has not been formally tested. Analysis of the records of all patients who underwent corpus callosotomy at the University of California, San Francisco, from 1986 to 1991 showed that, of 15 patients who underwent anterior or complete callosotomy, seven were entirely or nearly seizure-free, four had at least a 50% reduction in seizure frequency, and four had no change. To determine callosal size and extent of callosotomy, preoperative and postoperative magnetic resonance images were measured with computer-based planimetry. Seizure outcome was not significantly associated with preoperative callosal size or extent of callosotomy. Intelligence quotient scores did not change significantly after callosotomy. No severe neuropsychological deficits developed after anterior or complete callosotomy, even in patients with mixed cerebral dominance or bilateral language representation. These results indicate that division of the anterior one-half to two-thirds of the corpus callosum is nearly as effective as more extensive anterior sectioning or complete callosotomy in reducing drop-attack and generalized tonic-clonic seizures in appropriate patients, and that the extent of callosotomy is not an important factor on outcome when at least 50% to 65% of the callosum is divided. Mixed cerebral dominance and other unusual patterns of language and memory organization do not appear to increase the postoperative risk for neuropsychological deficits, regardless of the extent of anterior section.

Magnetic fields mimic the behavioral effects of REM sleep deprivation in humans

The discovery of rapid eye movement (REM) sleep by Aserinsky and Kleitman in 1953 initiated the impetus for sleep research and specifically the investigations of the effects of REM sleep deprivation (RSD) on animal and human behavior. The behavioral effects of RSD include the enhancement of motivational and "drive"-related behaviors. In laboratory animals, RSD has been reported to increase appetite, sexual behavior, aggressiveness, and locomotor activity. Moreover, RSD reportedly improves mood in patients with endogenous depression and heightens appetite and sexual interest in normal subjects. Since "drive"-related behaviors are thought to involve activation of limbic dopaminergic reward sites, RSD may enhance motivational behaviors through an action on limbic dopaminergic functions. In the present communication, we present two patients (one with multiple sclerosis and the other with Parkinson's disease) in whom treatment with magnetic fields produced behavioral effects which paralleled those observed in REM-sleep-deprived animals and humans. We propose, therefore, that the behavioral and mental effects of treatment with magnetic fields may be mediated via RSD and, by inference, involve activation of limbic dopaminergic reward sites.

Information processing in the separated hemispheres of callosotomy patients: does the analytic-holistic dichotomy hold?

The characterization of the left and right cerebral hemispheres as analytic and holistic, respectively, was evaluated with callosotomy patients. This distinction was operationalized by reference to the work of Garner, Kemler Nelson, and their colleagues on separable (analytic) and integral (holistic) dimensions of cognition. In one experiment, patients were asked to make similarity judgments when faced with triads of stimuli such that one pair matched on a criterial attribute (analytic) and another pair showed a family resemblance (holistic). The right hemisphere showed a stronger bias to judge on the basis of the criterial attribute. In a second experiment, each hemisphere was engaged separately in a concept formation task. Depending on the exemplars in a particular set, analytic or holistic processing was seen in either hemisphere. However, the left hemisphere was more likely to engage in analytic processing. The results suggest that both hemispheres are capable of either type of processing and may use either mode, depending on the nature of the task and stimulus material. Thus, the analytic/holistic distinction may not provide a simple, generalizable description of information processing differences between the two hemispheres.

Wallerian degeneration of the pyramidal tract in capsular infarction studied by magnetic resonance imaging

Using magnetic resonance imaging, we studied 24 patients with ischemic infarction of the internal capsule. Magnetic resonance imaging detected wallerian degeneration of the pyramidal tract below the capsular lesion in 11 patients (45.8%); all 11 had clinical evidence of pyramidal tract damage. In six additional patients magnetic resonance imaging findings, present only on axial slices, were considered to indicate possible wallerian degeneration. When motor deficit was associated with posterior limb lesions, magnetic resonance imaging detected wallerian degeneration of the pyramidal tract in 78.6% (11) of 14 patients.

Corpus callosum stimulation and stereotactic callosotomy in the management of refractory generalized epilepsy. Preliminary communication

Corpus callosum stimulation produced by chronically implanted electrodes, placed either by craniotomy or stereotactically, failed to control refractory generalized epilepsy in humans and also in experimentally produced penicillin epilepsy in cats. However, the patients that suffered craniotomy, frontal lobe retraction or pneumoencephalograms, without callosal section, showed remarkable improvement of their seizure condition due to these unspecific manipulation effects. Stereotactic anterior callosotomy emerged as a sequel of these functional neurosurgical findings, and as an alternative procedure to preclude undesirable neuropsychological and neurological side effects of split brain syndrome and of brain retraction, associated to conventional callosotomy. Ten patients with various disabling convulsive disorders have undergone this new operation, which showed to be less traumatic and better tolerated than open callosotomy.