Cynipid wasps systematically reprogram host metabolism and restructure cell walls in developing galls

Many insects have evolved the ability to manipulate plant growth to generate extraordinary structures called galls, in which insect larva can develop while being sheltered and feeding on the plant. In particular, cynipid (Hymenoptera: Cynipidae) wasps have evolved to form morphologically complex galls and generate an astonishing array of gall shapes, colors, and sizes. However, the biochemical basis underlying these remarkable cellular and developmental transformations remains poorly understood. A key determinant in plant cellular development is cell wall deposition that dictates the physical form and physiological function of newly developing cells, tissues, and organs. However, it is unclear to what degree cell walls are restructured to initiate and support the formation of new gall tissue. Here, we characterize the molecular alterations underlying gall development using a combination of metabolomic, histological, and biochemical techniques to elucidate how valley oak (Quercus lobata) leaf cells are reprogrammed to form galls. Strikingly, gall development involves an exceptionally coordinated spatial deposition of lignin and xylan to form de novo gall vasculature. Our results highlight how cynipid wasps can radically change the metabolite profile and restructure the cell wall to enable the formation of galls, providing insights into the mechanism of gall induction and the extent to which plants can be entirely reprogrammed to form unique structures and organs.

Reproducible growth of Brachypodium in EcoFAB 2.0 reveals that nitrogen form and starvation modulate root exudation

Understanding plant-microbe interactions requires examination of root exudation under nutrient stress using standardized and reproducible experimental systems. We grew Brachypodium distachyon hydroponically in fabricated ecosystem devices (EcoFAB 2.0) under three inorganic nitrogen forms (nitrate, ammonium, and ammonium nitrate), followed by nitrogen starvation. Analyses of exudates with liquid chromatography-tandem mass spectrometry, biomass, medium pH, and nitrogen uptake showed EcoFAB 2.0's low intratreatment data variability. Furthermore, the three inorganic nitrogen forms caused differential exudation, generalized by abundant amino acids-peptides and alkaloids. Comparatively, nitrogen deficiency decreased nitrogen-containing compounds but increased shikimates-phenylpropanoids. Subsequent bioassays with two shikimates-phenylpropanoids (shikimic and p-coumaric acids) on soil bacteria or Brachypodium seedlings revealed their distinct capacity to regulate both bacterial and plant growth. Our results suggest that (i) Brachypodium alters exudation in response to nitrogen status, which can affect rhizobacterial growth, and (ii) EcoFAB 2.0 is a valuable standardized plant research tool.

Results of surgical therapy of functioning pituitary adenomas

INTRODUCTION

Functioning pituitary adenomas lead to substantial morbidity and increased mortality associated with typical endocrine syndromes. Surgical therapy is an integral part of the management of these tumours. The aim of this study was to evaluate the results of surgical transnasal procedures in patients with functioning pituitary adenomas who underwent the surgery at the Department of Neurosurgery, University Hospital Olomouc.

METHODS

Patients with functioning pituitary adenoma (ACTH, GH, PRL) were indicated for surgery. All patients underwent preoperative and postoperative endocrinological examination and laboratory tests to assess excessive or deficient hormonal production and imaging examination.

RESULTS

The cohort consisted of 58 patients, 33 of whom were women and 25 men. The age range was 12-77 years (mean age 47.6 years). Microadenoma was diagnosed in 58.6% of patients and macroadenoma in 41.4% of patients. The most common hypersecretory syndrome was excessive production of growth hormone (56.9%), followed by excessive production of adrenocorticotropic hormone (24.1%) and prolactin (12.1%). In the group with excessive production of ACTH, complete remission was achieved after the first surgery in 78.6% of cases (72.8% for microadenomas (8) and 100% (3) cases in macroadenomas); in the group with excessive GH production in 51.4% (63.2% (7) in microadenomas and 46.2% (12) cases in macroadenomas). In the group with excessive production of PRL, it was 57.1% (100% (2) in microadenomas and 40% (2) cases in macroadenomas).

CONCLUSION

Surgical therapy in the presented cohort led to the normalisation of hormonal excessive production in 58.6% of cases. A combination of drug therapy and radiotherapeutic methods was necessary in the remaining cases to achieve hormonal remission.

Gibberellin and abscisic acid transporters facilitate endodermal suberin formation in Arabidopsis

The plant hormone gibberellin (GA) regulates multiple developmental processes. It accumulates in the root elongating endodermis, but how it moves into this cell file and the significance of this accumulation are unclear. Here we identify three NITRATE TRANSPORTER1/PEPTIDE TRANSPORTER (NPF) transporters required for GA and abscisic acid (ABA) translocation. We demonstrate that NPF2.14 is a subcellular GA/ABA transporter, presumably the first to be identified in plants, facilitating GA and ABA accumulation in the root endodermis to regulate suberization. Further, NPF2.12 and NPF2.13, closely related proteins, are plasma membrane-localized GA and ABA importers that facilitate shoot-to-root GA12 translocation, regulating endodermal hormone accumulation. This work reveals that GA is required for root suberization and that GA and ABA can act non-antagonistically. We demonstrate how the clade of transporters mediates hormone flow with cell-file-specific vacuolar storage at the phloem unloading zone, and slow release of hormone to induce suberin formation in the maturation zone.

Phase-contrast enhanced synchrotron micro-tomography of human meniscus tissue

OBJECTIVE

To investigate the feasibility of synchrotron radiation-based phase contrast enhanced micro-computed tomography (SR-PhC-μCT) for imaging of human meniscus. Quantitative parameters related to fiber orientation and crimping were evaluated as potential markers of tissue degeneration.

DESIGN

Human meniscus specimens from 10 deceased donors were prepared using different preparation schemes: fresh frozen and thawed before imaging or fixed and paraffin-embedded. The samples were imaged using SR-PhC-μCT with an isotropic voxel size of 1.625 μm. Image quality was evaluated by visual inspection and spatial resolution. Fiber voxels were defined using a grey level threshold and a structure tensor analysis was applied to estimate collagen fiber orientation. The area at half maximum (FAHM) was calculated from angle histograms to quantify orientation distribution. Crimping period was calculated from the power spectrum of image profiles of crimped fibers. Parameters were compared to degenerative stage as evaluated by Pauli histopathological scoring.

RESULTS

Image quality was similar between frozen and embedded samples and spatial resolutions ranged from 5.1 to 5.8 μm. Fiber structure, including crimping, was clearly visible in the images. Fibers appeared to be less organized closer to the tip of the meniscus. Fiber density might decrease slightly with degeneration. FAHM and crimping period did not show any clear association with histopathological scoring.

CONCLUSION

SR-PhC-μCT is a feasible technique for high-resolution 3D imaging of fresh frozen meniscus tissue. Further work is needed to establish quantitative parameters that relate to tissue degeneration, but this imaging technique is promising for future studies of meniscus structure and biomechanical response.

Safety of Intranasal Insulin in Type 2 Diabetes on Systemic Insulin: A Double-Blinded Placebo-Controlled Sub-Study of Memaid Trial

AIMS

To determine safety of intranasal insulin (INI) in MemAID trial participants with diabetes treated with systemic insulins.

MATERIALS AND METHODS

This randomized, double-blinded trial consisted of 24-week INI or placebo treatment once daily and 24-week follow-up. Safety outcomes were: 1) Short-term effects on glycemic variability, hypoglycemic episodes on continuous glucose monitoring (CGM) at baseline and on-treatment. 2) Long-term effects on glucose metabolism and weight on INI/placebo treatment and post-treatment follow-up. Of 86 screened subjects, 14 were randomized, 9 (5 INI, 4 Placebo) completed CGM at baseline and on-treatment, and 5 (2 INI, 3 Placebo) completed treatment and follow-up.

RESULTS

INI was safe and was not associated with serious adverse events, hypoglycemic episodes or weight gain. INI administration did not acutely affect capillary glucose. Glycemic variability on CGM decreased with INI, compared to baseline. On INI treatment, there was a long-term trend toward lower HbA1c, plasma glucose and insulin. No interactions with subcutaneous insulins were observed.

CONCLUSIONS

INI is safe in older people with diabetes treated with systemic insulins, and it is not associated with adverse events, hypoglycemia or weight gain. Future studies are needed to determine whether INI administration can reduce glycemic variability, improve insulin sensitivity and thus potentially lessen diabetes burden in this population.

Fertilizer Type Affects Stable Isotope Ratios of Nitrogen in Human Blood Plasma─Results from Two-Year Controlled Agricultural Field Trials and a Randomized Crossover Dietary Intervention Study

The stable nitrogen isotope ratio δ¹⁵N is used as a marker of dietary protein sources in blood. Crop fertilization strategies affect δ¹⁵N in plant foods. In a double-blinded randomized cross-over dietary intervention trial with 33 participants, we quantified the effect of fertilizer type (conventional: synthetic fertilizer and organic: animal or green manure) on δ¹⁵N in blood plasma. At study baseline, plasma δ¹⁵N was +9.34 ± 0.29‰ (mean ± standard deviation). After 12 days intervention with a diet based on crops fertilized with animal manure, plasma δ¹⁵N was shifted by +0.27 ± 0.04‰ (mean ± standard error) compared to synthetic fertilization and by +0.22 ± 0.04‰ compared to fertilization with green manure (both p < 0.0001). Accordingly, differences in the δ¹⁵N values between fertilizers are propagated to the blood plasma of human consumers. The results indicate a need to consider agricultural practices when using δ¹⁵N as a dietary biomarker.

Transnasal endoscopic surgery of sphenoid meningocele associated with pituitary adenoma. A case report

BACKGROUND

Transsphenoid meningoencephalocele is a congenital anomaly formed by herniation of an ependyma delimited sac through a bony defect into the sphenoid sinus. The sac contains cerebrospinal fluid and neurovascular structures. The prevalence of transsphenoid meningoencephalocele in the adult population is rare. It usually manifests as nasal liquorrhoea.

METHODS AND RESULTS

This case report presents an adult male who underwent surgery due to suspected pituitary macroadenoma. The surgery was performed endoscopically via the transnasal approach with a surprising finding of true transsphenoid meningoencephalocele. Ectopic solid tissue was found in the sphenoid sinus in which pituitary adenoma was histologically confirmed.

CONCLUSION

This paper presents a previously unpublished combination of true transsphenoid meningoencephalocele and pituitary adenoma in an adult individual.

The oxygen isotopic signature of soil- and plant-derived sulphate is controlled by fertilizer type and water source

The oxygen isotope signature of sulphate (δ¹⁸ O_sulphate ) is increasingly used to study nutritional fluxes and sulphur transformation processes in a variety of natural environments. However, mechanisms controlling the δ¹⁸ O_sulphate signature in soil-plant systems are largely unknown. The objective of this study was to determine key factors, which affect δ¹⁸ O_sulphate values in soil and plants. The impact of an ¹⁸ O-water isotopic gradient and different types of fertilizers was investigated in a soil incubation study and a radish (Raphanus sativus L.) greenhouse growth experiment. Water provided 31-64% of oxygen atoms in soil sulphate formed via mineralization of organic residues (green and chicken manures) while 49% of oxygen atoms were derived from water during oxidation of elemental sulphur. In contrast, δ¹⁸ O_sulphate values of synthetic fertilizer were not affected by soil water. Correlations between soil and plant δ¹⁸ O_sulphate values were controlled by water δ¹⁸ O values and fertilizer treatments. Additionally, plant δ³⁴ S data showed that the sulphate isotopic composition of plants is a function of S assimilation. This study documents the potential of using compound-specific isotope ratio analysis for investigating and tracing fertilization strategies in agricultural and environmental studies.

Non-Invasive Strategies for Nose-to-Brain Drug Delivery

Intranasal drug administration is a promising method for delivering drugs directly to the brain. Animal studies have described pathways and potential brain targets, but nose-to-brain delivery and treatment efficacy in humans remains debated. We describe the proposed pathways and barriers for nose-to-brain drug delivery in humans, drug properties that influence central nervous system delivery, clinically tested methods to enhance absorption, and the devices used in clinical trials. This review compiles the available evidence for nose-to-brain drug delivery in humans and summarizes the factors involved in nose-to-brain drug delivery.

[URGENT SURGICAL OPERATIONS FOR CROHN'S DISEASE IN CHILDREN]

Aim - the improvement of treatment results of patients with complicated Crohn's disease based on study and analysis of own results of surgical interventions. Since 2008 to 2020 years 23 patients at the age 1,5-17 years old with Crohn's disease in 3 pediatric surgical hospitals have been observed. The article presents the analysis of surgical treatment of these patients with complications of main pathology. Diagnostics is integrated and includes clinical and laboratorian examination of patients, X-ray, endoscopic, sonography methods of examination and morphological research method of clinical biopsy. Complications of Crohn's disease were presented by intestinal obstructions (34,78% of cases), intestinal perforations (26,09%), acute appendicitis with mesadenitis (13,04%), intraabdominal abscesses (8,7%), intestinal hemorragia from inflammatory wart (4,35%), perianal inflammatory complications with fistulas (13,04%). The article has covered all possible methods of surgical operations depending on the type of complication. The most frequent surgical interventions were resections of intestinal stenosis with formation of intestinal stomas. The majority of patients have achieved good results after surgical interventions. 5 (23,81%) patients have got a relaparotomias because of such postoperative complications as anastomotic failure (1), recurrence of intestinal perforation (2) and recurrence of intestinal obstruction (2). Mortality has not been observed. Conclusions. 1. Because of Crohn's disease is a progressive disease, the opportunity of emergence of acute surgical complications of this pathology preserves. Our data show that urgent surgical complications of Crohn's disease in 47,83% of patients were the first manifestation of the disease, which was diagnosed during treatment and verified morphologically in the postoperative period. 2. In most cases surgical complications were intestinal obstruction (34,78% cases) and intestinal perforations (26,09%), and the most frequent surgical interventions for Crohn's disease in children were resections of the affected areas of the intestine with formation of intestinal stomas. 3. The modern tactic of surgical treatment of complicated of Crohn's disease in children based on local intestinal resections with intestinal stomas. 4. It is very important to use a combined approach combining conservative and surgical treatment. Surgical treatment and drug treatment of Crohn's disease should be complementary treatments.

Memory advancement by intranasal insulin in type 2 diabetes (MemAID) randomized controlled clinical trial: Design, methods and rationale

BACKGROUND

Type 2 diabetes mellitus (T2DM) accelerates brain aging and increases the risk for dementia. Insulin is a key neurotrophic factor in the brain, where it modulates energy metabolism, neurovascular coupling, and regeneration. Impaired insulin-mediated brain signaling and central insulin resistance may contribute to cognitive and functional decline in T2DM. Intranasal insulin (INI) has emerged as a potential therapy for treating T2DM-related cognitive impairment.

METHODS/DESIGN

Ongoing from 2015, a prospective, two-center, randomized, double-blind, placebo-controlled trial of 210 subjects (120 T2DM and 90 non-diabetic older adults) randomized into four treatment arms (60 T2DM-INI, 60 T2DM-Placebo, 45 Control-INI, and 45 Control-Placebo) evaluating the long-term effects of daily intranasal administration of 40 International Units (IU) of human insulin, as compared to placebo (sterile saline) over 24 weeks and 24 weeks of post-treatment follow-up. Study outcomes are: 1) long-term INI effects on cognition, daily functionality, and gait speed; 2) identifying a clinically relevant phenotype that predicts response to INI therapy; 3) long-term safety.

CONCLUSION

This study addresses an important knowledge gap about the long-term effects of intranasal insulin on memory and cognition in older people with T2DM and non-diabetic controls, and may provide a novel therapeutic target for prevention and treatment of cognitive and functional decline and dementia. Trial Registration NCT02415556.

Mastoid foramen, mastoid emissary vein and clinical implications in neurosurgery

BACKGROUND

Mastoid emissary vein is especially important from the neurosurgical point of view, because it is located in variable number in the area of the occipitomastoid suture and it can become a source of significant bleeding in surgical approaches through the mastoid process, especially in retrosigmoid craniotomy, which is used for approaches to pathologies localized in the cerebellopontine angle. Ideal imaging method for diagnosis of these neglected structures when planning a surgical approach is high-resolution computed tomography. The aim of this work was to provide detailed information about this issue.

METHODS

We studied a group of 295 skulls obtained from collections of five anatomy departments and the National Museum. Both quantitative and qualitative parameters of the mastoid foramen were evaluated depending on side of appearance and gender. Individual distances of the mastoid foramen from clearly defined surface landmarks (asterion, apex of mastoid process, foramen magnum) and other anatomical structures closely related to this issue (width of groove for sigmoid sinus, diameters of internal and external openings of mastoid foramen) were statistically processed.

RESULTS

The most frequently represented type of the mastoid foramen is type II by Louis (41.2%). The differences between right and left sides were not statistically significant. In men there was a higher number of openings on the right side and in qualitative parameters the type III and IV predominated, whereas in women the types I and II were more frequent. In men, greater distances from the mastoid foramen were observed when evaluating qualitative parameters for defined surface landmarks. Mean size of the external opening diameter was 1.3 mm; however, several openings measured up to 7 mm.

CONCLUSIONS

Despite excellent knowledge of anatomy, however, good pre-operative examination using imaging methods and mastering of microsurgical techniques create the base for successful treatment of pathological structures in these anatomically complex areas.

Imaging Current-Induced Switching of Antiferromagnetic Domains in CuMnAs

The magnetic order in antiferromagnetic materials is hard to control with external magnetic fields. Using x-ray magnetic linear dichroism microscopy, we show that staggered effective fields generated by electrical current can induce modification of the antiferromagnetic domain structure in microdevices fabricated from a tetragonal CuMnAs thin film. A clear correlation between the average domain orientation and the anisotropy of the electrical resistance is demonstrated, with both showing reproducible switching in response to orthogonally applied current pulses. However, the behavior is inhomogeneous at the submicron level, highlighting the complex nature of the switching process in multidomain antiferromagnetic films.

An NPF transporter exports a central monoterpene indole alkaloid intermediate from the vacuole

Plants sequester intermediates of metabolic pathways into different cellular compartments, but the mechanisms by which these molecules are transported remain poorly understood. Monoterpene indole alkaloids, a class of specialized metabolites that includes the anticancer agent vincristine, antimalarial quinine and neurotoxin strychnine, are synthesized in several different cellular locations. However, the transporters that control the movement of these biosynthetic intermediates within cellular compartments have not been discovered. Here we present the discovery of a tonoplast localized nitrate/peptide family (NPF) transporter from Catharanthus roseus, CrNPF2.9, that exports strictosidine, the central intermediate of this pathway, into the cytosol from the vacuole. This discovery highlights the role that intracellular localization plays in specialized metabolism, and sets the stage for understanding and controlling the central branch point of this pharmacologically important group of compounds.

Obtaining the structure factors for an epitaxial film using Cu X-ray radiation

Determining atomic positions in thin films by X-ray diffraction is, at present, a task reserved for synchrotron facilities. Here an experimental method is presented which enables the determination of the structure factor amplitudes of thin films using laboratory-based equipment (Cu Kα radiation). This method was tested using an epitaxial 130 nm film of CuMnAs grown on top of a GaAs substrate, which unlike the orthorhombic bulk phase forms a crystal structure with tetragonal symmetry. From the set of structure factor moduli obtained by applying this method, the solution and refinement of the crystal structure of the film has been possible. The results are supported by consistent high-resolution scanning transmission electron microscopy and stoichiometry analyses.

Altered control of postural sway following cerebral infarction: a cross-sectional analysis

OBJECTIVE

Balance impairment is common following cerebral infarction. However, the effects of lesion hemisphere on postural control are largely unknown. We examined dependence upon vision and noninfarcted regional brain tissue volumes for postural control in individuals with right and left hemisphere middle cerebral artery (MCA) infarcts.

METHODS

Subjects with right MCA infarct (n = 17, age = 65 +/- 8 years, 7 +/- 6 years poststroke), left MCA infarct (n = 20, age = 65 +/- 8 years, 7 +/- 6 years poststroke), and controls (n = 55, age = 65 +/- 8 years) were studied. Postural control was defined by average velocity and the range and variability of mediolateral (ML) and anteroposterior (AP) sway during eyes-open and eyes-closed standing. Regional brain volumes were quantified using anatomic MRI at 3 Tesla.

RESULTS

Right and left hemisphere stroke groups had similar infarct volumes and outcomes. Subjects with right hemisphere infarcts demonstrated greater sway velocity, ML range, and ML variability with eyes closed compared to eyes open. In this group, smaller occipital lobe volumes were associated with greater eyes-open sway velocity (R = -0.64, p = 0.012) and ML range (R = -0.82, p = 0.001). Smaller cerebellar volumes were associated with greater eyes-closed sway velocity (R = -0.60, p = 0.015), ML range (R = -0.70, p = 0.007), and ML variability (R = -0.85, p < 0.001). These associations were not observed in left hemisphere infarct subjects or controls. AP sway was unaffected by infarct hemisphere or visual condition and did not correlate with regional brain volumes.

CONCLUSIONS

Right hemisphere middle cerebral artery infarcts are associated with increased dependence on vision and noninfarcted brain regions (i.e., occipital lobes, cerebellum) to control postural sway. Strategies emphasizing postural tasks under reduced visual conditions may enhance functional recovery in these individuals.

Tumor size and karyometric variables in brain astrocytoma

PURPOSE

To show any possible correlation of some karyometric variables with tumor size in patients with brain astrocytoma, in order to confirm karyometry as an objective histological method.

PATIENTS AND METHODS

The study included 63 patients of different ages and both genders with brain astrocytoma histologically confirmed on the surgically removed material. In all patients maximal tumor excision was done, and all were postoperatively treated according to different therapeutic protocols. Tumor size (preoperative CT scan) was correlated with the duration of survival and the values of some karyometric tumor variables: area, density, maximal axis, mean axis, minimal axis, circumference, roundness, integrated optical density (IOD) and number of nuclei.

RESULTS

Patients were separated into 3 groups according to the average tumor diameter. There were 34 cases of medium-sized tumors, 12 of small and 17 of large-sized tumors, and their respective survival was 83, 97 and 24 weeks. Patients with large tumors had statistically shorter survival compared to those with medium and small tumors (log-rank test, p=0.0122). Seven out of 9 examined karyometric variables were significantly related (p<0.05) to the tumor size: area, maximal axis, mean axis, minimal axis, circumference, roundness and IOD.

CONCLUSION

Patients with larger tumors have shorter survival. The results of our morphometric analysis of the tumor cell nuclei, after correlation with CT findings, revealed that nuclear pleomorphism and larger nuclear size are associated with larger brain astrocytomas.

Vasoreactivity and peri-infarct hyperintensities in stroke

OBJECTIVE

It is unknown if impaired cerebral vasoreactivity recovers after ischemic stroke, and whether it compromises perfusion in regions surrounding infarct and other vascular territories. We investigated the regional differences in CO2 vasoreactivity (CO2 VR) and their relationships to peri-infarct T2 hyperintensities (PIHs), chronic infarct volumes, and clinical outcomes.

METHODS

We studied 39 subjects with chronic large middle cerebral artery territory infarcts and 48 matched controls. Anatomic and three-dimensional continuous arterial spin labeling imaging at 3-Tesla MRI were used to measure regional cerebral blood flow (CBF) and CO2 VR during normocapnia, hypercapnia, and hypocapnia in main arteries distributions.

RESULTS

Stroke patients showed a significantly lower augmentation of blood flow at increased CO2 but greater reduction of blood flow with decreased CO2 than the control group. This altered vasoregulatory response was observed both ipsilateral and contralateral to the stroke. Lower CO2 VR on the stroke side was associated with PIHs, greater infarct volume, and worse outcomes. The cases with PIHs (n = 27) had lower CBF during all conditions bilaterally (p < 0.0001) compared to cases with infarct only.

CONCLUSIONS

Perfusion augmentation is inadequate in multiple vascular territories in patients with large artery ischemic infarcts, but vasoconstriction is preserved. Peri-infarct T2 hyperintensities are associated with lower blood flow. Strategies aimed to preserve vasoreactivity after an ischemic stroke should be tested for their effect on long-term outcomes.

Altered cerebral vasoregulation in hypertension and stroke

BACKGROUND

Autoregulation of blood flow that maintains steady perfusion over the range of systemic blood pressure is compromised by stroke.

OBJECTIVES

To determine whether cerebral vasoregulation is impaired in stroke during orthostatic stress.

METHODS

Subjects included 30 control subjects, 30 with hypertension, and 20 with minor stroke and were studied using transcranial Doppler. Bilateral blood flow velocities (BFVs) from middle cerebral arteries, heart rate, blood pressure (BP), and CO2 were obtained during hyperventilation and CO2 rebreathing during supine rest and tilt at 80 degrees. Side-to-side BFV difference, vasomotor range (VMR), and cerebrovascular resistance (CVR) were calculated during normo-, hypo-, and hypercapnia.

RESULTS

Mean BFVs were similar between groups in supine position but differed during tilt. BFV diminished on the stroke side during tilt with hyperventilation and CO2 rebreathing (p < 0.0001). CVR increased (p < 0.0001) and VMR decreased (p < 0.01) on the stroke side. Vasoregulation was preserved on the normal side. BFV asymmetry differentiated patients with stroke from the other groups (p < 0.0001). BFV difference between the normal vs stroke side was the largest in stroke-normotensive (n = 7) compared with stroke-hypertensive (n = 13) patients and the two other groups (p < 0.0001). BFV asymmetry in stroke was associated with lower orthostatic BP (p < 0.0001).

CONCLUSIONS

Cerebral vasoregulation is impaired with minor stroke, and cerebral blood flow depends on blood pressure. Decline of blood flow velocities during orthostatic stress may pose a risk of silent hypoperfusion.

Treatment of painful sensory neuropathy with tiagabine: a pilot study

To evaluate the effect of tiagabine hydrochloride in painful neuropathy in a pilot, open-label study. Painful neuropathy is characterized by preferential involvement of small sensory and autonomic fibers. Tiagabine increases gamma-aminobutyric acid and might enhance the central pain-control mechanisms. Seventeen patients (10 men, 7 women; mean age 51.4 +/- 7.7 y) with chronic painful neuropathy (>6 months) were enrolled in this study. Week 0: All pain medications were discontinued. Weeks 1-4: Dose of tiagabine was increased weekly by 4 mg orally up to 16 mg in week 4. Quantitative sensory testing for vibration, cooling, and heat-pain, and quantitative sudomotor axon reflex test (QSART) were done at week 0 and week 4. The McGill Pain Questionnaire was administered weekly. Nine patients completed the study; 8 patients discontinued the treatment. Baseline pain intensity was 6.2 +/- 3.1 on the McGill Pain Questionnaire scale (0-10 range). Low doses (4-8 mg) of tiagabine reduced pain symptoms by 16-38%, improving surface pain (37.5%), skin sensitivity (32.8%), burning (38.6%), cold (25.4%) and pain sharpness (29%; p <0.03). Dull and deep pain did not improve. Quantitative sensory testing abnormalities diminished with treatment (p <0.02). Autonomic test results did not change. This pilot study evaluated the potential of tiagabine hydrochloride (Gabitril) in treatment of painful sensory neuropathy. Pain symptoms and quantitative sensory test results improved with treatment, especially at low doses of tiagabine (4-8 mg). Higher doses (12-16 mg) were associated with increased number of adverse events. Tiagabine may have potential benefits for treatment of painful neuropathy; however, assessment of its efficacy in a larger study is needed.

Intracranial ossifications and microangiopathy at 8 Tesla MRI

Clinical evaluation and MR imaging of microangiopathy associated with hypertension is limited. We describe a case that illustrates sensitivity of MRI at 8 Tesla for imaging of microvasculature, iron, calcium deposits and silent white matter lesions (WML). A 60-year-old black hypertensive woman was evaluated for numbness in the face and extremities. MRI at 1.5 Tesla was unrevealing.MRI at 8 Tesla: Axial and sagittal Gradient Echo images were obtained with an 8T/80 cm human scanner and showed: 1) Large areas of signal voids due to ossifications and fat deposits within the falx. 2) Obstructed small vessels in the periventricular regions and distended cortical veins. 3) Numerous small WML, suggestive of mini-infarcts (<1 cm) and microhemorrhages. 4) Intracranial calcifications in the falx, tentorium, basal ganglia and chorioid plexus that were confirmed by CT scan. Atherosclerotic plaque in right carotid artery and reduced vasomotor reserve in middle cerebral arteries, documented by ultrasound, indicated large and small vessel disease.

CONCLUSIONS

MRI at 8 Tesla improves visualization of microangiopathy, ossifications and iron deposits due to enhanced magnetic susceptibility at ultra high magnetic field.

Ultra High Field MRI at 8 Tesla of Subacute Hemorrhagic Stroke

PURPOSE

Optimal treatment strategies and neurologic outcome after stroke depend on an accurate characterization of the lesion. There is a need for high resolution noninvasive imaging for assessment of the infarct size, perfusion, and vascular territory. MRI at the ultra high field (UHF) of 8 T offers unprecedented resolution, but its utility for stroke evaluation has not been determined yet.

METHOD

A 55-year-old man with hypertension experienced sudden onset of speech arrest and right-sided hemiparesis that resolved in < 24 h with minimal neurologic deficit. MRI at 1.5 T showed initially a left posterior frontal lesion with subacute infarct (hyperintense on T2-weighted spin echo images) and right-sided frontal and periventricular lesions consistent with chronic infarct. There were many smaller white matter lesions. Delayed studies showed high signal changes involving the gray matter only on T1-weighted images.

RESULTS

Gradient echo and rapid acquisition with relaxation enhancement (RARE) multislice images revealed a serpentine area of low signal in the left posterior frontal lobe gray matter suggestive of a hemorrhagic infarct, right-sided frontal lesion also showing iron deposits, multiple periventricular and cortical areas with abnormal high signal regions that were consistent with old infarcts, and numerous small vessels readily visible, more prominent on the right.

CONCLUSION

MRI at 8 T displays lesions with a high resolution and striking anatomic details. Susceptibility to iron and sensitivity to detect blood products are increased at 8 T. The imaging characteristics at high field are different from those at low field, but both represent findings of iron products.

Autonomic impairment in painful neuropathy

OBJECTIVES

1) To determine the degree and distribution and quantitate the severity of autonomic impairment in painful neuropathy (PN). 2) To assess the role of autonomic testing in evaluating PN.

METHODS

The authors studied 92 patients with PN (60 women and 32 men, age 56.9 +/- 12.4 years) using: 1) autonomic reflex testing (ART), Quantitative Sudomotor Axon Reflex Test (QSART), cardiac-vagal, head-up tilt, and surface skin temperature; 2) autonomic symptoms questionnaire; 3) nerve conduction (NCS) and laboratory studies; 4) quantitative sensory testing; 5) skin biopsy; and 6) Composite Autonomic Symptoms Score (CASS) scale to grade ART results from 0 (normal) to 10 (autonomic failure).

RESULTS

Autonomic involvement in PN had characteristic features. Main symptoms were pain, secretory and skin vasomotor signs, hypertension, and impotence. ART results were abnormal in 86 (93.5%) (CASS < 4), QSART in 67 (72.8%), cardiac-vagal index in 58 (63%), skin temperature in 51 (55.4%), orthostatic hypertension in 39 (42.3%), and family history of PN in 26 (21%) of patients. Group 1 (abnormal NCS) (n = 45) had more severe ART and sensory abnormalities than the Group 2 (normal NCS) (n = 47): 1) CASS 2.0 +/- 0.96 vs 1.55 +/- 0.88 (p < 0.01), cardiac-vagal index (p < 0.02), skin temperature (p < 0.02), hypertension (p < 0.03), cooling (p < 0.002), and vibration (p < 0.0005) thresholds.

CONCLUSIONS

Autonomic symptoms in painful neuropathy are predominantly cholinergic and form a unique constellation of features that are distinct from other autonomic neuropathies.

High resolution MRI of the brainstem at 8 T

A recently developed ultra high field MRI system operating at 8 T (UHFMRI) was applied for brainstem imaging. UHFMRI was performed in five healthy volunteers (three men, two women; age range 34--46 years). Sagittal and axial slices were obtained with the following settings: GE, TR 750--1,000 ms, TE 7-9 ms, FOV 20 cm, matrix 1,024 x 1,024 or 512 x 512 points, slice thickness 2 mm, resolution 195 or 390 microm/pixel. The brainstem structures were assigned based on anatomy and course. Images with good signal strength and homogeneity were acquired from the midbrain and the pons. Main intraaxial structures could be directly visualized. The periaqueductal gray matter and nuclei had higher signal intensity than the predominantly white matter structures such as the corticobulbar/corticopontine/corticospinal tracts, the sensory lemnisci, and the medial longitudinal fasciculus. Structures with high iron content such as the substantia nigra and the red nucleus were seen as prominent signal hypointensities. Numerous vessels traversing the brainstem including small perforators were also distinguished. It is concluded that UHFMRI enables the acquisition of high quality images of the upper brainstem with details approaching that of histologic specimen.

Hemodynamic and symptomatic effects of acute interventions on tilt in patients with postural tachycardia syndrome

A variety of approaches have been used to alleviate symptoms in postural tachycardia syndrome (POTS). Drugs reported to be of benefit include midodrine, propranolol, clonidine, and phenobarbital. Other measures used include volume expansion and physical countermaneuvers. These treatments may influence pathophysiologic mechanisms of POTS such as alpha-receptor dysfunction, beta-receptor supersensitivity, venous pooling, and brainstem center dysfunction. The authors prospectively studied hemodynamic indices and symptom scores in patients with POTS who were acutely treated with a variety of interventions. Twenty-one subjects who met the criteria for POTS were studied (20 women, 1 man; mean age, 28.7 +/- 6.8 y; age range, 14-39 y). Patients were studied with a 5-minute head-up tilt protocol, ECG monitoring, and noninvasive beat-to-beat blood pressure monitoring, all before and after the administration of an intervention (intravenous saline, midodrine, propranolol, clonidine, or phenobarbital). The hemodynamic indices studied were heart rate (ECG) and systolic, mean, and diastolic blood pressure. Patients used a balanced verbal scale to record any change in their symptoms between the tilts. Symptom scores improved significantly after the patients received midodrine and saline. Midodrine and propranolol reduced the resting heart rate response to tilt (p <0.005) and the immediate and 5-minute heart rate responses to tilt (p <0.002). Clonidine accentuated the immediate decrease in blood pressure on tilt up (p <0.05). It was concluded that midodrine and intravenous saline are effective in decreasing symptoms on tilt in patients with POTS when given acutely. Effects of treatments on heart rate and blood pressure responses generally reflected the known pharmacologic mechanisms of the agents.

Mechanisms of blood pressure alterations in response to the Valsalva maneuver in postural tachycardia syndrome

The postural tachycardia syndrome (POTS) is characterized clinically by orthostatic lightheadedness and tachycardia. When these patients perform a Valsalva maneuver, there is an excessive blood pressure increment after cessation of the maneuver (phase IV) that is sometimes associated with headaches. It is not known whether excessive phase IV is due to excessive peripheral vascular tone (an alpha-adrenergic mechanism) or is a manifestation of increased beta-adrenergic tone (hyperadrenergic state). The authors undertook a pharmacologic study evaluating the effect of intravenous phentolamine (alpha-adrenergic antagonist) and propranolol (beta-adrenergic antagonist) on the different phases of the Valsalva maneuver in a group of patients with POTS and age-matched normal control subjects. Patients with POTS had mean phases, when compared with controls, that were characterized by more negative II_E (p = 0.07), smaller II_L (p = 0.04), and significantly larger phase IV (p = 0.001). The effect of phentolamine was qualitatively and quantitatively different in POTS when compared with controls. Ten mg phentolamine in controls resulted in a significant accentuation of phase II_E (p = 0.001), attenuation of phase II_L (p = 0.002), and increase of phase IV (57.6 vs 30.7 mm Hg; p = 0.025). These changes resembled those of patients with POTS at baseline. In patients with POTS, the phase II abnormalities, already present, were further accentuated (p <0.001), and phase IV became smaller (50.6 vs 73.8 mm Hg; p = 0.09). Propranolol had no significant effect on phases II_E and II_L, but significantly reduced phase IV in both controls (p <0.05) and in patients with POTS (p <0.001) and improved the headache symptoms, when present, during and after phase IV. The authors conclude that phase IV is mainly under beta-adrenergic regulation and that the exaggerated phase IV in POTS is a result of a hyperadrenergic state.

Painful sensory neuropathy: prospective evaluation using skin biopsy

OBJECTIVE

In patients presenting with painful, burning feet with minimal signs of neuropathy, the following questions were addressed: 1) How many of these patients have a peripheral neuropathy? 2) What is the role of skin biopsy in establishing a diagnosis of neuropathy? 3) What conditions are associated with the neuropathy? and 4) What laboratory studies are useful in this patient population?

METHODS

A total of 117 consecutive patients referred for evaluation were prospectively studied. All underwent nerve conduction studies (NCS) and a battery of blood tests, including antinerve antibodies. If NCS were normal, a punch biopsy of the skin of the distal leg was performed to ascertain the intraepidermal nerve fiber (IENF) density. In a subset of 32 patients, the sensitivity of skin biopsy was compared to quantitative sudomotor axon test (QSART) and quantitative sensory tests (QST).

RESULTS

Three groups emerged. Group 1, with abnormal NCS (n = 60, 34 F/26 M, mean age 60 +/- 14 years), represented 51% of the cohort. The majority had neuropathies of undetermined cause, but 18 (30%) had associated conditions. Group 2, with normal NCS and reduced IENF density (n = 44, 29 F/15 M, mean age 57 +/- 14 years), represented 38% of the cohort. Three in this group had associated conditions. Group 3, with normal NCS and IENF density (n = 13, 6 F/7 M, mean age 53 +/- 13 years), represented 11% of the cohort; most had no diagnoses but two had MS. In a comparative subset analysis, skin biopsy was more sensitive than QSART or QST in diagnosing a neuropathy.

CONCLUSIONS

Patients presenting with painful feet are heterogeneous, consisting of both large and small fiber sensory neuropathies. In rare cases, a central cause for pain can be found. Over one-third of patients required a skin biopsy to diagnose a small fiber sensory neuropathy. A limited battery of blood tests facilitated diagnosis, but serum antinerve antibodies were not helpful.

Time-frequency mapping of R-R interval during complex partial seizures of temporal lobe origin

BACKGROUND

Activation of autonomic nervous system is common with seizures. No reliable biological markers of impending seizures have been found. Evaluation of autonomic changes might help elucidate the transition from interictal to ictal states.

METHODS

We studied twelve patients (eight females, four males), from 19 to 62 years old with temporal lobe complex partial seizures (CPS). Dynamics of autonomic functions from oscillations in R-R interval (RRI) using time-frequency mapping based upon a Wigner distribution during pre-ictal, ictal and post-ictal periods. Oscillations in RRI at respiratory frequencies (RF) (> 0.1 Hz) are parasympathetically mediated and at nonrespiratory frequencies (NONRF) (0.01-0.09 Hz) are under combined sympathetic and parasympathetic influence.

RESULTS

CPS evoked marked autonomic imbalance and tachycardia. Spectral powers at both RF_RRI and NONRF_RRI increased over the pre-ictal period. RF_RRI power then fell rapidly over the 30 s before seizure onset and remained markedly reduced during seizure (P < 0.004). NONRF_RRI power reached a maximum at seizure onset and declined to a minimum before the seizure cessation (P < 0.05).

CONCLUSION

Time-frequency analysis revealed that autonomic activation hallmarks clinical seizure onset for several minutes. After combined parasympathetic and sympathetic activation, rapid parasympathetic withdrawal occurred approximately 30 s before the seizure, and sympathetic activation peaks at seizure onset. Therefore, the transition from interictal to ictal states is relatively long and associated with subclinical autonomic changes.