Hemiplegia and bilateral globus pallidus infarcts after carbon monoxide poisoning: case report

The vast clinical manifestations of carbon monoxide (CO) poisoning can involve the neurological, neuropsychological and cardiac systems as well as others. In this case report, we describe our management of a 64-year-old woman exposed to CO in her apartment. Her presentation was unusual in that she had symmetric globus pallidus lesions, no evidence of thrombosis, but the lateralizing neurologic manifestation of severe hemiplegia.

[Hemiparkinsonism due to a solitary infarction of the right external segment of the globus pallidus: a case report]

Three months prior to presentation, a 76-year-old woman suffered from insomnia and was prescribed some antidepressants and hypnotics. At that time, brain MRI showed no cerebral infarcts. Having developed an action tremor of the left hand, bradykinesia, and unstable gait, she visited our hospital. Neurological examination revealed rigidity of the neck and left limbs, clumsiness of the left hand, action tremor, and decreasing swing of the left arm while walking. 123I-metaiodobenzylguanidine scintigraphy showed no decrease of the heart/mediastinum ratio. The second MRI showed an old cerebral infarct located just in the right external segment of the globus pallidus. Since drug-induced parkinsonism was suspected, paroxetine and trazodone were discontinued, but her symptoms did not improve. We concluded that her hemiparkinsonism was due to the cerebral infarct in the right external segment of the globus pallidus, because her symptoms did not respond to dopamine agonist and L-dopa therapy, and the onset of symptoms corresponded with the time of appearance of the cerebral infarct. This is a rare case that is important for understanding the mechanism of parkinsonism.

Disgust sensitivity predicts the insula and pallidal response to pictures of disgusting foods

The anterior insula has been implicated in coding disgust from facial, pictorial and olfactory cues, and in the experience of this emotion. Personality research has shown considerable variation in individuals' trait propensity to experience disgust ('disgust sensitivity'). Our study explored the neural expression of this trait, and demonstrates that individual variation in disgust sensitivity is significantly correlated with participants' ventroanterior insular response to viewing pictures of disgusting, but not appetizing or bland, foods. Similar correlations were also seen in the pallidum and orofacial regions of motor and somatosensory cortices. Our results also accord with comparative research showing an anterior to posterior gradient in the rat pallidum reflecting increased 'liking' of foods [Smith, K. S. and Berridge, K. C. (2005) J. Neurosci., 25, 849-8637].

Role of individual basal ganglia nuclei in force amplitude generation

The basal ganglia-thalamo-cortical loop is an important neural circuit that regulates motor control. A key parameter that the nervous system regulates is the level of force to exert against an object during tasks such as grasping. Previous studies indicate that the basal ganglia do not exhibit increased activity with increasing amplitude of force, although these conclusions are based mainly on the putamen. The present study used functional magnetic resonance imaging to investigate which regions in the basal ganglia, thalamus, and motor cortex display increased activity when producing pinch-grip contractions of increasing force amplitude. We found that the internal portion of the globus pallidus (GPi) and subthalamic nucleus (STN) had a positive increase in percent signal change with increasing force, whereas the external portion of the globus pallidus, anterior putamen, posterior putamen, and caudate did not. In the thalamus we found that the ventral thalamic regions increase in percent signal change and activation volume with increasing force amplitude. The contralateral and ipsilateral primary motor/somatosensory (M1/S1) cortices had a positive increase in percent signal change and activation volume with increasing force amplitude, and the contralateral M1/S1 had a greater increase in percent signal change and activation volume than the ipsilateral side. We also found that deactivation did not change across force in the motor cortex and basal ganglia, but that the ipsilateral M1/S1 had greater deactivation than the contralateral M1/S1. Our findings provide direct evidence that GPi and STN regulate the amplitude of force output. These findings emphasize the heterogeneous role of individual nuclei of the basal ganglia in regulating specific parameters of motor output.

[Validity of vascular depression as a specific diagnostic: a review]

INTRODUCTION

A number of authors have suggested that cerebrovascular disease may predispose, precipitate, or perpetuate some geriatric depressive syndromes. These "vascular depressions" may result from damage of striato-pallido-thalamo-cortical pathways which frequently occurs in cerebrovascular disease.

METHOD

We have searched the English and French literature published between 1996 (when the "vascular depression" hypothesis was first stated) and December 2004 through the Medline computer database and examined the validity of the concept of "vascular depression" thanks to four levels of validity: face validity, descriptive validity, construct validity and predictive validity. The face validity is the extent to which experts agree about the existence of a nosological entity.

RESULTS

The reviews published in this field broadly support the concept of "vascular depression" as a specific disorder. However many authors highlighted the fact that depression has been shown to precede vascular diseases and that depression and vascular diseases may both share some pathogenic or genetic determinants. These interactive and co-morbid relationships between depression and cerebrovascular diseases are difficult to disentangle. The descriptive validity refers to the degree of the clinical specificity of a disorder. It appears only moderate regarding the clinical studies carried out on this issue. However, a late-onset, the absence of a family history of mental illness, the lack of insight, lassitude, psychomotor retardation, a greater disability and particular neuropsychological dysfunctions may be associated with vascular depression. The construct validity, which refers to the degree to which the physiopathological processes involved in an illness are understood, appears difficult to establish because of the complex interactive relationships between cerebrovascular disease and depression. However, cerebrovascular diseases may contribute to the occurrence of depressive symptoms independently of its psychosocial burden. The predictive validity refers to the degree to which a syndrome is characterized by a specific response to treatment or a specific natural history. As regards response to treatment, vascular depression appears rather specific in the sense of a worse response to antidepressants and electroconvulsive therapy. The studies on the natural history of vascular depression lead to inconsistent results. According to some authors, this relative resistance to treatment may be explained by structural rather than functional, and thus potentially irreversible disruption in neural networks.

CONCLUSION

In conclusion, the systematic review of the validity of vascular depression broadly supports this concept. However, further studies are needed to decipher the relationships between depression and cerebrovascular disease. Finally, we suggest that it could be more relevant for future researches in this field if the diagnostic criteria for vascular depression were narrowed and required the presence of both neuro-imaging changes and cerebrovascular disease.

Is it possible to predict the long-term response to venlafaxine with the use of biological markers and psychophysiological methods?

INTRODUCTION

The present study investigated whether it is possible to predict the medium term response to venlafaxine using biological markers and psychophysiological methods.

MATERIAL

Fourteen (14) patients aged 21-60 years suffering from Major Depression according to DSM-IV were included in the study.

METHODS

The SCAN v 2.0 and the IPDE were used to assist clinical diagnosis. Patients were investigated with electrooculogram (EOG), Pattern-Reversal Visual Evoked Potentials (PR-VEPs), Dexamethasone Suppression Test (DST), D-fenfluramine Challenge Test, and brain Single Photon Emission Tomography (SPECT). Venlafaxine 150-225 mg per os daily was administered. The follow-up period was 2 years.

STATISTICAL ANALYSIS

Chi-square test and ANOVA were used for the analysis of data.

RESULTS

There was a lower left globus pallidus regional cerebral blood flow in patients with better response. On the contrary, chronic patients were closer to normality.

DISCUSSION

The results of the current study provide preliminary evidence concerning our ability to predict response to venlafaxine and to understand its way of action.

High frequency deep brain stimulation: what are the therapeutic mechanisms?

High frequency deep brain stimulation (HFS) used to treat the symptoms of Parkinson's disease (PD) was first assumed to act by reducing an excessive tonic GABAergic inhibitory output from the internal globus pallidus (GPi). Stimulation in GPi might produce this directly by mechanisms such as depolarization block or activation of presynaptic inhibitory fibers, and the same mechanisms evoked by HFS in the subthalamic nucleus (STN) could reduce the excitatory action of STN on GPi neurons. Although somatic recordings from neurons near the stimulation site may appear to support this potential mechanism, the action downstream from the site of stimulation often is not consistent with this interpretation. A more parsimonious explanation for the similar effects of HFS in STN or GPi and a lesion of either of these structures is that both HFS and pallidotomy interrupt an abnormal pattern of firing in cortico-basal ganglia-thalamocortical loops that is responsible for the symptoms of PD.

Normalizing motor-related brain activity: subthalamic nucleus stimulation in Parkinson disease

OBJECTIVE

To test whether therapeutic unilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) in patients with Parkinson disease (PD) leads to normalization in the pattern of brain activation during movement execution and control of movement extent.

METHODS

Six patients with PD were imaged off medication by PET during performance of a visually guided tracking task with the DBS voltage programmed for therapeutic (effective) or subtherapeutic (ineffective) stimulation. Data from patients with PD during ineffective stimulation were compared with a group of 13 age-matched control subjects to identify sites with abnormal patterns of activation. Conjunction analysis was used to identify those areas in patients with PD where activity normalized when they were treated with effective stimulation.

RESULTS

For movement execution, effective DBS caused an increase of activation in the supplementary motor area (SMA), superior parietal cortex, and cerebellum toward a more normal pattern. At rest, effective stimulation reduced overactivity of SMA. Therapeutic stimulation also induced reductions of movement related "overactivity" compared with healthy subjects in prefrontal, temporal lobe, and basal ganglia circuits, consistent with the notion that many areas are recruited to compensate for ineffective motor initiation. Normalization of activity related to the control of movement extent was associated with reductions of activity in primary motor cortex, SMA, and basal ganglia.

CONCLUSIONS

Effective subthalamic nucleus stimulation leads to task-specific modifications with appropriate recruitment of motor areas as well as widespread, nonspecific reductions of compensatory or competing cortical activity.

Evaluation of basal ganglia haemodynamic changes with perfusion–weighted magnetic resonance imaging in patients with Parkinson’s disease

PURPOSE

The aim of our study was to assess the regional cerebral blood flow (rCBF) of basal ganglia and thalami in patients with Parkinson's disease (PD) using perfusion-weighted magnetic resonance imaging (PW-MRI).

MATERIAL AND METHODS

Twenty subjects affected by idiopathic PD according to the United Kingdom Brain Bank criteria were enrolled in the study. Twenty normal subjects matched for age and gender were included as controls. After 20-day therapy withdrawal, the PD patients underwent PW-MRI. The rCBF was calculated both in patients and in controls. The regions of interest were manually positioned on rCBF maps over the caudate nucleus, the putamen, the external and internal globus pallidus, and over the ventrolateral nucleus of the thalamus. Data were normalised with those obtained from parieto-occipital white matter (POWM). Statistical analysis was performed using a parametric ANOVA test.

RESULTS

Patients showed a significant (p<0.01) interhemispheric asymmetry; rCBF values were higher on the more severely affected side. Controls showed no interhemispheric asymmetry.

CONCLUSION

Our study suggests that PW-MRI is a valuable tool for assessing haemodynamic changes in PD patients. Haemodynamic change pattern may be useful in the early diagnosis of PD.

Long-term functional consequences of quinolinic acid striatal lesions and their alteration following an addition of a globus pallidus lesion assessed using pharmacological magnetic resonance imaging

The present study tested the hypothesis that lesion to the rat globus pallidus (GP) can "normalize" the functioning of the basal ganglia-thalamocortical circuits in striatal-lesioned rats by assessing the functional connectivity of these regions using functional magnetic resonance imaging (fMRI). Changes in brain activation following systemic administration of amphetamine were assessed in (1) rats sustaining a unilateral lesion to the striatum, (2) rats sustaining a combined striatal and pallidal lesion, and (3) control rats. Striatal-lesioned rats showed attenuated cortical activation following amphetamine administration and lower correlations between the responses to amphetamine in different brain regions compared to control rats. Although the addition of an excitotoxic GP lesion failed to prevent striatal lesion-induced attenuation of cortical activation by amphetamine, it was effective in "normalizing" the correlations between the responses to amphetamine in the different areas. These results suggest that, although the GP lesion is ineffective in correcting the global changes in activity caused by the striatal lesion, it may have the capacity to partially restore alterations in functional connectivity resulting from the striatal lesion. These results are further discussed in view of our previous demonstration that lesions to the GP can reverse several behavioral deficits produced by a striatal lesion.

Bilaterale Palliduminfarkte bei Schlaf-Apnoe-Syndrom

Patients suffering from sleep apnea syndrome are known to be at higher risk of cardiac and cerebral infarction. In this case report, we describe bilateral pallidal lesions, which are normally seen after sudden asphyxia due to cardiac arrest or carbon monoxide intoxication. Some epidemiological and pathophysiological observations are cited.

fMRI reveals two distinct cerebral networks subserving speech motor control

BACKGROUND

There are few data on the cerebral organization of motor aspects of speech production and the pathomechanisms of dysarthric deficits subsequent to brain lesions and diseases. The authors used fMRI to further examine the neural basis of speech motor control.

METHODS AND RESULTS

In eight healthy volunteers, fMRI was performed during syllable repetitions synchronized to click trains (2 to 6 Hz; vs a passive listening task). Bilateral hemodynamic responses emerged at the level of the mesiofrontal and sensorimotor cortex, putamen/pallidum, thalamus, and cerebellum (two distinct activation spots at either side). In contrast, dorsolateral premotor cortex and anterior insula showed left-sided activation. Calculation of rate/response functions revealed a negative linear relationship between repetition frequency and blood oxygen level-dependent (BOLD) signal change within the striatum, whereas both cerebellar hemispheres exhibited a step-wise increase of activation at approximately 3 Hz. Analysis of the temporal dynamics of the BOLD effect found the various cortical and subcortical brain regions engaged in speech motor control to be organized into two separate networks (medial and dorsolateral premotor cortex, anterior insula, and superior cerebellum vs sensorimotor cortex, basal ganglia, and inferior cerebellum).

CONCLUSION

These data provide evidence for two levels of speech motor control bound, most presumably, to motor preparation and execution processes. They also help to explain clinical observations such as an unimpaired or even accelerated speaking rate in Parkinson disease and slowed speech tempo, which does not fall below a rate of 3 Hz, in cerebellar disorders.

Cerebral infarct and meningitis secondary to Lemierre's syndrome

The case is reported of a young man with Fusobacterium necrophorum septicemia who developed cavernous sinus thrombosis, meningitis, carotid artery stenosis and stroke. This article presents the only reported case of arterial stroke in Lemierre's syndrome. Clinical presentation, diagnostic difficulty and treatment are discussed.

Arm chorea secondary to an unruptured giant aneurysm

We describe the case of a 20-year-old male who developed right-arm choreic movements secondary to a giant unruptured aneurysm impinging upon the left thalamus, putamen, globus pallidus, cerebral peduncle, midbrain, and subthalamic nucleus. The aneurysm was treated successfully with coils and a supraclinoid balloon. Abnormal movements initially failed to ameliorate, but within a few months, it was possible to discontinue symptomatic haloperidol therapy, with only mild residual abnormal movements.

Alcohol-induced paroxysmal nonkinesogenic dyskinesia after pallidal hypoxic insult

We describe the first case of paroxysmal nonkinesogenic dyskinesia secondary to pallidal ischaemia, which is uniquely and specifically triggered by alcohol.

Iron-induced susceptibility effect at the globus pallidus causes underestimation of flow and volume on dynamic susceptibility contrast-enhanced MR perfusion images

BACKGROUND AND PURPOSE

Age-related iron accumulation in extrapyramidal nuclei causes T2 shortening, which may result in decreased signal intensity in these areas on MR images. Because the dynamic susceptibility contrast-enhanced technique uses heavily T2*- or T2-weighted images, the iron-induced susceptibility may have direct impact on perfusion imaging. The purpose of this study was to assess the effect of iron-induced susceptibility on the calculated perfusion parameters. The difference of this effect between gradient-echo and spin-echo sequences was also assessed.

METHODS

Dynamic susceptibility contrast-enhanced MR perfusion imaging data of 12 patients were used for this study. Perfusion images were obtained using a single shot spin-echo echo-planar imaging sequence in seven patients and a gradient-echo echo-planar imaging sequence in five patients. Region of interest measurements of relative cerebral blood flow, relative cerebral blood volume, and mean transit time were obtained at various parts of the gray matter, including the globus pallidus, putamen, caudate nucleus, thalamus, and cerebral cortex of temporal, frontal, and occipital lobes. The baseline signal intensity on the source images and the magnitude of signal change (DeltaR2* or DeltaR2) were also assessed.

RESULTS

The globus pallidus had statistically significantly lower values of relative cerebral blood flow, relative cerebral blood volume, baseline signal intensity, and magnitude of signal change compared with other parts of the gray matter for both gradient-echo and spin-echo sequences (P <.05). Underestimations of these values were more prominent for the gradient-echo than for the spin-echo sequence. Little variance in the measured mean transit time was noted.

CONCLUSION

Iron-induced susceptibility effect may lead to underestimation of relative cerebral blood flow and relative cerebral blood volume in the basal ganglia.

99Tc(m)-ECD SPET perfusion changes by internal pallidum stimulation in Parkinson's disease

High-frequency stimulation of the internal pallidum is an effective surgical approach for patients with advanced Parkinson's disease suffering from motor fluctuations and L-dopa induced dyskinesia. To study the acute effects of internal pallidum stimulation, changes in cerebral blood flow were measured by means of a single-day split-dose protocol using 99Tc(m)-ECD SPET. Nine patients with advanced Parkinson's disease and with a clinical picture predominated by tremor and drug-induced dyskinesia, were imaged before and immediately after electrostimulation. Brain perfusion data were mirrored to the same electrode side (five left and four right implants), co-registered and analysed statistically on a voxel-by-voxel basis (Statistical Parametric Mapping) and by an automated volume-of-interest approach. Acute stimulation of the internal pallidum induced a significantly decreased perfusion in the ipsilateral thalamus and striatum, as well as in the right parietal cortex. For the subgroup of seven patients with effective motor score improvements, a significant correlation between thalamic and striatal perfusion changes and UPDRS III motor score was present (P = 0.04). These results suggest that effective stimulation of the internal globus pallidus may produce symptom relief through decreased activity in pallido-thalamo-cortical circuits.

3D MRI studies of neuroanatomic changes in unipolar major depression: the role of stress and medical comorbidity

Increasing evidence has accumulated for structural brain changes associated with unipolar recurrent major depression. Studies of neuroanatomic structure in early-onset recurrent depression have only recently found evidence for depression-associated structural change. Studies using high-resolution three-dimensional magnetic resonance imaging (MRI) are now available to examine smaller brain structures with precision. Brain changes associated with early-onset major depression have been reported in the hippocampus, amygdala, caudate nucleus, putamen, and frontal cortex, structures that are extensively interconnected. They comprise a neuroanatomic circuit that has been termed the limbic-cortical-striatal-pallidal-thalamic tract. Of these structures, volume loss in the hippocampus is the only consistently observed change to persist past the resolution of the depression. Possible mechanisms for tissue loss include neuronal loss through exposure to repeated episodes of hypercortisolemia; glial cell loss, resulting in increased vulnerability to glutamate neurotoxicity; stress-induced reduction in neurotrophic factors; and stress-induced reduction in neurogenesis. Many depressed patients, particularly those with late-onset depression, have comorbid physical illnesses producing a high rate of hyperintensities in deep white matter and subcortical gray matter and brain damage to key structures involved in the modulation of emotion. Combining MRI studies with functional studies has the potential to localize abnormalities in blood flow, metabolism, and neurotransmitter receptors and provide a better integrated model of depression.

Arteries of the insula

OBJECT

The insula is located at the base of the sylvian fissure and is a potential site for pathological processes such as tumors and vascular malformations. Knowledge of insular anatomy and vascularization is essential to perform accurate microsurgical procedures in this region.

METHODS

Arterial vascularization of the insula was studied in 20 human cadaver brains (40 hemispheres). The cerebral arteries were perfused with red latex to enhance their visibility, and they were dissected with the aid of an operating microscope. Arteries supplying the insula numbered an average of 96 (range 77-112). Their mean diameter measured 0.23 mm (range 0.1-0.8 mm), and the origin of each artery could be traced to the middle cerebral artery (MCA), predominantly the M2 segment. In 22 hemispheres (55%), one to six insular arteries arose from the M1 segment of the MCA and supplied the region of the limen insulae. In an additional 10 hemispheres (25%), one or two insular arteries arose from the M3 segment of the MCA and supplied the region of either the superior or inferior periinsular sulcus. The insular arteries primarily supply the insular cortex, extreme capsule, and, occasionally, the claustrum and external capsule, but not the putamen, globus pallidus, or internal capsule, which are vascularized by the lateral lenticulostriate arteries (LLAs). However, an average of 9.9 (range four-14) insular arteries in each hemisphere, mostly in the posterior insular region, were similar to perforating arteries and some of these supplied the corona radiata. Larger, more prominent insular arteries (insuloopercular arteries) were also observed (an average of 3.5 per hemisphere, range one-seven). These coursed across the surface of the insula and then looped laterally, extending branches to the medial surfaces of the opercula.

CONCLUSIONS

Complete comprehension of the intricate vascularization patterns associated with the insula, as well as proficiency in insular anatomy, are prerequisites to accomplishing appropriate surgical planning and, ultimately, to completing successful exploration and removal of pathological lesions in this region.

Blood brain barrier destruction in hyperglycemic chorea in a patient with poorly controlled diabetes

A case of hemichorea in a patient with poorly controlled diabetes is reported. T1-weighted magnetic resonance imaging (MRI) showed an unusual homogeneous high-intensity area in the corpus striatum. Of interest in the case was the fact that the globus pallidus, which was enhanced with gadolinium at the onset of hemichorea, showed homogeneous high-intensity on a subsequent T1-weighted image. This indicated that blood brain barrier destruction preceded the signal intensity change in the basal ganglia. As far as the authors could determine, this is the first reported case showing such enhancement during the course of diabetic hemichorea.

Connexin expression in Huntington's diseased human brain

In Huntington's diseased human brain, it is in the caudate nucleus (CN) and globus pallidus (GP) of the basal ganglia where nerve cell death is seen most dramatically. The distribution of five gap junction proteins (connexins 26, 32, 40, 43 and 50) has been examined in these areas in normal and Huntington's diseased human brain using immunohistochemical techniques. There was no Cx50 expression observed and Cx40 was localized in the endothelial cells of blood vessels, with the Huntington's diseased brains having more numerous and smaller blood vessels than normal tissue. Cx26 and Cx32 revealed a similar distribution pattern to each other in both normal and diseased brains with little labelling in the CN but clear labelling in the GP. Cx43, expressed by astrocytes, was the most abundant connexin type of those studied. In both normal and diseased brains Cx43 in the GP was homogeneously distributed in the neuropil. In the CN, however, Cx43 density was both increased with Huntington's disease and became located in patches. Glial fibrillary acidic protein(GFAP) staining of astrocytes was also highly increased in the CN compared with normal brains. These labelling patterns indicate a reactive astrocytosis around degenerating neurons with an increased expression of astrocytic gap junctions. The enhanced coupling state between astrocytes, assuming the junctions are functional, could provide an increased spatial buffering capacity by the astrocytes in an attempt to maintain a proper environment for the neurons, helping promote neuronal survival in this neurodegenerative disorder.

Changes in cerebral activity pattern due to subthalamic nucleus or internal pallidum stimulation in Parkinson's disease

High-frequency electrical stimulation of the internal pallidum (GPi) or the subthalamic nucleus (STN) improves clinical symptoms of Parkinson's disease. In 12 parkinsonian patients, 6 with STN and 6 with GPi stimulators, we used H2(15)O positron emission tomography to evaluate whether changes in movement performance were accompanied by change in regional cerebral blood flow (rCBF). Patients were scanned both at rest and while performing a free-choice joystick movement, under conditions of effective and ineffective electrostimulation. During effective STN stimulation, movement-related increases in rCBF were significantly higher in supplementary motor area, cingulate cortex, and dorsolateral prefrontal cortex (DLPFC) than during ineffective stimulation. No significant change was observed in any of these areas during GPi stimulation. The difference between the effect of STN and GPi stimulation on movement-related activity was mainly localized to DLPFC. These results confirm the dominant role of nonprimary motor areas in the control of movement in parkinsonian patients and demonstrate the importance of STN input in the control of these areas.

Globus pallidus stimulation activates the cortical motor system during alleviation of parkinsonian symptoms

Studies of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced parkinsonism in monkeys suggest that excessive inhibitory outflow from the internal segment of the globus pallidus (GPi) suppresses the motor thalamus, which reduces activation of the cerebral cortex motor system, resulting in the slowness and poverty of movement of Parkinson's disease (PD). This hypothesis is supported by reports of high rates of spontaneous neuronal discharges and hypermetabolism in GPi (ref. 4-7) and impaired activation of the supplementary motor area (SMA) and dorsolateral prefrontal regions in PD patients. Furthermore, lesion or chronic high-frequency electrical (likely inactivating) stimulation of GPi (ref. 10-14) is associated with marked improvements in akinesia and rigidity, and the impaired activation of SMA is reversed when the akinesia is treated with dopamine agonists. To test whether improvement in motor function with pallidal surgery can be attributed to increased activity in premotor cortical regions, we assessed the changes in regional cerebral blood flow (rCBF) and parkinsonian symptoms during disruption of GPi activity with high-frequency stimulation delivered through implanted brain electrodes. Positron emission tomography (PET) revealed an increase in rCBF in ipsilateral premotor cortical areas during GPi stimulation, which improved rigidity and bradykinesia. These results suggest that disrupting the excessive inhibitory output of the basal ganglia reverses parkinsonism, via a thalamic relay, by activation of brain areas involved in the initiation of movement.

Involvement of N-methyl-D-aspartate receptor in the delayed transneuronal regression of substantia nigra neurons in rats

The substantia nigra pars reticulata (SNr) receives both inhibitory GABAergic and excitatory glutamatergic afferents from diverse origins. Ischemic injury to the striatum and/or the globus pallidus causes delayed transneuronal death of the SNr neurons, in the course of which neuronal disinhibition induced by loss of GABAergic inputs is supposed to trigger a lethal hypermetabolic process. In the in vivo experiment presented herein, we clarified the role of glutamatergic action via the N-methyl-D-aspartate receptor in this cell death process. Continuous intraventricular infusion (0.5 microliter/h) of the N-methyl-D-aspartate receptor antagonist MK-801 (1000 micrograms/ml), or of saline (control group) was initiated 24 h after 2 h of transient middle cerebral artery (MCA) occlusion in rats, by which massive ischemic injury was produced in the striatopallidal regions. The measured rectal temperature was not significantly altered in the MK-801-infused and in the control rats throughout the time period examined. The rats were killed at 15 days after MCA occlusion. The volume of the focal ischemic infarction of the MK-801-infused group did not significantly differ from that of controls. Also, MK-801-infusion did not significantly ameliorate the nigral atrophy subsequent to MCA occlusion. In association with a marked depletion of GABAergic afferent fibers, neuronal cell number in the ipsilateral SNr was significantly decreased in the control group. In contrast, the neuronal cell loss in the nucleus was completely prevented in the MK-801-infusion group. The data suggested that withdrawal of GABAergic inputs may cause a severe imbalance between excitation and inhibition of the SNr neurons and may eventually result in neurotoxicity mediated by the N-methyl-D-aspartate receptor. Suppression of glutamatergic excitatory effects by suitable drugs may be a reasonable therapy for the transneuronal death of the SNr neurons.

Disturbance of central vision after carbon monoxide poisoning

BACKGROUND

Cerebral achromatopsia is a disturbance of colour perception which may be complete or partial.

CLINICAL RECORD

A 28-year-old male patient presented five months after carbon monoxide poisoning with achromatopsia. The achromatopsia was unaccompanied by an inability to recognise faces (prosopagnosia) nor was there any disorder of form or depth perception.

RESULTS

Magnetic resonance imaging showed bilateral sharply defied areas of haemorrhagic infarction in the globus pallidus with extensive infarction involving temporal and occipital lobes and with apparent partial sparing of the visual cortex, presumably due to arterial insufficiency. The disturbance of central colour vision resolved spontaneously after a further period of 6 months.

CONCLUSION

The symptom of achromatopsia is analysed with particular reference to the recent work of Professor Zeki on disturbance of central colour vision following CO poisoning and the unusual MRI findings.

Spontaneous vascular mineralization in the brain of horses

Cerebral vascular mineralization was found in 12 (60%) of 20 3- to 10-year-old healthy horses collected at an abattoir. It was variable in degree and occurred mostly in the pallidal arteries showing two types of lesions; small globoid bodies along capillaries, and amorphous deposits in the wall of arterioles, small- or medium-sized arteries and veins. Both types were strongly positive for periodic acid-Schiff reaction, and weakly positive for von Kossa's and Berlin blue stains. Elemental analysis of the deposit revealed the presence of large amounts of aluminum, moderate amounts of phosphorus, zinc, calcium and iron, and a small amount of sodium.

[Arterial vascularization of the lenticular nucleus]

The arterial vasculature of the lenticular nucleus was studied on 30 human brains the vascular system of which was injected with Indian ink mixed with gelose. The arteries of the lenticular nucleus belong to the group of anterior central arteries issued from the internal carotid artery and its terminal branches, except for the posterior cerebral artery. Examination of serial sections made translucent by the Spalteholtz method enabled us to follow the courses of these vessels within the lenticular nucleus. In this nucleus two vascular networks were present, with different vascular organization and density. These differences were due to the histological structure and specific embryonic origin of each part of the lenticular nucleus.

Selective injury of the globus pallidus in children with post-cardiac surgery choreic syndrome

Occasionally children undergoing cardiac surgery using cardiopulmonary bypass with deep hypothermia and cardiac arrest develop a postoperative syndrome of acute chorea. The authors report the neuropathological findings in two such children surgically treated for congenital heart disease. Examination of the brain showed neuronal loss, reactive astrocytosis and degeneration of myelinated fibers (without frank necrosis) in the globus pallidus, primarily the outer segment, with sparing of other regions commonly susceptible to hypoxic-ischemic necrosis. The localization and relative mildness of the brain damage suggest a susceptibility of the globus pallidus to injury in this setting and implicate disruption of pallidal pathways in the pathogenesis of post-cardiac surgery choreic syndrome.

Evaluation of outcome of delayed neurologic sequelae after carbon monoxide poisoning by technetium-99m hexamethylpropylene amine oxime brain single photon emission computed tomography

Using brain computed tomography (CT) and single photon emission computed tomography (SPECT) with technetium-99m hexamethylpropylene amine oxime (99mTc HM-PAO) in 13 patients with delayed neurologic sequelae after carbon monoxide poisoning, we tried to evaluate the clinical outcome of delayed CO sequelae. Among the 13 initial brain CTs, seven showed low density in the cerebral white matter and one revealed hypodensity in both globi pallidi. Of the 7 follow-up CT scans, 3 have remained unchanged, but in 4 cases more aggravating patterns with cortical atrophy without the clinical correlation were observed. There was no correlation between the CT findings and the outcome of delayed CO sequelae. All initial SPECTs in 13 patients with delayed CO sequelae showed diffuse patchy hypoperfusion throughout the cerebral cortex. Among the follow-up SPECTs in 7 patients, 6 patients showed increased cerebral perfusion with the concomitant clinical improvement, but the SPECT of a patient in bedridden state had remained unchanged, compared with the initial SPECT. There seemed to be good correlation between the findings of SPECT and the outcome of delayed CO sequelae. In conclusion, 99mTc HM-PAO brain SPECT is more sensitive than CT, and may be a useful test in evaluating the clinical outcome of delayed neurologic sequelae after CO poisoning.

Vascular mineralization in the monkey brain

Mineralization of various degrees was found in the brains of 79 (59%) of 134 cynomolgus monkeys (Macaca fascicularis). There was no age dependency in the incidence or severity, nor were there any abnormalities in growth, weight gain, or neurologic signs, although a slight sex difference was observed. The lesions, which were basophilic and intensely positive for periodic acid-Schiff or von Kossa stain, occurred in the vascular walls of the globus pallidus in two types: globoid bodies with prominent concentric lamellar structures in and around the arteriolar and venular wall (type A) and fine granules in the media of small or medium-sized arteries (type B). Electron microscopic examination revealed dense deposits in the degenerated media of small or medium-sized arteries or the thickened walls of the arterioles. X-ray microanalysis demonstrated the presence of calcium, phosphorus, iron, zinc, magnesium, and aluminum.

NADPH-d activity in the islands of Calleja: a regulatory system of blood flow to the ventral striatum/pallidum?

We have used dihydronicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) histochemistry to study the anatomical relationships between the islands of Calleja (ICs), ventral striatum (VS) and ventral pallidum (VP), and the perforating branches of the anterior communicating and anterior cerebral arteries traversing the olfactory tubercle. The granule cells of the ICs are intensely positive for NADPH-d, a marker for neuronal nitric oxide synthetase (NOS), and closely surround all arterioles perfusing the VP and most of the arterioles supplying the VS. In contrast, they are not related to the arteries destined for the dorsal striatum. On the ground of the vasodilatory properties of the nitric oxide, we propose that the ICs may play a role in the regulation of blood flow to specific centres of the limbic forebrain.

Axial motor disturbances after hypoxic lesions of the globus pallidus

Four subjects aged between 29 and 60 years were examined because of axial motor impairment after hypoxic brain injury. Magnetic resonance imaging revealed circumscribed lesions of the globus pallidus in every case. The association of freezing of the gait, speech disorders, axial bradykinesia, and postural disturbances, with no rigidity or tremor and little or no distal akinesia, suggests a role of the globus pallidus in controlling axial motion.

Hemorrhagic necrosis and vascular injury in carbon monoxide poisoning: MR demonstration

MR imaging of a patient 3-years status post-carbon monoxide (CO) poisoning revealed areas of abnormal signal bilaterally in the region of the globus pallidus that had shorter T1 characteristics and longer T2 characteristics than cerebrospinal fluid, probably representing methemoglobin, and that is surrounded by a rim of decreased signal on T2-weighted images, felt to represent hemosiderin. This case demonstrates characteristic findings on MR imaging of CO poisoning, as well as observations that suggest prior focal hemorrhage. Typical findings, neuropathology, and the role of vascular injury and prognosis are discussed.

Review of the variability of the territories of the major cerebral arteries

The results of recent model studies indicate that the variability in territorial distribution of the major cerebral arteries may be much greater than has been previously recognized. We review the literature on the cortical and intracerebral territories of the anterior, middle, and posterior cerebral arteries. Although most authors claim that these territories are relatively consistent, the results of their studies show many and considerable discrepancies. The variability described by Beevor has been neither excluded nor completely confirmed, yet somehow the concept of a relatively unchanging pattern of the peripheral cerebral vascularization has gradually settled into the literature. We discuss the considerable variability of the cerebral territories, as well as the discrepancies in investigation techniques, injection materials, and specimen conditions that could be factors producing these dissimilar results. Our study shows that there are no arguments in the literature to negate the variability of the cerebral territories.

Symmetrical bilateral low-density lesions in the areas of supply by Heubner's arteries after aneurysm surgery

Three patients with symmetrical bilateral low-density areas which were the perfusion territories of Heubner's arteries are reported. The infarctions were demonstrated on computed tomography after aneurysm surgery. Two of them had an anterior communicating artery aneurysm and the other one had multiple aneurysms of both sides. They were operated upon in the acute stage after subarachnoid haemorrhage. As common factors, a thick and diffuse subarachnoid haemorrhage, an acute-stage operation, temporary clips to bilateral A1 segments or the internal carotid artery and a relatively low systemic blood pressure during operation were found. From these findings we conclude that the pathogenesis of the infarctions was due to occlusive changes affecting Heubner's arteries bilaterally.

CT of ischemic infarctions in the territory of the anterior choroidal artery: a review of 28 cases

The purpose of the present study was to examine the incidence, causal factors, and anatomic localizations of infarction in the territory of the anterior choroidal artery. We studied 28 patients who had CT evidence of infarction in this territory. The affected structures taken into consideration were the posterior limb of the internal capsule, the retrolenticular portion of the internal capsule, the internal portion of the globus pallidus, and the lateral thalamus. Three conclusions are drawn: that ischemic infarcts in the territory of the anterior choroidal artery are rare, representing 2.9% of all cerebral ischemic lesions in our material; that the incidence of a possible embolic origin is significant; and that the posterior two-thirds of the posterior limb of the internal capsule and the retrolenticular segment are the more frequently affected structures, and conversely, that the medial pallidus and the thalamus are less often involved.

Regional cerebral blood flow of acute carbon monoxide poisoning in cats

The mechanism of selective vulnerability of the cerebral white matter and pallidum in acute carbon monoxide (CO) poisoning was experimentally investigated by measuring regional cerebral blood flow (rCBF) with the iodo-[14C]antipyrine method. A CO group consisting of five cats was exposed to 0.2%-0.3% CO gas and the rCBF was measured when moderate systemic hypotension (70-80 mm Hg) occurred; because systemic hypotension of this level during exposing to 0.2%-0.3% CO gas induces typical cerebral lesions of acute CO poisoning in almost all cats [Okeda et al. Acta Neuropathol (Berl) 54:1-10 (1981)]. Controls were a hypotension group of three cats with moderate systemic hypotension induced for 1 h without CO exposure, and a control group of five cats which inhaled only air for 2 h. The rCBF of each structure in the CO and hypotension groups was evaluated as a percentage of that of the control group. The rCBF of the CO group exhibited a wide range (68%-127%) according to the structures examined, and the mean (94.6%) was large compared with that (range: 53%-82%, mean: 67.4%) of the hypotension group. In the CO group, the examined brain structures where divided in two groups according to the rCBF values; low-value structures and high-value structures. There was significant (P less than 0.05) difference between rCBFs of both the structure groups. The cerebral white matter and pallidum belonged to low-value structures, and these rCBFs did not show any significant difference from those of other structures in this structure group.(ABSTRACT TRUNCATED AT 250 WORDS)

Left globus pallidus abnormality in never-medicated patients with schizophrenia

Schizophrenia is a severe psychiatric disorder characterized by onset in young adulthood, the occurrence of hallucinations and delusions, and the development of enduring psychosocial disability. The pathophysiology of this disorder remains unknown. Studies of cerebral blood flow and metabolism designed to identify brain abnormalities in schizophrenia have been limited by inadequate methods of anatomical localization and the possibility of persistent medication effects. We have now used positron emission tomography and a validated method of anatomical localization in an attempt to identify abnormalities of regional cerebral blood flow in newly diagnosed never-medicated patients with schizophrenia. An exploratory study of 5 patients and 10 normal control subjects identified abnormally high blood flow in the left globus pallidus of patients with schizophrenia. A replication study of 5 additional patients and 10 additional control subjects confirmed this finding. No other abnormalities were found.

Regional cerebral blood flow in hemiparkinsonian patients. Emission computerized tomography of inhaled 133Xenon before and after levodopa

Regional and mean cerebral blood flow (rCBF, CBF) were measured by tomography of inhaled 133Xe in 18 hemiparkinsonian patients before and after levodopa (L-dopa). Baseline mean CBF was 55 ml/ (100 g X min) after an L-dopa-free interval of at least 10 h (range 10-13) and remained unchanged at 56.1 ml/ (100 g X min) after optimal clinical improvement was achieved by L-dopa. However, L-dopa reduced rCBF significantly (P less than 0.05) in the striatum contralateral to the symptomatic limbs. In patients with adverse reactions such as hyperkinesias and on/off symptoms, flow tended to increase bilaterally in striatum and often markedly in midline structures anatomically related to globus pallidus and thalamus. Compared with a normal population, the subcortical rCBF distribution was asymmetrical with a reduced flow (-18%) in the striatum contralateral to the symptomatic limbs and in midline structures anatomically related to globus pallidus and thalamus (-12%). Cortical CBF was inverse related to the duration of Parkinson's disease (P less than 0.05), probably reflecting an increasing mental deterioration with time.

An experimental study of the pathogenesis of the selective lesion of the globus pallidus in acute carbon monoxide poisoning in cats. With special reference to the chronologic change in the cerebral local blood flow

Twenty-eight mature cats were exposed to 0.3% carbon monoxide (CO) gas for 90-193 min using artificial ventilation. The systemic blood pressure (BP), venous pressure (VP), blood flow of the left common carotid artery (CF), and blood gas were monitored. The local blood flow (LBF) of the globus pallidus, putamen, or claustrum was measured by the hydrogen clearance method. Pallidal lesions were found histologically in 14 cats. The period of CO inhalation and the time thereafter were divided into the following four stages in the animals with pallidal lesions. Stage 1: Initial phase with rapid increase in the CF and LBF, and rapid decrease in the BP. Stage 2: Middle phase with slow decrease in the BP, CF, and LBF. Stage 3: Terminal phase with rapid decrease in the BP, CF, and LBF. Stage 4: Recovery phase. The changes in stage 3 were not so prominent in the animals without pallidal lesions. The LBF of the globus pallidus of the animals with lesions decreased to 67.3 +/- 20.7% of the initial value at the terminal stage of CO inhalation, while it was 188 +/- 46.7% in those without lesions. The difference was statistically significant (P less than 0.01). The LBF of the putamen or claustrum in the animals with lesions in the globus pallidus was 140 +/- 24.6% at this stage, and it was significantly higher than that of the globus pallidus (P less than 0.01). Other factors, such as CO inhalation time, degree of acidosis, and terminal CO-Hb concentration, did not correlate with the occurrence of the pallidal lesion.

Vascular supply pattern to rat caudatoputamen and globus pallidus: scanning electronmicroscopic study of vascular endocasts of stroke-prone vessels

The caudatoputamen (CP) and globus pallidus (GP) are supplied by vessels often involved with stroke in both rat and human. The pattern of vascular supply to the CP and GP in rat has, in contrast to humans, been only partially described. The vascular pattern to the rat CP and GP is described utilizing vascular endocasts and scanning electronmicroscopy in aging, normotensive rats. Endocasts were produced by intra-cardiac infusion of Batson's Corrosion Compound. The vascular pattern is complex, involving 1) recurrent vessels from the anterior cerebral artery, 2) branches from the arterial circle rostral or caudal to the origin of the middle cerebral artery (MCA), 3) up to 6 branches from the MCA, and 4) 2 major branches from the caudal part of the arterial circle. The vessels in groups 1--3 were serpentine, their luminal diameters abruptly reduced at branch points, and the angle of departure from the parent vessels approximated 90 degrees. These vessels supplied much of the CP and GP, while group 4 supplied the caudal CP with vessels arranged in a lattice-like fashion from the 2 penetrating parental arteries.

The relationship between Parkinson syndrome and vascular siderosis: an electron microprobe study

Vascular siderosis (VS) refers to the presence of mineralized small and medium-sized arteries in the globus pallidus, usually regarded as reflecting an aging process. The electron probe analysis of deposits in vascular siderosis in 10 patients dying of parkinsonism and in 8 other patients without parkinsonism is reported here. The microprobes identified a total of 11 elements in the VS in these 18 patients. Five elements--lead, aluminum, sulfur, manganese, and barium--were present only in VS associated with parkinsonism. Statistically, the association of lead was highly significant while that of aluminum and sulfur in 4. The significance of the presence of sulfur is difficult to assess since its compounds are normally present in large quantities in the brain. These findings raise the question whether lead and aluminum may be associated in some way with the pathogenesis of certain forms of Parkinson disease.

[Presence of aluminum and magnesium in the cerebral arteries and parenchyma of patients with striatonigral syndrome: study by Castaing's microprobe]

Electron probe microanalysis demonstrates the presence of aluminium, magnesium, iron, calcium, phosphorus in and around blood vessels in the pallidum (vascular siderosis) and in the putaminal parenchyma in five out of six cases of striatonigral degeneration, associated with orthostatic hypotension in two of these cases. These results suggest that striatonigral degeneration could be the result of a vascular disease, the result of an elemental intoxication of unknown cause.

The arterial angioarchitecture in lacunar state

The statistical data, obtained in seventy five brains with lacunar state, show that the lenticular nuclei and the periventricular arterial end-and borderzones are the main seats of the infarcts. In teen brains the relationship between the deep arterial angioarchitecture and the location of thirty lacunes is studied by means of the translucidation technique after filling the arterial system with a colloîdal barium sulphate solution. The deep perforating arteries are poorly filled and show several narrowings and post-stenotic dilatations. In twenty-four lacunes, an occlusion of the responsible artery is found. In the six remaining lacunes, no occlusion of the main artery is observed but the side-branches are not demonstrated. The significance of these findings and the relationship between the location of the occlusion and the topography of the lacune are discussed.

Morphological responses of cerebral tissues to temporary ischemia

The ultrastructural responses of cerebral tissue following temporary periods (1/2, 1,2,3, or 4 hour) of right, middle cerebral artery, (MCA) occlusion were studied acutely after a 3 day or 7 day interval following the removal of the MCA clip. Cortical and basal ganglia tissues for each ischemic duration were compared at 3 post-occlusive periods (acute, 3 days, 7 days). With the short periods of ischemic insult (1/2, 1, 2, 3, and 4 hour), the temporal and insular cortex contained no greater changes in the 7 day group than in the 3 day group. The basal ganglia were more susceptible to MCA occlusion as indicated by more marked cytological changes and/or necrosis in all intervals of ischemia.

[Characteristics of the vascular-capillary network and the relationship between capillaries and cells in the nucleus of Luys in the cat during postnatal ontogenesis]

The development of the Luy's nucleus of the cat is not accomplished by birth-time. Complex relationships between nerve cell and capillaries continue to change during postnatal ontogenesis. The function of the Luy's nucleus becomes perfect by the third month. It should be noted that maturation of nerve cells and the vascular network goes not in parallel: the enlargement of the nerve cell occurs smoothly while the increase of the vascular-capillary network density is undulatory. There are three peaks in the development of vascular-capillary network: the 20th day, one month and a half, adult cat.