Surgery for Obsessive-Compulsive Disorder and Transient Tremors as Newly Reported Side Effect: First Psychiatric Neurosurgery in Egypt

Introduction

The use of surgery for treatment of psychiatric conditions is a well-established strategy, especially in severe and resistant obsessive-compulsive disorder. Attractive anatomical and functional targets for stereotactic surgery are reported in some studies. Surgery for treatment of psychiatric conditions in our nation and Arab world is obscured and hidden because of several social and cultural limitations, which should be overcome. We report here the first psychiatric neurosurgery in our nation and how we overcome such community limitation. This the first report of postoperative tremor.

Case Presentation

Young patient presented with severe and persistent obsessive-compulsive disorder resistant to all non-surgical modalities for several years. Stereotactic ablation surgery was done under local anaesthesia. Marked improvement in our obsessive-compulsive disorder patient after psychiatric neurosurgery with self-limited tremor was not reported before in the literature. The medications were the same before and immediate after surgery and this is not a drug-induced tremor. Postoperative YBOCS showed 90% of improvement.

Conclusion

Surgery-induced tremor could be a self-limited side effect after surgery in obsessive-compulsive disorder. Safety and efficacy should be promoted in our nation and Arab world. Society and cultural limitations should be overcome by further research studies, intervention, and activism in the field of mental health systems in our nation and Arab countries to improve awareness.

Cost-effectiveness of HARNESS-MRI protocol in focal drug-resistant epilepsy in a limited-resources country: An Egyptian study

OBJECTIVES

The international league against epilepsy (ILAE) recommended the harmonized neuroimaging of epilepsy structural sequences (HARNESS-MRI) to improve the detection of epileptogenic lesions in patients with focal drug-resistant epilepsy (DRE). The application of this protocol is still limited in low-resource countries, mainly due to apparent high costs. We aimed to evaluate the cost-effectiveness of the HARNESS-MRI protocol in Egypt and highlighted our experience.

METHODS

Patients diagnosed with focal DRE at Cairo University epilepsy clinic underwent both conventional MRI (c-MRI) and HARNESS-MRI. Electro-clinical data were collected and analyzed. After the radiologists' initial diagnosis, a multidisciplinary team re-evaluated the MRI. Lesion detection rate and cost for detecting an extra lesion by HARNESS-MRI protocol were calculated.

RESULTS

The study included 230 patients with focal DRE (146, 62% males and 91, 38% females), with a mean age of 20.5 years. Epileptogenic lesions detected by c-MRI and HARNESS-MRI before and after the board meeting were 40, 106, and 131 lesions, respectively (P < 0.001). Sixty-nine percent of the lesions detected by HARNESS-MRI were missed on c-MRI; most commonly were mesial temporal sclerosis (MTS) and Malformations of cortical development (MCDs). Thirty-seven MTS and 32 MCDs were detected with HARNESS-MRI, compared to only 6 and 3, respectively, detected on c-MRI (P < 0.001). HARNESS-MR protocol is more cost-effective than c-MRI in detecting MRI lesions; it can save about 42$ for detecting an extra lesion in MRI.

CONCLUSION

The HARNESS-MRI protocol was cost-effective and highly recommended even in limited-resource countries for patients with focal DRE.

Resective epilepsy surgery in a limited-resource settings: A cohort from a multi-disciplinary epilepsy team in a developing country

BACKGROUND

Multidisciplinary pre-surgical evaluation is vital for epilepsy surgery decision and outcomes. Resective epilepsy surgery with assisted monitoring is currently a standard treatment for focal drug resistant epilepsy (DRE). In resource-limited countries, lack of epilepsy surgery center is a huge challenge. We presented and illustrated how to create a multidisciplinary protocol with resource-limited settings in a developing country and epilepsy surgery outcome using brain mapping and monitoring techniques for ensuring satisfactory resection.

METHODS

We created multicentric incomplete but complementary units covering all epilepsy-related sub-specialties and covering a wide geographical area in our country. Then, we conducted a prospective and multicentric study with low resource settings on patients with focal DRE, who underwent resective epilepsy surgery and were followed up for at least 12 months and were evaluated for postoperative seizure outcome and complications if present. Preoperative comprehensive clinical, neurophysiological, neuropsychological, and radiological evaluations were performed by multidisciplinary epilepsy team. Intraoperative brain mapping including awake craniotomy and direct stimulation techniques, neurophysiological monitoring, and electrocorticography was carried out during surgical resection.

RESULTS

The study included 47 patients (18 females and 29 males) with mean age 20.4 ± 10.02 years. Twenty-two (46.8%) patients were temporal epilepsy while 25 (53.2%) were extra-temporal epilepsy. The epilepsy surgery outcome at the last follow up was Engel Class I (seizure free) in 35 (74.5%), Class II (almost seizure free) in 8 (17%), Class III (worthwhile improvement) in 3 (6.4%), and Class IV (no worthwhile improvement) in 1 patient (2.1%).

CONCLUSION

With low resource settings and lack of single fully equipped epilepsy center, favorable outcomes after resective surgery in patients with focal DRE could be achieved using careful presurgical multidisciplinary selection, especially with using intraoperative brain mapping and electrocorticography techniques.

Radiosurgical Corpus Callosotomy for Intractable Epilepsy: Retrospective Long-Term Safety and Efficacy Assessment in 19 Patients an Review of the Literature

BACKGROUND

Some patients suffering from intractable epileptic seizures, particularly drop attacks (DAs), are nonremediable by curative techniques. Palliative procedure carries a significant rate of surgical and neurological complications.

OBJECTIVE

To propose evaluation of safety and efficacy of Gamma Knife corpus callosotomy (GK-CC) as an alternative to microsurgical corpus callosotomy.

METHODS

This study included retrospective analysis of 19 patients who underwent GK-CC between 2005 and 2017.

RESULTS

Of the 19 patients, 13 (68%) had improvement in seizure control and 6 had no significant improvement. Of the 13/19 (68%) with improvement in seizures, 3 (16%) became completely seizure-free, 2 (11%) became free of DA and generalized tonic-clonic but with residual other seizures, 3 (16%) became free of DA only, and 5 (26%) had >50% reduction in frequency of all seizure types. In the 6 (31%) patients with no appreciable improvement, there were residual untreated commissural fibers and incomplete callosotomy rather than failure of Gamma Knife to disconnect. Seven patients showed a transient mild complication (37% of patients, 33% of the procedures). No permanent complication or neurological consequence was observed during the clinical and radiological workup with a mean of 89 (42-181) months, except 1 patient who had no improvement of epilepsy and then aggravation of the pre-existing cognitive and walking difficulties (Lennox-Gastaut). The median time of improvement after GK-CC was 3 (1-6) months.

CONCLUSION

Gamma Knife callosotomy is safe and accurate with comparable efficacy to open callosotomy in this cohort of patients with intractable epilepsy suffering from severe drop attacks.

Functional and oncological outcome of petroclival chondrosarcoma operated on through an extradural anterior petrosectomy approach. A single center experience

BACKGROUND

Management of skull base chondrosarcoma (SBC) remains challenging due to its deep location and complex growth pattern. Non-total resection and postoperative residual mass are common features, with controversy regarding the need to offer systematic postoperative radiation therapy or additional surgery.

METHODS

A single-center retrospective cohort study was conducted on 10 consecutive patients harboring petroclival chondrosarcomas that were operated on between May 2007 and March 2019. After resection, the patients were allocated to a wait-and-rescan policy.

RESULTS

Patients were operated on through an extradural anterior petrosectomy (EAP). Subtotal tumor resection was achieved in all patients. The mean duration of follow-up was 70 months (range 25-137/median 67 months). Clinical outcomes dramatically improved in three (30%) patients, while five patients retained preoperative cranial nerve (CN) disturbances after surgery (50%). Two patients reported transient postoperative worsening of their symptoms (20%). All of the postoperative CN new deficits improved within one year, except in one patient who showed permanent facial nerve palsy. The preoperative median Karnofsky Performance Scale (KPS) score was 80 (range 70-100), and then it became 90 (range 70-100) postoperatively. Patients harboring a tumor residue were included in a wait-and-rescan policy. With this regimen, tumor control was obtained in seven patients (70% of cases until the last follow-up). Three patients (30%) showed progression of the residual; two of them were treated with adjuvant therapy, while an extra cranial growth residue was observed in the third.

CONCLUSION

Optimal and reasonable surgical resection of petroclival chondrosarcomas could be achieved with good to excellent functional outcomes through an EAP. In spite of a significant percentage of regrowth, only one patient required additional salvage surgery.

Increased Gray Matter Density in the Right Mesencephalic Tegmentum Is Associated With Better Engel Classes I and II After Radiosurgery for Hypothalamic Hamartomas

BACKGROUND

Hypothalamic hamartomas (HHs) are disabling congenital lesions, responsible for gelastic seizures frequently associated with catastrophic epilepsies, epileptogenic encephalopathy, and cognitive and psychiatric severe comorbidities. Stereotactic radiosurgery (SRS) is a well-established minimally invasive therapeutic approach.

OBJECTIVE

To assess whether pretherapeutic gray matter density (GMD) correlates with seizure outcome.

METHODS

We used voxel-based morphometry at whole-brain level, as depicted on pretherapeutic standard structural magnetic resonance neuroimaging. We examined 24 patients (10 male patients, 14 female patients; mean age, 12.7 yr; median, 9; range, 5.9-50) treated in Marseille University Hospital, France, between May 2001 and August 2018.

RESULTS

Most relevant anatomic area predicting postoperative Engel classes I and II vs III and IV after SRS for HHs was mesencephalic tegmentum. Higher pretherapeutic GMD in this area was associated with better outcomes for seizure cessation. The only other statistically significant clusters were right cerebellar lobule VIIIb and VIIIa. Lower pretherapeutic GMD in both clusters correlated with better Engel class outcomes. GMD decreased with age in the left mediodorsal thalamus.

CONCLUSION

Seizure cessation after SRS for HHs was associated with higher GMD in mesencephalic tegmental area, acknowledged to be involved in the neural control of explosive vocal behavior in animals. This area is connected by the mamillotegmental bundle to the lateral tuberal nucleus area of the hypothalamus, where HHs are known to rise. In the future, the detection of more gray matter in this "laugh" tegmental area based on pretherapeutic routine structural neuroimaging might help in patient selection for minimally invasive radiosurgery for HH.

Mask-Based versus Frame-Based Gamma Knife ICON Radiosurgery in Brain Metastases: A Prospective Randomized Trial

BACKGROUND

Radiosurgery is performed with a diversity of instruments relying usually either on a stereotactic frame or a mask for patient head fixation. Comfort and safety efficacy of the 2 systems have never been rigorously evaluated and compared.

MATERIAL AND METHOD

Between February 2016 and January 2017, 58 patients presenting with nonsmall cell lung cancer brain metastases have been treated by Gamma Knife radiosurgery (GKS) with random use of a frame or a mask for fixation were included patients older than 18, with <5 brain metastases (at the exclusion of brainstem and optic pathway's locations) and no earlier history of radiotherapy. The primary outcome measure was the pain scale assessment (PSA) at the beginning of the GKS procedure.

RESULTS

The PSA at the beginning of the GKS procedure was not different between the 2 groups. The PSA at the day before GKS, before magnetic resonance imaging, just after frame application, and the day after radiosurgery (departure) has shown no difference between the 2 groups. At the end of the radiosurgery itself (just after frame or mask removal) and 1 h after, the mean pain scale was higher in patients treated with the frame (p < 0.05 and p < 0.001, respectively) but 2 patients were not able to tolerate the mask discomfort and had to be treated with frame. Tumor control and morbidity probability were demonstrated to be no difference between the 2 groups in this population of patients with BM not in highly functional area. The median of the extra dose to the body due to the cone-beam computed tomography was 7.5 mGy with a maximum of 35 mGy in patients treated with a mask fixation (null in the others treated with frame). Mask fixation was associated to longer treatment time although the beam on time was not different between the 2 groups.

CONCLUSION

In selected patients, with brain oligo-metastases out of critical location, single-dose mask-based GKS can be done with a comfort and a safety efficacy comparable to frame-based GKS. There seems to be no clear patient data that confirm the value of the mask system with regards to comfort.

In vitro study of antimicrobial activity of some plant seeds against bacterial strains causing food poisoning diseases

In this research, some plant seeds powder was evaluated to find their potential effect to rule diseases of food poisoning. Antimicrobial effect of five plant seeds was examined contra Bacillus cereus, Staphylococcus aureus, Escherichia coli, Klebsiella. pneumonia and Candida albicans by using well diffusion method. Antimicrobial activity studies revealed high potential activity of plant seeds powder of Nigella sativa L., cucurbita pepo, Sesamum radiatum, Trigonella foenum-graecum, Linum usitatissimum with variable efficiency contra tested microbial strains with concentration of 100 mg/ml, except Sesamum radiatum scored no effect. The T. foenum and N. sativa seed powder showed the largest inhibition zone (24-20 mm) contra K. pneumonia, followed by S. aureus (20-18 mm) and C. albicans (15mm) respectively. The five plant seeds powder exhibited bacteriostatic and bactericidal effects with MIC's 20 and MBC 40 mg/ml against K. pneumonia, and MIC's 40 and MBC 60 mg/ml against S. aureus. The results of this study indicated that plants seeds powder have promising antimicrobial activities and their potential applications in food process. It could be utilized as a natural medicinal alternative instead of chemical substance.

Is Real-Time Inverse Planning Optimizing Dose to the Normal Brain? A Prospective Comparative Trial in a Series of Brain Metastases Treated by Stereotactic Radiosurgery

BACKGROUND

Radiosurgery has demonstrated good safety and efficacy in the treatment of multiple brain metastases (BMs). However, multi-target dose planning can be challenging and time-consuming. A recently developed real-time inverse treatment planning (IP) by convex optimization has been demonstrated to produce high-quality treatment plans with good conformity and selectivity in single-target plans. We intended to test the capacity of this IP to rapidly generate efficient plans while optimizing the preservation of normal tissue in multiple BM.

METHODS

Seventy-nine patients (mean age 62.4, age range 22-85) with a total of 272 BMs were treated by Gamma Knife Radiosurgery. All subjects were treated using a forward planning (FP) technique by an expert neurosurgeon. The new Intuitive Plan was applied and able to automatically generate an alternative plan for each patient. All planning variables were collected from the IP to be compared with the corresponding measurements obtained from the FP. A paired sample t test was applied to compare the 2 plans for the following variables: brain volumes receiving 10 Gy (V10) (primary endpoint), and 12 Gy (V12), planning indices (selectivity, coverage, gradient, and Paddick Conformity Index [PCI]), beam-on time (BOT), and integral doses. Additionally, the noninferiority margin for each item was calculated, and the 2 plans were compared for noninferiority using a paired t test.

RESULTS

The mean age of patients was 62.4 years old (age range 22-85), with a sex ratio of 1.02. The average number of lesions per patient was 3.4 (range 1-12). The mean prescription dose was 21.46 Gy (range 14-24 Gy). Noninferiority of the IP was concluded for V10, V12, prescription isodose volume, BOT, PCI, and selectivity. The V10 (and V12) was significantly lower with the IP (p < 0.001). These volumes were 8.69 cm3 ± 11.39 and 5.47 cm3 ± 7.03, respectively, for the FP and 7.57 cm3 ± 9.44 and 4.78 cm3 ± 5.86 for the IP. Only the coverage was significantly lower with the IP (-2.3%, p < 0.001), but both selectivity (+17%) and PCI (+15%) were significantly higher with the IP than FP (p < 0.001).

CONCLUSION

This IP demonstrated its capacity to generate multi-target plans rapidly, with a dose to the brain (V10) and BOT noninferior to the one of a human expert planner. These results would benefit from confirmation in a larger prospective series.

Morphology and molecular phylogeny of Heterobothrium lamothei (Monogenea: Diclidophoridae), a gill parasite infecting the tiger puffer fish Lagocephalus sceleratus (Tetraodontidae)

ABSTRACT Members of the family Diclidophoridae are potentially dangerous species for the puffer fish aquaculture worldwide. They are parasitic polyopisthocotyleans, with a posterior haptor equipped with clamps for attachment to the host's surface, allowing the worm to resist the flow of water to maintain its position on gills. The anterior body of the worm is deformable, allows the worm to feed on blood sucked from fish gills. The present study is the first description of a Heterobothrium species from the gills of the tiger puffer Lagocephalus sceleratus (Tetraodontidae) from the coasts of the Arabian Gulf at Jubail, Saudi Arabia morphologically by light microscopy as well as by molecular analysis of the parasite partial 28S rRNA through multiple sequence alignments and phylogeny by maximum likelihood analysis which is provided for the first time for the described species. Seventeen tiger puffer fish were captured alive from marine water off Saudi Arabia; gills were separated and further examined for parasitic infection. Nine fish were found infected with a monogenean parasite which was robust, equipped by two buccal organs at the tapered anterior end; the posterior haptor was rectangular with four symmetrically arranged clamps, with no isthmus. Marginal hooks absent. Ovary elongated, U-shaped, testes numerous, irregularly shaped and extended from the posterior part of the ovary to the anterior margin of the haptor. Copulatory organ muscular, as a spherical cup armed with 12 to 15 genital hooks. The molecular analysis of the parasite 28s rRNA and phylogeny revealed a percentage of identities between 87.47-89.09%, with Diclidophoridae species within the monophyletic clade of Mazocraeidea where a maximum percentage of 89.09% were obtained for the morphologically different sister taxon H. okamotoi. The results obtained from molecular analysis are consistent with the conclusions drawn from morphological classification where that the parasite recorded was morphologically similar to H. lamothei which was not characterized by molecular analysis before. The recovered sequences were deposited into the GeneBank under accession number MT322610.

Delayed Collet-Sicard syndrome after internal carotid dissection and Jefferson fracture. Case report and Review of Literature

Background:

Lower cranial nerve palsies, or Collet-Sicard syndrome, can be caused by many different etiologies including head trauma, basilar occipital fractures, tumors, and interventions. Few reports describe different presentations of this condition, and we present here a case study to increase awareness of and add to the variable spectrum.

Case Description:

A 56-year-old who had been hit while diving was admitted to our department. On examination, he was conscious without any signs of lateralization but presented with severe neck pain. CT brain and cervical spine revealed a C1 fracture with bilateral symmetrical fracture of the anterior and posterior arches (Jefferson’s fracture) and slight bilateral joint dislocation C1-C2 discreetly predominant on the left. One week later, he presented with dysarthria, dysphonia, swallowing disorder, anisocoria, tongue deviation, and palate deviation (XII, IX, and X). CT Angiography showed dissection of the internal carotid artery immediately after the carotid bulb. He has been treated conservatively with curative anticoagulants with stable symptoms. No surgical intervention had been proposed.

Conclusion:

Adding to the literature, delayed Collet-Sicard syndrome and lower cranial affection can be caused by missed carotid wall hematoma following severe craniocervical trauma associated with Jefferson’s fracture.

Use of Polyvinyl Alcohol Sponge Cubes for Vagal Nerve Stimulation: A Suggestion for the Wrapping Step. Technical Note and Step-by-Step Operative Technique

BACKGROUND

Vagal nerve stimulation (VNS) is an approved treatment for epilepsy and depression. Wrapping the helical electrodes around the nerve can prove technically challenging. However, a quick and efficient method to slightly elevate the nerve can highly facilitate this part of the procedure.

OBJECTIVE

To provide useful surgical tips to facilitate the procedure.

METHODS

Based on experience of more than 150 adult cases for mainly epilepsy (primary lead implant), the authors share their surgical technique to provide the experienced surgeons or newcomers to the field of VNS with some useful tips. All patients signed informed consent according to the local ethics committee guidelines.

RESULTS

The article consists of a detailed step-by-step description of the whole procedure illustrated through high-resolution colored photographs of the surgical field. Special reference is made to the usefulness of polyvinyl alcohol (PVA) sponge cubes to elevate the nerve instead of the commonly used silicon vessel loops.

CONCLUSION

The use of surgical microscope and PVA sponge cubes to elevate the nerve constitute key points to make VNS an easy surgery.

Long-term cognitive outcome after radiosurgery in epileptic hypothalamic hamartomas and review of the literature

OBJECTIVE

Epileptic patients with hypothalamic hamartoma (HH) frequently present cognitive impairments. Surgical techniques aiming at HH can be very efficient for epilepsy relief and cognitive improvement but are also demonstrated to carry a significant risk of additional reduction in memory function in these already disabled patients. Gamma knife radiosurgery (GKS) offers an efficient minimally invasive procedure. We evaluated the effect of stereotactic radiosurgery on cognitive outcome.

METHODS

We designed a prospective single-center case series study. Thirty-nine epileptic patients (median age = 17 years, range = 4-50) with HH underwent preoperative and postoperative testing of intelligence quotient (IQ; all patients), including a working memory component, and other memory function testing (for patients ≥16 years old). All patients were prospectively evaluated and underwent complete presurgical and postsurgical clinical, electrophysiological, endocrinal, and visual assessments. In all patients, the postoperative assessment was performed at least 3 years after radiosurgery. We explored what variables correlate with cognitive outcome. Literature review was done for other surgical techniques and their risks for cognitive complications after surgery.

RESULTS

No decline was observed in intellectual ability (including working memory) after GKS, and no memory decline was seen in adults. We observed significant improvement (>1 SD in z-score) in working memory index (46%) and processing speed index (35%), as well as improvement in full-scale IQ (24%), verbal comprehension index (11%), perceptual organization index (21%), verbal learning (20%), and visual learning (33%). Before GKS, the probability of seizure cessation was higher in patients with higher cognitive performance. After GKS, the cognitive improvement was significantly higher in the seizure-free patients compared to the non-seizure-free patients.

SIGNIFICANCE

We found clear cognitive improvement in a high percentage of patients but importantly no significant decline in intellectual ability (including working memory) and no decline in memory in adult patients 3 years after GKS. GKS compares favorably to the other surgical techniques in terms of cognitive outcome, with similar seizure freedom.

Clinical evaluation of a real-time inverse planning for Gamma Knife radiosurgery by convex optimization: a prospective comparative trial in a series of vestibular schwannoma patients

BACKGROUND

Gamma Knife radiosurgery (GKRS) inverse dose planning is currently far from competing effectively with the quality of dose planning developed by experienced experts. A new inverse planning (IP) method based on « efficient convex optimization algorithms » is proposed, providing high-quality dose plans in real time.

MATERIALS AND METHODS

Eighty-six patients treated by GKRS for vestibular schwannomas (VS) were recruited. The treatment plans created by the first author, who has 27 years of experience and has developed and delivered more than 15,000 dose plans, served as reference. A first set of basic constraints determined by default led the IP for an initial real-time dose plan. Additional constraints were interactively proposed by the planner to take other parameters into account. A second optimized plan was then calculated by the IP. The primary endpoint was the Paddick Conformity Index (PCI). The statistical analysis was planned on a non-inferiority trial design. Coverage, selectivity, and gradient indexes, dose at the organ(s) at risk, and 12 Gy isodose line volume were compared.

RESULTS

After a single run of the IP, the PCI was shown to be non-inferior to that of the "expert." For the expert and the IP, respectively, the median coverage index was 0.99 and 0.98, the median selectivity index 0.92 and 0.90, the median gradient index 2.95 and 2.84, the median dose at the modiolus of the cochlea 2.83 Gy and 2.86 Gy, the median number of shots 14.31 and 24.13, and the median beam-on time 46.20 min and 26.77 min. In a few specific cases, advanced tools of the IP were used to generate a second run by adding new constraints either globally (for higher selectivity) or locally, in order to increase or decrease these constraints focally.

CONCLUSION

These preliminary results showed that this new IP method based on « efficient convex optimization algorithms », called IntuitivePlan®, provided high-quality dose plans in real time with excellent coverage, selectivity, and gradient indexes with optimized beam-on time. If the new IP evaluated here is able to compete in real time with the quality of the treatment plans of an expert with extensive radiosurgical experience, this could allow new planners/radiosurgeons with limited or no experience to immediately provide patients with high-quality GKRS for benign and malignant lesions.

Epileptic hypothalamic hamartomas impact of topography on clinical presentation and radiosurgical outcome

INTRODUCTION

Evidence exists for the role of the hypothalamic hamartoma's topography as a determinant for the clinical presentation. How the hamartoma relation to the hypothalamic structures can make clinical presentations, severity and surgery outcomes different from patient to patient is largely unknown. Our aim was to analyze the effect of fine anatomical topography on clinical spectrum and radiosurgery outcome.

METHODS

Forty-eight epileptic patients with hypothalamic hamartoma were treated by Gamma Knife Surgery and were reviewed for fine topography and morphology using magnetic resonance neuroimaging. We evaluated different topographic patterns; contact to prominent structures (the mammillary body, tuber cinereum and pituitary stalk), the degree of involvement within sagittally-oriented regions, (mammillary, tuberal, and supra optic) coronally-oriented zones (periventricular, medial, and lateral), lesion dimensions (length, width, and height),and volumes (total, intra-hypothalamic, and extra-hypothalamic volumes). This data were statistically analysed for correlation with all clinical variables and epilepsy surgery outcome. We reviewed all the classification protocols in the literature.

RESULTS

Focal onset impaired awareness seizures started at an earlier age of onset with larger hypothalamic hamartoma volume and dimensions. Lateral extension within the hypothalamus was associated with more severe epilepsy, higher seizure frequency, more severe psychiatric comorbidity, hetero-aggression, hyperkinesia, and school difficulties. Presence of precocious puberty was positively correlated to anterior-posterior extension; tuberal region involvement, hypothalamic hamartoma volume, and type III-VI. Larger hypothalamic hamartoma presented precocious puberty at an earlier age of onset. After Gamma Knife Surgery, epilepsy outcome was better and rapid when lesion is smaller. Post-radiosurgical transient increased seizures were present when the mammillary region was more involved.

CONCLUSION

Clinical presentation of epileptic hypothalamic hamartoma is significantly affected by fine topography patterns and invaded hypothalamic areas. Gamma Knife Radiosurgery effect is better and rapid in smaller hamartoma (Type I-III) and seizure outcome was not affected by the invaded hypothalamic areas.

Morphology of the lips, cheeks, and the hard palate of the Egyptian water buffalo (Bubalus bubalis): a focus on histological, histochemical, and ultrastructural aspects

BACKGROUND

The available data is scanty about Egyptian water buffalo lips, cheeks, and palate.

AIMS

The current investigation was focused on describing the morphology of the lip, cheek, and palate.

METHODS

Our study included the gross, light, and electron microscopic examinations of ten heads of the Egyptian water buffalos.

RESULTS

The nasolabial plate surface carried numerous scales of keratinized epithelium. Internal labial surface and labial mucocutaneous junctions were covered with stratified squamous keratinized epithelium. Two types of hair follicles in the dermis included ordinary and cavernous types characterized by cavernous space. The conical papillae on the internal aspect of the oral commissure were projected from the mucous membrane. Seromucous glands were occasionally observed under the oral mucous membrane of the commissure and gave positive PAS and AB. Conical papillae density on the inner cheek surface had some variations: the rostral part had large papillae, while the dorsal part had numerous papillae than the ventral part, the caudal part had a smaller number of papillae, while the middle part was devoid of papillae. Parotid duct opening in the buccal vestibule was without papillae. Conical papillae had two surfaces; the rostral surface was highly keratinized than the caudal one. The buccal gland was a compound tubuloacinar mixed (mucoserous) gland and mucus acini only reacted to PAS and AB. The oral surface of palatine rugae was covered with highly keratinized epithelium than the aboral surface. Palatine glands showed PAS and AB positive.

CONCLUSION

The result describes the relationship between the available food particles, environmental conditions and the lip, cheek, and palate appearance, and structure.

VNS implantation in a NF1 patient: massive nerve hypertrophy discovered intra-operatively preventing successful electrode placement. Case report

For the vast majority of surgeons, no specific investigation is necessary before vagal nerve stimulation (VNS) implantation. We report our intraoperative unexpected finding of a massively enlarged vagus nerve in a patient with neurofibromatosis type 1 (NF1). The nerve hypertrophy prevented wrapping the coils of the helical electrode. The patient had no signs of vagus nerve dysfunction preoperatively (no hoarseness or dysphonia). This exceptional mishap is undoubtedly related to NF1-associated peripheral nerve sheath tumors. Even though it is not advisable to routinely perform any imaging prior to VNS, in such specific context, preoperative imaging work-up, especially cervical ultrasound, might be judicious to rule out any asymptomatic enlarged left vagus nerve.

A reconfigurable PID fault tolerant tracking controller design for LPV systems

This paper considers the design of a reconfigurable PID Fault Tolerant Tracking Controller (PID-FTTC) for Linear Parameter Varying (LPV) systems affected by actuator faults with the presence of disturbance. The LPV systems are represented through a polytopic LPV description with measurable gain scheduling functions. A new PID-FTTC scheme with a model reference, an adaptive PID controller and an Adaptive Polytopic Observer (APO), is developed. The main idea is to improve and to compare performances with this developed PID-FTTC versus previous similar FTC techniques especially about the settling time, the overshoot and integral error indices. By the way, this paper can reduce the conservatism of previous methods with more parameters design so as to avoid their disadvantages and to give better control loop performances especially in terms of accuracy and speed of trajectory tracking even when a fault occurs. So, in order to establish the stability of the reconfigured PID-FTTC, a new theoretical study is developed through the use of Linear Matrix Inequality (LMI). This new method is illustrated through a two-tank process where the results compared to previous ones, underline the improvements.

Anterior Thalamic Stimulation Induced Relapsing Encephalitis

Deep brain stimulation of the anterior thalamic nucleus is one of the promising therapeutic options for epilepsy. Several studies are still under way to further strengthen and clarify the mechanism, efficacy, and complications. Contrary to hardware-related and operation-related events, the stimulation-related adverse effect is mild, target-dependent, and adjustable. We present a case of relapsing herpes simplex encephalitis (HSE) as a newly reported and potentially fatal stimulation-related adverse effect following stimulation of the anterior thalamic nucleus (ANT-DBS) accompanied by fever, confusion, and cognitive impairment in a 32-year-old epileptic patient with a history of herpes meningoencephalitis 31 years earlier. The T2-weighted/FLAIR high-signal intensity in the temporal lobe developed at a "distance" from the stimulation target. The positive polymerase chain reaction of herpes virus deoxyribonucleic acid in the cerebrospinal fluid confirmed the diagnosis. The condition improved partially on acyclovir and stimulation stopped. Seizures disappeared and then returned after few months. The unique case report presents a rationale for considering history of herpes encephalitis as a relative contraindication for ANT-DBS, and HSE relapse should be suspected in patients with post-stimulation fever and/or altered consciousness.

A Rare Cause of Thoracic Spinal Cord Compression by Multiple Large Tarlov Cysts

Spinal extradural arachnoid cyst (SEAC) is a rare cause of spinal cord compression. Bifocal location of thoracic and sacral SEACs is rarely reported in the literature. We report a case of thoracic spinal cord compression by SEAC associated with asymptomatic multiple sacral Tarlov cysts (TC). The surgical management and postoperative outcome of the patient are discussed. A 34-year-old woman was referred to the hospital for acute thoracic pain with a history of chronic long-standing back pain. She complained of walking difficulties. Neurological examination demonstrated incomplete spastic paraplegia with sensory level in T9. Magnetic resonance imaging revealed a large cystic formation from T7-11 and at the level of the sacrum. We performed laminectomies at the level of interest from T7-11. The cysts were dissected from the underlying dura after removal of the cerebrospinal fluid. We found nerve tissue in the cysts. We excised the cyst and preserved the nerve roots. Subsequently, a duraplasty was performed with autologous grafts from the lumbar fascia. The condition of the patient improved after surgery and he was recovering well at follow-up. Although the surgical treatment of TC is controversial, especially at the sacral lumbar level, decompression at the dorsal level in this case is indisputable.

Effects of olive-cake supplementation on fatty acid composition, antioxidant status and lipid and meat-colour stability of Barbarine lambs reared on improved rangeland plus concentrates or indoors with oat hay plus concentrates

The effects of feeding system (indoor vs rangeland) and olive-cake (OC) supplementation (control vs supplemented) on fatty acid (FA) composition, lipid oxidation status and meat-colour stability were studied. Lambs were fed indoor with hay (OH) or reared on improved rangeland (RL). All lambs received concentrate at a rate of 400 g/head.day. Twenty-four 6-month-old Barbarine lambs with an average weight of 24.3 ± 1.1 kg were assigned into the following four groups: OH without OC, OH with OC, RL without OC and RL with OC. Supplemented groups received 280 g/day of OC. Lambs were reared for ~3 months and then slaughtered at 33 kg. Feeding lambs on rangeland increased proportions of polyunsaturated fatty acids (PUFA, P < 0.05), n-3 PUFA (P < 0.01) and long-chain n-3 PUFA (P < 0.01) and decreased those of C16:0 and monounsaturated fatty acids (P = 0.052). Higher PUFA : saturated FA (SFA) (P < 0.001) and lower n-6 : n-3 PUFA (P < 0.01) ratios were found for RL lambs. The peroxidisability index was higher (P = 0.024) for RL lambs. Whereas, a lower malondialdehyde concentration (P < 0.001) was found for meat of RL group after 5-day storage, because of a higher vitamin E concentration (P < 0.001) and catalase activity (P = 0.002). Moreover, colour was more stable for meat of RL lamb. OC supplementation reduced only superoxide dismutase activity (P = 0.033) and did not have any effect on lipid peroxidation and colour stability. No interactions were noted between the feeding system and olive-cake supplementation. Meat lambs produced on rangeland had a healthier fatty acid composition. Lipids were more stable to oxidation than was meat produced indoor with hay and concentrate.

Assessment of the genotoxicity of quinolone and fluoroquinolones contaminated soil with the Vicia faba micronucleus test

The genotoxicity of quinolone and fluroquinolones was assessed using the micronucleus (MN) test on Vicia faba roots by direct contact exposure to a solid matrix. Plants were exposed to quinolones (nalidixic acid) and fluoroquinolones (ciprofloxacin and enrofloxacin) alone or mixed with artificially contaminated soils. Four different concentrations of each of these antibiotics were tested (0.01, 0.1, 1 and 10 mg/Kg) for nalidixic acid and (0.005, 0.05, 0.5 and 5 mg/Kg) for ciprofloxacin and enrofloxacin. These antibiotics were also used in mixture. Exposure of Vicia faba plants to each antibiotic at the highest two concentrations showed significant MN induction. The lowest two concentrations had no significant genotoxic effect. The mixture of the three compounds induced a significant MN induction whatever the mixture tested, from 0.02 to 20 mg/Kg. The results indicated that a similar genotoxic effect was obtained with the mixture at 0.2 mg/Kg in comparison with each molecule alone at 5-10 mg/Kg. Data revealed a clear synergism of these molecules on Vicia faba genotoxicity.

Distribution of 16 EPA-priority polycyclic aromatic hydrocarbons (PAHs) in sludges collected from nine Tunisian wastewater treatment plants

Polycyclic aromatic hydrocarbons (PAHs) are organic compounds which may be present as contaminants in wastewater sewage sludge. Due to their toxicity and persistence in the solid phase, information should be gathered relating to their presence in sewage sludge in order to determine their contamination risks after land application. In this study, sewage sludge samples from nine Tunisian wastewater treatment plants (WWTPs) were characterized for the total content in 16 EPA-priority PAHs using an optimized extraction protocol. These WWTPs differ in the type of applied treatment and the wastewater source. Through this first assessment of PAHs in Tunisian sludges, their total concentration varied from 96 to the highest level of 7718 ng g(-1). Regardless of the source of wastewater, the highest PAH content was found in sludges deriving from untreated wastewater (natural lagooning). In addition, some correlation was found between the distribution patterns of each PAH, the type of applied treatment on one hand and the wastewater source on other hand.

Spectroscopic studies of inclusion complex of beta-cyclodextrin and benzidine diammonium dipicrate

Formation of inclusion complex between benzidine diammonium dipicrate and beta-cyclodextrin with stoichiometry 1:2 (guest-host) has been established by UV, (1)H NMR, (13)C NMR, IR spectra and powder X-ray diffractometry. (1)H NMR studies are used to confirm the inclusion and to provide information on the geometry of dipicrate inside the cavity of beta-cyclodextrin.

Optimisation of biodegradation conditions for the treatment of olive mill wastewater

The aim of the present paper was to optimise the conditions of aerobic treatment of olive mill wastewater. To do so, the waste was treated following the experimental optimal design methodology studying the set of factors susceptible to influence the treatment (pH, C/N ratio, aeration and temperature). The results of a first series of experiments showed a strong correlation between the reduction in the levels of polyphenols and three of the parameters studied, i.e. the C/N ratio, aeration and temperature. Optimised conditions led to a 94% drop in polyphenols. Then, for a finer study of the conditions, just two parameters were varied, the pH and the C/N ratio. The results showed that the conditions of pH modification (addition of lime or sodium hydroxide) and the C/N ratio (urea or ammonium nitrate) allowed the microbiological activity to be very significantly improved. This led to polyphenol reductions of 51% and 76%.

Fate of polycyclic aromatic hydrocarbons during composting of lagooning sewage sludge

The fate of 16 polycyclic aromatic hydrocarbons (PAHs), targeted by the USEPA agency, has been investigated during composting of lagooning sludge. Composting shows efficient decrease of the content and the bioavailability of each PAH. Biodegradation and sorption are suggested as the main mechanisms contributing to this decrease. During the stabilization phase of composting, extensive microbial degradation of PAHs, mainly those with a low number of aromatic rings, was achieved following development of intense thermophilic communities. However, partial sorption of PAH to non-accessible sites temporarily limits the mobility mainly of PAHs with a high number of aromatic rings plus acenaphthene and acenaphthylene, and allows them to escape microbial attack. During the maturation phase, the development of a mesophilic population could play an important role in the degradation of the remaining PAH. During this phase of composting, PAH sequestration and binding of their oxidative metabolites within new-formed humic substances might also explain PAH decrease at the end of composting. The tendency of change of content or bioavailability of various PAH compounds during composting is found to be strongly related to the number of their aromatic rings, their molecular weight and structure.

Origin and phylogenetic distribution of Alu DNA repeats: irreversible events in the evolution of primates

Over the past 60 million years, or so, approximately one million copies of Alu DNA repeats have accumulated in the genome of primates, in what appears to be an ongoing process. We determined the phylogenetic distribution of specific Alu (and other) DNA repeats in the genome of several primates: human, chimpanzee, gorilla, orangutan, baboon, rhesus, and macaque. At the population level studied, the majority of the repeats was found to be fixed in the primate species. Our data suggest that new Alu elements arise in unique, irreversible events, in a mechanism that seems to preclude precise excision and loss. The same insertions did not arise independently in two species. Once inserted and genetically fixed, the DNA elements are retained in all descendant lineages. The irreversible expansion of Alu s introduces a vector of time into the evolutionary process, and provides realistic (rather than statistical) answers to questions on phylogenies. In contrast to point mutations, the present distribution of individual Alu s is congruent with just one phylogeny. We submit that only irreversible and taxonomically relevant events are at the molecular basis of evolution. Most point mutations do not belong to this category.

Cleavage of structural components of mammalian vitreous by endogenous matrix metalloproteinase-2

Our goal was to determine if the major endogenous vitreous matrix metalloproteinase (MMP-2) could digest known collagenous components of the vitreous body. Matrix metalloproteinase-2 and its associated inhibitors were isolated from porcine vitreous by affinity column chromatography. The inhibitors were inactivated by chemical modification with dithiothreitol and iodoacetamide. The latent MMP-2 was then activated with the organomercurial, p-aminophenyl mercuric acetate (APMA). Bovine vitreous fibrillar collagens (types II, V/XI and IX) were isolated by pepsin extraction and differential salt precipitation. Intact type IX collagen was purified by selective salt precipitation followed by ion exchange and size exclusion chromatography. These isolated collagens were incubated for 6 to 24 h with different concentrations of activated MMP-2, and the extent of collagen degradation was analyzed. Activated MMP-2 was also introduced into freshly isolated vitreous gels and the degree of liquefaction was determined. Our results showed that the activated MMP-2 has no apparent effect upon type II collagen but can degrade type V/XI collagen and type IX collagen fragments (COL2 and COL2 + COL3). In addition, when the type IX collagen was in the intact helical form, MMP-2 appeared to selectively digest alpha 3 (IX) chains. This suggested that vitreous MMP-2 preferentially cleaved certain vitreous collagen chains into large fragments rather than small peptides. MMP-2 also disrupted the vitreous gel in vitro, releasing proteins but not hexuronic acid or sulfated glycosaminoglycans into the liquefied supernatant. We conclude that MMP-2 activity should be considered as a potential mechanism of vitreous liquefaction that is seen in aging and various pathological states.

Characterization of an endogenous metalloproteinase in human vitreous

The vitreous is a gel-like connective tissue that undergoes liquefaction during aging and pathological processes. We isolated and characterized a degradative enzyme from the vitreous of different species and identified it to be matrix metalloproteinase-2 (MMP-2). This enzyme was found in a latent form and may be associated with endogenous inhibitors. Vitreous isolated from both non-diabetic and diabetic patients contained MMP-2 in the same concentrations. However, the diabetic samples had an additional gelatinase activity at 92 kDa which may be associated with a compromised vasculature. These results suggest that the normal human vitreous contains an endogenous MMP and the appearance of an additional activity is associated with pathologic conditions.