Neurotransplantation therapy

Neurotransplantation may be a promising approach for therapy of cerebellar diseases characterized by a substantial loss of neurons. Neurotransplantation could rescue neurons from degeneration and maintain cerebellar reserve, facilitate cerebellar compensation, or help reconstruct damaged neural circuits by cell substitution. These mechanisms of action can be of varying importance according to the type of cerebellar disease. Neurotransplantation therapy in cerebellar ataxias is still at the stage of experimental studies. There is currently little knowledge regarding cerebellar patients. Nevertheless, data provided by experiments in animal models of cerebellar degeneration and both clinical studies and experiences in patients with other neurologic diseases enable us to suggest basic principles, expectations, limitations, and future directions of neurotransplantation therapy for cerebellar diseases.

Expansion diverticulum of the suprapineal recess causing cerebellar ataxia. A case report

As a result of long-standing cerebrospinal fluid (CSF) pulsation against the thinnest segments of the ventricular walls, focal enlargement of the ventricular system (diverticulum) may occur, mainly at the medial wall of the trigone of the lateral ventricles (atrial diverticula) or at the posterior wall of the third ventricle (expansion of the suprapineal recess). In the latter case, ocular signs are the most common symptoms, due to the severe deformation of the periaqueductal region. We describe a case of non-communicating hydrocephalus in a 36-year-old woman who presented a three-year history of cerebellar ataxia. Preoperative brain magnetic resonance (MR) scan showed marked supratentorial hydrocephalus with an apparently patent aqueduct of Sylvius, and an enlarged suprapineal recess causing cerebellar and tentorial dislocation. The patient was successfully treated by endoscopic third ventriculostomy and monitored by MR scans with phase-contrast sequences for assessment of CSF flow. Cerebellar ataxia is a very rare symptomatic onset for a suprapineal recess expansion diverticulum, which may cause obstructive hydrocephalus that can be effectively treated by endoscopic third ventriculostomy.

Primitive neuroectodermal tumor arising in long-standing cerebellar atrophy

Primitive neuroectodermal tumors (PNETs) account for one fifth of childhood brain tumors. Although little is known of the pathobiology of this tumor type, there are associations with both genetic syndromes and exposures to specific environmental agents. Progressive cerebellar atrophy predating the presentation of a primary brain tumor, in the absence of a genetic syndrome, has not been reported with PNETs. We report a case of a posterior fossa PNET occurring in association with long-standing cerebellar atrophy without evidence of a genetic syndrome. This case may represent an unrecognized paraneoplastic syndrome or a unique subtype of PNET.

Isolated cerebellar involvement in Rosai-Dorfman disease: case report

OBJECTIVE AND IMPORTANCE

Sinus histiocytosis or Rosai-Dorfman disease (RDD) is a rare but well-recognized disorder characterized by an unusual proliferation of histiocytic cells. Intracranial localization is a rare manifestation of RDD. Only three cases of localization in the posterior fossa have been reported in the literature. The present report describes the first case, to our knowledge, of cerebellar localization of RDD.

CLINICAL PRESENTATION

A 67-year-old woman was admitted to our institution with a 5-month history of cerebellar ataxia. Her medical history was unremarkable. The patient was alert and cooperative. No cranial nerve deficits were evident; Romberg positivity to the left side was recorded. No cutaneous abnormalities, lymphadenopathy, or hepatosplenomegaly were revealed by physical examination. Routine hematological and biochemical studies were normal except for the erythrocyte sedimentation rate, which was elevated. Radiologically, the lesion appeared as a well-defined and avascular mass in the right cerebellar lobe. Meningioma was considered the most likely diagnosis.

TECHNIQUE

The patient underwent a suboccipital craniotomy with complete excision of the lesion. Microscopic examination of the operative specimen revealed the presence of a mixed cellular population with predominant mature histiocytes. A peculiar feature was the presence of lymphocytes and monocytes within the cytoplasm of histiocytes (emperipolesis). Immunohistochemical study of the histiocytes revealed strong positivity for S-100, CD-68 antigen, and vimentin.

CONCLUSION

Involvement of the central nervous system in RDD appears to have a benign prognosis, especially in the absence of nodal diseases. Surgery is essential for diagnosis, and, when total removal is achieved, the outcome is generally good without risk of recurrence.

Cerebellar Grafts Partially Reverse Amino Acid Receptor Changes Observed in the Cerebellum of Mice with Hereditary Ataxia: Quantitative Autoradiographic Studies

We used quantitative autoradiography of [3H]CNQX (200 nM), [3H]muscimol (13 nM), and [3H]flunitrazepam (10 nM) binding to study the distribution of non-NMDA and GABAA receptors in the cerebellum of pcd mutant mice with unilateral cerebellar grafts. Nonspecific binding was determined by incubation with 1 mM Glu, 200 μM GABA, or 1 μM clonazepam, respectively. Saturation parameters were defined in wild-type and mutant cerebella. In mutants, non-NMDA receptors were reduced by 38% in the molecular layer and by 47% in the granule cell layer. The reduction of non-NMDA receptors in the pcd cerebellar cortex supports their localization on Purkinje cells. [3H] CNQX binding sites were visualized at higher density in grafts that had migrated to the cerebellar cortex of the hosts (4.1 and 11.0 pmol/mg protein, respectively, at 23 and 37 days after grafting) than in grafts arrested intraparen-chymally (2.6 and 6.2 pmol/mg protein, respectively, at 23 and 37 days after grafting). The pattern of expression of non-NMDA receptors in cortical vs. parenchymal grafts suggests a possible regulation of their levels by transacting elements from host parallel fibers. GABAA binding levels in the grafts for both ligands used were similar to normal molecular layer. Binding was increased in the deep cerebellar nuclei of pcd mutants: the increase in [3H]muscimol binding over normal was 215% and the increase in [3H]flunitrazepam binding was 89%. Such increases in the pcd deep cerebellar nuclei may reflect a denervation-induced supersensitivity subsequent to the loss of Purkinje axon terminal innervation. In the deep nuclei of pcd mutants with unilateral cerebellar grafts, [3H]muscimol binding was 31% lower in the grafted side than in the contralateral nongrafted side at 37 days after transplantation; [3H]fluni-trazepam binding was also lower in the grafted side by 15% compared to the nongrafted side. Such changes in GABAA receptors suggest a significant, albeit partial, normalizing trend of cerebellar grafts on the state of postsynaptic supersensitive receptors in the host cerebellar nuclei.

Carpal tunnel syndrome in amyotrophic lateral sclerosis and late onset cerebellar ataxia

We report on clinical and electrophysiological findings and management in nine patients who developed carpal tunnel syndrome during the course of amyotrophic lateral sclerosis and late onset cerebellar ataxia, two neurodegenerative diseases. The patients were treated with surgical decompression (five cases) and local steroid injections (four cases). Only one showed lasting relief of symptoms and significantly improved distal conduction in the median nerve at follow-up after 2 to 3 months. The symptoms and conduction data remained unchanged in three patients who could be followed for more than 1 year. We think that axonal neuropathy plays an important role in the development of carpal tunnel syndrome in these patients and accounts for the failure of the standard treatments.

[Paraneoplastic cerebellar degeneration: case report of a patient with breast carcinoma]

Case Report on a Breast Cancer Patient: A description of medical history, diagnosis and therapy of a patient with breast cancer is presented. The patient showed primary symptoms of vertigo and truncal and gait ataxia. The cause of this cerebellar disorder was a paraneoplastic cerebellar degeneration (PCD) characterized by anti-Purkinje cell antibodies (anti-Yo) directed against specific epitops shared by Purkinje and tumour cells. The presence of these antibodies in some patients suggests an autoimmune mechanism, although their role in pathogenesis has not been established. Usually malignancies of the breast and the ovaries are associated with anti-Yo positive PCD. The intensive search for the underlying neoplasma led to the identification of a malignant tumour of the right breast. Tumour excision of subsequent immunosuppressive treatment resulted in a progression of PCD. Antibody titers remained nearly unchanged during the course of the disease.

Paraneoplastic cerebellar degeneration: successful early detection and treatment of cancer through characterization of the anti-Purkinje cell antibody

Paraneoplastic cerebellar degeneration (PCD) is thought to be caused by an autoantibody against both tumor and neuronal tissue. Such autoantibodies are most frequently detected in patients with gynecological or breast cancer, and are designated as anti-Yo. We report here a patient with PCD whose underlying cancer could not be detected despite extensive tumor survey. IgG in her serum and cerebrospinal fluid reacted with the cytoplasm of cerebellar Purkinje cells immunohistochemically. On immunoelectron microscopy, the endoplasmic reticulum and Golgi complex were stained. Her IgG bound to the 58 kD band on immunoblots of cerebellar proteins. A reaction was also observed with the recombinant proteins deduced from the complementary DNA clone encoding a neuronal cell antigen reported by Sakai et al (Ann Neurol 28: 692, 1990). Based on these results, successful early resection of fallopian tube adenocarcinoma was performed. It is crucially important to characterize these PCD related autoantibodies for the early treatment of underlying malignant tumors.

Fetal tissue grafts for cerebellar atrophy

It has been shown in a rat model that surgical injury to the right cerebellum with resultant ataxia can be corrected by implantation of embryonic cerebellar tissue into the injured cerebellum. Histological examinations of the cerebellar tissue revealed that mitoses of Purkinje cells of the implanted group were increased substantially over the control group's. The surgically induced ataxia resolved more rapidly in the cerebellar implant group than the control group. Based on this experimental data, a similar technique was applied in 6 patients with severe hereditary cerebellar degenerative ataxia. The preliminary results in these 6 surgically implanted patients with heredity degenerative cerebellar disease show 2 with marked improvement, 3 with moderate improvement and 1 with improvement for 2 months followed by mild deterioration but still better than presurgery. We also studied immunological markers in the blood and CSF in an attempt to determine whether rejection of implanted tissue occurs.

Clinical outcome in children with acute cerebellar encephalopathy and neuroblastoma

Acute cerebellar encephalopathy (ACE)--ataxia often associated with opsoclonus, polymyoclonus, and irritability--may be associated with neuroblastoma and should be suspected in a child who presents with ACE. The survival in ten children with ACE associated with neuroblastoma was 100%. Most of the tumors were ganglioneuroblastomas. The abdomen was the most common location for the tumor in this study although it also can be found in the mediastinum. All patients with this syndrome had a localized tumor. With ACTH therapy, ACE may resolve early postoperatively, but it tends to recur in most patients, continuing for as long as 3 years after the initial operation. Treatment with ACTH or prednisone modifies and rapidly clears the symptoms during the acute episode of recurrent ACE as well as helps to resolve subsequent neurologic sequelae. Significant neurologic sequelae persisted in seven of ten patients and included deficits in cognition or intellect, hyperactivity, impulsivity, emotional lability, and mild motor deficits. Seizures were seen in one patient.

Diverticulum of the lateral ventricle causing cerebellar ataxia. Case report

A case of ventricular diverticulum causing cerebellar ataxia is presented. Computerized tomography clearly demonstrated the aperture of the diverticulum in the medial wall of the trigone and its extension into the posterior fossa. The diverticulum regressed and the cerebellar ataxia disappeared after placement of a ventriculoperitoneal shunt.

Herpes zoster oticus: surgery based upon prognostic indicators and results

We studied 28 patients with herpes zoster oticus prospectively over the six-year period between August 1974 and June 1980. We found that the results of measuring tear production, submandibular salivary flow, the response to maximal stimulation, and evoked electromyography gave us sufficient information to group these patients according to prognosis--either unfavorable or favorable--for spontaneous return of facial function. When the test results were 26% or more of normal, 100% of the patients had complete recovery without treatment; when the test results were 25% or less of normal, 69% had incomplete recovery: 19% had fair and 50% had poor recovery. Of the 31% with complete recovery, 4 were operated upon. The natural history of herpes zoster oticus in patients with a poor prognosis was improved if a transmastoid extralabyrinthine subtemporal decompression of the labyrinthine segment of the facial nerve was performed within 10 days of onset of the paralysis. The decision to perform this surgery was based upon the results of the prognostic tests mentioned above.

Myoclonic disease of Ramsey-Hunt treated by transtentorial bilateral dentatotomy from the right side

The idea that lesion of the nucleus dentatus may stop the pathological mechanism of Ramsey-Hunt disease led us to perform a dentatotomy in a female patient aged 28, who suffered from myoclonic movements for 6 years. Surgery was carried out by transtentorial approach from a burr hole in the right temporo-occipital region. The coagulation electrode was introduced first into the right nucleus dentatus; after its coagulation, myoclonic movements in the right extremities disappeared. For this reason, the left nucleus dentatus was also destroyed by introducing the electrode into the left side from the same right side burr hole through the midline. All myoclonic movements stopped at least transitorily.