Vagus nerve stimulation in the treatment of patients with pharmacoresistant epilepsy: our experiences

Vagus nerve stimulation (VNS) for the treatment of refractory partial epileptic seizures with or without secondary generalisation in patients older than 12 years was approved in Europe in 1994 and in the United States in 1997. We have studied the efficacy of VNS in patients with pharmacoresistant epilepsy hospitalized in the Neurology Department of the University Hospital Centre Zagreb. From 1997 to 2001 we have implanted VNS in 11 patients with pharmacoresistant epilepsy, who were magnetic resonance imaging (MRI) negative and from May 2007 to May 2009 in 11 patients with pharmacoresistant epilepsy, 9 of them were MRI positive, and were inoperable due to localisation of the pathomorphologic changes (ganglioglioma, hamartoma, various types of cortical dysplasia, porencephalic cysts), 2 were MR negative. In the group of MRI negative patients 1 patient had complex partial seizures (CPS), 6 patients had CPS with secondary generalisation, 2 patients had primary generalized epilepsy (PGE) including myoclonic, absence, atonic and tonic-clonic seizures, one patient had PGE and CPS, and 3 patients had Lennox-Gastaut syndrome (LGS). In the group of MRI positive patients one patient had elementary partial seizures (EPS) and CPS, two patients had EPS and CPS with secondary generalisation, one patient had CPS, 3 patients had CPS with secondary generalisation, and 2 patients had CPS with secondary generalisation as well as atonic seizures. After continuous follow-up of 11 MRI negative patients during 5 years and 2 MRI negative patients during one year there was decrease in mean-seizure frequency of 51.67%. After continuous follow-up of 9 MRI positive patients during 2 years there was decrease in mean-seizure frequency of 61.9%. The most frequent side effects were hoarseness, throat pain and cough in the "on phase" of the VNS, but they were mild and transitory. We can conclude that VNS was effective mode of therapy in our group of patients with pharmacoresistant epilepsy.     

Immunohistochemical procedures for the demonstration of peptide- and tyrosine hydroxylase-containing nerve fibers in cryostat sections of unfixed rapidly frozen tissue stored for long periods of time. A study on heart tissue

Traditional protocols for the immunohistochemical localization of peptides and tyrosine hydroxylase (TH) in nerve fibers in cryostat sections require the tissue to be thoroughly fixed and rinsed and to be processed for the cryostat sectioning and the immunohistochemical staining more or less directly after freezing. In the present study it was tested whether also unfixed, rapidly frozen tissue, conforming to guinea pig and bovine heart specimens, can be used for the visualization of neuropeptides [neuropeptide Y (NPY) and substance P (S P)] and TH in cryostat sections. The following observations were made: 1) NPY-immunoreactive (IR) and S P-IR nerve fibers could be clearly identified in both fixed and unfixed sections of this type of tissue. 2) TH-IR nerve fibers could be detected in unfixed tissue if the sections were post-fixed with aldehydes by the use of a two-step fixation process related to a sudden change of pH. However, the outlines of the nerve fibers were sometimes diffuse. 3) Storage of unfixed tissue for periods of up to 2.5 years at-80 degrees C did not lead to a decrease in immunoreactivity. 4) Somewhat higher concentrations of primary antibodies had to be used for sections of unfixed tissue than for sections of fixed tissue when the FITC method was used. This waste of antibodies was partly overcome by use of the biotin-streptavidin method. The glyoxylic acid induced catecholamine(CA)-fluorescence method for demonstration of sympathetic nerve fibers was also applied and was found to give optimal results after storage of tissue for up to 2.5 years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of EEG Biofeedback on Cognitive Flexibility in Children with Attention Deficit Hyperactivity Disorder With and Without Epilepsy

Attention deficit hyperactivity disorder (ADHD) is one of the most common developmental disorders in school-aged children. Symptoms consistent with ADHD have been observed in 8–77 % of children with epilepsy. Researchers have been motivated to search for alternative forms of treatment because 30 % of patients with ADHD cannot be treated by psychostimulants. Several studies support the use of a multimodal treatment approach that includes neurofeedback (NF) for the long-term management of ADHD. These studies have shown that NF provides a sustained effect, even without concurrent treatment with stimulants. We aimed to assess cognitive flexibility in ADHD children with and without temporal lobe epilepsy (TLE), and to evaluate the effects of NF on cognitive flexibility in these groups of children. We prospectively evaluated 69 patients with ADHD aged 9–12 years. The control group was 26 ADHD children without TLE who received no treatment. The first experimental group comprised 18 children with ADHD. The second experimental group comprised 25 age-matched ADHD children with TLE. This group was further divided in two subgroups. One subgroup comprised those with mesial temporal lobe epilepsy (16 patients, 9 with hippocampal sclerosis and 7 with hippocampal atrophy), and the other with lateral temporal lobe epilepsy (9 patients, 5 with temporal lobe dysplasia, 3 with temporal lobe cysts, and 1 with a temporal lobe cavernoma). We treated their ADHD by conducting 30 sessions of EEG NF. Reaction time and error rates on the Trail Making Test Part B were compared before and after treatment, and significant differences were found for all groups of patients except those who had mesial temporal lobe epilepsy with hippocampal atrophy. Our results demonstrate that in most cases, NF can be considered an alternative treatment option for ADHD children even if they have TLE. Additional studies are needed to confirm our results.     

Effect of Aging on Tyrosine Hydroxylase Protein Content and the Relative Number of Dopamine Nerve Terminals in Human Caudate

This study examined the effect of aging on the relative number of dopamine (DA) nerve terminals in human caudate nucleus, their content of tyrosine hydroxylase (TH) protein, and the relative abundance of TH monomers with different molecular weights. Preliminary studies on brain tissue cryopreservation, performed with rat striatum, indicated that intact synaptosomes can be prepared from fresh tissue slowly frozen in 0.32 M sucrose with 5% dimethyl sulfoxide and then thawed rapidly prior to synaptosome preparation. Synaptosomes were prepared in this manner from postmortem caudate nucleus tissue obtained from normal humans 1 month to 63 years of age. To determine the relative number of DA nerve terminals for each individual, dopaminergic synaptosomes were selectively labeled with a monoclonal antibody to TH and quantified by fluorescence-activated cell sorting. To determine the relative amount of TH protein for each individual, the concentration of TH protein in the same synaptosomal preparations was determined using immunoblots. Our results suggest that caudate TH levels plateau soon after birth and tend to remain relatively stable during aging, since no changes in either the relative number of TH-containing nerve terminals or the concentration of TH protein were found in subjects 15-63 years of age. In light of previous studies showing an age-related loss of DA cell bodies, these findings suggest that remaining DA neurons compensate to maintain caudate levels of TH protein and TH-containing nerve terminals. Immunoblot studies identified three forms of TH monomer (60.6, 61.7, and 65.1 kDa), indicating that mRNAs coding for high molecular mass forms of TH may be actively translated in human brain. No age-related differences in the relative abundance of these forms were found.     

Immunohistochemical procedures for the demonstration of peptide- and tyrosine hydroxylase-containing nerve fibers in cryostat sections of unfixed rapidly frozen tissue stored for long periods of time

Summary Traditional protocols for the immunohistochemical localization of peptides and tyrosine hydroxylase (TH) in nerve fibers in cryostat sections require the tissue to be thoroughly fixed and rinsed and to be processed for the cryostat sectioning and the immunohistochemical staining more or less directly after freezing. In the present study it was tested whether also unfixed, rapidly frozen tissue, conforming to guinea pig and bovine heart specimens, can be used for the visualization of neuropeptides [neuropeptide Y (NPY) and substance P (S P)] and TH in cryostat sections. The following observations were made: 1) NPY-immunoreactive (IR) and S P-IR nerve fibers could be clearly identified in both fixed and unfixed sections of this type of tissue. 2) TH-IR nerve fibers could be detected in unfixed tissue if the sections were post-fixed with aldehydes by the use of a two-step fixation process related to a sudden change of pH. However, the outlines of the nerve fibers were sometimes diffuse. 3) Storage of unfixed tissue for periods of up to 2.5 yeart at –80° C did not lead to a decrease in immunoreactivity. 4) Somewhat higher concentrations of primary antibodies had to be used for sections of unfixed tissue than for sections of fixed tissue when the FITC method was used. This waste of antibodies was partly overcome by use of the biotin-streptavidin method. The glyoxylic acid induced catecholamine(CA)-fluorescence method for demonstration of sympathetic nerve fibers was also applied and was found to give optimal results after storage of tissue for up to 2.5 years. The study shows that the use of unfixed rapidly frozen tissue represents a fast and realistic method for the demonstration of neuropeptide immunoreactivity, that it to some extent can be used for the visualization of TH-containing nerve fibers and that it is a suitable method to maintain longterm neuropeptide and TH immunoreactivity as well as long-term CA-fluorescence reaction.     

The diabetic polyneuropathy. I. Relation between impaired function in peripheral nerves and clinical findings

789 patients with diabetes mellitus were studied by clinical and electroneurographical investigation. Motor and sensory conduction velocities of the median nerve and motor conduction velocity of the tibial nerve were determined. 86.1% of the patients suffered from juvenile diabetes, and 13.9% from maturity onset diabetes. Average duration of the disease was 9.5 years, average age of the patients was 26.7 years. Clinical signs of polyneuropathy were found in 19.1%. In 40.9% of the patients at least one of 3 conduction velocities was found to be delayed. Patients with clinical signs of polyneuropathy exhibited delayed nerve conduction velocities and delayed distal latencies. Diagnosis of polyneuropathy almost with certainty is possible by determining the three nerve conduction velocities and the three corresponding distal latencies. 22% of patients without clinical signs of polyneuropathy exhibited electroneurographical signs of impaired peripheral nerve function. Heredity, body weight, lipid metabolism, actual metabolic balance, and treatment were found to be without any significant influence on nerve conduction velocity.     

MicroRNA与癫痫的研究进展

癫痫是大脑神经元高度同步化异常放电所导致的短暂的大脑功能障碍的一种慢性疾病。癫痫的发病原因十分复杂,目前主要治疗方式是药物治疗,但仍然有30%左右的难治性癫痫患者依靠药物治疗未能控制癫痫发作,因此从分子角度研究癫痫的发病机制及治疗是近年来癫痫研究的热点。微小RNA(miRNA)在癫痫患者及癫痫动物模型海马组织中存在差异性表达,通过抑制miRNA的差异表达在一定程度上可以缓解癫痫的症状,这为癫痫的治疗开辟了新的途径和方向。因此随着miRNA与癫痫相关性研究深度的不断加深,有望能够为癫痫的诊断及治疗提供一个全新的思路。     

Nestin in the temporal neocortex of the intractable epilepsy patients

Nestin is one kind of intermediate filament protein, which is considered as a typical marker of neural precursor cells. Considerable evidence supports nestin may have actively functions in neurogenesis and gliosis. Our aim was to investigate nestin expression in the temporal neocortex of patients with intractable epilepsy (IE), and then to discuss the possible role of nestin in IE. Tissue samples from the temporal neocortex of 32 patients who had surgery for IE were used to detect nestin expression by immunohistochemistry, immunofluorescence. We compared these tissues with 12 histologically normal temporal neocortex from intracranial hypertension patients who had decompression procedures. In this study, we found some nestin positive cells in the normal temporal neocortex, but in the intractable epilepsy, they were upregulated, increasing with length of course and seizure frequency. Optical density (OD) value in epileptic tissue was determined 0.246 ± 0.030, and 0.134 ± 0.040 in the control (P < 0.05). Double lables of immunofluorescence showed some nestin positive cells coexpression with glial fibrillary acidic protein (GFAP), while some coexpression with microtubule-associated protein-2 (MAP₂). These findings provided some evidence for increased neurogenesis and gliosis in epilepsy, which could be associated with intractable epilepsy.     

Method for determining kallikrein of tissue origin in blood plasma and its clinical significance

Based on a study of the kininogenase activity of the total plasma kallikrein in the presence of 3 concentrations of the soybean inhibitor trypsin (0.5, 1.0, 10.0 micrograms/ml) one can measure at a time the activity of tissue kallikrein (without specifying the source) and the activity of 3 forms of plasma kallikrein, including its adsorption on kaolin that characterizes the conformational structure of the enzyme. Examination of 10 healthy subjects and 136 patients revealed a 10 to 20-fold increase in the content of tissue kallikrein in plasma of 70% of diabetes mellitus patients and a 2.5 to 3-fold elevation in 50% of patients with chronic occupational bronchitis, and in 30% of patients suffering from chronic hepatitis. The method suggested makes it possible to have a better insight into the physiological and pathogenetic role of the kinin system and may be used for laboratory control over the treatment efficacy.     

Frequency of anticardiolipin, antinuclear and anti-beta2 glycoprotein I antibodies in children with epilepsy

A high prevalence of epilepsies in specific immunological diseases suggests that the immune system may play a role in the pathogenesis of epilepsy or might be associated with it. In this study the frequency of anticardiolipin antibodies (aCL), antinuclear antibodies (ANA) and anti-beta2-glycoprotein I antibodies (anti-beta2-GPI) in 40 children with epilepsy and in 38 healthy subjects was determined. Positive aCL was found in 3 patients, and anti-beta2-GPI in 1 patient. In control group they were negative. ANA antibodies were negative in both groups. Duration of epilepsy < 1 year was observed in all three patients with positive aCL. No statistically significant difference was found concerning the presence of these antibodies between patients and controls. There was no statistically significant correlation of age, sex, age at the onset of epilepsy, duration of epilepsy, type of epilepsy, seizure frequency or specific antiepileptic medications with the presence of any measured antibodies.     

Immunocytochemical localization of a substance in the eyestalk of the prawn,Palaemon serratus,reactive with an anti-FMRF-amide rabbit serum

Summary By use of a specific antiserum against the molluscan cardio-excitatory tetrapeptide FMRF-amide in combination with the PAP-method it was possible to obtain positive immunocytochemical reactions in several neurosecretory regions of the eyestalk of the prawn Palaemon serratus. FMRF-amide-like material was found in perikarya and nerve fibers of the medulla terminalis and in neurons in the lamina ganglionaris. The immunoreactivity observed in the glandular tissue located at the basal insertion of the eyestalk muscles must be ascribed to a non-specific reaction. The identification of immunopositive nerve fibers, ending on a nerve bundle in the medulla terminalis, and the fact that immunoreactive material was absent in the neurohemal sinus gland seem to indicate a neurotransmitter/neuromodulator function.     

Effect of alloxan-diabetes on multiple forms of hexokinase in adipose tissue and lung

Comparison has been made of the effect of alloxan-diabetes on the multiple forms of hexokinase (EC 2.7.1.1) in adipose tissue and lung. Types I and II hexokinase were distinguished in adipose tissue by their different stabilities to heat treatment, which made it possible to determine the activity of each form spectrophotometrically; additional confirmatory evidence was obtained from starch-gel electrophoresis. Type II hexokinase was markedly depressed in adipose tissue from alloxan-diabetic rats. Lung contained types I, II and III hexokinase, type I predominating. There was no significant change in the pattern of these multiple forms of hexokinase in lung from alloxan-diabetic rats. These results are discussed in relation to current ideas that the insulin-sensitivity of a tissue may be correlated with the content of type II hexokinase.     

Evidence for linkage of adolescent-onset idiopathic generalized epilepsies to chromosome 8-and genetic heterogeneity

Several loci and candidate genes for epilepsies or epileptic syndromes map or have been suggested to map to chromosome 8. We investigated families with adolescent-onset idiopathic generalized epilepsy (IGE), for linkage to markers spanning chromosome 8. The IGEs that we studied included juvenile myoclonic epilepsy (JME), epilepsy with only generalized tonic-clonic seizures occurring either randomly during the day (random grand mal) or on awakening (awakening grand mal), and juvenile absence epilepsy (JAE). We looked for a gene common to all these IGEs, but we also investigated linkage to specific subforms of IGE. We found evidence for linkage to chromosome 8 in adolescent-onset IGE families in which JME was not present. The maximum multipoint LOD score was 3.24 when family members with IGE or generalized spike-and-waves (SW) were considered affected. The LOD score remained very similar (3.18) when clinically normal family members with SW were not considered to be affected. Families with either pure grand mal epilepsy or absence epilepsy contributed equally to the positive LOD score. The area where the LOD score reaches the maximum encompasses the location of the gene for the beta3-subunit of the nicotinic acetylcholine receptor (CHRNB3), thus making this gene a possible candidate for these specific forms of adolescent-onset IGE. The data excluded linkage of JME to this region. These results indicate genetic heterogeneity within IGE and provide no evidence, on chromosome 8, for a gene common to all IGEs.     

GDNF-ADSCs-APG embedding enhances sciatic nerve regeneration after electrical injury in a rat model

The pluripotency of adipose-derived stem cells (ADSCs) makes them appropriate for tissue repair and wound healing. Owing to the repair properties of autologous platelet–rich gel (APG), which is based on easily accessible blood platelets, its clinical use has been increasingly recognized by physicians. The aim of this study was to investigate the effect of combined treatment with ADSCs and APG on sciatic nerve regeneration after electrical injury. To facilitate the differentiation of ADSCs, glial cell line–derived neurotrophic factor (GDNF) was overexpressed in ADSCs by lentivirus transfection. GDNF-ADSCs were mingled with APG gradient concentrations, and in vitro, cell proliferation and differentiation were examined with 5-ethynyl-2′-deoxyuridine staining and immunofluorescence. A rat model was established by exposing the sciatic nerve to an electrical current of 220 V for 3 seconds. Rat hind-limb motor function and sciatic nerve regeneration were subsequently evaluated. Rat ADSCs were characterized by high expression of CD90 and CD105, with scant expression of CD34 and CD45. We found that GDNF protein expression in ADSCs was elevated after Lenti-GDNF transfection. In GDNF-ADSCs-APG cultures, GDNF was increasingly produced while tissue growth factor-β was reduced as incubation time was increased. ADSC proliferation was augmented and neuronal nuclei (NeuN) and glial fibrillary acidic protein (GFAP) expression were upregulated in GDNF-ADSCs-APG. In addition, limb motor function and nerve axon growth were improved after GDNF-ADSCs-APG treatment. In conclusion, our study demonstrates the combined effect of ADSCs and APG in peripheral nerve regeneration and may lead to treatments that benefit patients with electrical injuries.     

Onchocerciasis-associated epilepsy: an update and future perspectives

Onchocerciasis-associated epilepsy (OAE) is an important neglected public health problem in areas with high ongoing onchocerciasis transmission. The risk that children in such areas develop epilepsy is related to their Onchocerca volvulus microfilarial (mf) load. Before the implementation of mass treatment with ivermectin, microfilariae were detected in cerebrospinal fluid (CSF). More recently, neither O. volvulus microfilariae nor DNA were detected in CSF or brain tissue; however, these samples were obtained years after seizure onset. It is possible that during fever-induced increased blood–brain barrier permeability, microfilariae enter the brain and, upon dying, cause an inflammatory reaction inducing seizures. Including OAE in the onchocerciasis disease burden estimation may mobilise extra resources for onchocerciasis disease elimination and treatment/care of OAE-affected persons/families.     

Comparative assessment of hemodynamic parameters in ventricular septal defect, obtained by Doppler echocardiography and catheterization of cardiac cavities

The study was undertaken to assess hemodynamic parameters by Doppler echocardiography in patients with ventricular septal defect (VSD) and pulmonary hypertension. Seventy-two patients aged 5 months to 9 years (mean 2.5 years) who had isolated VSD were examined. The authors conclude that it is possible and necessary to assess hemodynamics in the lesser circulation by using Doppler echocardiography. The method permits monitoring the time course of changes in the right heart, which makes it possible to follow the natural history of disease without applying invasive studies.     

Neurogenic inflammation of gingivomucosal tissue in streptozotocin-diabetic rat

Previously it was assumed that nerve fibres are involved in the neurogenic inflammation induced by mechanical or chemical irriations. It has been also suggested that in diabetes mellitus the unmyelinated small diameter fibers are impaired as a result of diabetic neuropathy. Therefore, our aim was to study the alterations of the nerve processes in the gingivomucosal tissue in streptozotocin (STZ)-diabetic rats. Light- and electronmicroscopical examinations were made to analyze the changes in nerve fibres. After one week of steptozotocin treatment, the gingivomucosal tissue had inflammatory cell infiltration and some degenerated nerve fibres were also observed. Dense mitochondria, disorganization of cell organelles, and appearance of myelin-like dense bodies were found in the axons of degenerared nerve fibres. Semiquantitative analysis showed that 14 +/- 4% of the unmyelinated nerve fibres degenerated after one week of STZ treatment. However, degeneration of the myelinated nerve fibers was not observed. Two weeks after STZ treatment, most of the unmyelinated and myelinated nerve fibers showed degeneration (86 +/- 5%) and the placement of the ligature revealed a non-inflammatory connective tissue adjacent to a normal epithelium. The myelin sheath was disrupted and dark axoplasm with cytolysosomes became manifest. These findings demonstrated that both unmyelinated and myelinated nerve fibers are altered and inflammatory reaction exists in the gingivomucosal tissue only in the early stage of diabetes mellitus.     

GSLII positivity is not confined to oligodendrocytes in adult mammalian CNS

The in vivo binding pattern of the lectin Griffonia simplicifolia II (GSLII) was evaluated in sections of adult cat optic nerve following reports that it is a marker for oligodendrocytes in adult rodent CNS and that it may also be an oligodendroglial lineage marker. Following as closely as possible the immunocytochemical methodology employed in these reports, staining for GSLII was incorporated into sets of consecutive one micron thick sections comprising known cell-type specific reference markers backed up by electron microscopy. With this correlative protocol both lectin positive and lectin negative cells could be reliably identified. The material examined included normal control tissue and tissue containing previously studied demyelinating lesions of various ages in which oligodendrocyte progenitors and precursors have been characterized. GSLII was found to stain not only mature oligodendrocytes in adult cat optic nerve but also activated microglia, macrophages, polymorphonuclear leucocytes and other haematogenous cells. Lectin positivity was not found in oligodendroglial precursors, endothelial cells, astrocytes or ramified microglia. This study emphasises that care needs to be taken before assigning lineage marker status to individual lectins or antibodies.     

富亮氨酸胶质瘤失活1蛋白抗体脑炎的病理特征及临床分析（附1 例案例报道）

目的:探索富亮氨酸胶质瘤失活1蛋白(LGI1)抗体相关自身免疫性脑炎的临床特点及治疗。方法:报道l例LG I1抗体阳性相关自身免疫性脑炎的临床资料,并结合相关文献讨论该病的临床病理特点。结果:老年男性,亚急性起病,反复多次发作并进行性加重,以近记忆下降、癫痫、认知和睡眠障碍为主要表现;头颅MRI示脑萎缩;LGI1抗体阳性。结论:本病患者具有认知功能、睡眠障碍及癫痫等,血清和脑脊液中抗LGI1抗体阳性,但无低钠血症,头颅影像学检查正常;急性发作期给予免疫抑制剂治疗后可获良好效果。     

Effect of near normoglycaemia for two years on progression of early diabetic retinopathy,nephropathy, and neuropathy: the Oslo study.

Forty five insulin dependent diabetics were randomised to treatment with continuous subcutaneous insulin infusion (CSII), multiple insulin injections (five or six daily), or conventional twice daily insulin injections. Near normoglycaemia was obtained with CSII and multiple injections but not with conventional treatment (p less than 0.01). Hypoglycaemic coma was observed less frequently with CSII than with multiple injections and conventional treatment (p less than 0.001), but blood glucose concentrations below 2.5 mmol/l (45 mg/100 ml) were more common. After two years fewer retinal microaneurysms and haemorrhages had developed in the patients given CSII and multiple injections compared with those given conventional treatment, in whom the number had increased significantly (p less than 0.01). Motor nerve conduction velocity deteriorated in the patients given conventional treatment; in those given CSII it was unchanged during the first year but had improved after two years (p less than 0.01). Glomerular hyperfiltration was reduced with CSII, but no change occurred in urine albumin excretion rates. Long term near normoglycaemia may prevent the progression of early stages of late diabetic complications.