Effects of anterior thalamic nucleus DBS on interictal heart rate variability in patients with refractory epilepsy.

OBJECTIVE: Heart rate variability (HRV) changes were investigated by several studies after resective epilepsy surgery/vagus nerve stimulation. We examined anterior thalamic nucleus (ANT)-deep brain stimulation (DBS) effects on HRV parameters. METHODS: We retrospectively analyzed 30 drug-resistant epilepsy patients' medical record data and collected electrocardiographic epochs recorded during video- electroencephalography monitoring sessions while awake and during N1- or N2-stage sleep pre-DBS implantation surgery, post-surgery but pre-stimulation, and after stimulation began. RESULTS: The mean square root of the mean squared differences between successive RR intervals and RR interval standard deviation values differed significantly (p < 0.05) among time-points, showing increased HRV post-surgery. High (0.15-0.4 Hz) and very low frequency (<0.04 Hz) increased, while low frequency (0.04-0.15 Hz) and the LF/HF ratio while awake decreased, suggesting improved autonomic regulation post-surgery. Change of effect size was larger in patients where both activated contacts were located in the ANT than in those where only one or none of the contacts hit the ANT. CONCLUSIONS: In patients with drug-resistant epilepsy, ANT-DBS might positively influence autonomic regulation, as reflected by increased HRV. SIGNIFICANCE: To gain a more comprehensive outcome estimation after DBS implantation, we suggest including HRV measures with seizure count in the post-surgery follow-up protocol.

Efficacy of Cerebrolysin Treatment as an Add-On Therapy to Mechanical Thrombectomy in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion: Study Protocol for a Prospective, Open Label, Single-Center Study With 12 Months of Follow-Up.

This study is designed to determine the efficacy of Cerebrolysin treatment as an add-on therapy to mechanical thrombectomy (MT) in reducing global disability in subjects with acute ischemic stroke (AIS). We have planned a single center, prospective, open-label, single-arm study with a 12-month follow-up of 50 patients with moderate to severe AIS, with a small established infarct core and with good collateral circulation who achieve significant reperfusion following MT and who receive additional Cerebrolysin within 8 h of stroke onset compared to 50 historical controls treated with MT alone, matched for age, clinical severity, occlusion location, baseline perfusion lesion volume, onset to reperfusion time, and use of iv thrombolytic therapy. The primary outcome measure will be the overall proportion of subjects receiving Cerebrolysin compared to the control group experiencing a favorable functional outcome (by modified Rankin Scale 0-2) at 90 days, following stroke onset. The secondary objectives are to determine the efficacy of Cerebrolysin as compared to the control group in reducing the risk of symptomatic secondary hemorrhagic transformation, improving neurological outcomes (NIHSS 0-2 at day 7, day 30, and 90), reducing mortality rates (over the 90-day and 12 months study period), and improving: activities of daily living (by Barthel Index), health-related quality of life (EQ-5D-5L) assessed at day 30, 90, and at 12 months. The other measures of efficacy in the Cerebrolysin group will include: assessment of final stroke volume and penumbral salvage (measured by CT/CTP at 30 days) and its change compared to baseline volume, changes over time in language function (by the 15-item Boston Naming Test), hemispatial neglect (by line bisection test), global cognitive function (by The Montreal Cognitive Assessment), and depression (by Hamilton Depression Rating Scale) between day 30 and day 90 assessments). The patients will receive 30 ml of Cerebrolysin within 8 h of AIS stroke onset and continue treatment once daily until day 21 (first cycle) and they will receive a second cycle of treatment (30 ml/d for 21 days given in the Outpatient Department or Neurorehabilitation Clinic) from day 69 to 90.

Automated quantification of atrophy and acute ischemic volume for outcome prediction in endovascular thrombectomy.

Background: Short- and long-term outcomes from endovascular thrombectomy (EVT) for large vessel occlusion stroke remain variable. Numerous relevant predictors have been identified, including severity of neurological deficits, age, and imaging features. The latter is typically defined as acute changes (most commonly Alberta Stroke Programme Early CT Score, ASPECTS, at presentation), but there is little information on the impact of imaging assessment of premorbid brain health as a determinant of outcome. Aims: To examine the impact of automated measures of stroke severity and underlying brain frailty on short- and long-term outcomes in acute stroke treated with EVT. Methods: In 215 patients with anterior circulation stroke, who subsequently underwent EVT, automated analysis of presenting non-contrast CT scans was used to determine acute ischemic volume (AIV) and e-ASPECTS as markers of stroke severity, and cerebral atrophy as a marker of brain frailty. Univariate and multivariate logistic regression were used to identify significant predictors of NIHSS improvement, modified Rankin scale (mRS) at 90 and 30 days, mortality at 90 days and symptomatic intracranial hemorrhage (sICH) following successful EVT. Results: For long-term outcome, atrophy and presenting NIHSS were significant predictors of mRS 0-2 and death at 90 days, whereas age did not reach significance in multivariate analysis. Conversely, for short-term NIHSS improvement, AIV and age were significant predictors, unlike presenting NIHSS. The interaction between age and NIHSS was similar to the interaction of AIV and atrophy for mRS 0-2 at 90 days. Conclusion: Combinations of automated software-based imaging analysis and clinical data can be useful for predicting short-term neurological outcome and may improve long-term prognostication in EVT. These results provide a basis for future development of predictive tools built into decision-aiding software in stroke.

Teleradiology-based stroke network in Western and Southern Transdanubia in Hungary / Stroke-ellátást támogató teleradiológiai hálózat a Nyugat- és Dél-Dunántúlon.

Összefoglaló. Bevezetés: A stroke kezelésének lehetoségei az utóbbi években jelentosen megváltoztak: a thrombolysis után bevezetésre került a mechanikus thrombectomia, és a terápiás idoablak is jelentosen kitágult az utóbbi évek nagy multicentrikus tanulmányai alapján. Ezek a lehetoségek új igényeket fogalmaztak meg a képalkotó diagnosztikával szemben: az ischaemia okozta morfológiai elváltozások mellett az artériás és a kollaterális rendszer állapotát, valamint bizonyos esetekben az agy szöveti perfúzióját is szükséges meghatározni. Ezeket a komplex kiértékelési feladatokat ma már mesterségesintelligencia-algoritmusok támogathatják, melyek a kiértékelést pár perc alatt elvégezve segítenek a terápiás döntés kialakításában. Célkituzés: A Dél- és a Nyugat-dunántúli régióban hat intézmény részvételével egy dedikált stroke teleradiológiai hálózat kialakítása. Módszer: A stroke-CT-kiértékelo szoftver és a képkommunikáció integrációja, a vizsgálati protokollok technikai paramétereinek egységesítése, a kiértékelési eredmények teleradiológiai megjelenítése valósult meg a hálózat kialakítása során. Eredmények: A hálózat egységesítette nemcsak a stroke-CT-protokollok beállításait, de beutalási és értékelési szempontjait is. A stroke-CT-kiértékelések és a mechanikus thrombectomiák száma is emelkedett az elmúlt egy évben. Következtetés: A dedikált teleradiológiai stroke-hálózat segítségével optimalizálni kívánjuk a régió stroke-ellátását: egyrészt lehetoleg ne maradjanak ellátatlanul a thrombectomiából valószínuleg profitáló betegek, másrészt ne terheljük az ellátórendszert olyan esetekkel, melyekrol a teljes dokumentáció ismeretében derül ki, hogy nem javasolt a beavatkozás. Orv Hetil. 2021; 162(17): 668-675. INTRODUCTION: The possibilities of cerebral stroke management have changed substantially during the last few years. Following a few multicentric studies, mechanical thrombectomy became an established method besides thrombolysis. In addition, the therapeutic window for both methods is much wider now than before. These changes described above demanded more information of CT morphological changes due to ischemia, but the condition and functionality of the arterial and collateral system, and occasionally tissue perfusion performance should also be characterized. Recently, evaluation of different computer tomographic (CT) measurements can be done using artificial intelligence based methods, which perform data analysis in a few minutes. OBJECTIVE: To establish a dedicated stroke teleradiology network with artificial intelligence based image analysis in Western and Southern Transdanubia in Hungary that involves six partner institutes. METHOD: Integration of automated image analysis with teleradiology software was established, and the technical parameters of examination protocols were unified. Results of stroke CT image analysis became accessible through the teleradiology network. RESULTS: The daily use of integrated central image analysis and image communication had a positive impact on referrals and therapeutic evaluation of stroke cases. The number of image processing and mechanical thrombectomy increased during the last year. CONCLUSION: With the help of the dedicated teleradiology stroke network, we want to optimize the stroke care in the region: on the one hand, patients who are likely to benefit from thrombectomy should not be left unattended, on the other, the health care system should not be burdened with cases, when intervention is not recommended having the complete clinical data accessed. Orv Hetil. 2021; 162(17): 668-675.

Epstein-Barr virus encephalitis mimicking clinical and electroencephalographic characteristics of herpes simplex encephalitis.

A rare case of EBV encephalitis initially diagnosed as Herpes simplex infection is presented to highlight the importance of EBV specific intrathecal ELISA and liquor PCR based differential diagnosis when Herpes simplex encephalitis specific clinical symptoms, neuroimaging signs and electroencephalographic features are present. The case report also suggests that acyclovir treatment might be beneficial for the long term outcome in adult EBV encephalitis patients.

Bidirectional modulation of primary visual cortex excitability: a combined tDCS and rTMS study.

PURPOSE: In the motor cortex (M1), transcranial direct current stimulation (tDCS) can effectively prime excitability changes that are evoked by a subsequent train of repetitive transcranial magnetic stimulation (rTMS). The authors examined whether tDCS can also prime the cortical response to rTMS in the human visual cortex. METHODS: In nine healthy subjects, the authors applied tDCS (10 minutes; +/-1 mA) to the occipital cortex. After tDCS, they applied a 20-second train of 5 Hz rTMS at 90% of phosphene threshold (PT) intensity. A similar rTMS protocol had previously demonstrated a strong priming effect of tDCS on rTMS-induced excitability changes in M1. PTs were determined with single-pulse TMS before and immediately after tDCS and twice after rTMS. RESULTS: Anodal tDCS led to a transient decrease in PT, and subsequent 5 Hz rTMS induced an earlier return of the PT back to baseline. Cathodal tDCS produced a short-lasting increase in PT, but 5 Hz rTMS did not influence the tDCS-induced increase in PT. In a control experiment on four subjects, a 20-second train of occipital 5 Hz rTMS left the PT unchanged, whereas a 60-second train produced a similar decrease in PT as anodal tDCS alone. CONCLUSIONS: Compared with previous work on the M1, tDCS and rTMS of the visual cortex only produce short-lasting changes in cortical excitability. Moreover, the priming effects of tDCS on subsequent rTMS conditioning are relatively modest. These discrepancies point to substantial differences in the modifiability of human motor and visual cortex.

Prevention of electrical stimulation-induced increase of c-fos immunoreaction in the caudal trigeminal nucleus by kynurenine combined with probenecid.

The systemic administration of nitroglycerine, regarded as a migraine model, was previously observed to result in an increased number of c-fos immunoreactive secondary sensory neurons in the caudal trigeminal nucleus, which forward nociceptive impulses to the thalamus. The present investigation tested the hypothesis of whether kynurenine in combination with systemically administered probenecid protects second-order trigeminal neurons against stimulation arriving via central processes of trigeminal ganglion cells. Electrical stimulation of the trigeminal ganglion, one of the experimental migraine models, is known to induce an increase in the number of c-fos immunoreactive second-order nerve cells projecting to the thalamus. Since the synapses between first- and second-order trigeminal neurons are presumed to be mediated by excitatory amino acids, postsynaptic NMDA receptors should be inhibited by kynurenic acid, an endogenous NMDA receptor antagonist. Kynurenic acid, however, does not cross the blood-brain barrier, and its use as a neuroprotective agent is therefore not feasible. In contrast, kynurenine, from which kynurenic acid is formed on the action of kynurenine aminotransferase, passes the blood-brain barrier without difficulty. After the i.p. injection of kynurenine combined with probenecid it was found that the stimulation-induced increase in the c-fos immunoreactivity of the secondary sensory neurons does not occur.

Task-related modulation in the monkey inferotemporal cortex.

The latencies of the neuronal responses from the inferotemporal cortical cells were analyzed in animals performing a visual fixation task and a recognition task with the same stimulus set. A consistent reduction in response latencies of about 10 ms was observed in favor of the recognition task. It was found that behavioral relevance reduces the latency in the inferotemporal cortex and it was concluded that behavioral significance accelerates information processing. This effect has not been described previously.

Task-related temporal and topographical changes of cortical activity during ultra-rapid visual categorization.

The aim of our study was to provide electrophysiological evidence about the modulation of the categorization process by task requirements in the human brain. Event-related potentials (ERP) were recorded during three different categorization tasks using matched stimulus sets. In all cases, the subjects were required to differentiate between "animal" and "non-animal" stimuli. In the first task (two-choice task), they were asked to press corresponding buttons to each stimulus types. The second task was a go/no-go paradigm, only animal stimuli required motor response. The third task was a counting task; participants had to count the animal stimuli without any motor response. The reaction times in the go/no-go paradigm were significantly shorter. ERP differences between animal and non-animal pictures in the go/no-go task also appeared earlier and were localized at more posterior scalp positions compared to the two-choice task. Comparing animal responses in the two-choice task and in the go/no-go paradigm, we found a significant difference in the 130- to 170-ms time window over the fronto-central, centro-parietal regions. Similar differences were found between the responses to animal pictures in the two-choice task and in the counting paradigm. We used brain electric source analysis (BESA) algorithm on difference waves to localize the best fitting dipoles and determine the localization of brain areas contributing to scalp potential differences. The results show that different task requirements evoke different activity in the medial part of the temporal pole. The data we provided here draw attention to the careful handling of results obtained from categorization experiments, because different task requirements can affect the early categorization process itself.

Effect of 6-hydroxydopamine treatment on kynurenine aminotransferase-I (KAT-I) immunoreactivity of neurons and glial cells in the rat substantia nigra.

Parkinson's disease (PD), a progressive neurodegenerative disorder, is characterized by a preferential loss of dopaminergic neurons in the substantia nigra pars compacta (SNPC). Neurons in the SNPC are known to express tyrosine hydroxylase (TH); therefore, in a commonly used PD model, 6-hydroxydopamine (6-OHDA), a selective catecholamine neurotoxin, induces neuronal death in SNPC. We have shown with immunohistochemical techniques that kynurenine aminotransferase-I (KAT-I), the enzyme taking part in the formation of kynurenic acid (KYNA)--the only known endogenous selective NMDA receptor antagonist and a potent neuroprotective agent--is also expressed in the rat SNPC. We found that KAT-I and TH co-exist in the very same neurons of SNPC and that 6-OHDA injected into the lateral ventricle produced loss of the majority of nigral neurons. Densitometric analysis proved that, in consequence of 6-OHDA treatment, not only TH but also KAT-I immunoreactivity diminished considerably in the remaining SNPC neurons. Astrocytes in the substantia nigra were found to express KAT-I under normal conditions; the amount of this enzyme increased after administration of 6-OHDA, whereas microglial cells became KAT-I immunoreactive only after 6-OHDA treatment. Since intrinsic KYNA in SNPC neurons is perceptibly insufficient to protect them from the deleterious effect of 6-OHDA, it is hypothesized that biochemical approaches which increase KYNA content of the central nervous system might prevent the deleterious effect of 6-OHDA and, supposedly, also the neuronal degradation characterizing PD.

Effect of electrical stimulation of the reticular nucleus of the rat thalamus upon c-fos immunoreactivity in the retrosplenial cortex.

Electrical stimulation of the reticular nucleus of the rat thalamus results in activation of c-fos immunoreactivity in nerve cells of the ipsilateral retrosplenial cortex. The c-fos immunoreactive neurons are mainly concentrated in lamina IV of the retrosplenial cortex. Conversely, electrical stimulation of the retrosplenial cortex induced c-fos immunoreactivity in the ipsilateral reticular nucleus of the thalamus. The results of the electrical stimulation suggest a direct synaptic connection between the cerebral cortex and the ipsilateral reticular thalamic nucleus. Simultaneous immunohistochemical staining proves that the majority of nerve cells and dendro-dendritic terminals in the reticular thalamic nucleus contain parvalbumine and, at the same time, also GABA. The role of GABA-ergic parvalbumine immunoreactive terminals in the reticular thalamic nucleus seems to be related to integration and processing of impulses and attentional gating, distinguishing between noxious and innocuous inputs.

GABAergic parvalbumin-immunoreactive large calyciform presynaptic complexes in the reticular nucleus of the rat thalamus.

In the reticular thalamic nucleus of the rat, nearly all neurons are parvalbumin-immunoreactive. We found that in addition, though superficially similar to large parvalbumin-immunoreactive neurons, also numerous peculiar parvalbumin-immunoreactive complexes are present in the reticular thalamic nucleus which are not identical with parvalbumin-immunoreactive perikarya, as shown by nuclear variation curves. Light and electron microscopic immunocytochemical studies revealed that these parvalbumin-immunoreactive complexes are brought about by parvalbumin-immunoreactive calyciform terminals which establish synapses with large, parvalbumin-immunonegative dendritic profiles. Transection of thalamo-reticular connections did not cause any alteration of calyciform terminals in the reticular thalamic nucleus. Nuclear counterstaining revealed that parvalbumin-immunoreactive calyciform terminals originated from local parvalbumin-immunoreactive interneuronal perikarya, which, depending of the length of the "neck" protruding from the perikaryon, establish somato-dendritic, axo-dendritic or dendro-dendritic synapses. Light and electron microscopic immunocytochemical investigations prove that the parvalbumin-immunoreactive calyciform complexes contain also GABA, that are likely to be inhibitory. In accordance with literature data, our results suggest that parvalbumin-immunoreactive GABAergic calyciform terminals in the reticular thalamic nucleus may be instrumental in intrinsic cell-to-cell communications and, as such, may be involved in synchronisation of thalamo-cortical oscillations, in the production of sleep spindles and in attentional processes.

Achromatic shape processing in the inferotemporal cortex of the macaque.

The responses of single neurones in the inferior temporal cortex of awake macaque monkeys to chromatic and achromatic stimuli were investigated, with the aim of determining whether colour-independent processing occurs in this last unimodal area of the ventral visual pathway. There were no differences in the firing rate of the responses (responsiveness) or the selectivity of the inferior temporal neurons towards greyscale and coloured images. The latency of the responses was the same in the two conditions. These results stress the importance of the inferior temporal cortex in colour-independent object recognition.

Direct current stimulation over MT+/V5 modulates motion aftereffect in humans.

While there is strong evidence for the central role of the human MT+/V5 in motion processing, its involvement in motion adaptation is still the subject of debate. We used transcranial direct current stimulation (tDCS) to test whether MT+/V5 is part of the neural network involved in the long-term adaptation-induced motion after-effect in humans. It was found that both cathodal and anodal stimulation over MT+/V5 resulted in a significant reduction of the perceived motion after-effect duration, but had no effect on performance in a luminance-change-detection task used to determine attentional load during adaptation. Our control experiment excluded the possibility that the observed MT+/V5 stimulation effects were due to a diffused modulation of the early cortical areas, i.e. by the stimulation applied over MT+/V5. These results provide evidence that external modulation of neural excitability in human MT+/V5 affects the strength of perceived motion after-effect and support the involvement of MT+/V5 in motion adaptation processes.

Distributed population coding of multisensory spatial information in the associative cortex.

This study describes a possible mechanism of coding of multisensory information in the anterior ectosylvian visual area of the feline cortex. Extracellular microelectrode recordings on 168 cells were carried out in the anterior ectosylvian sulcal region of halothane-anaesthetized, immobilized, artificially ventilated cats. Ninety-five neurons were found to respond to visual stimuli, 96 responded to auditory stimuli and 45 were bimodal, reacting to both visual and auditory modalities. A large proportion of the neurons exhibited significantly different responses to stimuli appearing in different regions of their huge receptive field. These neurons have the ability to provide information via their discharge rate on the site of the stimulus within their receptive field. This suggests that they may serve as panoramic localizers. The ability of the bimodal neurons to localize bimodal stimulus sources is better than any of the unimodal localizing functions. Further, the sites of maximal responsivity of the visual, auditory and bimodal neurons are distributed over the whole extent of the large receptive fields. Thus, a large population of such panoramic visual, auditory and multisensory neurons could accurately code the locations of the sensory stimuli. Our findings support the notion that there is a distributed population code of multisensory information in the feline associative cortex.

Kynurenine aminotransferase in the supratentorial dura mater of the rat: effect of stimulation of the trigeminal ganglion.

Electrical stimulation of the trigeminal ganglion has been widely used as a model of nociception, characterizing migraine. This treatment is known to evoke release of neuropeptides and neurotransmitters from nerve fibers of the dura mater. On the basis of immunocytochemical investigations, we found that under normal conditions, surface membranes of Schwann cells surrounding nerve fibers in the supratentorial dura mater display kynurenine aminotransferase-immunoreaction (KAT-IR); also KAT-IR are the granules of mast cells and the cytoplasms of macrophages (histiocytes). In consequence of stimulation of the trigeminal ganglion, Schwann cells in the dura mater became conspicuously swollen while their KAT-IR decreased considerably; also KAT-IR of mast cells and macrophages decreased significantly. At the same time, nitric oxide synthase (NOS)-IR of nerve fibers in the dura mater increased, suggesting release of nitric oxide (NO), this is known to be involved in NMDA receptor activation leading to vasodilation followed by neurogenic inflammation. Because kynurenic acid (KYNA) is an antagonist of NMDA receptors, we hypothesize that KYNA and its synthesizing enzyme, KAT, may play a role in the prevention of migraine attacks.