Ataxia and tremor due to lesions involving cerebellar projection pathways: a DTI tractographic study in six patients.

Focal lesions of brainstem, thalamus, and subcortical white matter may cause movement disorders that are clinically indistinguishable from cerebellar symptoms. It is suspected that ataxia in these cases is due to damage of efferent or afferent pathways of the cerebellum. However, the precise anatomical correlate often remains undefined. We used deterministic diffusion tensor magnetic resonance imaging (DTI) tractography to study the anatomical relationship between lesions causing ataxia and efferent cerebellar pathways. Study subjects were six male patients with focal lesions of different etiology (demyelination, hemorrhage, ischemia, neoplasm) outside the cerebellum. Five patients had cerebellar-like ataxia with prominent contralateral upper limb involvement. One patient with an almost midline mesencephalic lesion had a symmetrical ataxic syndrome. We used 3T MRI (Intera, Philips Medical Systems, Best, Netherlands) and DTI tractography (32 directions, StealthViz DTI, Medtronic Navigation, Louisville, USA) to delineate the dentato-rubro-thalamo-cortical tract (DRT). In all patients, tractography demonstrated focal lesions affecting the DRT in different locations. We conclude that in vivo mapping of cerebral pathways using DTI tractography in patients with focal extracerebellar brain lesions may provide direct evidence of circumscribed damage to the DRT, causing unilateral cerebellar-like ataxia. Also, a unilateral mesencephalic lesion at the level of the crossing of the DRT may cause bilateral ataxia.

[Long-term care of Parkinson patients with deep brain stimulation]. / Langzeitbehandlung von Parkinsonpatienten mit Tiefer Hirnstimulation.

For more than 15 years deep brain stimulation of the subthalamic nucleus and globus pallidus internus have become therapeutic options in advanced Parkinson's disease. The number of patients with long-term treatment is increasing steadily. This review focuses on issues of the long-term care of these Parkinson's patients, including differences of the available deep brain stimulation systems, recommendations for follow-up examinations, implications for medical diagnostics and therapies and an algorithm for symptom deterioration. Today, there is no profound evidence that deep brain stimulation prevents disease progression. However, symptomatic relief from motor symptoms is maintained during long-term follow-up and interruption of the therapy remains an exception.

[Deep brain stimulation for Parkinson's disease and camptocormia? A case report]. / Tiefe Hirnstimulation bei Morbus Parkinson mit Kamptokormie? Ein Fallbericht.

Camptocormia is recognised as a severe postural movement disorder complicating neurodegenerative diseases like Parkinson's disease (PD) and multisystem atrophy. Pathophysiologically two main hypotheses are discussed: (i) a disorder of the basal ganglia resulting in axial dystonia and rigidity on the one hand and (ii) an extensor truncal myopathy on the other hand. Therapeutic efforts often result in limited success. Therefore, reports on improvements by deep brain stimulation (DBS) are of great interest. However, the role of DBS in the treatment of camptocormia remains unclear. Here, we report a female PD patient who responded well to DBS of the subthalamic nucleus for severe dyskinesias and fluctuations. However, after 6 months she started to develop a rapidly progressing camptocormia which did not respond to DBS. The clinical and electrophysiological examination suggested a truncal erector myopathy. The inconsistent reports on the effects of DBS on camptocormia in PD patients suggest heterogeneous pathogenetic pathways. A pathophysiological subtype with predominant basal ganglia dysfunction and responsivity to DBS, however, seems to be rather rare. A myopathy, in contrast, seems to be more frequent and DBS is not effective in this condition. Therefore, camptocormia in PD patients is not an established indication for DBS.

[Rehabilitation of Parkinson's patients with deep brain stimulation. Experiences of the Neurological Rehabilitation Center Godeshöhe]. / Rehabilitation von Parkinson-Patienten mit Tiefenhirnstimulation. Erfahrungen des Neurologischen Rehabilitationszentrums Godeshöhe.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has become an important therapeutic option in patients with advanced Parkinson's disease (PD). An increasing number of patients are referred for hospital rehabilitation after initial programming. The role of further DBS and medication adjustments for this rehabilitation therapy is uncertain. METHODS: This study was a retrospective analysis of a hospital rehabilitation program with a systematic algorithm to improve DBS efficacy in PD patients referred within 3 months after electrode implantation. This study analyzed (1) changes of stimulation parameters and medication and (2) changes in the performance of activities of daily living as measured by the Barthel index. RESULTS: After an average of 20.4±10.7 days following surgery 95 PD patients were hospitalized for an average rehabilitation period of 29.0±11.2 days. Technical dysfunctions were found in 3 (3.1%) patients and a bilateral electrode dislocation in 1 (1.1%) patient. Stimulation parameters were adjusted on 7.3±4.0 days, sometimes with several adjustments on the same day. Until discharge the stimulation amplitude was significantly increased from 2.1±0.8 V to 3.0±0.8 V. Moreover, in 70 (73.7%) patients active stimulation contacts were changed. The mean levodopa equivalent dosage decreased from 529±290 mg/die to 300±277 mg/die. The Barthel index increased significantly by 10.3±12.4 points. CONCLUSION: Further DBS and medication adjustments play an important role for hospital rehabilitation of PD patients after initial DBS programming in DBS centers.

Myoclonus-dystonia: significance of large SGCE deletions.

Myoclonus-dystonia (M-D) is an autosomal-dominant movement disorder caused by mutations in SGCE. We investigated the frequency and type of SGCE mutations with emphasis on gene dosage alterations and explored the associated phenotypes. We tested 35 M-D index patients by multiplex ligation-dependent probe amplification (MLPA) and genomic sequencing. Mutations were found in 26% (9/35) of the cases, all but three with definite M-D. Two heterozygous deletions of the entire SGCE gene and flanking DNA and a heterozygous deletion of exon 2 only were detected, accounting for 33% (3/9) of the mutations found. Both large deletions contained COL1A2 and were additionally associated with joint problems. Further, we discovered one novel small deletion (c.771_772delAT, p.C258X) and four recurrent point mutations (c.289C>T, p.R97X; c.304C>T, p.R102X; c.709C>T, p.R237X; c.1114C>T, p.R372X). A Medline search identified 22 articles on SGCE mutational screening. Sixty-four unrelated M-D patients were described with 41 different mutations. No genotype-phenotype association was found, except in patients with deletions encompassing additional genes. In conclusion, a rigorous clinical preselection of patients and careful accounting for non-motor signs should precede mutational tests. Gene dosage studies should be included in routine SGCE genetic testing.

Effects of bilateral pallidal or subthalamic stimulation on gait in advanced Parkinson's disease.

Bilateral high-frequency stimulation of the internal globus pallidus (GPi) and the subthalamic nucleus (STN) both alleviate akinesia, rigidity, and tremor in idiopathic Parkinson's disease. To test the specific effect of these procedures on gait, we used quantitative gait analysis in addition to relevant subscores of the Unified Parkinson's Disease Rating Scale in a group of 10 patients with advanced Parkinson's disease treated by GPi stimulation and eight patients treated by STN stimulation. Patients were assessed before and 3 months after surgery. Thirty age-matched healthy subjects served as controls. The non-random selection allowed a descriptive but no direct statistical comparison of the respective procedure. Gait analysis showed significant stimulation-induced improvements of spatiotemporal gait and step parameters in both patient groups. Moreover, the effects on step length and cadence suggested a differential effect of both basal ganglia targets. Hence, the increase in gait velocity in the STN group was almost exclusively due to a significant increase in step length, while in the GPi group statistically non-significant increases in both step length and cadence contributed.

Deep brain stimulation of the internal pallidum did not improve chorea in a patient with neuro-acanthocytosis.

We report the failure of bilateral globus pallidus internus deep brain stimulation to improve chorea in a patient with chorea-acanthocytosis. Prior to this surgery the patient had experienced a striking but short lived amelioration of symptoms with clozapine therapy.

Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD.

The authors retrospectively compared 1-year results of bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN; n = 16) and internal pallidum (GPi) (n = 11) in advanced PD and found about equal improvements in "off" period motor symptoms, dyskinesias, and fluctuations. STN stimulation reduced medication requirements by 65% and required significantly less electrical power. These advantages contrasted with a need for more intensive postoperative monitoring and a higher incidence of adverse events related to levodopa withdrawal.

TNF alpha induces a protein kinase C-dependent reduction in astroglial K+ conductance.

Incubation of cultured cortical astrocytes with tumor necrosis factor alpha (TNF alpha) led to a marked reduction of membrane potential. Here we report that this depolarization depends on activation of protein kinase C (PKC), since it could be blocked by the PKC antagonists staurosporine and H7 and it could be mimicked by direct activation of PKC using the phorbol ester phorbol 12-myristate 13 acetate (PMA). Analyses of whole cell currents revealed a reduction of inwardly rectifying K+ currents whereas K+ outward currents were not affected. We conclude that TNF alpha induces changes of basic electrophysiological properties of astrocytes which are similar to those induced by proliferation or an in vitro model of traumatic injury.

Ammonia-induced depolarization of cultured rat cortical astrocytes.

Exposure of cultured rat cortical astrocytes to increased concentrations of ammonia has been shown to induce morphological and biochemical changes similar to those found in hyperammonemic (e.g., hepatic) encephalopathy in vivo. Alterations of electrophysiological properties are not well investigated. In this study, we examined the effect of ammonia on the astrocyte membrane potential by means of perforated patch recordings. Exposure to millimolar concentrations of NH4Cl induced a slow dose-dependent and reversible depolarization. At steady state, i.e., after several tens of minutes, the cells were significantly depolarized from a resting membrane potential of -96.2 +/- 0.6 mV (n = 83, S.E.M.) to -89.1 +/- 1.6 mV (n = 7, S.E.M.) at 5 mM NH4Cl, -66.3 +/- 3.6 mV (n = 9, S.E.M.) at 10 mM NH4Cl and -50.4 +/- 2.5 mV (n = 12, S.E.M.) at 20 mM NH4Cl, respectively. In order to examine the underlying depolarizing mechanisms we determined changes in the fractional ion conductances for potassium, chloride and sodium induced by 20 mM NH4Cl. No significant changes were found in the fractional sodium or chloride conductances, but the dominating fractional potassium conductance decreased slightly from a calculated 0.86 +/- 0.04 to 0.77 +/- 0.04 (n = 9, S.E.M.). Correspondingly, we found a significant fractional ammonium ion (NH4+) conductance of 0.23 +/- 0.02 (n = 10, S.E.M.) which was blocked by the potassium channel blocker barium and, hence, most likely mediated by barium-sensitive potassium channels. Our data suggest that the sustained depolarization induced by NH4Cl depended on changes in intracellular ion concentrations rather than changes in ion conductances. Driven by the high membrane potential NH4+ accumulated intracellularly via a barium-sensitive potassium conductance. The concomitant decrease in the intracellular potassium concentration was primarily responsible for the observed slow depolarization.

Forskolin and PMA pretreatment of HT29 cells alters their chloride conductance induced by cAMP, Ca2+ and hypotonic cell swelling.

HT29 cells were preincubated with forskolin (10(-5) mol/l, FORHT) or phorbol 12-myristate 13-acetate (PMA) (10(-7) mol/l, PMAHT) for 20 h, which has been shown previously and is also shown here, to upregulate and downregulate, respectively, the expression of the cystic fibrosis transmembrane conductance regulator (CFTR). CFPAC-1 cells underwent the same protocols. HT29 cells were examined by slow (SWC) and fast (FWC) whole-cell patch-clamp techniques. The results of SWC and FWC were indistinguishable and were pooled. CFPAC-1 cells were examined with FWC. The membrane voltage (V) of FORHT was -41.8 +/- 1.4 mV (n = 77) and that of PMAHT was -43.6 +/- 2.4 mV (n = 76). The conductance (G) of FORHT (9.4 +/- 0.9 nS, n = 77) was significantly larger than that of PMAHT (3.7 +/- 0.4 nS, n = 76). Acute application of forskolin (10(-5) mol/l, FOR) plus 0.5 mmol/l 8-(4-chlorophenylthio)-cAMP (cAMP) depolarized V by 12 (FORHT) and 8 (PMAHT) mV, respectively. The acute increase of G by FOR plus cAMP was by 7.6 +/- 1.9 nS for FORHT (n = 22) and only 2.2 +/- 1 nS for PMAHT (n = 13). ATP (10(-4) mol/l) depolarized V in both types of cells. It enhanced G by 16.7 +/- 4.1 nS in FORHT (n = 14) and significantly less (by 5.5 +/- 1.2 nS, n = 14) in PMAHT. Also the G increase lasted longer in FORHT. Neurotensin (NT, 10(-8) mol/l) also had a stronger and longer lasting effect in FORHT.(ABSTRACT TRUNCATED AT 250 WORDS)

Increase in cytosolic Ca2+ regulates exocytosis and Cl- conductance in HT29 cells.

Increases of cytosolic Ca2+, as occur with agonists such as ATP, neurotensin (NT), hypotonic cell swelling and ionomycin, enhance the membrane conductance (GM) and hence the input conductance (GI) of HT29 cells. In the present study we have examined whether these increases in GM are paralleled by exocytosis. To this end the membrane capacitance (CM) of HT29 cells was measured by patch clamp techniques. Two methods to monitor CM were used: a direct method (DM) and a phase tracking method (PTM). With the DM the following results were obtained. NT (10(-8) mol/l, n = 9) increased GM and CM significantly from 2.4 +/- 0.3 nS and 23.5 +/- 3 pF to 32 +/- 8 nS and 27.3 +/- 3.1 pF respectively. ATP (10(-4) mol/l, n = 29) had a very similar effect. GM and CM were increased from 5.7 +/- 1 nS and 36 +/- 4.4 pF to 111 +/- 21 nS and 44 +/- 5.4 pF respectively. Hypotonic cell swelling (160 mosmol/l, n = 18) had a comparable effect: GM and CM were increased from 4.9 +/- 1 nS and 30 +/- 4.1 pF to 46 +/- 10 nS and 37 +/- 4.9 pF respectively. Ionomycin (10(-7) mol/l, n = 4) gave similar results. With the PTM it was possible to monitor the rapid changes in GM and CM, as they were induced by ATP (n = 42) and NT (n = 29), with high time resolution.(ABSTRACT TRUNCATED AT 250 WORDS)

Small-conductance chloride channels induced by cAMP, Ca2+, and hypotonicity in HT29 cells: ion selectivity, additivity and stilbene sensitivity.

Previous studies in HT29 cells utilizing the cell-attached nystatin (CAN) method [Greger R, Kunzelmann K (1991) Pflügers Arch 419:209-211] have revealed that the Cl- channels induced by cAMP or by increasing cytosolic Ca2+, e.g. by addition of ATP, and by hypotonic cell swelling share in common their conductance, which was so small in our studies [Kunzelmann et al. (1992) Pflügers Arch (in press)] that we could not resolve it at the single-channel level. This prompted the question whether these Cl- conductances can be distinguished in terms of their ion selectivity and sensitivity towards inhibitors. Whether these pathways are additive or not was also examined. The present study utilized the whole-cell patch-clamp and the CAN methods. A total of 160 patches were studied. In whole-cell patches 8-(4-chlorophenylthio)-cAMP (cAMP, 0.1 +/- 1 mmol/l) induced a significant depolarization by 5 mV and a twofold increase in conductance (G) from 6.2 +/- 1.5 nS to 11.7 +/- 3.2 nS (n = 15). Total replacement of Cl- by Br- and I- in cAMP-treated cells hyperpolarized the membrane voltage (V) significantly from -35 +/- 2.8 to -39 +/- 3.4 and -45 +/- 3.3 mV respectively, but had no detectable effect on G, which was 11.9 +/- 3.3 nS in the case of Br- and 11.8 +/- 3.3 nS in the case of I-. Hence, the permselectivity of the cAMP pathway was I- > Br- > Cl-, but the conductances for these anions were all indistinguishable.(ABSTRACT TRUNCATED AT 250 WORDS)

cAMP and Ca2+ act co-operatively on the Cl- conductance of HT29 cells.

Previous studies in HT29 cells have revealed that the Cl- channels induced by cAMP or by increasing cytosolic Ca2+, e.g. by addition of ATP, and by hypotonic cell swelling share in common all examined properties, such as ion selectivity and blocker sensitivity. In addition, it was shown that conductances induced by either pathway were not additive. Therefore all three pathways apparently act on the same type of small conductance Cl- channel. In CFPAC-1 cells the general properties of the Cl- conductance were identical. However, the cAMP response was absent. In both cell types the Ca(2+)-mediated conductance response was transient. Here we examine the kinetics of the conductance increases induced by neurotensin (NT, 10(-8) mol/l) or ATP (10(-5) mol/l) in HT29 and CFPAC-1 cells using the slow (nystatin) or fast whole cell patch clamp technique, and we ask whether cAMP influences these kinetics. In the continuous presence of NT the conductance response in both cell types was very transient. It collapsed with a time constant (tau) of 39 (30-56 s) in HT29 and of 33 (27-41 s) in CFPAC-1 cells. The ATP response was also transient with a tau of 49 (42-57 s) in HT29 cells and 102 (77-152 s) in CFPAC-1 cells. Pre-treatment by membrane permeable cAMP (10(-3) mol/l) enhanced the baseline conductance in HT29 but not in CFPAC-1 cells. Furthermore, the ATP- and NT-induced conductance increases became significantly less transient in HT29 but not in CFPAC-1 cells.(ABSTRACT TRUNCATED AT 250 WORDS)