T3-T4 Disc Herniations: Clinical Presentation, Imaging, and Transaxillary Approach.

OBJECTIVE: To describe a cohort of T3-T4 thoracic disc herniations (TDHs), their clinical and radiologic characteristics, and unique thoracoscopic transaxillary approach (TAA). METHODS: All patients operated on for a T3-T4 TDH with minimal follow-up of 1 year were selected. RESULTS: Eight TAA procedures (6 males and 2 females) were included (1.4%). Six patients reported axial pain, irradiating in 2, 4 sensory changes, 1 objective and 1 merely subjective motor weakness. Only 1 TDH was calcified, none was giant, 2 were accompanied by myelomalacia, and 2 by a small segmental syrinx. A cardiothoracic surgeon helped with exposure through a curved axillary incision using anterior cervical and more recently double-ring wound retractors. All patients were operated on using a 10-mm 30° rigid (three-dimensional) high-definition scope. There were no major complications and a good outcome with symptomatic relief in 7 of 8 patients. CONCLUSIONS: T3-T4 TDHs are infrequent but may be underdiagnosed because they tend to be small and their signs and symptoms may mimic a cervical problem involving the shoulders and even the arms. There may be a male predominance. The TAA is straightforward, safe, efficacious, and well tolerated despite the supposed vulnerability of the upper thoracic spinal cord. Dissection between large crowded subpleural veins characteristic for the upper thoracic spine and ensuring adequate dura decompression when the steep angle may partially obscure the tip of the instruments does require some extra time. Thorough knowledge of the unique anatomy of the upper thorax is mandatory and the assistance of a cardiothoracic surgeon is highly recommended.

The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse.

In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.

History of an abusive head trauma including a lucid interval and a retinal hemorrhage is most likely false.

A lucid interval (LI) is the period of time between regaining consciousness after a short period of unconsciousness, resulting from a head injury and deteriorating after the onset of neurologic signs and symptoms caused by that injury. The incentive for this study was the case of a father who left his 14-week-old infant with the nanny in whose custody the infant had collapsed. The nanny denied involvement in the injury, and the father became a suspect. Of 47 abusive head trauma (AHT) cases, 8 were found to have an LI in the past. The history of the cases were thoroughly analyzed and compared with evidence in the literature. An LI is not compatible with an inertial brain injury. Shaking has either an immediate effect or no effect, which means that an LI occurs only in pure impact or blunt injuries. When "shaking lesions" are found including a retinal hemorrhage while the history mentions an LI, the story most likely is false, regardless of whether the perpetrator confesses. The finding of an LI may change the assessment of an AHT case. Lucid interval is a valuable variable in the diagnostic accuracy of an AHT.

Delta-storage pool disease as a mimic of abusive head trauma in a 7-month-old baby: a case report.

A seven-month-old baby was admitted to a hospital emergency department after collapsing suddenly while staying with his nanny. The baby displayed classic symptoms of shaken baby syndrome, including subdural haemorrhage, cytotoxic cerebral oedema, and bilateral retinal hemorrhages. Child protection services were informed, but both the parents and the nanny denied any involvement. In the subsequent weeks, the baby developed three other episodes of new subdural bleeding and a medico-legal investigation was started into the origin of the repeated subdural bleeding. Eventually, platelet aggregation tests and electron microscopy diagnosed a delta-storage pool disease; that is, a haemostatic disorder involving dense granules of the platelets. Initial minor blunt trauma may have resulted in subdural bleeding, while subsequent retinal haemorrhage could have been facilitated by the underlying haemostatic disorder. Delta-storage pool disease should be considered as a possible mimic of abusive head trauma similar to other rare conditions such as Menkes disease and type 1 glutaric aciduria.

Confessed abusive blunt head trauma.

It is generally accepted that terms referring to specific craniocerebral injury mechanisms must be replaced by the more general term abusive head trauma (AHT). Although blunt impact trauma remains an essential part of AHT, it has received far less attention in the literature than shaken-impact injuries. The current article presents 19 confessed cases of a series of 47 highly suspected AHT cases. Of these, 13 were confessed shaken-impact cases, and the other 6 confessed blunt trauma cases. There were no significant differences in the appearance of subdural hematoma, which was present in each case. Retinal hemorrhage, which was present in 10 of the 13 shaken-impact cases in which an ophthalmologic examination was conducted, occurred in 2 of the 6 blunt trauma cases. In 1 case, retinal hemorrhage probably had of metabolic origin. Skull fractures with an overlying subgaleal hematoma and a subdural hematoma below the fracture side were found in 5 of the blunt trauma cases but was also seen in the 2 shaken-impact cases with a skull fracture. The most important finding was a lucid interval (LI) in 3 blunt AHT cases. An LI does not seem to occur in shaking injuries because of the immediate and persistent effect of brain damage that such injuries involve. Therefore, LI makes it important to conduct a detailed investigation of the clinical course in time in suspected AHT cases.

Clinical characteristics and surgical outcome in 25 cases of childhood tight filum syndrome.

OBJECTIVE: Tight filum syndrome (TFS) is caused by a thick (abnormal T1 MRI), shortened (low-lying conus), or non-elastic filum (strictly normal MRI). We carefully analyzed children treated for suspect TFS with or without radiological abnormalities. METHODS: Twenty-five children, operated between 2002 and 2009, were retrospectively identified. All children had been evaluated by a multidisciplinary team preoperatively. Symptoms, signs and diagnostic test results were categorized (neurologic, urologic, orthopedic, dermatologic) and compared pre- and one year postoperatively. Normal MR was defined as conus medullaris (CM) at or above mid-body L2 and filum diameter less than 2 mm. Occult TFS (OTFS) was defined as TFS with normal MR. DEMOGRAPHICS: 17 girls, 8 boys, age 2-18 years, including 11 syndromal children. CLINICAL PRESENTATION: all children had problems in the neurologic category and at least one other category: urologic (n = 17), orthopedic (n = 21), and dermatologic (n = 11). MR findings: low-lying CM (n = 14) including 2 with thick filum, normal CM but fatty filum (n = 2), strictly normal (n = 9). Clinical outcome one year postoperatively: neurologic 20 improved, 5 stabilized; urologic 13 improved, 3 stabilized, 1 worsened; orthopedic (8 children presenting with scoliosis) 3 improved, 4 stabilized, 1 worsened. All children with OTFS (n = 9) improved in at least one and 8 improved in all affected categories. CONCLUSIONS: Children with strong clinical suspicion for TFS (≥ 2 affected categories) with or without abnormal MR findings will likely benefit from surgery. In such cases we suggest a detailed full spine MR, a multidisciplinary diagnostic work-up, and eventual untethering through an interlaminar microsurgical approach.

Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome.

OBJECT: Thoracic disc herniations (TDHs) may occasionally present with an acute myelopathy, defined as a variable degree of motor, sensory, and sphincter disturbances developing in less than 24 hours, and resulting in a Frankel Grade C or worse. Confronted with such a patient, the surgeon has to decide whether to perform an emergency operation and whether to use an anterior or posterior approach. The authors analyze their own experience and the pertinent literature, focusing on clinical presentation, imaging findings, surgical timing, technique, and outcome. METHODS: Among 250 patients who underwent surgery for symptomatic TDH, 209 had at least 1 year of follow-up at the time of writing, including 8 patients who presented with an acute myelopathy. They were surgically treated using standard thoracoscopic microdiscectomy, careful blood pressure monitoring, and intravenous methylprednisolone. The authors analyzed pre- and postoperative neuroimaging, and Frankel scores preoperatively, at discharge, and 1 year postoperatively. RESULTS: Although 5 patients had multiple TDHs, the symptomatic TDH was invariably situated between T9-10 and T11-12. Seven TDHs were giant, 6 were calcified, 6 were accompanied by myelomalacia, and 4 were accompanied by segmental stenosis. Although sudden dorsalgia was the initial symptom in 6, a precipitating event was noted in only 1. All patients had severe neurological deficits by the time they underwent surgery. Frankel grades improved from B to D in 2 patients, from C to E in 4, and from C to D and B to E in 1 patient each. All patients regained continence and ambulation. Transient complications were CSF leak (in 2 patients), and intraoperative blood loss greater than 1000 ml, reversible ischemic neurological deficit, and subileus (in 1 patient each). CONCLUSIONS: Approximately 4% of TDHs present with an acute myelopathy. They are often situated between T9-10 and T11-12, large or giant, and even calcified. They almost invariably cause important cord compression (sometimes aggravated by an associated segmental stenosis) and myelomalacia. Their clinical presentation may be misleading, and diagnosis may be delayed until other causes (especially vascular) have been excluded and the clinical picture has become more complete. Interestingly, whereas a precipitating event or trauma is rarely present, dorsalgia frequently precedes profound myelopathy and may help to make an early diagnosis. Remarkable recovery is possible even with profound neurological deficit, a delay of several days, in the elderly, and in the presence of myelomalacia, provided the spinal cord is adequately decompressed and intraoperative hypotension is strictly avoided. Although alternative approaches more familiar to most neurosurgeons may be used, the anterior transthoracic approach has the advantage of reaching the TDH in front of the compromised spinal cord, avoiding any manipulation. In experienced hands, thoracoscopic microdiscectomy combines the advantage and versatility of an anterior approach with minimal postoperative discomfort. The authors conclude that TDH-related acute myelopathy may have a favorable outcome when managed correctly, and they strongly recommend that every single patient should undergo surgical treatment.

Long-term outcome of thalamic deep brain stimulation in two patients with Tourette syndrome.

OBJECTIVE: Thalamic deep brain stimulation for intractable Tourette Syndrome was introduced in 1999 by Vandewalle et al. In this follow-up study, the authors report on the long-term (6 and 10 years) outcome in terms of tic reduction, cognition, mood and side effects of medial thalamic deep brain stimulation in two previously described Tourette patients. METHODS: The authors compared the outcome of two patients at 6 and 10 years after surgery with their preoperative status and after 8 months and 5 years of treatment, respectively. Standardised video recordings were scored by three independent investigators. Both patients underwent (neuro)psychological assessment at all time points of follow-up. RESULTS: Tic improvement observed at 5 years in patient 1 (90.1%) was maintained at 10 years (92.6%). In patient 2, the tic improvement at 8 months (82%) was slightly decreased at 6 years (78%). During follow-up, case 1 revealed no changes in cognition, but case 2 showed a decrease in verbal fluency and learning which was in line with his subjective reports. Case 2 showed a slight decrease in depression, but overall psychopathology was still high at 6 years after surgery with an increase in anger and aggression together with difficulties in social adaptation. Besides temporary hardware-related complications, no distressing adverse effects were observed. CONCLUSION: Bilateral thalamic stimulation may provide sustained tic benefit after at least 6 years, but to maximise overall outcome, attention is needed for postoperative psychosocial adaptation, already prior to surgery.

Intramedullary cavernoma presenting with hematomyelia: report of two girls.

INTRODUCTION: Less than 20 children with intramedullary cavernoma (ImC) have been reported in the English literature; however, cases with an unfavorable outcome may be underreported. Whereas these are predominantly boys, we report two girls who presented with hematomyelia (one cervical, one thoracic) and an acute, severe neurological deficit. CASE MATERIAL: A 10-year-old girl complaining about lower thoracic pain for several days suddenly developed lower body dysesthesias and paraparesis. Magnetic resonance (MR) demonstrated hematomyelia (T8-T11), intramedullary edema (T6-L1), and an ImC at T9-T10. Within an hour, she progressed to paraplegia and was therefore operated immediately. She slowly recovered regaining independent ambulation and continence. MR after 2 years shows no recurrence. A 7-year-old girl suddenly developed cervicalgia and paresis of her left arm and leg. MR demonstrated hematomyelia and an ImC at C4-C6. She gradually recovered with minimal residual deficit at 3 months and was subsequently operated uneventfully. Multiple cerebral cavernomas and a familial autosomal cavernous malformation syndrome were diagnosed. The following 1.5 years, she complained of intermittent cervicalgia and left brachial dysesthesias, with MR suggesting active residual cavernoma. Interestingly, her complaints gradually disappeared, and she is currently asymptomatic. MR after 3.5 years shows minimal cord swelling no longer suggesting active residual cavernoma. CONCLUSION: With adequate surgical treatment either in the acute phase in case of dramatic deterioration or after clinical recuperation, prognosis of symptomatic ImC may be surprisingly good. However, subtotally resected lesions and/or syndromal cases may recur, requiring further treatment. Definitive answers await more cases with longer follow-up.

Two brothers with a symptomatic thoracic disc herniation at T11-T12: clinical report.

BACKGROUND: In contrast to what is commonly believed, thoracic disc herniations are not rare lesions. Their etiopathogenesis is largely unknown, but may be linked to trauma, Scheuermann's disease or a degenerative back. OBJECTIVE: We report two brothers with a symptomatic thoracic disc herniation at T11-T12 and address the possibility of a genetic factor as well as other factors in the etiopathogenesis of (symptomatic) thoracic disc herniations. CLINICAL FEATURES: Both brothers were in their early thirties and had a physically demanding job, however, only the first one was a smoker and was diagnosed with Scheuermann's disease. CONCLUSION: The etiology of thoracic disc herniations is likely multifactorial. Their occurrence in siblings may reflect some genetic predisposition or may be merely coincidental, given the high prevalence of thoracic disc herniations in asymptomatic individuals. Further research, including genetic studies, is warranted.

Spinal congenital dermal sinus in a chick embryo model. Laboratory investigation.

OBJECT: The origin of spinal congenital dermal sinuses is not known. A local nondisjunction of the closing neural tube and the epidermal ectoderm is thought to be the cause of this malformation. In this experimental study, a nondisjunction was mimicked in chick embryos to create an animal model for the dermal sinus. METHODS: A piece of amniotic tissue was implanted in the closing neural tube in ovo in chick embryos at 2 days of incubation. A total of 50 embryos were manipulated. After a further incubation time of 2-7 days, the embryos were macroscopically and histologically evaluated. RESULTS: Dermal sinus-like anomalies were induced in 24 embryos. The induced abnormalities varied from superficial, epidermal lesions to epidermal dimples continuing as a strand of tissue toward the neural tube. This strand invariably was of nonneuronal origin. Additionally, in 3 embryos a split cord malformation was noted, most likely caused by damage to the neural tube during implantation. CONCLUSIONS: Implantation of donor amniotic tissue in the closing chick neural tube does result in a dimple, from which a strand of tissue continues to the neural tube in various cases, indicating that formation of a dermal sinus-like anomaly can be successfully induced by experimental continuation of the connection between neural tube and surface ectoderm. This finding strengthens the hypothesis that a human dermal sinus arises after nondisjunction of neural tube and surface ectoderm.

Effect of spinal cord stimulation in Type I complex regional pain syndrome with 2 rare severe cutaneous manifestations.

The authors present the case of a 49-year-old female patient with complex regional pain syndrome-Type I (CRPSI) who was suffering from nonhealing wounds and giant bullae, which dramatically improved after spinal cord stimulation (SCS). The scientific literature concerning severe cutaneous manifestations of CRPS-I and their treatment is reviewed. Nonhealing wounds and bullae are rare manifestations of CRPS-I that are extremely difficult to treat. Immediate improvement of both wounds and bullae after SCS, such as in this case, has not been reported previously in literature. Considering the rapidly progressive nature of these severe skin manifestations, immediate treatment, possibly with SCS, is mandatory.

Long-term behavioral outcome after early-life hyperthermia-induced seizures.

Febrile seizures (FS) are among the most common types of seizures in the developing brain. It has been suggested that FS cause cognitive deficits that proceed into adulthood, but the information is conflicting. The aim of the present study was to determine whether experimental FS have long-term cognitive or behavioral deficits. FS were induced by hyperthermia (30 minutes, approximately 41 degrees C) in 10-day-old rat pups, and behavioral testing was performed. Hippocampus-dependent water maze learning, locomotor activity, and choice reaction time parameters (e.g., reaction time) were generally not affected by FS. However, more detailed analysis revealed that reaction times on the right side were slower than those on the left in controls, whereas this was not observed after FS. Early-life experimental FS did not cause overt cognitive and behavioral deficits, which is in line with previous work, but eliminated the lateralization effect in reaction time known to occur in normal controls, an effect that may be due to the combination of FS and kainic acid or to FS alone.

Short- and long-term limbic abnormalities after experimental febrile seizures.

Experimental febrile seizures (FS) are known to promote hyperexcitability of the limbic system and increase the risk for eventual temporal lobe epilepsy (TLE). Early markers of accompanying microstructural and metabolic changes may be provided by in vivo serial MRI. FS were induced in 9-day old rats by hyperthermia. Quantitative multimodal MRI was applied 24 h and 8 weeks later, in rats with FS and age-matched controls, and comprised hippocampal volumetry and proton spectroscopy, and cerebral T2 relaxometry and diffusion tensor imaging (DTI). At 9 weeks histology was performed. Hippocampal T2 relaxation time elevations appeared to be transient. DTI abnormalities detected in the amygdala persisted up to 8 weeks. Hippocampal volumes were not affected. Histology showed increased fiber density and anisotropy in the hippocampus, and reduced neuronal surface area in the amygdala. Quantitative serial MRI is able to detect transient, and most importantly, long-term FS-induced changes that reflect microstructural alterations.

Cytogenesis in the dentate gyrus after neonatal hyperthermia-induced seizures: what becomes of surviving cells?

PURPOSE: Febrile seizures (FS) are early-life seizures thought to play a role in epileptogenesis. By labeling cells that were dividing immediately following experimental FS, we previously demonstrated that significantly more of these newborn cells in the dentate gyrus (DG) survived 8 weeks later, relative to animals that did not experience FS. The purpose of the present study was to determine the long-term fate of these newborn cells. METHODS: On postnatal day (PN) 10, hyperthermia-induced seizures (HT, +/-42 degrees C core temperature) were evoked in Sprague-Dawley rats and littermates were used as normothermia controls (NT, +/-35 degrees C core temperature). From PN11 to PN16, rats were injected with bromodeoxyuridine (BrdU) to label dividing cells. At PN66, we evaluated the number of BrdU-labeled cells in the DG that colocalized with the neuronal marker NeuN, glial marker glial fibrillary acidic protein (GFAP), neuronal excitatory amino acid transporter 3 (EAAT3), GABAergic neuronal marker glutamic acid decarboxylase 67 (GAD67) or microglia marker tomato lectin (TL). RESULTS: In all rats, almost all BrdU-labeled cells in the DG, that showed double-labeling, colocalized with NeuN, and rarely with GFAP, GAD67, or TL. In NT controls and HT rats that did not experience seizures ("HT-no seizures"), approximately 23% of BrdU-labeled cells colocalized with EAAT3, which was significantly different from 14% in HT rats that did experience seizures (HT + FS). DISCUSSION: Early-life seizures decrease the population of newborn cells that survive and mature into EAAT3-positive neurons and do not affect the GABAergic cell population. This may affect hippocampal physiology in young adulthood.

The microanatomical environment of the subthalamic nucleus. Technical note.

High-frequency stimulation of the subthalamic nucleus (STN) is a widely performed method to treat advanced Parkinson disease. Due to the limitations of current imaging techniques, the 3D microanatomy of the STN and its surrounding structures in the mesencephalon are not well known. Using images they obtained using a 9.4-tesla magnetic resonance (MR) imaging unit, the authors developed a 3D reconstruction of the STN and its immediate surroundings. During the postmortem investigation of a human brain, a sample of tissue in the area around the STN was isolated. This brain tissue was scanned in the three orthogonal planes at 1-mm slice thickness. The images generated were compared with photographs of conventionally stained brain tissue slices in different neuroanatomical books, and a 3D reconstruction was made. High-field MR imaging is an appropriate method for visualizing the microanatomy of the STN and its surroundings. The images allow an optimal analysis of the microenvironment of the STN in the three orthogonal planes and can be used for 3D reconstructions of this area with possible clinical applications in the future.

Preoperative localization of herniated thoracic discs using myelo-CT guided transpleural puncture: technical note.

OBJECTIVE: In recent years, video-assisted thoracoscopic microdiscectomy has gained acceptance as a minimally invasive, safe, and efficient technique suited for herniated thoracic discs from T4T5 until T11T12. However, correct localization is difficult and wrong level exploration is an ever-present threat. We present a reliable and time-efficient localizing technique. MATERIALS AND METHODS: In 86 consecutive cases, 1 day preoperatively intrathecal contrast was administered and a computed tomography (CT) scan was performed in prone position. Using local anesthesia, a hollow needle was advanced above the corresponding rib and through the pleura. The inner wire and corresponding pathological level were easily identified endoscopically. CONCLUSION: Myelo-CT provides detailed anatomical information, which is often helpful in determining the side of operative approach and the extent of bone removal needed. Needle localization obviates fluoroscopy, saves OR time, and allows the surgeon to focus on the technically demanding procedure. Furthermore, it is a relatively simple and safe technique.

Correlation of postmortem 9.4 tesla magnetic resonance imaging and immunohistopathology of the human thoracic spinal cord 7 months after traumatic cervical spine injury.

OBJECTIVE: To correlate high-resolution magnetic resonance imaging (MRI) with immunohistopathology in the injured human spinal cord. METHODS: Postmortem MRI scans at a field strength of 9.4 T, as well as standard histology and immunohistochemistry, were performed on an excised specimen of human high thoracic spinal cord, obtained 7 months after the initial trauma, several segments below a severe spinal cord lesion (C5). RESULTS: A precise correlation is described between MRI and immunohistochemistry of the long white matter tracts undergoing Wallerian degeneration and of an extension of the cervical lesion into the high thoracic cord. CONCLUSION: MRI, the only imaging technique that currently provides useful information on the spinal cord parenchyma after trauma, is rapidly evolving. High-field scanners of up to 9.4 T are being clinically tested. The present postmortem investigation of an isolated spinal cord specimen demonstrates the precise correlation that can be achieved between imaging and pathology. In future investigations, this type of technique can lead to a more precise description of spinal cord injuries and their consequences in remote tissue. Translation into the clinical setting will improve diagnosis and follow-up of spinal cord injured patients.

The Currarino triad: neurosurgical considerations.

OBJECTIVES: The Currarino triad, a relatively uncommon hereditary disorder, is often associated with tethered cord and anterior myelomeningocele. Little is known of the implications of these neuroanatomic malformations or of the neurosurgical attitude. The objective of this study is to identify the spinal cord and meningeal malformations associated with the Currarino triad and to discuss the risks and benefits of surgical intervention. METHODS: We analyzed the spinal cord malformations and the neurosurgical involvement with the Currarino triad by retrospective chart review. RESULTS: The Currarino triad neuroanatomic malformations were identified in five patients. The Currarino triad was associated with a tethered cord in three patients, a myelomeningocele in five patients, a syrinx in two patients, a fistula between the colon and spinal canal in two patients, and an Arnold-Chiari Type 1 malformation in one patient. CONCLUSION: Full spine imaging is required for all patients diagnosed with the Currarino triad. Magnetic resonance imaging of the head should be performed in every patient with neuroanatomic anomalies. Surgery of an anterior myelomeningocele is not necessarily indicated, only in the rare case in which the space-occupying aspect is expected to cause constipation or problems during pregnancy or delivery. Constipation directly after birth is seen in virtually all patients with the triad. Therefore, constipation cannot be used to diagnose a tethered cord syndrome nor indicate tethered cord release. Fistulas between the spinal canal and colon have to be operated on directly.

The supraspinal network in the control of erection.

Penile erection is a complex event controlled by vascular, hormonal and neuronal systems. The neuronal system involved in erection is often divided into spinal and supraspinal networks. It is generally accepted that the spinal system directly controls erection and that the supraspinal network modulates this control mechanism through different ascending and descending pathways. In contrast to the spinal control of erection, relatively little is known about the supraspinal network. In the present review, the authors outline the supraspinal network involved in the control of penile erection. Firstly, the brain regions reported to be involved in erection are described and the brain circuit of erection is outlined. Subsequently, the neuromediators involved in erection are summarised. Finally, these data are discussed in the light of therapeutic possibilities in the management of erectile dysfunction by targeting the supraspinal system.