Low-dose ACTH therapy for West syndrome: initial effects and long-term outcome.

BACKGROUND: Most Japanese pediatric neurologists attempt other treatments before using adrenocorticotropic hormone (ACTH) therapy for West syndrome (WS), and even then, they use only a low-dose synthetic ACTH to avoid serious adverse effects. In this multi-institutional study, the authors analyzed the initial effects, adverse effects, and long-term outcome in patients treated with low-dose synthetic ACTH in Japan. METHODS: The medical records of 138 patients with WS, who were treated with low-dose synthetic ACTH therapy for the first time at the authors' institutions between 1989 and 1998, were analyzed. RESULTS: At the end of ACTH therapy, excellent effect on seizures was noted in 106 of 138 (76%) patients, good effect in 23 (17%), and poor effect in 9 (7%). Initial effects on EEG were excellent in 53 of 138 (38%) patients, good in 76 (55%), and poor in 9 (7%). As for seizure prognosis at the time of follow-up, 51 of 99 (52%) patients were seizure-free, whereas 48 (48%) patients had seizures. Mental outcome was normal in 6 of 98 (6%) patients, mild mental retardation in 16 (16%), moderate mental retardation in 26 (27%), and severe mental retardation in 50 (51%). The initial effects of ACTH on seizures and long-term outcome were not dose dependent (daily dosage 0.005 to 0.032 mg/kg, 0.2 to 1.28 IU/kg; total dosage 0.1 to 0.87 mg/kg, 4 to 34.8 IU/kg). The severity of adverse effects correlated with total dosage of ACTH, and the severity of brain volume loss due to ACTH correlated well with the daily dosage and total dosage of ACTH. CONCLUSION: Low-dose synthetic ACTH therapy is as effective for the treatment of WS as the higher doses used in previous studies. The dosage of synthetic ACTH used in the treatment of WS can be decreased as much as possible to avoid serious adverse effects.

Global ischemia-induced increases in the gap junctional proteins connexin 32 (Cx32) and Cx36 in hippocampus and enhanced vulnerability of Cx32 knock-out mice.

Gap junctions are conductive channels that connect the interiors of coupled cells. In the hippocampus, GABA-containing hippocampal interneurons are interconnected by gap junctions, which mediate electrical coupling and synchronous firing and thereby promote inhibitory transmission. The present study was undertaken to examine the hypothesis that the gap junctional proteins connexin 32 (Cx32; expressed by oligodendrocytes, interneurons, or both), Cx36 (expressed by interneurons), and Cx43 (expressed by astrocytes) play a role in defining cell-specific patterns of neuronal death in hippocampus after global ischemia in mice. Global ischemia did not significantly alter Cx32 and Cx36 mRNA expression and slightly increased Cx43 mRNA expression in the vulnerable CA1, as assessed by Northern blot analysis and in situ hybridization. Global ischemia induced a selective increase in Cx32 and Cx36 but not Cx43 protein abundance in CA1 before onset of neuronal death, as assessed by Western blot analysis. The increase in Cx32 and Cx36 expression was intense and specific to parvalbumin-positive inhibitory interneurons of CA1, as assessed by double immunofluorescence. Protein abundance was unchanged in CA3 and dentate gyrus. The finding of increase in connexin protein without increase in mRNA suggests regulation of Cx32 and Cx36 expression at the translational or post-translational level. Cx32(Y/-) null mice exhibited enhanced vulnerability to brief ischemic insults, consistent with a role for Cx32 gap junctions in neuronal survival. These findings suggest that Cx32 and Cx36 gap junctions may contribute to the survival and resistance of GABAergic interneurons, thereby defining cell-specific patterns of global ischemia-induced neuronal death.

Different responses to auditory and somaesthetic stimulation in patients with an excessive startle: a report of pediatric experience.

OBJECTIVES: Children with cerebral injury often exhibit brief muscle contraction to a variety of stimuli. However, it remains to be determined whether or not the pattern of the reaction is stereotypical irrespective of the site stimulated. To answer this question, we studied electromyographic (EMG) responses to three types of stimuli in children. METHODS: The EMG responses of cranial and limb muscles were recorded after acoustic or somaesthetic stimulation in 6 patients and 23 control subjects. RESULTS: Acoustic stimuli evoked patterned motor activity with a rostrocaudal progression. Nose-tapping stimuli elicited reflex EMG activity in the VIIth cranial muscles that was similar to the R1 component of the electrical blink reflex. Sternum-tap stimuli evoked motor activity in the sternocleidomastoid and arm muscles, and this reflex was probably mediated through the cervical cord (H-reflex). Moreover, late reflexes were evoked following these early reflexes in the patients. In particular, atypical forms of myoclonic jerks were evoked on sternum-tap stimuli. CONCLUSIONS: Many types of primitive reflexes were evoked following three types of stimuli. These reflexes included startle reflex, trigeminomotor reflex, H-reflex and atypical forms of myoclonus, and they were enhanced in the patient group. There are many startle-mimicking reflexes.

The development for polymer actuator active catheter system.

SUMMARY: Electric stimuli polymer-metal composite actuator material has been developed for active catheter system and other widely new applications. Thepolymer actuator is made of ion exchange polymer and gold as electrode, and a pulse voltage of 3 volts on the actuator gave a quick bend 90 degree angle. This composite material is possible to make small size, light and soft actuator. So now we can actually develop an active catheter for the interventional radiology surgery. The prototype polymer actuator active catheter has been developed by using polymer actuator technology and Micro Electronics Mechanical System (MEMS) technologies. The active catheter is controllable from the outside of the body by electric signal. The tip part of the catheter is made of the polymer actuator tube and bends 90 degree angles. The animal tests (dog) showed good actuator performance to control right direction and bending angle at bifurcation of blood vessel and aneurysms.

Rapid turnover of tryptophan hydroxylase is driven by proteasomes in RBL2H3 cells, a serotonin producing mast cell line.

Previously we demonstrated that tryptophan hydroxylase (TPH) undergoes very fast turnover driven by ATP-dependent proteolysis in serotonin producing mast cells [Hasegawa et al. (1995) FEBS Lett. 368, 151-154]. We searched for the major proteases involved in the rapid degradation of TPH in RBL2H3 cells. Among various protease inhibitors tested, proteasome inhibitors MG115, MG101, MG132, and lactacystin effectively inhibited the intracellular degradation of TPH. Administration of the proteasome inhibitors to cultured cells caused more than a 5-fold accumulation of TPH. Administration of the inhibitors together with cycloheximide stabilized the amount of TPH with no appreciable increase or decrease. Although MG-series proteasome inhibitors could inhibit calpain, the involvement of calpain was excluded since the cysteine protease inhibitor E-64-d, which acts on calpain, had no effect. Extracts of RBL2H3 cells were shown to contain a protease that digests TPH in an ATP-dependent manner and is sensitive to proteasome inhibitors. The ubiquitination of TPH could be visualized by Western blot analysis using both anti-TPH and anti-ubiquitin antibodies. Based on these results, we conclude that 26S proteasomes are mainly involved in the degradation of TPH. In the reported amino acid sequences of TPH from various sources including human, rabbit, rat, and mouse, a PEST sequence that is widely shared among short-lived proteins has been recognized. It was noted that the PEST sequence lies within the most conserved portion of the enzyme, the pteridine binding site.

Knockdown of AMPA receptor GluR2 expression causes delayed neurodegeneration and increases damage by sublethal ischemia in hippocampal CA1 and CA3 neurons.

Considerable evidence suggests that Ca(2+)-permeable AMPA receptors are critical mediators of the delayed, selective neuronal death associated with transient global ischemia and sustained seizures. Global ischemia suppresses mRNA and protein expression of the glutamate receptor subunit GluR2 and increases AMPA receptor-mediated Ca(2+) influx into vulnerable neurons of the hippocampal CA1 before the onset of neurodegeneration. Status epilepticus suppresses GluR2 mRNA and protein in CA3 before neurodegeneration in this region. To examine whether acute downregulation of the GluR2 subunit, even in the absence of a neurological insult, can cause neuronal cell death, we performed GluR2 "knockdown" experiments. Intracerebral injection of antisense oligodeoxynucleotides targeted to GluR2 mRNA induced delayed death of pyramidal neurons in CA1 and CA3. Antisense-induced neurodegeneration was preceded by a reduction in GluR2 mRNA, as indicated by in situ hybridization, and in GluR2 protein, as indicated by Western blot analysis. GluR2 antisense suppressed GluR2 mRNA in the dentate gyrus but did not cause cell death. The AMPA receptor antagonist 6-cyano-7-nitroquinoxiline-2,3-dione (CNQX) and the Ca(2+)-permeable AMPA receptor channel blocker 1-naphthyl acetyl spermine protected against antisense-induced cell death. This result indicates that antisense-induced cell death is mediated by Ca(2+)-permeable AMPA receptors. GluR2 antisense and brief sublethal global ischemia acted synergistically to cause degeneration of pyramidal neurons, consistent with action by a common mechanism. These findings demonstrate that downregulation of GluR2 is sufficient to induce delayed death of specific neuronal populations.

Iron dependence of tryptophan hydroxylase activity in RBL2H3 cells and its manipulation by chelators.

Tryptophan hydroxylase requires Fe2+ for in vitro enzyme activity. In this study, the intracellular activity of tryptophan hydroxylase was assessed by applying 3-hydroxybenzylhydrazine (NSD-1015), an inhibitor of aromatic l-amino acid decarboxylase, to monolayer cultures of RBL2H3 cells, a serotonin producing mast cell line. The effect of manipulating intracellular 'free' iron levels on enzyme activity was analyzed by administration of iron chelators. Desferrioxamine (DFO) suppressed the intracellular enzyme activity. Salicylaldehyde isonicotinoyl hydrazone (SIH) also suppressed enzyme activity, but stimulated it when administered in the Fe-bound form. Hemin also stimulated enzyme activity, which progressively increased over several hours to more than sixfold the initial level. DFO and SIH inhibited the hemin stimulatory effect when administered simultaneously with hemin. Both suppression and stimulation with these chelators took place without a significant decrease or increase in the amount of enzyme. These results indicate that there was an inadequate supply of Fe2+ in the cells to support full activity of tryptophan hydroxylase.

Biphasic changes in F3/contactin expression in the gerbil hippocampus after transient ischemia.

We studied changes in expression of F3/contactin (F3), a neuron-specific adhesion molecule, in the gerbil hippocampus after transient forebrain ischemia for 5 min. By immunohistochemical techniques using F3 antibody, we found a biphasic change in immunoreactivity for F3 in the CA1 area after ischemia. Western blotting of F3 protein showed a similar biphasic change. F3 immunoblots decreased to 67% of the control at 1 week, but then they increased and attained 159% at 3 weeks and 152% at 5 weeks after ischemia. Immunoreactivity of a neurofilament (NF145) showed a similar biphasic change to F3 but to a lesser extent. In contrast, microtubule-associated protein 2 (MAP2) immunoreactivity uniformly decreased after ischemia. In situ hybridization revealed that F3 messenger RNA (mRNA) hybridization signals in CA1 area were greatly reduced 1 week after ischemia, while the signals in the CA3 area were unchanged and even increased 3 weeks after ischemia. Damage to CA3 neurons by hyperthermic ischemia blocked the F3 increase in area CA1. Our results suggest that the initial decrease in F3 following ischemia reflects loss of CA1 neurons and the late increase in F3, which shows that a similar time course with neurofilaments may be caused by neurite sprouting.

Electrophysiological study of myoclonus in pediatric practice.

Myoclonus can be caused from a variety of central nervous system disorders. With regard to its pathophysiology, much work has been done in adult patients, but reports from pediatric clinics are scarce. We describe the clinical and electrophysiological features of four different types of myoclonus in children using back averaging technique. In a patient with cortical reflex myoclonus, myoclonic jerks were induced in the distal right arm by taps on the ipsilateral fingers. Myoclonus was preceded by the cortical spike which was localized posterior to the central sulcus contralateral to the myoclonus, and the cortical spike was time-locked to the myoclonus. In a patient with subcortico-cortical myoclonus, myoclonus occurred as a focal motor seizure. Myoclonic jerks were preceded by generalized cortical waves which were of maximal amplitude over the cortex contralateral to the myoclonus, and cortical waves time-locked to the myoclonus. A patient with spinal myoclonus had rhythmical and segmental myoclonus. Myoclonus was induced in both arms after electrical stimulation at the wrist with a latency which was slightly longer than that of the F wave. In a patient with brainstem myoclonus, muscle activity was bilaterally synchronous and was predominant in the proximal flexors. The pattern of muscle recruitment suggested that the myoclonus signal travelled downward along the spinal cord and upward through the brainstem. The back averaging technique is essential in the differential diagnosis of myoclonus.

Reduced calcium elevation in hippocampal CA1 neurons of ischemia-tolerant gerbils.

Transient forebrain ischemia causes selective neuronal death in the hippocampal CA1 neurons. A short sublethal ischemic episode preceding ischemia of longer duration is known to increase tolerance against cell death. The mechanisms of this ischemic tolerance are still poorly understood. Here we show, using Ca2+ imaging, that intracellular calcium ([Ca2+]i) elevation in CA1 neurons after an anoxic-aglycemic episode is markedly inhibited in the ischemia-tolerant gerbil. The hippocampus of gerbils which did not acquire tolerance showed a high [Ca2+]i elevation during the anoxic-aglycemic episode, similar to controls. Since hypoxia/ischemia-induced neurodegeneration can be triggered by cytoplasmic Ca2+ overload, the tolerant gerbil may regulate calcium and keep [Ca2+]i below the critical level for initiating neuronal death.

Modified Bankart procedure for recurrent anterior dislocation and subluxation of the shoulder in athletes.

Thirty-four athletes (34 shoulders) with recurrent anterior glenohumeral instability were treated with a modified Bankart procedure, using a T-shaped capsular incision in the anterior capsule. The inferior flap was advanced medially and/or superiorly and rigidly fixed at the point of the Bankart lesion by a small cancellous screw and a spike-washer. The superior flap was advanced inferiority and sutured over the inferior flap. Twenty-five athletes (median age: 22) were evaluated over a mean period of follow-up of 65 months. The clinical results were graded, according to Rowe, as 22 (88%) excellent, 3 (12%) good, and none as fair or poor. The mean postoperative range of movement was 92 degrees of external rotation in 90 degrees of abduction. Elevation and internal rotation was symmetrical with the opposite side. Twenty-four patients returned to active sport, 22 at their previous level. This modified Bankart procedure is an effective treatment for athletes with recurrent anterior glenohumeral instability.

Intracerebral Schwannoma--case report.

A 15-year-old girl presented with a rare intracerebral schwannoma manifesting as epileptic seizure. Computed tomography, magnetic resonance imaging, and cerebral angiography showed a right parietooccipital lobe tumor. The preoperative diagnosis was malignant glioma, but immunohistochemical and ultrastructural examinations showed the tumor was indistinguishable from peripheral schwannoma. Only 29 cases of schwannomas not related to the cranial nerve have been reported, mostly in children and young adults. The origin appears to be ectopic or perivascular elements in the brain. Such intracerebral schwannomas can be classified according to origins into intra-axial, periventricular, dural attachment, and other types.

Opsoclonus-myoclonus syndrome with abnormal single photon emission computed tomography imaging.

The single photon emission computed tomography (SPECT) findings in 2 patients with opsoclonus-myoclonus syndrome (OMS) who had similar symptoms in the acute stage of the disease are described. In 1 patient with encephalitis, SPECT showed increased blood flow in most of the cerebellum; the highest accumulation of the radiotracer was found in the cerebellar vermis and neighboring structures. These changes disappeared with clinical improvement. In the other patient with chronic OMS, SPECT demonstrated hypoperfusion in most of the cerebellum. Our results suggest that the cerebellum, particularly its middle portion, is involved in the generation of OMS. SPECt is a useful method that enables us to detect in vivo functional impairment in patients with OMS.

Electrographic study of brainstem reflex myoclonus.

A patient with post-hypoxic brainstem reflex myoclonus was examined. In spontaneous jerks electromyographic activity started in the sternocleidomastoid and spread down the spinal cord bilaterally. A similar jerk was elicited by somaesthetic or acoustic stimulation. The patient's blink reflex suggested bilateral pontine lesions at least. Thus, the pattern of muscle activation pointed to a brainstem origin of the myoclonus. Spinal conduction studies conducted during the jerks suggested that the myoclonus signal facilitated a path identical to the spinobulbospinal reflex demonstrated in animals.

Cyclic changes in NMDA receptor activation in hippocampal CA1 neurons after ischemia.

We studied N-methyl-D-aspartate (NMDA) receptor-mediated synaptic potentials in CA1 pyramidal neurons using hippocampal slices of gerbils after transient forebrain ischemia. In the presence of 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and bicuculline, stimulation of Schaffer collateral/commissural fibers induced field excitatory postsynaptic potentials (fEPSP) activated by NMDA receptors. We found that in many slices after ischemia, prolonged low-frequency stimulation (0.1-10 Hz) caused repeated depression and potentiation of the NMDA-mediated fEPSP. Changes in fEPSP amplitude were dependent on stimulus frequency and the cycle frequency ranged from 0.08 to 2.5 cycles/min. These cyclic changes were blocked by application of BAPTA-AM, a membrane-permeable Ca2+ chelator, but were little affected by application of verapamil or by lowering the Ca2+ in bathing solution. Intracellular recordings from CA1 neurons revealed that low-frequency stimulation caused periodic depolarizations of membrane potential accompanied by depression of the excitatory postsynaptic potentials. The cyclic changes of fEPSPs were blocked by inhibitors of protein kinase C (PKC) but were unaffected by inhibitors of Ca2+/calmodulin-dependent protein kinase II (CaMKII) or myosin light-chain kinase (MLCK). These results suggest that stimulus-dependent NMDA-receptor activation, mediated by PKC, takes place in the postischemic CA1 neurons and that the cyclic change may reflect abnormal intracellular Ca2+ signaling processes leading to neuronal degeneration.

Intracellular inositol 1,3,4,5-tetrakisphosphate enhances the calcium current in hippocampal CA1 neurones of the gerbil after ischaemia.

1. To examine the role of the phosphoinositide cascade triggered by disturbed Ca2+ homeostasis in ischaemic neurones, inositol 1,3,4,5-tetrakisphosphate (InsP4) was applied to the cytoplasmic face of membrane patches isolated from CA1 pyramidal neurones in the gerbil hippocampus. 2. In outside-out recordings, InsP4 induced an inward current which was increased by raising the extracellular [Ca2+]. In contrast, no clear channel openings could be observed in patches from neurones of sham-operated gerbils. 3. Open probabilities of InsP4-activated channels were significantly decreased upon application of omega-conotoxin but were not affected by omega-agatoxin or nifedipine. 4. In inside-out patches using high concentrations of Ca2+, Ba2+ or Sr2+ in the pipette solution, InsP4 enhanced inward currents. 5. Application of the isomers of InsP4 slightly enhanced the currents, but inositol 1,4,5-trisphosphate (InsP3) had no effect. 6. In the absence of InsP4 there was a single main Ba2+ current peak of 4.0 pA in amplitude, whereas upon its application two main peaks of 3.0 and 7.2 pA were present. 7. The open probabilities of these channels were apparently increased by InsP4. 8. These findings support the view that a disturbed phosphoinositide cascade occurs in the hippocampal pyramidal neurones after ischaemia and the InsP4 thus formed plays an important role in promoting the Ca2+ accumulation which results in neuronal death.

Stimulation of tryptophan hydroxylase production in a serotonin-producing cell line (RBL2H3) by intracellular calcium mobilizing reagents.

RBL2H3 cells showed a remarkable increase in their level of tryptophan hydroxylase (up to 25-fold), the rate-limiting enzyme in serotonin biosynthesis, by stimulation with intracellular calcium mobilizers A23187, thapsigargin, and tBuBHQ as well as by stimulation with an antigen in the presence of IgE. The increase in the enzyme protein was visualized by Western blot analysis using anti-tryptophan hydroxylase antiserum. The enzyme turnover (Hasegawa et al., FEBS Lett., 368 (1995) 151-154) was not slowed down during the rise in tryptophan hydroxylase. Actinomycin D prevented the stimulation-induced elevation of the enzyme. These findings strongly suggest that this stimulation was achieved by the accelerated biosynthesis of tryptophan hydroxylase.