Brain activation in the chronic phase of traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional clinical study. OBJECTIVES: Plastic changes within cortical areas occur after traumatic spinal cord injury (TSCI). The aim of the study was to assess cortical activation in the chronic phase of TSCI using functional magnetic resonance imaging (fMRI). SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: Ten right-handed patients with paraplegia and 18 healthy controls were studied by fMRI. Individuals performed simple flexion/extension of the right hand fingers and the right ankle during fMRI. The activation volumes, maximum t values (T max) and centres of gravity (COG) were calculated. RESULTS: The mean time since trauma was 1848±1046 days (range 388-4459). During hand movements, the volume of activation (VOA) in the contralateral primary motor cortex was significantly larger among the TSCI patients who did not recover compared with the controls (4112 vs 2777, P=0.02). The VOA did not enlarge during the ankle movements (2420 vs 1114, P=0.08). There was a significant relationship between the VOA in Brodmann area 4 (BA4) and American Spinal Injury Association motor score during hand movements (r=-0.67, P=0.03). A positive correlation was found during hand movements in the VOA of BA4 and time since injury (r=0.62, P=0.05). CONCLUSIONS: We found increased cortical activation in the chronic phase of thoraco-lumbar TSCI that may be caused by increased use of upper limbs.

Health-related quality of life in patients with traumatic spinal cord injury in Estonia.

OBJECTIVES: To describe health-related quality of life (HRQoL) in persons with traumatic spinal cord injury (TSCI) and to assess factors that affect HRQoL. STUDY DESIGN: Cross-sectional. METHODS: Eighty Estonian-speaking TSCI patients from the Estonian TSCI database were included in the study. The RAND-36 questionnaire, the Life Orientation Test, the Emotional State Questionnaire and the Brief Social Support Questionnaire were used. RESULTS: There were 66 men and 14 women; the mean age was 38.9±14.8 years. The mean time that had elapsed since injury was 4.2 years. According to the RAND-36 scales, the lowest scores were given for physical health-related domains, followed by the energy/fatigue and the general health domains. The regression analysis adjusted to age and gender revealed that age, employment and category of the American Spinal Injury Association (ASIA) Impairment Scale during the acute phase of injury were significant factors in predicting physical functioning (P<0.001). Age, depression and general anxiety were significant predictors of emotional well-being (P<0.001). Age and depression were independently associated with general health (P<0.001). CONCLUSION: As expected, physical functioning and physical role limitation were the most pronounced deficits in HRQoL. Compared with data from other countries, all scores for the RAND-36 scales are lower in Estonian TSCI patients. The HRQoL following TSCI is affected by severity of injury, depression, age and employment status.

Brain activation in the acute phase of traumatic spinal cord injury.

STUDY DESIGN: Prospective clinical study. BACKGROUND: The aim of the study was to investigate cortical reorganisation after traumatic spinal cord injury (TSCI) using functional magnetic resonance imaging (fMRI). SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: We studied six right-handed tetraplegic TSCI patients at 1, 3 and 12 months after the injury and 12 age- and gender-matched healthy controls. Individuals performed simple test-rest cycles of flexion/extension of the right-hand fingers and flexion/extension of the right ankle during fMRI. The volumes of activation (VOA), maximum t-values, centres of gravity (COG) and weighted laterality indexes were calculated. RESULTS: There was no recovery of neurologic function in three patients and, according to the American Spinal Injury Association (ASIA) Impairment Scale the remaining three recovered. A positive correlation between the VOA in the primary motor cortex and the ASIA impairment scale (1 month: r=0.82, P=0.002; 3 Month: r=0.63, P=0.03; 12 Month: r=0.23, P=0.52) was found. The study also revealed a pattern of cortical activation that was increased among the patients who recovered (in Brodmann area 4 (BA 4), P=0.06; BA 1-2-3-5, P=0.08; BA 6, P=0.05). During the hand task there was an expansion of COG laterally, anteriorly and inferiorly among the patients who recovered. During the hand movement the cortical activation was less lateralised among the patients compared with the controls (P<0.05). CONCLUSION: Our study has found broadening of cortical activation and shift of COG during the first year after TSCI, depending on the recovery.

Functional MRI of the cortical sensorimotor system in patients with hereditary spastic paraplegia.

OBJECTIVES: The study aimed to use functional magnetic resonance imaging to ascertain changes in sensorimotor system function in patients with hereditary spastic paraplegia and to correlate it with severity of spasticity and paresis. SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: Nine patients with autosomal-dominant pure HSP and 14 age- and sex-matched healthy controls were investigated with a 1.5T fMRI scanner during flexion/extension of the right-hand fingers and right ankle. Images were analysed with a general linear model and Statistical Parametrical Mapping software. Highest Z-scores were identified from probability maps, and weighted laterality indices were calculated using combined bootstrap/histogram analysis; these were correlated with clinical severity of spasticity and paresis. RESULTS: During hand movements, clusters located in contralateral primary sensorimotor and premotor areas activated in both controls and patients. Bilateral activation occurred in the supplementary motor area, parietal operculum and cerebellum (predominantly ipsilateral). During the ankle task, bilateral activation was noted in the primary sensorimotor area, supplementary motor area and cerebellum. Activation clusters in HSP patients were smaller than those in controls in the sensorimotor area, especially during the ankle task, and more pronounced ipsilaterally in cerebellum both during hand and ankle motor tasks. Spasticity was significantly associated with contralateral activation in the sensory area and correlated negatively with the highest Z-scores in Brodmann areas 1-2-3 and 4. CONCLUSION: Our results suggest changes in cortical sensorimotor network function in patients with HSP compared with healthy subjects. Lower activation in patients might reflect damage to the corticospinal tract, be influenced by compensatory mechanisms, and/or be a reflection of neurorehabilitation.

High incidence of traumatic spinal cord injury in Estonia.

STUDY DESIGN: Retrospective population-based cohort study. OBJECTIVES: To provide national data on epidemiology of traumatic spinal cord injury (TSCI) among the population of Estonia from 1997 to 2007. SETTING: All Estonian hospitals. METHODS: Medical records of patients with TSCI from all regional, central, general and rehabilitation hospitals in Estonia were retrospectively reviewed. Epidemiological characteristics, etiology, neurological level and severity of injury, concomitant injuries were analyzed. RESULTS: A total of 595 patients with TSCI from 1 January 1997 to 31 December 2007 were identified. The male to female ratio was 5.5:1. The mean age at injury was 39.0 years. The crude incidence rate was 39.7 (95% confidence interval: 36.6-43.0) per million population. The most frequent cause of TSCI was falls (41%), followed by traffic accidents (29%). Alcohol consumption preceded 43% of injuries. The lesion level was cervical in 59.4%, thoracic in 18.3% and lumbar/sacral in 22.3%. CONCLUSION: Compared to recent studies from Europe, where the incidence of TSCI is between 15 and 30 per million population, the incidence of TSCI in Estonia is among the highest. The rates are significantly higher in men compared with women and especially among the youngest men. The leading cause of TSCI is falls. A significant proportion of injuries are related to alcohol consumption before trauma in Estonia.

Survival of patients with primary CNS tumours in Estonia.

We studied a population-based survey that included 1417 patients with a primary central nervous system (CNS) tumour diagnosed in Estonia between 1986 and 1996. Survival rates at 1 and 5 years and median survival by histology and patient's age at diagnosis were estimated. Median survival time for all tumours was 33.2 months and 1- and 5-year survival rates were 59.3 and 46.0%, respectively. In multivariate analysis, younger age, better clinical condition (i.e. a Karnofsky Performance Status (KPS) score of 60 and more) and tumour histology were all dependent prognostic factors for better survival. Risk of death was more than 8 times greater for glioblastoma (Risk Ratio (RR) 8.31) and approximately seven times greater for anaplastic astrocytoma (RR 7.22) and other gliomas (RR 5.74) compared with meningiomas. Comparing the first (1986-1989) and the third (1994-1996) time periods, statistically significant improvements in survival occurred for all tumours and astrocytomas. Declines in survival during the second period (1990-1993) were statistically significant for all the tumour groups, but the most striking decrease took place in patients with glioblastoma. Age-specific rates showed that the increase in survival was more evident for patients aged between 45 and 64 years.

Changes of local cerebral blood flow concomitant to lead-exposure in adult rabbits.

Lead is considered a pathogenic factor of atherosclerosis and arterial hypertension, which are main risk factors of cerebrovascular disease. The brain microvasculature preferentially accumulates lead and its function is sensitive to its toxic effect. Influence of inorganic lead-exposure (20 mg/kg-I group, 40 mg/kg II group) for 10 days on local cerebral blood flow (lCBF) in hypothalamus (HYP) and cerebral cortex (CTX) of rabbits was studied by means of the hydrogen clearance method. Corresponding results were compared to sham operated group (III group). During lead-exposure lCBF was reduced in both investigated regions. The reduction of lCBF in HYP was reduced in both investigated regions. The reduction of lCBF in HYP was 12.9% (P < 0.05) in I and 19.9% (P < 0.001) in II group; corresponding changes in CTX were -16.9% (statistically non-significant -N) in I and 1.4% (NS) in II group. Present finding suggest that inorganic lead induces cerebral microvascular dysfunction with following changes in lCBF. These alteration have a biphasic character Although these disturbances reveal a tendency towards normalization, it is possible to presume that higher concentrations of ingested lead cause more severe injury to endothelium of brain microvasculature.

Coping strategies in patients following subarachnoid haemorrhage.

OBJECTIVES: To assess psychological coping strategies and their relationship with outcome in patients after primary subarachnoid haemorrhage (SAH). PATIENTS AND METHODS: In 51 unselected patients (24 males, 27 females; mean age 46 years) in an average 15.7+/-12.0 months after SAH usage of coping strategies were assessed by means of Estonian COPE-D test with 15 four-items scales and compared to those obtained from 51 age-, sex- and education-matched healthy persons. The data were analysed according to age, sex and education of the patients, initial severity of disease, localization of aneurysm and outcome characteristics. RESULTS: Patients after SAH reported using social support strategy less than control persons (P<0.05) with a tendency of using acceptance-oriented strategy. Task-oriented coping styles were less used (P<0.05) by patients with severe initial state, who had more marked late disability and dependence in daily living. Healthy women used social support more than men; patients and control persons 50 years or older used task-oriented strategies less than younger persons (P<0.05). CONCLUSION: The structure of coping strategies used by patients after SAH differs compared to healthy persons. The differences in using coping strategies are related to age of the patients, functional state and degree of adaptation after SAH.

Seizure disorders in patients with brain tumors.

The aim of this study was to analyze the clinical data of patients with epileptic seizures and diagnosed brain tumors. Analysis included 711 patients with primary and secondary brain tumors. 165 (23%) patients had experienced at least one seizure before tumor diagnosis. The mean time from the first epileptic seizure to tumor diagnosis was 16 months. The patient's age, location and pathology of tumor were associated with occurrence of seizures. Seizures were more common in patients aged 30-50 years. Tumors involving the frontal, frontoparietal, temporal and frontotemporal lobes were associated with occurrence of seizures. According to the histological diagnosis, patients with mixed gliomas (62%), oligodendrogliomas (53%) and astrocytomas (42%) experienced seizures most frequently.