Retardation in the slow axonal transport of cytoskeletal elements during maturation and aging.

Using the pulse-labeling method, the rate of the slow component (SC) of axonal transport was analyzed during maturation and aging. Ventral motor neurons and retinal ganglion cells of 3-, 6-, and 24-month-old Fischer 344 rats were radiolabeled with 35S-methionine. To measure the rates of SCa and SCb subcomponents, distributions of the total radiolabeled proteins and certain cytoskeletal proteins (actin, clathrin, tubulin, and the neurofilament proteins) were analyzed in the ventral root-sciatic nerve and optic nerve. Our results show that the rate of transport for both SCa and SCb proteins decreases with age in ventral motor axons and optic axons. For example, in ventral motor axons the rates of both SCa and SCb decreased 40% between 6 and 24 months. These results, with those of others, show that the rate of slow transport gradually decreases in the neurons of adult rats (7,11) The factors that may contribute to the slowing are discussed.

Effect of conditioning lesion on axonal sprout formation at nodes of Ranvier.

The effect of a conditioning lesion on the time-course of axonal sprout formation after a subsequent testing lesion was evaluated in myelinated axons of the rat sciatic nerve. Transmission electron microscopy of longitudinal nerve sections was used to examine nodes of Ranvier located 200-500 micron proximal to the testing lesion. The conditioning lesion was a cut of the tibial nerve at the ankle; the testing lesion, made 2 weeks later, was a crush of the sciatic nerve at the hip. Sprouts were defined as unmyelinated evaginations of the nodal axolemma that (1) had reached the basement membrane of the Schwann cell, and (2) were located between the myelin sheath of the distal paranode and the basement membrane. Photomicrographs of the nodes at 9, 18, and 27 hours after the testing lesion were assigned to one of seven categories: normal, retracted, myelin degeneration, axonal degeneration, type A sprout formation (cytoskeleton absent), type B sprout formation (cytoskeleton present), and type B sprout degeneration. By 9 hours after the testing lesion, type B sprout formation was found in 9% of the nodes in control nerves (testing lesion alone) and 33% of those in conditioned nerves (P less than .01). A 33% incidence of type B sprout formation was not reached in control nerves until 27 hours after the testing lesion. Since the conditioning lesion was located 50 mm distal to the testing lesion and did not induce neuronal death, earlier sprout formation can be attributed to a neuronal response to the conditioning lesion rather than to a putative factor that arises from pre-degenerated fibers and acts on newly formed sprouts.

Conditioning nerve crush accelerates cytoskeletal protein transport in sprouts that form after a subsequent crush.

To examine the relationship between axonal outgrowth and the delivery of cytoskeletal proteins to the growing axon tip, outgrowth was accelerated by using a conditioning nerve crush. Because slow component b (SCb) of axonal transport is the most rapid vehicle for carrying cytoskeletal proteins to the axon tip, the rate of SCb was measured in conditioned vs. sham-conditioned sprouts. In young Sprague-Dawley rats, the conditioning crush was made to sciatic nerve branches at the knee; 14 days later, the test crush was made where the L4 and L5 spinal nerves join to form the sciatic nerve in the flank. Newly synthesized proteins were labeled in motor neurons by injecting 35S-methionine into the lumbar spinal cord 7 days before the test crush. The wave of pulse-labeled SCb proteins reached the crush by the time it was made and subsequently entered sprouts. The nerve was removed and sectioned for SDS-PAGE and fluorography 4-12 days after the crush. Tubulins, neurofilament proteins, and representative "cytomatrix" proteins (actin, calmodulin, and putative microtubule-associated proteins) were removed from gels for liquid scintillation counting. Labeled SCb proteins entered sprouts without first accumulating in parent axon stumps, presumably because sprouts begin to grow within hours after axotomy. The peak of SCb moved 11% faster in conditioned than in sham-conditioned sprouts: 3.0 vs. 2.7 mm/d (p less than 0.05). To confirm that sprouts elongate more rapidly when a test crush is preceded by a conditioning crush, outgrowth distances were measured in a separate group of rats by labeling fast axonal transport with 3H-proline 24 hours before nerve retrieval.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery from paraplegia caused by spontaneous spinal epidural hematoma.

Three surgically treated cases of paraplegia caused by spontaneous spinal epidural hematoma are reported, along with summarized findings from 32 previously reported cases. Patients who recovered within 6 months had endured a shorter interval between loss of their ability to walk and surgical decompression than patients who did not recover (26 hours versus 48 hours; p less than 0.02). When this interval exceeded approximately 36 hours, the probability of recovery fell below 50 percent.

Treatment of adult-onset obstructive hydrocephalus with low- or medium-pressure CSF shunts.

Nine patients with nontumor obstructive hydrocephalus of adult onset underwent 13 shunt placements; low-pressure valves (closing pressure, 20 to 50 mm H2O) were employed for 5 placements, and medium-pressure valves (closing pressure, 55 to 85 (mm H2O) were employed for 8 placements. The use of a low-pressure valve was followed by objective improvement in all five instances, whereas the use of a medium-pressure valve was followed by objective improvement in only two of eight instances (p = 0.021). The treatment of adult-onset obstructive hydrocephalus may require low-pressure shunts because of the high outflow resistance that characterizes this condition.

Stages of axonal regeneration following optic nerve crush in goldfish: contrasting effects of conditioning nerve lesions and intraocular acetoxycycloheximide injections.

The progress of axonal outgrowth after a crush lesion of the goldfish optic nerve can be determined by examining longitudinal silver-stained sections at selected intervals. The outgrowth of leading axons proceeded at 0.46 mm/day after an initial delay of 4.2 days. Outgrowth can be rapidly characterized by differentiating among a series of qualitatively different stages. In the sprouting (S) phase of regeneration, stage S1 is defined by the presence of isolated axonal sprouts reaching into the crush zone, and stage S2 by bundles of sprouts in the crush zone. In the elongation (E) phase of regeneration, stage E1 is defined by bundles that bridge the crush zone, stage E2 by bundles that reach the optic chiasm, and stage E3 by bundles that reach the level of the hypothalamus. During normal regeneration, stage E2 was attained 7-9 days after the crush (testing lesion), and stage E3 at 11 days. However, if the testing lesion had been preceded by a similar (conditioning) lesion 2 weeks earlier, stage E2 was reached at 3 days and stage E3 at 5 days. Conversely, when a protein synthesis inhibitor (acetoxycycloheximide) was injected into the right eye daily from the 5th through 9th day after a testing lesion, the injected side lagged 1-2 stages behind the contralateral control side in nerves examined on the 10th day.

Effect of a conditioning lesion on optic nerve regeneration in goldfish.

Following a 'test lesion' (crush) of the optic nerve in goldfish, histological study of axons in silver-stained sections showed that outgrowth of the leading axons began after an initial delay of 4.3 days and proceeded at 0.34 +/- 0.03 mm/day. When a 'conditioning lesion' (crush at the same site) preceded the testing lesion by 2 weeks, the initial delay was 2.5 days and the outgrowth rate was 0.74 +/- 0.13 mm/day (P less than 0.01). Two additional methods, utilizing intraocular injections of tritiated proline or fucose to label axonally transported proteins, were used to examine the outgrowth of leading optic axons. (a) Measurement of the distances reached by labeled axons in the nerve at 6 and 10 days after a testing lesion alone yielded an initial delay of 4.6 days and an outgrowth rate of 0.41 +/- 0.04 mm/day. However, when a conditioning lesion preceded the testing lesion, labeled optic axons were already found to have reached the optic tectum by 10 days after the testing lesion, indicating an outgrowth rate in excess of 0.64 mm/day. (b) Determination of the times at which labeled axons arrived at the optic tectum showed that the outgrowth rate after a testing lesion along was 0.40 mm/day whereas when the testing lesion was preceded by a conditioning lesion it was 0.74 mm/day. Thus, as a result of a conditioning lesion the initial delay was reduced by nearly half and the outgrowth rate was nearly doubled.

Protein synthesis and axonal transport in goldfish retinal ganglion cells during regeneration accelerated by a conditioning lesion.

Axonal outgrowth in goldfish retinal ganglion cells following a testing lesion of the optic axons is accelerated by a prior conditioning lesion. Changes in protein synthesis and axonal transport were examined during the accelerated regeneration. The conditioning lesion was an optic tract cut made 2 weeks prior to the testing lesion, which consisted of a tract cut at the chiasma, so that nerves subjected to either a conditioning lesion ('conditioned nerves') or a sham operation ('sham-conditioned nerves') could be examined in the same animal. In the retinal ganglion cells of conditioned nerves, the incorporation of [3H]proline into protein began to increase between 1 and 8 days after the testing lesion. The amount of fast-transported labeled protein was elevated to about 8 X normal by 1 day after the testing lesion but had decreased to about 3-5X normal at 8 and 22 days. The 8 and 22 day values were not significantly different from those in sham-conditioned nerves or nerves that had received a testing lesion alone. For slow protein transport, the instantaneous amount transported was 15-16 X normal in the conditioned nerves at 1 and 8 days after the testing lesion, and the velocity of slow transport, which was already elevated above normal by 1 day after the testing lesion, was elevated still further by 8 days--to a value in excess of 1.5 mm/day (compared to 0.2-0.4 mm/day in normal animals). We believe that the enhanced outgrowth resulting from the conditioning lesion is due to a transient increase in the amount of fast transport (possibly responsible for a decreased delay in the initiation of sprouting), and a sustained increase in the amount and velocity of slow transport (which may account for an increased rate of elongation).

Protein synthesis and fast axonal transport in regenerating goldfish retinal ganglion cells.

To characterize the fast component of axonal transport in regenerating goldfish optic axons, the incorporation of L-2,3-[3H]proline into newly-synthesized proteins in the cell bodies of the retinal ganglion cells and the amount of transported labeled protein were determined at 2-36 days after cutting the optic tract. Both the incorporation and the amount of transported protein had doubled by 10 days after the lesion and continued to increase to about 5 times normal at 15 days, a time when a large proportion of the regenerating axon population had reached the optic tectum. Near-normal levels were recovered by 36 days. In contralateral control neurons, the incorporation of L-2,3-[3H]proline was unchanged from normal throughout, whereas the amount of labeled transported protein entering control axons was decreased by 55% at 2 and 10 days after the testing lesion, returning to normal by 15 days. An increase in fast transport velocity was seen in the regenerating axons beginning at 10 days after the lesion. However, a similar velocity increase was also seen in the contralateral control axons and in undamaged axons following removal of the cerebral hemispheres. Therefore, the velocity increase was not a specific consequence of axotomy.

Effect of acetoxycycloheximide and dibutyryladenosine cyclic 3':5'-monophosphate on axonal regeneration in the goldfish optic nerve.

Acetoxycycloheximide (AXM) or dibutyryl cyclic AMP (dbcAMP) was injected unilaterally into the vitreous humor of the eye beginning 5-6 days after bilateral optic nerve crush. Injections were repeated every 12-24 h for a total of 3-5 days; goldfish were sacrificed 10 days after lesioning the nerves. At a low dosage of AXM (0.1 microgram daily for 5 days), the mean outgrowth distance in treated neurons was 60% less than in contralateral control neurons. At a high dosage (0.3 microgram daily for 4 days), outgrowth was immediately blocked in both treated and contralateral control axons. Dibutyryl cyclic AMP, in a dose of 5 microM every 12 h for 3 days, produced a 38% reduction in outgrowth distance, associated with a 30% reduction in protein synthesis by the retinal ganglion cells and a 73% reduction in the amount of protein carried by the fast component of axonal transport.

Axonal regeneration in the rat sciatic nerve: effect of a conditioning lesion and of dbcAMP.

After the sciatic nerve had been crushed at the level of the mid-thigh, the rate of outgrowth of the regenerating axons was measured by using the pinch test to locate the leading sensory axons. This standard crush lesion ("testing" lesion) elicited axonal outgrowth at a rate of 4.3 +/- 0.1 mm/day, with an initial delay (before the axons entered the degenerating distal stump) of 1.6 days. A "conditioning" lesion (transection of the tibial nerve at the ankle), made two weeks before the testing lesion, caused an increase of 23% in the outgrowth rat (P less than 0.02), with no appreciable change in the initial delay. Dibutyryl cyclic AMP (dbcAMP) was found to have no effect on the rate of axonal outgrowth measured by the pinch test. Histological examination of the pinch-tested nerves showed that the drug also had no effect on the numbers of regenerating silver-stained axons or fluorescent noradrenergic axons seen at various levels distal to the testing lesion.

Ganglioside synthesis and transport in regenerating sensory neurons of the rat sciatic nerve.

The sciatic nerves of rats were crushed with fine forceps and allowed to survive for 3 or 7 days, at which time the 5th lumbar dorsal root ganglion was injected with [3H]glucosamine. Animals were killed 18 h later and the nerves proximal and distal to the crush site were cut into 3 mm segments. Gangliosides were purified from these segments, and radioactivity was separately measured in gangliosides, neutral glycolipids and glycoproteins. For all 3 fractions, radioactivity was distributed similarly between the crush site and point of maximum axonal elongation. A second smaller peak of ganglioside radioactivity was seen to span a few segments immediately distal to the point of maximum axonal elongation. We propose two possible explanations for this: (1) it represents ganglioside synthesis by Schwann cells (from blood-borne [3H]glucosamine) as part of the mitogenic response of these cells to the reappearance of axons; or (2) recently synthesized, transported gangliosides are released from the growth cone and taken up by adjacent mitogenic Schwann cells.

Nerve regeneration and thyroid hormone treatment.

On the basis of 3 reports that thyroid hormone treatment stimulates axon outgrowth in rats with nervous system injuries, a 43-year-old patient with an ulnar nerve laceration was given desiccated thyroid (up to 360 mg/day) following nerve suture. The Hoffmann-Tinel sign of sensory axon outgrowth advanced at a rate of 5.0 mm/day in the forearm, approximately 200% faster than the anticipated rate. A good functional result was obtained in 7 months. On the maximum dosage of desiccated thyroid, the patient developed mild weight loss associated with an increased appetite; there was no other sign or symptom of hyperthyroidism. Further investigation of the role of thyroid hormone during nerve regeneration seems warranted.

Hydrocephalus in coccidioidal meningitis: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Coccidioidomycosis was once confined to the southwest United States and northern Mexico. It has become a larger concern because of the concentration of military bases in these areas, the increasing mobility of populations, and the rising population of immunocompromised persons. Outside endemic areas, the diagnosis is rarely considered. Patients with coccidioidomycosis may develop occult basilar meningitis progressing to communicating hydrocephalus and death. CLINICAL PRESENTATION: A 60-year-old white man presented with a 1-month history of vertigo, falls, and vomiting. Computed tomography of the head revealed mild hydrocephalus. Lumbar puncture results were remarkable for 1065 mg/dl protein; acid-fast bacillus stain, Gram's stain, and culture results were negative. Postgadolinium magnetic resonance imaging demonstrated enhancement of basilar and cervical meninges, suggesting inflammation, and communicating hydrocephalus. For 48 hours, the patient's level of consciousness decreased progressively. INTERVENTION: A ventriculoperitoneal shunt was placed, and antifungal agents were initiated on an emergent basis. CONCLUSION: Coccidioidomycosis should be considered in the differential diagnosis of occult basilar meningitis. The diagnosis is established by the discovery of a high (>1:2) titer of complement-fixing antibody in the cerebrospinal fluid. Communicating hydrocephalus is a common complication of untreated coccidioidal meningitis, and it may develop during appropriate treatment (oral fluconazole, 200-400 mg/d, continued indefinitely). Patients with hydrocephalus and evidence of increased intracranial pressure require a shunt.

Treatment of normal pressure hydrocephalus with low versus medium pressure cerebrospinal fluid shunts.

In a retrospective study, 39 patients received a low pressure (20 to 50 mm H2O) shunt and 33 received a medium pressure (55 to 85 mm H2O) shunt for the treatment of normal pressure hydrocephalus (NPH). Pre- and postoperative computed tomographic scans were obtained in 32 patients, permitting us to determine the influence of shunt pressure on ventricular size. A reduction in 3rd ventricle width was found to correlate with clinical improvement and was observed more frequently after the placement of a low pressure shunt than after the placement of a medium pressure shunt. When results were evaluated in patients who did not have advanced NPH or develop postoperative complications, gait was markedly improved in 60% of those receiving a low pressure shunt as opposed to 23% of those receiving a medium pressure shunt (P less than 0.05).

Peripheral nerve surgery.

In treating the three main surgical problems of peripheral nerves--nerve sheath tumors, entrapment neuropathies, and acute nerve injuries--the overriding consideration is the preservation and restoration of neurologic function. Because of this, certain other principles may need to be compromised. These include achieving a gross total excision of benign tumors, employing conservative therapy as long as a disease process is not clearly progressing, and delaying repair of a nerve transection until the skin wound has healed. Only three pathophysiologic processes need be considered: neurapraxia (focal segmental dymyelination), axonotmesis (wallerian degeneration caused by a lesion that does not disrupt fascicles of nerve fibers), and neurotmesis (wallerian degeneration caused by a lesion that interrupts fascicles). With nerve sheath tumors and entrapment neuropathies, the goal is minimize the extent to which neurapraxia progresses to axonotmesis. The compressive force is relieved without carrying out internal neurolysis, a procedure that is poorly tolerated, presumably because a degree of nerve ischemia exists with any long-standing compression. When the nerve has sustained blunt trauma (through acute compression, percussion, or traction), the result can be a total loss of function and an extensive neuroma-in-continuity (scarring within the nerve). However, the neural pathophysiology may amount to nothing more than axonotmesis. Although this lesion, in time, leads to full and spontaneous recovery, it must be differentiated from the neuroma-in-continuity that contains disrupted fascicles requiring surgery. Finally, with open nerve transection, the priority is to match the fascicles of the proximal stump with those of the distal stump, a goal that is best achieved if primary neurorrhaphy is carried out.

Peripheral nerve surgery--today and looking ahead.

The trend in peripheral nerve surgery is toward earlier definitive treatment of the lesion, based on the optimal use of preoperative and intraoperative electrodiagnostic techniques. Newer diagnostic tools include computed tomography (CT) and thermography. Knowledge is still being gained about the technology and limitations of the autogenous nerve grafts that are being used to overcome nerve gaps. The technique of nerve anastomosis is undergoing rapid improvement, and better methods have been developed for identifying motor and sensory fascicles at the time of operation. Research activity into the problem of nerve damage produced at the time of trimming nerve stumps promises to change to the technology of nerve repair in the near future. For benign nerve sheath tumors (schwannoma, neurofibroma), the trend is away from nerve excision and in the direction of tumor enucleation. Histologic methods for diagnosing malignant nerve tumors have been improved, making it possible to embark on radical excision with less hesitation. The pain syndromes (causalgia, phantom limb pain, and stump pain) that may follow nerve injury continue to present a problem in management, but steady progress is being made toward a rational program of management. A more distant prospect is for pharmacologic and electrophysiologic methods to accelerate axonal regeneration.

Diagnostic status and treatment recommendations for Persian Gulf War Veterans with multiple nonspecific symptoms.

BACKGROUND: Unexplained symptoms have frequently been observed in deployed Persian Gulf War veterans (GWVs). Using factor analysis, the Centers for Disease Control and Prevention (CDC) has established criteria for Gulf War illness (GWI). We report here on the prevalence of GWI, identify comorbidities, and compare these with those of veterans without GWI. METHODS: GWVs who consented to complete questionnaires and laboratory measures were given complete physical and mental health examinations. Outcome measures included CDC criteria for GWI, the Medical Outcomes Study Short Form 36 (SF-36), clinical and laboratory evaluations, and structured psychiatric interviews. RESULTS: One hundred twenty GWVs were enrolled, and 89 received complete physical and mental health examinations; 83% met CDC criteria for GWI. Veterans with GWI (1) were older, (2) reported more combat exposure, (3) scored higher on measures of depression, post-traumatic stress disorder, and fibromyalgia, and (4) had poorer health-related quality of life. More than half had anxiety or depressive disorders, and 93% had at least one medical and/or psychiatric diagnosis. The SF-36 predicted mental health status with a positive predictive value of 81.58. By adding the Hamilton D rating for depression, the positive predictive value increased to 88.57. INTERPRETATION: The CDC criteria accurately identified GWVs negative for GWI. Most GWVs were positive for GWI. Neither CDC criteria nor CDC severity rankings distinguish between veterans with psychiatric syndromes and those without: both groups endorsed the same symptoms. More than half of those with GWI had a treatable anxiety or depressive disorder. The SF-36 was a valid predictor of mental health status, particularly when paired with the Hamilton depression interview.