[Neurosurgery for Spasticity].

The sequelae of neurosurgical diseases are an increasingly important component of neurologists' clinical practice. Moreover, spasticity is one of the most common of these effects. While spasticity may be useful in compensating for a loss in motor strength, it frequently becomes harmful and leads to further functional losses. When patients with harmful spasticity cannot be managed through physical therapy, neurosurgical treatment must be considered. We present the current state of knowledge relating to the assessment and treatment of spasticity, especially selective peripheral neurotomy and intrathecal baclofen therapy. To continue developing therapies for spasticity, we must be familiar with the characteristics of various treatment methods used to treat spasticity and create frameworks for regional alliances that focus primarily on education and rehabilitation programs targeting spasticity treatment that involve patients, patients' families, and medical staff.

Reductive Amination/Cyclization of Keto Acids Using a Hydrosilane for Selective Production of Lactams versus Cyclic Amines by Switching of the Indium Catalyst.

Described herein is that the catalytic construction of N-substituted five- and six-membered lactams from keto acids with primary amines by reductive amination, using an indium/silane combination. This relatively benign and safe catalyst/reductant system tolerates the use of a variety of functional groups, especially ones that are reduction-sensitive. A direct switch from synthesizing lactams to synthesizing cyclic amines is achieved by changing the catalyst from In(OAc)3 to InI3. This conversion occurs by further reduction of the lactam using the indium/silane pair.

Pain Relief Following Selective Tibial Neurotomy for Spastic Equinus Foot Secondary to Stroke and Traumatic Brain Injury.

OBJECTIVE: Selective tibial neurotomy (STN) has been indicated for spastic equinus foot (SEF); however, the impact of this procedure on quality of life and activities of daily living has not been evaluated in detail. This study aimed to evaluate the surgical outcomes of STN and its effect on SEF accompanied by pain. METHODS: We evaluated 26 patients (mean age: 59.6 ± 15.2 years; 14 men and 12 women) who underwent STN for SEF, 10 of whom complained of spontaneous pain preoperatively. We used the following scales for clinical evaluation: the Modified Ashworth Scale, Medical Research Council (MRC), 10-m walking test, Functional Independence Measure, and numeric rating scale for pain. These scales were evaluated preoperatively and postoperatively. Differences in clinical characteristics were compared between the 10 patients with pain and the 16 patients without pain. RESULTS: Significant differences were observed in all evaluation scale scores except for the Functional Independence Measure, and no serious adverse events were reported. Pain intensity was significantly improved from 6.4 ± 2.0 to 2.7 ± 2.3 (P < 0.05). An analysis showed that the preoperative mean Medical Research Council score of ankle movement was significantly lower in patients with pain but recovered to the same level postoperatively at the 6-month follow-up. CONCLUSIONS: Our study showed significant improvements in spasticity and its associated symptoms, and STN effectively addressed spastic pain and motor weakness. Among various treatment modalities, STN may be positively indicated for patients with spastic pain in the lower leg.

Successful long-term deep brain stimulation for hemichorea-hemiballism in a patient with diabetes. Case report.

The authors report a case of hemichorea-hemiballism (HC-HB) that was successfully treated using deep brain stimulation (DBS). A 65-year-old right-handed man exhibited a sudden onset of right HC-HB without a diabetic coma. At admission T1-weighted magnetic resonance (MR) images revealed a high-intensity signal in the left striatum, contralateral to the patient's involuntary movements. The HC-HB continued for 5 months after onset of the condition despite medical treatment and a decreased intensity of the signal on T1-weighted MR images. The patient underwent placement of a quadripolar DBS electrode in the left thalamus, including the left ventral oralis (VO) anterior and posterior nuclei (the VO complex). Postoperatively, the right-sided HC-HB disappeared rapidly during electrical stimulation and there were no neurological deficits. The authors demonstrate that DBS can be an effective treatment for medically refractory HC-HB. This is the first case of HC-HB that has been successfully treated with DBS.

Chronic motor cortex stimulation in the treatment of central and neuropathic pain. Correlations between clinical, electrophysiological and anatomical data.

Thirty-two patients with refractory central and neuropathic pain of peripheral origin were treated by chronic stimulation of the motor cortex between May 1993 and January 1997. The mean follow-up was 27.3 months. The first 24 patients were operated according to the technique described by Tsubokawa. The last 13 cases (eight new patients and five reinterventions) were operated by a technique including localisation by superficial CT reconstruction of the central region and neuronavigator guidance. The position of the central sulcus was confirmed by the use of intraoperative somatosensory evoked potentials. The somatotopic organisation of the motor cortex was established peroperatively by studying the motor responses at stimulation of the motor cortex through the dura. Ten of the 13 patients with central pain (77%) and ten of the 12 patients with neuropathic facial pain had experienced substantial pain relief (75%). One of the three patients with post-paraplegia pain was clearly improved. A satisfactory result was obtained in one patient with pain related to plexus avulsion and in one patient with pain related to intercostal herpes zooster. None of the patients developed epileptic seizures. The position of the stimulating poles effective on pain corresponded to the somatotopic representation of the motor cortex. The neuronavigator localisation and guidance technique proved to be most useful identifying the appropriate portion of the motor gyrus. It also allowed the establishment of reliable correlations between electrophysiological-clinical and anatomical data which may be used to improve the clinical results and possibly to extend the indications of this technique.

[A case report of tuberculous meningitis: limits of detection using polymerase chain reaction (PCR) and treatments].

A 40-year-old man with intractable meningitis was transferred to our hospital 6 weeks after onset. On admission, he showed consciousness disturbance, meningeal signs and right oculomotor nerve palsy. MRI demonstrated prominent cisternal enhancement and hydrocephalus. We suspected tuberculous meningitis as the diagnosis, and treated with antituberculotics, though he died of midbrain infarction day 11 of the treatment. Before and during the admission, bacterial cultures, PCR, smear examination of cerebrospinal fluid(CSF) were repeated. But no evidence of tuberculosis was obtained. Cultures of the brainstem fragments detected mycobacterium, which was finally confirmed by a PCR method after his death. PCR provides a rapid and reliable diagnosis of tuberculous meningitis, although there is a potential for false-negative. Thus the clinical, radiological and CSF findings should be stressed. Corticosteroids treatment should be considered in cases with ischemic lesions.

Dicyclopenta[a,d]cyclooctene: A [14]Annulene Containing Two Zero-Atom Cross-Links.

14π-Electrocyclization across the two pentafulvenoid moieties of pentafulvene 1 occurs upon heating to provide dicyclopenta[a,d]cyclooctene 2 [Eq. (1)]. The nonalternant hydrocarbon 2 shows diatropic character and a distinctive absorption spectrum with the longest wavelength maximum at 767 nm.

Spinal syringomyelia following subarachnoid hemorrhage.

Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated at Kinki University School of Medicine. Two of the 198 patients had syringomyelia following aneurysmal SAH; thus the rate of syringomyelia associated with aneurysmal SAH was 1.0%. Patient 1 was a 54-year-old woman who presented with back pain, back numbness and gait disturbance 20 months after SAH. Her MRI revealed syringomyelia of the spinal cord from C2 to T10. She underwent shunting of the syrinx to the subarachnoid space. Patient 2 was a 49-year-old man, who was admitted to the hospital with headache, diplopia, hoarseness, dysphagia and ataxia five months after SAH. MRI revealed syringomyelia from the medulla oblongata to C6, and an enlargement of the lateral and fourth ventricles. After foramen magnum decompression and C1 laminectomy, a fourth ventricle-subarachnoid shunt was placed by insertion of a catheter. Spinal arachnoiditis and spinal syringomyelia are rare but important chronic complications after SAH.

Neuromodulation using intrathecal baclofen therapy for spasticity and dystonia.

Intrathecal baclofen (ITB) therapy is a treatment for intractable spasticity due to a variety of causes. Continuous intrathecal administration of baclofen, an agonist of the inhibitory neurotransmitter γ-aminobutyric acid, inhibits excitation of motor neurons at the spinal level and thus suppresses spasticity. This therapy was introduced clinically in the Europe and the United States in the 1990s, and was finally approved by the Japanese Ministry of Health, Labour and Welfare in Japan in 2005. Clinical use has been permitted since 2006, and reports of therapeutic efficacy are now appearing in Japan. ITB therapy is a non-destructive treatment that enables administration of baclofen from an implantable pump under the control of a programmer, and represents an outstanding treatment method offering both reversibility and adjustability. Indications for ITB therapy have been expanding in recent years to include not only spasticity, but also various causes dystonia. And ITB therapy can greatly improve activities of daily living and quality of life, and this treatment is attracting attention as a neuromodulatory therapy that also affects metabolic and respiratory functions and even state of consciousness. We here report the surgical methods and therapeutic outcomes for 22 patients who underwent ITB therapy for spastic and dystonic patients in our hospital, together with an investigation of the effects on metabolic and respiratory functions.

Hemiparesis caused by cervical spontaneous spinal epidural hematoma: a report of 3 cases.

We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C3-C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2-C4 level. The condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical symptoms of sudden neck pain and radicular pain with progression to hemiparesis.

Feasibility study of the simultaneous integrated boost (SIB) method for malignant gliomas using intensity-modulated radiotherapy (IMRT).

BACKGROUND: Intensity-modulated radiotherapy (IMRT) using the simultaneous integrated boost (SIB) method was designed for treating malignant gliomas. The purpose of this study was to investigate feasibility of this treatment. METHODS: Between December 2000 and November 2002, six patients with malignant gliomas were enrolled in this study. IMRT delivered 70 Gy/28 fractions (fr)/daily 2.5 Gy to the gross tumor volume (GTV) and 56 Gy/28 fr/daily 2.0 Gy to the surrounding edema defined as the clinical target volume annulus (CTV-a). The feasibility of the treatment was assessed from both physical and clinical points of view. RESULTS: No delay due to acute radiation toxicity was observed in any of the patients. The tumor recurred locoregionally in five of the six patients. The glioblastoma (GBM) recurred in two patients during the radiotherapy and in three patients at 5.4, 4.0 and 7.0 months after the start of radiotherapy. The sites of recurrence or progression were local in the GTV in four patients and in one patient subependymal dissemination was observed. Three patients, two with GBMs and one with anaplastic astrocytoma, died of the disease at 4, 16 and 7 months after the start of radiotherapy, respectively. CONCLUSIONS: The treatment of 70 Gy/28 fr/daily 2.5 Gy to the GTV and 56 Gy/28 fr/daily 2.0 Gy to the CTV-a was feasible both physically and clinically.