Deep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor Syndromes.

INTRODUCTION: In tremor syndromes, pharmacological therapy is the primary treatment, but deep brain stimulation (DBS) is used when it is insufficient. We explore the use of DBS, focusing on the globus pallidus internus for dystonia and the ventral intermediate nucleus (VIM) for tremor conditions. We introduce the posterior subthalamic area (PSA) as a potential target, suggesting its efficacy in tremor reduction, particularly in rare tremor syndromes. We aim to evaluate the efficacy and safety of double targeting the VIM and PSA in rare tremor conditions, highlighting the limited existing data on this. METHODS: Between 2019 and 2023, 22 patients with rare tremor syndromes were treated with bilateral DBS of the VIM and PSA. This case series consisted of 7 isolated head tremor, 1 hepatic encephalopathic tremor due to Abernethy syndrome, 2 voice tremor, 4 dystonic tremor, and 8 Holmes tremor (2 multiple sclerosis, 2 cerebellar insult, and 4 posttraumatic) patients. Patients' preoperative and 12-month postoperative tremor scores were compared, and the optimum VIM and PSA stimulation areas were investigated. RESULTS: There was a significant reduction in the mean TRS score from 3.70 (±0.57) to 0.45 (±0.68) after 12 months of surgery. Specific outcomes for different indications were observed: for head tremor, 6 of 7 patients showed a reduction in TRS scores to 0 points; the vocal tremor patients demonstrated improvement; this change was not statistically significant, which is likely to be due to the low number of patients in this subgroup; the dystonic tremor patients showed either complete tremor abolition or a reduction in TRS scores; the Holmes tremor patients showed an 80% reduction in TRS scores; and the hepatic encephalopathy tremor and Abernethy syndrome patients showed a 75% improvement in TRS scores. The stimulation parameters converged on the VIM and dorsal PSA. Complications included the need for electrode repositioning, infections requiring electrode removal and re-implantation, dysarthria, and stimulation-induced ataxia, which was resolved by adjusting the stimulation parameters. DISCUSSION: The literature on DBS for rare tremors is limited. Double targeting of the VIM and PSA appears to produce promising improvements on the outcomes reported in the existing literature on VIM-only DBS. The proximity of the VIM and PSA allows for flexible electrode placement, contributing to the potential success of the dual-target approach. We also discuss the theoretical advantages of targeting the PSA based on the distribution of tremor circuits, emphasizing the need for further research and electrophysiological studies.

A new described mechanisms of intestinal glandular atrophy induced by vagal nerve/Auerbach network degeneration following subarachnoid hemorrhage: The first experimental study.

Stress ulcers is a trouble complication of subarachnoid hemorrhage (SAH). Although gastrointestinal ulcerations may be attributed to increased HCL secretion in SAH; the exact mechanism of that complication has not been investigated definitively. We studied if vagal network degeneration may cause intestinal atrophy following SAH. Study was conducted on 25 rabbits, with 5 control group (Group-A), 5 SHAM group (Group-B), and 15 SAH group via injection of autologue blood to cisterna magna. Seven animals followed for seven days (Early Decapitated-Group-C) and eight animals followed 21 days (Late Decapitated-Group-D). The vagal nodosal ganglia (NGs), Auerbach plexuses and goblet cells of duodenums were examined by current stereological methods and compared statistically. The mean numbers of degenerated axon density/mm2 of gastric branches of vagal nerves was 8 ±â€¯2, 34 ±â€¯11, 189 ±â€¯49 and 322 ±â€¯81 in the Group A, B, C, and D respectively. The mean numbers of degenerated neuron density/mm3 of NGs was 5 ±â€¯2, 54 ±â€¯7, 691 ±â€¯87 and 2930 ±â€¯410 in the Group A, B, C, and D respectively. The mean numbers of degenerated Auerbach neurons 2 ±â€¯1, 4 ±â€¯1, 12 ±â€¯3 and 27 ±â€¯5/mm3 in the Group A, B, C, and D respectively. The mean numbers of degenerated goblet cells/mm3 were 4.3 ±â€¯1.02, 11.5 ±â€¯0.26, 143 ±â€¯26 and 937 ±â€¯65 Group A, B, C, and D respectively. Statistical analysis showed that vagal network ischemia could cause intestinal bleeding and so atrophy in SAH progression. Statistical analyses of groups were; Group-D/Group-A < 0.001, Group-D/Group-B < 0.005, Group-C/Group-A < 0.005. Undiscovered effect of ischemic vagal network injuries should be regarded as a major cause of stress ulcerations following SAH which has not been mentioned in the literature.

Protective effects of alpha-lipoic acid on experimental sciatic nerve crush injury in rats: assessed with functional, molecular and electromicroscopic analyses.

AIM: The present study aimed to demonstrate protective effects of alpha lipoic acid on experimental sciatic nerve crush injury model assessed with functional and electronmicroscopy analyses. METHODS: In this study, groups were; Group 1; sham operated, Group 2; applied only sciatic nerve crush (Control), Group 3; Sciatic nerve crush + treated ALA 25 mg/kg (received orally) and Group 4; Sciatic nerve crush + treated ALA 50 mg/kg. Subsequently, sciatic nerves crush injury induced by forceps. At the second and fourth week, all animals were evaluated for sciatic functional index (SFI) and histomorphometric analyses with electronmicroscopy. RESULTS: The SFI was significantly increased for both ALA-treated groups 30 days post-injury compared with control groups. The elecronmicroscopy results demonstrated that the axon diameter, the myelin diameter, the area of regenerating axon and miyelin were better in the treatment group than in the control group. Also ALA decreased IL-1ß and Caspase 3 levels that increased in SNC group. CONCLUSIONS: These results suggest that ALA neuroprotective agent for peripheral nerve injury (PNI) and promoted peripheral nerve regeneration via its anti-inflammatory and antiapoptotic effects.

The Osborn wave in accidental hypothermia.

Hypothermia is generally defined as a core body temperature less than 35 degrees C (95 degrees F), and is one of the most common environmental emergencies encountered by emergency physicians. A 32-year-old male hunter was admitted to the hospital with altered mental status. He remained unconscious, Glasgow Coma Scale (GCS) score was recorded as 5/15, and pupils were dilated and unreactive. His vital signs showed a heart rate of 48 beats/min, respiratory rate of 10 breaths/min, blood pressure of 95/50 mm Hg, and rectal temperature of 31 degrees C. An electrocardiogram (ECG) was obtained and showed marked sinus bradycardia and J waves. His finger-stick glucose was 85. He was intubated. After 3 h of active rewarming, his temperature was 34 degrees C, and the repeat ECG showed near-complete resolution of the J waves and acceleration of the sinus rate to 68 beats/min. At the same time, emergency head computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) and subdural hemorrhage. The patient died on the third day of admission. In this case we want to indicate that J waves and obtunded state could be due to either SAH or hypothermia, and SAH could have been missed if initial obvious hypothermia had been believed to cause all symptoms.

Air guns: toys or weapons?

Air guns and blank guns may appear relatively harmless at first glance, but they are, in fact, potentially destructive, even lethal, weapons. Approximately 2 to 2.5 million nonpowder firearms are sold annually, and again approximately 12.9 per 100,000 population are treated for such injuries in hospital emergency departments each year in the United States. Unfortunately, these guns are considered to be a toy for children. Therefore, incidents of air gun injuries are gradually increasing. Although such injuries may initially be considered trivial, it may signify severe internal tissue pathologies. These apparently trivial injuries may have catastrophic consequences if unnoticed. In this study, we report 4 cases with head injury due to a shot by these guns. The cases indicate that these people had used the guns belonging to their parents for the purpose of suicide. The cases also show that these machines are not innocent.