Rolandic type cerebral palsy in children as a pattern of hypoxic-ischemic injury in the full-term neonate.

Magnetic resonance images (MRIs) of the brains of 11 patients aged from 1 week to 12 years with a distinctive type of cerebral palsy were selected based on distribution of cerebral lesions, which were restricted to bilateral perirolandic cortical and subcortical regions, including frequent symmetric involvement of basal ganglia and ventrolateral nucleus of thalami. Retrospectively, the perinatal history and clinical features were reviewed to correlate clinical data with this distinctive pattern of brain injury. Clinically affected neonates had an encephalopathy associated with a severe perinatal asphyxial event. Older children with cerebral palsy survived a similar perinatal course and demonstrated spastic quadriparesis with bulbar or pseudobulbar involvement, lack of verbal speech and variable delays in cognitive development. The distribution of hypoxic-ischemic lesions involving bilateral perirolandic regions, basal ganglia, and thalami, appears to correlate with increased metabolic areas of primary myelination in full-term neonates, but not with arterial border zones nor a single cerebral artery distribution. Myelination is a critical process in maturing brain associated with marked increase in tissue respiration and thus greater susceptibility to oxygen deprivation. It is believed that the extent of hypoxic-ischemic brain injury is determined principally by brain maturity and regional metabolic rates at time of insult and this correlates with active myelination in full-term neonates. This study confirms previous data from neuropathologic literature and recent reports of neuroimaging studies of asphyxiated neonates. In addition, retrospective analysis of the clinical data enables recognition of a type of cerebral palsy that might be the hallmark of hypoxic-ischemic injury in term neonates.

Outcome of patients with small-cell lung cancer during 20 years of clinical research at the US National Cancer Institute.

OBJECTIVE: To determine the outcome of all patients with small-cell lung cancer (SCLC) treated at the US National Cancer Institute between April 1973 and April 1993. DESIGN: We retrospectively analyzed a series of 594 consecutive patients with SCLC treated at a single institution during a 20-year period to assess changes in duration of survival and toxicity related to various treatment regimens. MATERIAL AND METHODS: For analysis, patients were grouped by decade, and the duration of survival of patients with limited- and extensive-stage SCLC was examined to assess whether patients treated during the first decade of the study (1973 through 1983), when cyclophosphamide-based regimens were used, had different outcomes than those treated during the second decade (1983 through 1993), when cisplatin-based regimens were used. Patients had a minimal follow-up of 2 years. RESULTS: No significant difference was found in the survival of patients with limited- or extensive-stage SCLC treated during the second decade in comparison with during the first decade of the study. Among patients with extensive-stage SCLC, performance status 3 or 4 and metastatic lesions of the liver and central nervous system had a significant adverse effect on survival in both the first and the second decade. Among patients with limited-stage disease, performance status 3 or 4 had the most significant adverse influence on survival during the overall study period. In addition, in a multivariate analysis, etoposide-cisplatin plus twice-daily chest radiotherapy was significantly associated with prolonged survival (P = 0.003). CONCLUSION: We noted no significant change in the duration of survival of patients with either limited-or extensive-stage SCLC treated at our institution during a 20-year period. A multivariate analysis showed that patients with limited-stage SCLC given a cisplatin-based regimen plus chest radiotherapy lived modestly longer than similar patients given cyclophosphamide regimens at our institution. No evidence was found of changes in pretreatment factors that would affect survival.

Magnetic resonance angiography demonstrates vascular healing of carotid and vertebral artery dissections.

BACKGROUND AND PURPOSE: Dissection of the carotid and vertebral arteries is most accurately diagnosed with conventional angiography. MR techniques are sensitive for detecting the abnormalities associated with dissection but may lack specificity. We hypothesized that MR may be useful for serial monitoring of dissection and may therefore guide therapy. METHODS: All patients with angiographically proven carotid and/or vertebral artery dissection from July 1994 to June 1996 were followed for a median duration of 10.5 months. Of these 29 patients (44 vessels), 18 were concurrently evaluated with MR, and a target group of 9 patients (17 vessels) was prospectively followed with MR at 3-month intervals. RESULTS: In the 18 patients with both imaging studies at baseline, angiography revealed 30 dissected vessels while MR detected 27 (90%). In the target group of 9 patients, initial MR identified 15 of the 17 dissections diagnosed with angiography. Serial MR revealed complete healing in 5 vessels, improvement in 6 vessels, no change in 4 vessels, and worsening in 2 vessels. The radiographic features most likely to resolve were stenosis and mural hematoma, while occlusion and luminal irregularity tended to persist. Late ischemic events occurred in 2 patients, both with persistent MR evidence of dissection, one while subtherapeutic on warfarin therapy and the other occurring 1 week after warfarin was discontinued. CONCLUSIONS: MR is a reliable noninvasive method for following the vascular response to treatment and may guide the course of a clinical trial comparing medical therapies for carotid and vertebral artery dissection.

Capillary hemangioma of the neck: prenatal MR findings.

Prenatal MR findings of a case of extracranial capillary hemangioma simulating an encephalocele at sonography are reported. MR imaging had an adjunctive diagnostic role in excluding the possibility of an encephalocele. The capillary hemangioma had diffuse T2 hypointensity prenatally, which is atypical of postnatal imaging findings.

Anterior choroidal artery aneurysm and stroke.

We report the unique combination of a mid anterior choroidal artery (AChA) aneurysm and ischemic stroke presenting as a movement disorder in a young man. The mechanism for stroke in the AChA territory may either reflect a cause or an effect of aneurysm formation. We provide evidence for both arguments and speculate on the anatomic basis for the initial presentation of hemibody spasm.

Patients with limited-stage small-cell lung cancer treated with concurrent twice-daily chest radiotherapy and etoposide/cisplatin followed by cyclophosphamide, doxorubicin, and vincristine.

PURPOSE: A phase II trial in patients with limited-stage small-cell lung cancer treated with induction etoposide/cisplatin plus twice-daily chest radiotherapy was conducted in an attempt to increase response rates and prolong survival. PATIENTS AND METHODS: Fifty-four previously untreated patients with limited-stage small-cell cancer were treated with etoposide/cisplatin and concurrent radiotherapy at 1.5 Gy twice daily for 3 weeks to a total dose of 45 Gy. Patients then received three more cycles of etoposide/cisplatin followed by four cycles of vincristine, doxorubicin, and cyclophosphamide or an individualized chemotherapy regimen. RESULTS: Nine patients are alive and free of cancer a median of 4 years (range, 2 to 7) from the start of treatment. Thirty-eight have had progression of their cancer at a median of 1.2 years (range, 0.5 to 5.4) and all have died of small-cell cancer. Thirteen of these 38 patients' (34%) only site of initial relapse was in the CNS and all died of CNS metastases. Five patients died during therapy or from its complications and two patients died of causes other than relapsed small-cell lung cancer and toxicity. The median survival time is 21.3 months, with an actual survival rate of 83% at 1 year, and actuarial survival rates of 43% at 2 years and 19% at 5 years. CONCLUSION: This combined modality regimen for patients with limited-stage small-cell lung cancer results in a 2-year survival rate of 43%, but the principal cause of death in these patients is still relapse of the original cancer. Isolated CNS metastases caused more than 30% of the cancer deaths.

Obesity and therapy-related toxicity in patients treated for small-cell lung cancer.

BACKGROUND: Obese individuals have altered pharmacokinetics for many medications when compared with the non-obese. For the oncologist treating an obese cancer patient, these changes in drug disposition may potentially cause increased therapy-related toxicity. As a consequence, oncologists frequently treat obese patients with dose reductions in an effort to decrease chemotherapy toxicity. However, little clinical data exist to either support or refute this policy. PURPOSE: The clinical course of a cohort of patients treated for small-cell lung cancer (SCLC) was evaluated to determine if the obese patients had an increase in therapy-related toxicity. METHODS: The study sample included 262 patients with histologically confirmed SCLC treated in clinical trials from 1977 through 1993. Before 1986, patients with limited stage SCLC were treated with a cyclophosphamide-based regimen with (n = 47) or without (n = 46) chest radiotherapy. Subsequent patients with limited stage disease (n = 54) received etoposide and cisplatin plus twice-daily chest radiotherapy. Patients with extensive stage SCLC were randomly treated with standard-dose (n = 46) or high-dose etoposide plus cisplatin (n = 44); poor-risk patients with extensive stage disease (n = 25) were assigned to standard dose etoposide plus cisplatin. For all patients, actual body weight was used when determining initial doses of chemotherapy. The measure of relative weight was the body mass index (BMI), which was calculated from the pretreatment height and weight data. The BMI was evaluated both on a continuum and with patients grouped into BMI levels (normal, obese, and severely obese). Toxicity parameters were collected during induction chemotherapy and were compared with the BMI. In addition, the overall survival of the entire cohort was evaluated, with patients divided into different groups based on their BMI level. RESULTS: We performed 170 comparisons between the BMI as a continuum or the BMI level and the 15 toxicity parameters. There were no consistent associations of significance found between increasing BMI or BMI levels and increasing toxicity from therapy. When survival was evaluated, no statistically significant differences were found between the survival of patients within the different BMI levels. CONCLUSIONS: In this group of 262 patients with SCLC, obesity at the start of treatment was not associated with increased toxicity from treatment or a shortened survival. No support for empiric chemotherapy dose reductions based on ideal body weight was evident from this study.

Rheumatoid nodulosis of the meninges.

Rheumatoid nodulosis of the brain and leptomeninges has been reported only rarely, usually in patients with severe rheumatoid arthritis (RA). We describe the occurrence of leptomeningeal rheumatoid nodulosis occurring in a patient with nondeforming RA occurring in the setting of methotrexate therapy.

MR imaging of diplomyelia.

We present an unusual case of duplication of the fifth lumbar vertebra and sacrum in a 6-year-old boy. The spinal cord was also duplicated and tethered by bone spurs bilaterally. The imaging features and the embryological basis of diplomyelia are discussed.

The significance of carotid stenosis or ulceration.

Data from the medical treatment group of the Aspirin in TIA study were reviewed, and prospective analysis of patients with asymptomatic bruits was performed to see whether carotid stenosis (0 to 49% or 50 to 99%) or ulceration produced an increased risk of ipsilateral TIA or infarct. In symptomatic arteries, greater than 50% stenosis without ulceration implied a higher risk of subsequent symptoms. Ulceration was associated with an increased risk only in nonstenotic vessels. Lesion anatomy was not related to outcome in asymptomatic arteries, and the incidence of cerebral infarct was low. Factors other than anatomy must play a large role in determining subsequent risk.

Bovine adrenal chromaffin cells: high-yield purification and viability in suspension culture.

A method for purifying chromaffin cells from adult, bovine, adrenal medullae and the techniques for maintaining the cells in suspension culture for at least 14 days are presented. Perfusion of medullae with a collagenase-containing medium produced a cell fraction that contained, in addition to chromaffin cells, a significant percentage of non-chromaffin cells. These cells were found to attach more rapidly than chromaffin cells to glass and tissue-culture plasticware. Using this property, we devised a selective plating procedure that yielded approximately 1-2 x 10(8) chromaffin cells per adrenal medulla at a purity of 95% or higher. On the basis of catecholamine levels and enzyme activities, suspension (as opposed to monolayer) cultures were chosen to further investigate their potential as a model system for the regulation of adrenergic function. In contrast to chromaffin cells cultured in monolayer, chromaffin cells in suspension had a more rounded appearance and formed multicellular aggregates with time in culture. Very few neurite-like structures, commonly observed in monolayer cultures, were present in the suspension cultures. Also, inhibitors of mitosis were not necessary to prevent overgrowth by non-chromaffin cells as there was little or no cell division in the suspension cultures. Catecholamine levels were relatively stable for at least 2 weeks, although a gradual decline in epinephrine occurred after day 5. Unlike other enzymes involved in catecholamine metabolism, phenylethanolamine N-methyl transferase activity declined significantly with time in culture in parallel to the gradual loss of epinephrine. In addition, both oxygen consumption and amino acid incorporation into proteins were relatively stable. Thus, the primary suspension cultures of adult, bovine chromaffin cells seem to offer several advantages for studying long-term regulation of chromaffin cell function and provide a stable source of adrenergic cells for examining short-term regulatory processes.

Parental trisomy 21 mosaicism.

A family with three children with trisomy 21 in which the mother is a phenotypically normal, trisomy 21/normal mosaic was studied. Chromosome 21 fluorescent heteromorphisms were used to document that two of the three number 21's in two of the Down syndrome offspring were of maternal origin. Five cytogenetic surveys in which both parents of a child with trisomy 21 were studied have been reviewed. From these data, it is estimated that 3% of couples producing a child with trisomy 21 can be explained by parental mosaicism. From 17 informative sibships, with one parent mosaic, the segregation ratio was estimated to be 0.43 +/- 0.11.

Reproductive risk of t(13q14q) carriers: case report and review.

We report a four-generation kindred with a balanced 13q14q Robertsonian translocation. The proband had the Down sydrome, due to trisomy of chromosome 21; he also carried the balanced D-group translocation. S segregation analysis of 86 sibships was performed to examine the risk of t(13q14q) carrier parents having trisomy 21, 47,XXY, or trisomy 13 children by which a number of families were ascertained. None of these disorders recurred after birth of the propositi. The frequency of abortions was not different from that of the general population. The conditional segregation ratio for balanced translocation carriers among the phenotypically normal offspring of carrier parents was 0.55 +/- 0.04.

Impaired retention of visual discriminated escape training produced by subseizure amygdala stimulation.

These experiments examined the effects on memory of posttrial, subseizure, electrical stimulation of the amygdala. Rats were trained in a visual discriminated avoidance Y-maze. Each animal received 6 tirals on the training day. Retention, tested the following day, was measured both by the number of correct choices on the first 6 retraining trials and by the number of trials to a criterion of 5 of 6 correct choices. If administered 2 min, 1 h, or 4 h, but not 10 h, after training, bilateral amygdala stimulation significantly impaired retention as measured 24 h after training. In a second experiment, rats received unilateral amygdala stimulation in order to examine better the anatomical localization of effective stimulation sites. The unilateral stimulation was administered either 2 min, 10 min, 1 h, or 4 h after training. The behavioral procedures were the same as those used in the first experiment. For animals stimulated 2 min after training, the optimal stimulation region was one which extended rostrally from the ventrolateral portion of the basomedial nucleus to the dorsomedial region of the amygdala near the stria terminalis and nucleus centralis. For animals stimulated after a 10 min training-treatment interval, this amygdala region was not an effective stimulation site. However, in these animals, stimulation of the basolateral nucleus impaired later retention. Unilateral, posttraining amygdala stimulation administered 1 or 4 h after training did not appear to produce retention deficits. The findings of these experiments thus indicate that posttrial unilateral or bilateral amygdala stimulation impairs retention of discriminated avoidance training. Furthermore, the specific amygdala site at which posttrial stimulation impairs later retention varies with the training-treatment interval.