The role of modern imaging modalities on deep brain stimulation targeting for mental illness.

INTRODUCTION: The reversible nature of deep brain stimulation (DBS) brought renewed interest on surgery to medically intractable mental illnesses. The explosion of anatomical and functional imaging has allowed the development of new potential targets and the understanding of historical targets. METHODS: Fifteen patients undergoing stereotactic surgery for movement disorders, at UCLAs interventional MRI operating-room, were studied with fiber tracking. Stereotactic targets and fiber tracking were determined on MRIs using the Schaltenbrand-Wahren atlas for definition in the iPlan software. Cingulate, subcaudate, BA25/CgWM, amygdala, posterior hypothalamus, orbitofrontal cortex, nucleus accumbens, anterior limb of the internal capsule and dorsomedial thalamus were studied. DTI parameters used ranged from 10 to 20mm for voxel size in the x/y/z planes, fiber length was kept constant at 36 mm, and fractional anisotropy (FA) threshold varied from 0.20 to 0.25. RESULTS: Reliable interconnectivity of targets were determined with DTI and related to PET imaging. Mental illness targets were observed with functional and fiber tract maps. This confirmation yields reliability to DTI imaging in order to determine novel targets and enhance the understanding of areas not well understood. CONCLUSIONS: Currently available imaging techniques, the reversibility of DBS to modulate targets promises to bring a brighter future for surgery of mental illness.

[Early and late physiological effects of balloon mitral valvuloplasty]. / Adaptações fisiológicas precoces e tardias após valvotomia mitral por cateter balão.

PURPOSE: To evaluate the early and late cardiorespiratory responses after balloon mitral valvuloplasty. METHODS: Nine female patients aged 35 +/- 9 years with mitral stenosis, in class II or III (NYHA) underwent up-right ergoespirometric test, resting electrocardiogram and echocardiogram before, 3 to 5 days (early evaluation) and 8 to 12 months (late evaluation) after mitral valvuloplasty. All patients were treated with digitalis and diuretics. RESULTS: During late evaluation, 44% patients were in class II and 56% were in class I (NYHA). The resting heart rate decreased (87 +/- 11 bpm vs 85 +/- 7 bpm vs 75 +/- 9 bpm) and the number of steps increased (4 +/- 1 steps vs 5 +/- 2 steps vs 6 +/- 1 steps); the peak oxygen uptake improved only in the late evaluation (16 +/- 3 mL/kg/min vs 18 +/- 4 mL/kg/min vs 22 +/- 7 mL/kg/min). The anaerobic threshold, minute ventilation (VE) and ventilatory equivalent for oxygen showed no change. The heart rate (1st step: 124 +/- 18 bpm vs 112 +/- 13 bpm vs 87 +/- 15 bpm), O2 uptake (1st step: 10 +/- 2 mL/ kg/min vs 8 +/- 2 mL/kg/min vs 8 +/- 2 mL/kg/min) and VE decreased during submaximal exercise in early and late phases. The mitral valve area decreased in the late evaluation (0.94 cm2 vs 1.66 cm2 vs 1.20 cm2). CONCLUSION: Although partial restenosis tended to occur in these patients, they improved the functional class and cardiorespiratory performance and cardiocirculatory load during submaximal exercise.

[Cardiorespiratory response during exercise in heart transplant recipients. Comparative ergoespirometric analysis with normal health subjects]. / Respostas cardiorrespiratórias durante exercício em portadores de transplante cardíaco. Análise ergoespirométrica comparativa com indivíduos normais.

PURPOSE: To evaluate the cardiorespiratory response of heart transplant (HT) recipients. METHODS: Nine HT recipients (GI) underwent ergospirometric tests and were compared to 9 apparently healthy, sedentary subjects with similar sex, age, weight and height (GII). All were male patients aging 48 +/- 12 years, in functional class I (NYHA) an average of 23 +/- 21 months after HT. They were receiving cyclosporin, azathioprine, prednisone, dipyridamole and antihypertensive drugs. The tests were symptom-limited and they were interrupted due to exhaustion. RESULTS: During peak exercise, GI had a significantly lower physical performance related to lower VO2, VE, VEO2, HR, endurance time and work load. At the anaerobic threshold, VO2, endurance time and work load levels were also significantly lower in GI. The physical performance was similar between the groups in the 40W load. CONCLUSION: The cardiorespiratory performance in GI was significantly lower at peak exercise and similar to GII in the 40W load, showing the HT benefits cardiac patients during usual activities.

Adaptaçöes fisiológicas precoces e tardias após valvotomia mitral por cateter baläo / Early and late physiological effects of balloon mitral valvuloplasty

OBJETIVO - avaliaçäo näo invasiva das respostas cardiopulmonares ao exercício a curto e longo prazo após valvotomia por cateter baläo. MÉTODOS - Estudaram-se 9 pacientes do sexo feminino, 35ñ9 anos, com estenose mitral, tipo funcional II ou III, em uso de digitálicos e diuréticos, através de teste ergoespirométrico, eletrocardiograma e ecocardiograma, antes e após valvotomia em fase precoce (3 a 5 dias) e tardia (8 a 12 meses). RESULTADOS - Os pacientes evoluíram para tipo funcional II (44 por cento) ou I (56 por cento), na fase tardia. Houve reduçÝo da freqüência cardíaca de repouso (87ñ11bpm vs 85ñ7bpm vs 75ñ9bpm) e elevaçäo do número de estágios (4ñ1 estágios vs 5ñ2 estágios vs 6ñ1 estágios); a capacidade aeróbica máxima aumentou apenas na fase tardia (16ñ3mL/kg/min vs 18ñ4mL/kg/min vs 22ñ7mL/kg/min). O limiar anaeróbico, a ventilaçäo pulmonar e o equivalente ventilatório do O2 (Oxigênio 2) permaneceram inalterados. Nas cargas submáximas de exercício ocorreu reduçäo da freqüência cardíaca (estágio I: 124ñ18bpm vs 112ñ13bpm vs 87ñ15bpm), consumo de O2 (Oxigênio 2) (estágio I: 10ñ2mL/kg/min vs 8ñ2mL/kg/min vs 8ñmL/kg/min) e ventilaçäo pulmonar, nas fases precoce e tardia. A área valvar mitral mostrou reduçöes na fase tardia (0,94cm² vs 1,66cm² vs 1,20cm²). CONCLUSÄO - Apesar da tendência à reestenose parcial, houve melhora no tipo funcional e no desempenho cardiopulmonar com diminuiçäo da sobrecarga circulatória no exercício submáximo.

Primary central nervous system lymphoma. Results at the University of California at Los Angeles and review of the literature.

The authors report 24 patients with primary central nervous system lymphoma (PCNSL) treated from 1977 to 1992. There were 13 females and 11 males. Median age was 57 (range: 17-84). Patients were symptomatic for a median of 3 months. Headache was the most common complaint. Median Karnofsky performance score was 70. There were 19 patients with solitary PCNSL, and 5 had multiple deposits. Disease was confined to the supratentorium in 23 patients. Cerebrospinal fluid cytology was positive in 5 of 22 patients examined. All patients received whole-brain irradiation with or without supplemental tumor boost. Tumor doses ranged from 10 to 60 Gy. Intrathecal chemotherapy was administered to 16 patients and 7 received systemic agents. After follow-up ranging from 1 to 66 months, median survival and progression-free survival were each 8 months. One- and 3-year actuarial survival rates were 50% and 36%, respectively. One- and 3-year actuarial progression-free rates were 41% and 15%, respectively. Relapse occurred in 18 patients, and in 17 there was a component of local progression. Lesions recurred in the spinal meninges in 1 patients and in the vitreous in 1. Patients with Karnofsky performance status > or = 70 demonstrated median progression-free survival of 27 months, compared to 4 months for patients < 70 (p = .024). No other significant patient or treatment-related prognostic factors were identified. Clinical dementia occurred in 2 of 11 patients surviving at least 1 year. Review of the literature indicates PCNSL demonstrates relative radioresistance. The most immediate improvement in prognosis for patients with PCNSL can be achieved by properly sequencing systemic and intrathecal chemotherapy with radiation therapy.

Biopsia de lesoes encefalicas por trepanacao. / Biopsy of encephalic lesions by trephining

O diagnostico anatomopatologico das lesoes encefalicas de natureza expansiva e necessario para a instituicao do tratamento adequado. Muitas lesoes localizadas nas estruturas cerebrais profundas ou em centros nervosos de grande importancia funcional nao podem ser abordadas por procedimentos neurocirurgicos habituais, sem riscos para os doentes. Nesses casos, a biopsia percutanea, estereotaxica ou assistida pela tomografia computadorizada deve ser empregada para esclarecimento diagnostico. Os autores apresentam o resultado da bipsia por trepanacao de lesoes encefalicas inabordaveis pelos metodos neurocirurgicos tradicionais, em 63 doentes. O procedimento foi realizado a mao livre em 18 casos, por estereotaxia em 28 e por estereotomografia em 17. O indice de mortalidade e de morbidade foi baixo. Cinco doentes foram, durante o mesmo ato operatorio, submetidos a radioterapia intersticial por tecnica de "after loading". Os criterios de selecao, a avaliacao pre-operatoria e as vantagens da biopsia por trepanacao sao discutidos

Neurotomia por radiofrequencia dos ramos recorrentes posteriores das raizes lombares. / Radiofrequency neurotomies of the recurrent posterior branches of the lombar roots: for treatment of back pain and sciatica

As lombalgias e as lombociatalgias sao, algumas vezes, resistentes aos metodos terapeuticos convencionais. Os autores apresentam o resultado do tratamento de lombalgias e lombociatalgias (por meio da neurotomia percutanea dos ramos recorrentes posteriores das raizes lombares) realizado em 50 doentes da clinica neurocirurgica do Hospital 9 de Julho de Sao Paulo e na Clinica de Dor da Clinica Neurologica do Hospital das Clinicas da FMUSP.Doze doentes haviam sido submetidos previamente a laminectomia e a exerese do disco intravertebral. Trinta e dois apresentavam lombalgia apenas e 18 dor lombar irradiada para os membros inferiores. Os resultados foram excelentes em 24 horas, bons em 20 e nulos em 6. Nao ocorreram complicacoes serias

[Incidental syringohydromyelography: report of a case]. / Siringohidromielografia incidental: registro de um caso.

The radiological findings of syringomyelography are described in a five years old patient who underwent a percutaneous injection of opaque contrast medium (Lipiodol) into the intraspinal syringomyelic cavity. The clinical picture, the usual diagnostic methods and the place of syringomyelography for the diagnosis of syringomielia are discussed.

Siringohidromielografia incidental: registro de um caso. / Incidental syringohydromyelography: report of a case

E relatado o caso de doente de 5 anos de idade, com siringomielia no qual a administracao de contraste, destinado a exame perimielografico, foi realizado incidentalmente, no interior da cavidade siringomielica. Sao considerados alguns aspectos relativos aos metodos diagnosticos dessa entidade