Clinical, neurodiagnostic, and MR findings in children with spinal and brain stem multiple sclerosis

PURPOSE: To describe the clinical, neurodiagnostic, and MR findings in seven children with brain stem and spinal multiple sclerosis. METHODS: Spinal or brain stem multiple sclerosis was diagnosed in seven children between 1986 and 1992. All patients had neurologic and MR examinations as well as neurodiagnostic testing, including spinal fluid analysis and brain stem and auditory evoked potentials. RESULTS: Three children had clinical findings and masslike lesions in the brain stem (two) or spinal cord (one) suggestive of neoplasm, which prompted biopsy (two) or radiation therapy (one). Five of six patients with spinal involvement had cord swelling with increased signal on T2-weighted images over at least three cord segments, and two children had essentially holocord involvement. Three children had normal cranial MR at presentation. CONCLUSIONS: Multiple sclerosis involvement of the brain stem and spinal cord may be associated with extensive swelling and MR signal changes suggestive of neoplasm without typical cerebral white matter abnormalities. Serial clinical and neuroimaging examinations may be necessary to make a definitive diagnosis of multiple sclerosis in children.     

Critical care medicine

A postmortem case of HTLV-I associated myelopathy (HAM)/tropical spastic paraparesis (TSP) with a history of remission and exacerbation of neurological signs and symptoms, resembling those of multiple sclerosis is reported. MRI analysis revealed lesions in the periventricular white matter in addition to atrophy of the thoracic spinal cord, characteristic of HAM/TSP. The cerebral periventricular areas consisted of ill-defined paucity of myelin sheaths with astrocytic gliosis and hyaline thickening of blood vessels. The poorly demarcated white matter lesions found in both brain and spinal cord were different from plaques found in multiple sclerosis. It is suggested that, in some cases of HAM/TSP, inflammatory lesions that destroy myelin can involve not only the spinal cord but also the cerebral periventricular white matter.     

Effects of microgravity and bone morphogenetic protein II on GFAP in rat brain

Enzyme activities and protein levels of several protein and lipid kinases were measured in postmortem tissue from patients who died with amyotrophic lateral sclerosis (ALS) as well as from control subjects. Patients who died with ALS had increased activities and protein levels of phosphatidylinositol 3-kinase (PI 3-K) in particulate fractions of spinal cord tissue compared with control subjects. The PI 3-K activity increased with PI 3-K protein level, indicating no change in specific PI 3-K activity in ALS. No differences in PI 3-K activities were found in cytosolic fractions of spinal cord, or in motor and visual cortices, from ALS patients compared with those from controls. PI 3-K activities and protein levels were unchanged in brain tissue from patients who died with Alzheimer's disease compared with those from controls. PI 3-K is a lipid kinase that is important for cell survival and is activated in response to many growth factors. Increased PI 3-K activities in particulate fractions of spinal cord from ALS patients may be related to the increase of PI 3-K protein levels found in this tissue. The protein kinases Erk2, protein kinase B (PKB), and p70 ribosomal S6 kinase (S6K) showed no differences in activities in spinal cord tissue between ALS patients and controls. However, the amounts of PKB and S6K protein were significantly higher in ALS patients, whereas Erk2 protein amount was unchanged compared with controls. Protein kinase C activity was increased in spinal cord tissue from ALS patients, which is consistent with our previous report. The increased activity of PI 3-K in spinal cord tissue from patients with ALS implicates the involvement or activation of PI 3-K in ALS, as either a cause or a consequence of the neuron loss. The lack of up-regulation in the activities of PKB and S6K in ALS tissue supports an impairment in signal transduction cascades mediated by PI 3-K in this neurodegenerative disease.     

Activation of PKC reverses apparent NMDA receptor reduction in ALS

The binding of [3H]MK-801 to NMDA receptors was reduced by 40-45% in the dorsal and ventral horns of spinal cords from patients who died with amyotrophic lateral sclerosis (ALS) compared with controls. These results reflect either neurone death with concomitant receptor loss or regulation-related receptor decreases independent of motoneurone degeneration. To distinguish between these possibilities we explored aspects of NMDA receptor regulation using phorbol ester to activate protein kinase C (PKC). Spinal cord sections were exposed to phorbol ester before incubation with [3H]MK-801 to determine levels of NMDA binding. Phorbol ester treatment increased [3H]MK-801 binding in both ALS and control tissue to almost identical levels of specific binding for both groups. The increased [3H]MK-801 binding could be completely blocked by concurrent exposure of spinal cord sections to H-7, a general protein kinase inhibitor. These results suggest that NMDA receptors in ALS spinal cord are decreased as a result of abnormal enzyme activity independent of motoneurone degeneration.     

Beneficial effects of acetazolamide on paroxysmal attacks of girdle sensation in multiple sclerosis

A 56-year-old woman with a 40-year history of multiple sclerosis (MS) developed paroxysmal attacks of girdle sensation in the Th5-6 dermatomes. The attacks lasted 20-60 minutes and occured up to three times per week. T2-weighted MR imaging of the spinal cord showed high intensity area from Th5 to Th8. Electrocardiography, echocardiography and laboratory findings did not indicate ischemic heart disease; therefore, the paroxysms were attributed to the spinal cord lesions. Attacks were successfully suppressed by acetazolamide 250 mg/day. Although carbamazepine is frequently used to treat paroxysmal attacks in MS, we would like to suggest that acetazolamide may also be beneficial in some patients with paroxysmal symptoms.     

Multiple sclerosis of the spinal cord: magnetic resonance appearance

OBJECTIVE: To determine the MR appearance of spinal cord multiple sclerosis (MS) plaques in patients presenting with myelopathy by using a high-field (1.5 T) imager. MATERIALS AND METHODS: We studied 119 patients who underwent high-field (1.5 T) MR studies of the spinal cord for evaluation of myelopathy. All 119 patients were thought to have possible findings of spinal cord MS at the time of the MRI interpretation. RESULTS: Sixty-four plaques were studied in 47 patients with clinically definite MS and adequate quality MRI. Of these patients 68% had a single spinal cord plaque, 19% had two plaques, and 13% had three or more plaques. Sixty-two percent of the plaques occurred in the cervical spinal cord and most frequently involved the posterior (41%) and lateral (25%) aspects of the spinal cord. None of the 64 lesions involved the entire thickness of the spinal cord. The lesion length varied from 2 to 60 mm, with 84% of the lesions < 15 mm in length. The spinal cord diameter was unchanged in 84% of plaques, enlarged at the level of the lesion in 14%, and atrophic in 2%. Just over half (55%) of the plaques enhanced with intravenously administered gadolinium. Of the patients who received synchronous head and spinal cord examinations on the same day, 24% had normal findings on the MR study of the head. Follow-up spinal cord studies were available in nine patients. New lesions developed in two patients, while previously described lesions resolved. In three patients only new lesions developed. In four patients no change occurred in the existing number of cord plaques. CONCLUSION: Spinal cord demyelinating plaques present as well-circumscribed foci of increased T2 signal that asymmetrically involve the spinal cord parenchyma. Knowledge of their usual appearance may prevent unnecessary biopsy. An MR examination of the head may confirm the imaging suggestion of spinal cord demyelinating disease, because up to 76% of patients have abnormal intracranial findings. In the remaining 24% of cases in which the clinical diagnosis is not certain and MR findings in the head are negative, a follow-up spinal cord study is recommended, because these lesions evolve and change over time.     

Agouti serum L-asparaginase. II. Chromatographic fractionation and characterization of the enzymatically active component

Bladder and urethral innervation was studied in 52 patients with multiple sclerosis using a signal tracing technique (evoked reflex latency measurement). The majority of the patients showed prolonged signal transit times indicative of demyelinating plaques localised to the lumbosacral spinal cord. Futhermore, impairment of the corticospinal innervation of the pudendal nucleus was found in 29 patients indicating lesions of the pyramidal tract.     

Optic neuromyelitis: a necrotizing disease of the central nervous system]

Optic neuromyelitis is characterized by simultaneous or successive necrotizing lesions involving the optic nerves and the spinal cord. We report two females with the disease, aged 30 and 34 years old. In the latter, a neuropathological study was done. Both patients had clinical, neuroradiological and pathological features that differed from those of primary demyelinating syndromes such as multiple sclerosis. These patients illustrate the selectivity of optic nerve and spinal cord lesions. The latter involve mainly pyramidal and Goll tracts while, within the necrotizing lesions of the optic chiasma, the fibers of the unaffected optic nerve are spared. This pattern suggests a selective injury to some population of axons. Blood vessels were not affected in the necrotizing areas and the lesions did not follow a vascular territory, therefore a vascular mechanism causing the disease is unlikely. The clinical and neuropathological features of neuromyelitis optic suggest a selective involvement of some axons.     

Middle lobe syndrome: apropos of 5 cases

The capacity of embryonic spinal cord tissue in the repair of injured structure of spinal cord has been noted for years. In order to investigate the embryonic spinal cord graft in the repair of motor function of injured spinal cord, the embryonic spinal cord tissue was transplanted to the hemisection cavity in spinal cord in adult rat. One hundred adult Wistar Rats were used to simulate the hemisectional injury of spinal cord by drilling 2-3 mm cavity in lumbar enlargement. Sixty rats were treated with rat embryonic spinal cord tissue grafting while the other forty were chosen as control. The outcome was evaluated according the combined behavioural score (CBS) and motor evoked potential (MEP) in the 1, 2, 4 and 12 weeks. The grafting group was superior to the control as assessed by CBS (P < 0.05), especially within 4 weeks. (P < 0.01). The restoration of the latent peak of early wave(P1, N1) was better in the grafting group, too. This suggested that embryonic spinal cord graft could improve the recovery of motor function of injured spinal cord in adult rat. The effect of the embryonic spinal cord tissue graft might be concerned with its secretion of several kinds of neurotrophic factors, nerve growth factor, nerve transmitted factor, or adjustment of hormone.     

Degradation of chondroitin sulfate proteoglycan enhances the neurite-promoting potential of spinal cord tissue

The contribution of chondroitin sulfate proteoglycan (CSPG) in the suppression of axonal growth in rat spinal cord has been examined by means of an in vitro bioassay in which regenerating neurons are grown on tissue section substrata. Dissociated embryonic chick dorsal root ganglionic neurons were grown on normal and injured adult spinal cord tissue sections treated with chondroitinases. Neuritic growth on normal spinal cord tissue was meager. However, both the percentage of neurons with neurites and the average neurite length were substantially greater on sections treated with chondroitinase ABC. Enzymes that specifically degraded dermatan sulfate or hyaluronan were ineffective. Neuritic growth was significantly greater on injured (compared to normal) spinal cord and a further dramatic increase resulted from chondroitinase ABC treatment. Neurites grew equally within white and gray matter regions after chondroitinase treatment. Observed increases in neurite outgrowth on chondroitinase-treated tissues were largely inhibited in the presence of function-blocking laminin antibodies. These findings indicate that inhibitory CSPG is widely distributed and predominant in both normal and injured spinal cord tissues. Additionally, inhibitory CSPG is implicated in negating the potential stimulatory effects of laminin that might otherwise support spinal cord regeneration.     

Chronic relapsing experimental allergic encephalomyelitis. Studies in vascular permeability changes

The vascular permeability in the nervous system to Evans blue-albumin and horseradish peroxidase was studied in chronic relapsing EAE in strain 13 and Hartley guinea pigs. The disease was induced by single sensitization of immature animal and was characterized clinically by remissions and relapses. Recent and old demyelinating plaques in the spinal cord were present. These showed an increased permeability to the protein tracers. The blood-brain barrier in these plaques are therefore disturbed and also in this respect the condition is similar to the multiple sclerosis lesions.     

Functional interactions between spinal cord grafts suggest asymmetries dictated by graft maturity

Fetal spinal cord tissue grafts have been advocated as a possible repair strategy for spinal cord injury. In the present study, we used intraocular spinal cord grafts to model the interactions which may occur between fetal and adult spinal cord after making such a graft and to study to which extent functional connections can be expected to occur between the host and graft tissue. We first grafted fetal spinal cord to the anterior chamber of the eye where it was allowed to mature. A second piece of fetal spinal cord was then sequentially grafted in contact with the first graft. Electrophysiological recordings made from the older graft while electrically stimulating the younger graft provided evidence for an excitatory innervation from the younger spinal cord graft to the mature spinal cord which appeared to be glutamatergic. However, we only rarely found excitatory inputs from the first, mature spinal cord graft to the younger graft. Fiber connections between the two spinal cord grafts were verified by retrograde tracing and neurofilament immunohistochemistry. In no case was a trophic influence on graft volume observed between spinal cord grafts regardless of whether the transplantations were performed sequentially or at the same time. Even the introduction of a second graft to immature spinal cord tissue was ineffective. In contrast, we found a marked trophic, neuron-rescuing effect of spinal cord grafts upon cografts of fetal dorsal root ganglia. This latter observation is consistent with the hypothesis that spinal cord tissue can exert a trophic effect on developing sensory ganglia and demonstrates that many sensory neurons can survive in the presence of a central target and in the absence of the appropriate peripheral target. These intraocular experiments predict that fetal spinal cord grafted to the injured adult spinal cord may develop effective excitatory inputs with the host, while host-to-graft inputs may develop to a considerably smaller extent. Our results also suggest that the adult spinal cord does not exert marked trophic effects on growth of fetal spinal cord, while it does exert a trophic influence on central projections of dorsal root ganglia.     

Segregation of optic axons based on central target: the medial optic tract in Rana pipiens

The electrophysiological integrity of the adult rat spinal cord was assessed at the lumbar, lower cervical and cortical levels after the animals sustained a severe contusion injury at the mid-thoracic level (T8) and received either carbon filament cultured with fetal spinal cord tissue implants, fetal tissue implants, or carbon filament implants alone. Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were recorded from all animal groups at the end of the 8-week survival period. The results of this study demonstrate that the spinal cord injured animals that received carbon filament cultured with fetal spinal cord tissue implants had the highest degree of electrophysiological recovery, indicating that this combination plays an important role in promoting recovery after injury.     

Leukotriene synthesis after intracerebral hemorrhage: a further indicator for their pathophysiologic significance in the CNS]

Linomide (quinoline-3-carboxamide) is a synthetic immunomodulator that suppresses several experimental autoimmune diseases. Here we report the effects of Linomide on chronic progressive and/or relapsing experimental autoimmune encephalomyelitis (PR-EAE), a CD4+ T cell mediated animal model of multiple sclerosis (MS). PR-EAE induced in DA rats by inoculation with homogenized guinea pig spinal cord and Freund's complete adjuvant, was strongly suppressed by Linomide administered daily subcutaneously from the day of inoculation. Linomide dose-dependently delayed the interval between immunization and onset of clinical PR-EAE, reduced severity and relapse of clinical PR-EAE, and shortened clinical PR-EAE. These clinical effects were associated with the down-modulation of CNS antigen-induced T cell responses and production of proinflammatory cytokines (IFN-gamma and TNF-alpha) as well as with upregulation of IL-4 (except in spleen MNC), IL-10 and TGF-beta in both spleen MNC and the spinal cord. These effects indicate that Linomide can suppress PR-EAE and may mediate its suppressive effects by regulation of cytokines.     

Acute-stage para- and tetraplegia

A quarter of a century ago, in October 1964, the first spinal cord injury center in Switzerland was opened at Geneva University Hospital. At that time all para- and tetraplegics were classified as "high-risk" patients. Early mortality, covering the initial four weeks following trauma, was still around 15%. The available resources for diagnostic assessment were limited to clinical examination and neuroradiological assessment (subsequently improved by the introduction of tomography and gas myelography). A great many patients suffered a deteriorated neurological level due to inadequate, multiple transfers between hospitals. Most patients who are paralyzed following a road-traffic accident show severe polytrauma. Their chances of survival and functional recovery have greatly improved in recent years due to efficient emergency transport by helicopter, admission to an intensive care unit (respiratory therapy, prophylactic anticoagulation, gastrointestinal cytoprotection, prevention of pressure sores, etc.) and a comprehensive medico-surgical team approach (orthopedic surgeons, neurosurgeons, ICU specialists, internists, etc.). Evaluation of the spine and spinal cord by NMR and CT scan allows precise assessment of the extent of CNS damage and provides additional guide-lines regarding efficient surgical reposition and spinal fusion. Ongoing experimental research in neurophysiology and neurobiochemistry of the brain and spinal cord is presently yielding some interesting results which hold out new hopes for functional recovery in some specific types of incomplete spinal cord trauma.     

The low sensitivity of fluid-attenuated inversion-recovery MR in the detection of multiple sclerosis of the spinal cord

PURPOSE: To confirm the expected superiority of fluid-attenuated inversion-recovery (FLAIR) over conventional fast spin-echo MR imaging in the detection of multiple sclerosis (MS) of the spinal cord. METHODS: Fifteen subjects with known MS involving the spinal cord and brain were studied prospectively. The entire cord was imaged with a phased-array coil on a 1.5-T MR system. Sagittal T1-weighted and fast spin-echo proton density- and T2-weighted images were followed by fast FLAIR images. FLAIR parameters were varied to optimize lesion conspicuity with optimal inversion times (TIs) ranging from 2400 to 2600. Lesion conspicuity and detection were compared between the fast spin-echo and FLAIR images by three radiologists who reached agreement by consensus. RESULTS: The FLAIR technique effectively suppressed cerebrospinal fluid (CSF) signal and reduced CSF pulsation and truncation artifacts in all cases. Shorter imaging parameters (repetition time of 4000 to 6000, TI of 1500 to 2000) uniformly decreased lesion conspicuity in all subjects. Of 11 cord lesions in five subjects imaged with the longer parameters (repetition time of 8000 to 11,000, TI of 2400 to 2600), three were not seen on FLAIR images, four were less conspicuous on FLAIR images, and four were seen equally or better on FLAIR images. CONCLUSION: Although successful in suppressing CSF signal and reducing imaging artifacts, fast FLAIR imaging appears unreliable in the detection of MS lesions in the spinal cord.     

Effect of the levonorgestrel-releasing intrauterine system on the uterine artery pulsatility index in postmenopausal hormone replacement therapy

Previous studies have demonstrated a significant reduction of N-methyl-D-aspartate (NMDA) receptor binding in spinal cord sections from patients who died with amyotrophic lateral sclerosis (ALS) compared to that in control patients. The reduction in NMDA receptor binding in ALS could be increased toward control values by treatment with phorbol ester, suggesting a role for receptor protein phosphorylation in this disorder. In the present study we have evaluated the time course of recovery of [3H]MK-801 binding following phorbol ester treatment to assess protein phosphatase activity in spinal cord sections from ALS and control subjects. Phorbol ester-stimulated changes in [3H]MK-801 binding returned to untreated values significantly faster in ALS tissue compared to control and could not be blocked by the coapplication of the protein phosphatase inhibitors sodium vanadate or sodium beta-D-glycerol phosphate. Okadaic acid coapplication blocked recovery in both ALS and control tissue at a concentration range at which phosphatase 2B (calcineurin) would likely be inhibited. The results suggest that abnormal levels or activity of protein phosphatases, including calcineurin, may be involved in the abnormal levels of NMDA receptors in ALS and may play some role in the pathogenesis of the disease.     

Forensic psychiatric expertise in brain tumors]

Dynamics of transplants of human embryonic spinal cord fragments development in adult rat spinal cord was studied in immunosuppression. Transplants were shown to take roots and their cellular elements proliferated and differentiated. The peculiarity of such transplants is the lack of rough glio-connective tissue scar. Graft development in the spinal cord depends on histoblastic potential of the tissue transplanted and recipient spinal cord reaction to the transplantation.     

A comparison of the effects of glial cell line-derived neurotrophic factor on spinal cord and cortex cerebri grafts

Glial cell line-derived neurotrophic factor (GDNF) has trophic effects on developing dopamine neurons, enhances survival of embryonic motoneurons in vitro and prevents axotomy-induced motoneuron atrophy in vivo. Here we investigate effects of GDNF on grafts of cortex cerebri tissue from E18, P1 and P8 donors and on spinal cord tissue for P8 and adult animals transplanted to the anterior chamber of the eye of host rats. Grafts were treated with GDNF or cytochrome C on days 0, 5, 10, 15, 20 and 25 (total amounts 0.5 microgram GDNF/eye/injection). Spinal cord grafts from P8 donors treated with GDNF grew to sizes larger than controls, had higher numbers of neuron-like cells and showed increased areas of neurofilament immunoreactivity and decreased glial fibrillary acidic protein immunoreactivity. In contrast to the P8 spinal cord grafts, there were no such effects observed in adult spinal cord grafts or in E18, P1 or P8 cerebral cortex grafts. To determine if an endogenous source of GDNF might exert similar effects on spinal cord grafts, we transplanted spinal cord tissue from P1 together with pieces of developing kidney, known to express high levels of GDNF mRNA. Spinal cord cografted with kidney tissue grew to a slightly larger extent then controls. We conclude that GDNF exerts a powerful trophic effect on P8 spinal cord grafts, although GDNF appears unable to support survival of grafted adult spinal cord tissue. Grafts of cortex cerebri from several different stages of development were not affected.     

Comprehensive viral immunology of multiple sclerosis. I. Clinical, epidemiological, and CSF studies

Epidemiological, clinical, and CSF data were collected on 87 patients with clinically definite multiple sclerosis (MS) and 50 with probable MS. As part of a study of immunologic reactivity to viral antigens, a control group separated into 26 patients with probable inflammatory neural disease and 140 with noninflammatory neural disease was similarly studied. Among the groups with MS, females predominated and both Oriental and Spanish surnamed patients were under-represented. The spinal cord, optic nerves, and brainstem were the most common sites of initial disease and more than 20% of the patients had only cord symptoms after several years of disease activity. Of several CSF assays used, determination of oligoclonal IgG bands by agarose electrophoresis was most useful diagnostically.