I read with interest the paper by Benedetti et al., entitled
'Rituximab in patients with chronic inflammatory demyelinating
polyradiculoneuropathy: a report of 13 cases and review of the
literature'(1).
Rituximab, a monoclonal antibody that binds to the CD20 antigen on B-
lymphocytes, has been approved to eliminate B cell precursors, normal and
malignant B cells and to reduce antibody titers (2,3). Some authors argued
tha...
I read with interest the paper by Benedetti et al., entitled
'Rituximab in patients with chronic inflammatory demyelinating
polyradiculoneuropathy: a report of 13 cases and review of the
literature'(1).
Rituximab, a monoclonal antibody that binds to the CD20 antigen on B-
lymphocytes, has been approved to eliminate B cell precursors, normal and
malignant B cells and to reduce antibody titers (2,3). Some authors argued
that the benefit of Rituximab may be exerted by reducing the pathogenic
antibodies or by inducing immunoregulatory T cells (4).
Chronic polyneuropathies associated with IgM paraproteinemia (almost 50%
have high serum titers of anti-MAG antibodies) indicate either an
underlying monoclonal gammopathy of undetermined significance (MGUS) or a
malignant plasma cell dyscrasia. In chronic inflammatory demielinating
poliradiculoneuropathy (CIDP), the immunopathological processes are still
unclear.
Benedetti et al described 13 CIDP patients, 5 without haematological
disease, 4 had MGUS, 2 had lymphoma, 1 had
Waldestrom macroglobulinemia and 1 had idiopathic thrombocytopenic purpura.
Peripheral blood immunophenotypes before treatment have not been reported.
The patient #1 (see Table 1), who had been previously described (5), had
a small lymphocyitic B-cell lymphoma CD20 and the dramatic improvement
after Rituximab therapy supported a role of B cells in the pathogenesis of
polyneuropathy (6)
The immunologic status of the other patients with CIDP has not been
described in detail, placing an issue on which target rituximab acted,
particularly for patients without hematologic malignancies . It is likely
that patients with IgM MGUS,
Waldenstrom macroglobulinemia and non-Hodgkin's lymphoma were affected by chronic polyneuropathies associated with IgM
paraproteinemia, all Rituximab responsive.
Electrophysiological data, available in 6 patients, have not been
reported. I would like to ask the authors to provide information in order
to explain that 10% changes in motor conduction velocity (MCV) values are considered as
indicators of therapeutic efficacy. Recently, some authors have reported
that INCAT dysability score and Medical Research Council sum score (MRC)
correlated with improvement in compound muscle action potential (CMAP)
amplitudes of nerves tested (7). The increase in CMAP amplitude, and not
MCV, may explain the muscle strength improvement.
References
1. Benedetti L, Briani C, Franciotta D, Fazio R. Rituximab in patients
with chronic inflammatory demyelinating polyradiculoneuropathy: a report
of 13 cases and review of the literature. J Neurol Neurosurg Psychiatry.
2010 Jul 16. [Epub ahead of print]
2. Dalakas MC. B cells in the pathophysiology of autoimmune neurological
disorders: a credible therapeutic target. Pharmacol Ther. 2006;112(1):57-
70
3. Dalakas MC. Invited article: inhibition of B cell functions:
implications for neurology. Neurology. 2008;70(23):2252-60.
4. Dalakas MC, Rakocevic G, Salajegheh M, Dambrosia JM, Hahn AF, Raju R et
al. Placebo-controlled trial of rituximab in IgM anti-myelin-associated
glycoprotein antibody demyelinating neuropathy. Ann Neurol. 2009
Mar;65(3):286-93.
5. Briani C, Zara G, Zambello R et al. Rituximab-responsive CIDP. Europ J
Neurol 2004;11:788-91
6. Briani C, Zambello R, Cavallaro T, Ferrari S, Lucchetta M, Pollanz S,
Grisold W. Improvement of peripheral nervous system manifestations of B-
cell non-Hodgkin's lymphoma after rituximab therapy. J Peripher Nerv Syst.
2009 Jun;14(2):146-8
7. Bril V, Banach M, Dalakas MC, Deng C, Donofrio P, Hanna K et al.
Electrophysiologic correlations with clinical outcomes in CIDP. Muscle
Nerve. 2010 Jul 21. [Epub ahead of print]
Extradural cortical stimulation (ECS) for post-stroke aphasia (PSA)
Cherney et al (1) conducted an 8 patient controlled study whose
conclusion was that ECS may enhance the effect of rehabilitation for PSA.
This study was conducted by implanting the stimulating paddle supplied by
NorthStar Neuroscience (NSN), a company now out of business. Cherney et
al. point to several weaknesses of their study, but omit to dis...
Extradural cortical stimulation (ECS) for post-stroke aphasia (PSA)
Cherney et al (1) conducted an 8 patient controlled study whose
conclusion was that ECS may enhance the effect of rehabilitation for PSA.
This study was conducted by implanting the stimulating paddle supplied by
NorthStar Neuroscience (NSN), a company now out of business. Cherney et
al. point to several weaknesses of their study, but omit to discuss
several more.
1-This is not the first study of surgery for treatment of post-stroke
aphasia. Two previous case reports by Canavero and Kim showed that ECS can
enhance rehabilitation of PSA (see review in 2). Both targeted the
premotor cortex, similarly to Cherney et al. Thus, Cherney et al. merely
confirm that the premotor cortex is a valid target.
2-Cherney et al.'s study comes in the
aftermath of the Everest study, the pivotal study by NSN, which employed
the same kind of approach to ECS enhancement of stroke rehabilitation,
i.e. same stimulating apparatus and same fMR-guided target choice and
implantation. The adequately powered Everest study failed to achieve
statistical significance (and led to NSN's
demise), whereas smaller studies sponsored by the same company did not.
Most likely, a similar study of PSA with the same technology and methods
would also fail. Cherney et al.'s study is thus
inconsequential in this respect.
3- Some of the major limitations of the rationale and methods
employed by Cherney et al. include: 1-a fixed frequency of stimulation (50
Hz): anybody experienced in ECS knows that there is no such thing as a
fixed frequency for
any application (2), and both low (<50 Hz) or high (>100Hz)
frequency stimulation must be assessed; 2- too short rehabilitation time
(6 weeks), with other studies taking 6-12 months (2); 3- patients were
only implanted on the stroke side: the contralateral side is also a viable
target (2); 4- only patients displaying fMR activation of the premotor
area (BA6) were implanted: fMR hot-
spots may not portend successful implantation,
as shown in other reports (2). Dual/triple-target stimulation, as uniquely
afforded by ECS, appears indicated in many stroke cases, including the
hand motor area, with its demonstrated role in language processing (see
refs, in 2). Although the shape of the NSN electrode encompasses a wider
area than currently used strips, nonetheless the stimulated area is still
not large enough.
4- In Cherney et al.'s paper, fMR showed
both post-treatment increase or decrease according to severity of aphasia,
which would point to different neural processing (activation vs
inhibition). Interestingly, our iomazenil-SPECT study suggested GABA
changes induced by ECS even at a distance from primary targets of
stimulation.
5- The strength of ECS lies in its lack of mortality or permanent
morbidity, and no risk of intracranial hemorrhage or infection (unlike
subdural approaches). The smooth course of the US
authors' patients is to be expected.
6- ECS can be guided by preoperative TMS assessment. A flap is not
necessary, as one-two burr holes are enough for any single stimulating
strip, making the technique even safer (2).
In conclusion, we urge functional neurosurgeons to pursue this
promising field of neuromodulation as alternative strategies for stroke
rehabilitation are still imperfect.
Sergio Canavero, MD (US FMGEMS)
Turin Advanced Neuromodulation Group (TANG)
Turin, Italy
sercan@inwind.it
REFERENCES
1- Cherney LR, Erickson RK, Small SL. Epidural cortical stimulation
as adjunctive treatment for non-fluent aphasia: preliminary findings. JNNP
2010;
2- Canavero S. Textbook of therapeutic cortical stimulation, New York:
Nova Science, 2009, pp 231-272
Canavero S, Bonicalzi V, Intonti S, Crasto S, Castellano G. Effects of
bilateral extradural cortical stimulation for plegic stroke
rehabilitation. Neuromodulation 2006; 9: 28-33
We thank Dr. Marini and colleagues for their interest in our
article.1 They commented on the use of nosocomial infections as primary
outcome and the randomised yet non-double-blinded study design.
Secondarily, they shared their disappointing results from the utilization
of antibiotics-impregnated ventricular catheters.
In our centers, we have achieved a ventricular-catheter-related
cere...
We thank Dr. Marini and colleagues for their interest in our
article.1 They commented on the use of nosocomial infections as primary
outcome and the randomised yet non-double-blinded study design.
Secondarily, they shared their disappointing results from the utilization
of antibiotics-impregnated ventricular catheters.
In our centers, we have achieved a ventricular-catheter-related
cerebrospinal fluid infection rate of less than 5%, with protocol-driven
ventricular catheter care, no catheter exchange every 5 days, adequate
subcutaneous tunneling, and dual prophylactic antibiotcs.2,3,4 However,
one criticism of this successful policy is that dual prophylactic
antibiotics increase antibiotic pressure and cause a surge of resistant
infections, especially in intensive care units. The application of
antibiotics-impregnated catheters as local antibiotic prophylaxis, without
the need for repeated cerebrospinal fluid instillations, seemed to be a
perfect solution and thus we designed the study. The catheters were
unblinded as no available plain catheters were of similar colors as
antibiotics-impregnated catheters. The same methodology was applied in a
recently completed multi-center study sponsored by Codman & Shurtleff,
Inc., a Johnson & Johnson Company (Establishment of Baseline and
Comparative Infection Rates for the Codman BACTISEALTM External
Ventricular Drainage System).
In centers with background ventricular-catheter-related cerebrospinal
fluid infection rates of more than 5%, antibiotics-impregnated catheters
reduced cerebrospinal fluid infection in both randomized controlled trial
and historical cohort studies.5,6,7 Similar to Dr. Marini and colleagues,
Harrop and colleagues indeed carried out a 1961-patient study between 2003
and 2008. They were able to show that the institution, discontinuation,
and reinstitution of antibiotics-impregnated catheters were the most
important determinants ventricular-catheter-related cerebrospinal fluid
infections.7
Dr. Marini and colleagues described their cohort study of 55
patients, in which two-thirds of the 67 catheters used were impregnated
with antibiotics. They reported a high cerebrospinal fluid infection rate
of 13.4%, half of which was caused by gram-positive cocci and half caused
by gram-negative bacilli. The exact infection rates and organisms
responsible were not described for each group, though we presume that the
infection in the antibiotics-impregnated catheters was mostly caused by
gram-negative bacilli. The weakness is that their results are likely to be
underpowered to detect any difference between cerebrospinal fluid
infection rates. One must remember that other aspects of infection control
are important in bringing down infection rates, such as antibiotic cover
during surgery, adequate subcutaneous tunneling and protocol-driven
ventricular catheter care. Unfortunately, with the data provided by Dr.
Marini and colleagues, we are afraid that their conclusion is invalid.
References
1. Wong GK, Ip M, Poon WS, et al. Antibiotics-impregnated ventricular
catheter versus systemic antibiotics for prevention of nosocomial CSF and
non-CSF infections: a prospective randomised clinical trial. J Neuro
Neurosurgery Psychiatry (2010). Doi:10.1136/jnnp.2009.198523
2. Poon WS, Ng S, Wai S. CSF antibiotic prophylaxis for neurosurgical
patients with ventriculostomy: a randomized study. Acta Neurochir Suppl
(Wien) 1998; 71:146-148.
3. Wong GK, Poon WS, Wai S, et al. Failure of regular external ventricular
drain exchange to reduce cerebrospinal fluid infection: result of a
randomized controlled trial. J Neurol Neurosurg Psychiatry 2002; 73:759-
761.
4. Wong GK, Poon WS. Failure of regular external ventricular exchange to
reduce CSF infection: authorsÃÆ’ƒÃ‚¢ÃÆ’‚€ÃÆ’‚â„¢ reply. J Neurol
Neurosurg Psychiatry 2003; 74:1599.
5. Zabramski JM, Whiting D, Darouiche RO, et al. Efficacy of antimicrobial
-impregnated external ventricular drain catheters: a prospective,
randomized, controlled trial. J Neurosurg 2003; 98:725-730.
6. Muttaiyah S, Ritchie S, John S, et al. Efficacy of antibiotic-
impregnated external ventricular drain catheters. Journal of Clinical
Neuroscience 2010; 17:296-298.
7. Harrop JS, Sharan AD, Ratliff J, et al. Impact of a standardized
protocol and antibiotic-impregnated catheters on ventriculostomy infection
rates in cerebrovascular patients. Neurosurgery 2010; 67(1):187-191.
Sadjadi and colleagues show that in IBM, as in most chronic illness,
mood plays a role in QoL. It would be a surprise if mood didn't play a
role in measured QoL. QoL assessment uses subjective measures, for
example "how would you rate your health?", and a patient's response to
such a question is likely to be altered by mood. Hence QoL questionnaires
can also act as mood questionnaires. Indeed, the awkward realisation i...
Sadjadi and colleagues show that in IBM, as in most chronic illness,
mood plays a role in QoL. It would be a surprise if mood didn't play a
role in measured QoL. QoL assessment uses subjective measures, for
example "how would you rate your health?", and a patient's response to
such a question is likely to be altered by mood. Hence QoL questionnaires
can also act as mood questionnaires. Indeed, the awkward realisation is
that if QoL didn't reflect mood then it wouldn't be a subjective scale. A
consequence is that anti-depressant medication or cognitive behavioural
therapy might well improve QoL (by changing the way an individual
perceives and reports their disability) without making any impact on
functional ability. Perhaps the only way around this would be to correct
each patient's QoL result for that individual's mood at the time of
questionnaire completion.
Dear Sir,
We write in response to the rapid response by Kleine et al. The disparity
between the sensitivity of El Escorial in our study (1) and the work by
Boekestein et al (2) and de Carvalho (3), we suggest is as a result of the
differing neurophysiology protocols. Boekestein et al and de Carvalho use
at least 3 times the insertions used in our standard protocols. The
protocol used in our study is tailored for everyday...
Dear Sir,
We write in response to the rapid response by Kleine et al. The disparity
between the sensitivity of El Escorial in our study (1) and the work by
Boekestein et al (2) and de Carvalho (3), we suggest is as a result of the
differing neurophysiology protocols. Boekestein et al and de Carvalho use
at least 3 times the insertions used in our standard protocols. The
protocol used in our study is tailored for everyday clinical diagnosis
rather than the detailed research protocol undertaken by de Carvalho et
al.
We agree with Kleine et al that the Awaji Shima criteria (4) do risk
having a lower sensitivity in patients with UMN disease in one region,
although this was not the case in our study or the study by deCarvalho et
al.
We note that in the study by Boekstein et al in which the sensitivity of
the Awaji criteria was less, that fasciculations were not systematically
sought. As the recognition of complex fasciculations is the major
advantage of Awaji over El-Escorial we suspect this is the reason for the
reported lower sensitivity by Boekstein et al.
We have not evaluated how a modification of the Awaji criteria, allowing
simple fasciculations as evidence of lower motor neuron dysfunction,
affects specificity and therefore can not comment further on this.
References
1. Douglass CP, Kandler RH, Shaw PJ, McDermott CJ. An evaluation
of neurophysiological criteria used in the diagnosis of motor neuron
disease. J Neurol Neurosurg Psychiatry 2010;81:646-9.
2. Boekestein WA, Kleine BU, Hageman G, Schelhaas HJ, Zwarts MJ.
The sensitivity and specificity of the Awaji electrodiagnostic criteria
for amyotrophic lateral sclerosis. Retrospective comparison of the Awaji
recommendations and revised El Escorial criteria for ALS. Amyotroph
Lateral Scler 2010.
3. de Carvalho M, Dengler R, Eisen A, England JD, Kaji R, KimuraJ,
Mills K, Mitsumoto H, Nodera H, Shefner J, Swash M. Electrodiagnostic
criteria for diagnosis of ALS. Clin Neurophysiol 2008;119:497-503.
4. de Carvalho M, Swash M. Awaji diagnostic algorithm increases
sensitivity of El Escorial criteria for ALS diagnosis. Amyotroph Lateral
Scler 2009;10:53-7.
PK Sethi*, A Batra**, L Khanna***
Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
While going through the article, The Scan Rule, published in JNNP of
March 2010, Vol; 81 explaining the utility of scan score over conventional
CT scans in diagnosing or ruling out small intra cerebral haemorrhages, we
think that SCAN SCORES cannot score over con...
PK Sethi*, A Batra**, L Khanna***
Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
While going through the article, The Scan Rule, published in JNNP of
March 2010, Vol; 81 explaining the utility of scan score over conventional
CT scans in diagnosing or ruling out small intra cerebral haemorrhages, we
think that SCAN SCORES cannot score over conventional CT scans, given such
reasons like the lack of CT scans and neuroinfrastructure facilities.
It may be a useful method to rule out minor intra cerebral bleeds
utilising this score at places where there are scarcity of CT scans, so
that early antiplatelet therapy can be started to prevent early recurrent
ischemic stroke.
However, if we look at all aspects of the discussion, it can be said
that it is unreasonable for a stroke patient to keep waiting for
radiological confirmation for 7-10 days before an intracranial haemorrhage
is diagnosed. It is worth noting that even in a developing country like
India, there is no scarcity of CT scan centres. CT scans are available in
all small diagnostic centres in the city. All this has been started as a
private partnership in healthcare where the CT scan machines are installed
at a huge cost. In India, CT scans are done at reasonable rates which
include the cost of interpreting the scan and a waiting time of less than
12 hours. The cost of each CT scan is not more than $20. The scan centers
earn their revenue not by high charges, but by increasing their numbers of
patients and by working all days in the week. If we compare different
parts of the country, we see that metropolitan cities like Delhi in India
have nearly 90 CT scan centres and smaller cities like Meerut have 26 CT
scans machines.
So, instead of waiting for a CT scan and clinically ruling out an
intracerebral haemorrhage by the SCAN rule it is advisable to start an
entrepreneurship making available more number of CT scans to avoid the
possibility of treating a small intra cerebral haemorrhage with apparently
ZERO SCAN score with the antiplatelet agents.
Also, one could probably avert the dangers of misdiagnosing intracerebral
hemorrhage for infarction caused by the delays in scanning.
*Senior Consultant Neurologist, **Consultant Neurologist, ***Senior
Resident,.
Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
Dear Editor,
We read with interest the article by Wong et al (J Neurol Neurosurg Psychiatry published online May 12, 2010) suggesting that antibiotic impregnated ventricular catheters are as effective as systemic antibiotics to prevent nosocomial infections and cerebro-spinal fluid (CSF) infections in patients with external ventricular drain.
Impregnated catheters are designed to prevent specifically CSF catheter related inf...
Dear Editor,
We read with interest the article by Wong et al (J Neurol Neurosurg Psychiatry published online May 12, 2010) suggesting that antibiotic impregnated ventricular catheters are as effective as systemic antibiotics to prevent nosocomial infections and cerebro-spinal fluid (CSF) infections in patients with external ventricular drain.
Impregnated catheters are designed to prevent specifically CSF catheter related infections. However the primary endpoint was the occurrence of any nosocomial infection in this non-double blinded trial. The proportion of patients with nosocomial infection was not significantly different between the impregnated catheter group and the conventional catheter coupled with systemic antibiotic group. There was also no difference between groups for the secondary endpoint, which was the occurrence of a CSF infection.
At our University Hospital, catheter used for CSF shunts are usually clindamycin-rifampicin impregnated catheters (Bactiseal, Codman, Johnson and Johnson, Raynham, MA). A surveillance of CSF infections has been implemented since January, 2007. We were confronted in 2009 to a shortage of impregnated catheters and therefore some patients received non impregnated catheter. We subsequently conducted a survey using the surveillance data in order to assess ventricular catheter related infection incidence and risk factors. We also assessed whether the lack of antibiotic impregnation of the catheter was a risk factor for CSF infection.
The survey took place in a tertiary care, University teaching hospital. All neurosurgery inpatients with a ventricular catheter inserted between January 1, 2009 and June 30, 2009 were included and followed-up until catheter removal, or for the 30 days following catheter insertion if the catheter had not been removed after 30 days. Patients aged less than eighteen, and patients with a medical history of CSF infection or a known CSF infection were excluded from the study.
The surgical procedure was performed in the operating room by a trained neurosurgeon. Patients received either a impregnated ventricular catheter or a non-impregnated catheter depending on availability and did not receive any systemic prophylactic antibiotics.
The following data were prospectively recorded: age, gender, indication for the catheter (intracranial hemorrhage, or other indication), intracranial pressure measurement, ventricular catheter placement duration, hospitalization in Intensive Care Unit (ICU), and catheter antibiotic impregnation.
We used Center for Desease Control definitions of CSF infections: pathogenic bacteria isolated from CSF or at least two clinical criteria (hyperthermia > 38 degree Celsius, consciousness dysfunction or meningeal signs) associated to an antibiotherapy with at least 1 biological abnormalities (leucocytes in CSF, hyperproteinorrachy and hypoglucorrachy, or bacteria found on CSF direct examination, or positive blood culture, or CSF antigens, or IgM antibody detection, or IgG antibodies X 4 on 2 successive samples).
Ventricular catheter-related infection cumulative incidence and incidence density per 1000 catheter-days were calculated with their 95% confidence intervals. Categorical variables were compared by Fisher's exact test. A multivariate logistic regression was performed including age, sex, catheter antibiotic impregnation, measuring of CSF pressure, indication for the catheter, ICU hospitalization, and ventricular catheter placement duration more than 18 days (third quartile of our ventricular catheter placement duration).
Ninety-six ventricular catheters were inserted in 68 patients between January 1 and June 30, 2009. Twenty-nine ventricular catheters were excluded (10 were inserted in patients aged less than eighteen years old, 12 were inserted in patients with an infected ventricular catheter and 7 in patients who had a history of CSF infection). Sixty-seven ventricular catheters were therefore included (66% were antibiotic impregnated). They were inserted in 55 patients (mean age 49.1 years /- 13.9, male-female sex ratio: 1.4) during 945 catheter-days. The mean duration of ventricular catheter was 14 days.
Nine CSF infections occurred, with a cumulative incidence of 13.4% CI95%[6.3%-24.0%] and an incidence density of 9,5/1000 catheter-days. Fifty-six percent of identified bacteria were cocci gram plus (coagulase negative Staphylococcus n=3, Staphylococcus aureus methicillin susceptible n=1, bacillus n=1), and 44 % were gram negative bacilli (Acinetobacter baumanii n=1, Enterobacter cloacae n=1, Escherichia coli n=1, Klebsiella pneumoniae n=1).
On univariate analysis, antibiotic non-impregnated catheter and catheter placement duration >18 days were significantly associated with an increased risk of ventricular catheter-related infection (respectively RR=4.8 CI95%[1.1-13.9] and RR=3.7 CI95%[1.1-12.1]). On multivariate analysis, only ventricular catheter placement duration was a significant risk factor for ventricular catheter-related infection (adjusted OR : 8.1 CI95%[1.1-59.6])
In conclusion, we observed a cumulative incidence of 13.4%, both higher than incidence observed by Korinek et al.1. We found no significant effect of antibiotic impregnated ventricular catheters to prevent CSF infection. This lack of significant protection may be explained by our sample size. Catheter placement duration was the only independent variable associated with ventricular catheter related infection, as previously shown by Arabi et al.2
Impregnated ventricular catheters have been shown to reduce CSF ventricular catheter related colonisation.3 A large randomized essay is required in order to evaluate the effectiveness in reducing CSF infections.
References
1. Korinek AM, Reina M, Boch AL, et al., Prevention of external ventricular drain-related ventriculitis. Acta Neurochir (Wien) 2005;147:39-45.
2. Arabi Y, Memish ZA, Balkhy HH, et al., Ventriculostomy-associated infections: Incidence and risk factors. Am J Infect Control 2005;33:137-43.
3. Zabramski JM, Whithing D, Darouiche RO, et al., Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial. J Neurosurg 2003;98:725-30.
Acknowledgement: The authors thank Richard Medeiros, Rouen University Hospital Medical Editor for editing the manuscript
An one-and-a-half syndrome as first described by C. Miller-
Fisher in 1967 is characterized by an ipsilateral horizontal gaze paresis
or palsy and an internuclear ophthalmoplegia or INO on
contralateral horizontal gaze. An exotropia may be present in primary
position but does not have to be present. The association of exotropia in
the one-and-a-half syndrome is sometimes called "paralytic pontine
exotropia" In addition t...
An one-and-a-half syndrome as first described by C. Miller-
Fisher in 1967 is characterized by an ipsilateral horizontal gaze paresis
or palsy and an internuclear ophthalmoplegia or INO on
contralateral horizontal gaze. An exotropia may be present in primary
position but does not have to be present. The association of exotropia in
the one-and-a-half syndrome is sometimes called "paralytic pontine
exotropia" In addition there may be a concomitant esotropia if there is a
simultaneous involvement of the sixth cranial nerve. The horizontal gaze
palsy may arise from a lesion in the ipsilateral paramedian pontine
reticular formation (PPRF) only; the ipsilateral abducens nucleus alone;
both the ipsilateral PPRF and the abducens nucleus, or lesions of the
fibers from the ipsilateral abducens nucleus to the lateral rectus and to
the contralateral medial longitudinal fasciculus (MLF) producing the INO.
An INO is characterized by paresis or paralysis of adduction of the
ipsilateral eye on attempted horizontal gaze to the contralateral side and
a dissociated horizontal jerk nystagmus in the contralateral abducting
eye. If convergence is intact then the lesion of the MLF does not extend
rostrally to the mesencephalon. Sometimes a vertical deviation from skew
is associated with the above horizontal ocular motor disturbances.
In our patient the ocular motility showed mild left hypertropia (skew
deviation) and a moderate incomitant exotropia. The near reaction and
convergence effort could overcome the adduction deficit in the left eye
consistent with a more caudal left pontine INO. On right gaze, he had a
severe underaction of adduction in the left eye associated with an
abducting dissociated horizontal nystagmus in the right eye and he had a
moderate underaction of abduction in the left eye due to a left sixth
nerve paresis but not a horizontal gaze paresis. Magnetic
resonance imaging showed a focal haemorrhagic lesion in the floor of the
aqueduct in the region of the dorsal pons.Thus the suggested description,
"half and half".
We thank Dr. Aboul-Enein et al. for their interest about our recent
paper. We apologize for the missing references. For the first one
(Bichuetti et al.) we missed it in our pubmed research probably due to a
misclassification of the key words. For the second one (Aboul-Enein et
al.), the paper was not published before our article was in press. We are
a little bit concern to include in our references abstract of posters....
We thank Dr. Aboul-Enein et al. for their interest about our recent
paper. We apologize for the missing references. For the first one
(Bichuetti et al.) we missed it in our pubmed research probably due to a
misclassification of the key words. For the second one (Aboul-Enein et
al.), the paper was not published before our article was in press. We are
a little bit concern to include in our references abstract of posters.
Many mistakes can be include in abstract form of poster that are
frequently submitted quickly due to the deadline of the congress. It was
the case concerning our poster explaining the differences between the
abstract from Multiple sclerosis and our recent paper. Of course the right
number of patients and controls is in the full paper. We think that the
most important fact is that all the three papers are in the similar
direction confirming that normal apparent white and grey matter are really
normal in NMO evaluated by spectroscopy MR.
we have read with great interest the paper by de Seze et al.,
entitled "Magnetic resonance spectroscopy evaluation in patients with
neuromyelitis optica" (1).
Neuromyelitis optica (NMO) is a rare disease and most studies rely on
a small sample size. Calling attention to previous publications on
magnetic resonance spectroscopy (MRS) in patients with NMO might
strengthen the results of de Seze et al. Bi...
we have read with great interest the paper by de Seze et al.,
entitled "Magnetic resonance spectroscopy evaluation in patients with
neuromyelitis optica" (1).
Neuromyelitis optica (NMO) is a rare disease and most studies rely on
a small sample size. Calling attention to previous publications on
magnetic resonance spectroscopy (MRS) in patients with NMO might
strengthen the results of de Seze et al. Bichuetti et al (2) and our group
(3) achieved nearly identical results as found by de Seze et al.
Furthermore we performed chemical shift imaging MRS at 3 Tesla, a
technique able to quantify absolute concentrations of the metabolites in
the normal appearing white matter (NAWM) instead of metabolite ratios
only.
De Seze et al and our group presented their data previously as
posters at the same session of the 23th Congress of the European Committee
for Treatment and Research in Multiple Sclerosis (ECTRIMS) in 2008 (3, 4).
We were therefore aware of their data and find it confusing that
metabolite ratios in the NAWM of NMO patients and healthy controls
presented at ECTRIMS (3) were essentially the same as published in
JNNP(1), while the number of NMO patients changed from 25 to 24, and the
number of healthy controls from 15 to 12.
NMO is a rare disease and the number of patients included in studies
is generally low. To overcome this limitation data for each patient should
be traceable.
We would like to ask the authors to provide detailed information in
order to explain these confusing data.
References:
1. de Seze J, Blanc F, Kremer S, et al. Magnetic resonance
spectroscopy evaluation in patients with neuromyelitis optica. J Neurol
Neurosurg Psychiatry. 2010; 81:409-11.
2. Bichuetti DB, Rivero RL, de Oliveira EM, et al. White matter
spectroscopy in neuromyelitis optica: a case control study. J Neurol.
2008; 255:1895-9. Epub 2009 Jan 22.
3. Aboul-Enein F, Krssak M, Hoftberger R, Prayer D, Kristoferitsch W.
Diffuse white matter damage is absent in neuromyelitis optica. AJNR Am J
Neuroradiol. 2010; 31:76-9. Epub 2009 Sep 12.
4. de Seze J, Blanc F, Kremer S, et al. Magnetic resonance
spectroscopy evaluation in patients with neuromyelitis optica. Multiple
Sclerosis 2008; 14:S101-S101.
5. Aboul-Enein F, Krssak M, Jecel J, et al. Magnetic resonance
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S101.
I read with interest the paper by Benedetti et al., entitled 'Rituximab in patients with chronic inflammatory demyelinating polyradiculoneuropathy: a report of 13 cases and review of the literature'(1). Rituximab, a monoclonal antibody that binds to the CD20 antigen on B- lymphocytes, has been approved to eliminate B cell precursors, normal and malignant B cells and to reduce antibody titers (2,3). Some authors argued tha...
Extradural cortical stimulation (ECS) for post-stroke aphasia (PSA)
Cherney et al (1) conducted an 8 patient controlled study whose conclusion was that ECS may enhance the effect of rehabilitation for PSA. This study was conducted by implanting the stimulating paddle supplied by NorthStar Neuroscience (NSN), a company now out of business. Cherney et al. point to several weaknesses of their study, but omit to dis...
To the editor,
We thank Dr. Marini and colleagues for their interest in our article.1 They commented on the use of nosocomial infections as primary outcome and the randomised yet non-double-blinded study design. Secondarily, they shared their disappointing results from the utilization of antibiotics-impregnated ventricular catheters.
In our centers, we have achieved a ventricular-catheter-related cere...
Sadjadi and colleagues show that in IBM, as in most chronic illness, mood plays a role in QoL. It would be a surprise if mood didn't play a role in measured QoL. QoL assessment uses subjective measures, for example "how would you rate your health?", and a patient's response to such a question is likely to be altered by mood. Hence QoL questionnaires can also act as mood questionnaires. Indeed, the awkward realisation i...
Dear Sir, We write in response to the rapid response by Kleine et al. The disparity between the sensitivity of El Escorial in our study (1) and the work by Boekestein et al (2) and de Carvalho (3), we suggest is as a result of the differing neurophysiology protocols. Boekestein et al and de Carvalho use at least 3 times the insertions used in our standard protocols. The protocol used in our study is tailored for everyday...
SCAN SCORE VS. SCAN-- WHICH IS JUSTIFIED
PK Sethi*, A Batra**, L Khanna*** Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
While going through the article, The Scan Rule, published in JNNP of March 2010, Vol; 81 explaining the utility of scan score over conventional CT scans in diagnosing or ruling out small intra cerebral haemorrhages, we think that SCAN SCORES cannot score over con...
Impregnated catheters are designed to prevent specifically CSF catheter related inf...
An one-and-a-half syndrome as first described by C. Miller- Fisher in 1967 is characterized by an ipsilateral horizontal gaze paresis or palsy and an internuclear ophthalmoplegia or INO on contralateral horizontal gaze. An exotropia may be present in primary position but does not have to be present. The association of exotropia in the one-and-a-half syndrome is sometimes called "paralytic pontine exotropia" In addition t...
We thank Dr. Aboul-Enein et al. for their interest about our recent paper. We apologize for the missing references. For the first one (Bichuetti et al.) we missed it in our pubmed research probably due to a misclassification of the key words. For the second one (Aboul-Enein et al.), the paper was not published before our article was in press. We are a little bit concern to include in our references abstract of posters....
Sir,
we have read with great interest the paper by de Seze et al., entitled "Magnetic resonance spectroscopy evaluation in patients with neuromyelitis optica" (1).
Neuromyelitis optica (NMO) is a rare disease and most studies rely on a small sample size. Calling attention to previous publications on magnetic resonance spectroscopy (MRS) in patients with NMO might strengthen the results of de Seze et al. Bi...
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