NEUROCHIRURGIE Thalamic stimulation as treatment for primary erythromelalgia: a case report.

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Imogene Ryan
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1 NEUROCHIRURGIE DELYE H., LAGAE L., VERMYLEN J., NUTTIN B.:Thalamic stimulation as treatment for primary erythromelalgia: a case report. Neurosurgery, 2005; 57: ONS-404. Objective and importance: We report the use of bilateral thalamic stimulation in a case of primary erythromelalgia with immediate and important pain relief for 3 years. Clinical presentation: A 12-year-old boy experiencing primaryerythromelalgia had a 4-year history of recurrent attacks of severe burning pain in both feet, accompanied by local reddening, swelling, and heating of the skin. The attacks were triggered by warmth and exercise. The pain was relieved only by elevation and cooling of the lower limbs, which he achieved by immersing his legs in a bucket of ice water, resulting in severe ulceration of the skin. Intervention: Because of the gradual aggravation of the signs and symptoms and resistance of the patient's condition to several medical therapies, the patient received spinal cord stimulation. The implants were removed twice because of recurrent infection. Finally, the patient was treated with bilateral electrical stimulation of the ventral posterolateral thalamic nucleus, which resulted in important pain control until 3 years later. The patient was able to avoid water immersions, and all ulcerations disappeared. Conclusion: We conclude that thalamic stimulation was successful in this case of primary erythromelalgia. DE VLEESCHOUWER S., VAN CALENBERGH F., VAN LOON J., NUTTIN B., GOFFIN J., PLETS C.: Risk analysis of thrombo-embolic and recurrent bleeding events in the management of intracranial haemorrhage due to oral anticoagulation. Acta Chir. Belg., 2005; 105(3): Purposes: Intracranial haemorrhage (ICH) is a rare but potentially devastating complication of oral anticoagulants (OAC). This raises the difficult clinical choice between either permanent cessation of OAC, or continuing OAC and if so, when to restart. To make this choice, one needs to balance the thrombo-embolic risk after cessation of OAC against the risk of recurrent intracranial haemorrhage when OAC are restarted. There are few published data to base this difficult clinical decision on. Methods We present an observational study of a consecutive series of 108 patients, collected prospectively and admitted to our department, with an OAC-related intracranial haemorrhage, in whom we assessed the thrombotic event rate and the recurrent intracranial bleeding rate during follow-up. Results: In the 25 patients in whom OAC were reinstituted no new thrombo-embolic events occurred

2 (0/506 unprotected patient-days). In the group of patients in whom OAC were not restarted (n = 81), the thromboembolic event rate was 8/11590 unprotected patientdays, of which only 2 were cerebrovascular thromboembolisms. The overall risk of a thrombo-embolic complication can be estimated to be 0.66 events/1000 patient-days at risk (95% exact confidence limits of 0.3 to 1.3 events/1000 patient-days at risk). In three patients the thrombo-embolic event was fatal. We saw recurrent intracranial bleeding in eight patients, 2 of which were fatal. Seven of these occurred before the restarting of the OAC. Conclusions: In OAC-related intracranial haemorrhages, OAC can be stopped safely for a considerable period, with a very low overall thrombotic event rate. The recurrent bleeding risk after restarting OAC is low. Recurrent bleeding mostly occurred before restarting OAC and is probably caused by insufficient or unsustained correction of the initial coagulation deficit. Immediate reversal of anticoagulation provides the patient with the best possible treatment options including surgery. OAC-related intracranial haemorrhages can therefore be actively treated. DE VLEESCHOUWER S., VAN GOOL S.W., VAN CALENBERGH F.: Immunotherapy for malignant gliomas: emphasis on strategies of active specific immunotherapy using autologous dendritic cells. Childs Nerv Syst., 2005; 21(1): Review: In this review, we discuss immunotherapy for malignant gliomas. Emphasis: The emphasis is on the novel strategy of active specific immunotherapy using dendritic cells as antigen-presenting cells, especially its theoretical concepts and advantages, specific requirements, critical issues, pre-clinical and early clinical experience. Dendritic cell vaccination is situated in the diversity of other immunotherapeutical approaches. Further discussion: Future directions, challenges, and drawbacks will be discussed. FEYS P., HELSEN W., LIU X., MOOREN D., ALBRECHT H., NUTTIN B., KETELAER P.: The effect of peripheral cooling on intention tremor caused by multiple sclerosis. J. Neurol. Neurosurg. Psych., 2005; 76(3): Objective: To investigate the effect of peripheral sustained cooling on intention tremor in patients with multiple sclerosis (MS). MS induced upper limb intention tremor affects many functional activities and is extremely difficult to treat. Materials/Methods: Deep (18 degrees C) and moderate (25 degrees C) cooling interventions were applied for 15 minutes to 23 and 11 tremor arms of patients with MS, respectively. Deep and moderate cooling reduced skin

3 temperature at the elbow by 13.5 degrees C and 7 degrees C, respectively. Evaluations of physiological variables, the finger tapping test, and a wrist step tracking task were performed before and up to 30 minutes after cooling. Results: The heart rate and the central body temperature remained unchanged throughout. Both cooling interventions reduced overall tremor amplitude and frequency proportional to cooling intensity. Tremor reduction persisted during the 30 minute post cooling evaluation period. Nerve conduction velocity was decreased after deep cooling, but this does not fully explain the reduction in tremor amplitude or the effects of moderate cooling. Cooling did not substantially hamper voluntary movement control required for accurate performance of the step tracking task. However, changes in the mechanical properties of muscles may have contributed to the tremor amplitude reduction. Conclusions: Cooling induced tremor reduction is probably caused by a combination of decreased nerve conduction velocity, changed muscle properties, and reduced muscle spindle activity. Tremor reduction is thought to relate to decreased long loop stretch reflexes, because muscle spindle discharge is temperature dependent. These findings are clinically important because applying peripheral cooling might enable patients to perform functional activities more efficiently. FEYS P., HELSEN W., LIU X., NUTTIN B., LAVRYSEN A., SWINNEN S., KETELAER P.: Interaction between eye and hand movements in multiple sclerosis patients with intention tremor. Movement Disorders, 2005; 20: Deficient eye and hand movements are present in patients with multiple sclerosis. In the present study, eye and hand movements were simultaneously measured during visually guided wrist step-tracking tasks in 16 patients with intention tremor and 15 healthy controls. The coupling between eye and hand movements was analyzed during simultaneous eye-hand tracking, and interactions were studied by comparing the coordinated eye-hand condition with isolated eye- or hand-tracking conditions. Despite movement abnormalities, the onset of eye and hand movements was highly correlated and an invariant coupling between the saccadic completion time and hand peak velocity was found, suggesting that the temporal coupling was very much preserved. The differences between the experimental tracking conditions suggest that, in MS patients with intention tremor, the ocular system influenced the hand movements. Intention tremor amplitude was reduced when there was no preceding saccadic eye movement, whereas conversely, eye movements were not affected by different hand tremor severity.

4 FEYS P., MAES F., NUTTIN B., HELSEN W., MALFAIT V., NAGELS G., LAVRYSEN A., WUGUANG L.: Relationship between multiple sclerosis intention tremor severity and lesion load in the brainstem. Neuroreport, 2005; 16(12): Intention tremor due to multiple sclerosis is clinically similar to cerebellar tremor. This study investigated, in 14 multiple sclerosis patients, the relationship between intention tremor severity and the lesion load in different infratentorial regions. Tremor amplitude was quantified during step-tracking tasks. The lesion load was measured on magnetic resonance images using an automated segmentation method. Intention tremor amplitude was significantly related to lesion load in the brainstem but not in the cerebellum. Specifically, tremor amplitude correlated with the lesion load in the contralateral pons, and patients with more severe tremor in both arms had a greater lesion load bilaterally in the pons. These results support the view that multiple sclerosis intention tremor is related to dysfunction of cerebellar inflow and/or outflow pathways. VAN LAERE K., CEYSSENS S., VAN CALENBERGH F., DE GROOT T., MENTEN J., FLAMEN P., BORGMANS G., MORTELMANS L.: Direct comparison of (18)F-FDG and (11)C-methionine PET in suspected recurrence of glioma: sensitivity, inter-observer variability and prognostic value. Eur. J. Nucl. Med. Mol. Imaging, 2005; 32(1): Purpose: (18)F-fluorodeoxyglucose (FDG) and (11)Cmethionine (MET) PET imaging studies allow the investigation of metabolism and amino acid transport in brain tumours. Their (relative) usefulness and prognostic value in suspected recurrence or progression of primary brain tumours after previous therapy is an issue of debate. The aim of this study was to compare directly both radioligands in this setting. Methods: Cerebral uptake of FDG and MET was determined sequentially on the same day in 30 patients (21 males, nine females; age 40.4+/-15.6 years), on average 4.0 years (range ) after therapy for a primary brain tumour (23 grade II-IV astrocytomas, four oligodendrogliomas and three mixed oligoastrocytomas). Images were acquired on a Siemens HR+ dedicated PET camera. Two observers scored FDG and MET scans independently. Semi-quantitative indices defined by the tumour (maximum)-to-background ratio were calculated based on manual ROI delineation and by using MET ROIs for FDG after automated coregistration. Patient follow-up was conducted until the last contact with inconspicuous clinical findings (average 41 months, range months after PET) [(n=10)] or until death (n=20). Results: Overall median survival was 15.0 months. MET showed pathologically increased uptake in 28/30 scans, and FDG in 17/30. The inter-observer agreement was 100% for MET and 73% for FDG. Using Kaplan-Meier

5 survival analysis, significant differences were found for both FDG (cut-off 0.8, log-rank p=0.007) and MET (cutoff 2.2, log-rank p=0.014). The combination of FDG and MET information resulted in the highest prognostic accuracy (p=0.003), while MET alone was the best prognostic predictor in the subgroup of patients with primary astrocytoma (n=23). Conclusion: FDG and MET PET studies provide complementary prognostic information in patients with suspected brain tumour recurrence or progression after primary therapy. MET is considered the single agent of choice in the evaluation of these patients because of its sensitivity and clearer delineation of the suspected recurrence.

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U pper limb tremor affects the performance of many 373 PAPER Effects of peripheral cooling on intention tremor in multiple sclerosis P Feys, W Helsen, X Liu, D Mooren, H Albrecht, B Nuttin, P Ketelaer... See end of article for authors affiliations... Correspondence