Part Of Internal Capsule Research Articles

Diffusion tensor imaging of white matter lesions with cognitive impairment

Objective To explore abnormal microstructural changes of white matter in patients with white matter lesions using diffusion tensor imaging(DTI), and to determine the association of such abnormalities of DTI parameters with cognitive function. Methods The objects who have already confirmed with WML were collected from March 2012 to February 2018 through magnetic resonance imaging (MRI) scan from the neurology department of Beijing Tiantan Hospital.Use The hamilton depression scale(HAMD) and the hamilton anxiety scale(HAMA) to eliminate anxiety and depression, and divided into WML-CN group, WML-VCIND group and WML-VAD group with Mini-mental state examination (MMSE), Montreal Cognitive Assessment (MOCA)and clinical dementia rating(CDR). In addition, select the healthy elderly people without WML by MRI scan as the normal control group.All of the subjects were detected with the superconduct magnetic resonance imaging system (German SIEMENS 3.0T ) for the DTI scanning.Original images were processed with VBA.Then explore the changes of FA and MD of DTI in whole brain and regions of interest in NC group, WML-CN group, WML-VCIND group and WWML-VAD group, and its correlation with the severity of cognitive impairment in patients with WML. Results The damage degree of the fiber microstructure of brain white matter was significantly correlated with the total grade point of MoCA (P<0.01). In figure FA, the variance analysis of F test results showed that the significant brain areas were the splenium of the corpus callosum, the genu of corpus callosum, bilateral posterior internal capsule, retrolenticular part of internal capsule, anterior thalamic radiation, partial inferior longitudinal fasciculus and inferior fronto-occipital fasciculus, cingulate, external capsule, upper and posterior part of the radiation crowns, partial superior longitudinal fasciculus, etc.(P<0.05 after FWE correction based on TFCE method). In Figure MD, the variance analysis of F test results showed that the statistically significant brain areas mainly included the left external capsule and hook, partial genu and splenium of corpus callosum, Bilateral, bilateral inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, anterior thalamic radiation, retrolenticular part of internal capsule, cingulate, etc (P<0.05 after FWE correction based on TFCE). Conclusion No matter whether cognitive impairment exists in patient with WML or not, all DTI parameters are different from those of normal people.The integrity of white matter fiber has been damaged with different degrees.The more severe the cognitive impairment in the external manifestations of patients with WML, the greater the damage to the intrinsic white matter microstructure. Key words: White matter lesions; Cognitive impairment; Diffusion tensor imaging; White matter fiber

EP 22. Deep brain stimulation of ventral internal capsule for refractory obsessive compulsive disorder

OCD is generally believed to be one of the most distressing of all anxiety disorders. Some OCD patients remain refractory and run a chronic deteriorating course. Therapeutic option in this group was initially limited to ablative surgery like anterior capsulotomy or anterior cingulotomy. Current study is aimed to see the effect of deep brain stimulation of posterior and ventral part of internal capsule on severity of OCD symptoms after three months, six months and then yearly follow-ups. Present series consisted of two patients having intractable OCD. Two psychiatrists independently assessed each patient. Both the patients full filled the criteria for OCD (33.30) according to the Diagnostic and Statistical Manual of Psychiatric Disorders 4th edition (DSM IV). Both failed to improve following treatment with at least 3 selective serotonin reuptake inhibitors (SSRIs) and have completed Cognitive Behavior Therapy (CBT) Outcome of both the patients was measured by Y-BOCS scale (Yale-Brown Obsessive-Compulsive Scale), BDI (Beck Depression Inventory) and MMSE (Mini mental scale examination). The pre and post operative assessment was done by two clinical psychologists who independently assessed both the patients Target for stimulation was deep ventral at anterior limb of internal capsule just posterior to anterior commissure 5–6 mm from midline. Leads were implanted stereotactically on both sides under local anaesthesia and sedation. Quadripolar stimulating electrode (Model 3387 Medtronic) were used on both sides and they are connected to Pulse Generator (Medtronic) by connecting leads under general anaesthesia. In the first case non rechargeable pulse generator (Kinetra) was used while in the second case rechargeable pulse generator (Activa RC) was used. Programming of device was started after six weeks and continued for six to eight months till patient show significant improvement. Medications were kept unchanged. Neuropsychiatric evaluation was done after three months and six months. Afterwards yearly follow-up was done. Our primary aim of this study is to determine the efficacy of DBS for OCD and to compare its result to traditional anterior capsulotomy. The literature indicates that anterior capsulotomy produces a 35% improvement in OCD symptoms in about 45% of operated patients. Present series of two patients showed very significant improvement in both cases. Our first case reported 68.42% improvement in her OCD symptoms as her Y-BOCS score reduced from 38 to 12 and (45.45%) of improvement in BDI score after one year. Similar finding was observed in second patient where Y-BOCS reduced from 38 to 10 (73.68% improvement) and BDI improved to 70.83%. There was no change in MMSE score in both cases that signifies no adverse effect on mental status. Both the patients showed more than 35% improvement that was much superior to results achieved by bilateral capsulotomy. Very significant improvements in present series relates to the placement of leads that were more posterior and ventral. There was recurrence of symptoms of OCD in first patient after nineteen months related to depletion of battery that improved after replacement with newer one. This problem was rectified in second patient where rechargeable DBS system was used that has long battery life. Conclusion We conclude that DBS of VC/VS complex is very safe and effective in refractory OCD and the shows considerable promise for future. The long term result of this small controlled study is much better as compared to lesioning (capsulotomy).

PP04.7 – 2998: H1N1 cerebral vasculitis: A case report on 5 years old boy

Objective Report a case of a 5 years old boy, previously healthy, that few days after the diagnosis of H1N1 virus infection, began to develop neurological signs, characterized at first by left central facial palsy, followed two days later by complete left hemiparesis. There was severe drowsiness only on the first day. The pacient did not had seizures, speech disorders, nor altered mental status. Methods The pacient was submitted to a complete laboratory study that did not show abnormalities. The Cerebral Spinal Fluid did not shows abnormalities. The MRI demonstrated subacute ischaemic areas on right basal ganglia, parts of internal capsule, thalamus and corona radiata. The MRI Angiography demonstrated middle cerebral artery stenosis in the M1 segment and A1 stenosis of the anterior cerebral artery. Results After three weeks of the first neurological symptons, there was almost complete recovery of the neurological impairement, only observed by a discrete gait instability and reflex assimetry. A new MRI was performed three months later, that demonstrated gliosis in the white matter in right internal capsule, and basal ganglia. The MRI Angiography had become almst normal, with progressive recovery of the blood flow. He just received oral corticosteroid and antiplatelet therapy. Conclusion Reports of H1N1 with stroke secondary to cerebral vasculitis are rare and use to be related with immunization. Apparently, the prognosis suggests to the good, as we can observe by the progressive recovery dispite the first clinical signs and MRI abnormal findings. Maybe this viral cerebral vasculits can be compared with post-varicella cerebral vasculits on the prognosis and physiopatology, but more cases and investigation must to be done.

A novel autosomal dominant leukodystrophy with specific MRI pattern.

Etiologic diagnosis of adulthood leukodystrophy is challenging in neurologic practice. We describe here the clinico-radiological features of a novel autosomal dominant leukodystrophy in a single family. Clinical and MRI features were recorded in a three generation family. Exome sequencing was performed in two affected relatives and one healthy member. Four total relatives (3 women and 1 man, mean age at onset: 45, range 32-59) were followed: 2 for migraine and 2 for cognitive loss. MRI features were homogeneous in the four affected relatives: extensive and symmetrical white matter hyperintensities on T2-weighted images, with a posterior predominance, involvement of the middle cerebellar peduncles, corpus callosum and the posterior limb of the internal capsules. An extensive metabolic screening was negative. In addition, sequencing of pathogenic genes involved in dominant leukodystrophies (NOTCH3, LMNB1, GFAP, CSF1R) was negative. No mutation has been identified yet with exome sequencing. This report is peculiar because of dominant inheritance, adult onset, highly homogeneous white matter hyperintensities on T2-weighted MR images, predominant in the middle cerebellar peduncles and posterior part of internal capsule and absence of mutation of the genes involved in dominant leukodystrophies.

White fiber dissection of brain; the internal capsule: a cadaveric study

This study was done to study the three dimensional anatomy of internal capsule's white fibers completely by cadaveric dissection and its relation to basal ganglia and other related anatomical structures. Eight formalin fixed cerebral hemispheres were dissected for internal capsule under operating microscope. Klingler's technique of fiber dissection was adopted. The internal capsule was dissected from superiolateral inferior and medial surface of cerebral hemisphere. During and after dissection its relation with basal ganglia and other related structures were studied. The internal capsule was demonstrated by dissecting fibers of all its parts. Fibers that forms the internal capsule originate from different parts of cerebral cortex and pass through corona radiata that lies in lateral periventricular area and lateral to the caudate nucleus above the upper border of lentiform nucleus. The internal capsule is situated medial to lentiform nucleus and lateral to caudate nucleus and thalamus. Caudally it continues in the midbrain as cerebral peduncle. It has an anterior limb, genu, posterior limb, retrolentiform and sublentiform part. The relation of different parts of internal capsule with surrounding structures were also shown. Knowledge of the microsurgical anatomy of the internal capsule and other white fibers tracts is essential for neurosurgeons and other neuroscientists.