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A 25 year old man, with a family history of multiple sclerosis in two preceding generations, developed transient sensory changes and incoordination, initially on the left side, and then several months later on the right side in association with an elevated CSF gamma globulin. This was followed by an acute optic neuritis. During the latter episode he developed a positive brain scan which was unaccompanied by any clinical findings explained by a lesion in that area. Cerebral arteriography was normal and the brain scan returned to normal four weeks later, possibly as a result of blood brain barrier restoration. Abnormal brain scans appear to occur only during acute exacerbations of demyelinating disease, and multiple sclerosis should be part of the differential diagnosis of a positive brain scan in a person in the appropriate age range. [ABSTRACT FROM AUTHOR]

Neuroserpin, a recently identified inhibitor of tissue-type plasminogen activator (tPA), is primarily localized to neurons within the central nervous system, where it is thought to regulate tPA activity. In the present study neuroserpin expression and its potential therapeutic benefits were examined in a rat model of stroke. Neuroserpin expression increased in neurons surrounding the ischemic core (ischemic penumbra) within 6 hours of occlusion of the middle cerebral artery and remained elevated during the first week after the ischemic insult. Injection of neuroserpin directly into the brain immediately after infarct reduced stroke volume by 64% at 72 hours compared with control animals. In untreated animals both tPA and urokinase-type plasminogen activator (uPA) activity was significantly increased within the region of infarct by 6 hours after reperfusion. Activity of tPA then decreased to control levels by 72 hours, whereas uPA activity continued to rise and was dramatically increased by 72 hours. Both tPA and uPA activity were significantly reduced in neuroserpin-treated animals. Immunohistochemical staining of basement membrane laminin with a monoclonal antibody directed toward a cryptic epitope suggested that proteolysis of the basement membrane occurred as early as 10 minutes after reperfusion and that intracerebral administration of neuroserpin significantly reduced this proteolysis. Neuroserpin also decreased apoptotic cell counts in the ischemic penumbra by more than 50%. Thus, neuroserpin may be a naturally occurring neuroprotective proteinase inhibitor, whose therapeutic administration decreases stroke volume most likely by inhibiting proteinase activity and subsequent apoptosis associated with focal cerebral ischemia/reperfusion. (Blood. 2000;96:569-576)

Background and Objective: This report provides results of CSF analyses done in a subset of relapsing remitting MS patients participating in a placebo-controlled, double-blind, phase III clinical trial of IFNbeta-Studies supported by the National Multiple Sclerosis Society (grants RG2019, RG2827),a (Avonex , Biogen). The clinical trial demonstrated that IFNbeta-1a treatment resulted in significantly reduced disability progression, annual relapse rate, and new brain lesions visualized by cranial magnetic resonance imaging. The objectives of the current study were to determine: (a) whether CSF abnormalities in MS patients correlated with disease or MRI characteristics, and (b) effects of IFNbeta-1a therapy on these CSF abnormalities., Methods: CSF was analyzed from 262 (87%) of the 301 study subjects at entry into the clinical trial, and a second CSF sample was analyzed from 137 of these 262 subjects after 2 years of therapy. CSF cell counts, oligoclonal bands (OCB), IgG index, and free kappa light chains were measured using standard assays. Baseline CSF results were compared with demographic, disease, and MRI parameters. Differences in on-study relapse rate, gadolinium enhancement, and EDSS change according to baseline CSF status was used to determine the predictive value of CSF for subsequent clinical and MRI disease activity. Change in CSF parameters after 104 weeks were used to determine the effects of treatment., Results: (1) At study baseline, 37% of the subjects had abnormal CSF WBC counts, 61% had abnormal levels of CSF free kappa light chains, 84% had abnormal IgG index values, and 90% were positive for OCB. (2) Baseline IgG index, kappa light chains, and OCB showed weakly positive, statistically significant correlations with Gd-enhanced lesion volume and T2 lesion volume. WBC showed a statistically significant correlation with Gd-enhancing lesion volume but was uncorrelated with T2 lesion volume. (3) There was an associated between baseline CSF WBC counts and on-study clinical and MRI disease activity in placebo recipients. (4) IFNbeta-1a treatment resulted in significantly reduced CSF WBC counts, but there was no treatment-related change in CSF IgG index, kappa light chains, or OCB, which remained relatively stable over time in both patient groups., Conclusions: The current study documents significant reductions in CSF WBC counts in patients treated with IFNbeta-1a for 104 weeks. This finding is considered relevant to the therapeutic response, since CSF WBC counts were found to be positively correlated with subsequent clinical and MRI disease activity in placebo-treated relapsing MS patients.

We compared the ability of the Kurtzke Expanded Disability Status Scale (EDSS) and a composite outcome of non-physician-based measures of time to ambulate 25 feet (TA) and manual dexterity (the Box and Block Test [BBT], and 9-Hole Peg Test [9HPT]) to discriminate treatment effects in the Phase III study of interferon beta-1a. A log-rank comparison of Kaplan-Meier curves by treatment group showed the non-physician-based composite of BBT, 9HPT, and TA was of comparable sensitivity (P = 0.013) in discriminating sustained treatment failure as the EDSS alone (P = 0.029). The composite of BBT, 9HPT, TA, and EDSS was more sensitive (P = 0.009) in discriminating sustained treatment failure than the EDSS alone. Compositive outcomes of the EDSS and non-physician-based measures of manual dexterity and timed ambulation provide an appealing strategy to reduce the number of patients required to discriminate treatment effects in MS clinical trials.

The accepted standard treatment of relapsing multiple sclerosis consists of medications for disease symptoms, including treatment for acute exacerbations. However, currently there is no therapy that alters the progression of physical disability associated with this disease. The purpose of this study was to determine whether interferon beta-1a could slow the progressive, irreversible, neurological disability of relapsing multiple sclerosis. Three hundred one patients with relapsing multiple sclerosis were randomized into a double-blinded, placebo-controlled, multicenter phase III trial of interferon beta-1a. Interferon beta-1a, 6.0 million units (30 micrograms¿, was administered by intramuscular injection weekly. The primary outcome variable was time to sustained disability progression of at least 1.0 point on the Kurtzke Expanded Disability Status Scale (EDSS). Interferon beta-1a treatment produced a significant delay in time to sustained EDSS progression (p = 0.02). The Kaplan-Meier estimate of the proportion of patients progressing by the end of 104 weeks was 34.9% in the placebo group and 21.9% in the interferon beta-1a-treated group. Patients treated with interferon beta-1a also had significantly fewer exacerbations (p = 0.03) and a significantly lower number and volume of gadolinium-enhanced brain lesions on magnetic resonance images (p-values ranging between 0.02 and 0.05). Over 2 years, the annual exacerbation rate was 0.90 in placebo-treated patients versus 0.61 in interferon beta-1a-treated patients. There were no major adverse events related to treatment. Interferon beta-1a had a significant beneficial impact in relapsing multiple sclerosis patients by reducing the accumulation of permanent physical disability, exacerbation frequency, and disease activity measured by gadolinium-enhanced lesions on brain magnetic resonance images. This treatment may alter the fundamental course of relapsing multiple sclerosis.

Gerbil cerebral cortical synaptosomes loaded with the fluorescent calcium probe FURA-2 were used to study depolarization-induced presynaptic cytosolic free calcium concentration, as an in vitro model of cerebral ischemia. The depolarization-induced increase in intrasynaptosomal cytosolic free calcium concentration is not sodium-dependent or sodium channel-dependent and may be due to an influx of extrasynaptosomal calcium resulting from a cadmium- and omega-conotoxin-sensitive, nickel-, nifedipine-, and nimodipine-insensitive voltage-regulated channel. The depolarization-induced increase in intrasynaptosomal free cytosolic calcium concentration is also inhibited by flunarizine, a calcium antagonist that has protective effects in animal models of cerebral anoxia and ischemia. Our results suggest that presynaptic calcium uptake following depolarization may be mediated in part by an N-type channel. Flunarizine may block presynaptic calcium accumulation, in part, by blocking this N-type channel; this blockade may be just one of several mechanisms by which flunarizine exerts protective effects following cerebral ischemia.

Calcium antagonists are of potential value in preventing neuronal death following cerebral ischemia or anoxia. Prevention of calcium influx into neurons, not just preservation of cerebral blood flow, is necessary if these agents are to be protective. To be of value clinically in humans, these agents must be effective even if administered after the ischemic insult has occurred. Experimental studies suggest that flunarizine, which inhibits calcium influx following brain anoxia, prolongs clinical survival and prevents neuronal death even when administered after the ischemic event, has no known significant toxic effects in humans following acute administration, has important potential value in the treatment of stroke, and should be evaluated in controlled clinical trials of patients with acute stroke.

An improved method is described for the collection of breath for the subsequent assay of acetaldehyde and other volatile components. Breath is collected in a Pyrex gas-collecting tube sealed at both ends with Teflon taps. Prior to collection or assay of the samples, this tube is heated to 72 degrees C; breath is sampled for assay by piercing a rubber septum on a sideport with the needle of a similarly heated gas-tight syringe, and injected into a gas chromatograph (GC). The advantages of this system are: (1) Avoidance of the artefacts encountered in the assay of acetaldehyde in the blood; (2) suitability for sample collection at a site remote from the GC laboratory; (3) avoidance of sample loss by leakage, contamination, or partitioning into water condensed from breath; and (4) compatibility with a "nondedicated" GC lacking any special gas-collecting circuitry. A typical study of a normal human volunteer is described, demonstrating the rise and fall of the concentration of acetaldehyde and ethanol in the breath following the ingestion of an oral dose of ethanol.

A patient with transient monocular rotary-vertical nystagmus demonstrated decreased gain of vertical pursuit and normal vestibulo-ocular reflex on electrooculogram. A supranuclear brain stem lesion, resulting in lack of monocular inhibition of oculomotor neurons, is postulated on the basis of these findings.

The effort to employ therapeutic drug monitoring in the management of patients with convulsive disorders has been extremely successful. Fortunately, the drugs used by the majority of these patients are readily measured in plasma, and in most cases the plasma concentration is a valid measure of the appropriateness of the dosage of drug administered. Monitoring also helps to ensure patient compliance to drug schedules and allows appropriate adjustment of dosage in patients who are taking concomitant drugs that influence anticonvulsant drug levels. Accurate and reliable quantitative methodology is available to all laboratories, with the method of analysis selected reflecting the technical capabilities of the laboratory personnel.

This article reviews the uses of arteriography, venous digital subtraction angiography, and duplex carotid sonography in the evaluation of patients with an asymptomatic carotid bruit or carotid system transient ischemic attack. It concludes with a description of the authors' guidelines for their use.

An audit of 2,641 toxicology requests from the Georgetown University Hospital Emergency Department from 1981 through 1984 was conducted to assess the contribution of toxicology laboratory results to the clinical evaluation of the intoxicated patient. Positive findings were obtained in 80% of the patients tested. Ethanol was the most common intoxicant, accounting for 48% of all positive results and an average serum concentration of 250 mg/dl. Multiple drug use was documented in 28% of the patients with positive results; some ingested as many as six substances. Women were more likely than men to be polydrug users. A comparison of laboratory findings with diagnosis based on history and examination for 76 patients revealed that the laboratory provided additional information on the nature of the intoxication two-thirds of the time. Our conclusion is that the toxicology laboratory offering a broadly based screening service when properly utilized by the emergency department staff can aid in establishing an accurate diagnosis and provide a guide to therapy in the intoxicated patient.

An analytical method for the measurement of quaternary ammonium compounds in biological fluids has been developed. Samples are prepared by forming the corresponding iodides, which are extracted and isolated. The residue is taken into n-hexane or into water and part of the solution obtained is injected onto the gas chromatograph where thermal degradation takes place. The methyl iodide released is measured by a 63Ni electron capture detector. This method is quite sensitive and detects with good reliability and reproducibility as little as 10(-14) mole quaternary ammonium compound.