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Difference between revisions of "Codice criptato: Ipereccitabilità del sistema trigeminale"
Codice criptato: Ipereccitabilità del sistema trigeminale (view source)
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==== 3° Step: MNR encefalo ==== | ==== 3° Step: MNR encefalo ==== | ||
La risonanza magnetica del cervello, utilizzando le sequenze Turbo Spin Echo, Fluid Attenuated Inversion Recovery e Gradient Echo, è stata condotta prima e dopo la somministrazione endovenosa del mezzo di contrasto. I risultati hanno mostrato la presenza di un'area tondeggiante di circa 1,5 cm di diametro situata in prossimità della cisterna quadrigeminale a livello della ghiandola pineale. C'era anche una leggera dilatazione del sistema ventricolare sopratentoriale, che appariva in asse ed era più evidente in prossimità delle corna temporali, con un bordo periventricolare con un fenomeno di assorbimento di liquidi transependimale,<ref>Peter H Yang, Alison Almgren-Bell, Hongjie Gu, Anna V Dowling, Sangami Pugazenthi, Kimberly Mackey, Esther B Dupépé, Jennifer M Strahle. Etiology- and region-specific characteristics of transependymal cerebrospinal fluid flow. J Neurosurg Pediatr. 2022 Aug 12;1-11. doi: 10.3171/2022.7.PEDS2246. Online ahead of print.</ref> caratteristiche che suggerivano una diagnosi provvisoria di cavernoma pineale. (Figura 2 e 3) | |||
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<gallery widths="340" heights="300" perrow="2" slideshow""=""> | <gallery widths="340" heights="300" perrow="2" slideshow""=""> | ||
File:Pineal cavernoma pre surgery 1.jpeg|'''Figure 2:''' | File:Pineal cavernoma pre surgery 1.jpeg|'''Figure 2:''' Si può vedere il bordo periventricolare, che indica l'assorbimento transpendimale di liquido (freccia). | ||
File:Pineal cavernoma pre surgery 2.jpg|'''Figure 3:''' | File:Pineal cavernoma pre surgery 2.jpg|'''Figure 3:''' Sul piano sagittale della RM dell'encefalo con mezzo di contrasto (gadolinio) si vede l'esteso cavernoma (freccia). | ||
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<gallery mode="slideshow" widths="300" heights="170" perrow="1" caption="''Visual Cognitive gallery''"> | <gallery mode="slideshow" widths="300" heights="170" perrow="1" caption="''Visual Cognitive gallery''"> | ||
File:Bruxer Jaw jerk.jpeg|''<math>\gamma_2=</math> Jaw jerk: As a first step, the assertion that the specific phase highlights an anomaly, even if of minor importance, such as amplitude asymmetry, should always be considered, but the absolute value of the amplitudes on each side should also be noted at the same time. Note in the lower section of the window that the right masseter shows an amplitude of 5 mV while the left one of 8.50 mV. The question to ask is: What is the population mean jaw jerk amplitude? This question is of essential importance because it allows us to understand whether this asymmetry is primarily functional or organic and secondly to quantify its absolute response, but with respect to what? | File:Bruxer Jaw jerk.jpeg|''<math>\gamma_2=</math> Jaw jerk: As a first step, the assertion that the specific phase highlights an anomaly, even if of minor importance, such as amplitude asymmetry, should always be considered, but the absolute value of the amplitudes on each side should also be noted at the same time. Note in the lower section of the window that the right masseter shows an amplitude of 5 mV while the left one of 8.50 mV. The question to ask is: What is the population mean jaw jerk amplitude? This question is of essential importance because it allows us to understand whether this asymmetry is primarily functional or organic and secondly to quantify its absolute response, but with respect to what? Riflesso mandibolare: Come primo passo, va sempre considerata l'asserzione che videnzi un'anomalia, anche se di minore importanza, come l'asimmetria delle ampiezze, ma va annotato anche il valore assoluto delle ampiezze su ciascun lato. Si noti nella parte inferiore della finestra che il massetere destro mostra un'ampiezza di 5 mV mentre quello sinistro di 8,50 mV. La domanda da porsi è: qual è l'ampiezza media dello riflesso mandibolare nella popolazione? Questa domanda è di fondamentale importanza perché ci permette di capire se questa asimmetria è in primo luogo funzionale od organica e in secondo luogo di quantificarne la risposta assoluta, ma rispetto a cosa? | ||
File:Bruxer MEP.jpeg|'''<math>\gamma_1=</math> Trigeminale Root-MEPs:''' To the motor evoked response of the trigeminal roots recorded on the masseter muscles called bRoot-MEPs.<ref>Frisardi G. The use of transcranial stimulation in the fabrication of an occlusal splint. J Prosthet Dent, 1992, DOI: 10.1016/0022-3913(92)90345-b</ref><ref>G. Frisardi 1, P. Ravazzani, G. Tognola, F Grandori. Electric versus magnetic transcranial stimulation of the trigeminal system in healthy subjects. Clinical applications in gnathology. J Oral Rehabil.1997 Dec;24(12):920-8. doi: 10.1046/j.1365-2842.1997.00577.x.</ref> This neurophysiological response indicates the anatomical component of the trigeminal motor system of the individual being examined and contextually the absolute amplitude value which, obviously, would correspond to the neuronal energy evoked by the depolarization of all the trigeminal motor fibres contained in the motor root. This very important datum determines the absolute value to which other reflections such as jaw jerk and lateral symmetry refer. Already from these first two questions, we can conclude that the average amplitude <math>\approxeq 30%</math>of the Root-MEPs we are faced with a datum far beyond the limit, namely <math>\approxeq 79%</math>which represents a sort of hyper-excitability of the midbrain response. | File:Bruxer MEP.jpeg|'''<math>\gamma_1=</math> Trigeminale Root-MEPs:''' To the motor evoked response of the trigeminal roots recorded on the masseter muscles called bRoot-MEPs.<ref>Frisardi G. The use of transcranial stimulation in the fabrication of an occlusal splint. J Prosthet Dent, 1992, DOI: 10.1016/0022-3913(92)90345-b</ref><ref>G. Frisardi 1, P. Ravazzani, G. Tognola, F Grandori. Electric versus magnetic transcranial stimulation of the trigeminal system in healthy subjects. Clinical applications in gnathology. J Oral Rehabil.1997 Dec;24(12):920-8. doi: 10.1046/j.1365-2842.1997.00577.x.</ref> This neurophysiological response indicates the anatomical component of the trigeminal motor system of the individual being examined and contextually the absolute amplitude value which, obviously, would correspond to the neuronal energy evoked by the depolarization of all the trigeminal motor fibres contained in the motor root. This very important datum determines the absolute value to which other reflections such as jaw jerk and lateral symmetry refer. Already from these first two questions, we can conclude that the average amplitude <math>\approxeq 30%</math>of the Root-MEPs we are faced with a datum far beyond the limit, namely <math>\approxeq 79%</math>which represents a sort of hyper-excitability of the midbrain response. | ||
File:Bruxer SP2.jpg|'''<math>\gamma_3=</math> Masseteric Silent Period:''' Doubt could arise about being in a situation of degenerative and/or demyelinating neuropathy but the test of the electric masseter silent period annuls this hypothesis as both the latency and the duration of the first and second silent period (ES1 and ES2) are symmetrical. Also, the interposed activity of reactivation of the motor units which divides the two silent periods results in symmetry in the integral area between the sides. This data can only highlight hyperexcitability of the trigeminal system by coupling a second electrical stimulus following the first and evoking what has been described, i.e. the recovery cycle of the Inhibitory Masseter Reflex (<sub>rc</sub>RIM) | File:Bruxer SP2.jpg|'''<math>\gamma_3=</math> Masseteric Silent Period:''' Doubt could arise about being in a situation of degenerative and/or demyelinating neuropathy but the test of the electric masseter silent period annuls this hypothesis as both the latency and the duration of the first and second silent period (ES1 and ES2) are symmetrical. Also, the interposed activity of reactivation of the motor units which divides the two silent periods results in symmetry in the integral area between the sides. This data can only highlight hyperexcitability of the trigeminal system by coupling a second electrical stimulus following the first and evoking what has been described, i.e. the recovery cycle of the Inhibitory Masseter Reflex (<sub>rc</sub>RIM) | ||
File:Recovery cycle.jpeg|'''<math>\gamma_4=</math> Recovery Cycle of MIR:''' The recovery cycle of the crRIM masseteric inhibitory reflex must be conceptually coupled to the exaggerated amplitude of the jaw jerk because it indicates a condition of hyperexcitability which certainly involves the mesencephalic nuclei with increased excitability of the <math>\gamma</math> motoneurons and of the polysynaptic circuitry responsible for inhibition of the motor neuron of the masseter silent period. Take into account the value of the cognitive process of the neural network which has identified the decryption key of neural hyperexcitability in the <sub>cr</sub>RIM. Only with the jaw jerk exam, we would never reached the decryption until the patient's symptoms had worsened enough to require an MR but we all know that this eventuality could be delayed and fatal. Logically, the diagnosis following this process could have been made even 10 years earlier because a sort of attenuated hyperexcitability would certainly have already been present such as to make the physician suspicious. | File:Recovery cycle.jpeg|'''<math>\gamma_4=</math> Recovery Cycle of MIR:''' The recovery cycle of the crRIM masseteric inhibitory reflex must be conceptually coupled to the exaggerated amplitude of the jaw jerk because it indicates a condition of hyperexcitability which certainly involves the mesencephalic nuclei with increased excitability of the <math>\gamma</math> motoneurons and of the polysynaptic circuitry responsible for inhibition of the motor neuron of the masseter silent period. Take into account the value of the cognitive process of the neural network which has identified the decryption key of neural hyperexcitability in the <sub>cr</sub>RIM. Only with the jaw jerk exam, we would never reached the decryption until the patient's symptoms had worsened enough to require an MR but we all know that this eventuality could be delayed and fatal. Logically, the diagnosis following this process could have been made even 10 years earlier because a sort of attenuated hyperexcitability would certainly have already been present such as to make the physician suspicious. | ||
File:Pineal cavernoma pre surgery 2.jpeg|'''<math>\gamma_5=</math> MR imaging of Pineal Cavernoma:''' The conclusion of the process as already described indicates that a Cavernosa Pineal is very difficult to attack due to its anatomical position. The patient was referred to a specialist center in neurosurgery in Verona by Prof. Albino Bricolo who succeeded in eliminating the vascular malformation through endoscopic surgery and giving our dear patient 'Bruxer' a dignified life without a dental bite plane. | File:Pineal cavernoma pre surgery 2.jpeg|'''<math>\gamma_5=</math> MR imaging of Pineal Cavernoma:''' The conclusion of the process as already described indicates that a Cavernosa Pineal is very difficult to attack due to its anatomical position. The patient was referred to a specialist center in neurosurgery in Verona by Prof. Albino Bricolo who succeeded in eliminating the vascular malformation through endoscopic surgery and giving our dear patient 'Bruxer' a dignified life without a dental bite plane. | ||
</gallery> | </gallery> | ||
</center> | </center> | ||