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The natural history of untreated glioblastoma is well known Less than one- fth of all patients survive for 1 year after the onset of symptoms, and only about 10 percent live beyond 2 years (Shapiro) Age is the most important prognostic factor in this group of tumors; fewer than 10 percent of patients over age 60 survive for 18 months, in comparison to two-thirds of patients under age 40 Survival with anaplastic astrocytoma is somewhat better, typically 3 to 5 years Cerebral edema and increased intracranial pressure are usually the immediate causes of death Survival rates with treatment are discussed below The diagnosis must usually be con rmed by a stereotactic biopsy or by a craniotomy that aims to remove as much tumor as is feasible at the same time At operation, only part of the tumor can be removed; its multicentricity and diffusely in ltrative character defy the scalpel Partial resection of the tumor ( debulking ), however, seems to prolong survival slightly Treatment Except for palliation, little can be done to alter the course of glioblastoma For a brief period, corticosteroids, usually dexamethasone in doses of 4 to 10 mg every 4 to 6 h, are helpful if there are symptoms of mass effect such as headache or drowsiness; local signs and surrounding edema tend to improve as well Anticonvulsants are not required unless there have been seizures, but some neurologists and neurosurgeons administer them in order to pre-empt a convulsion Serious skin reactions (erythema multiforme and Stevens-Johnson syndrome) may occur in patients receiving phenytoin at the same time as cranial radiation (Delattre et al) Usually a maximally feasible resection, the debulking described above, is combined with external beam radiation and chemotherapy Total cranial irradiation (4500 cGy), boosted with a dose to the region of the tumor (1500 to 2000 cGy), increases survival by.

FIGURE 6-1

ansa sweeps around the internal capsule; the fasciculus traverses the internal capsule in a number of small fascicles and then continues medially and caudally to join the ansa in the prerubral eld Both of these ber bundles join the thalamic fasciculus, which then contains not only the pallidothalamic projections but also mesothalamic, rubrothalamic, and dentatothalamic ones These projections are directed to separate targets in the ventrolateral nucleus of the thalamus and to a lesser extent in the ventral anterior and intralaminar thalamic nuclei The centromedian nucleus of the intralaminar group projects back to the putamen and, via the parafascicular nucleus, to the caudate A major projection from the ventral thalamic nuclei to the ipsilateral premotor cortex completes the large cortical-striatal-pallidal-thalamic-cortical motor loop (the prepyramidal circuit, mentioned above) with conservation of the somatotopic arrangement of motor bers, once again emphasizing the nexus at the thalamic nuclei

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Physiologic evidence indicates that a balanced functional architecture, one excitatory and the other inhibitory, is operative within the individual circuits The direct striatomedial pallidonigral pathway is activated by glutaminergic projections from the sensorimotor cortex and by dopaminergic nigral (pars compacta) striatal projections Activation of this direct pathway inhibits the medial pallidum, which, in turn, disinhibits the ventrolateral and ventroanterior nuclei of the thalamus As a consequence, thalamocortical drive is enhanced and cortically initiated movements are facilitated The indirect circuit arises from putaminal neurons that contain gamma-aminobutyric acid (GABA) and smaller amounts of enkephalin These striatal projections have an inhibitory effect on the lateral pallidum, which, in turn, disinhibits the subthalamic nucleus through GABA release, providing excessive subthalamic drive to the medial pallidum and substantia nigra pars reticulata The net effect is thalamic inhibition that reduces thalamocortical input to the precentral motor elds and impedes voluntary movement These complex, and in part still theoretical anatomic and physiologic relationships have been summarized in numerous schematic diagrams similar to Fig 4-4 and those in Lang and Lozano and in Standaert and Young (see References) Restated, enhanced conduction through the indirect pathway leads to hypokinesia (by increasing pallidothalamic inhibition), whereas enhanced conduction through the direct pathway results in hyperkinesia (by reducing pallidothalamic inhibition) The direct pathway is perceived by Marsden and Obeso as facilitating cortically initiated movements and the indirect pathway as suppressing potentially con icting and unwanted motor patterns In Parkinson disease, for example, loss of dopaminergic input from the substantia nigra diminishes activity in the direct pathway and increases activity in the indirect pathway; the net effect is to increase inhibition of the thalamic nuclei and to reduce excitation of the cortical motor system Further insight into Parkinson disease has come from the discovery that it can be faithfully reproduced in humans and primates by the toxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) This toxin was discovered accidentally in drug addicts who self-administered an analogue of meperidine The toxin binds with high af nity to monoamine oxidase (MAO), an extraneural enzyme that transforms it to a toxic metabolite pyridinium The latter is bound by melanin in the dopaminergic nigral neurons in.

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element is heated, the ink expands and forms a bubble of ink on the nozzle When the bubble becomes large enough, it bursts onto the paper and creates a dot of color Although this process sounds messy, bubblejets provide better printouts than the original inkjets Today, generally, the term inkjet is used to refer to all printers that use ink, including inkjets, and bubblejets Inkjet and bubblejet printers are usually inexpensive The significant costs of these printers are the cartridges: it is not unusual for it to cost between 12 and 25 cents per printed page So, while inkjet and bubblejets may be inexpensive, often they are not a bargain Inkjet printers use friction-feed rollers to move the paper through the printer In friction feed, a stack of pages is kept in a feeder tray A rubber or plastic roller uses friction to grab the top page and pull it into the printer Some advantages to this type of feed are that you don t have to worry about lining up the page perforations or the holes and sprockets, and you don t have to separate pages from one another when the printout is finished Unlike tractor-feed printers, friction-feed printers can be used to print on paper that has an irregular shape or size You can even print on envelopes and cards

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