Alessandro Alvano

Prediction of the response to citalopram and reboxetine in post-stroke depressed patients

Rationale and objectiveDepression is a significant complication of stroke. The effectiveness of antidepressant drugs in the management of post-stroke depression (PSD) has been widely investigated. However, the choice of antidepressant drug is critically influenced by its safety and tolerability and by its effect on concurrent pathologies. Here we investigate the efficacy and safety of a selective serotonin reuptake inhibitor (SSRI), citalopram, and a noradrenaline reuptake inhibitor (NARI), reboxetine, in post-stroke patients affected by anxious depression or retarded depression.MethodsThis was a randomized double-blind study. Seventy-four post-stroke depressed patients were diagnosed as affected by anxious or retarded depression by using a synoptic table. Randomisation was planned so that 50% of the patients in each subgroup were assigned for 16 weeks to treatment with citalopram and the remaining 50% were assigned to treatment with reboxetine. The Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale (HDRS) and a synoptic table were used to score depressive symptoms.ResultsBoth citalopram and reboxetine showed good safety and tolerability. Citalopram exhibited greater efficacy in anxious depressed patients, while reboxetine was more effective in retarded depressed patients.ConclusionsCitalopram or other SSRIs and reboxetine may be of first choice treatment in PSD because of their good efficacy and lack of severe side effects. In addition, PSD patients should be classified according to their clinical profile (similarly to patients affected by primary depression) for the selection of SSRIs or reboxetine as drugs of choice in particular subgroups of patients.

Tic disorders: from pathophysiology to treatment

Tic disorders are stereotypic behaviours,more frequent than once believed, and therefore likely to be encountered by primary care physicians. Tics usually begin in childhood and are the clinical hallmark of Tourette Syndrome (TS), the most common cause of tics. TS is a relatively common neurobehavioural disorder with a spectrum of manifestations that wax and wane during its natural course. The pathophysiology of tics, at molecular and cellular level, is still unknown,whereas structural and functional neuroimaging studies have shown the involvement of the basal ganglia and related cortico–striato–thalamo–cortical circuits, and the dopaminergic neuronal system. Moreover, TS has a strong genetic background. The management of TS is often complicated by the presence of attention–deficit/hyperactivity disorder, obsessivecompulsive disorder, and other behaviour disorders. The correct diagnosis is a fundamental step for a proper management of these disorders, and a multimodal treatment is usually indicated. This approach includes educational and supportive interventions, as well as pharmacological treatments when tics are at their worst.

Different clinical and evolutional patterns in late idiopathic and vascular parkinsonism.

AbstractObjectiveThe aim of this study was to examine the clinical picture of Parkinson’s disease (PD) and vascular parkinsonism (VP) in the elderly, in an attempt to differentiate the clinical history, symptoms, signs and response to therapy.Material and methodsThirty–two elderly patients with late onset PD and 45 with VP were enrolled and the clinical features of two groups were compared. All patients underwent brain MRI and were scored using the Unified Parkinson’s Disease Rating Scales (UPDRS) –II, –III.ResultsPatients with PD had a younger age at onset and a longer duration of the disease as compared to patients with VP. Nearly all PD patients showed a good response to levodopa therapy, while only 29% of patients with VP were responsive to levodopa treatment. Vascular risk factors as well as postural tremor, gait disorders and pyramidal signs with lower body predominance, were more frequent in patients with VP. Ninety–three % of PD patients had normal MRI, whereas all patients with VP had cerebral vascular lesions. UPDRS–II, –III scores at baseline were higher in VP than in PD patients and their increases throughout the follow–up period were more marked in VP than in PD patients.ConclusionsClinical history, symptoms, signs, response to therapy, and brain imaging help to differentiate PD and VP as two clinical entities with different clinical, prognostic and therapeutic implications, even if the coexistence of PD and a cerebral vascular disease in elderly patients is not infrequent and can make the diagnosis difficult.

Evaluation of the Prophylactic Efficacy of Amitriptyline and Citalopram, Alone or in Combination, in Patients with Comorbidity of Depression, Migraine, and Tension-Type Headache

Antidepressants are used to treat chronic daily headache disorders such as migraine and chronic tension-type headache (TTH), which are often associated with depression and anxiety. Here, we studied the efficacy and tolerability of amitriptyline and citalopram, given alone or in combination, in patients with ‘triple’ comorbidity of depression, TTH, and migraine. Eighty-eight patients were enrolled in the study and randomly divided into two groups. The first group received amitriptyline and the second citalopram for 16 weeks. Patients were assessed at weeks 0, 4, 8, and 16. The two drugs were equally efficacious in relieving depressive symptoms, although amitriptyline was more efficacious than citalopram in reducing migraine and TTH attacks. Patients who did not respond to monotherapy (<30% of improvement in the clinical scores) were treated with a combination of the two drugs for 16 additional weeks. In these selected patients, the combined treatment produced a substantial improvement in depression, migraine and TTH without producing major side effects such as those commonly related to the ‘serotonergic’ syndrome. The results indicate that a combined therapy with amitriptyline and citalopram may be particularly beneficial for patients with TTH, migraine and comorbid depression that do not respond to monotherapy.

Is it safe to use antidepressants after a stroke

Depression is an important complication of stroke. Although antidepressants are widely used for the treatment of poststroke depression (PSD), prescription is critically influenced by their safety, tolerability and by the impact on co-morbidities. The authors reviewed the literature on the use of antidepressants after stroke. Selective serotonin re-uptake inhibitors are effective and have a good profile of safety and tolerability in PSD. They are, therefore, used as first-line drugs in the treatment of PSD, although potential cardiovascular and cerebrovascular effects, drug–drug interactions and intolerability in a minority of patients have to be considered. Other antidepressants appear to be safe and effective in selected patients. PSD patients should be classified according to their clinical profile for the selection of the drug of choice in particular sub-groups of patients.

Blink reflex abnormalities in Tourette syndrome

OBJECTIVE Tourette syndrome (TS) is a not uncommon disorder which represents the most complex manifestation of the spectrum of tic disorders, with onset during childhood or early adolescence. There are no definitive tests for diagnosis of TS. The objective of this study has been to demonstrate whether neurophysiological abnormalities of the blink reflex can be observed in patients affected with TS and correlate with the severity of TS. METHODS We enrolled 17 patients with Tourette syndrome, diagnosed according to DSM IV Diagnostic Criteria, and 10 healthy volunteers. Tic severity was assessed using a self rating scale (Tourette Syndrome Symptom List, TSSL) and examiner ratings (Yale Global Tic Severity Scale (YGTSS), and Tourette-Syndrome Global Scale (TSGS)). The blink reflex was elicited by stimulating the supraorbital nerve in order to measure the early response (R1), homolateral and contralateral R2 (late) responses, amplitude of R1 and duration of R2. RESULTS We observed a mean duration of R2 significantly longer in the patient group than in the control group (P<0.01, Student t test), without any statistically significant differences of R1 and R2 latencies and of R1 amplitude between the patient group and the control group. Correlations between changes in clinical rating scores and R2 duration were tested by simple linear regression analysis, which has not demonstrated a significant correlation between TSSL scores, clinical rating scores (measured by TSGS and YGTSS) and duration of R2. CONCLUSIONS A pattern as to excitability of the blink reflex can be a frequent abnormality in TS patients, not correlated with its severity.

Prediction of the response to citalopram and reboxetine in post-stroke depressed patients: the reasons of the enrollment of patients without cognitive impairment

Depression is frequently observed either as a primitive pathology or as a complication of cerebrovascular disorders. Current nosographical classification of depressions does not supply information based on a supposed clinical– biochemical correlation, which could be useful to select appropriate therapeutic options. Similarly to what described for primary depression (Rampello et al. 1991, 1995), we attempted to characterize different subtypes of post-stroke depression, i.e. anxious or retarded post-stroke depression (Rampello et al. 2004), in order to predict the therapeutic response to specific pharmacological treatments, taking into account the safety and tolerability of drugs, as well as the age and possible comorbidity in post-stroke depressed patients. Spalletta and Caltagirone (2003) argued that the enrollment of patients without cognitive deficit or with very mild cognitive impairment could be a limitation in our study. We excluded patients with MMSE score <22 for a number of reasons. First, the enrollment of patients with mild-to-severe cognitive impairment would have made the characterization of the two subtypes of depression difficult. In addition, the inclusion of these patients would have seriously complicated the evaluation of drug treatment. Thus, although the suggestion of Spalletta and Caltagirone is interesting and warrants further examination, the aim of our study was to select post-stroke depressed patients according to particular clinical profiles that are predictive of therapeutic response.

Left temporal glioblastoma presenting with the involvement of selective memory: a case report.

Glioblastoma multiforme, the most malignant and frequent glioma [1], is found more frequently in the left hemisphere [2,3] and produces symptoms by a combination of focal neurological deficits. We describe the case of a 65-year-old man admitted, with a diagnosis of TIA made in another department, after appearance of recurring episodes of selective amnesia, initially concerning only the remembrance of familiar numbers (such as his own telephone number or address number, etc.) and lately regarding other numbers, dates and names. A neuropsychological battery was performed in order to evaluate patient’s cognitive functions. The Mini Mental State Examination [5], Constructive apraxia test [6], Trail Making Test (TMT A,B) [7] and Raven Coloured Progressive Matrices [8] did not point out abnormalities of visual and spatial abilities, attention, recognition of numbers and letters, visual research, motor velocity and motor coordination, control and executive functions, and set shifting and problem solving abilities. Verbal supraspan learning test [6] was performed to analyse the memory’s functions. The total number of words recalled from Long-Term Memory (LTM) was 31 (corrected for patient’s age and years of school 1⁄4 29; equivalent score (ES) 1⁄4 0), that was below normal for patient’s age and years of school. The total number of words not casually recalled from Long-Term Memory (LTM) was 2 (corrected=0; ES=0), that was below normal. The number of words recalled after 5 min from Long-Term Memory (LTM) was 2 (corrected 1⁄4 1.75; ES 1⁄4 0), that is under the normal range. Verbal fluency for semantic category test [9] was performed to evaluate the patient’s language-output abilities; the recall of words from lexical memory was 22 (corrected score= 26; ES=1), that was border-line. Memory complaint questionnaire (MAC-Q) [10] was administered for a subjective patient’s evaluation of memory functions and the score was 30, that was above normal score (<25). MAC-Q showed a severe impairment indicated by patient in the remembrance of familiar numbers (such as his own telephone number or frequently used postal codes, address and telephone numbers). We did not observe any other neuropsychological disorders. The objective neurological examination did not point out any clinically evident deficiency. The cardiologic examination revealed arterial hypertension of 2nd degree. The ecocolordoppler showed plaques in both the carotid axes and a stenosis of left internal carotid above 30%. MRI showed a roundish area not homogeneously hypointense in T1-weighted scans (Figure 1) and hyperintense in T2 weighted scans (Figure 2). This area was located in the left temporal lobe, and became soaked with the means of contrast. Electroencephalography (EEG) revealed slowing on the left temporal derivations. The patient was transferred to the department of neurosurgery, where he underwent an operation of removal. The histological examination pointed out the presence of GBM. This case of unusual memory disorder, selective for numbers, names and dates is an original manifestation of clinical–neurological expressiveness of a glioblastoma of the left temporal lobe. As a result, a clinical picture characterised by neuropsychological deficits (of all or some of the superior cognitive functions), imposes the differential diagnosis also with neoplastic disorders, whose premonitory symptoms, even in absence of objective neurological disorders, may be represented by selective deficits concerning the expressive forms of language and the memory.