Damien Fetter

Varicella-zoster virus acute myelitis in a patient with MS treated with natalizumab

Yeung et al.1 studied a case of varicella-zoster virus (VZV) myelitis in a patient with MS treated with natalizumab (NTZ). We wanted to stress another manifestation of VZV infection in NTZ-treated patients. A patient with MS recently came to …

Decline in Verbal Fluency After Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease: A Microlesion Effect of the Electrode Trajectory?

BACKGROUND Decline in verbal fluency (VF) is frequently reported after chronic deep brain stimulation (DBS) of the subthalamic nucleus (STN) in Parkinson disease (PD). OBJECTIVE We investigated whether the trajectory of the implanted electrode correlate with the VF decline 6 months after surgery. METHODS We retrospectively analysed 59 PD patients (mean age, 61.9 ± 7; mean disease duration, 13 ± 4.6) who underwent bilateral STN-DBS. The percentage of VF decline 6 months after STN-DBS in the on-drug/on-stimulation condition was determined in respect of the preoperative on-drug condition. The patients were categorised into two groups (decline and stable) for each VF. Cortical entry angles, intersection with deep grey nuclei (caudate, thalamic or pallidum), and anatomical extent of the STN affected by the electrode pathway, were compared between groups. RESULTS A significant decline of both semantic and phonemic VF was found after surgery, respectively 14.9% ± 22.1 (P < 0.05) and 14.2% ± 30.3 (P < 0.05). Patients who declined in semantic VF (n = 44) had a left trajectory with a more anterior cortical entry point (56 ± 53 versus 60 ± 55 degree, P = 0.01) passing less frequently trough the thalamus (P = 0.03). CONCLUSIONS Microlesion of left brain regions may contribute to subtle cognitive impairment following STN-DBS in PD.

Non-motor fluctuations in Parkinson's disease: prevalence, characteristics and management in a large cohort of parkinsonian outpatients.

OBJECTIVE To describe demographic and clinical characteristics in a group of Parkinsons disease (PD) patients with non-motor fluctuations (NMF) and to evaluate the management of medications proposed to treat NMF. METHODS Three hundred and three PD patients (mean age, 66 ± 10.3 years; mean disease duration, 10.1 ± 6.5 years) were enrolled. Each patient was interviewed in a non-directed fashion about the main NMF manifestations, i.e. dysautonomic, mental, and sensory symptoms. Both groups of patients with and without NMF were compared. Dysautonomia, motor fluctuations, age, disease duration, and LEDD were included in a multiple regression to determine which were predictive of NMF. RESULTS NMF were found in 57 (19%) patients, mean age 65 ± 10.1 years, mean age at onset of PD 53.7 ± 10.9 years, mean disease duration 12.5 ± 6.9 years. NMF occurred on average 9.8 ± 7.7 years after the onset of PD. Fifty patients (86%) with NMF had also MF and 10 (21%) had PDD. Twenty-five (44%) patients suffered from sensory, 28 (49%) from autonomic and 25 (44%) from neuropsychiatric symptoms. Both disease and L-Dopa treatment durations, and LEDD were significantly higher in NMF patients group. Motor fluctuations (p = 0.0016) and presence of dysautonomia (p = 0.007) were found to be two independent predictors of NMF. CONCLUSION The development of new instruments to assess NMF is crucial for optimized management of advanced PD.

Does early verbal fluency decline after STN implantation predict long-term cognitive outcome after STN-DBS in Parkinson's disease?

BACKGROUNDS An early and transient verbal fluency (VF) decline and impairment in frontal executive function, suggesting a cognitive microlesion effect may influence the cognitive repercussions related to subthalamic nucleus deep brain stimulation (STN-DBS). METHODS Neuropsychological tests including semantic and phonemic verbal fluency were administered both before surgery (baseline), the third day after surgery (T3), at six months (T180), and at an endpoint multiple years after surgery (Tyears). RESULTS Twenty-four patients (mean age, 63.5 ± 9.5 years; mean disease duration, 12 ± 5.8 years) were included. Both semantic and phonemic VF decreased significantly in the acute post-operative period (44.4 ± 28.2% and 34.3 ± 33.4%, respectively) and remained low at 6 months compared to pre-operative levels (decrease of 3.4 ± 47.8% and 10.8 ± 32.1%) (P < 0.05). Regression analysis showed phonemic VF to be an independent factor of decreased phonemic VF at six months. Age was the only independent predictive factor for incident Parkinsons disease dementia (PDD) (F (4,19)=3.4, P<0.03). CONCLUSION An acute post-operative decline in phonemic VF can be predictive of a long-term phonemic VF deficit. The severity of this cognitive lesion effect does not predict the development of dementia which appears to be disease-related.

Drugs with potential cardiac adverse effects: Retrospective study in a large cohort of parkinsonian patients.

INTRODUCTION/OBJECTIVE Drugs with potential cardiac adverse effects are commonly prescribed in Parkinsons disease (PD). To describe demographic and clinical characteristics in a group of PD patients with cardiac events and to evaluate risk factors. PATIENTS AND METHODS We sampled 506 consecutive PD patients (211 women/295 men), median age 68.3±10.6 years (range 36-95) and median disease duration 11.2±6.5 years (range 1-49). Medications with potential cardiac effects, i.e. QT prolongation (citalopram, escitalopram, venlafaxine, sertraline, domperidone, amantadine, solifenacin), ventricular arrhythmia (rivastigmine, clozapine, midodrine, sildenafil, tadalafil) and ischemic heart disease (rasagiline, entacapone, tadalafil) were recorded. Demographic and clinical data were collected prospectively; cardiac events were obtained retrospectively. RESULTS Twenty-four patients (4.7%) (9 women/15 men) presented a cardiac event. Fifteen (62.5%) patients had dysautonomia, 4 (16.6%) a history of heart disease and 8 (33.3%) were taking one or more drugs with a definite potential cardiac adverse effect. Age (75.9±6.6 yr vs. 67.8±11 yr), disease duration (14.7±3.6 yr vs. 11±6.5 yr), dysautonomia (62.5% vs. 24.5%) and dementia associated with PD (37.5% vs. 14.6%) were significantly higher in the group with cardiac events (P<0.05). Cofactors increasing the risk for cardiovascular events were age and dysautonomia. DISCUSSION/CONCLUSION Our results indicate that the neurodegenerative process in Parkinsons disease is associated with a higher risk of cardiovascular complications.

Pre-operative obesity may influence subthalamic stimulation outcome in Parkinson's disease

BACKGROUND Pre-operative predictive factors for optimal post-operative effect of subthalamic nucleus (STN) stimulation in Parkinsons disease (PD) have been previously reported. No study has explicitly assessed the link between excess pre-operative body weight and STN stimulation outcome. METHODS We retrospectively compared STN stimulation outcomes of 36 PD patients with excess pre-operative body weight (group 1) and 36 matched normal-weight pre-operative (group 2) PD patients. We focused on the post-operative outcomes in the sub-group of 12 obese (group 3) PD patients. RESULTS The post-operative motor improvement and the reduction of severity of levodopa-related complications were not statistically different between groups 1 and 2 (P>0.05). In the obese group (group 3), the axial sub-score significantly improved by 29.8% in the on-drug/on-stimulation conditions whereas the improvement was not significant in the off-drug/on-stimulation condition (22.4%, P=0.20). The post-operative Mattis Dementia Rating Score was significantly reduced in group 1 and group 3. DISCUSSION We considered that the post-operative axial impairment observed in the obese PD patients might be essentially consecutive to disease progression and/or post-operative DBS consequences, i.e. surgical procedure or electrical stimulation itself. Moreover, it could be argued that musculoskeletal disorders associated with obesity were responsible for the incomplete efficacy of STN stimulation on axial sub-scores, by increasing gait and balance impairment. CONCLUSION Pre-operative obesity may be regarded as a predictive clinical factor of axial and cognitive impairment after STN-DBS.

Subjective Perceived Motor Improvement after Acute Levodopa Challenge in Parkinson’s Disease

BACKGROUND Previous studies found a poor association between parkinsonian patients reported subjective improvement after commencing dopaminergic treatment and improvements in objective measures of motor impairment by clinician. OBJECTIVE To compare PD patients subjective perceived motor improvement after acute levodopa challenge test with objective motor improvement assessed by the clinician using the UPDRS part III. To analyze clinical characteristics, i.e. age, disease duration, cognitive performance or severity of axial features, that may have influenced patients perception. METHODS Fifty-seven consecutive PD patients (23 women, 34 men; mean age, 63.4±7.7 years) (Hoehn and Yahr off score, 2.5±0.7; mean disease duration, 11.4±4.1 years) completed the acute levodopa challenge. The percentage of improvement in motor disability, i.e. objective motor improvement, was determined with respect to the off-drug condition. RESULTS Bland & Altman visual analysis reveals a high degree of correlation between objective and subjective perceived motor improvement. Both the axial sub-scores in the off- and on-state (respectively, P = 0.006 and P = 0.024) and the presence of peak-dose dyskinesia (P = 0.043) significantly influence the difference between objective and subjective perceived motor improvement. CONCLUSIONS This is the first study reporting on how PD patients assessed their motor improvement after acute levodopa challenge. These findings suggest a strong correlation between objective motor improvement assessed by the clinician using the UPDRS part III and subjective perceived motor improvement reported by the patient.

Clavicle fracture mimicking dropped-head syndrome in a patient with multiple system atrophy

Dropped-head syndrome is characterized by an abnormal ante-fixed posture of the neck, usually observed in patients with neurodegenerative disorders such as multiple system atrophy (MSA) [1]. We report an unusual cause of acute antero- and latero-collis in a patient with MSA.

Recurrent Bilateral Dislocation of the Temporomandibular Joint Induced by Clonazepam in a Parkinsonian Patient.

To the Editor: D islocation of the temporomandibular joint (TMJ) is a distressing situation that may occur as a result of daily activities such as yawning, laughing, or during events that require keeping the mouth open for a long time. Generally of unknown origin, it may result from trauma, articulation disorders, or changes in the equilibrium of the masticatory muscles. Some degenerative neurological disorders, especially those occurring with spasticity as well as orofacial and oromandibular dystonia, might be related to TMJ dislocation. Drug-induced bilateral TMJ dislocations are rarely described. Herewe report the case of a parkinsonian patient who experienced recurrent dislocations of the TMJ after clonazepam treatment. A 68-year-old womanwas followed-up regularly for Parkinson disease (PD) in our center. She had no other medical history. Parkinson disease had been diagnosed 10 years earlier. Her medical treatment included the following: 600 mg per day of levodopa, 12 mg per day of ropinirole, and 200 mg per day of amantadine. Because she complained of vivid dreams and abnormal nocturnal motor behavior during the preceding 4 months, we hypothesized that she had rapid eye movement sleep behavior disorder, and 0.5 mg of clonazepam at bedtime was prescribed. The morning after the first intake, the patient was unable to close her mouth and presented excessive drooling. She had neither pain nor muscle spasms. Physical examination and x-ray confirmed the diagnosis of bilateral TMJ, which was successfully reduced by simple manual manipulationwithout need of a muscle relaxant drug. The patient no longer wished to take

Non-traumatic cervical C1-C2 subluxation.

Joint Bone Spine - In Press.Proof corrected by the author Available online since jeudi 3 avril 2014