Gaetano Salomone

Alpha and beta EEG power reflects L-dopa acute administration in parkinsonian patients

Aim: To evaluate the effect of an acute L-dopa administration on eye-closed resting state electroencephalographic (EEG) activity of cognitively preserved Parkinsonian patients. Methods: We examined 24 right-handed patients diagnosed as uncomplicated probable Parkinson’s disease (PD). Each patient underwent Unified Parkinson’s Disease Rating Scale (UPDRS)-part-III evaluation before and 60 min after an oral load of L-dopa-methyl-ester/carbidopa 250/25 mg. Resting condition eyes-closed EEG data were recorded both pre- and post L-dopa load. Absolute EEG power values were calculated at each scalp derivation for Delta, Theta, Alpha and Beta frequency bands. UPDRS scores (both global and subscale scores) and EEG data (power values of different frequency bands for each scalp derivation) were submitted to a statistical analysis to compare Pre and Post L-Dopa conditions. Finally, a correlation analysis was carried out between EEG spectral content and UPDRS scores. Results: Considering EEG power spectral analysis, no statistically significant differences arose on Delta and Theta bands after L-dopa intake. Conversely, Alpha and Beta rhythms significantly increased on centro-parietal scalp derivations, as a function of L-dopa administration. Correlation analysis indicated a significant negative correlation between Beta power increase on centro-parietal areas and UPDRS subscores (Rigidity of arms and Bradykinesia). A minor significant negative correlation was also found between Alpha band increase and resting tremor. Conclusions: Assuming that a significant change in EEG power spectrum after L-dopa intake may be related to dopaminergic mechanisms, our findings are consistent with the hypothesis that dopaminergic defective networks are implicated in cortical oscillatory abnormalities at rest in non-demented PD patients.

Dyskinesias during levodopa–carbidopa intestinal gel (LCIG) infusion: Management inclinical practice

The continuous levodopaecarbidopa intestinal gel (LCIG) infusion is a valid alternative for motor control in advanced Parkinsons disease (PD). It has been demonstrated to improve motor fluctuation with a global increase in ON-time, generally without the outbreak of troublesome hyperkinesias [1]. However both peakdose and biphasic dyskinesias are observed in patients undergoing LCIG treatment. Here is reported our experience with a PD patient, whose LCIG treatment was challenged by the outbreak of peculiar dyskinesiasfollowingthe PEG-J-tube bedtime flushing. A 73 yearsold woman was affected by advanced PD with motor fluctuations. Because of her extreme susceptibility to develop dyskinesias even with very small doses of levodopa (otherwise defined as “brittle response” [2]), the maximum acceptable oral treatment was of 475 mg fractionated in 9 small doses a day. APEG-J was inserted and LCIG therapy was started in order to obtain a lower and more stable therapeutic regimen. A significant reduction of the OFFperiods and of the dyskinesias were obtained through a LCIG titration of the morning dose to1.5 ml (30 mg of levodopa), of the continuous dose to 1.0 ml (20 mg) per hour per 16 h a day (total dose of 350mg) and of the extra-doses to 1.0 ml (20mg). Nevertheless, at the end of the daily treatment, the mandatory operation of flushing the PEG-J-tube after pump disconnection [3] resulted in stereotypical violent peak-dose choreo-dystonic hyperkinesias that required patient protections to prevent disastrous falls. The tube cleaning led to the immediate delivery of the 3 ml (60 mg) of levodopa-gel contained in the device. Unfortunately the patient was highly sensitive to levodopa; so much that extra-doses have to be set at 1 ml (20mg) per dose. LCIG pump turning off may result in biphasic dyskinesias due to the incipient discontinuation of the levodopa effect; in this case the simple interruption of the infusion did not lead to any dyskinesia contrary to what was observed after bedtime tube cleaning. In fact through the flushing the patient received extra 60 mg of levodopa gel, that is three times the dose needed to overcome OFF-period, resulting in violent peak-dose dyskinesias. Levodopa gel is contained in a reservoir bag inside a hard plastic cassette. A used reservoir bag was cleaned out from residual gel through a solution of diluted ethyl alcohol delivered through a syringe connected to the cassette tube, and later rinsed with room temperature tap water. Then, the cassette was connected to the tube and the water was administered at usual maintenance dose (1 ml/h), so that it could slowly push the column of levodopa gel contained in the tube. After 3 h, water completely replaced the gel in the tube, and cleaning operations could be easily performed without the risk of delivering a high bolus of levodopa

Oscillatory Activities in Neurological Disorders of Elderly: Biomarkers to Target for Neuromodulation

Non-invasive brain stimulation (NIBS) has been under investigation as adjunct treatment of various neurological disorders with variable success. One challenge is the limited knowledge on what would be effective neuronal targets for an intervention, combined with limited knowledge on the neuronal mechanisms of NIBS. Motivated on the one hand by recent evidence that oscillatory activities in neural systems play a role in orchestrating brain functions and dysfunctions, in particular those of neurological disorders specific of elderly patients, and on the other hand that NIBS techniques may be used to interact with these brain oscillations in a controlled way, we here explore the potential of modulating brain oscillations as an effective strategy for clinical NIBS interventions. We first review the evidence for abnormal oscillatory profiles to be associated with a range of neurological disorders of elderly (e.g., Parkinson’s disease (PD), Alzheimer’s disease (AD), stroke, epilepsy), and for these signals of abnormal network activity to normalize with treatment, and/or to be predictive of disease progression or recovery. We then ask the question to what extent existing NIBS protocols have been tailored to interact with these oscillations and possibly associated dysfunctions. Our review shows that, despite evidence for both reliable neurophysiological markers of specific oscillatory dis-functionalities in neurological disorders and NIBS protocols potentially able to interact with them, there are few applications of NIBS aiming to explore clinical outcomes of this interaction. Our review article aims to point out oscillatory markers of neurological, which are also suitable targets for modification by NIBS, in order to facilitate in future studies the matching of technical application to clinical targets.

Corrigendum: oscillatory activities in neurological disorders of elderly: biomarkers to target for neuromodulation

[This corrects the article on p. 189 in vol. 9, PMID: 28659788.].

An Unusual Cause of Dementia: Essential Diagnostic Elements of Corticobasal Degeneration—A Case Report and Review of the Literature

Corticobasal degeneration (CBD) is an uncommon, sporadic, neurodegenerative disorder of mid- to late-adult life. We describe a further example of the pathologic heterogeneity of this condition. A 71-year-old woman initially presented dysarthria, clumsiness, progressive asymmetric bradykinesia, and rigidity in left arm. Rigidity gradually involved ipsilateral leg; postural instability with falls, blepharospasm, and dysphagia subsequently developed. She has been previously diagnosed as unresponsive Parkinsons Disease. At our clinical examination, she presented left upper-arm-fixed-dystonia, spasticity in left lower limb and pyramidal signs (Babinski and Hoffmann). Brain MRI showed asymmetric cortical atrophy in the right frontotemporal cortex. Neuropsychological examination showed an impairment in visuospatial functioning, frontal-executive dysfunction, and hemineglect. This case demonstrates that association of asymmetrical focal cortical and subcortical features remains the clinical hallmark of this condition. There are no absolute markers for the clinical diagnosis that is complicated by the variability of presentation involving also cognitive symptoms that are reviewed in the paper. Despite the difficulty of diagnosing CBD, somatosensory evoked potentials, motor evoked potentials, long latency reflexes, and correlations between results on electroencephalography (EEG) and electromyography (EMG) provide further support for a CBD diagnosis. These techniques are also used to identify neurophysiological correlates of the neurological signs of the disease.

Teaching Video NeuroImages: Running into a “useless” hand

A 68-year-old woman presented with an insidious onset of strictly asymmetric left arm clumsiness (video at Neurology.org) in absence of any brain lesion but mild right hemisphere hypotrophy (figure). The presence of limb apraxia and bradykinesia fostered the clinical diagnosis of possible corticobasal syndrome, in the context of suspected corticobasal degeneration.1 Bradykinesia and apraxia are 2 possible different faces of hypokinesia; their correct discrimination is not a diagnostic problem if a higher-level disturbance of praxis is present. An isolated limb apraxia is a confounder, and its early recognition allows clinicians to suspect parkinsonism with apraxia as a prominent feature.2

The Clinical Course of a Drug-induced Acute Dystonic Reaction in the Emergency Room

Background Acute dystonic reactions following the administration of safe, reliable drugs can occur and must be promptly recognized and treated in the emergency room. Phenomenology Shown The entire clinical course of an acute dystonic reaction due to metoclopramide, from early motor signs to full-blown clinical symptoms and resolution. Educational Value Providing elements for early recognition of a drug-induced movement disorder phenomenology.

Lumbosacral multiradiculopathy responsive to antibiotic therapy: description of four patients with lumbar spondylosis and a superimposed Lyme disease.

AbstractLyme disease is a diffuse zoonosis caused by spirochaetes of the Borrelia burgdorferi species complex. Neurological manifestations of the disease, involving central or peripheral nervous system, are common. This study describes four consecutive patients with an MRI-proven lumbosacral spondylosis, who complained of progressive worsening of symptoms in the last months in which serological evaluation suggested a superimposed B. Burgdorferi infection. Four patients, all from the Lazio region, were admitted to the Department of Neurology. Extensive laboratory studies and clinical, anamnestic and neurophysiological evaluation were performed in all cases. In all cases, anamnesis revealed a previous diagnosis of lumbosacral foraminal stenosis. Clinical and neurophysiological findings were consistent with a lumbosacral multiradiculopathy. Considering serological evaluation suggestive of a superimposed B. burgdorferi infection a proper antibiotic therapy was started. All cases showed a marked improvement of symptoms. Clinicians should be aware that in all cases of lumbosacral multiradiculopathy, even if a mechanical cause is documented, B. burgdorferi may be a simply treatable condition.