John Ellul

Family history of stroke in stroke types and subtypes

Many studies have provided data showing that family history of stroke (FHS) is associated with an increased risk of stroke. The association of the FHS with the various stroke subtypes has not been adequately studied. The purpose of this study was to assess the association of the FHS with the two major stroke types (cerebral haematomas and ischaemic strokes) and the four stroke subtypes (cardioembolic, large artery disease, small artery disease, and undetermined) in a Greek population. The FHS was obtained from 421 consecutive acute stroke patients and from 239 matched control subjects. Positive FHS was observed in 49% of all stroke patients compared with 28% of the control subjects [adjusted OR=2.06 (95% confidence intervals (CI) 1.42-3.00)]. Haematomas, ischaemic strokes, and from the ischaemic strokes, both large and small artery disease strokes were strongly associated with positive FHS compared with the control subjects [adjusted OR=2.06 (95% CI 9-3.04), 2.07 (95% CI 1.09-3.91), 2.05 (95% CI 1.24-3.38), and 2.76 (95% CI 1.55-4.91), respectively]. There was no difference between maternal and paternal heritable contribution.In conclusion, FHS was found in this study to be an independent risk factor for all strokes combined, for each stroke type, and for the large and small-artery disease stroke subtypes, but not for the cardioembolic and undetermined stroke subtypes.

The effects of commonly prescribed drugs in patients with Alzheimer’s disease on the rate of deterioration

Background: Prescribed drugs in patients with Alzheimer’s disease may affect the symptomatic progression of their disease, both positively and negatively. Aim: To examine the effects of drugs on the progression of disease in a representative group of patients with Alzheimer’s disease. Methods: Patients with the diagnosis of probable Alzheimer’s disease were recruited from the community. The prescribed drugs taken by 224 patients (mean age 82.3 years) were recorded at initial assessment and then correlated in logistic regression analysis with progression of the disease, defined as an increase of one point or more in the Global Deterioration Scale over the next 12-month period. Results: Patients who were taking antipsychotic drugs and sedatives had a significantly higher risk of deterioration than those who were taking none (odds ratios (ORs) 2.74 (95% confidence interval (CI) 1.17 to 6.41) and 2.77 (95% CI 1.14 to 6.73), respectively). Higher risk of deterioration was observed in those who were taking both antipsychotic and sedative drugs together (OR 3.86 (95% CI 1.28 to 11.7). Patients taking drugs licensed for dementia, drugs affecting the renin–angiotensin system and statins had a significantly lower risk of deterioration than those who were not taking any of these drugs (ORs 0.49 (95% CI 0.25 to 0.97), 0.31 (95% CI 0.11 to 0.85) and 0.12 (95% CI 0.03 to 0.52), respectively). Conclusion: Our findings have implications for both clinicians and trialists. Most importantly, clinicians should carefully weigh any potential benefits of antipsychotics and benzodiazepines, especially in combination, against the risk of increased decline. Researchers need to be aware of the potential of not only licensed drugs for dementia but also drugs affecting the renin–angiotensin system and statins in reducing progression in clinical trials.

Factors associated with drug–induced visual hallucinations in Parkinson's disease

AimsVisual hallucinations are common in medicationtreated Parkinsons disease (PD) patients. Although their etiology is unknown several factors seem to be involved in their pathogenesis. The aim of this study was to identify possible risk factors and determine clinical characteristics associated with the development of visual hallucinations in PD.Methods166 consecutive patients fulfilling clinical criteria for PD were studied. During a semi–structured interview, demographic characteristics and clinical variables were recorded. Motor, cognitive and psychiatric status was also assessed. Patients with and without visual hallucinations were compared using non–parametric tests, and logistic regression was applied to significant data.ResultsDuring the month before evaluation 20.4% of our patients experienced visual hallucinations (11.4% benign, 9% malignant). Logistic regression analysis identified three factors independently associated with visual hallucinations: long duration of Parkinsons disease, dementia, and disease severity as measured by the UPDRS total score.ConclusionsOur findings indicate that apart from well established risk factors such as cognitive impairment and disease duration, disease severity is also important for the development of visual hallucinations in PD. Furthermore, the presence of bradykinesia and instability, the absence of tremor and the severity of rigidity and bradykinesia (limb and axial) may act as cofactors.

Clinical phenotype in patients with alpha-synuclein Parkinson's disease living in Greece in comparison with patients with sporadic Parkinson's disease.

OBJECTIVE An Ala53Thr mutation of the α-synuclein gene has been recently identified as a rare cause of autosomal Parkinsons disease (PD). The clinical characteristics of 15 patients with PD living in Greece with the Ala53Thr α-synuclein mutation (α-synPD) were compared with patients with sporadic Parkinsons disease (sPD). METHODS An investigator, blind to the results of the genetic analysis, examined 15 patients with α-synPD and 52 consecutive patients with sPD. Demographic data, age at onset of the illness, modality of presentation, and duration of PD were collected. The unified Parkinsons disease rating scale, the Hoehn and Yahr scale, and the Schwab-England scale were completed. The patients with α-synPD were matched for duration of disease with 32 of the 52 patients with sporadic PD (MsPD group). RESULTS Patients with the α-synuclein mutation were significantly younger (mean 7.6 years), showed the first sign of the disease significantly earlier in life (mean 10.8 years), and had significantly longer duration of the disease compared with patients with sPD. Tremor at onset of the disease was present in only one (6.7%) of the patients with α-synPD, whereas it was present in 32 (61.5%) of the patients with sPD (p=0.0006). During the course of the disease one patient in the α-synPD group went on to develop tremor compared with six patients in the sPD group. Rigidity, bradykinesia, postural instability, orthostatic hypotension, intellectual impairment, depression, complications of therapy, and clinical severity of the disease at the time of examination did not differ significantly between patients with α-synPD and those with sPD, or between patients with α-synPD and the MsPD group. CONCLUSION The younger age at onset of the illness, the much lower prevalence of tremor, and the longer duration of the disease characterise the clinical phenotype in this sample of patients with α-synPD. The other symptoms and signs of the illness did not seem to differentiate the patients with α-synPD from those with sPD.

Deep brain stimulation for secondary dystonia: results in 8 patients

BackgroundDystonia is a medically intractable condition characterized by involuntary twisting movements and/or abnormal postures. Deep Brain Stimulation (DBS) has been used successfully in various forms of dystonia. In the present study, we report on eight patients with secondary dystonia, treated with DBS in our clinic.MethodEight patients (five males, three females) underwent DBS for secondary dystonia. The etiology of dystonia was cerebral palsy (n = 2), drug-induced (n = 1), post encephalitis (n = 2) and postanoxic dystonia (n = 3). The functional capacity was evaluated before and after surgery with the use of Burke-Fahn-Mardsen Dystonia Rating Scale (BFM scale), both movement and disability scale (MS and DS, respectively). The target for DBS was the globus pallidus internus (GPi) in 7 patients and in one patient, with postanoxic damaged pallidum, the ventralis oralis anterior (Voa) nucleus. Brain perfusion scintigraphy using Single Photon Emission Computed Tomography (SPECT) was performed in two separate studies for each patient, one in the “off-DBS” and the other in the “on-DBS” state.FindingsPostoperative both MS and DS scores were found to be significantly lower compared to preoperative scores (p = 0.018 and p = 0.039, respectively). Mean improvement rate after DBS was 41.4% (0 – 94.3) and 29.5% (0 – 84.2) in MS and DS scores, respectively. The SPECT Scan, during the “on-DBS” state, showed a decrease in regional cerebral blood flow (rCBF), compared to the “off-DBS” state.ConclusionsOur results seem promising in the field of secondary dystonia treatment. More studies with greater number of patients and longer follow-up periods are necessary in order to establish the role of DBS in the management of secondary dystonia. Finally, the significance of brain SPECT imaging in the investigation of dystonia and functional effects of DBS should be further evaluated.

Vegetative State and Minimally Conscious State: A Review of the Therapeutic Interventions

Background/Aims: The purpose of the present article is a systematic review of the proposed medical or surgical treatments in patients in chronic vegetative state (VS) or minimally conscious state (MCS), as well as of their mechanisms of action and limitations. Methods: For this review, we have agreed to include patients in VS or MCS having persisted for over 6 months in posttraumatic cases, and over 3 months in nontraumatic cases, before the time of intervention. Searches were independently conducted by 2 investigators between May 2009 and September 2009 in the following databases: Medline, Web of Science and the Cochrane Library. The electronic search was complemented by cross-checking the references of all relevant articles. Overall, 16 papers were eligible for this systematic review. Results: According to the 16 eligible studies, medical management by dopaminergic agents (levodopa, amantadine), zolpidem and median nerve stimulation, or surgical management by deep brain stimulation, extradural cortical stimulation, spinal cord stimulation and intrathecal baclofen have shown to improve the level of consciousness in certain cases. Conclusion: The treatments proposed for disorders of consciousness have not yet gained the level of ‘evidence-based treatments’; moreover, the studies to date have led to inconclusiveness. The published therapeutic responses must be substantiated by further clinical studies of sound methodology.

The effect of depression on motor function and disease severity of Parkinson's disease.

OBJECTIVES Approximately 40% of patients with Parkinsons disease (PD) experience symptoms of depression. Our aim was to evaluate the effect of depression on disease severity, motor function and other phenotypic characteristics of PD. PATIENTS AND METHODS We studied 32 PD patients with major depression (PD-D) according to the DSM-IV criteria and 32 PD patients with no depression (PD-C) matched for gender, age of onset and duration. RESULTS Major depression in PD patients was associated with increased disease severity, poorer motor function and worse performance in the activities of daily living as measured by UPDRS scores. Furthermore, there was an association of depression with the severity of bradykinesia and axial rigidity. CONCLUSIONS Depression in PD can have a profound negative impact on a patients sense of wellbeing and motor functioning. Therefore, PD patients should be routinely and carefully screened for the presence of depression and appropriate management should be considered. Larger studies on the subject are warranted.

A double-blind study on a patient with tardive dyskinesia treated with pallidal deep brain stimulation

Background –  Tardive dyskinesia (TD) is a neurological disorder typically induced by long‐term exposure to neuroleptics. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) may represent a therapeutic alternative for TD, which is often resistant to conservative treatment.

In-hospital direct cost of acute ischemic and hemorrhagic stroke in Greece

Objectives –  The geographic inequity and the wide variation in the patterns of care of stroke found across Europe together with the lack of health economics evaluation in Greece led to this prospective study, aiming to provide data on in‐hospital direct cost of patients with an acute stroke in Greece, and to identify independent prognostic factors.

Clinical and epidemiological features of motor neuron disease in south‐western Greece

Objective –  To evaluate the epidemiological and clinical features of motor neuron disease (MND) in a region (835,000 inhabitants) of south‐western Greece.