N. Sternic

Theophylline increases “on” time in advanced parkinsonian patients

l-dopa is the most effective symptomatic treatment for PD. Its chronic use, however, is frequently complicated by the development of disabling motor side effects.1 These may result from alterations in the fine-tuned neurochemical balance in the output pathways of basal ganglia. Thus, experimental therapies combining l-dopa and agents that modulate the output pathways of basal ganglia should be encouraged.2 An ideal therapeutic target is adenosine A2A receptor, which is co-localized with dopamine D2 receptor on neurons of the indirect striatopallidal pathway.3 Supporting this view is our study showing that adenosine A2A-receptor blockade potentiates the anti-PD effects of dopamine agonists in a rat model of PD.4 These data prompted us to test the effect of the adenosine antagonist theophylline in PD patients.nnAll patients were diagnosed with clinically definite idiopathic PD as previously defined5 and were divided into either early PD (EPD; Hoehn & Yahr stage ≤2 and not yet on l-dopa) or advanced PD (APD; Hoehn & Yahr stage >2 and on l-dopa) with l-dopa–induced motor side effects; all APD patients were …

Sudden hearing loss as the initial monosymptom of multiple sclerosis.

Hearing loss is an uncommon symptom in multiple sclerosis. We report two patients in whom unilateral sudden hearing loss was the first monosymptomatic manifestation of multiple sclerosis. We confirmed the initial central auditory dysfunction suggested by audiometric findings and brainstem auditory evoked potentials by MRI, which showed a unilateral pontine lesion in one patient and a lesion in the medulla oblongata in the other.

Increased total homocysteine level is associated with clinical status and severity of white matter changes in symptomatic patients with subcortical small vessel disease

OBJECTIVEnElevated plasma total homocysteine (tHcy) is an independent risk factor for ischemic stroke and has been linked to cerebral small vessel disease (SVD), in particular. Controversy persists as to whether increased tHcy is associated with functional status and cognitive decline in these patients.nnnMETHODSnPlasma tHcy, MTHFR polymorphism, vascular risk factors, functional and cognitive status and severity of lesions on MRI, assessed with the Age-Related White Matter Changes (ARWMC) visual grading scale, were analyzed in 95 patients with SVD and 41 healthy control subjects.nnnRESULTSnPlasma tHcy levels were higher in patients with SVD (14.4±5.0 μmol/L) compared to healthy SVD-free controls (8.9±3.9 μmol/L). In SVD patients, tHcy levels strongly correlated with cognitive status (age-adjusted risk 5.8, 95% CI 1.3-25.3, p=0.015), functional status (age-adjusted risk 3.2, 95% CI 1.2-8.8, p=0.022) and severity of MRI lesions (age-adjusted risk 1.2, 95% CI 1.1-1.4; p=0.004). Only total ARWMC score was independently associated with increased tHcy levels (OR 1.2, 95%CI 1.1-1.4, p=0.004). Independent predictors of WMC occurrence were tHcy levels (OR 1.2, 95%CI 1.1-1.3, p=0.003) and mRS score (OR 2.2, 95%CI 1.2-4.1, p=0.017).nnnCONCLUSIONSnIn patients with cerebral SVD there is a positive association of increased plasma tHcy levels with clinical status and severity of WMC.

Penicillamine‐induced lethal status dystonicus in a patient with Wilson's disease

A 37‐year‐old man with Wilsons disease is described, in whom the introduction of penicillamine therapy was followed after 3.5 weeks by the development of the status dystonicus with a fatal outcome.

Cluster headache as a first manifestation of multiple sclerosis: case report and literature review

Cluster headache (CH) is estimated to be the most common primary trigeminal autonomic headache, although it is a rare disabling medical condition. Dominant symptoms of CH include severe unilateral orbital, supraorbital, and/or temporal pain, lasting from 15 to 180 minutes if untreated, associated with at least one of various autonomic symptoms during the headache, such as conjunctival injection, lacrimation, nasal congestion and rhinorrhea, facial sweating, miosis, ptosis, and eyelid edema. Headache is not frequently a symptom of multiple sclerosis (MS). The most commonly reported primary headaches are migraine without aura and a tension-type headache. Several described cases involved complicated migraine, ophthalmoplegic migraine-like headache, and finally cluster-like headache. We present a case of a 45-year-old male patient who had typical CH attacks as the initial and only clinical manifestation of MS, which was diagnosed after cerebrospinal fluid (CSF) isoelectric focusing and brain magnetic resonance imaging (MRI) investigation. He presented as a typical cluster-like headache patient since in the background of the CH symptoms and signs, were MS demyelinating lesions. In a patient with CH symptoms one should always think about the possibility of cluster-like-headache, which presents the CH patient with different underlying diseases, so we proposed a protocol to evaluate such patients and exclude diseases that could be in the background of CH symptoms.

Bereitschaftspotential in depressed and non-depressed patients with Parkinson's disease

Impaired initiation and slowed execution of movements are two of the principal characteristics of Parkinsons disease (PD). A similar pattern of movement impairments (psychomotor retardation) can be seen frequently in patients with idiopathic depression. In addition, affective disorders have been frequently reported in patients with different basal ganglia disorders. The aim of this study was to determine whether there are some particularities in the cerebral electrical activity during the preparation and execution of voluntary internally paced movements (i.e., Bereitschaftspotential, BP) in depressed PD patients, which can distinguish them from non‐depressed PD patients, as well as from healthy controls. The BPs were recorded in 16 patients with idiopathic PD, eight of whom were depressed (PD‐D), and eight of whom were not (PD‐ND). Additional recordings were taken from a group of eight age‐ and sex‐matched healthy subjects. Depression was classified using the Research Diagnostic Criteria and the two PD groups were matched for age, disease severity, and disease duration. The amplitudes and slopes of the BPs from PD patients were generally smaller than in controls, but there was no specific pattern of BP changes that distinguished depressed from non‐depressed PD patients. In addition, there was no particular association between measures of depression severity and BP parameters. The data suggest that presence of depression in PD might not have any additional deteriorating influence on already impaired preparation for self‐paced spontaneous movements.

What are the differences between younger and older patients with symptomatic small vessel disease

OBJECTIVEnAlthough typically linked to aging, small vessel disease (SVD) is also observed in younger adult patients, with common vascular risk factors (RF). We aimed to investigate features of SVD occurrence at an early adult age.nnnPATIENTS AND METHODSnVascular RF, functional and cognitive status and severity of lesions on MRI expressed as total score on Age-Related White Matter Changes (ARWMC) scale were analyzed in 200 consecutive patients with cerebral SVD admitted to a tertiary neurological hospital. Variables were compared between younger (35-55 years) and older (>56 years) patients.nnnRESULTSnIn this study, 63 (31.5%) of patients were 55 years or younger. Both age groups had comparable RF profiles, but smoking emerged as an independent predictor for SVD at a younger age (OR 2.9; 95% CI 1.5-5.5; p=0.002). Younger patients had better functional (OR 1.8; 95% CI 1.3-2.5; p=0.0001) and cognitive (χ(2) 13.94; p=0.0009) status compared to older patients. However, two thirds of younger patients had some degree of cognitive deficit. Total score on ARWMC scale was lower in younger patients (mean 12.3 in younger versus 15.2 in older, OR 1.11; 95% CI 1.0-1.18; p=0.001). There was a strong correlation in both groups between functional score, cognitive status and ARWMC score (p<0.0001).nnnCONCLUSIONnIn our dataset, younger patients with SVD shared common vascular RF with older patients. In the group aged ≤55, better functional and cognitive status and less severe MRI changes were noted. However, a substantial number of younger SVD patients presenting with TIA or ischemic stroke had various deficits.

Role of prediabetes in stroke

Stroke is one of the leading causes of death and probably the greatest cause of adult disability worldwide. Diabetes mellitus (DM) is a state of accelerated aging of blood vessels. Patients with diabetes have increased risk of stroke. Hyperglycemia represents a risk factor for poor outcome following stroke, and probably is just a marker of poor outcome rather than a cause. Lowering of blood glucose levels has not been shown to improve prognosis. Also, prevention of stroke risk among patients with DM is not improved with therapy for reduction of glucose levels. On the other hand, prediabetes, a metabolic state between normal glucose metabolism and diabetes, is a risk factor for the development of DM type 2 and subsequently for stroke. Several methods are known to identify prediabetes patients, including fasting plasma glucose levels, 2-hour post load glucose levels, and glycosylated hemoglobin levels. In this text, we tried to summarize known data about diagnosis, epidemiology, risk factors, pathophysiology, and prevention of prediabetes in relation to DM and stroke.

A novel Notch3 Gly89Cys mutation in a Serbian CADASIL family

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common heritable cause of stroke and vascular dementia in adults. We present a family from Serbia presenting with stroke and depression in the lack of vascular risk factors, with brain MRI indicating CADASIL. A novel NOTCH3 Gly89Cys mutation was located in exon 3. This report illustrates that in the setting of a positive family history with typical clinical and MRI features, even with an atypical form of pedigree, a high suspicion of CADASIL should lead to genetic testing.

Efficacy of intravenous magnesium sulfate in severe migraine attacks

Abstract The aim of this open study was to make a preliminary estimate of the efficacy and tolerability of intravenously administered magnesium sulfate (1 g) in comparison to subcutaneously administered sumatriptan in the treatment of severe migraine attacks. The study comprised 22 consecutive patients whose attacks were treated with magnesium sulfate (5 ml of a 20% solution), and the results were compared with those of another group of 14 consecutive patients whose attacks were treated with sumatriptan (6 mg).Immediately before and 10, 20 and 30 minutes after injections, patients reported pain intensity on a verbal 0–10 scale. Pain disappearance or pain relief >50% were considered significant. Efficacy of sumatriptan was superior that of to magnesium sulfate 20 minutes after the injections (p<0.05) and comparable after 30 minutes (magnesium therapy was successful in 68% in comparison to 79% of patients treated with sumatriptan). After only 10 minutes, 3 patients treated with magnesium sulfate were pain free, with the same effect in 5 (22.5%) and 10 (45%) patients after 20 and 30 minutes, respectively. The rate of headache recurrence was low and no major adverse effects were recorded. In conclusion, magnesium sulfate may be a well-tolerated pharmacological alternative for the treatment of severe migraine attacks.