Roberto Ciordia

Use of ziprasidone in parkinsonian patients with psychosis.

Twelve patients with Parkinson disease and psychosis were included in an open-label 12-week trial of ziprasidone. Two patients withdrew from the treatment because of adverse effects. The remaining 10 patients reported a significant improvement in psychiatric symptoms. Altogether, there was no deterioration of motor symptoms (UPDRS III score: basal 40.4 ± 11, 1, first month 41.1 ± 10.8; final visit, 37.7 ± 13.3). Two patients (20%) suffered a slight deterioration in motor symptoms and another patient suffered deterioration of gait. No analytic alterations or serious adverse effects that could limit the use of ziprasidone were observed. Although controlled trials are needed, the findings suggest that ziprasidone may be effective in parkinsonian patients with psychosis.

Sleep complaints and their relation with drug treatment in patients suffering from Parkinson's disease.

The aim of this research was to quantify sleep problems in patients suffering from Parkinsons disease by means of the new Parkinsons Disease Sleep Scale (PDSS) and to correlate such problems with the possible influence of current drug treatment. A total of 70 patients (36 men and 34 women) with a diagnosis of Parkinsons disease were enrolled. Their mean age was 69.7 ± 8.2 years, and duration of disease was 7.4 ± 4.8 years. All patients completed the PDSS and the Unified Parkinsons Disease Rating Scale (UPDRS Parts I–IV). Drug consumption and doses were registered. The mean score on the PDSS scale was 109.23 ± 19.75 and on the UPDRS III scale was 25.24 ± 11.35. The lowest scores were obtained in Item 3 (sleep fragmentation): 5.53 (2.46); and in Item 8 (nocturia): 5.75 (2.91). There was a weak correlation between the PDSS and UPDRS III (cc = −0.355, P = 0.003), PDSS and UPDRS I (cc = −0.272, P = 0.02), and PDSS and UPDRS IV (cc = −0.416, P < 0.001). Motor conditions, mental state, and drug complications influence sleep quality. Although this effect was significant, it was not of a great magnitude. Dopaminergic drugs did not increase daytime sleepiness. As a whole, sleep quality in patients who took dopaminergic agonists did not differ from that of patients who took levodopa in monotherapy.

Tako-tsubo cardiomyopathy in a patient with bilateral lesions in the dorsal medulla

Tako-tsubo-like cardiomyopathy (TTC) is much more common than originally thought. The exact pathophysiology of TTC is unclear. The most accepted theory proposes myocardial stunning of neurogenic origin, supported by the frequent antecedent of emotional or physical stress, suggesting a catecholamine-mediated mechanism. We present a patient with this syndrome and bilateral damage of the dorsal medulla oblongata likely affecting both solitary tract nuclei. Our case points to a link between baroreflex failure and TTC, highlighting the important role of sympathetic discharge in the pathophysiology of TTC.

Abnormal multifocal cerebral blood flow on Tc-99m HMPAO SPECT in a patient with anti-NMDA-receptor encephalitis.

-aspartate receptor (NMDA-R) encephali-tis has been related with teratomas of the ovary in youngwomen. However, this syndrome is non-paraneoplastic inabout 40% of patients, particularly in the youngest patients[1, 3]. This encephalitis is associated with antibodies againstthe NMDA-R NR1 and NR2 subunits. The clinical pictureincludes movement disorders (dystonia, orolingual dyski-nesias, chewing movements, myoclonias,…), decreasedlevel of consciousness, seizures, central hypoventilation andautonomic disturbances. Frequently it is preceded by psy-chiatric symptoms such as changes of mood, behavior andpersonality, or acute psychosis.Brain MRI is normal or with mild changes in mostpatients. To date, scarce data from functional neuroimagingstudies [4] or MR spectroscopy are available. Few neuro-pathological cases have been described [2, 6, 7].We present a patient with anti-NMDA-R encephalitiswith a previously unreported abnormal multifocal cerebralblood flow on Tc-99m HMPAO SPECT.A 14-year-old girl was admitted to the ICU for an acutepsychiatric episode that developed 48 h after an upperrespiratory tract infection. She showed agitation, auditoryand visual hallucinations and aberrant behaviour. A con-ventional neurological examination, CT of the brain andfunduscopy were normal. A lumbar tap yield a colourlessCSF with 140 lymphocytes/ml and a normal glucose andprotein level. PCR for HSV DNA and cytology were nor-mal or negative.In the following days she worsened, developing a gen-eralized dystonia, severe facial grimacing and oculogyriccrisis with a decreased level of consciousness. Autonomicsymptoms were present with hypertensive crisis, tachy-cardia and hypersalivation. The patient did not developcentral hypoventilation. She showed generalized seizuresand was treated with phenytoin.Two gadolinium-enhanced brain MRI were normal(Fig. 1). Several EEGs showed continuous 2.5–3.5 Hz slowwaves without spikes. Brain Tc-99m HMPAO SPECTimages showed multiple focal areas of increased radiotraceruptake in both striatum and cerebral cortex more intense inthe frontal lobes (Fig. 1). Antibodies to NR1/NR2 hetero-mers of the NMDA receptor were found in CSF (immuno-logical studies performed by Drs F. Graus and A. SaizNeurology Service, Hospital Clinic, Universitat de Barce-lona). Ovarian teratoma or other tumors were not identifiedwith repeated specifically oriented CT, MRI, or ultrasound.The patient did not improve after one high dose steroidcourse. A dramatic recovery was observed with the admin-istration of IVIg at standard doses. Repeated brain-Tc-99mHMPAO-SPECT showed a near complete normalization.Brain MR Spectroscopy was performed after resolution of

Factors influencing the symmetry of Parkinson's disease symptoms

INTRODUCTION The presence of asymmetry in symptoms and clinical signs favours the diagnosis of Parkinsons disease (PD). The aim of this study is to analyse this symptom asymmetry as a function of different variables and compare it with other parkinsonisms. MATERIALS AND METHODS 201 Patients with PD were studied. The sample was supplemented with 29 patients diagnosed with MSA-P (according to the criteria established by the American Academy of Neurology) and 17 with PSP (according to the criteria established by the NINDS-SPSP International Workshop). The symmetry was evaluated, based on items 20-23, 25 and 26 of the Unified Parkinsons Disease Rating Scale, by subtracting the motor score for the left side from that for the right side. Those patients with a difference of one point or more were designated as being asymmetric. RESULTS Around 16.4% of patients presented symmetrical clinical symptoms. There were no differences between those patients with or without family history of the disease. Those patients with symmetric symptoms were found to have longer symptomatic disease duration (10.8 vs. 7.9 years), a worse mental state (UPDRS I: 3.9 vs. 3.2), a higher incidence of complications (UPDRS IV: 4.5 vs. 3.2) and had their activities of daily living (ADL) affected to a greater degree (UPDRS II: 13.0 vs. 11.0). Around 48.3% of the MSA-P patients and 52.9% of the PSP patients showed symmetric symptoms. CONCLUSIONS The degree of symmetry is not useful in differentiating between sporadic and familial PD. However, the observation of highly symmetrical symptoms in a patient with short evolution time indicates that an atypical parkinsonism should be suspected.