Sigliti-Henrietta Pelidou

Patient compliance with SSRIs and gabapentin in painful diabetic neuropathy.

BackgroundAnticonvulsants are widely used for treatment of painful diabetic neuropathy. Selective serotonin reuptake inhibitors (SSRIs) are not first-line drugs but are commonly prescribed medicines for chronic pain. The majority of patients are hesitant to use these drug groups, thus their compliance remains an issue. ObjectiveTo compare patient compliance and the effectiveness of 2 SSRIs (paroxetine or citalopram) and 1 anticonvulsant (gabapentin) in patients with painful diabetic neuropathy. MethodsThis was a 6 months prospective trial in 101 patients with painful diabetic neuropathy and minimum score of 2 on a pain intensity scale ranging of 0 to 4. Compliance was assessed with patient interviews and pill counts. Adverse events, early discontinuation or satisfaction with treatment were also evaluated. ResultsPatients receiving SSRIs reported greater satisfaction and fewer concerns of the side-effects with their treatment (P<0.05) compared with the patients taking gabapentin. There was statistically significant better mood in the SSRI group (P<0.05). Overall, 43.5% of those taking SSRIs noticed no effect on the pain control, 50% felt better, and 6.5% felt worse. Among the patients taking gabapentin, 51% felt better, 40.5% noticed no effect, and 8.5% felt worse. Finally, on the pill count, more patients on SSRIs (93.5%) than on gabapentin (82.9%) were taking over the 75% of their medication (P<0.05). ConclusionsThe lack of negative effects on quality of life, the better compliance, and the comparable efficiency of SSRIs suggest that these drugs may be considered as alternative to gabapentin in painful diabetic neuropathy.

Multiple sclerosis presented as clinically isolated syndrome: the need for early diagnosis and treatment

Objective To aid in the timely diagnosis of patients who present with clinically isolated syndrome (CIS). Patients and methods We studied 25 patients (18 women, 7 men), originally presented in our clinic with a CIS suggestive of multiple sclerosis (MS). All patients underwent the full investigation procedure including routine tests, serology, cerebrospinal fluid (CSF) examinations, evoked potentials (EPs), and magnetic resonance imaging (MRI) of brain and cervical spinal cord. Patients were imaged at baseline, and every three months thereafter up to a year. Results The CIS was consisted of optic neuritis in 12 cases, incomplete transverse myelitis (ITM) in 7 cases, Lhermitte sign in 2 cases, internuclear ophthalmoplegia (INO) in 2 cases, mild brainstem syndrome in 1 case, and tonic-clonic seizures in 1 case. Using the baseline and three-month scans 18/25 (72%) patients developed definite MS in one year of follow up while 7 (28%) had no further findings during this observation period. Immunomodulatory treatments were applied to all definite MS patients. Conclusion In light of new treatments available, MRIs at 3 month intervals are helpful to obtain the definite diagnosis of MS as early as possible.

MRI deterioration in herpes simplex encephalitis despite clinical recovery.

Objectives:Herpes simplex virus type 1 is a sporadic cause of viral encephalitis. Relapse of encephalitis occurs in up to 10% of patients, manifested by recurrent symptoms, clinical and MRI findings, and the presence of herpes simplex virus type 1 DNA in the cerebrospinal fluid (CSF). Methods:We describe the clinical features, MRI findings and outcome in 2 patients with herpes simplex encephalitis during the acute phase and 6 months after the onset of encephalitis. Results:Both patients had a good response to treatment and an excellent recovery. Despite clinical recovery, in a 6-month follow-up MRI lesions consistent with recurrence were disclosed, without any clinical findings or CSF abnormalities. Conclusions:The mechanism underlying this MRI deterioration is unclear and an immune-mediated mechanism may be involved. Thus, MRI deterioration after herpes simplex encephalitis should be interpreted with caution and it does not always represent a relapse, especially when the imaging studies do not correlate with the clinical and CSF findings.

Agenesis of the corpus callosum associated with narcolepsy-cataplexy.

We describe a 24-year-old man with episodes of intense desire to sleep for periods ranging from 2min to 3h, episodes of generalized weakness and inability to speak without alteration of consciousness, frequent hypnagogic hallucinations during sleep and occasionally transient paralysis of limbs upon awakening. Brain MRI demonstrated elevation of the third ventricle, a characteristic lack of depiction of the corpus callosum and extension of the bihemispheric fissure to the third ventricle. We assume that structural changes of the base of frontal lobes, diencephalon and brainstem, can be accountable for symptomatic narcolepsy and cataplexy.

Thrombosis and Recanalization of Straight Sinus

We describe a case of a 14-year-old boy who presented to the emergency department with nausea, vomiting, headache, and mental status changes. Noncontrast computed tomography scan of the brain in the emergency department revealed bilateral thalamic and striatocapsular infarcts. The patient was diagnosed with possible thrombosis of the thalamostriate veins, which was confirmed with urgent magnetic resonance venography (MRV). Magnetic resonance venography revealed that the thrombosis was extended to the straight sinus and the internal cerebral veins. Thrombosis of the straight sinus in children results in a rare stroke with inconsistent clinical manifestations, depending on collateral venous circulation of the thrombosed sinus. The diagnosis is quite difficult, especially when symptoms are nonspecific and variable. Timely diagnosis, based on the decision of performing emergency magnetic resonance imaging and MRV, followed by the administration of anticoagulation therapy may reverse this condition as in our patient who made an excellent recovery.

Neurological manifestations of connective tissue diseases mimicking multiple sclerosis

The objective of the study was to analyze retrospectively the clinical, laboratory and imaging findings of multiple sclerosis (MS), such as the manifestations in a cohort of 132 patients referred to the neurology in and outpatient clinic. The proposed clinical and laboratory diagnostic criteria for MS and connective tissue disorders were systematically assessed in 132 consecutive patients. Cerebrospinal fluid serology and brain or spinal cord MRI were studied in all cases. In patients suspected for connective tissue disorder, schirmer test, rose bengal staining and biopsy of minor salivary glands were performed. A total of 115 (87%) patients were diagnosed to have definite MS, while 17 (13%) were diagnosed to have connective tissue disorder. Positive neurological and MRI findings were observed in both groups. The majority of patients with connective tissue disorder demonstrated extra-neurological manifestations like Raynaud’s phenomenon, arthritis, livedo reticularis, purpura and presence of multiple autoantibodies in their sera. All patients with MS should be screened systematically for connective tissue disorder. In the absence of pathognomonic clinical and laboratory findings, the diagnosis of MS is a diagnosis of exclusion.

Disc herniation or ependymoma recurrence

Aristeidis H. Katsanos1, Ioannis Sarmas1, Sotirios Giannopoulos1,2, Sigliti-Henrietta Pelidou1,2, Athanassios P. Kyritsis1,2 1Department of Neurology, School of Medicine, University of Ioannina, 45110 Ioannina, Greece. 2Neurosurgical Intitute, School of Medicine, University of Ioannina, 45110 Ioannina, Greece. In this paper, a 41-year-old female with previous history of ependymoma is reported. The patient underwent gross-total resection of the tumor and ventriculo-peritoneal shunt placement, followed by radiotherapy to the posterior fossa and the upper-cervical spinal cord region. Three years later she developed numbness in her right arm, body and leg. Magnetic resonance imaging (MRI) of the entire neuraxis revealed no evidence of tumor recurrence, while a small enhancing area was noted in the left anterolateral spinal cord at the level of the C1-C2 vertebrae and a left posterior-lateral herniated disk in the C5-C6 level which was not present in the earlier MRI at initial diagnosis. Lumbar punctures were negative for malignant cells. The patient’s symptoms were first attributed to radiation-induced effect. Follow-up results of brain and the cervical spine MRI were performed which showed disappearance of the small abnormality in the left C2 spinal cord area but persistence of the herniated C5-C6 disk. Thus, the current diagnosis of right-sided numbness due to pressure of the left anterolateral spinothalamic tracts from the herniated C5-C6 disk was made. This is a unique case, in which herniated disk pressuring effects needed to be differentiated from both radiation-induced treatment effect and tumor recurrence.