Sofia Markoula

MRI evaluation of the basal ganglia size and iron content in patients with Parkinson's disease

AbstractObjectiveTo evaluate by MRI the area size and the degree of iron accumulation in basal ganglia nuclei that are implicated in the pathogenesis of Parkinsons disease (PD).Methods40 patients with idiopathic PD and 40 controls were examined on a 1. 5 Tesla MR imager, using a multiecho SE sequence 2000/20, 40, 60, 80, 100, 120, 140, 160 (TR/TE). The T2 relaxation time (T2) and the area of substantia nigra zona compacta (SNc), substantia nigra zona reticulata (SNr), putamen (Pu), globus pallidus external (GPe), globus pallidus internal (GPi), caudate nucleus (CN), locus coeruleus (LC) and subthalamic nucleus (STN) were assessed.ResultsThe T2 of SNc (76. 8 ± 6. 0) was lower and of Pu (79.5 ± 6.0) and GPe (69.5 ± 7.0) was higher in patients than in controls (78.6 ± 3.8, 77.4 ± 3.9 and 67.3 ± 5.7, respectively), p < 0.05. The area of CN (125.9 ± 20.2) and Pu (201.5 ± 48.7) was higher in patients than in controls (110.7 ± 21.5 and 180.1 ± 41.1, respectively), p < 0.05. A more pronounced decrease in the T2 of SNc (73.6 ± 8.9) was observed when the more affected side of patients was evaluated separately. In patients with disease duration > 5 years the T2 of STN (71.5 ± 6.3) was lower and the area of Pu was higher (215.3 ± 54.9) compared with those with disease duration ≤ 5 years (75.8 ± 10.9 and 190.9 ± 41.0 respectively), p < 0.05.ConclusionsThese findings suggest that dysfunction of the basal ganglia circuitry in PD may affect iron content not only in SNc but in STN, Pu and GPe as well. Compensatory sprouting of the remaining dopaminergic fibers could account for the increased area of the CN and Pu.

Vitamin D receptor gene polymorphisms in multiple sclerosis patients in northwest Greece

BackgroundPolymorphisms of the vitamin D receptor (VDR) gene have been linked to both multiple sclerosis (MS) and osteoporosis. We examined the frequency of the Taq-I and Bsm-I polymorphisms of the vitamin D receptor (VDR) gene in 69 patients with MS and 81 age and sex-matched healthy individuals. Genotyping of Taq-I (rs731236) and Bsm-I (rs1544410) was performed using TaqMan® SNP Genotyping Assay. All patients and controls had determination of body mass index (BMI), bone mineral density (BMD) and smoking history.ResultsThe mean age of patients was 39 ± 10.5 years compared to 38.7 ± 10.7 years of the controls (p = 0.86), the BMI was 24.8 ± 4.2 kg/m2 compared to 25.7 ± 4.8 kg/m2 of the controls (p = 0.23), the BMD in the lumbar spine 0.981 ± 0.15 compared to 1.025 ± 013 of the controls (p = 0.06) and the total hip BMD was 0.875 ± 0.14 compared to 0.969 ± 0.12 of the controls (p < 0.001). There were no differences of the Taq-I (TT, CT, CC) and Bsm-I genotypes (GG, GA, AA) and allelic frequencies between MS and control individuals. Multivariate analysis also failed to show any association of the Taq-I and Bsm-I polymorphisms and MS or sex, BMI, BMD and smoking history.ConclusionsThis study suggests that the Taq-I and Bsm-I polymorphisms of the VDR gene are not associated with MS risk, BMI or BMD in the Greek population studied.

Lateral medullary ischaemic events in young adults with hypoplastic vertebral artery

Objective: To present three cases of young adults with lateral medullary ischaemic events associated with a hypoplastic vertebral artery (VA). All three patients had two additional atherosclerotic or non-atherosclerotic risk factors for stroke. Patients and methods: One female, aged 40 years, and two males, aged 38 and 37 years, each with two risk factors for stroke, presented to the emergency department with acute onset of symptoms and findings consistent with lateral medullary syndrome. All three patients underwent emergency CT scan of the brain followed by MRI and magnetic resonance angiography (MRA). Results: The CT scans were negative in all patients. MRI revealed a lateral medullary lesion in only one patient. All three patients had a hypoplastic VA ipsilateral to the clinical ischaemic event on MRA. Conclusions: Hypoplasia of VA is not considered a risk factor for stroke as it is a common variant in up to 75% of the general population. However, in our patients, hypoplastic VA coexisted with two risk factors and resulted in stroke. Thus although a hypoplastic VA may not be an uncommon asymptomatic finding, it may contribute to stroke if additional risk factors are present.

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.

GUILLAIN-BARRE SYNDROME IN NORTHWEST GREECE

Objective –  We present the epidemiological and clinical‐laboratory features of Guillain‐Barré syndrome (GBS) in northwest Greece over a 9.5‐year period.

A systematic approach to the management of patients with brain metastases of known or unknown primary site

PurposeTo establish an empirical systematic approach for the management of brain metastases from a variety of cancers.MethodsThe English literature was reviewed from 2000 to 2011 and all clinical trials (phase II, phase III and retrospective studies) regarding therapy of brain metastases were selected for more detailed review. Some key articles published prior to 2000 were also included in the review as are supplemental recommendations based on our clinical experience.ResultsPatients with brain metastases from small cell lung cancer (SCLC) at the initial cancer diagnosis can be treated with concomitant whole-brain radiation therapy (WBRT) and chemotherapy or first with chemotherapy followed by WBRT. In all other cases, brain metastases are currently treated independently of the management of the extracranial disease with surgery or radiosurgery followed by WBRT. In radioresistant tumors (melanoma, sarcoma, renal cell carcinoma), WBRT may be omitted initially but administered at recurrence. Where surgery or radiosurgery is not an option for patients, WBRT should be administered. Prophylactic WBRT should be given in patients with SCLC and considered in patients with non-small cell lung cancer. Apart from its use in SCLC, chemotherapy for the treatment of brain metastases is reserved for patients enrolled in clinical trials.ConclusionBrain metastases should be treated aggressively and independently of the primary site tumor especially if the performance status of the patient is good. The role of chemotherapy should be addressed in the context of clinical trials.

Gender association of the angiotensin-converting enzyme gene with ischaemic stroke

We examined the association of the NG011648 polymorphism (insertion/deletion) of the angiotensin-converting enzyme (ACE) gene with ischaemic stroke occurrence, subtype of ischaemic stroke and ischaemic stroke patients’ gender. Patients with first ever ischaemic stroke were recruited prospectively in a period of 18 months. Controls were matched with the patients for age, gender, and known risk factors for stroke. Demographic data, medical history, and vascular risk factors were collected. Genotypes were determined by polymerase chain reaction (PCR) and restriction enzyme analysis. Stroke and control groups were compared in regard to the prevalence of the NG011648 polymorphism. One hundred and seventy-six patients with ischaemic stroke and 178 controls were recruited and genotyped for NG011648 polymorphism (I/D) of the ACE gene. No significant difference in allele and genotype distributions emerged between control and patient groups, nor in the two subtype groups of lacunars and large artery atherosclerosis. After the data were stratified by gender, a low incidence of II homozygosity in female patients versus female controls (p = 0.05) and male patients (p = 0.013, Z score: -2.49) was found. Our results indicate that I/D polymorphisms may have a role in stroke onset, in respect to gender, with a possible favourable effect of II genotype in females.

Functional impact and prevalence of polymorphisms involved in the hepatic glucuronidation of valproic acid

Metabolism of valproic acid, a widely used drug, is only partially understood. It is mainly metabolized through glucuronidation and acts as a substrate for various UDP-glucuronosyltransferases (UGTs). UGTs metabolizing valproic acid in the liver are UGT1A3, UGT1A4, UGT1A6, UGT1A9 and UGT2B7, with UGT1A6 and UGT2B7 being the most prominent. Polymorphisms in genes expressing these enzymes may have clinical consequences, regarding dosing, blood levels of the drug and adverse reactions. Not all genes are well studied and studies, where they exist, report conflicting results. Prevalence of polymorphisms and various haplotypes is also of great importance, as it may suggest different therapeutic approaches in various populations. Presented here is a review of currently known polymorphisms, their functional impact, when known, and their prevalence in different populations, highlighting the current state of understanding and areas where there is a lack of data and suggesting new perspectives for further research.

First Case of Lacosamide-Induced Psychosis

Lacosamide (LCM) is a newer antiepileptic drug with a favorable safety profile used in partial epilepsy as adjunctive therapy. The most common side effects include dizziness, headache, confusion, diplopia, nausea, nasopharyngitis, and vomiting. Although sporadic cases of drug-induced psychosis have been reported for some antiepileptic drugs, this was not the case for LCM. We describe the first case of LCM-induced psychosis in a patient with drug-resistant partial epilepsy during the first week of treatment initiation, stressing the importance of clinicians remaining alert for abnormal behavioral symptoms.

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.