Yasser Awaad

Use of Levetiracetam to Treat Tics in Children and Adolescents With Tourette Syndrome

Some drugs currently used to treat tics in pediatric patients have drawbacks, including the risk of side effects. New therapeutic options with better safety profiles are needed. Levetiracetam is an antiepileptic drug with atypical mechanisms of action that might be beneficial for this indication. We evaluated the effects of levetiracetam on motor and vocal tics, behavior, and school performance in children and adolescents with tics and Tourette syndrome (TS). Sixty patients, ≤18 years of age, with tics and TS were enrolled in this prospective, open‐label study. The initial starting dose of levetiracetam was 250 mg/day. The dosage was titrated over 3 weeks to 1,000 to 2,000 mg/day. Clinical outcomes were assessed with the Clinical Global Impression Scale, Yale Global Tic Severity Scale, and Revised Conners Parent Rating Scale. Behavior and school performance were also recorded. All 60 patients showed improvements based on all of the scales used, and 43 patients improved with regard to behavior and school performance. Levetiracetam was generally well tolerated. Three patients discontinued treatment because of exaggeration of preexisting behavioral problems. Levetiracetam may be useful in treating tics in children and adolescents. Given its established safety profile, levetiracetam is a candidate for evaluation in a well‐controlled trial.

Complications of intrathecal baclofen pump: prevention and cure.

Increasingly, spasticity is managed with surgically implanted Intrathecal Baclofen pumps. Intrathecal Baclofen pump revision surgery unrelated to programmable pump end-of-life is not uncommon, requiring special attention during pre-, intra-, and postoperative management. We aimed to identify and describe complications of Intrathecal Baclofen pump as well as to report avoidance and management of complications. Methods and Materials. Through 2002–2006, at the department of neurosurgery, Henry Ford and Oakwood Health Systems, Intrathecal Baclofen pumps were implanted in 44 patients: 24 children versus 20 adults; 30 “primary-implant-patients”; 14 “revision-only patients”. We evaluated reasons for revision surgeries and diagnostic workup requirements. Results. Eight primary-implant-patients required 14 revisions and 7 of revision-only patients needed 13 procedures. Seven patients with slowly increasing baclofen-resistant spasticity had either (i) unsuspected pump-catheter connector defects, (ii) an X-ray-documented pump-catheter connector defect, (iii) X-ray-demonstrated fractured catheter with intrathecal fragment. Implant infections occurred in 4 cases. Scintigraphy revealed occult CSF leakage N=1 and intrinsic pump failure N=1. Conclusion. Intrathecal Baclofen pumps, although very gratifying, have a high, technique-related complication incidence during implant life. Meticulous technique, high clinical suspicion, appropriate workup, and timely surgical management can reduce surgical complications of Intrathecal Baclofen pump implantation.

Neurologic Complications of Systemic Disease

1. n nThe following scenario is part of a two-question series, Discussion & References included at the end of series. n nYou are evaluating a 16-year-old female with a history of increasing headache for the last 2 months. The headache is episodic pounding but has become daily. She reported increasing of her weight by 5 Ib., and she is abnormally sweaty. On exam she has mild proximal muscle weakness, hyperreflexia and a new intention tremor. n nWhat lab test are you going to order to reach the diagnosis? n nA. n nCreatine Kinase n n n n nB. n nElectrolytes n n n n nC. n nTissue Transglutaminase IgA n n n n nD. n nThyroid Hormone n n n n nE. n nBun/Cr

Short Q/A

1. n nAll the following are components of or functionally related to the basal ganglia n nEXCEPT n nA. n ncaudate nucleus n n n n nB. n nred nucleus n n n n nC. n nSub-thalamic nucleus n n n n nD. n nputamen n n n n nE. n nsubstantia nigra

Ethics and Professionalism

1. n nA 7-year-old boy is admitted to the ICU after an out-of-hospital cardiac arrest. He was being treated for vomiting and headache that became daily after initially being intermit-tent, paroxysmal and focal on the right side. There was a family history of migraine and he reported visual blurring at the onset of vomiting and headache in the left visual field. He had a non-contrast CT scan that was unremarkable and no sign of intercurrent illness. He was initially treated with sumatriptan but as this produced no real relief he was hospitalized and given ondansetron with analgesia. After 2 days in the hospital he was discharged slightly improved on scheduled ondansetron and acetaminophen. The following morning he was discovered pulseless in his bed. His father began CPR and emergency medical technicians arrived within 5 min. He was intubated and ECG showed ventricular fibrillation. By the time he was transported to the ER at 30 min he had a sinus rhythm and blood pressure. His exam in the ER showed no pupillary light reflex and absent corneal reflex, extraocular movements, and gag. CT scan was normal except for indistinct gray-white differentiation. An EEG at 10 h post-arrest showed electrocerebral silence. Evaluation for cause of his arrest was negative except for the presence of a prolonged QT interval of 0.48 suggesting he may have acquired long QT syndrome secondary to ondansetron. A repeat EEG shows electrocerebral silence and his exam is unchanged. n nWhat is your approach with the family? n nA. n n“If only I had seen this child…” You explain that you never use ondansetron for nausea and vomiting in the setting of migraine and your approach to migraine would have likely resulted in resolution of his symptoms prior to discharge making only rescue medications necessary. You suggest they withdraw support since he is brain dead on your exam. n n n n nB. n n“Your child is dead according to my tests…” You explain that after cardiac arrest loss of pupillary light response is associated with death or vegetative state 95% of the time and he has not improved so he cannot recover. The EEG confirms your opinion. n n n n nC. n n“Let me summarize what I know about your son…” You describe the history as you know it and then your exam and test results describing how you arrive at the conclusion the child is brain dead. After asking for questions you give your opinion that support should be withdrawn. n n n n nD. n nTo be sure we understand each other, could you tell me what you understand is going on with your son…” You listen to the family’s ideas and answer any questions that arise from your opening statement and then explain your exam and the EEG results. After allowing questions and discussions with the family you state your recommendation that support be withdrawn. n n n n nE. n n“The studies and my exam show there is no hope…” You present the data from the CT scan, EEG and your exam and state that the child is brain dead. You wait for questions and when there are none excuse yourself.

Botulinum neurotoxin-A in idiopathic chondrolysis: a report of two cases.

Two cases of idiopathic chondrolysis were treated by botulinum neurotoxin-A injections, with a favorable outcome. The treatment consisted of botulinum neurotoxin-A injections, followed by an intensive rehabilitation program. No surgery was needed. Both patients were symptom-free and showed an extremely satisfactory range of motion. Radiographs indicated reconstitution of the joint space in both cases. We believe that botulinum neurotoxin-A injections combined with an intensive rehabilitation program may be considered a new potential management modality and is worth attempting and studying when one considers the results of previously published reports.

Botulinum Toxin and Tourette Syndrome

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