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Feil K, Rattay TW, Adeyemi AK, Goldschagg N, Strupp ML. [What's behind cerebellar dizziness? - News on diagnosis and therapy]. Laryngorhinootologie 2024; 103:337-343. [PMID: 37989215 DOI: 10.1055/a-2192-7278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Vertigo and dizziness comprise a multisensory and multidisciplinary syndrome of different etiologies. The term "cerebellar vertigo and dizziness" comprises a heterogenous group of disorders with clinical signs of cerebellar dysfunction and is caused by vestibulo-cerebellar, vestibulo-spinal or cerebellar systems. About 10 % of patients in an outpatient clinic for vertigo and balance disorders suffer from cerebellar vertigo and dizziness. According to the course of the symptoms, one can considers 3 types: permanent complaints, recurrent episodes of vertigo and balance disorders, or an acute onset of complaints. The most common diagnoses in patients with cerebellar vertigo and dizziness were as follows: degenerative disease, hereditary forms and acquired forms. In a subgroup of patients with cerebellar vertigo, central cerebellar oculomotor dysfunction is indeed the only clinical correlate of the described symptoms. 81 % of patients with cerebellar vertigo suffer from permanent, persistent vertigo and dizziness, 31 % from vertigo attacks, and 21 % from both. Typical clinical cerebellar signs, including gait and limb ataxia or dysarthria, were found less frequently. Key to diagnosis is a focused history as well as a thorough clinical examination with particular attention to oculomotor function. Regarding oculomotor examination, the most common findings were saccadic smooth pursuit, gaze-evoked nystagmus, provocation nystagmus, rebound nystagmus, central fixation nystagmus, most commonly downbeat nystagmus, and disturbances of saccades. Thus, oculomotor examination is very sensitive in diagnosing cerebellar vertigo and dizziness, but not specific in distinguishing different etiologies. Laboratory examinations using posturography and a standardized gait analysis can support the diagnosis, but also help to estimate the risk of falls and to quantify the course and possible symptomatic treatment effects. Patients with cerebellar vertigo and dizziness should receive multimodal treatment.
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Affiliation(s)
- Katharina Feil
- Schwerpunkt neurovaskuläre Erkrankungen, Neurologische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Tim W Rattay
- Schwerpunkt neurodegenerative Erkrankungen, Neurologische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany
- Hertie-Institut für klinische Hirnforschung, Universitätsklinikum Tübingen, Tübingen
| | - Adedolapo Kamaldeen Adeyemi
- Schwerpunkt neurovaskuläre Erkrankungen, Neurologische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Nicolina Goldschagg
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
- Deutsches Schwindel- und Gleichgewichtszentrum, DSGZ, Ludwig-Maximilians-Universität München, München, Germany
| | - Michael Leo Strupp
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
- Deutsches Schwindel- und Gleichgewichtszentrum, DSGZ, Ludwig-Maximilians-Universität München, München, Germany
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Manto M, Cendelin J, Strupp M, Mitoma H. Advances in cerebellar disorders: pre-clinical models, therapeutic targets, and challenges. Expert Opin Ther Targets 2023; 27:965-987. [PMID: 37768297 DOI: 10.1080/14728222.2023.2263911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Cerebellar ataxias (CAs) represent neurological disorders with multiple etiologies and a high phenotypic variability. Despite progress in the understanding of pathogenesis, few therapies are available so far. Closing the loop between preclinical studies and therapeutic trials is important, given the impact of CAs upon patients' health and the roles of the cerebellum in multiple domains. Because of a rapid advance in research on CAs, it is necessary to summarize the main findings and discuss future directions. AREAS COVERED We focus our discussion on preclinical models, cerebellar reserve, the therapeutic management of CAs, and suitable surrogate markers. We searched Web of Science and PubMed using keywords relevant to cerebellar diseases, therapy, and preclinical models. EXPERT OPINION There are many symptomatic and/or disease-modifying therapeutic approaches under investigation. For therapy development, preclinical studies, standardization of disease evaluation, safety assessment, and demonstration of clinical improvements are essential. Stage of the disease and the level of the cerebellar reserve determine the goals of the therapy. Deficits in multiple categories and heterogeneity of CAs may require disease-, stage-, and symptom-specific therapies. More research is needed to clarify how therapies targeting the cerebellum influence both basal ganglia and the cerebral cortex, poorly explored domains in CAs.
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Affiliation(s)
- Mario Manto
- Service des Neurosciences, University of Mons, Mons, Belgium
| | - Jan Cendelin
- Department of Pathophysiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo medical University, Tokyo, Japan
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Huang H, Shakkottai VG. Targeting Ion Channels and Purkinje Neuron Intrinsic Membrane Excitability as a Therapeutic Strategy for Cerebellar Ataxia. Life (Basel) 2023; 13:1350. [PMID: 37374132 DOI: 10.3390/life13061350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
In degenerative neurological disorders such as Parkinson's disease, a convergence of widely varying insults results in a loss of dopaminergic neurons and, thus, the motor symptoms of the disease. Dopamine replacement therapy with agents such as levodopa is a mainstay of therapy. Cerebellar ataxias, a heterogeneous group of currently untreatable conditions, have not been identified to have a shared physiology that is a target of therapy. In this review, we propose that perturbations in cerebellar Purkinje neuron intrinsic membrane excitability, a result of ion channel dysregulation, is a common pathophysiologic mechanism that drives motor impairment and vulnerability to degeneration in cerebellar ataxias of widely differing genetic etiologies. We further propose that treatments aimed at restoring Purkinje neuron intrinsic membrane excitability have the potential to be a shared therapy in cerebellar ataxia akin to levodopa for Parkinson's disease.
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Affiliation(s)
- Haoran Huang
- Medical Scientist Training Program, The Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Vikram G Shakkottai
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Lv J, Han M, Xiang Z, Gong R, Shi C, Hua Q, Zhang R, Du C. Chlorzoxazone Alleviates Experimental Autoimmune Encephalomyelitis via Inhibiting IL-6 Secretion of Dendritic Cells. J Immunol 2022; 208:1545-1553. [PMID: 35277421 DOI: 10.4049/jimmunol.2100169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 01/12/2022] [Indexed: 06/14/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating autoimmune disease with chronic inflammatory demyelination of the CNS. Experimental autoimmune encephalomyelitis (EAE) is an important animal model to study MS, with many pathological phenomena similar to MS. Th17 cells are important regulators of EAE and MS pathogenesis. Most cytokines needed for Th cell development are secreted by APCs, such as dendritic cells (DCs). Consequently, MS could be improved by inhibiting cytokine secretion from DCs. In this study, we reported that chlorzoxazone could ameliorate EAE pathogenesis via inhibiting IL-6 production by DCs. The EAE signs in the chlorzoxazone-treated group of mice were relieved, which was mainly manifested as lower clinical scores, a decrease in the number of immune cells, and a reduction of demyelination in the CNS. Moreover, the proportion of Th17 cells in the spleen and CNS decreased significantly. In vitro experiments showed that chlorzoxazone treatment significantly reduced DC-derived IL-6 production. In the DC-T cell coculture experiment, significantly decreased Th17 differentiation was observed after chlorzoxazone treatment. In addition, mass spectrometric analysis was performed to elucidate the mechanism by which chlorzoxazone affected EAE and DC function. We showed that the effect of chlorzoxazone on inhibiting the secretion of IL-6 by DCs may be mediated via the AMP-activated protein kinase pathway. Overall, our study elucidated the key role of chlorzoxazone in regulating EAE pathogenesis and suggested that it might be used as a new drug for MS patients.
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Affiliation(s)
- Jie Lv
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Mengyao Han
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Zhenglong Xiang
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Ran Gong
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Changjie Shi
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Qiuhong Hua
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Ru Zhang
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Changsheng Du
- Putuo People's Hospital, Shanghai Key Laboratory of Signaling and Disease Research, School of Life Sciences and Technology, Tongji University, Shanghai, China
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Strupp ML, Straumann D, Helmchen C. Nystagmus: Diagnosis, Topographic Anatomical Localization and Therapy. Klin Monbl Augenheilkd 2021; 238:1186-1195. [PMID: 34784642 DOI: 10.1055/a-1525-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nystagmus is defined as rhythmic, most often involuntary eye movements. It normally consists of a slow (pathological) drift of the eyes, followed by a fast central compensatory movement back to the primary position (refixation saccade). The direction, however, is reported according to the fast phase. The cardinal symptoms are, on the one hand, blurred vision, jumping images (oscillopsia), reduced visual acuity and, sometimes, double vision; many of these symptoms depend on the eye position. On the other hand, depending on the etiology, patients may suffer from the following symptoms: 1. permanent dizziness, postural imbalance, and gait disorder (typical of downbeat and upbeat nystagmus); 2. if the onset of symptoms is acute, the patient may experience spinning vertigo with a tendency to fall to one side (due to ischemia in the area of the brainstem or cerebellum with central fixation nystagmus or as acute unilateral vestibulopathy with spontaneous peripheral vestibular nystagmus); or 3. positional vertigo. There are two major categories: the first is spontaneous nystagmus, i.e., nystagmus which occurs in the primary position as upbeat or downbeat nystagmus; and the second includes various types of nystagmus which are induced or modified by certain factors. Examples are gaze-evoked nystagmus, head-shaking nystagmus, positional nystagmus, and hyperventilation-induced nystagmus. In addition, there are disorders similar to nystagmus, such as ocular flutter or opsoclonus. The most common central types of spontaneous nystagmus are downbeat and upbeat, infantile, pure torsional, pendular fixation, periodic alternating, and seesaw nystagmus. Many types of nystagmus allow a precise neuroanatomical localization: for instance, downbeat nystagmus, which is most often caused by a bilateral floccular lesion or dysfunction, or upbeat nystagmus, which is caused by a lesion in the midbrain or medulla. Examples of drug treatment are the use of 4-aminopyridine for downbeat and upbeat nystagmus, memantine or gabapentin for pendular fixation nystagmus, or baclofen for periodic alternating nystagmus. In this article we are focusing on nystagmus. In a second article we will focus on central ocular motor disorders, such as saccade or gaze palsy, internuclear ophthalmoplegia, and gaze-holding deficits. Therefore, these types of eye movements will not be described here in detail.
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Affiliation(s)
- Michael Leo Strupp
- Neurologische Klinik der Ludwig-Maximilians-Universität München, Deutschland.,Deutsches Schwindel- und Gleichgewichtszentrum der Ludwig-Maximilians-Universität München, Deutschland
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Abstract
PURPOSE OF REVIEW This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN). RECENT FINDINGS Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies. SUMMARY DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic.
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Affiliation(s)
- Tu M Tran
- Department of Ophthalmology and Visual Neurosciences
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences
- Department of Neurology
- Department of Neurosurgery, University of Minnesota, Minneapolis, USA
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Abstract
Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.
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Affiliation(s)
- Mallory J Raymond
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue MSC 550, 11th Floor, Charleston, SC 29425, USA
| | - Esther X Vivas
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, 550 Peachtree Street Northeast, 11th Floor, Atlanta, GA 30308, USA.
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Zwergal A, Dieterich M. [Update on diagnosis and therapy in frequent vestibular and balance disorders]. Fortschr Neurol Psychiatr 2021; 89:211-220. [PMID: 33873210 DOI: 10.1055/a-1432-1849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The 8 most frequent vestibular disorders account for more than 70% of all presentations of vertigo, dizziness, and imbalance. In acute (and mostly non-repetitive) vestibular disorders acute unilateral vestibulopathy and vestibular stroke are most important, in episodic vestibulopathies benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, and in chronic vestibular disorders bilateral vestibulopathy/presbyvestibulopathy, functional dizziness and cerebellar dizziness. In the last decade, internationally consented diagnostic criteria and nomenclature were established for the most frequent vestibular disorders, which can be easily applied in clinical practice. The diagnostic guidelines are based on history taking (including onset, duration, course, triggers, accomanying symptoms), clinical examination, and only a few apparative tests (by videooculography and audiometry) for securing the diagnosis. Treatment of vestibular disorders includes physical training (repositioning maneuvers, multimodal balance training) and pharmacological approaches (e.g., corticosteroids, antiepileptics, antidepressants, potassium-canal-blockers, drugs enhancing neuroplasticity). For most drugs, high-level evidence from prospective controlled trials is lacking. In clinical practice, the most frequent vestibular disorders can be treated effectively, thus avoiding chronicity and secondary comorbidity (by immobility, falls or psychiatric disorders such as anxiety or depression).
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Affiliation(s)
- Andreas Zwergal
- LMU Klinikum, Neurologische Klinik und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
| | - Marianne Dieterich
- LMU Klinikum, Neurologische Klinik und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
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Ritter-Makinson S, Clemente-Perez A, Higashikubo B, Cho FS, Holden SS, Bennett E, Chkhaidze A, Eelkman Rooda OHJ, Cornet MC, Hoebeek FE, Yamakawa K, Cilio MR, Delord B, Paz JT. Augmented Reticular Thalamic Bursting and Seizures in Scn1a-Dravet Syndrome. Cell Rep 2020; 26:54-64.e6. [PMID: 30605686 PMCID: PMC6555418 DOI: 10.1016/j.celrep.2018.12.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/07/2018] [Accepted: 12/03/2018] [Indexed: 11/26/2022] Open
Abstract
Loss of function in the Scn1a gene leads to a severe epileptic encephalopathy called Dravet syndrome (DS). Reduced excitability in cortical inhibitory neurons is thought to be the major cause of DS seizures. Here, in contrast, we show enhanced excitability in thalamic inhibitory neurons that promotes the non-convulsive seizures that are a prominent yet poorly understood feature of DS. In a mouse model of DS with a loss of function in Scn1a, reticular thalamic cells exhibited abnormally long bursts of firing caused by the downregulation of calcium-activated potassium SK channels. Our study supports a mechanism in which loss of SK activity causes the reticular thalamic neurons to become hyperexcitable and promote non-convulsive seizures in DS. We propose that reduced excitability of inhibitory neurons is not global in DS and that non-GABAergic mechanisms such as SK channels may be important targets for treatment. In a mouse model of Dravet syndrome (DS) resulting from voltage-gated sodium channel deficiency, Ritter-Makinson et al. find that inhibitory neurons of the reticular thalamic nucleus are paradoxically hyperexcitable due to compensatory reductions in a potassium SK current. Boosting this SK current treats nonconvulsive seizures in DS mice.
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Affiliation(s)
- Stefanie Ritter-Makinson
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Alexandra Clemente-Perez
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Physiology, University of California, San Francisco, San Francisco, CA 94158, USA; Neurosciences Graduate Program, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Bryan Higashikubo
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Frances S Cho
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Physiology, University of California, San Francisco, San Francisco, CA 94158, USA; Neurosciences Graduate Program, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Stephanie S Holden
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Physiology, University of California, San Francisco, San Francisco, CA 94158, USA; Neurosciences Graduate Program, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Eric Bennett
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Ana Chkhaidze
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Oscar H J Eelkman Rooda
- Department of Neuroscience, Erasmus MC, Rotterdam, the Netherlands; Department of Neurosurgery, Erasmus MC, Rotterdam, the Netherlands
| | - Marie-Coralie Cornet
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94158, USA; Department of Pediatrics, Catholic University of Louvain, Louvain, Belgium
| | - Freek E Hoebeek
- Department of Neuroscience, Erasmus MC, Rotterdam, the Netherlands; Department of Neurosurgery, Erasmus MC, Rotterdam, the Netherlands; NIDOD Institute, Wilhelmina Children's Hospital, University Medical Center Utrecht and Brain Center Rudolf Magnus, Utrecht, the Netherlands
| | - Kazuhiro Yamakawa
- Laboratory for Neurogenetics, RIKEN Brain Science Institute, Wako, Japan
| | - Maria Roberta Cilio
- Department of Neurology, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Bruno Delord
- Institut des Systèmes Intelligents et de Robotique (ISIR), Sorbonne University, 4 Place Jussieu, 75005 Paris, France
| | - Jeanne T Paz
- Gladstone Institute of Neurological Disease, San Francisco, San Francisco, CA 94158, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA 94158, USA; Neurosciences Graduate Program, University of California, San Francisco, San Francisco, CA 94158, USA; Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA 94158, USA.
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Abstract
Here we describe the case of a patient with episodic dizziness and gait imbalance for 7 years and a negative family history. On clinical examination, interictally, the patient presented with gaze-evoked nystagmus and rebound nystagmus and slight dysarthria. MRI of the brain was normal and peripheral-vestibular function was bilaterally intact. Based on genetic testing (episodic ataxia panel), a heterozygote splice site variant in intron 1 of the FGF14 gene was identified. This report adds important new evidence to previous observations that pathogenic variants in the FGF14 gene may result in variable phenotypes, either in progressive spinocerebellar ataxia (type 27) or in episodic ataxia as in our case. Our patient responded well to acetazolamide (reduction in the frequency of attacks by about two thirds), supporting the hypothesis of a sodium channelopathy.
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Affiliation(s)
- M Schesny
- Department of Neurology, University Hospital Zurich, Frauenklinikstr. 26, 8091, Zurich, Switzerland
| | - F Joncourt
- Division of Human Genetics, Department of Pediatrics, University Hospital Berne, Berne, Switzerland
| | - Alexander A Tarnutzer
- Department of Neurology, University Hospital Zurich, Frauenklinikstr. 26, 8091, Zurich, Switzerland. .,University of Zurich, Zurich, Switzerland.
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Norizadeh Tazehkand M, Yılmaz MB. Klorzoksazonun antibakteriyel etkisinin belirlenmesi. Cukurova Medical Journal 2019. [DOI: 10.17826/cumj.459036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Abstract
INTRODUCTION Vertigo and dizziness are common chief complaints of vestibular and ocular motor disorders (lifetime prevalence 30%). Treatment relies on physical, pharmacological, psychological and rarely surgical approaches. Eight groups of drugs are currently used in vestibular and ocular motor disorders, namely anti-vertiginous, anti-inflammatory, anti-menière's, anti-migrainous medications, anti-depressants, anti-convulsants, aminopyridines and agents that enhance vestibular plasticity. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of medications that are used for peripheral, central and functional vestibular and ocular motor disorders. The level of evidence for the respective drugs is described alongside the pathophysiological premises supporting their use. The authors place particular focus on translation and back-translation in vestibular pharmacological research and the repurposing of known drugs for new indications and rare disorders. EXPERT OPINION The use of drugs in vestibular and ocular motor disorders is often based on open-label, non-controlled studies and expert opinion. In the future, strong evidence derived from RCTs is needed to support the effectiveness and tolerability of these therapies in well-defined vestibular and ocular motor disorders. Vestibular pharmacological research must be guided by a better understanding of the molecular targets relevant in the pathophysiology of vestibular and ocular motor disorders.
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Affiliation(s)
- Andreas Zwergal
- a Department of Neurology , University Hospital LMU , Munich , Germany.,b German Center for Vertigo and Balance Disorders , DSGZ, LMU Munich , Munich , Germany
| | - Michael Strupp
- a Department of Neurology , University Hospital LMU , Munich , Germany.,b German Center for Vertigo and Balance Disorders , DSGZ, LMU Munich , Munich , Germany
| | - Thomas Brandt
- b German Center for Vertigo and Balance Disorders , DSGZ, LMU Munich , Munich , Germany.,c Clinical Neurosciences , LMU Munich , Munich , Germany
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Abstract
Purpose To test the hypothesis that eye muscle surgery in treatment of patients with acquired downbeat nystagmus results in improvement measures of visual and ocular motor function. Methods This is a prospective, interventional case series analysis of clinical and electrophyisological data before and after eye muscle surgery in 17 patients with acquired downbeat nystagmus who did not respond to medical treatments. Outcome measures included: 1) routine demography and clinical characteristics, 2) subjective oscillopsia (SO), 3) binocular best-corrected visual acuity in the null position (BVA), 3) primary position strabismic deviation (SD), 5) anomalous head posture (AHP), 6) contrast sensitivity function (CS), and 7) nystagmus slow phase velocity (SPV). All patients were followed at least 12 months. Parametric and non-parametric statistical analysis of outcome measure data above pre- and post-treatment were perfomed using standard software on grouped data using computerized software. Results Patients' age ranged from 5 to 85 years (average 27 years). About 59% were male. Follow up ranged from 1-10 years (average 2.0 years). Around 70% had an associated central nervous systemic diagnosis, 100% had an AHP, oscillopsia and decreased CS, 53% had other eye disease, and 59% had strabismus. There were no complications from surgery. There were signficant post-treatment improvements in mean/median group BVA, SO, SD, AHP, CS, and SPV. Conclusion This study supports the hypothesis that eye muscle surgery as treatments for patients with acquired downbeat nystagmus can result in improvements in multiple aspects of ocular motor and visual functions.
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Affiliation(s)
- Richard W Hertle
- Department of Ophthalmology, The Considine Research Institute and The Children's Vision Center, Akron Children's Hospital, Akron; Department of Surgery, The Northeastern Ohio Medical University, Rootstown, Ohio, USA
| | - Ashraf Ahmad
- Department of Ophthalmology, Case Western Reserve University and University Hospitals, Cleveland, Ohio, USA
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Abstract
PURPOSE OF REVIEW This article discusses visual disorders in both Parkinson disease (PD) and other Parkinsonian disorders. It is organized largely by the anatomical site of pathology and emphasizes practical treatments. Targeted treatment options include medications, surgery, occupational, and physical therapies as well as optical aids. RECENT FINDINGS The causes of visual complaints in Parkinson disease and other similar disorders are being more clearly identified. A new medication approved specifically to treat hallucinations in PD now is available. There is increased understanding of the important role that an ophthalmologist can play in the care of these patients. Finally, research and therapeutic development are unmet needs in accessing and treating visual complaints in PD and Parkinsonian disorders. A better understanding of Parkinson-related visual complaints and of available treatment options is important to optimize patient safety and quality of life. Vision impairment leads to difficulties in many common activities including reading, ambulating, and driving. Falls and injuries, made more likely because of impaired vision, result in an early loss of independence. Awareness of the problem, patient education, ophthalmologic care, selected therapeutics, physical therapy, and occupational therapy are crucial to maximizing quality of life in these patients.
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Affiliation(s)
- Joseph Savitt
- Department of Neurology, University of Maryland School of Medicine, 110 South Paca Street 3rd Floor, Baltimore, MD, 21201, USA.
| | - Michaela Mathews
- Department of Ophthalmology, University of Maryland School of Medicine, Baltimore, MD, USA
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Rowe FJ, Hanna K, Evans JR, Noonan CP, Garcia‐Finana M, Dodridge CS, Howard C, Jarvis KA, MacDiarmid SL, Maan T, North L, Rodgers H. Interventions for eye movement disorders due to acquired brain injury. Cochrane Database Syst Rev 2018; 3:CD011290. [PMID: 29505103 PMCID: PMC6494416 DOI: 10.1002/14651858.cd011290.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acquired brain injury can cause eye movement disorders which may include: strabismus, gaze deficits and nystagmus, causing visual symptoms of double, blurred or 'juddery' vision and reading difficulties. A wide range of interventions exist that have potential to alleviate or ameliorate these symptoms. There is a need to evaluate the effectiveness of these interventions and the timing of their implementation. OBJECTIVES We aimed to assess the effectiveness of any intervention and determine the effect of timing of intervention in the treatment of strabismus, gaze deficits and nystagmus due to acquired brain injury. We considered restitutive, substitutive, compensatory or pharmacological interventions separately and compared them to control, placebo, alternative treatment or no treatment for improving ocular alignment or motility (or both). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (containing the Cochrane Eyes and Vision Trials Register) (2017, Issue 5), MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, AMED Ovid, PsycINFO Ovid, Dissertations & Theses (PQDT) database, PsycBITE (Psychological Database for Brain Impairment Treatment Efficacy), ISRCTN registry, ClinicalTrials.gov, Health Services Research Projects in Progress (HSRProj), National Eye Institute Clinical Studies Database and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The databases were last searched on 26 June 2017. No date or language restrictions were used in the electronic searches for trials. We manually searched the Australian Orthoptic Journal, British and Irish Orthoptic Journal, and ESA, ISA and IOA conference proceedings. We contacted researchers active in this field for information about further published or unpublished studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of any intervention for ocular alignment or motility deficits (or both) due to acquired brain injury. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. We used standard methods expected by Cochrane. We employed the GRADE approach to interpret findings and assess the quality of the evidence. MAIN RESULTS We found five RCTs (116 participants) that were eligible for inclusion. These trials included conditions of acquired nystagmus, sixth cranial nerve palsy and traumatic brain injury-induced ocular motility defects. We did not identify any relevant studies of restitutive interventions.We identified one UK-based trial of a substitutive intervention, in which botulinum toxin was compared with observation in 47 people with acute sixth nerve palsy. At four months after entry into the trial, people given botulinum toxin were more likely to make a full recovery (reduction in angle of deviation within 10 prism dioptres), compared with observation (risk ratio 1.19, 95% CI 0.96 to 1.48; low-certainty evidence). These same participants also achieved binocular single vision. In the injection group only, there were 2 cases of transient ptosis out of 22 participants (9%), and 4 participants out of 22 (18%) with transient vertical deviation; a total complication rate of 24% per injection and 27% per participant. All adverse events recovered. We judged the certainty of evidence as low, downgrading for risk of bias and imprecision. It was not possible to mask investigators or participants to allocation, and the follow-up between groups varied.We identified one USA-based cross-over trial of a compensatory intervention. Oculomotor rehabilitation was compared with sham training in 12 people with mild traumatic brain injury, at least one year after the injury. We judged the evidence from this study to be very low-certainty. The study was small, data for the sham training group were not fully reported, and it was unclear if a cross-over study design was appropriate as this is an intervention with potential to have a permanent effect.We identified three cross-over studies of pharmacological interventions for acquired nystagmus, which took place in Germany and the USA. These studies investigated two classes of pharmacological interventions: GABAergic drugs (gabapentin, baclofen) and aminopyridines (4-aminopyridines (AP), 3,4-diaminopyridine (DAP)). We judged the evidence from all three studies as very low-certainty because of small numbers of participants (which led to imprecision) and risk of bias (they were cross-over studies which did not report data in a way that permitted estimation of effect size).One study compared gabapentin (up to 900 mg/day) with baclofen (up to 30 mg/day) in 21 people with pendular and jerk nystagmus. The follow-up period was two weeks. This study provides very low-certainty evidence that gabapentin may work better than baclofen in improving ocular motility and reducing participant-reported symptoms (oscillopsia). These effects may be different in pendular and jerk nystagmus, but without formal subgroup analysis it is unclear if the difference between the two types of nystagmus was chance finding. Quality of life was not reported. Ten participants with pendular nystagmus chose to continue treatment with gabapentin, and one with baclofen. Two participants with jerk nystagmus chose to continue treatment with gabapentin, and one with baclofen. Drug intolerance was reported in one person receiving gabapentin and in four participants receiving baclofen. Increased ataxia was reported in three participants receiving gabapentin and two participants receiving baclofen.One study compared a single dose of 3,4-DAP (20 mg) with placebo in 17 people with downbeat nystagmus. Assessments were made 30 minutes after taking the drug. This study provides very low-certainty evidence that 3,4-DAP may reduce the mean peak slow-phase velocity, with less oscillopsia, in people with downbeat nystagmus. Three participants reported transient side effects of minor perioral/distal paraesthesia.One study compared a single dose of 4-AP with a single dose of 3,4-DAP (both 10 mg doses) in eight people with downbeat nystagmus. Assessments were made 45 and 90 minutes after drug administration. This study provides very low-certainty evidence that both 3,4-DAP and 4-AP may reduce the mean slow-phase velocity in people with downbeat nystagmus. This effect may be stronger with 4-AP. AUTHORS' CONCLUSIONS The included studies provide insufficient evidence to inform decisions about treatments specifically for eye movement disorders that occur following acquired brain injury. No information was obtained on the cost of treatment or measures of participant satisfaction relating to treatment options and effectiveness. It was possible to describe the outcome of treatment in each trial and ascertain the occurrence of adverse events.
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Affiliation(s)
- Fiona J Rowe
- University of LiverpoolDepartment of Health Services ResearchWaterhouse Building (B211)1‐3 Brownlow StreetLiverpoolUKL69 3GL
| | - Kerry Hanna
- University of LiverpoolDepartment of Health Services ResearchWaterhouse Building (B211)1‐3 Brownlow StreetLiverpoolUKL69 3GL
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Carmel P Noonan
- Aintree University Hospitals NHS Foundation TrustDepartment of OphthalmologyLower LaneLiverpoolUKL9 7AL
| | - Marta Garcia‐Finana
- University of LiverpoolBiostatisticsBlock F, Waterhouse Bld1‐5 Brownlow StreetLiverpoolUKL69 3GL
| | - Caroline S Dodridge
- Oxford University Hospitals NHS TrustOrthopticsOxford Eye Hospital, John Radcliffe Hospital, Headley WayOxfordUKOX3 9DU
| | - Claire Howard
- Salford Royal NHS Foundation TrustOrthopticsStott LaneSalfordManchesterUKM6 8HD
| | - Kathryn A Jarvis
- University of LiverpoolOccupational TherapyBrownlow HillLiverpoolUKL69 3GB
| | - Sonia L MacDiarmid
- Warrington and Halton Hospitals NHS Foundation TrustDepartment of OrthopticsLovely LaneWarringtonUKWA5 2QQ
| | - Tallat Maan
- Pennine Care NHS Foundation TrustCommunity Eye Service225 Old StreetAshton‐under‐LyneUKOL6 7SR
| | - Lorraine North
- Frimley Park NHS Foundation TrustOrthopticsPortsmouth RoadFrimleySurreyUKGU16 7UJ
| | - Helen Rodgers
- Newcastle UniversityInstitute of NeuroscienceNewcastleUKNE2 4HH
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Bushart DD, Chopra R, Singh V, Murphy GG, Wulff H, Shakkottai VG. Targeting potassium channels to treat cerebellar ataxia. Ann Clin Transl Neurol 2018; 5:297-314. [PMID: 29560375 PMCID: PMC5846455 DOI: 10.1002/acn3.527] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 12/22/2022] Open
Abstract
Objective Purkinje neuron dysfunction is associated with cerebellar ataxia. In a mouse model of spinocerebellar ataxia type 1 (SCA1), reduced potassium channel function contributes to altered membrane excitability resulting in impaired Purkinje neuron spiking. We sought to determine the relationship between altered membrane excitability and motor dysfunction in SCA1 mice. Methods Patch-clamp recordings in acute cerebellar slices and motor phenotype testing were used to identify pharmacologic agents which improve Purkinje neuron physiology and motor performance in SCA1 mice. Additionally, we retrospectively reviewed records of patients with SCA1 and other autosomal-dominant SCAs with prominent Purkinje neuron involvement to determine whether currently approved potassium channel activators were tolerated. Results Activating calcium-activated and subthreshold-activated potassium channels improved Purkinje neuron spiking impairment in SCA1 mice (P < 0.05). Additionally, dendritic hyperexcitability was improved by activating subthreshold-activated potassium channels but not calcium-activated potassium channels (P < 0.01). Improving spiking and dendritic hyperexcitability through a combination of chlorzoxazone and baclofen produced sustained improvements in motor dysfunction in SCA1 mice (P < 0.01). Retrospective review of SCA patient records suggests that co-treatment with chlorzoxazone and baclofen is tolerated. Interpretation Targeting both altered spiking and dendritic membrane excitability is associated with sustained improvements in motor performance in SCA1 mice, while targeting altered spiking alone produces only short-term improvements in motor dysfunction. Potassium channel activators currently in clinical use are well tolerated and may provide benefit in SCA patients. Future clinical trials with potassium channel activators are warranted in cerebellar ataxia.
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Affiliation(s)
- David D Bushart
- Department of Molecular & Integrative Physiology University of Michigan Ann Arbor Michigan
| | - Ravi Chopra
- Department of Neurology University of Michigan Ann Arbor Michigan
| | - Vikrant Singh
- Department of Pharmacology University of California Davis California
| | - Geoffrey G Murphy
- Department of Molecular & Integrative Physiology University of Michigan Ann Arbor Michigan.,Molecular & Behavioral Neuroscience Institute University of Michigan Ann Arbor Michigan
| | - Heike Wulff
- Department of Pharmacology University of California Davis California
| | - Vikram G Shakkottai
- Department of Molecular & Integrative Physiology University of Michigan Ann Arbor Michigan.,Department of Neurology University of Michigan Ann Arbor Michigan
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18
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Kalla R, Teufel J, Feil K, Muth C, Strupp M. Update on the pharmacotherapy of cerebellar and central vestibular disorders. J Neurol 2016; 263 Suppl 1:S24-9. [PMID: 27083881 PMCID: PMC4833819 DOI: 10.1007/s00415-015-7987-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/20/2015] [Accepted: 11/29/2015] [Indexed: 01/02/2023]
Abstract
An overview of the current pharmacotherapy of central vestibular syndromes and the most common forms of central nystagmus as well as cerebellar disorders is given. 4-aminopyridine (4-AP) is recommended for the treatment of downbeat nystagmus, a frequent form of acquired persisting fixation nystagmus, and upbeat nystagmus. Animal studies showed that this non-selective blocker of voltage-gated potassium channels increases Purkinje cell excitability and normalizes the irregular firing rate, so that the inhibitory influence of the cerebellar cortex on vestibular and deep cerebellar nuclei is restored. The efficacy of 4-AP in episodic ataxia type 2, which is most often caused by mutations of the PQ-calcium channel, was demonstrated in a randomized controlled trial. It was also shown in an animal model (the tottering mouse) of episodic ataxia type 2. In a case series, chlorzoxazone, a non-selective activator of small-conductance calcium-activated potassium channels, was shown to reduce the DBN. The efficacy of acetyl-DL-leucine as a potential new symptomatic treatment for cerebellar diseases has been demonstrated in three case series. The ongoing randomized controlled trials on episodic ataxia type 2 (sustained-release form of 4-aminopyridine vs. acetazolamide vs. placebo; EAT2TREAT), vestibular migraine with metoprolol (PROVEMIG-trial), cerebellar gait disorders (sustained-release form of 4-aminopyridine vs. placebo; FACEG) and cerebellar ataxia (acetyl-DL-leucine vs. placebo; ALCAT) will provide new insights into the pharmacotherapy of cerebellar and central vestibular disorders.
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Affiliation(s)
- Roger Kalla
- Division of Cognitive and Restorative Neurology, Department of Neurology, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Julian Teufel
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital Munich, Campus Grosshadern, Munich, Germany
| | - Katharina Feil
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital Munich, Campus Grosshadern, Munich, Germany
| | - Caroline Muth
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital Munich, Campus Grosshadern, Munich, Germany
| | - Michael Strupp
- Division of Cognitive and Restorative Neurology, Department of Neurology, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
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19
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Abstract
Depending on the temporal course, three forms of vertigo syndrome can be differentiated: 1) vertigo attacks, e.g. benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, 2) acute spontaneous vertigo lasting for days, e.g. acute unilateral vestibulopathy, brainstem or cerebellar infarction and 3) symptoms lasting for months or years, e.g. bilateral vestibulopathy and functional vertigo. The specific therapy of the various syndromes is based on three principles: 1) physical treatment with liberatory maneuvers for BPPV and balance training for vestibular deficits, 2) pharmacotherapy, e.g. for acute unilateral vestibulopathy (corticosteroids) and Menière's disease (transtympanic administration of gentamicin or steroids and high-dose betahistine therapy); placebo-controlled pharmacotherapy studies are currently being carried out for acute unilateral vestibulopathy, vestibular paroxysmia, prophylaxis of BPPV, vestibular migraine, episodic ataxia type 2 and cerebellar ataxia; 3) psychotherapy for functional dizziness.
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Affiliation(s)
- M Strupp
- Neurologische Klinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland. .,Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland.
| | - M Dieterich
- Neurologische Klinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.,Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland.,SyNergy, Munich Cluster for Systems Neurology, München, Deutschland
| | - A Zwergal
- Neurologische Klinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.,Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - T Brandt
- Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland.,Institut für Klinische Neurowissenschaften, Klinikum der Universität München, Campus Großhadern, München, Deutschland
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20
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Feil K, Bremova T, Muth C, Schniepp R, Teufel J, Strupp M. Update on the Pharmacotherapy of Cerebellar Ataxia and Nystagmus. Cerebellum 2015; 15:38-42. [DOI: 10.1007/s12311-015-0733-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Tang P, Li S, Wang L, Yang H, Yan J, Li H. Inclusion complexes of chlorzoxazone with β- and hydroxypropyl-β-cyclodextrin: Characterization, dissolution, and cytotoxicity. Carbohydr Polym 2015; 131:297-305. [DOI: 10.1016/j.carbpol.2015.05.055] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/22/2015] [Accepted: 05/23/2015] [Indexed: 01/05/2023]
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22
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Tang P, Wang Q, Xu K, Wang L, Li S, Li H. Investigation the complex of 2,6-di-O-methyl-β-cyclodextrin and chlorzoxazone: preparation, characterization, dissolution, and cytotoxicity. J INCL PHENOM MACRO 2015. [DOI: 10.1007/s10847-015-0556-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Christophersen P, Wulff H. Pharmacological gating modulation of small- and intermediate-conductance Ca(2+)-activated K(+) channels (KCa2.x and KCa3.1). Channels (Austin) 2015. [PMID: 26217968 DOI: 10.1080/19336950.2015.1071748] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
This short review discusses pharmacological modulation of the opening/closing properties (gating) of small- and intermediate-conductance Ca(2+)-activated K(+) channels (KCa2 and KCa3.1) with special focus on mechanisms-of-action, selectivity, binding sites, and therapeutic potentials. Despite KCa channel gating-modulation being a relatively novel field in drug discovery, efforts in this area have already revealed a surprising plethora of pharmacological sites-of-actions and channel subtype selectivity exerted by different chemical classes. The currently published positive modulators show that such molecules are potentially useful for the treatment of various neurodegenerative disorders such as ataxia, alcohol dependence, and epilepsy as well as hypertension. The negative KCa2 modulators are very effective agents for atrial fibrillation. The prediction is that further unraveling of the molecular details of gating pharmacology will allow for the design of even more potent and subtype selective KCa modulators entering into drug development for these indications.
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Affiliation(s)
| | - Heike Wulff
- b Department of Pharmacology ; University of California, Davis ; Davis , CA USA
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24
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Strupp M, Zwergal A, Feil K, Bremova T, Brandt T. Pharmacotherapy of vestibular and cerebellar disorders and downbeat nystagmus: translational and back-translational research. Ann N Y Acad Sci 2015; 1343:27-36. [PMID: 25903394 DOI: 10.1111/nyas.12774] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There are currently eight groups of drugs for the pharmacotherapy of vertigo, nystagmus, and cerebellar disorders: antiemetics; anti-inflammatories, antimenieres, and antimigraineous medications; antidepressants, anticonvulsants, aminopyridines, and acetyl-DL-leucine ("the eight A's"). In acute unilateral vestibulopathy, corticosteroids improve the recovery of peripheral vestibular function, but there is not sufficient current evidence for a general recommendation. There is also insufficient evidence that 48 or 144 mg/day betahistine has an effect in Ménière's disease. Therefore, higher dosages are currently recommended; in animal studies, it was shown that betahistine increases cochlear blood flow. In vestibular paroxysmia, oxcarbazepine was effective (one yet not randomized controlled trial (RCT)). Aminopyridines are recommended for the treatment of downbeat nystagmus (two RCTs) and episodic ataxia type 2 (EA2, one RCT). There are so far no RCTs on vestibular migraine, so currently no treatment can be recommended. Acetyl-dl-leucine improves cerebellar ataxia (three observational studies); it also accelerates central compensation in an animal model of acute unilateral lesion, but RCTs were negative. There are ongoing RCTs on vestibular paroxysmia with carbamazepine (VESPA), acute unilateral vestibulopathy with betahistine (BETAVEST), vestibular migraine with metoprolol (PROVEMIG), benign paroxysmal positional vertigo with vitamin D (VitD@BPPV), EA2 with 4-aminopyridine versus acetazolamide (EAT-2-TREAT), and cerebellar ataxias with acetyl-DL-leucine (ALCAT).
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Affiliation(s)
- Michael Strupp
- Department of Neurology, German Center for Vertigo and Balance Disorders and Institute for Clinical Neurosciences, University Hospital Munich, Campus Grosshadern, Munich, Germany
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25
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Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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26
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Ilg W, Bastian AJ, Boesch S, Burciu RG, Celnik P, Claaßen J, Feil K, Kalla R, Miyai I, Nachbauer W, Schöls L, Strupp M, Synofzik M, Teufel J, Timmann D. Consensus paper: management of degenerative cerebellar disorders. Cerebellum 2014; 13:248-68. [PMID: 24222635 DOI: 10.1007/s12311-013-0531-6] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Treatment of motor symptoms of degenerative cerebellar ataxia remains difficult. Yet there are recent developments that are likely to lead to significant improvements in the future. Most desirable would be a causative treatment of the underlying cerebellar disease. This is currently available only for a very small subset of cerebellar ataxias with known metabolic dysfunction. However, increasing knowledge of the pathophysiology of hereditary ataxia should lead to an increasing number of medically sensible drug trials. In this paper, data from recent drug trials in patients with recessive and dominant cerebellar ataxias will be summarized. There is consensus that up to date, no medication has been proven effective. Aminopyridines and acetazolamide are the only exception, which are beneficial in patients with episodic ataxia type 2. Aminopyridines are also effective in a subset of patients presenting with downbeat nystagmus. As such, all authors agreed that the mainstays of treatment of degenerative cerebellar ataxia are currently physiotherapy, occupational therapy, and speech therapy. For many years, well-controlled rehabilitation studies in patients with cerebellar ataxia were lacking. Data of recently published studies show that coordinative training improves motor function in both adult and juvenile patients with cerebellar degeneration. Given the well-known contribution of the cerebellum to motor learning, possible mechanisms underlying improvement will be outlined. There is consensus that evidence-based guidelines for the physiotherapy of degenerative cerebellar ataxia need to be developed. Future developments in physiotherapeutical interventions will be discussed including application of non-invasive brain stimulation.
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Affiliation(s)
- W Ilg
- Department of Cognitive Neurology, Hertie Institute for Clinical Brain Research and Centre for Integrative Neuroscience, Tübingen, Germany
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Qureshi SS, Beh SC, Frohman TC, Frohman EM. An update on neuro-ophthalmology of multiple sclerosis: the visual system as a model to study multiple sclerosis. Curr Opin Neurol 2014; 27:300-8. [DOI: 10.1097/wco.0000000000000098] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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