Limb-kinetic apraxia affects activities of daily living in Parkinson's disease: a multi-center study

BACKGROUND AND PURPOSE

Impaired dexterity (fine hand movements) is often present in Parkinson's disease (PD), even at early to moderate disease stages. It has a detrimental impact on activities of daily living (ADL) such as buttoning, contributing to reduced quality of life. Limb-kinetic apraxia, a loss of the ability to make precise, independent but coordinated finger and hand movements, may contribute to impaired dexterity even more than bradykinesia per se. However, the impact of limb-kinetic apraxia on ADL remains controversial. Our aim was to identify the strongest predictor of buttoning and unbuttoning in PD. It was hypothesized that coin rotation (a surrogate of limb-kinetic apraxia) represents the most important determinant.

METHODS

Sixty-four right-handed, early to moderate PD patients were recruited from three movement disorder centers (Hoehn andYahr stages 1-3). Buttoning, unbuttoning and coin rotation (right and left hand) represented the target tasks. Motor impairment was assessed according to the Unified Parkinson's Disease Rating Scale.

RESULTS

Multiple linear regression analysis showed that coin rotation with the right hand was the only significant predictor of buttoning (P < 0.001) and unbuttoning (P = 0.002). Notably, measures of bradykinesia or overall motor impairment did not represent significant predictors.

CONCLUSIONS

Constituting the novel key finding, limb-kinetic apraxia seems to be particularly relevant for ADL requiring dexterity skills in PD, even at early to moderate disease stages. Our results prompt research into the pathophysiological background and therapeutic options to treat limb-kinetic apraxia. The simple coin rotation test provides valuable information about ADL-related dexterity skills.

Endovascular stroke therapy in Austria: a nationwide 1-year experience

BACKGROUND AND PURPOSE

Based on a tight network of stroke units (SUs) and interventional centres, endovascular treatment of acute major intracranial vessel occlusion has been widely implemented in Austria. Documentation of all patients in the nationwide SU registry has thereby become mandatory.

METHODS

Demographic, clinical and interventional characteristics of patients who underwent endovascular treatment for acute ischaemic stroke in 11 Austrian interventional centres between 1 October 2013 and 30 September 2014 were analysed.

RESULTS

In total, 301 patients (50.5% women; median age 70.5 years; median National Institutes of Health Stroke Scale score 17) were identified.193 patients (64.1%) additionally received intravenous thrombolysis. The most frequent vessel occlusion sites were the M1 segment of the middle cerebral artery (n = 161, 53.5%), the intracranial internal carotid artery (n = 60, 19.9%) and the basilar artery (n = 40, 13.3%). Stent retrievers were used in 235 patients (78.1%) and adequate reperfusion (modified Thrombolysis in Cerebral Infarction scores 2b and 3, median onset to reperfusion time 254 min) was achieved in 242 patients (81.4%). Symptomatic intracranial haemorrhage occurred in 7%. 43.8% of patients (n = 132) had good functional outcome (modified Rankin Scale score 0-2) and the mortality rate was 20.9% (n = 63) after 3 months. Compared to the anterior circulation, vertebrobasilar stroke patients had higher mortality. Patients with secondary hospital transportation had better outcomes after 3 months than in-house treated patients.

CONCLUSION

Our results document nationwide favourable outcome and safety rates of endovascular stroke treatment comparable to recent randomized trials. The ability to provide such data and the need to further optimize such an approach also underscore the contribution of respective registries.

MRI negative meningeal myeloma with abducens nerve palsies responding to intrathecal chemotherapy

Meningeal involvement of multiple myeloma is rare. A patient with multiple myeloma presented with bilateral abducens nerve palsies. In the MRI neither lytic skull lesions nor meningeal enhancement could be found. The diagnosis was based on CSF studies and cytology. A neurologic remission was achieved with intrathecal chemotherapy.

Differential functional benefits of ultra highfield MR systems within the language network

Several investigations have shown limitations of fMRI reliability with the current standard field strengths. Improvement is expected from ultra highfield systems but studies on possible benefits for cognitive networks are lacking. Here we provide an initial investigation on a prominent and clinically highly-relevant cognitive function: language processing in individual brains. 26 patients evaluated for presurgical language localization were investigated with a standardized overt language fMRI paradigm on both 3T and 7T MR scanners. During data acquisition and analysis we made particular efforts to minimize effects not related to static magnetic field strength differences. Six measures relevant for functional activation showed a large dissociation between essential language network nodes: although in Wernicke's area 5/6 measures indicated a benefit of ultra highfield, in Broca's area no comparison was significant. The most important reason for this discrepancy was identified as being an increase in susceptibility-related artifacts in inferior frontal brain areas at ultra high field. We conclude that functional UHF benefits are evident, however these depend crucially on the brain region investigated and the ability to control local artifacts.

Subjective memory complaints, depressive symptoms and cognition in Parkinson's disease patients

BACKGROUND AND PURPOSE

The goal of this study was to establish the prevalence of subjective memory complaints (SMCs) and depressive symptoms (DS)s and their relation to cognitive functioning in patients with Parkinson's disease (PD).

METHODS

In all, 248 controls and 104 PD patients were included in the study. The PD group was subdivided into three PD subtypes with mild cognitive impairment (MCI) according to the Petersen criteria and three PD subtypes with MCI according to the Litvan criteria.

RESULTS

Substantial SMCs were reported by 7.7% of controls and 16.3% of the PD patients (P < 0.001). A clinically relevant degree of DSs was evident in 16.6% of controls compared with 40.4% in the PD group (P < 0.001). An analysis of variance revealed a statistically significant difference for SMCs across all Petersen groups as well across all Litvan groups. Two-factor analyses of variance with the factors cognitive status (MCI subtype) and depressive state (depressed versus not depressed) and SMCs as dependent variable revealed significant results.

CONCLUSIONS

Approximately 15% of PD patients seeking help in a movement disorder clinic report significant SMCs, with an increasing degree from cognitively healthy PD to PD-MCI. Significant DSs increase SMCs across all cognitive status groups.

The effect of early prednisolone treatment on the generalization rate in ocular myasthenia gravis

BACKGROUND AND PURPOSE

Several small retrospective studies have observed that patients with a purely ocular manifestation of myasthenia gravis (MG) are significantly less likely to convert to a generalized disease when treated early on with corticosteroids. However, given the limited number of reported patients in the literature these findings still remain controversial.

METHODS

In order to increase the number of published cases, we performed a retrospective analysis on 44 patients with newly diagnosed ocular MG who were subsequently either treated with corticosteroids or received no immunosuppressive therapy at all. The generalization rate was assessed at the end of a 2-year follow-up period.

RESULTS

Whereas none of 17 treated patients generalized, 11 of 27 (41%) untreated patients developed generalized symptoms. The difference between the groups was significant (P=0.003).

CONCLUSIONS

Our results agree well with previous studies on this issue. Taken together, published data indicate risk ratios for generalization of below 0.32 under corticosteroid treatment in comparison to untreated patients.

Theory of mind & cognitive flexibility

Theory of mind (ToM) refers to the capacity to attribute certain independent mental states, contents and processes to others - such as desires, concepts, intentions, beliefs and emotions (Wimmer & Perner, 1983). As there is a body of research with respect to the development of ToM in children, much less is known about adult mentalizing abilities, especially regarding the relationship between cognitive functioning and ToM. The present study aims to investigate a new instrument, called ToM-Stories and its relationship to the established ToM-Picture-Test (Bruene et al. 2005) and to cognitive functioning by using the Trail Making Test. Our ToM-Stories consist of brief stories, each describing a real life situation of various degree of complexity. All of them involve unintended misleadings in the sense of a false belief. Their comprehension requires mindreading at different levels of intentionality. The sample was composed of 79 adults, 45 (57%) women and 34 (43%) men, ranging in age from 18 to 88. Reliability analyses of the ToM-Stories yielded a Cronbach’s alpha of 0.79 (false belief-first order), 0.74 (false belief-second order), and 0.65 (false belief-third order). Correlation analyses showed moderate values between ToM-Stories and the Tom-Picture-Test (r = 0.496; p ≤ 0.0001) as well as the Trail Making Test B-A (r = −0.481; p ≤ 0.0001). The findings of the current study provide evidence that cognitive flexibility is an important competence in promoting representational understanding of the mind.

Type of edema in posterior reversible encephalopathy syndrome depends on serum albumin levels: an MR imaging study in 28 patients

PRES is a clinicoradiologic entity, combining seizures, blindness, and coma with MR imaging findings of predominantly vasogenic and occasional cytotoxic edema. In this clinical report, we determined the type of edema by using DWI and FLAIR sequences on MR imaging as well as ADC maps in 28 patients with PRES. The neuradiologic findings were correlated with levels of serum albumin, which is a main contributor to colloid osmotic pressure and vascular integrity. The presence of vasogenic edema was significantly associated with decreased serum albumin levels, which may be a particular risk factor for the development of PRES.

Disruption of nigrostriatal and cerebellothalamic pathways in dopamine responsive Holmes' tremor

Holmes' tremor is an unusual combination of rest, postural and kinetic tremor of the extremities. Medical treatment of this condition still remains unsatisfactory. The case of a 20-year-old female patient is reported who developed right-sided Holmes' tremor 9 months after a left-sided, cavernoma induced midbrain/pontine haemorrhage at the age of 16 years. Beta-CIT single photon emission computed tomography revealed abolished dopamine transporter activity in the left basal ganglia and striatum, in accordance with missing ipsilateral tegmento-frontal connectivity (medial forebrain bundle), demonstrated by diffusion tensor MRI. Tractography showed reduced fibre connectivity of the superior and middle cerebellar peduncles on the lesioned side. Administration of pramipexole and L-DOPA led to a clinically significant reduction in tremor severity. In conclusion, our results support the notion that Holmes' tremor was a result of diminished striatal dopaminergic input in our patient.

[What roll does the sense of coherence in coping with Morbus Parkinson play?]

PURPOSE OF THE STUDY

In this study the relevance of sense of coherence (SOC) for coping with an illness was examined in subjects with Parkinson's disease. According to Antonovsky's model (1997) the sense of coherence is an important resource when it comes to dealing with stressors. To take into consideration the integrated view of Parkinson patients, severity of the illness (UPDRS) was determined by the neurologist and tendency toward depression was recorded.

METHOD

51 patients with PD (mean age: 67.7; 43.1% female; 56.9% male) and 59 volunteers without any neurological illness (mean age: 65.7; 54.2% female; 45.8% male) took part in this study. The sample was recruited from the Neurological Department of the Medical University of Vienna. This quasi-experimental sample was assessed with standardized self-assessment questionnaires: FKV-LIS-SE, SOC-Scale and GDS. Correlations, t-tests, U-tests, multivariate analyses of variance and linear regressions were used for calculation.

RESULTS

Persons with PD were characterized by lower SOC (p<.01) and higher scores on depression (p<.01), compared to persons of the control group. Parkinson patients tend to use depressive and minimizing coping strategies (p<.01). In addition the study indicates an influence of SOC and tendency toward depression on coping (R(2)=0.43). Sense of coherence and coping strategies are independent of severity of illness, but there is a significant association between the duration of illness and active-problem focused coping.

CONCLUSION

In general, sense of coherence correlates only with psychological variables, and not with physical variables. Results indicate the importance of SOC on effective coping. Therefore strengthening of SOC is important, especially in context with chronic neurological illness. Individual orientated analysis of resources should be implemented in every counselling interview, so that possibilities for activities of daily living and leisure can be developed.

Neutralizing antibodies in dystonic patients who still respond well to botulinum toxin type A

BACKGROUND

Complete secondary therapy failure due to antibodies against botulinum toxin A (BoNT/A-ABs) may raise extensive treatment difficulties. We tested whether neutralizing BoNT/A-ABs can be detected in dystonic patients with good clinical responses to botulinum toxin A (BoNT/A) treatment.

METHODS

We used the ninhydrin sweat test (NST) and the mouse diaphragm test (MDT) in 28 subjects. Of 119 dystonic patients who responded well to BoNT/A, we randomly selected 14 and compared the results of the NST and MDT with 14 healthy controls.

RESULTS

Higher BoNT/A-AB titers correlated significantly with smaller anhidrotic areas. We found seven patients with borderline antibody (AB) values (MDT 0.4 to 0.8 mU/mL) with significantly smaller anhidrotic areas (NST) compared with healthy controls and AB-negative patients. Risk factors for smaller anhidrotic areas were short injection intervals but not prolonged exposure to BoNT/A or high injection doses.

CONCLUSIONS

These data demonstrate that >40% of dystonic patients who respond well to botulinum toxin A (BoNT/A) show partial nonresponsiveness on the ninhydrin sweat test and have low titers of neutralizing BoNT/A antibodies.

Inclusion body myopathy and Paget disease is linked to a novel mutation in the VCP gene

Mutations in the valosin-containing protein (VCP) on chromosome 9p13-p12 were recently found to be associated with hereditary inclusion body myopathy, Paget disease of the bone, and frontotemporal dementia (IBMPFD). We identified a novel missense mutation in the VCP gene (R159H; 688G>A) segregating with this disease in an Austrian family of four affected siblings, who exhibited progressive proximal myopathy and Paget disease of the bone but without clinical signs of dementia.

Loss of normal circadian profile of urine excretion in idiopathic restless legs syndrome

BACKGROUND

This study was performed to elucidate preliminary observations of excessive nighttime urine excretion in idiopathic restless legs syndrome (iRLS).

METHODS

Seventeen patients, with normal serum creatinine, blood urea nitrogen, and urate, and 11 healthy controls were examined. We measured excretory renal function parameters (urine volume, osmolarity, sodium, chloride, potassium, calcium, phosphate, microalbumin, aldosterone, creatinine) between 7:00 am and 10:00 pm and between 10:00 pm and 7:00 am.

RESULTS

During the nighttime, volume (P=0.006), sodium (P=0.009), and chloride excretion (P=0.001) were significantly higher, and osmolarity (P=0.025) was significantly lower in patients as compared to controls. In comparing daytime to nighttime, controls showed the physiological reduced nocturnal excretion of volume (P=0.009) and chloride (P=0.023), and an increased osmolarity (P=0.026), but patients showed similar excretion rates of these parameters (all differences ns).

CONCLUSIONS

These data indicate a loss of normal circadian profile of urine excretion in iRLS. The elevated nighttime excretion, with values similar to those in the daytime, hint at a possibly elevated fluid, sodium, and chloride intake during daytime.

Apomorphine in idiopathic restless legs syndrome: an exploratory study

BACKGROUND

Dopaminergic and opioidergic drugs have been found to be effective in patients with restless legs syndrome (RLS).

OBJECTIVES

To test the effect of apomorphine--a combined opioidergic and dopaminergic agonist--and subsequent selective antagonism by naloxone and metoclopramide on subjective and objective symptoms in patients with idiopathic RLS.

METHODS

Nine patients with RLS were pretreated with oral domperidone for three days. A modified suggested immobilisation test (SIT) was carried out between 8 pm and 1 am under the following conditions of intravenous drug administration: baseline-apomorphine-apomorphine plus naloxone-apomorphine plus metoclopramide. Outcome variables were a visual analogue scale (VAS) of subjective RLS symptoms and EMG documented periodic leg movements while awake (PLMW).

RESULTS

Compared with baseline, apomorphine resulted in a rapid and significant improvement in subjective RLS symptoms as measured by VAS (54.5% improvement; p = 0.011), and an almost immediate cessation of PLMW, measured by PLMW index (98.0% improvement; p = 0.012). Neither additional naloxone nor metoclopramide blocked this effect significantly. While given apomorphine with metoclopramide, there was a trend to reappearance of PLMW.

CONCLUSIONS

Apomorphine may be an effective treatment for idiopathic RLS. Its effectiveness may reflect both to its dopaminergic and its opioidergic activity, and is not diminished significantly by blocking only one of these pathways. The trend to a worsening of the PLMW index with metoclopramide hints at a primarily dopaminergic effect of apomorphine in idiopathic RLS.

A randomized, double-blind, placebo controlled study on analgesic effects of botulinum toxin A

OBJECTIVE

Botulinum toxin type A (BTXA) is used to treat neurologic disorders associated with increased muscle tone. Its use is often associated with pain relief.

METHODS

A possible direct analgesic effect of BTXA on C and Adelta fibers was studied on 16 healthy volunteers receiving 30 U BTXA into one forearm and pure saline into the other. To exclude the secondary effect due to muscular tone reduction, BTXA was injected intradermally. Thermal sensory testing of heat pain (threshold and tolerance) and neuroselective current sensory testing of current pain threshold/tolerance were performed at baseline and 3, 14, and 28 days after treatment. Thereafter, on day 28, capsaicin was administered simultaneously into both forearms to evaluate a possible peripheral effect and central effect on pain processing and on the axon reflex flare.

RESULTS

The authors observed no significant difference in any of the perception outcome measures between BTXA and placebo pretreated areas. Flare areas as a result of the release of neuropeptides after capsaicin application showed no differences.

CONCLUSIONS

The results suggest that pain reduction after BTXA treatment is mediated through its effect on muscle tone rather than a direct analgesic effect.

Botulinum toxin in the treatment of rare head and neck pain syndromes: a systematic review of the literature

BACKGROUND

Botulinum neurotoxin (BoNT) is used to treat various neurological disorders associated with pathologically increased muscle tone. Botulinum toxin inhibits the release of the neurotransmitter acetylcholine at the neuromuscular junction thereby inhibiting striatal muscle contractions. Besides the reduction in muscle tone BoNT tends to reduce pain in pain syndromes associated with muscle spasm. In addition, BoNT has been proposed as an analgesic, suggesting alternative non-cholinergic mechanisms of action.Surprisingly, BoNT was reported as a potential treatment for tension-type headache and migraine-both primary headache syndromes without an apparent muscular component-however, varying responses to BoNT have been found, overall without sufficient evidence for a general treatment. In this systematic review we set out to clarify the efficacy and safety of BoNT in the treatment of rare head and neck pain syndromes (e. g. cervicogenic headache, chronic paroxysmal hemicrania, cluster headache, trigeminal neuralgia, temporomandibular disorders, cervical dystonia and whiplash injuries).

OBJECTIVES

To assess the analgesic efficacy and safety of botulinum toxins versus other medicines, placebo or no treatment in rare head and neck pain syndromes.

SEARCH STRATEGY

We searched the bibliographic databases MEDLINE, EMBASE and PASCAL Biomed to May 2003. We also reviewed the reference lists from identified articles including reviews and meta-analyses of treatment studies. Furthermore we searched booklets of scientific congresses in the field of neurology for potentially relevant studies. Additional reports were identified from the reference list of the retrieved papers, and by contacting experts in the field.

SELECTION CRITERIA

Randomized controlled trials (RCTs) with any dose of BoNT for rare head and neck pain syndromes, describing subjective pain assessment as either the primary or a secondary outcome, were included in this review.

DATA COLLECTION AND ANALYSIS

All trials were quality scored and two independent reviewers extracted data. Results were compared for differences, and discrepancies were resolved by discussion.

MAIN RESULTS

Fourteen RCTs of BoNT in cervical dystonia were included in this review. All except one showed significant pain relief following BoNT treatment compared to placebo. Studies providing dichotomous outcome data were pooled using the Peto method. The overall effect was found to be highly significant (OR 4.795 [95% CI 5.551-6.473]). For cervicogenic headache, two RCTs-one positive study and one negative study-were included. Two studies addressing chronic neck pain were included in this review. Both studies did not reveal significant effects. Furthermore, one small trial (N = 15 patients) focussing BoNT in temporomandibular disorders was included,without demonstrating significant effectiveness but a high proportion of patients lost to follow-up and a high rate of adverse effects. For the use of BoNT in cluster headache, chronic paroxysmal hemicrania and trigeminal neuralgia no RCTs were identified. Adverse effects (AEs) were found to be mild to moderate and dose-dependent. They were summarized where possible, irrespective of the formulation used and condition treated (OR = 5.066 [95% CI 2.770-9.265], number-needed-to-harm (NNH) = 5.5 [range 4.4-17]).

REVIEWERS' CONCLUSIONS

There is convincing evidence for the effectiveness of BoNT in the treatment of pain associated with cervical dystonia. Due to the frequent adverse effects predominantly observed with higher doses, the trade off in risk and benefit should be carefully considered in each case. For all other rare head and neck pain syndromes we found no RCTs (cluster headache, chronic paroxysmal hemicrania, trigeminal neuralgia) and only a few small sized trials (cervicogenic headache, chronic neck pain, temporomandibular disorders). We were therefore unable to draw any definite conclusions.

Normal striatal D2 receptor binding in idiopathic restless legs syndrome with periodic leg movements in sleep

Dopaminergic treatment is very effective in restless legs syndrome (RLS) and periodic leg movements in sleep (PLMS). However, neuroreceptor imaging studies that addressed altered striatal dopaminergic function have given controversial results. In this present study, 14 patients with idiopathic RLS (iRLS) and PLMS with a good response to dopaminergic and non-dopaminergic treatment and ten healthy sex- and age-matched controls were investigated off-medication by using 123I-IBZM and SPECT. RLS symptoms and sleep disturbances were evaluated using three nights of polysomnography, the Pittsburgh Sleep Quality Index, and the International RLS Study Group (IRLSSG) rating scale. The patients presented with sleep disturbances, a high PLMS index (56.2 +/- 33.1 per h), and severe RLS symptoms during SPECT (IRLSSG rating scale 23.1 +/- 8.0), and showed no significant differences in striatal to frontal IBZM binding to D2 receptors compared to controls (ratio striatum/frontal cortex, right side 1.60 +/- 0.10 vs 1.63 +/- 0.08, P = 0.35, NS; left side 1.61 +/- 0.11 vs 1.63 +/- 0.08, P = 0.51, NS). These findings show normal function of striatal D2 receptors in successfully treated patients with iRLS and PLMS. Dopaminergic and non-dopaminergic pretreatment does not appear to change striatal D2 receptor binding as compared to healthy controls. Structures other than striatal D2 receptors are discussed as possible causes of the treatment effects in RLS.

Relation between depression and anxiety in dystonic patients: implications for clinical management

Past clinical research has identified depression as the most common psychiatric disorder associated with cervical dystonia (CD). The purpose of our study is to document different patterns of psychopathology, the frequency of psychiatric disorders, and possible correlation with the neurological disorder in patients with CD. Forty patients with CD were investigated to assess levels of psychopathology on two self-rated scales: the Beck Depression Inventory (BDI) and Symptom Check List (SCL-90). To determine the presence of psychiatric disorders, the patients were evaluated using the standard instrument in the DSM-III-R (Structured Clinical Interview Schedule, SCID). A small group of dystonic patients (12%) had higher levels of psychopathology, with significant amounts of concomitant anxiety and depression on the BDI and SCL-90. SCID criteria for at least one psychiatric disorder were fulfilled in 22 patients (55%), including both the lifetime and current diagnoses. The most frequent diagnostic categories were anxiety (40%) and major depressive disorders (37.5%). In 17 patients (42.5%), criteria for at least one lifetime diagnosis were fulfilled prior to the onset of CD. Psychiatric evaluation does not indicate one specific disorder associated with CD. The presence of anxiety and depression symptoms before and during the course of dystonia, without a possible causal relationship, could mean that the alteration of a chain of physiological events in the central nervous system may not lead to a single clinical picture. The relatively high overall lifetime prevalence of anxiety and depressive disorders may indicate the need for a broader diagnostic and therapeutic approach to patients with focal dystonia.

Efficacy and safety of a standardised 500 unit dose of Dysport (clostridium botulinum toxin type A haemaglutinin complex) in a heterogeneous cervical dystonia population: results of a prospective, multicentre, randomised, double-blind, placebo-controlled, parallel group study

Results from a dose-ranging study in a selected group of de novo patients with rotational cervical dystonia (CD) suggest that 500 units of Dysport (Clostridium botulinum toxin type A haemaglutinin complex) is the optimal starting dose. The present study aimed to confirm the efficacy and safety profile of this dose in a population of CD patients more representative of those seen in a typical dystonia clinic. A total of 68 patients with moderate to severe CD (Tsui score > or = 9) were randomly assigned to receive placebo or Dysport 500 units. Treatment was administered according to the clinical pattern of head deviation, using a standardised injection protocol. A total of 21 patients (11 Dysport, 10 placebo) had not previously received botulinum toxin type A (BtxA) injections, and 47 patients (24 Dysport, 23 placebo) had received BtxA more than 12 weeks previously. Assessments were performed at baseline and weeks 4, 8 and 16. Patients defined as non-responders at week 4 were re-treated in an open phase with 500 units of Dysport at week 6, and were followed up at week 10. Significant between-group differences in Tsui scores were present at weeks 4 (p=0.001) and 8 (p=0.002). Similarly, there were significant between-group differences (p < 0.001) in patient and investigator assessments of response in favour of Dysport at weeks 4 and 8. Also, more Dysport (49%) than placebo (33%) patients were pain-free at week 4 (p=0.02). Overall, 30/35 (86 %) Dysport patients and 14/33 (42%) placebo patients were classified as responders at week 4. Adverse events were reported by 15/35 Dysport patients and 9/33 placebo patients. Open phase treatment produced improvements in Tsui (p < 0.001) and pain scores (p=0.011), and 23/24 patients were classified as responders. Although individual dose titration and muscle selection is desirable, this study demonstrated that a dose of 500 units of Dysport injected into clinically identified neck muscles without electromyographic guidance is safe and effective in the treatment of patients with the major clinical types of cervical dystonia.

Sleep disorders and depression in patients with Parkinson's disease

OBJECTIVES

Sleep disorders and depression are frequent in patients with Parkinson's disease (PD). However, the exact prevalence and the causality are still unknown.

PATIENTS AND METHODS

We interviewed 56 consecutive PD patients and 59 age-matched healthy controls concerning sleep disorders and depression. Sleep Disorders Questionnaire (SDQ) and Zung Depression Scale (ZDS) were used as standardized valid and reliable psychometric tests.

RESULTS

Patients with PD had significantly higher values in the clinical-diagnostic scale narcolepsy (P=0.01), correlating with the L-dopa dose (P=0.007). Concerning sleep apnea (P=0.49), psychiatric sleep disorder (P=1.00) and periodic limb movement disorder (P=0.12), no significant difference could be identified. PD patients showed significantly higher depression scores than healthy control subjects (P=0.01), increasing with the duration of PD (P=0.04).

CONCLUSION

The significant higher narcolepsy score in PD patients must be seen due to dopaminergic medication and PD-specific neurodegeneration and immobility rather than due to narcolepsy. This leads to the conclusion that extreme caution is advised when carrying out the SDQ and interpreting the results in various persons and patient groups with motor problems. The strong association of depression, disease severity and sleep disorders in PD patients underlines the importance of identifying and treating both conditions in these patients.

Treatment of focal hyperhidrosis with botulinum toxin type A: long-term follow-up in 61 patients

BACKGROUND

The blocking action of botulinum toxin type A (BTX-A) on cholinergically innervated sweat glands has been used successfully to treat patients with focal hyperhidrosis.

OBJECTIVES

To investigate the long-term efficacy and safety of intradermal injections of BTX-A.

METHODS

We performed an open-label study in 61 patients treated over a period of 3 years for axillary or palmar hyperhidrosis. A total dose of 400 mU BTX-A (Dysport) was injected into both axillae or 460 mU BTX-A (Dysport) into both palms. The injections were repeated after relapse. Objective quantification of sweat production was performed using digitized ninhydrin-stained sheets.

RESULTS

Four weeks after BTX-A treatment the median reduction in sweat production was 71% compared with baseline (P < 0.001) in the axillary group and 42% (P = 0.005) in the palmar group. Subjective assessment of sweat production by the patients using a visual analogue scale (0, no sweating; 100, the most severe sweating) showed a significant reduction in both the axillary (P < 0.001) and palmar groups (P < 0.001). Secondary disturbances due to focal hyperhidrosis interfering with daily activities were markedly improved in both groups. The median time interval between the sets of injections was 34 weeks for axillary hyperhidrosis and 25 weeks for palmar hyperhidrosis. The treatment of palmar hyperhidrosis was complicated by transient but not disabling weakness of the small hand muscles in nine of 21 patients.

CONCLUSIONS

Repeated intradermal injections of BTX-A in patients with axillary and palmar hyperhidrosis are as effective as first treatments.

Remote effects of chronic botulinum toxin treatment: electrophysiologic results Do not indicate subclinical remodelling of noninjected muscles

This study investigates the remote effects of botulinum toxin injections by examining the motor unit architecture of noninjected distant muscles. In 21 dystonia patients treated with botulinum toxin (n = 11, mean cumulative dose = 815 mU; n = 10, mean cumulative dose = 7,207 mU) and 10 control individuals, a blinded single-fiber electromyography of the vastus lateralis muscle was performed. The main outcome measure was fiber density (FD), thus measuring the effect of different cumulative doses on remote reinnervation. FD was normal in all patients treated with botulinum toxin. FD did not differ between the three groups studied. No relationship was found between FD and cumulative dose. Therefore, in this specific patient population, muscles remote to the site of injection showed no FD change months after the injection. We conclude that there was no evidence of remote reinnervation and remodelling of motor units with cumulative chemodenervation.

To do or not to do? Magnetic resonance imaging in mild traumatic brain injury

Clinical quantification of mild traumatic brain injury (MTBI) patients should be based on Glasgow coma scale (GCS) score, duration of loss of consciousness (LOC) and post-traumatic amnesia (PTA). In addition, a short practicable neuropsychological test might be useful in detecting minor memory and attentional deficits. MRI appears to be the most sensitive imaging method for assessing MTBI so far, but information regarding a visualized lesion is not usually utilized in the classification of MTBI. Magnetic resonance imaging (MRI) should, therefore, play a major role in any MTBI classification scheme. An appropriate MRI protocol has to be chosen using at least T1 weighted, T2 weighted, proton density and gradient-echo (GRE) sequence images, all in at least two planes, in order to detect and classify all lesions precisely. Owing to the fact that acute lesions may be missed, it is advisable to perform MRI in the first 2 weeks following trauma. Further research is necessary to clarify the relationship between chronic symptoms after MTBI and MRI abnormalities. It may, thus, be possible to provide optimal strategies for emergency department management, to define a group of patients with a need for acute and rehabilitative intervention after MTBI, and to predict their outcome.

Hypertrophic chronic pachymeningitis as a localized immune process in the craniocervical region

Hypertrophic chronic pachymeningitis (HCP) is a rare disorder that causes intracranial or spinal thickening of the dura mater. This report describes a patient with progressive HCP in the craniocervical region associated with signs of rheumatic disease. A ventricular-atrial shunt had to be inserted because of increased intracranial pressure. The patient improved after suboccipital craniotomy, C1 to C6 laminectomy, and removal of the thickened dura. Additional therapy with methotrexate stopped progression, which was documented by MRI and PET.

[Treatment of the spastic drop foot with botulinum toxin type A in adult patients]

Spastic drop foot can be managed by physical measures, local pharmacological agents, oral anti-spastic drugs and surgical procedures. Recent studies have documented the clear effect of botulinum toxin type A (BTX-A) in the treatment of the spastic drop foot, particularly by reducing the resistance against passive movement and increasing the range of motion. Functional benefit and pain reduction have also been observed. The use of BTX-A is safe and free of serious side effects. Individual realistic treatment goals must be defined by the rehabilitation team before the treatment. Possible purposes of the treatment are the achievement of a straight foot to allow weight bearing or application of an orthosis and to reduce the premature activation of the calf muscles during gait. Other treatment goals are the facilitation of nursing care, as well as physical and occupational therapy. BTX-A injections can reduce pain, and prevent pressure ulcers or surgical interventions. Early physiotherapy or occupational therapy may increase the treatment effect of BTX-A. Close cooperation between the neurologist, physiotherapist, occupational therapist, nursing staff and other multidisciplinary rehabilitation team members is essential to maximize the benefit for the patients.

[Botulinum toxin in the treatment of focal hyperhidrosis]

INTRODUCTION

Botulinum A toxin (BTX-A) acts primarily at peripheral cholinergic synapses, inhibiting the release of acetylcholine. Initially it has been used to block the neuromuscular junction in focal dystonic and spastic syndromes. Recently there has been suggestions for potential clinical indications in non-muscular diseases where cholinergic terminals play a role.

GUSTATORY SWEATING

In 1995 physicians reported a long-lasting anhidrotic effect of intracutaneous BTX-A injections in patients suffering from gustatory sweating (Frey's syndrome). Consequently, a number of clinical studies demonstrated good efficacy of intradermal injections of botulinumtoxin in patients with focal hyperhidrosis.

FOCAL HYPERHIDROSIS OF THE PALMS AND AXILLAE

Focal hyperhidrosis is usually confined to the palms and axillae. Excessive sweating may be a social handicap and an occupational hazard. The management of focal hyperhidrosis remains controversial. Topical antiperspirants are only effective in very mild cases. Iontophoresis with tap water or anticholinergic drugs is messy and time consuming with only short-lived effect. Sympathectomy, the cornerstone of surgical management, is usually effective in palmar hyperhidrosis. Complications of this technique include surgical risks, postoperative and cosmetic problems and compensatory hyperhidrosis.

AXILLARY HYPERHIDROSIS

Several studies confirmed that intracutaneous injections of botulinum toxin are useful in the majority of patients with axillary hyperhidrosis resistant to conventional treatment. In axillary hyperhidrosis total doses are ranging from 200-400 mU Dysport or from 80 to 130 mU Botox to reach a good clinical response. Injections are usually well tolerated and no serious side-effects have been observed. The mean duration of anhidrotic effect ranges between 3 and 9 weeks.

PALMAR HYPERHIDROSIS

The use of botulinumtoxin in patients with palmar hyperhidrosis is rather difficult. The therapeutic window is smaller because injections are complicated by transient weakness of the small hand-muscles. Furthermore the injections at the palms are painful which can be overcomed by application of local anaesthetics or the blockade of the ulnar and median nerves. The duration of anhidrotic effect ranges from 20 to 50 weeks.

CONCLUSION

Intracutaneous injections of botulinum-toxin should be offered to patients with focal hyperhidrosis of the palms and axillae causing serious social, psychologic and occupational problems, resistant to other conventional treatment options.