Genetic counselling in ALS: facts, uncertainties and clinical suggestions

The clinical approach to patients with amyotrophic lateral sclerosis (ALS) has been largely modified by the identification of novel genes, the detection of gene mutations in apparently sporadic patients, and the discovery of the strict genetic and clinical relation between ALS and frontotemporal dementia (FTD). As a consequence, clinicians are increasingly facing the dilemma on how to handle genetic counselling and testing both for ALS patients and their relatives. On the basis of existing literature on genetics of ALS and of other late-onset life-threatening disorders, we propose clinical suggestions to enable neurologists to provide optimal clinical and genetic counselling to patients and families. Genetic testing should be offered to ALS patients who have a first-degree or second-degree relative with ALS, FTD or both, and should be discussed with, but not offered to, all other ALS patients, with special emphasis on its major uncertainties. Presently, genetic testing should not be proposed to asymptomatic at-risk subjects, unless they request it or are enrolled in research programmes. Genetic counselling in ALS should take into account the uncertainties about the pathogenicity and penetrance of some genetic mutations; the possible presence of mutations of different genes in the same individual; the poor genotypic/phenotypic correlation in most ALS genes; and the phenotypic pleiotropy of some genes. Though psychological, social and ethical implications of genetic testing are still relatively unexplored in ALS, we recommend multidisciplinary counselling that addresses all relevant issues, including disclosure of tests results to family members and the risk for genetic discrimination.

Asymmetric Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a heterogeneous disorder according to clinical, electrophysiological, immunologic and pathologic findings. It has usually been considered as an immune-mediated polyneuropathy clinically characterised by acute symmetric muscle weakness and areflexia. We describe a patient who, after a Campylobacter jejuni infection, developed an acute motor-sensory neuropathy with marked and persistent asymmetry of clinical and electrophysiological findings. He had a high titre of anti-GM1 IgG antibodies and cytoalbuminologic dissociation and was responsive to intravenous immunoglobulins. Investigations and three years of follow-up excluded mimics of GBS. Tendon areflexia has recently been challenged as a mandatory diagnostic criterion in GBS; likewise marked and persistent motor asymmetry does not exclude the diagnosis of GBS.

Chronic axonal-demyelinating polyradicular neuropathy associated with mycosis fungoides: a case report

Case of a 58-year-old patient diagnosed as having mycosis fungoides (MF) who presented with sensory ataxia, limbs weakness and neurophysiological and laboratory signs indicative of autoimmune chronic mixed axonal-demyelinating sensory-motor polyradicular neuropathy. The possibility that MF may be associated with an immunomediated peripheral neuropathy, even in the absence of a direct invasion of the nerves and widespread visceral involvement, should be considered.

Long term effectiveness of intravenous immunoglobulin in Churg-Strauss syndrome

OBJECTIVE

To study the long term effectiveness of intravenous immunoglobulin and plasmapheresis associated with prednisone and cyclophosphamide in Churg-Strauss syndrome.

SUBJECTS

and methods: We studied 18 subjects with new onset Churg-Strauss syndrome. All received the "standard" treatment based on prednisone (1 mg/kg/day for 1 month and then slowly tapered) and cyclophosphamide (2 mg/kg/day for 6 months in severe cases). In nine patients, synchronised cycles with plasmapheresis and intravenous immunoglobulin (2 g/kg) were repeated monthly for 6 months and every other month for a further three cycles. Clinical (disease activity monitored by Birmingham vasculitis activity score (BVAS) and damage index (modified Rankin score)) and functional (C reactive protein, blood eosinophil count, and electromyogram-electoneurogram) parameters were collected during treatment and the 3 year follow up period.

RESULTS

After 12 months, all patients in the treatment group and four (44%) in the control group were in remission. At the end of the 3 year follow up period, we documented significant differences in BVAS (p<0.01), global damage (p<0.02), modified Rankin score (p<0.04), and the daily maintenance prednisone dose (p<0.002) between the two groups. We found a tendency towards lower frequency of relapse and incidence of osteoporosis in the treatment group.

CONCLUSION

Complete clinical and functional recovery with a long term stable remission and a low incidence of side effects can be achieved by intravenous immunoglobulin associated with plasmapheresis in patients with Churg-Strauss syndrome.

The importance of suspecting superficial siderosis of the central nervous system in clinical practice

Once the central nervous system surface is greatly encrusted with haemosiderin, even removing the source of bleeding will have little effect on the progression of clinical deterioration. Superficial siderosis of the central nervous system is rare and insidious, but magnetic resonance imaging has turned a previously late, mainly autoptical diagnosis into an easy, specific, in vivo, and possibly early one. Avoiding long diagnostic delay will be very important in those cases susceptible of causal treatment.

Influence of early high-dose steroid treatment on Bell's palsy evolution

The objective of this double-blind, randomized, placebo-controlled study was to test the efficacy of high-dose prednisone, administered as early as possible, in modifying the natural progression of Bell's palsy. Sixty-two consecutive patients, enrolled within 72 hours of facial palsy onset, were assigned to high dose intravenous prednisone in combination with intramuscular polyvitaminic therapy (group A) or polyvitaminic therapy alone (group B). Clinical grading of facial muscle strength and length of absence from work were evaluated. An early worsening of facial muscle strength was observed in controls, leading to the divergence in the trends of the grading scores in the two groups; this result was not confirmed in the long-term follow-up. Treated patients returned to work earlier than controls. In conclusion, early treatment based on high-dose corticosteroids slightly accelerates spontaneous improvement in Bell's palsy.

Cyclosporin A and intravenous immunoglobulin treatment in polymyositis/dermatomyositis

OBJECTIVE

To describe the treatment of polymyositis (PM) and dermatomyositis (DM) with prednisone (PRED) and cyclosporin A (CSA) alone or associated with intravenous immunoglobulin (IVIg) and plasmapheresis (PEX).

METHODS

Between 1992 and 1999 CSA and PRED were used to treat 20 patients with idiopathic myositis (12 with DM, eight with PM), diagnosed according to the Bohan and Peter criteria. In patients with refractory or relapsed disease, IVIg was added alone (seven cases) or synchronised with PEX (six cases). A standardised protocol was used to evaluate the patients, and assess disease activity and treatment response.

RESULTS

Despite a transient response to PRED and CSA in 16/20 cases, this combination did not induce full remission in 13/20 cases, which led to the IVIg trial with or without PEX. Patients receiving PRED and CSA plus IVIg had a significantly higher probability of maintaining complete remission at the end of the four year follow up period than those treated with PRED and CSA alone (p<0.001). No further benefit was added by the PEX. The presence of arthritis significantly correlated with a poorer response to treatment (p<0.05). Adverse effects were gingival hyperplasia (one patient) and transient renal dysfunction (one).

CONCLUSIONS

This open study suggests that combined treatment with PRED, CSA, and IVIg is useful in patients with myositis, even those with refractory or relapsed disease; no increase in the number or type of side effects is seen.

Spontaneous intracranial hypotension: the value of brain measurements in diagnosis by MRI

Caudal brain displacement is inconstantly reported as an MRI feature of spontaneous intracranial hypotension (SIH). We reviewed the clinical data and MRI of eight patients diagnosed as having SIH and investigated the possibility of more precise assessment. On midsagittal images we measured four anatomical landmarks: the position of the cerebellar tonsils, fourth ventricle, and infundibular recess, plus the angle between the bicommissural line and a line tangential to the floor of the fourth ventricle; midsagittal images from 89 normal controls were also measured. On statistical analysis, all measurements differed in the two groups, and the difference was significant for the cerebellar tonsils, fourth ventricle, and infundibular recess. Some overlap between patients and controls was found for each measurement; however, all the patients had two (two patients) or more (six) values outside the range in normal controls range or not above their 1st quartile. Measurement of the position of the third ventricle seemed particularly sensitive. We suggest that examination of midsagittal images can help in diagnosing clinically suspected SIH.

An unusual spinal presentation of Whipple disease

SUMMARY

When Whipple disease (WD) is confined to the CNS, diagnosis may be difficult. We report a case of WD with spinal presentation in an otherwise healthy woman who had a 5-year history of relapsing-remitting cervico-thoracic myelopathy. We suggest that the diagnosis of WD should be considered in the presence of an enlarged and enhancing spinal cord even in the absence of any systemic involvement.

Usefulness of hand rehabilitation after carpal tunnel surgery

The purpose of this randomized trial was to assess the clinical evolution after carpal tunnel release in subjects with long-term carpal tunnel syndrome. The evaluation criteria were symptom occurrence, motor performance, and delay in returning to work. A total of 100 subjects were assessed four times (prior to surgery, and 12 days, 1 month, and 3 months after surgery) using the Boston carpal tunnel questionnaire, the nine-hole peg test (NHPT), and the Jebsen-Taylor test (JTT). Subjects were randomized to a rehabilitation program or to a progressive home exercise program. No difference in symptom occurrence between the two groups was detected after 1 and 3 months. One month after surgery, only patients in the first group showed motor dexterity improvement according to NHPT and JTT scores. At the 3-month follow-up, the two groups did not differ but the group undergoing rehabilitation showed a shorter return-to-work interval. A rehabilitation approach after hand surgery is clinically relevant to accelerate recovery but neither modifies functional recovery nor reduces symptom occurrence.

A multidimensional assessment of multiple sclerosis: relationships between disability domains

OBJECTIVE

To test the feasibility of a multidimensional assessment based on both task-related and self-evaluation questionnaire scores in patients with multiple sclerosis (MS); ii) to correlate the results from selective measures with the severity of illness in terms of the Expanded Disability Status Scale (EDSS) score; iii) to assess the relationships between different domains of MS-related disability and handicap.

PATIENTS AND METHODS

Eighty-three MS patients (M/F 31/52; age 43.26 +/- 10.9 years, range 21-72) underwent a standard clinical evaluation of motor abilities (by means of the Rivermead Mobility index, Timed Walking Test, Nine Hole Peg test and Hauser Ambulation Index) and cognitive performances (using Digit Symbol, Buschke-Fuld selective remind test, "FAS"-Word Fluency, Wisconsin Card Sorting test and Block design test). The Beck Depression inventory, MS Specific Fatigue Scale, Functional Assessment of MS and London Handicap Scale were applied to evaluate mood, fatigue, quality of life and handicap, respectively. Minimal Record of Disability measures - MRD (i.e. EDSS, Inability Status Scale and Environmental Status Scale) were also applied to test the criterion validity of the selected disability and handicap scales. The Kruskal-Wallis H-test for independent samples tested differences between subgroups with an increasing EDSS score (<3.5, 3.5-6.0, >6.0). The covariance and redundancy of measures included in the multidimensional assessment were evaluated through Factor Analysis. The Multiple Regression Analysis was used to detect the relative impact of either motor or cognitive disabilities and depression on handicap and quality of life.

RESULTS

The multimodal assessment took 70 min on average to be performed, being well accepted by patients. Motor abilities worsened as the EDSS score rose, unlike cognitive performances which proved to be similarly impaired at different severity levels. Measures of fatigue and depression were not related to EDSS values. The chosen measures were assigned by Factor Analysis to 4 domains corresponding to motor performance, executive performance, cognitive abilities and quality of life, respectively. Regression analysis showed how handicap and depression independently affect quality of life. While the handicap score is mostly influenced by motor ability, as measured by the Rivermead Mobility Index, the depression score grows independently of any physical or cognitive disability and seems to be related to fatigue self-assessment scores.

CONCLUSIONS

A multidimensional approach to MS patient assessment allows a more detailed and sensitive evaluation of their disability profile and perceived difficulties, leading to a care programme tailored to the patient's needs.

Motor evoked potentials in a case of stiff-man syndrome: a longitudinal study

The clinical and neurophysiological findings in a patient with a typical stiff-man syndrome and their three-year evolution are described. The patient had high titers of anti-glutamic acid decarboxylase antibodies in both serum and cerebrospinal fluid. Magnetic resonance imaging (MRI) of brain and spinal cord was normal. Transcranial magnetic stimulation (TMS) revealed a distinctive motor evoked potential (MEP) pattern in proximal lower limb muscles consisting of markedly increased MEP amplitudes and MEP/M ratios, reduced excitability thresholds, and absent silent period. However, MEP latencies, central and peripheral conduction times and amplitudes obtained by magnetic spinal root stimulation were normal. Treatment with benzodiazepine and baclofen normalized both the clinical picture and the MEP values. TMS may be useful both as a diagnostic tool and to monitor the response to drug treatment.

Reversible combined cognitive impairment and severe polyneuropathy resulting from primary hyperparathyroidism

Central and peripheral nervous systems may be involved in primary hyperparathyroidism (PHP). The efficacy of parathyroidectomy in reversing neurological symptoms is still a matter of controversy. We describe the case of a 71-year-old white male with a 10-year history of PHP who developed progressive cognitive dysfunction and severe sensorimotor axonal polyneuropathy. Successful parathyroidectomy reversed with a different temporal course both the central and peripheral nervous system involvements.

Reproducibility of normal facial motor nerve conduction studies and their relevance in the electrophysiological assessment of peripheral facial paralysis

To determine the intra-examiner intertrial reproducibility of normal facial motor nerve conduction studies (FNCS) and their relevance in electrophysiological assessments of peripheral facial paralysis, 52 patients with acute unilateral Bell's palsy were examined on two separate occasions 1 months apart. Three electroneurographic methods were assessed. On the unaffected side of the face, FNCS are reliable when performed by a single examiner over time. Nevertheless, compound muscle action potential (CMAP) baseline-to-peak and peak-to-peak amplitude showed a rather high intertrial variability. Reproducibility of the assessed surface electrode recording procedures was similar. Regarding the affected side, in patients with mild axonotmesis of the facial nerve variations of electroneurographic parameters 1 months apart fell within the range of normal intertrial variability. In patients with severe or moderate axonotmesis, the distal latency and the M wave amplitude variations showed significant intertrial variations. Reproducibility of FNCS appears to be similar to that found in limb motor nerves. Normal variability curtails the sensitivity of FNCS in detecting mild facial nerve axonotmesis, although this technique remains useful in severe cases.

Electrically evoked long-latency responses in human forearm, arm and shoulder muscles

Little is known about electrically evoked long-latency responses (LLR) in muscles other than hand muscles. We obtained LLR in forearm, arm and shoulder muscles by ipsilateral homonymous and heteronymous mixed and pure cutaneous electrical stimulation of the median or ulnar nerve in healthy subjects and in patients with focal unilateral Central Nervous System lesions. Our results point out the important role played by hand afferents in the sensorimotor coordination of multiarticulate upper limb movements.

Acute monophasic focal demyelinating diseases of the central nervous system: longitudinal clinico-neuroradiological study of two patients

We report the clinical features and laboratory-instrumental findings in two patients with acute monophasic demyelinating disease with focal clinical expression: one case of incomplete cervical transverse myelitis and one of focal supratentorial encephalitis. We describe the clinical course and evolution of the neuroradiological findings (CT and MRI) and discuss their pathological meaning and diagnostic value.

[Polyneuropathies associated with lymphoplasmacytic dyscrasias: the clinical and instrumental characteristics of a 38-patient case load]

A varying percentage from 40 to 60% of patients having lymphoplasmacytic dyscrasias with a monoclonal component shows a clinical or subclinical polyneuropathy. From a different viewpoint, a monoclonal gammopathy has been detected in 10% of patients effected by chronic idiopathic polyneuropathy. A case study of 38 patients with lymphoplasmacytic dyscrasia subjected to clinical, immunohematological and electrophysiological examination revealed a high prevalence of polyneuropathy (84%), mainly axonal (72%) and often subclinical. The neuropathy was evenly distributed between patients having malignant and benign lymphoplasmacytic dyscrasias. No statistically significant correlation was found between the presence of neuropathy and the main clinical and immunohematological data. This supports the concept that the pathogenesis of polyneuropathy associated with lymphoplasmacytic dyscrasias may be multifactorial. Nor can it be ruled out that the paraprotein may in fact be secondary to the polyneuropathy or sometimes a simple coincidence.

[Peripheral neuropathy associated with Castleman's lymphoma]

Castleman's lymphoma is a rare clinicopathological entity and is often difficult to classify nosographically. From the histopathological point of view two variants are recognized, one hyalino-vascular and one plasma cellular. Moreover Castleman's lymphoma may be multifocal or unifocal (located within the thorax in 70% of patients). The plasma cellular variant is often associated with systemic symptoms such as fever, sweating, organomegaly, polyneuropathy, and mono- or polyclonal gammopathy. We describe a rare case of unifocal, plasma cellular-type Castleman's lymphoma located in the mediastinum, asymptomatic at onset but later dominated by neurological symptoms (chronic isolated polyneuropathy whose clinical expression was predominantly motor). A brief review is presented of the main clinico-histological characteristics of Castleman's lymphoma together with some hypotheses about the pathogenesis of the associated neuropathy.

Chronic multifocal demyelinating neuropathy simulating motor neuron disease

We describe a patient with a chronic acquired predominantly motor polyneuropathy. His clinical picture initially led to a diagnosis of lower motor neuron form of amyotrophic lateral sclerosis. However electrophysiological examination revealed multifocal, prevalently proximal, conduction blocks at sites not prone to compression. Distinguishing this unusual polyneuropathy from motor neuron diseases is critical, since the former is a potentially, treatable disorder.

Meningoencephalomyeloradiculoneuritis in one case of Borrelia burgdorferi infection (Lyme disease)

We describe a patient having serologically confirmed Borrelia burgdorferi infection manifesting meningoencephalomyeloradiculoneuritis. The clinical and MRI features suggested a multifocal vascular nervous system involvement. EMG-ENG showed abnormalities consistent with axonal degeneration initially involving the more proximal segments of the lower limb nerves.

Evidence of central nervous system involvement in chronic demyelinating neuropathies associated with "benign" gammopathies

Recent papers underline the possible involvement of the central nervous system when an acquired peripheral demyelinating disease occurs and vice-versa. We describe five patients with chronic polyneuropathy and "benign" gammopathy, monoclonal (IgM-K, IgA-k, IgG-k) in three cases and polyclonal (IgG, IgM) in two cases; the monoclonal gammopathies were detected in cases of peripheral nerve disease. Three patients showed tremor and signs of pyramidal system impairment when the peripheral damage had improved or was stable. All cases underwent a longitudinal assessment according to clinical, CSF, EMG-ENG, neuroradiological and pathological criteria. The MRI finding always showed multiple alterations of encephalic white matter. When related to neurophysiological and pathological data supporting a chronic demyelinating neuropathy, such results point to possible encephalic involvement in chronic polyneuropathies due to a pathogenetic mechanism common to both.

[On a case of Fahr's disease]

A case of idiopathic Fahr's disease with interesting clinical and neuroradiological findings is described. The nosological identity and the pathogenetic factors of this complex condition are discussed.