Investigation of the nonmotor symptoms in patients with STN-DBS therapy in comparison with those without STN-DBS

The impact of STN-DBS on NMS remains rather as an underestimated topic. Besides, the significance of NMSs in QOL indexes of PD subjects with STN-DBS is unknown. We primarily aimed to evaluate the NMSs and their significance in QOL indexes in PD subjects comparatively with and without STN-DBS therapy. We enrolled all consecutive PD subjects with and without STN-DBS who applied to our movement disorders outpatient clinics between January/2023 and September/2023. We performed comprehensive assessments of the motor and nonmotor features including the clinical scales of Movement Disorder Society-sponsored revision of the MDS-UPDRS, NMSS, HAM-A, HAM-D, and the PDQ-39. Overall, 48 PD subjects with STN-DBS and 161 without STN-DBS treatment were included. The comparative analyses revealed that the sub-scores of the MDS-UPDRS-2, -3 and -4 were higher in the STN-DBS group. However, the MDS-UDPRS-1 and the total scores of the NMSS were similar between groups. Among eight subitems of the NMSS, only, the sub scores of the mood/cognition and the gastrointestinal tract differed. Remarkably, the significant correlations between the scores of the QOL and the NMSS scores in the STN-DBS (-) group, did not persist within the STN-DBS group. Remarkably, the correlations between the NMSS and PQQ-39 disappeared for most of the sub scores within the STN-DBS group. We found indirect evidence regarding the benefit of STN-DBS therapy on NMSs in our cross-sectional study. Besides, we found weaker impact of NMSs in QOL indexes in PD subjects with STN-DBS therapy.

Analyses of the clinical factors and freezing of gait in association with the quality-of-life indexes in Parkinson's disease subjects with and without STN-DBS therapy

INTRODUCTION

In this research, paying particular attention to freezıng of gait (FOG), we aimed to investigate the associations between the clinical features and quality of lilfe (QOL) indexes comparatively in our PD subjects with and without STN-DBS therapy.

METHODS

All consecutive PD subjects with and without STN-DBS who applied to our movement disorders outpatient clinics between January/2022 and September/2022; and accepted to participate in the study were enrolled. The demographic data and clinical features were noted. Besides, the MDS-UPDRS, the FOG Questionnaire (FOGQ) and the Parkinson's Disease Questionnaire (PDQ-39) have also been performed on all individuals.

RESULTS

Overall, 105 patients with PD participated in this study (34 patients with STN-DBS, 71 patients without STN-DBS). No difference was found in the PDQ-39 scores between patients with and without STN-DBS. The correlation analyses between the PQQ-39 scores and the clinical parameters revealed significant moderate correlations with the FOGQ score and low correlations with MDS-UPDRS scores. The analyses repeated in either patient group showed that there were no correlations between the MDS-UPDRS scores and PDQ-39 indexes in the DBS group. Besides, the correlations between the PDQ-39 scores and the FOG scores were more prominent in patients without DBS therapy.

CONCLUSION

FOG was found to be associated with worse QOL status in both patients with and without STN-DBS therapy. However, the correlations analyses in either group showed that FOG was a more significant determinant in the QOL indexes in patients without DBS. Future studies evaluating the impact of other clinical features such as falls and gait impairment in QOL of patients with STN-DBS may provide contributions to the current evidence.

Temporal Investigations of the Changes in Presynaptic Inhibition Associated With Subthalamic Nucleus-Deep-Brain Stimulation

BACKGROUND AND PURPOSE

There are controversies regarding the role of presynaptic inhibition (PSI) in the mechanisms underlying the efficacy of deep-brain stimulation (DBS) in Parkinson's disease (PD). We sought to determine the involvement of PSI in DBS-related mechanisms and clinical correlates.

METHODS

We enrolled PD subjects who had received subthalamic nucleus DBS (STN-DBS) therapy and had been admitted to our clinic between January 2022 and March 2022. The tibial H-reflex was studied bilaterally during the medication-off state, and all tests were repeated 10 and 20 minutes after the simulation was turned off. Simultaneous evaluations based on the Movement-Disorder-Society-sponsored revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III) were performed in all of the patients.

RESULTS

Ultimately we enrolled 18 patients aged 58.7±9.3 years (mean±standard deviation, 10 females). Fifty percent of the patients showed a decrease in the MDS-UPDRS-III score of more than 60% during the stimulation-on period. Comparative analyses of the repeated measurements made according to the stimulation status revealed significant differences only in the left H-reflex/M-response amplitude ratio (H/M ratio). However, no difference in the left H/M ratio was found in the subgroup of patients with a prominent clinical response to stimulation (n=9). Analyses of the less-affected side revealed differences in the H-reflex amplitude and H/M ratio.

CONCLUSIONS

We found evidence of PSI recovery on the less-affected side of our PD subjects associated with STN-DBS. We hypothesize that the involvement of this spinal pathway and its contribution to the mechanisms of DBS differ between individuals based on the severity of the disease and which brainstem regions and descending tracts are involved.

Subjective Assessments of Voice in Parkinson's Disease Subjects with and without STN-DBS Therapy

Introduction

The causal relation between STN-DBS and speech problems and the associated clinical features are in the incipient stages of being investigated.

Methods

All the Parkinson's disease (PD) subjects with and without STN-DBS who applied to our movement disorders outpatient clinics between January 2022 and June 2022 and agreed to participate in the study were enrolled. The demographic data and clinical features were noted. Besides, the MDS-UPDRS was administered during the medication off-state in all subjects. All the participants completed the voice handicap index (VHI). Besides, the Freezing of Gait Questionnaire (FOGQ) and the quality of life (QoL) scales including the Parkinson's Disease Questionnaire (PDQ-39) and the Schwab and England Activities of Daily Living (ADL) scale were also administered to all the individuals.

Results

We have included 66 patients with PD (F/M = 23/43). Thirty-five patients were those with DBS therapy whereas 31 patients were without. The results of the comparative analyses between the patients with and without DBS therapy revealed that the DBS group had a higher disease duration (P = 0.006) and FOGQ scores (P = 0.008). The VHI scores did not differ between groups (P = 0.577), and the correlation analyses did not reveal an association between the VHI scores and the duration of DBS therapy. However, the VHI scores correlated with the disease duration as well as the FOG scores.

Conclusion

We did not find convincing evidence supporting the increased risk of speech disturbance with STN-DBS therapy. We suggest that the frequent existence of speech disturbance in this patient subgroup with STN-DBS is associated with the classical nature of PD.

Controlled-Release Levodopa for the Treatment of Rapid Motor Fluctuations in Parkinson's Disease Subjects with Subthalamic Nucleus Deep Brain Stimulation

Objectives  We aimed to investigate the efficiency of controlled-release levodopa/benserazide (Madopar HBS) use during daytime in our pilot study on advanced-stage Parkinson's disease (PD) subjects with deep brain stimulation of the subthalamic nucleus (STN-DBS) therapy. Methods  We have evaluated all PD subjects with STN-DBS who had admitted to our outpatient polyclinic between February 2022 and March 2022. Among these patients, those who were taking levodopa therapy at least five times throughout the day and the efficiency of levodopa lasted less than 3 hours were detected. The standard levodopa therapy was switched to Madopar HBS in all patients who accepted the therapy chance and the clinical evaluation of the patients on Madopar HBS therapy was performed in the second month of the therapy. Results  Ultimately, the follow-up of all four patients in whom the levodopa therapy was changed to Madopar HBS yielded a significant reduction in the "off" periods and improvement in the PSQ-39 scores. Conclusion  We suggest the use of Madopar HBS in PD patients with STN-DBS surgery suffering from motor fluctuations, particularly in the subgroup with milder dyskinesias. Future study results of a large number of PD subjects with STN-DBS therapy are warranted to confirm our observations. The results of these studies may provide critical applications in clinical practice.

The gait parameters in patients with Parkinson's Disease under STN-DBS therapy and associated clinical features

OBJECTIVE

We aimed to investigate the gait parameters in patients with subthalamic nucleus deep brain stimulation (STN-DBS) therapy using quantitative gait analyses and reveal the associated clinical features.

METHODS

Parkinson's disease (PD) subjects with STN-DBS who applied to our movement disorders outpatient clinics between December/2021 and March/2022 were enrolled. In addition to the evaluation of the demographic data and the clinical features; clinical scales measuring the freezing of gait (FOG), falls and quality of life were performed. A gait analyzer program was used to perform gait analysis.

RESULTS

Thirty patients with a mean age of 59.4 ± 8.3 (F/M = 7/23) were enrolled. The comparative analyses between the tremor-dominant and akinetic-rigid (AR) subtype patients showed that the step time asymmetry measures were higher in the AR group. The comparative analyses according to the symptom onset side showed that the step length was smaller in those with left-side symptom onset. The correlation analyses showed that there were correlations between the quality-of-life indexes and FOG questionnaire and falls efficacy scale (FES) scores. Finally, the correlation analyses between clinical scales and gait parameters revealed that there were significant correlations between the FES scores and the step length asymmetry (SLA).

CONCLUSION

We found a strong relationship between falls and quality of life indexes of our patients under STN-DBS therapy. In this patient group, particular evaluation of fallings and the follow-up of SLA in gait analysis may constitute important points during the evaluation of patients in routine clinical practice.

Investigation of the factors associated with hemichorea/hemiballismus in post-stroke patients

Classical knowledge highlights the role of lesions of the subthalamic nuclei (STN) in the pathophysiology of hemichorea/hemiballismus (HH). However, the published reports indicate various other lesion regions in the majority of post-stroke cases with HH. Ergo, we aimed to investigate the significance of the lesion site and clinical features for developing HH in post-stroke patients. Overall, we retrospectively scanned all the patients with stroke who were hospitalized between 01/06/2022 and 31/07/2022 in our neurology clinic. The data regarding the demographic features, comorbidities, stroke etiologies, and laboratory findings, including serum glucose and HBA1C were retrospectively recruited using the electronic-based medical record system. The cranial magnetic resonance imaging (MRI) and computed tomography images have been systematically evaluated for the presence of lesions in localizations that are previously associated with HH. We conducted comparative analyses between patients with and without HH to reveal the discrepancies between groups. The logistic regression analyses were also performed to reveal the predictive values of some features. Overall, the data of 124 post-stroke patients were analyzed. The mean age was 67.9 ± 12.4 years (F/M = 57/67). Six patients were determined to develop HH. The comparative analyses between patients with and without HH revealed that the mean age tended to be higher in the HH group (p = 0.08) and caudate nucleus involvement was more common in the HH group (p = 0.005). Besides cortical involvement was absent in all subjects developing HH. The logistic regression model revealed the presence of a caudate lesion and advanced age as factors associated with HH. We found that the caudate lesion was a crucial determinant of the occurrence of HH in post-stroke patients. With the significance of the other factors of increased age and cortical sparring, we observed differences in the HH group may be investigated also in future-related studies on larger groups.

The utility of quantitative MRI parameters in discriminating progressive supranuclear palsy from Parkinson's disease

OBJECTIVE

We sought to re-evaluate the utility of all the quantitative neuroimaging parameters attributed to progressive supranuclear palsy (PSP) in discrimination between PSP and Parkinson' s disease (PD) subjects in our cohort. We aimed to propose some practical clinical remarks in this field.

METHODS

In our retrospective study, 19 patients with 'probable' PSP and 37 patients with PD were enrolled. The radiological measurements of PSP, described in the previous reports, have been calculated in all subjects. The comparisons between the groups were performed and the measures regarding the accuracy of these parameters in the differentiation of PSP from PD subjects were analyzed.

RESULTS

We found that the values of magnetic resonance parkinsonism index-2 (MRPI-2), pontine-to-midbrain area (P/M) ratio, P/M 2 ratio, and 3rdV/bifrontal width ratio had high AUC values and very good discriminative powers. The analyses revealed that; for the discrimination of PSP from PD subjects, a 3rdvent/bifrontal width cut-off value of 0.30 had 42.1 % sensitivity and 97.3 % specificity; a P/M cut-off value of 6.03 had a 52.6 % sensitivity and 97.3 % specificity; and an MRPI-2 cut-off value of 7.43 had 57.9 % sensitivity and 97.3 % specificity. Remarkably, we also found that the presence of high values for both P/M and 3rdV/bifrontal ventricle rate had a positive predictive value of 100% for the diagnosis of PSP.

CONCLUSION

Our study results support the utility of previously defined neuroimaging parameters in distinguishing PSP and PD subjects. Besides, combined use of a high P/M ratio and 3rdV/bifrontal width may be practical and present strictly high evidence for the diagnosis of PSP.

A Rare Patient with Hereditary Spastic Paraparesis with Parkinsonism

Herein, we present a rare patient with hereditary spastic paraparesis (HSP) in whom significant parkinsonism was involved in the clinic. Besides, the dopamine transport single-photon emission computed tomography scan also showed decreased tracer uptake in the bilateral striatum. Via the presentation of this patient, we discuss the parkinsonian findings in patients with HSP. We think that the observations of dopaminergic neuron vulnerability in HSP patients raise the possibility that degeneration of central dopaminergic neurons may contribute to the phenotype of HSP. The documentation of these rare variants will aid to understand the unknown pathophysiology of the disease course.

Comparative analysis of freezing of gait in distinct Parkinsonism types by diffusion tensor imaging method and cognitive profiles

Freezing of gait (FOG) is an episodic gait pattern that is common in advanced Parkinson's disease (PD) and other atypical parkinsonism syndromes. Recently, disturbances in the pedunculopontine nucleus (PPN) and its connections have been suggested to play a critical role in the development of FOG. In this study, we aimed to demonstrate possible disturbances in PPN and its connections by performing the diffusion tensor imaging (DTI) technique. We included 18 patients of PD with FOG [PD-FOG], 13 patients of PD without FOG [PD-nFOG] and 12 healthy subjects as well as a group of patients with progressive supranuclear palsy (PSP), an atypical parkinsonism syndrome which is very often complicated with FOG [6 PSP-FOG, 5 PSP-nFOG]. To determine the specific cognitive parameters that can be related to FOG, deliberate neurophysiological evaluations of all the individuals were performed. The comparative analyses and correlation analyses were performed to reveal the neurophysiological and DTI correlates of FOG in either group. We have found disturbances in values reflecting microstructural integrity of the bilateral superior frontal gyrus (SFG), bilateral fastigial nucleus (FN), left pre-supplementary motor area (SMA) in the PD-FOG group relative to the PD-nFOG group. The analysis of the PSP group also demonstrated disturbance in left pre-SMA values in the PSP-FOG group likewise, while negative correlations were determined between right STN, left PPN values and FOG scores. In neurophysiological assessments, lower performances for visuospatial functions were demonstrated in FOG ( +) individuals for either patient group. The disturbances in the visuospatial abilities may be a critical step for the occurrence of FOG. Together with the results of DTI analyses, it might be suggested that impairment in the connectivity of disturbed frontal areas with disordered basal ganglia, maybe the key factor for the occurrence of FOG in the PD group, whereas left PPN which is a nondopaminergic nucleus may play a more prominent role in the process of FOG in PSP. Moreover, our results support the relationship between right STN, and FOG as mentioned before, as well as introduce the importance of FN as a new structure that may be involved in FOG pathogenesis.

Investigation of the gait parameters after donepezil treatment in patients with alzheimer' s disease

INTRODUCTION

Clinical studies remark that gait disturbance is common in patients with Alzheimer's disease (AD). However, the treatment response of gait disturbance in those patients may constitute a more interesting issue that is rarely addressed.

METHODS

In this prospective, interventional study, we included 14 consecutive patients with a new diagnosis of AD. Basal gait analysis was performed using a 'Gait Analyzer' program that was uploaded to a mobile phone. The gait parameters including Step time (ST), step length (SL), step number (SN), gait velocity (GV), and cadence were measured. Afterward, donepezil 5 mg daily was initiated, and the re-assessments were re-performed 8 weeks after the treatment.

RESULTS

The mean age was 71.78 ± 5.02 (F/M = 8/6). The evaluations after the donepezil treatment showed that there was a significant improvement in the SN (p = 0.021) and SL (p = 0.001) in comparison to the basal evaluations. The repeated analysis in the subgroup of early-stage AD subjects (n = 10) yielded that there were significant improvements in SN (p = 0.003), SL (p = 0.005), and cadence (p = 0.026) after treatment.

CONCLUSIONS

Our results support the efficiency of cholinergic treatment in gait functions in AD subjects.

Investigation of the changes in the presynaptic inhibition in association with the subthalamic nucleus stimulation in Parkinson's disease

BACKGROUND AND PURPOSE

Presynaptic inhibition (PSI) is a critical spinal inhibitory mechanism for modulating muscle coordination by adjusting both supraspinal motor commands and sensory feedback at the spinal level. The literature data regarding the role of PSI in the efficiency of STN-DBS therapy in Parkinson's disease (PD) are limited. We aimed to investigate the possible alteration in this pathway in association with the STN stimulation (STIM) within the very early period after the STIM is off.

METHODS

We performed the H-reflex investigation on 8 PD subjects with STN-DBS who applied to our polyclinic for routine clinical evaluations. The investigations were initially performed at the STIM-on period and repeated after the STIM set is off for 5 min. A within-subjects ANOVA was used to test for a significant difference between the STIM-on and -off states for the variables of (repeated measures) H-latency, H amplitude, M amplitude, H/M amplitude, H threshold, and M threshold.

RESULTS

The results of the analyses did not reveal marked changes in the variables of the H-reflex between the STIM-on and -off states.

CONCLUSION

PSI do not alter in the very early period after the STIM is off. Taken together with the related literature data and our study results, it can be hypothesized that the PSI might involve in the DBS efficiency in the later phase of the STIM as a compensatory mechanism. Further prospective studies including a larger number of patients with serial electrophysiological recordings to investigate the temporal course of the underlying dynamics are required to clarify these discussions.

Idiopathic normal pressure hydrocephalus-like MRI features in patients with progressive supranuclear palsy: a comparative case-control study

BACKGROUND

The occurrence of neurodegenerative disease in patients with normal pressure hydrocephalus (NPH) is emphasized in recent reports. Based on this common co-occurrence, some of the hydrocephalic disorders appearing in late adulthood have been hypothesized to result from initially unapparent parenchymal abnormalities of neurodegenerative origin. Among these diseases, progressive supranuclear palsy (PSP) has been specifically remarked on. We aimed to comparatively investigate the neuroimaging clues of iNPH in our PSP subjects.

METHODS

Eighteen patients with a clinical diagnosis of PSP, 44 with Parkinson's disease (PD), and 44 healthy control (HC) individuals were enrolled. The disproportionately enlarged subarachnoid space hydrocephalus (DESH) score, the Evans' index (EI), and the callosal angle (CA) were measured on the conventional magnetic resonance imaging (MRI). The comparative analyses were performed using IBM SPSS Statistics 26.

RESULTS

We found that dilated Sylvian fissures score (p = 0.016) and focal sulcal dilatation score (p = 0.037) were higher in the PSP group in comparison to HC whereas the CA score was higher in PSP subjects in comparison to both PD patients and HC (p = 0.000). Remarkably, the DESH score was also found to be higher in the PSP group in comparison to the age-matched HC group (p = 0.024).

CONCLUSIONS

We found that the NPH-like MRI features were more common in PSP subjects in comparison to PD subjects and age-matched HC. These results may provide critical contributions to the literature regarding the overlap between PSP and NPH.

Reversible Splenial Lesion Syndrome developing in the setting of sleep deprivation

In this report, we present a rare case of reversible splenial lesion syndrome which was etiologically associated with sleep deprivation. Up to our knowledge, there is no previous research reporting sleep deprivation as an inducer agent of RESLES. To elucidate our observation, future reports of larger case series are surely warranted. The clarification of the possible association between sleep deprivation and the reversible splenial lesion may also provide substantial perspectives regarding the mechanisms and health impact of sleep deprivation; the functional and pathophysiological role of the splenial corpus callosum in sleep physiology. Besides, we think that the awareness of this entity should increase among clinicians to avoid unnecessary investigations as the case in our patient.

Temporal lobe parenchyma herniation: An etiological cause of headache or coexistence?

This report illustrates a patient presenting with a unilateral headache at whom brain magnetic resonance imaging showed temporal lobe parenchyma herniation. In our patient, there were no clinical or neuroimaging findings of increased intracranial pressure (ICP) that might lead to a headache. On the other hand, considering the dynamic nature of headache in our patient, we cannot exclude a mechanism of possible episodic ICP increments that might be related to encephalocele. We think that the detailed illustration of this case may present substantial perspectives for further deliberations regarding the headache pathophysiology.

The potential significance of reversed stapes reflex in clinical practice in idiopathic intracranial hypertension

Background:

Stapes reflex test is a method of evaluating the involuntary muscle contraction of the stapedius muscle in response to a high-intensity sound stimulus. The formation of this reflex involves the intact function of the 7^th nerve, brain stem, 8^th nerve, and middle ear. Due to ease of administration and information yielded, the stapedial reflex is considered one of the most powerful differential diagnostic audiological procedures. Numerous studies have remarked on the fluid communication between the intracochlear and intracranial spaces through the cochlear aqueduct. Currently, the potential significance of a noninvasive audiological technique in the discrimination of raised intracranial pressure constitutes a crucial topic of interest.

Methods:

We have performed the pre-LP and post-LP detailed otorhinolaryngological investigations, including the detailed inspection, audiometric testing, tympanometry, and stapedial reflex in a total of four consecutive patients with IIH.

Results:

We found that the stapedial reflex was bilateral absent initially in two of the patients. However, the second stapedial reflex investigations after LP showed reversal of the reflex responses in both of the patients.

Conclusions:

We suggest some hypotheses and propose some clinical applications. Future studies focusing on the potential utility of this reflex in the monitorization of IIH may provide crucial perspectives.

Rare Case of Wernicke Encephalopathy with Initial Negative Diffusion-Weighted Imaging

In this report, we present a rare patient with Wernicke encephalopathy (WE) in whom the initial magnetic resonance imaging (MRI) was normal. However, cranial MRI, performed two weeks later, showed lesions compatible with WE. Via the presentation of this patient, we discuss the need for future studies of larger cases including the temporal evaluation of the MRI characteristics of Wernicke encephalopathy.

Dramatic improvement of segmental Zoster Paresis by late-onset antiviral therapy

Focal paresis secondary to Herpes zoster (HZ) is a rare neurological complication and should be kept in mind in the differential diagnosis of acute weakness with corresponding dermatomal rashes. In this case report, we illustrate an 84-year-old male patient, who presented with focal upper extremity weakness following HZ on right C4-8 dermatome. After clinical and electrophysiological evaluations, segmental zoster paresis was diagnosed. Although antiviral medication(oral brivudine) had been administered previously, oral valacyclovir and low dosage methylprednisolone were initiated. In the following 2 months interval, a progressive and dramatic recovery in extremity weakness and neuropathic pain were achieved. The clinical course of this patient may give substantial perspectives regarding the clinical evaluation of similar cases.