[Clinical experience in the treatment of motor fluctuations in Parkinson's disease. Delphi consensus of a group of experts in movement disorders]

INTRODUCTION

Motor fluctuations are one of the most common complications of Parkinson's disease and their treatment is still a complex matter. Therefore, from the Neurology Movement Disorders Group we present our clinical experience in the treatment of these complications, with the intention of it being useful in decision-making in daily clinical practice.

DEVELOPMENT

Nineteen questions were developed based on a literature review and an open survey answered by members of this group. These issues were discussed in two phases, using the Delphi methodology. Considering the results of the survey, levodopa dose adjustment and dopamine agonists are the option with the best efficacy/tolerability ratio in the treatment of motor fluctuations. Rotigotine is useful in the motor fluctuations associated with gastroparesis, and intermittent subcutaneous apomorphine has positive effects in patients with unpredictable off periods. The most relevant adverse effect associated with dopamine agonists is impulse control disorder. Catechol-O-methyltransferase inhibitors are useful in the initial stages of motor fluctuations, especially in wearing off. Monoamine oxidase inhibitors are generally drugs that are well-tolerated and useful in motor fluctuations. If these measures are not effective, second-line treatments should be indicated on a case-by-case basis.

CONCLUSION

The clinical profile of patients with Parkinson's disease is paramount in deciding the most appropriate therapy for the treatment of motor fluctuations.

[Myths and evidence on the use of botulinum toxin: neuropharmacology and dystonia]

INTRODUCTION

Botulinum toxin type A (BTA) is a bacterial endotoxin, whose therapeutic use has had a dramatic impact on different neurological disorders, such as dystonia and spasticity.

AIM

To analyze and summarize different questions about the use of BTA in our clinical practice.

DEVELOPMENT

A group of experts in neurology developed a list of topics related with the use of BTA. Two groups were considered: neuropharmacology and dystonia. A literature search at PubMed, mainly for English language articles published up to June 2016 was performed. The manuscript was structured as a questionnaire that includes those questions that, according to the panel opinion, could generate more controversy or doubt. The initial draft was reviewed by the expert panel members to allow modifications, and after subsequent revisions for achieving the highest degree of consensus, the final text was then validated. Different questions about diverse aspects of neuropharmacology, such as mechanism of action, bioequivalence of the different preparations, immunogenicity, etc. were included. Regarding dystonia, the document included questions about methods of evaluation, cervical dystonia, blepharospasm, etc.

CONCLUSION

This review does not pretend to be a guide, but rather a tool for continuous training of residents and specialists in neurology, about different specific areas of the management of BTA.

Antidepressants in Parkinson's disease. Recommendations by the movement disorder study group of the Neurological Association of Madrid

INTRODUCTION

Although antidepressants are widely used in Parkinson's disease (PD), few well-designed studies to support their efficacy have been conducted.

DEVELOPMENT

These clinical guidelines are based on a review of the literature and the results of an AMN movement disorder study group survey.

CONCLUSIONS

Evidence suggests that nortriptyline, venlafaxine, paroxetine, and citalopram may be useful in treating depression in PD, although studies on paroxetine and citalopram yield conflicting results. In clinical practice, however, selective serotonin reuptake inhibitors are usually considered the treatment of choice. Duloxetine may be an alternative to venlafaxine, although the evidence for this is less, and venlafaxine plus mirtazapine may be useful in drug-resistant cases. Furthermore, citalopram may be indicated for the treatment of anxiety, atomoxetine for hypersomnia, trazodone and mirtazapine for insomnia and psychosis, and bupropion for apathy. In general, antidepressants are well tolerated in PD. However, clinicians should consider the anticholinergic effect of tricyclic antidepressants, the impact of serotonin-norepinephrine reuptake inhibitors on blood pressure, the extrapyramidal effects of antidepressants, and any potential interactions between monoamine oxidase B inhibitors and other antidepressants.

[Galantamine therapy in dementia associated with CADASIL]

INTRODUCTION

Cholinergic neuronal impairment has been suggested in cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencefalopathy (CADASIL). Cholinomimetic therapy could be useful.

CASE REPORTS

Four patients with CADASIL and dementia were treated with the acetylcholinesterase inhibitor galantamine and we assessed cognitive, behavioral, functional and the caregiver burden aspects. Three patients showed either mild improvement or stabilization in the behavior and caregiver burden.

CONCLUSION

Our results suggest some benefit from galantamine treatment and they could support the existence of a cholinergic deficit in CADASIL.

[Adult-onset subacute sclerosing panencephalitis: clinicopathological findings]

INTRODUCTION

Subacute sclerosing panencephalitis is a disease affecting the central nervous system that is produced by persistent infection by a defective measles virus. This disease is very infrequent and its incidence has gone down even further in western countries since the introduction of generalised measles vaccinations. Onset of the disease is usually during infancy or adolescence. Reports of cases beginning during adulthood are scarce.

CASE REPORT

We describe the case of a 30-year-old female with a slowly progressive subacute clinical picture consisting in behavioural disorders, with defrontalisation, cortico-subcortical cognitive impairment, long tract signs and visual disorders, which led the patient into a vegetative state. Four years after the onset of symptoms the patient died. The different electroencephalogram recordings performed did not show any periodic activity and magnetic resonance imaging of the head revealed cerebral atrophy with hyperintense lesions in T2 sequences in white matter. The histological study of the brain showed a chronic inflammatory infiltration with neuronal loss and demyelination, as well as intranuclear inclusions and neurofibrillary degeneration.

CONCLUSIONS

The appearance of subacute sclerosing panencephalitis in adulthood is exceptional. Diagnosis requires a high degree of clinical suspicion, above all in the absence of typical symptoms, such as myoclonias or periodic complexes in EEG recordings.

[Anticoagulant treatment in hemorrhagic brains infarts due to large sinus venous thrombosis]

Cerebral venous and sinus thrombosis is an infrequent condition which presents with a wide spectrum of signs and a variable mode of onset. Sinus thrombosis may cause isolated intracranial hypertension but also may cause cerebral venous infarcts, which are frequently hemorrhagic. Treatment with antithrombotic agents is controversial because there is only one randomised controlled trial with unfractionated heparin. We report a 46- years-old man complaining of progressive headache, paraparesis and dysphasia. After admission, his neurological status worsened and he developed tetraparesis, depressed level of consciousness and seizures. A cranial computarized tomography (CT) scan showed multiple hyperdensities suggestive of hemorrhagic infarcts. Magnetic resonance imaging (MRI) study confirmed extensive cerebral venous thrombosis. Unfractionated heparin was administered for two weeks followed by acenocumarol. Within a few days his neurological status improved, and five weeks after admission the patient only hadd slight neurological deficit. After 11 years of follow-up, he has had a complete recovery. The G20210A mutation in the prothrombin gene was detected as a likely risk factor for venous thrombosis. Therapeutical and diagnosis aspects are discussed. We review the previous literature on the topic.

[CADASIL: a case with clinical, radiological, histological and genetic diagnoses]

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare inherited cerebrovascular disease. The onset of clinical symptoms occurs with migraine with aura, transient ischemic attacks, recurrent subcortical ischemic infarcts, neuropsychiatric changes reaching subcortical dementia. Brain magnetic resonance images show multiple deep cerebral infarcts in white matter and basal ganglia and diffuse leukoencephalopathy. Neuropathologic hallmark consists of deposition of small electron dense granular patches related to the basement membrane of vascular smooth muscle cells with degeneration of smooth muscle cells and media and luminal obliteration. Recently, the genetic characteristics of this disorder have been reported. Missense mutations in notch3 gene localized in chromosome 19 are involved in its pathogenesis. Only three families from Spain have been reported. Here we describe a patient with typical clinical symptoms, neuroimaging and pathology of CADASIL. C406T (Arg110Cys) mutation in notch3 gene was found. We comment on the clinical symptoms of different members of the patient's family.

[Prognosis factors in conservatively treated patients with non-traumatic supratentorial intracerebral hematoma]

We have carried out a retrospective study of 90 patients who were diagnosed of non traumatic supratentorial intracerebral hematoma by computerized tomography and received conservative treatment. Clinical features and laboratory and radiographic findings during acute stage as well as the course of the patients during hospital stay (mean, 34 days) are analyzed. The overall mortality rate was 21%. The factors having a significant influence on prognosis were: degree of neurologic impairment at admission, degree of motor impairment at admission, progression of neurologic impairment after the admission, level of glycemia at admission, extent of the hematoma, and presence of mass effect in CT. We conclude that the extent of the hematoma and the level of glycemia at admission are the primary prognostic factors without being related to each other. The "critical" values were 40 cc for the extent of the hematoma and 130 mg/dl for glycemia at admission. Patients with higher values had a poorer prognosis with a worse clinical condition at discharge.

[Congenital muscular dystrophy. Apropos of 4 cases]

Four cases of congenital muscular dystrophy are reported. Muscular weakness and hypotonia, with different clinical severity, was present from birth in three patients; in the fourth one, it began at two months old. Three cases had joint contractures. One patient died by respiratory infection. Serum CK level was very high in all of them. Muscle biopsies showed pathologic changes consistent with muscular dystrophy with endomysial and perimysial fibrosis and fatty infiltration. Authors analysed this illness emphasizing clinical and biochemical (CK) data so that an early diagnosis can be suspected.