[Topography of secondary dystonia lesions]

Biological causes provoking dystonia can not be systematized, with the exception of the small group of levodopa-responsive dystonia. Therefore the pathophysiology of the dystonic syndrome can be approached by considering the site of the lesions. In 40 cases of uni or bilateral symptomatic dystonias, this site could be identified with CT Scan or MRI. Twenty-one were located in the striatum, six in the pallidum, seven in the thalamus, six in the midbrain. Each group is characterized by etiologic and clinical criteria, sometimes associated with abnormal movements. In the striatal group, the most important, dystonia was often associated by athetosis or choreoathetoid abnormal movements. In some cases, in children, lesions were vascular due to impairment of lenticulo-striatal arteries, often following cranial trauma. The pallidal lesions were usually provoked by metabolic or infectious agents. Most thalamic dystonias were of vascular origin, sometimes accompanied by myoclonia. Midbrain lesions were usually vascular with tremor. Athetosis occurred after striatal rarely after pallidal lesions. It is advisable not to assimilate dystonia and athetosis as both are simultaneously observed if the lesions are located in the striatum, rarely in the the pallidum but not in the midbrain.

Four novel mutations in the tyrosine hydroxylase gene in patients with infantile parkinsonism

Mutation detection in the tyrosine hydroxylase gene (TH) was performed in patients from two families. DNA sequencing revealed the presence of four novel missense mutations (exon 9 and 14 in family A, exon 8 and 9 in family B); the mutations were confirmed with restriction enzyme analysis, and did not occur in control alleles. Three mutations are in the catalytic domain of the enzyme and one may disturb tetramerization. At the moment, all patients are in the fourth decade of life. For more than 30 years they have been able to live a normal life with low-dose L-DOPA medication.

[Action of piribedil in Parkinson disease. Multicenter study]

OBJECTIVES

Several controlled trials have shown that Trivastal (piribedil), a direct dopamine agonist, is active in the treatment of Parkinson's disease. The aim of the present clinical trial was to assess the efficacy of Trivastal 50 mg LP administered as monotherapy in patients naive to treatment with L-dopa.

PATIENTS AND METHODS

This 3-month multicenter study was conducted in 113 patients (66 men and 47 women), aged 63.1 +/- 0.6 years, with a 2.1 +/- 0.2 year history of Parkinson's disease and a mean Hoehn and Yahr stage of 1.82. Tremor was the predominant clinical feature in 42 patients; the 71 others presented with the full parkinsonian syndrome. Trivastal 50 mg LP doses were increased stepwise, up to doses of 150-250 mg/day at the end of the 3-month study period. Patients were clinically assessed at 1, 2 and 3 months using the Webster scale and the HARD depression scale.

RESULTS

In the 90 patients who completed the study, tremor fell from 1.7 to 1.0 (-41%, p < 0.001), bradykinesia from 1.5 to 0.8 (-47%, p < 0.001) and rigidity from 1.3 to 0.9 (-31%, p < 0.001). The 32 patients in whom tremor was the predominant feature improved their total score on the Webster scale from 5.8 to 4.7 (-19%, p < 0.05). The 58 patients with the full parkinsonian syndrome improved their total Webster score from 11.8 to 6.9 (-42%, p < 0.001). The depression score fell from 10.2 to 7.3 (p < 0.001), the most marked improvement being in mood and inhibition.

CONCLUSION

Monotherapy with Trivastal 50 mg LP at a mean dose of 200 mg/day is effective on the major symptoms of Parkinson's disease.

[Recessive dopa-responsive form of dystonia due to a mutation of the tyrosine hydroxylase gene]

The cause of Dystonia Musculorum Deformans (DMD) is most frequently unknown, therefore the treatment can only be symptomatic and often disappointing. In 1971 we reported the first two cases of recessive dopa-responsive dystonia, simulating a severe form of idiopathic DMD, however remarkably well reacting to levodopa treatment. We found that the first above mentioned two cases are related to mutations in the tyrosine hydroxylase gene itself in the chromosome 11p. An other variety which is dominant, with marked diurnal fluctuation, is due to mutations of a cofactor of the tyrosine hydroxylase, located in chromosome 14q. Consequently a trial of dopa treatment should be given in all diseases evoking a DMD diagnosis. Further more it is possible to confirm the diagnosis by a genetic inquiry.

Clinical assessment of olfactory dysfunction in Parkinson's disease

We used two simple tasks to test the capacities of patients with Parkinson's disease to discriminate and identify olfactory stimuli. The patients presented defective odor identification abilities whereas their capacity to discriminate between odors was apparently unaffected. This raises a question about the nature of olfactory dysfunction in Parkinson's disease. Further clinical data is required for analysis of this dysfunction. We therefore propose simple and rapid tests appropriate for clinical use with Parkinson's disease patients.

Juvenile-onset spinal muscular atrophy caused by compound heterozygosity for mutations in the HEXA gene

Progressive proximal muscle weakness is present both in spinal muscular atrophy (SMA) type III (Kugelberg-Welander disease) and in GM2 gangliosidosis, diseases that segregate in an autosomal recessive fashion. The SMN gene for SMA and the HEXA gene for GM2 gangliosidosis were investigated in a woman with progressive proximal muscle weakness, long believed to be SMA type III (Kugelberg-Welander type). She and her family underwent biochemical studies for GM2 gangliosidosis. Analysis of SMN excluded SMA. Biochemical studies on GM2 gangliosidosis showed deficiency in hexosaminidase A activity and increased GM2 ganglioside accumulation in the patient's fibroblasts. The HEXA gene was first analyzed for the Gly269-->Ser mutation characteristic for adult GM2 gangliosidosis. Since the patient was carrying the adult mutation heterozygously, all 14 exons and adjacent intron sequences were analyzed. A novel mutation in exon 1 resulting in an A-to-T change in the initiation codon (ATG to TTG) was identified. The adult patient is a compound heterozygote, with each allele containing a different mutation. Although mRNA was transcribed from the novel mutant allele, expression experiments showed no enzyme activity, suggesting that neither the TTG nor an alternative codon serve as an initiation codon in the HEXA gene.

[Juvenile GM2 gangliosidosis with progressive spinal muscular atrophy onset]

GM2 gangliosidosis are caused by a beta-hexosaminidase A enzyme deficiency. Mutations in the gene leaving residual enzyme activity give rise to juvenile and adult forms of the disease which have a great clinical heterogeneity. We report three cases which have been considered for some time as Kugelberg-Welander disease. beta-hexosaminidase A was determined with the sulfated synthetic substrate, 4-méthylumbelliferyl-N-acetylglucosamine 6-sulfate (4-MUGS), which allowed the diagnosis. Two of these cases from one family had normal values of hexosaminidase A in serum as found in the B1 variant. Compound mutations were detected. The B1 variants had a classical B1 mutation (G533-->A) and a new mutation located on exon 11. The patient of the second family had the classical mutation of adult GM2 gangliosidosis (Gly269-->Ser) and a new mutation on exon 1, at the initiation codon.

A new mutation in the HEXA gene associated with a spinal muscular atrophy phenotype

We describe two adult siblings who had had mild GM2 gangliosidosis since childhood. They presented with spinal muscular atrophy and dysarthria, and one sibling also had mental disturbances. Laboratory studies established the diagnosis of the B1 variant of GM2 gangliosidosis, because the hexosaminidase (Hex) A deficiency was not present upon testing with the unsulfated synthetic substrate 4-methylumbelliferyl N-acetylglucosaminide. HEXA gene analysis proved that the patients are compound heterozygotes for the previously identified G533-->A mutation and for a new mutation, G1171-->A, at exon 11. This new mutation affects a conserved amino acid and results in a Val-->Met substitution at position 391 of the HEXA gene. Full sequence of the alpha-subunit cDNA of Hex A revealed no other mutation. Assays for Hex A activities in patients suspected of having GM2 gangliosidosis should be performed with the sulfated substrate 4-methylumbelliferyl N-acetylglucosamine 6-sulfate.

Dystonia-parkinsonism syndrome resulting from a bullet injury in the midbrain

Images

Abnormal movement related potentials in patients with lesions of basal ganglia and anterior thalamus

Movement-related cortical potentials (MRCPs) were recorded from scalp electrodes during wrist flexion in 15 dystonic patients with bilateral (nine) or unilateral (six) circumscribed lesions in the striatum (eight), pallidum (six), or anterior thalamus (one). The results were compared with those of 10 age-matched healthy volunteers. The early (BP) and late (NS') MRCP components were assessed in terms of their gradients and distribution on the scalp in Cz, C3', and C4'. The gradients of both BP and NS' components were significantly flatter in the patients with bilateral lesions than in the control subjects. Also, the BP gradient was maximum at Cz, and the NS' component was contralaterally predominant in the control subjects but not in the patients. In patients with unilateral lesions, the gradients were flatter (p < 0.05) during movement of the dystonic wrist than during movement of the normal wrist. This difference was significant for BP and NS', regardless of the location of the electrodes. Also, the normal topographic predominance of BP at Cz and of contralateral NS' disappeared. The BP and NS' components of the MRCPs are thought to reflect preparatory activity in the supplementary motor area and the primary motor cortex before movement. Reduced BP and NS' gradients in patients with both bilateral and unilateral lesions of the basal ganglia, which project towards the supplementary motor area, are consistent with this hypothesis. The bilateral nature of these reductions suggests that both the ipsilateral and the contralateral motor cortex are involved in the genesis of the MRCPs and that the dystonia in these patients is associated with impaired motor preparation.

Botulinum antibodies in dystonic patients treated with type A botulinum toxin: frequency and significance

We measured serum antibodies to botulinum toxin (ABT) in 96 patients with focal dystonia who had been treated with type A botulinum toxin. The frequency of detectable ABT was 3% (three patients). Patients with ABT had received more than 50 ng of botulinum toxin, and the shortest time between two injections was significantly less than in patients without ABT. The clinical evolution of the three patients was heterogeneous: one had decreased effectiveness with repeated injections, another had persistent improvement, and the third never responded to toxin injections.

Linkage analysis in British and French families with idiopathic torsion dystonia

Idiopathic torsion dystonia is most commonly caused by an autosomal dominant gene or genes with reduced penetrance. An idiopathic torsion dystonia locus has been mapped to chromosome 9q34 in one large non-Jewish and several Jewish kindreds in the USA. Linkage analysis was performed in 27 (26 British, one French) small families with idiopathic torsion dystonia, three of which were Ashkenazi Jewish, using the highly polymorphic loci argininosuccinate synthetase (ASS) and Abelson oncogene (ABL) which map to 9q34. The cumulative lod score for the more informative ASS locus at a recombination fraction of 0.001 was -6.72. A large component of this score was derived from three non-Jewish families, indistinguishable clinically from the others, in which individual lod scores excluded a disease locus tightly linked to ASS. Analysis of all the data using HOMOG showed significant heterogeneity, but evidence for linkage of an idiopathic torsion dystonia gene to 9q34 in a subset of families. The allelic association observed between ASS/ABL and idiopathic torsion dystonia in Ashkenazi families in the USA was also present in British Jewish kindreds. These data suggest genetic heterogeneity in idiopathic torsion dystonia but indicate the existence of a locus for idiopathic torsion dystonia at 9q34 in both Jewish and non-Jewish kindreds in the UK.

Chronic administration of L-dopa affects the movement-related cortical potentials of patients with Parkinson's disease

The chronic effect of L-Dopa administration on the movement-related cortical potentials (MRCPs) was studied in two groups of patients with Parkinson's disease (PD): patients de novo (DN) and patients with on-off fluctuations. The BP and NS' premovement components of MRCPs associated with wrist flexion were assessed by their gradients and by their distribution on the midline (CZ) and the ipsilateral and contralateral hand sensorimotor areas. The treatment efficacy was controlled by a decrease in PD score (Columbia University Rating Scale). The BP component was absent in four out of nine patients DN. After 3 months of treatment, BP and NS' were recorded in six out of seven patients, and the NS' slope was significantly increased in all patients. In the off phase, MRCPs from patients with on-off fluctuations did not present a BP component. In the on phase, the NS' slope was increased and the BP was recorded in two out of nine patients. These patients exhibited an earlier PD stage (Hoehn and Yahr, stage 3). These two patterns of changes in the MRCPs induced by L-Dopa treatment suggest that the BP component was recorded in patients DN when a partial resolution of the nigrostriatal activity could occur. In patients with severe fluctuations, the dopaminergic striatal pathway was more severely affected and the increase of the NS' component demonstrated the activation of extrastriatal dopamine sites within the central nervous system (limbic and cortical structures, in particular).

Postural disturbances due to homonymous hemianopic visual ataxia

Patients with visual defects often complain of disturbances of equilibrium. In order to measure the influence of visual stimulation on posture, a study was made comparing the posture of hemianopic patients with that of healthy volunteers before and after occlusion of half of the monocular visual field. Hemianopia increases lateral oscillations in patients in the standing position and the projection of the body's centre of gravity shifts towards the hemianopia: in the volunteers, the same shift is noted after masking half the visual field. A tonic effect of visual information is discussed.

Activity and acceptability of piribedil in Parkinson's disease: a multicentre study

Several controlled trials have shown that the dopamine agonist, Trivastal (piribedil), is active in the treatment of Parkinson's disease, particularly with regard to tremor. To determine its efficacy as monotherapy in patients previously untreated with levodopa, a 3-month multicentre study was conducted with Trivastal 50 mg LP in 113 patients with idiopathic Parkinson's disease. The study population consisted of 66 men and 47 women, aged 63.1, SD 0.6 (43-79) years with a 2.1, SD 0.2 (1-15) year history of Parkinson's disease. Mean disease stage was 1.82 (1-4) by the Hoehn and Yahr classification. Tremor was the predominant clinical feature in 42 patients; the remaining 71 patients displayed the full parkinsonian syndrom. Trivastal 50 mg LP was prescribed stepwise up to doses of 150-250 (207, SD 6.4) mg/day at the end of 3 months. No concomitant anti-parkinsonian medication was given. Patients were clinically assessed at 1, 2 and 3 months on the Webster scale, a specific tremor scale and the HARD depression scale. Mean results were as follows in the 90 patients completing the study. On the Webster scale, tremor fell from 1.7 to 1 (-41%, P less than 0.001), bradykinesia from 1.5 to 0.8 (-47%, P less than 0.001) and rigidity from 1.3 to 0.9 (-31%, P less than 0.001); on the specific scale, rest tremor decreased in daily duration and amplitude from 3.9 to 2.4 (-39%, P less than 0.001) and from 2.9 to 2.1 (-35%, P less than 0.001), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The shadow of movement

Movement is preceded, accompanied and followed by reactions which give to the primary action its correct execution and ensure that the body's axis, together with the limbs, maintains the right balance. If these reactions are interfered with, incoordination of movement, lack of balance, hypertonia or dystonia may all appear. In the case of dystonia, postural mechanisms tend to become dominant and take over from the kinetic component of movement. In the upper limbs, the dystonic posture follows patterns analogous to those used by monkeys for postural purposes. Thus, while the initial mechanisms of movement represent highly sophisticated processes thoroughly adapted to living in an upright state, the reactions that go with the movement are more primitive and probably have a less helpful role.

TGF-beta-like activity produced during regression of exacerbations in multiple sclerosis

Samples representative of different stages of disease from a longitudinal study of multiple sclerosis patients were tested in the anchorage-independent growth assay for TGF-beta and an increased activity was detected in the supernatants from 2-day blood cell cultures from patients with active disease compared to patients without active disease and healthy donors. Within the group of patients with active disease, the TGF-beta like activity was significantly increased in the subgroup of patients tested during the period of regression of the symptoms where it appeared in 86.9% of the samples. These results suggest that TGF-beta or a TGF-beta like factor may play a role in regeneration processes in multiple sclerosis.

Intravascular lymphomatosis (neoplastic angioendotheliosis) of the central nervous system: case report and literature review

A 63-year-old woman developed gradual slowness, recurrent multifocal deficits, severe constitutional symptoms and hypopituitarism which progressed to death over 2.5 months. Elevation in lactico dehydrogenases was the main biological abnormality. Necropsy showed an intravascular malignant proliferation which proved to be a lymphoma of B-lineage. In order to better define diagnostic criteria, we reviewed previously reported cases of intravascular lymphomatosis of the central nervous system. A strategy for establishing the diagnosis is proposed.

[Movement-related cortical potentials in aged subjects]

Cortical potentials related to freely-executed voluntary wrist flexion (MRPs) were studied in 35 subjects aged 23-80 years. The characteristics of the MPRs in aged subjects were determined in comparison data from 14 young subjects aged 23-40 years. The analysis concerned 3 components of the MRPs: the slow negative shifts (NS1 and NS2) before the movement onset and the motor potential (MP). In the aged subject, the latencies measured at Cz show a significant lengthening of the NS1 and of the duration of NS2 (NS' of Shibasaki et al, 1980). The mean amplitude of the NS1 peak at Cz is decreased, and those of N1 (the negative peak before the movement) and MP are not significantly different from those of the young subjects. The NS2 component in the aged subject (between NS1 and N1) is thus increased. In contrast to the young subjects, who present a predominance of N1 and MP amplitudes of the contralateral motor cortex over the ipsilateral cortex, the aged subjects lose lateralization of these components. Recording of MRPs with subdural electrodes (Neshige et al, 1988) shows taht NS1 results from the activity of the supplementary motor area and from the ipsi-contralateral primary motor cortex. The increase in NS2 might be interpreted as an expression of activity coming from other structures to compensate for the reduction in NS1 in the aged subject and to maintain the level of the motor potential MP.

(99mTc)-HM-PAO SPECT and cognitive impairment in Parkinson's disease: a comparison with dementia of the Alzheimer type

Regional cerebral perfusion was evaluated by single photon emission tomography (SPECT) using (99mTc)-HM-PAO as a tracer, in thirty Parkinsonian patients with (n = 15) or without (n = 15) dementia, nineteen patients with dementia of the Alzheimer type (DAT) and thirteen control subjects. HM-PAO uptake was measured in the frontal, parietal, temporal and occipital cortex and tracer perfusion was expressed as cortical/cerebellar activity ratios. Regional HM-PAO ratios in nondemented Parkinsonian patients did not differ from controls, whereas in demented patients with Parkinson's disease (DPD) a significant reduction was found in the parietal, temporal and occipital cortex. Tracer uptake ratios were significantly reduced in all regions in the DAT group. Thus DPD and DAT shared a common pattern of marked posterior hypoperfusion, although the perfusion defect was greater and more extensive in the DAT patients.

Spasmodic torticollis--review of 220 patients

220 patients with isolated and idiopathic spasmodic torticollis were followed and treated over a 14 year period. Each patient was given a short questionnaire leading to the present retrospective data analysis. In most areas, including female preponderance and frequency of postural tremor, the findings confirmed previous studies and highlighted particular points: importance of psychopathological antecedents and association with stressful life-events. The discussion deals with some of the conflicting debates surrounding this unusual disorder. What is the role of psychopathological factors? What is the therapeutic prognosis? The best therapeutic results were obtained by combining anticholinergic drugs, local injections and rehabilitation.

[Changes in movement-related cortical potentials in Parkinson's patients before and after treatment with levodopa]

Cortical potentials associated with voluntary, self-paced wrist flexion (MRPs) were recorded from 3 scalp locations (Cz and psi contralateral hand motor area) in patients with Parkinson's disease (9 de novo patients and 30 L-Dopa treated patients). The analysis concerned 3 components of the MRPs: the 2 slow negative shifts (NS1 and N1) before the movement onset and the motor potential (MP). The NSI amplitude was measured at Cz, the peak negativity N1 and MP from contralateral hand motor area location. The potential distribution was also studied. The amplitude of the MRPs components was the same as in the normals. But in de novo patients, the potential distribution of the NS1 component was different; a Cz preponderance of the NS1 amplitude was not found. In patients treated with L-Dopa, there is a negative correlation between the changes in amplitude and the changes in clinical rating for NS1, N1 and MP components. The decrease in the MRPs components was significant from stage III and IV of the Hoehn and Yahr scales. After L-Dopa therapy, the NS1 component from de novo patients was increased in amplitude. The amplitude of the MRPs components from patients with L-Dopa induced clinical fluctuations was reduced during "off" period in comparison to "on" period. The findings suggest that the NS1 potential and the N1 and MP components share 2 distinct systems for the control of voluntary movement. Their mechanism in Parkinson's disease is discussed.

A comparative technetium 99m hexamethylpropylene amine oxime SPET study in different types of dementia

Regional cerebral perfusion was evaluated by single photon emission computed tomography (SPET) using technetium 99m hexamethylpropylene amine oxime (99mTc-HMPAO) as a tracer, in 13 control subjects and 44 age-matched patients suffering from dementia of the Alzheimer's type (DAT, n = 19), presumed Pick's disease (n = 5), idiopathic Parkinson's disease with dementia (DPD, n = 15) and progressive supranuclear palsy (PSP, n = 5). HMPAO uptake was measured in the superior frontal, inferior frontal, parietal, temporal and occipital cortices, and the perfusion values were expressed as cortical/cerebellar activity ratios. As compared with controls, tracer uptake ratios in the DAT group were significantly reduced over all cortical regions, with the largest defects in the parieto-temporal and superior frontal cortices. A marked hypoperfusion affecting the superior and inferior frontal cortices was found in Pick's disease, whereas a mild but significant hypoperfusion was observed only in the superior frontal cortex of patients with PSP. In the DPD group, HMPAO uptake was significantly reduced in the parietal, temporal and occipital cortices, but not in the frontal cortex. These results show that DAT and DPD share an opposite anteroposterior HMPAO uptake defect as compared with the Pick's and PSP groups.

Effect of controlled-release carbidopa/levodopa on motor performance in advanced Parkinson's disease

Twenty parkinsonian patients were treated with controlled-release carbidopa/levodopa (Sinemet CR). All were affected by therapeutic response fluctuations related to the timing of drug administration. The daily dosage after 1 year, 766 mg +/- 250 mg, was increased by 23% compared with standard Sinemet dosage, without additional secondary effects. Parkinsonian scores improved by 43%; the prolongation of "on" periods was 63%. Nevertheless, 7 patients withdrew from this study during the 1st month of treatment. Only 1 withdrew due to an adverse reaction to the formulation, a recurrence of hallucinations. The progressive effect of the 1st morning dose and the often unpredictable time at which the product first takes effect were found to be frustrating for the other patients who withdrew. We believe that this disappointment can be avoided by giving new patients the controlled-release formulation from the start of therapy.

Increased production of interferon gamma and tumor necrosis factor precedes clinical manifestation in multiple sclerosis: do cytokines trigger off exacerbations?

We have carried out a longitudinal study of interferon (IFN) and tumor necrosis factor (TNF) using a whole-blood mitogen stimulation assay in 20 multiple sclerosis (MS) patients and in a healthy control group. We set up individual profiles and the results were quite constant for each individual, both in healthy donors and in the patients in remission. Before exacerbations, however, we found an increase of IFN-gamma and TNF production preceding clinical symptoms by a maximum of 2 weeks. In benign cases, the increase disappeared rapidly, even before the appearance of symptoms, whereas we found sequelae whenever the increase persisted during weeks. In chronic progressive patients, we frequently found intervening increases. It may be that IFN-gamma and TNF trigger off exacerbations at a very early stage and that these cytokines may also play a role in maintaining disease in chronic progressive and invalidating forms.

[The electrophysiological approach to tardive dyskinesias]

Electrological study of TD is of value on two counts: it facilitates diagnosis in cases where the origin of the dyskinesia is not known, it enables objective monitoring of therapeutic studies. TD electromyographic recordings are highly specific. The recording shows: either, continuous activity of irregular amplitude corresponding to that which is called "tardive dystonia" in a clinical context, or, discontinuous irregular activity sometimes grouped into bursts of activity of relatively long duration, with a rhythm of 0.5 to 2 Hz during the temporal sequences, which are of variable duration. This type of activity is the same as that found in movements induced by L-dopa (L-dopa IM). In both cases, these involuntary movements only occur after several months' or years' treatment. They predominate in the oro-facial region. However, reactions to various pharmacological agents are not identical. While activity is decreased by neuroleptics and increased by L-dopa, anticholinergics have no effect on L-dopa IM whereas they exacerbate TD. GABA decreases TD but is ineffective against L-dopa IM. The reaction of these movements to L-dopa and neuroleptics, suggests that both reflect hypersensitivity to dopamine. Their different reactions to GABA lead one to suppose that GABA modulation of the dopaminergic system is defective in TD.

Bilateral brain dysfunction during motor activation in type II schizophrenia measured by EEG mapping

In this final electroencephalographic (EEG) mapping study of our series on motor dysfunction in neuroleptic-treated schizophrenic patients, we studied 10 right-handed patients with marked negative symptomatology [type II; raw score on the SANS (Munich version) 31.4 +/- 5.1]. Simple and multisensorimotor tasks involving both the dominant and nondominant hand were used for cortical activation. All tasks were referred to resting states obtained after specially designed relaxation procedures. In contrast to predominantly type I patients (SANS-MV score 12.3 +/- 4.9) of our previous EEG mapping studies, we found for resting states minor evidence (only) of increased power values in the frequency bands delta and theta. Furthermore, in contrast to signs of "left hemisphere dysfunction" and possible "compensatory right hemisphere overactivation" during motor tasks, which we discussed previously for our type I patients, we found for the type II schizophrenics a bilateral brain dysfunction. This consisted of "nonreactivity" in all frequency bands except alpha, in which, on the contrary, a "hyperreactivity" seemed to be present. In combination with evidence of bilateral hemispheric dysfunction in type II patients reported by other authors using EEG, evoked potentials, regional cerebral blood flow (rCBF) and magnetic resonance imaging (MRI) methods, this suggests that marked bilateral brain dysfunction may be correlated in schizophrenia with a clinical syndrome corresponding rather to the "negative pole" of the positive-negative dimension. In contrast, "left hemisphere dysfunction" and "signs of compensatory overactivation" seem to be linked more to a "positive" symptomatology. Finally, discrepancies of our EEG mapping and rCBF findings during motor activity suggest, speculatively, "uncoupling" between electrical and circulatory parameters in schizophrenia involving both hemispheres in type II, and predominantly the left hemisphere in type I, patients.

A comparative evaluation of the short orientation memory concentration test of cognitive impairment

In order to assess the relative sensitivity and specificity of Katzman's short orientation memory concentration test (OMCT), 89 non demented patients and 44 patients affected by vascular or degenerative dementia were consecutively evaluated by three different mental status tests. The OMCT appeared equivalent to the Mini Mental State Examination in identifying dementia. Optimum sensitivity and specificity, respectively 88% and 94%, were achieved by a 10/11 cut-off score, giving a 11% false positive rate. Among patients with Alzheimer's disease, the OMCT score was correlated with mean values of a simple reaction time. It was also correlated with the Wechsler global MQ and the orientation, logical memory and paired associates items of the scale. There was no relationship between the OMCT score and the coloured Progressive Matrices IQ. The OMCT was reliable when given at 1 month interval. Serial evaluations did not show any significant practice effect.

Peripheral neuropathies during hypoxaemic chronic obstructive airways disease

Peripheral nervous system alterations during chronic obstructive airways disease (COAD) with respiratory insufficiency seem more frequent than usual neurological practice would suggest. Almost a third of COAD patients have clinical evidence of peripheral neuropathy and two thirds have electrophysiological abnormalities. The presentation consists of a polyneuropathy often subclinical or with predominantly sensory signs, which has the neurophysiological and pathological features of predominantly axonal neuropathy. The presumed etiopathogenic factors are multiple: chronic hypoxia, tobacco smoke (which contains at least three neurotoxic constituents) alcoholism, malnutrition and adverse effects of certain drugs. Hypoxia probably plays the leading part, either by direct action on nerves fibres or by enhancing the effects of other neurotoxic factors or deficiencies.

Therapeutic response to progabide in neuroleptic- and L-dopa-induced dyskinesias

The results of two trials conducted in human dyskinesia with progabide, a specific gamma-aminobutyric acid (GABA) receptor agonist, are reviewed. In one trial, 13 parkinsonian patients with L-DOPA-induced dyskinesia (LDD) and "on-off" fluctuations were included in a double-blind controlled trial progabide versus placebo. No change was observed during this trial in the severity of dyskinesia on progabide treatment but the drug significantly extended the "on" period as compared with placebo. In the second trial, 20 patients with neuroleptic-induced dyskinesia (TD) entered an open dose ranging trial with progabide. Fourteen of the 16 patients who completed the trial had a good-to-excellent therapeutic response. According to these results, progabide does not seem to have the same therapeutic benefit in LDD as TD. These data suggest that the hypothesis of a dopaminergic supersensitivity as a similar pathogenic substrate for both clinical conditions should be reconsidered. If this hypothesis remains the most consistent to explain the occurrence of LDD, the therapeutic effect of progabide in TD is an argument for an implication of the GABAergic system in the appearance of TD.

Clinical trial of Madopar HBS in parkinsonian patients with fluctuating drug response after long-term levodopa therapy

23 parkinsonian patients, 11 men and 12 women with an average age of 62 +/- 10 years, were recruited for an open substitution study of standard Madopar by Madopar HBS (hydrodynamically balanced system). All patients were presenting fluctuations in efficacy associated or not with abnormal involuntary movements. The patients in this study had been suffering from Parkinson's disease for 16 +/- 6 years and were severely disabled (Hoehn and Yahr grade III-V). The substitution was carried out dose for dose from one day to another. During the first month the dosage titration was aimed at finding the optimal therapeutic effect. After 120 days 13 patients were continuing the treatment while 10 had stopped it because of lack of therapeutic advantage. After 120 days, as compared to the initial state, end-of-dose fluctuations improved by 47%, the parkinsonian symptomatology by 54% and the abnormal involuntary movements improved by 33%. The daily dose of Levodopa had to be increased from 580 +/- 230 to 710 +/- 240 mg. The results obtained were excellent in 5 cases, good in 6 and moderate in 2 cases.

Auditory perception of music measured by brain electrical activity mapping

The brain electrical activity of right-handed normal subjects was studied while they were exposed to auditory stimulation of the music type. The material presented was a note, a scale and a melody, recorded on magnetic tape. Each stimulus condition lasted 45 sec. The first 30 sec were analysed using brain electrical activity mapping in the delta (1-4 Hz), alpha (8-12 Hz) and beta 2 (18-24 Hz) frequency bands. The results showed significant bilateral reaction differences for all conditions, showing a left midtemporal activation predominance for the note and scale conditions, but a right midtemporal and frontal predominance for the melody. The results are discussed in terms of functional specialization for different levels of processing.

Patients with Alzheimer's disease show an increased content of 15 Kdalton somatostatin precursor and a lowered level of tetradecapeptide in their cerebrospinal fluid

The relative proportions of both somatostatin-14 and its precursors somatostatin-28 and the 15 Kdalton prosomatostatin were evaluated by radioimmunoassay in the cerebrospinal fluid of patients with Alzheimer's disease. It was observed that the patients have a lowered content in the tetradecapeptide somatostatin while they exhibit a significant increase in unprocessed 15 Kda precursor. These results indicate that these patients possess impaired processing mechanisms which may be responsible for the lowered content in mature somatostatin-14. These observations may provide a valuable test for the ante-mortem diagnosis of the disease. They are discussed in connection with others suggesting that Alzheimer's patients may be selectively altered in their somatostatinergic neurones of their cerebral cortex (Morrison et al. (1985) Nature 314, 90-92. Roberts et al. (1985) Nature 314, 92-94).

[Assay of anti-acetylcholine receptor antibodies in myasthenic syndromes of newborn infants]

Eighteen neonates were investigated for antibodies directed against acetylcholine receptors. No antibody was detected in 3 cases of congenital myasthenic syndrome, whereas positive results (3.5 to 250 nM) were obtained in 7 cases of transitory neonatal myasthenia and in 7 of 8 asymptomatic infants born to myasthenic mothers. The neonatal antibodies are fully cleared within 1 to 6 months (half-life: 9 days to 2 and a half months). The prognostic value of the maternal and infantile antibody titers is limited: maternal titer at the end of pregnancy, though usually higher in the mothers of myasthenic children, do not predict or preclude the occurrence of transitory myasthenia, and there is no clear correlation between the severity and duration of the myasthenia and the initial titer or the level of the child's antibodies. The assay which measures antibodies against acetylcholine receptors is useful in that it confirms the diagnosis of transitory myasthenia and excludes congenital myasthenic syndromes.

EEG mapping of left hemisphere dysfunction during motor performance in schizophrenia

With a newly developed system of brain electrical activity mapping we studied 10 right-handed, neuroleptic-treated schizophrenics (five of the disorganized, five of the paranoid type, corresponding to 295.1 and .3 in DSM-III), compared with 10 normal controls. Increasingly complex motor tasks were used for cortical activation, all functional states being referenced to resting states recorded after a special relaxation program. We found higher delta and theta amplitudes during rest, as noted in previous studies, and lower beta power values. As a major result, however, we found a widespread left hemisphere dysfunction in schizophrenics, predominantly in the left primary sensory and motor areas. Additionally, we found signs of a "compensatory" overactivation in patients in motor tasks, when this hemisphere is not "used" by normal persons. The results support our findings obtained with this method during multisensory motor coordination in schizophrenia. The results in these patients suggest that these are not merely vigilance, attention, or motivation dysfunctions, but rather specific cortical correlates of impaired motor performance.

Motor responses measured by brain electrical activity mapping

The brain electrical activity of right-handed normal subjects was studied while they were exposed to motor performance tasks that were of increasing difficulty. Each task lasted 45-60 s, and a 30-s period of each task was analyzed by a spectrum analyzer. Data are presented in topographic maps showing the electrical activity for each task, in delta (1-4 cycles [c]/s), alpha (8-12 c/s), and beta 2 (18-24 c/s). The results showed a bilateral decrease in amplitude in sensorimotor areas relative to baseline, for a single hand movement. Tasks that required the programming of movement showed baseline/task differences in amplitude in additional areas; the right frontal area, the prefrontal area, the posterior parietal area, and the left temporal area. The results obtained suggest that different topographical areas are involved in motor tasks that require increased level of programming.

Severe chorea after acute carbon monoxide poisoning

Ten days after an acute exposure to carbon monoxide, a 33-year-old woman exhibited severe chorea. CT scan revealed bilateral lucencies of the pallidum and anterior arm of the internal capsule. Chorea was successfully treated by chlorpromazine and did not relapse after treatment withdrawal. The mechanism of chorea in acute carbon monoxide poisoning is discussed.

Motor responses measured by brain electrical activity mapping

The brain electrical activity of right-handed normal subjects was studied while they were exposed to motor performance tasks that were of increasing difficulty. Each task lasted 45-60 s, and a 30-s period of each task was analyzed by a spectrum analyzer. Data are presented in topographic maps showing the electrical activity for each task, in delta (1-4 cycles [c]/s), alpha (8-12 c/s), and beta 2 (18-24 c/s). The results showed a bilateral decrease in amplitude in sensorimotor areas relative to baseline, for a single hand movement. Tasks that required the programming of movement showed baseline/task differences in amplitude in additional areas; the right frontal area, the prefrontal area, the posterior parietal area, and the left temporal area. The results obtained suggest that different topographical areas are involved in motor tasks that require increased level of programming.

Somatostatin-like immunoreactivity and acetylcholinesterase activities in cerebrospinal fluid of patients with Alzheimer disease and senile dementia of the Alzheimer type

Somatostatin-like immunoreactivity (SLI) and acetylcholinesterase (AchE) activities were measured in the cerebrospinal fluid of 25 patients with senile dementia of the Alzheimer type (SDAT). Both SLI levels and AchE activities were reduced in the CSF of SDAT patients. The SLI levels and AchE activities were not correlated with the duration and the dementia score. However, in two patients the CSF SLI concentration was in agreement with the SLI levels in the frontal cortex obtained by biopsy. Our findings suggest that CSF SLI may be a good index of cortical SLI activities.

Ageing and Parkinson's disease

Based on the examination of 400 patients suffering from Parkinson's disease, the main symptoms of motor and brain ageing have been underlined. Motor ageing is evidenced by the importance of akinesis, while rigor and quaking are limited, and by the arrival of dystonic attitudes which tend to last. Brain ageing is revealed by memory disturbances, mental disorders and delusions without phasic or praxis troubles. The comparative study of different types of dementia did not allow clinical or anatomopathological confirmation.

[Agenesis of the corpus callosum in a man with complete mosaic trisomy 8]

The coexistence in an epileptic patient of a radiologically confirmed agenesis of the corpus callosum and other somatic abnormalities, notably skeletal, prompted us to perform a karyotype which showed an extra chromosome 8. The trisomy 8-callosal agenesis association is not exceptional, but it may easily be missed owing to the absence or scarcity of clinical signs of the cerebral malformation. We would suggest that patients with confirmed agenesis of the corpus callosum should be investigated for trisomy 8 and conversely, that patients with trisomy 8 detected during examination for a characteristic malformative syndrome should be systematically investigated for abnormality of the neocortical commissure.

Mood disorders in left and right brain-damaged patients: comparison between ratings and self-ratings on the same adjective mood scale. Some methodological problems

In the context of recent developments of the lateralization model of emotions, this study investigates the intensity of depressive mood in left (LBD) and right (RBD) unilateral brain-damaged patients, comparing expression and experience of negative emotion through rating and self-rating scales. Seventeen BD inpatients (6 LBD, 8 RBD and 3 neurological patients without lesions) completed the Zerssen 28-item mood scale a few days after their admission to hospital. During the same period, 2 nurses, one working during the morning, the other during the afternoon and 1 clinician, a neuropsychiatrist, under the instruction of rating the patient mood state, completed independently the same mood scale. Results show that there is a strong agreement among the self-rating and the observers' total scores, which is high between the clinician and the patient but less strong between the 2 nurses and each nurse and the patient. Morever, self-rating scores are significantly different from those attributed by observers. The comparison between LBD and RBD showed that LBD rated themselves as more depressed than RBD, but the differences were statistically significant in the case of the clinician ratings only. These results have been interpreted with reference to methodological problems rather than in terms of a possible discrepancy between expression and experience of affect.