The premorbid personality of patients with Parkinson's disease: evidence with the Tridimensional Personality Questionnaire

The premorbid personality traits of 102 patients with Parkinson's disease (PD) and 57 age-matched healthy controls were studied by the recently developed Tridimensional Personality Questionnaire. We found significantly fewer (p < 0.05) of a group of traits called "novelty seeking" (NS), but no changes in "harm avoidance" (HA) and "reward dependence" (RD), in PD patients, for the period approximately 5-10 years before the onset of the disease, compared to controls. Individuals who are lower than average in NS and average in HA and RD are described as reflective, rigid, loyal, stoic, slow-tempered, frugal, orderly, and persistent Since NS is thought to be directly related to central dopaminergic reactivity, the premorbid expression of these behaviors may be the reflection of neurochemical deficits (hypodopaminergic tone) accompanying the presymptomatic phase of PD.

Regional patterns of brain tissue loss associated with depression in Parkinson disease

OBJECTIVE

To investigate, using MRI and voxel-based morphometry (VBM), whether specific patterns of gray matter (GM) and white matter (WM) loss are associated with depression in patients with Parkinson disease (PD).

METHODS

Forty patients with PD and 26 healthy subjects were studied. Patients were diagnosed with depression using DSM-IV criteria. The Hamilton Depression Rating Scale (HDRS) was administered to patients. The topographic distribution of brain tissue loss in patients with PD and controls was assessed using VBM as implemented in Statistical Parametric Mapping (SPM5).

RESULTS

Twenty-four patients with PD were diagnosed as nondepressed (PD-NDep) and 16 as having depression (PD-Dep). Patient groups were similar in terms of clinical findings, except for the HDRS score (p < 0.001). Compared to controls, patients with PD showed common GM loss in the right anterior cingulate (AC) cortex and insula, and in the left middle frontal and angular gyri (p < 0.001). No regions of WM loss common to PD-NDep and PD-Dep patients relative to healthy controls were found. PD-Dep vs PD-NDep patients showed WM loss in the right AC bundle and inferior orbitofrontal (OF) region (p < 0.001). In patients with PD, HDRS score correlated with WM loss in the right inferior OF region (r = -0.51, p < 0.05).

CONCLUSIONS

Tissue loss in several WM regions within the cortical-limbic network occurs in PD-Dep vs PD-NDep patients. Such pattern of brain atrophy overlaps with key regions involved in major depressive disorders, suggesting an increased vulnerability of this neural circuit in PD. This may partially account for the high prevalence of depression in PD.

Do women benefit more from systemic thrombolysis in acute ischemic stroke? A Serbian experience with thrombolysis in ischemic stroke (SETIS) study

OBJECTIVE

The female sex is associated with increased stroke severity and relatively poor functional recovery. Several studies have demonstrated that women with stroke benefit more from intravenous thrombolysis compared with men, while others found the nullification of gender effect among women treated with recombinant tissue plasminogen activator (rtPA). The purpose of our study was to determine any gender differences in the efficacy and safety of systemic thrombolysis among patients with acute ischemic stroke in Serbia.

METHODS

Data were from the Serbian experience with intravenous thrombolysis in ischemic stroke (SETIS) study, a prospective, ongoing, multicenter, open, and observational study in Serbia of all patients who have received rtPA for acute ischemic stroke. We analyzed sex differences in the baseline characteristics, functional outcome and treatment complications.

RESULTS

Among 60 women and 96 men with stroke and treated with intravenous thrombolysis, we found that at day 90, no significant sex differences in excellent functional outcome (50.9% of women vs. 57.0% of men, p=0.5), favorable functional outcome (61.4% of women vs. 68.8% of men, p=0.38) or death (8.8% of women vs. 12.9% of men, p=0.60). These results were constant even after adjustments for age, severity of basal neurological deficit and onset to treatment time.

CONCLUSION

There were no sex differences in functional outcome at 90 days after the stroke among patients treated with IV rtPA. This finding might confirm that thrombolytic therapy nullifies usual sex differences in stroke outcome and suggests that women with stroke may benefit more from rtPA treatment.

Characteristics of dystonic movements in primary and symptomatic dystonias

OBJECTIVE

To compare clinical characteristics of the involuntary movements in primary and symptomatic dystonias.

PATIENTS AND METHODS

132 consecutive patients with the diagnosis of primary dystonia and 51 consecutive patients with secondary dystonia caused by well defined structural lesion(s) of the central nervous system, with particular emphasis on the characteristics of involuntary movements.

RESULTS

Eight variables with the highest risk contribution to either symptomatic or primary dystonias were identified: dystonic movement in secondary dystonia was much more frequently presented at rest, whereas the presence of dystonic tremor, chronic inflammatory process, or peripheral trauma located in the region that is later affected by dystonia, as well as the use of sensory tricks and development of spontaneous remissions, classified the affected patients more often in the category of those with primary dystonia.

CONCLUSION

The study identified several clinical features that may be helpful in differentiating primary from secondary dystonia.

MR imaging of the brain in patients with hepatic form of Wilson's disease

The aim of this study was to detect the sites and frequency of possible lesions by brain magnetic resonance imaging (MRI; 1,5T) in a group of 16 neurologically asymptomatic patients with hepatic form of Wilson's disease (WD; seven untreated and nine under treatment). Abnormal MR findings of the brain were found in 75% of patients. Lesions in brain parenchyma were detected in all untreated, drug-naive patients and in 44% of treated patients. Abnormal signal in globus pallidus, putamen, and caudate nucleus was revealed in 86, 71 and 71% of treated and in 33, 33 and 22% of untreated patients, respectively. In five of eight patients with putaminal pathology (62.5%) and in four of seven patients with caudate nuclei involvement (57%), only proton density 2-weighted sequence (PDW) exhibited sensitivity for lesion detection, with both T1W and long echo T2W sequences being insensitive. This superiority of PDW sequence was even more pronounced in the group of untreated patients in whom 80% of putaminal pathology was visible exclusively on this sequence. The lower frequency of lesions in the group of treated in comparison with untreated patients indicated that they might be reversible in the course of chronic chelating therapy.

SCA2 and SCA3 mutations in young-onset dopa-responsive parkinsonism

In this study no one of our 85 patients of Serbian origin with young-onset (</= 45 years) dopa-responsive parkinsonism (YOP), previously proved negative for PARK1 and PARK2 mutations, had either spinocerebellar ataxia type 2 (SCA2) or SCA3 mutation. These data do not prove the significance of these two mutations in either sporadic or familial YOP suggestive of Parkinson's disease.

The effect of stage of Parkinson's disease at the onset of levodopa therapy on development of motor complications

The aim of this study was to ascertain whether the stage of Parkinson's disease (PD) (according to the Hoehn and Yahr staging system) would affect the length of time between the introduction of levodopa therapy and appearance of levodopa-associated motor complications. Forty patients with clinically definite PD were studied. In all, clinical and therapeutic data were collected from the time of diagnosis to the time of levodopa-associated motor complications (i.e. dyskinesia, motor fluctuations). In 17 patients, levodopa could be started in Hoehn and Yahr stage I (H & Y-I; 16.2 months after the onset of PD), whilst in 13 patients levodopa could be started in H & Y-II (19.6 months after the onset of the disease) and in 10 in H & Y-III (45.1 months after the onset of PD). Cox proportional hazard regression model shows that the PD patients in whom the initial levodopa treatment was introduced at stage III develop both dyskinesias and motor fluctuations significantly earlier than the patients whose levodopa started in stage I and II of PD. The median interval to develop dyskinesias was 66, 72 and 24 months for patients in whom levodopa was introduced in stage I, II and III, respectively. These values were 64, 55 and 14 months for motor fluctuations. These findings add to the clinical arguments that favour an essential role of severity of PD at levodopa initiation as a risk factor for the development of levodopa-associated motor complications.

DYT1 mutation in primary torsion dystonia in a Serbian population

Primary torsion dystonia (PTD) is a clinically and genetically heterogeneous movement disorder. A GAG deletion at position 946 in the DYT1 gene is responsible for most cases of autosomal dominant early-onset PTD. We analysed the DYT1 mutation in 50 patients from a Serbian population, selected according to the proposed guidelines for diagnostic testing: (a) 38 patients with PTD onset < 26 years, and (b) 12 patients with the disease onset +/- 26 years, but with at least one affected family member with early-onset dystonia. Only three apparently sporadic patients among the 50 individuals tested were positive for the GAG deletion in the DYT1 gene: one with typical, generalized, one with long-lasting, non-progressive segmental, and one with multifocal dystonia. Molecular analysis of relatives in 2 families revealed that the lack of family history was due to reduced penetrance.

[Effect of slow repetitive transcranial magnetic stimulation on depression in patients with Parkinson 's disease]

Parkinson's disease (PD), that has usually been associated with movement disorders, is also associated with depression in about 40% of patients [9]. Transcranial magnetic stimulation (TMS) is a new non-invasive technique for direct stimulation of the cerebral cortical neurons [1]. Several open studies have shown that repetitive TMS (rTMS) at both rapid (rapid rTMSi: > 1 Hz) and low frequencies (slow rTMSi: < 1 Hz) may have antidepressant action [2-6]. The study included 8 patients diagnosed as PD fulfilling the DSM-IV criteria for major depression (5 patients) and dysthymia (3 patients). Magnetic stimulator, 200 Mag-Stim, total output 2 T and a circular coil of 90 mm, were used. For ten consecutive days, between noon and 1 p.m. the patients were stimulated with apprx. 80% of the output (1.6 T) at 0.5 Hz. The daily treatment implied stimulation of both sides of the head (first the right, then the left) at four sites (prefrontal, frontal, parietal and occipital regions) with 5 stimulations each site (20 stimulations per hemisphere). Before the beginning of the study, 2-3 hours after the last stimulation (day 10), 7 and 14 days after completion of the treatment, the patients were subjected to scoring on the Hamilton Depression Rating Scale [11] and Unified Parkinson's Disease Rating Scale (UPDRS) [12]. The HDRS values before initiation of rTMS were 19.2 +/- 3.1, with significant fall (p < 0.01) after 10 days of stimulation (14.9 +/- 3.2), 17 days (12.2 +/- 2.7) and 24 days (13.6 +/- 5.3) after the beginning of the study, suggesting that the antidepressive effect persisted even two weeks after discontinuation of stimulation. The UPDRS values were monitored concomitantly. The values on this scale failed to alter significantly. In conclusion, rTMS is a relatively safe and painless method associated with antidepressant action in PD patients. Treatment of depression in PD is of great importance, but the choice of medication is accompanied with numerous limitations [20]. Antidepressant action of rTMS and its maintenance for two weeks after discontinuation of stimulation enables usage of this method in PD in phases of exacerbation of depressive symptoms at least over the period required to reach the full effect of selected medication.

Penicillamine-induced lethal status dystonicus in a patient with Wilson's disease

A 37-year-old man with Wilson's disease is described, in whom the introduction of penicillamine therapy was followed after 3.5 weeks by the development of the status dystonicus with a fatal outcome.

Bereitschaftspotential in depressed and non-depressed patients with Parkinson's disease

Impaired initiation and slowed execution of movements are two of the principal characteristics of Parkinson's disease (PD). A similar pattern of movement impairments (psychomotor retardation) can be seen frequently in patients with idiopathic depression. In addition, affective disorders have been frequently reported in patients with different basal ganglia disorders. The aim of this study was to determine whether there are some particularities in the cerebral electrical activity during the preparation and execution of voluntary internally paced movements (i.e., Bereitschaftspotential, BP) in depressed PD patients, which can distinguish them from non-depressed PD patients, as well as from healthy controls. The BPs were recorded in 16 patients with idiopathic PD, eight of whom were depressed (PD-D), and eight of whom were not (PD-ND). Additional recordings were taken from a group of eight age- and sex-matched healthy subjects. Depression was classified using the Research Diagnostic Criteria and the two PD groups were matched for age, disease severity, and disease duration. The amplitudes and slopes of the BPs from PD patients were generally smaller than in controls, but there was no specific pattern of BP changes that distinguished depressed from non-depressed PD patients. In addition, there was no particular association between measures of depression severity and BP parameters. The data suggest that presence of depression in PD might not have any additional deteriorating influence on already impaired preparation for self-paced spontaneous movements.

[Effect of slow repetitive transcranial magnetic stimulation on depression in patients with Parkinson disease]

Parkinson's disease (PD), that has usually been associated with movement disorders, is also associated with depression in about 40% of patients [1-9]. Transcranial magnetic stimulation (TMS) is a new non-invasive technique for direct stimulation of the cerebral cortical neurons [1]. Several open studies have shown that repetitive TMS (rTMS) at both rapid (rapid rTMSi > 1 Hz) and low frequencies (slow rTMSi < 1 Hz) may have antidepressant action [2-6]. The study included 8 patients diagnosed as PD fulfilling the DSM-IV criteria for major depression (5 patients) and dysthymia (3 patients). Magnetic stimulator, 200 Mag-Stim, total output 2 T and a circular coil of 90 mm, were used. For ten consecutive days, between noon and 1 p.m. the patients were stimulated with apprx. 80% of the output (1.6 T) at 0.5 Hz. The daily treatment implied stimulation of both sides of the head (first the right, then the left) at four sites (prefrontal, frontal, parietal and occipital regions) with 5 stimulations each site (20 stimulations per hemisphere). Before the beginning of the study, 2-3 hours after the last stimulation (day 10), 7 and 14 days after completion of the treatment, the patients were subjected to scoring on the Hamilton Depression Rating Scale [11] and Unified Parkinson's Disease Rating Scale (UPDRS) [12]. The HDRS values before initiation of rTMS were 19.2 +/- 3.1, with significant fall (p < 0.01) after 10 days of stimulation (14.9 +/- 3.2), 17 days (12.2 +/- 2.7) and 24 days (13.6 +/- 5.3) after the beginning of the study, suggesting that the antidepressive effect persisted even two weeks after discontinuation of stimulation. The UPDRS values were monitored concomitantly. The values on this scale failed to alter significantly. In conclusion, rTMS is a relatively safe and painless method associated with antidepressant action in PD patients. Treatment of depression in PD is of great importance, but the choice of medication is accompanied with numerous limitations [20]. Antidepressant action of rTMS and its maintenance for two weeks after discontinuation of stimulation enables usage of this method in PD in phases of exacerbation of depressive symptoms at least over the period required to reach the full effect of selected medication.

[Buspirone in the treatment of cerebellar ataxia]

Ataxia is defined as a disturbance which, quite independent of any motor weakness, alters direction and extent of voluntary movement and impairs the sustained voluntary of reflex muscle contraction necessary for maintaining postiue and equilibrium [1]. Since pathophysiological basis of cerebeller ataxia is still not completely clear, the current therapeutic attempts are mainly symptom-oriented [3]. One possible approach could be a modification of potentially involved neurotransmitter systems of the cerebellum, where particularly interesting is the serotonergic system. However, attempts with levorotatory form of tryptophan (5-HT precursors) proved to be ineffective [4, 5]. Since receptors in the cerebellum are mainly of 5-HTIA subtype, the use of specific agonists might be a more reasonable therapy [6]. The study initially involved 11 patients, but only 9 completed the protocol due to unfavorable side effects. Our open label prospective study lasted for 15 weeks. The patients were tested before the beginning of the treatment (initial visit), at 7th (first visit) and 11th week (second visit) of continuous therapy, and eventually at 15th week (final visit). The daily dose was 40 mg at the first and 60 mg at the second visit. We used the evaluation scale gurposed for cerebellar functions testing (speech, gait, coordination and ocular movements). Significant improvement of cerebellar ataxia in patients under buspiron therapy has been noted. We analyzed the results obtained from our 9 patients (4 females and 5 males), of which 6 patients suffered from cerebellar degeneration, one from multiple sclerosis, one from Ramsey-Hunt syndrome, and one from pontine myelinolysis. At the initial visit the patient score was 18.9 (SD = 7.3), subsequently, at the iirst visit the score was 15.4 (SD = 8), while the second visit yielded the score of 12.9 (SD = 8.2), and finally, after a two-weeks lasting wash-out period, it was 17.7 (SD = 7.1) (Table 1). It was found that patients exhibiting mild ataxia showed a better improvement in comparison to the patients who had marked cerebellar symptoms at the beginning of the treatment (Table 2). In conclusion, our prospective study shows that buspiron treatment improves cerebellar symptoms.

[Clinical features of essential tremor]

Essential tremor is a dominant hereditary disorder with incomplete penetration manifested in action, postural tremor with no signs of parkinsonism, cerebellar lesions or other neurological signs [1]. The diagnosis of essential tremor is established on the basis of the clinical picture, and is greatly variable and insufficiently defined [5].

MATERIAL AND METHODS

The study concerned patients with the diagnosis of essential tremor established by the International Association for Tremor Studies in 1995 where tremor was classified into definite++, possible and probable [6]. All patients were subjected to a special questionnaire including demographic and clinical characteristics of tremor. Detailed neurological examinations focusing the presence of extrapyramidal signs were carried out. Fischer's Exact test was used for statistical analysis.

RESULTS

The study comprised 107 patients (55 males, 41 females), aged 17-84 years (57.3 +/- 15.6) and 7-77 (46.3 +/- 17.9) at onset of the disease. Postural tremor was present in 36% of patients, postural tremor with intentional deterioration in 16%, statopostural tremor in 21% and continuous tremor in 17% of subjects. Extrapyramidal signs were present in 31% of patients, and clumsiness in fine alternating movements was present in 17 patients. The patients with longer duration of illness were significantly more clumsy in fine alternating movements (Fischer's Exact test; p = 0.507 < 0.05), but not in the presence of extrapyramidal signs (Fischer's Exact test; p = 0.507 > 0.05).

DISCUSSION

Essential tremor is described as a dominant inherited postural tremor. Koller et al. [9] describe dominantly kinetic tremor occurring with movements, while Martinelli et al. [10] describe continuous tremor manifested at rest, posture and with movements. Static tremor was considered as a result of the disease progression [8]. In our patients those with longer duration of the disease were frequently more clumsy in fine alternating movements, but not in manifestation of extrapyramidal signs. Continuous tremor is probably a subgroup of essential tremor; suggests a more pronounced role of cerebellum in its genesis.

[Clinico-genetic study of type I spinocerebelllar ataxia]

Inherited, autosomal-dominant cerebellar ataxia (ADCA) comprises a genetically and clinically heterogenous group of neurodegenerative disorders. Clinical classification of these disorders was an important step [2] in differentiation among several types, the most common one being ADCA-I, accompanied with supranuclear ophthalmoplegia, optic nerve atrophy, symptoms of the basal ganglia lesions, dementia and amyotrophia. Molecular-genetic studies indicated genetic heterogeneity of ADCA-I with mutations of genetic loci on chromosome 6p (spinocerebellar ataxia type 1; SCA1), 12q (SCA2), 14q (SCA3), 19p (SCA6) and 16q (SCA4) [3]. Spinocerebellar ataxia type 1 (SCA1) is characterized by cerebellar ataxia, ophthalmoplegia and pyramidal signs [4], but also with other neurological findings that tend to prevent clinical differentiation among patients with SCA1, SCA2 and SCA3. The mutation inducing SCA1 is an instable expansion of trinucleotide (CAG) repeats in the coding region on chromosome 6 [5]. Herein, we report clinical features in patients from two families with SCA1: family I with 15 and family II with 8 affected members in 4 consecutive generations. The acceptable data (history, examination and/or insight into medical records) were obtained for 9 patients in family I and 7 patients in family II. The age at the onset of the disease was 37.8 +/- 11.3 years (mean value +/- SD) (range: 27-60) for all the patients, or 31.8 +/- 10.7 years (range: 7-60) for family I and 45.0 +/- 8.4 years (range: 35-55) for family II. Duration of the disease was 8.9 +/- 4.6 years (range: 3-15); 10.8 +/- 4.1 (range 5-15) and 5.7 +/- 3.8 years (range: 3-10) for families I and II, respectively. The mean number of CAG repeats in the mutated allele for SCA1 of the affected individuals was 50.5 +/- 6.2 (range 45-64). A significant inverse correlation (p < 0.05) was noted between the number of CAG repeats and the age at the onset of the disease (Figure 3). Similarity of initial symptoms in SCA1 was noted. They include simultaneous gait-related problems and dysarthria (usually slurred speech). Occurrence of other neurological signs (Table 3) was also predictable in most cases and depended on the phase of SCA1 at the time of examination. Generally, it is believed that intra- and interfamilial phenotypic heterogeneity in SCA1 is lower than in SCA2 and SCA3 [12]). In conclusion, typical clinical manifestations of SCA1, at least in early phases of the disease, according to our study, include gait ataxia, dysarthria, brisk muscle reflexes and marked hand ataxia; the age at the onset of the disease was inverse, and clinical progression was directly related to the number of CAG repeats in the mutated allele on chromosome 6. Nevertheless, significant differences in clinical properties of this inherited disease are possible among different affected families.

[Indications for carotid endarterectomy in patients with symptoms: when, where?]

Carotid endarterectomy (CEA) is one of the most commonly used surgical methods in the treatment of cerebral stroke with both therapeutic and also prophylactic implications. CEA has been used in surgical practice for 40 years. At the beginning it was very popular and was widely used. Later, the opposite extreme was reached, and its therapeutic efficacy was denied unjustifiably. However, at the beginning of the ninetieth three large controlled studies were completed (North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial and Veterans Administrations Symptomatic Trial) and the results of these trials were the basis for establishing the solid criteria for the surgical procedure in some groups of symptomatic patients with stenosis of the internal carotid artery. Thus, CEA was in again. In accordance with the attitudes of the American Association Ad Hoc Committee (1995), evidenced indications for CEA in patients with symptomatic stenosis of the internal carotid artery (in the group with surgical risk less than 6%) include (a) single or recurrent episodes of TIA in the last 6 months, "crescendo" TIA combined with carotid stenosis > 70% with or without plaque ulceration, with or without antiplatelet therapy, and (b) mild stroke in last 6 months with carotid stenosis > 70% with or without plaque ulceration, with or without antiplatelet therapy. The authors report their experience and results of a six-month pilot study of 301 patients, of whom 248 were operated on for symptomatic carotid stenosis with low combined perioperative morbidity and mortality (0.6%). Also, indications for surgical reconstruction of carotid and coronary arteries in patients with marked signs of atherosclerosis in both arterial systems are discussed.

[Importance of the number of trinucleotide repeat expansions in the clinical manifestations of Huntington's chorea]

INTRODUCTION

In 1993 the gene responsible for Huntington's disease (IT15) was isolated [5]. It was mapped to the tip of the short arm of chromosome 4 and within its coding sequence, near the 5' end, it contained a certain number of trinicleotide (CAG)n (cytosine-adenine-guanine) repeats (Figure 1). This gene codes for a protein (348 kd) called "huntington" that is widely expressed, and its sequence is not related to any protein [6]. The normal range of (CAG)n repeat numbers within IT15 was reported to be between 6 and 37 [6]. Mutation responsible for Huntington's disease implied expansion of (CAG)n repeats: in patients with Huntington's disease the pathologic range was determined to be between 35 and 121 repeats [7-10].

PATIENTS AND METHODS

In this study we correlated the age at onset, rate of progression and initial symptoms of Huntington's disease with the number of trinucleotide (CAG)n repeats in IT15. DNA was isolated from peripheral blood leukocytes of patients fulfilling clinical criteria for definite and probable Huntington's disease [2]. Genetic verification of Huntington's disease was made by the previously described and modified PRC (polymerase chain reaction) technique [17, 18]. In our laboratory a gene with 40 or more repeats was considered as a marker of Huntington's disease.

RESULTS

The study comprised 26 patients (11 women and 15 men). At the onset of Huntington's disease they were between 19 and 66 years old (36.6 12.8 years), with the duration of the disease between 1 and 15 years (5.8 4.3 years). The number of (CAG)n, repeats in IT15 ranged between 40 and 95 (49.9 14.1). The negative correlation between the (CAG)n, count in the expanded allele and the age at onset of the disease has been confirmed. Regression analysis showed the correlation coefficient of -0.54 (p = 0.012). The effect of trinucleotide (CAG)n, repeats on the initial clinical manifestations and rate of progression of Huntington's disease is only one of the growing group of "CAG-repeat" disorders that also include entities such as spinocerebellar ataxia-type 1 and 3, spinobulbar muscular atrophy and dentato-rubo-pallidoluysian atrophy [6].

[Clozapine in the treatment of adverse psychiatric manifestations of long-term therapy with levodopa]

INTRODUCTION

Chronic administration of dopaminomimetic drugs, levodopa before all, to patients with Parkinson's disease (PD) is accompanied with numerous complications. Psychiatric complications are not only frequent, but also difficult to manage. Reduction of the daily dose or complete discontinuation of dopaminomimetic therapy and usage of conventional neuroleptic drugs may relieve the psychotic symptoms, but both these approaches are associated with unacceptable deterioration of motor symptoms. The aim of the study is to present our experience in the treatment of levodopa-induced psychoses by clozapine in patients with PD. Clozapine is a non-typical antipsychotic drug with low potential fr inducing extrapyramidal symptoms.

METHODS

A two-year open study in which clozapine was used as the treatment of choice covered 16 patients with PD and psychosis (8.7% of all patients with PD treated at the Department of CNS Degenerative Diseases, Institute of Neurology, Clinical Centre of Serbia, Belgrade). All patients presented for examination with psychotic manifestations whose severity necessitated hospitalization so that the whole study was conducted on the in-patient basis. Patients with haematological disorders, history of epileptic seizures or major dysfunction of the heart, liver and kidneys were not included in the study. In none of the patients EEG records suggested epileptic focl or other major disorders. The stage of PD was determined according to Hoehn and Yahr scale. After the comprehensive evaluation, the treatment was initiated with a bedtime dose of 6.25-12.5 mg clozapine, with gradual increase in 6.25 mg increments in two or three day intervals until the dose which optimally relieved the psychotic symptoms. The levodopa doses were not reduced, except in cases when clozapine action was not satisfactory after the 50 mg dose had been reached. The patients were subjected to daily evaluation of therapeutic response and adverse effects (particularly in the first 19 days) while the blood count and leukocyte formula were determined twice a week.

RESULTS

A group of 16 patients with PD consisted of 7 women and 9 men, average age 64.8 years (range 51-72), and average duration of PD 13.7 years (range 7-19). All patients received the combination of levodopa and benserazide, mean dose 875.5 mg (range 500-1250 mg), while eight patients received bromocriptine (15 mg), as well. Relief of psychotic symptoms was achieved in 12 (75%) patients in whom the improvement was manifest 5-7 days after the onset of clozapine therapy. The average daily dose of clozapine in this group of patients was 30 mg (range 12.5-100 mg) which was continued even after the discharge of the patients, in the follow-up period of 6-18 months, with unchanged effect. In two patients the therapy was discontinued due to marked orthostatic hypotension and somnolence. In another two patients (13%) the therapy failed to induce the desired effect in spite of the clozapine dose increase to 300 mg.

DISCUSSION

The basic conclusion of our study is that clozapine effectively suppresses levodopa-induced psychoses in patients with PD. Low daily doses are required, while no reduction of levodopa and other dopaminomimetic drugs is needed. Thus, antipsychotic action of clozapine does not affect the treatment of the underlying disease, i.e. relief of parkinsonism.

Effect of physostigmine and verapamil on active avoidance in an experimental model of Alzheimer's disease

The present study was performed to investigate and compare the effect of acetylcholinesterase inhibitor, physostigmine (0.045, 0.060 and 0.075 mg/kg sc, 30 min before the tests) and Ca-antagonist, verapamil (1.0, 2.5, 5.0 and 10.0 mg/kg sc, 30 min before the tests), on two-way active avoidance (AA) learning (acquisition and performance) in nucleus basalis magnocellularis (NBM)-lesioned rats. Bilateral electrolytic lesions of NBM induced significant decrease of acquisition and performance of AA responses in rats. Physostigmine (0.060 mg/kg) significantly improved only acquisition of AA, while verapamil (2.5 and 5.0 mg/kg) significantly improved both type of AA behavior in NBM-lesioned rats. These results suggest that altered calcium homeostasis might play significant role in pathogenesis of experimental induced Alzheimer's disease (AD) and that administration of calcium antagonist such as verapamil might successfully ameliorate disturbances of learning and memory appeared after lesions of NBM.

Correlation between Bereitschaftspotential and reaction time measurements in patients with Parkinson's disease. Measuring the impaired supplementary motor area function?

For a long time, reaction time (RT) testing has been used for objective assessment of characteristics of the movement impairments in patients with Parkinson's disease (PD). On the other hand, it is supposed that Bereitschaftspotential (BP) reflects CNS preparatory activity for the execution of voluntary movements, and amplitudes of BP are generally smaller in PD. In order to analyze possible correlations between two methods, we studied 15 drug-naive patients with idiopathic PD (Hoehn and Yahr stage from 1 to 2.5). BP was recorded from three scalp locations: Cz, C3, and C4, and Lateralized Potential (LP) was additionally calculated as a C3-C4 difference waveform. We recorded amplitudes of the initial part of BP (at 650 ms before movement-NS1), the maximal amplitude immediately before movement onset (N1), and the N1-NS1 difference (NS2), from the Cz and LP recordings. Two RT testing paradigms were used: Simple Reaction Time (SRT) and Choice Reaction Time (ChRT). The only significant correlation between RT parameters and BP amplitudes from Cz was negative correlation between dT (difference time between Choice Reaction Time and Simple Reaction Time), on one hand, and NS1 (P = 0.006) and N1 (P = 0.026), on the other. However, Cz-NS2 did not correlate with any of the RT parameters. Our data suggest that PD patients with smaller difference between ChRT and SRT, that is presumably caused by the lesser capacity of the movement pre-programming, have smaller (i.e., less negative) BP amplitudes. This association is especially pronounced for the earlier, NS1 amplitude that is supposed to reflect the activity of the supplementary motor area (SMA). The diminished capacity of SMA activation may be the cause of the both, smaller early BP amplitudes, and smaller ChRT-SRT difference, in PD patients.

[Delayed-onset dystonia due to asphyxia in the perinatal period]

The phenomenon of delayed-onset dystonia following presumed "static" brain injuries was described after stroke and head trauma. Burke et al. described a different category of secondary dystonia, where perinatal injury (asphyxia) caused minimal or no immediate neurological deficit, with the delay of years before dystonia emerged. This type of dystonia following perinatal injury has been termed "delayed onset dystonia due to static encephalopathy of childhood". According to the definition of dystonia, we were able to select 5 patients with the aetiologic diagnosis of perinatal asphyxia from the group of 347 out- and inpatients (1.4%) treated for various types of dystonia at the Movement Disorders Department (Institute of Neurology, CCS, Belgrade) from November 1986 to November 1994. At onset of dystonia the mean age of patients was 13.2 years (range from 10 to 17), with combined initial involvement of the arm and neck in 3 patients. The period from the onset of the disease to the maximum severity lasted 8.2 years (range from 4 to 14), resulting in segmental brachial dystonia in 3, hemidystonia and generalized dystonia in one patient each (Table 1). The adverse perinatal events are described in Table 2. Three of our patients had delayed achievements of developmental milestones. All patients were regularly schooled and had preserved intellectual capacities, except the patient 3 whose achievements were below average (IQ = 86). Different drugs were administered (Table 3), but moderate effects were achieved only with trihexyphenidyl in two patients (daily doses of 24 mg and 30 mg, respectively), and baclofen (80 mg p.d.) in one patient. In this study we describe 5 new patients who fulfilled the criteria for the diagnosis of delayed-onset dystonia due to perinatal asphyxia (Tables 1 and 2). We accepted the approach of Saint-Hilaire et al. to suggest a relationship between perinatal asphyxia and later occurrence of dystonia in our 5 patients. However, coincident occurrence of a primary dystonia with a static encephalopathy of childhood due to perinatal asphyxia cannot be excluded. This phenomenon of delayed appearance of dystonia was also described in other forms of static cerebral injury; i.e. stroke, head trauma or anoxic brain damage. Interestingly enough, age at the time of anoxia or brain insults seemed to be crucial for the development of dystonia: those who suffer acute brain insults during childhood or early life are more likely to develop dystonia than the older patients. Therefore, the "static" nature of encephalopathy induced by perinatal asphyxia is questionable. Finally, this study strengthens the suggestion that perinatal asphyxia can lead to delayed-onset dystonia, and, since "some of these patients closely resemble cases of idiopathic torsion dystonia, the prior occurrence of asphyxia should be used as a criterion of exclusion for that diagnosis".

Impairment of cortical inhibition in writer's cramp as revealed by changes in electromyographic silent period after transcranial magnetic stimulation

Changes in silent period (SP) duration following transcranial magnetic stimulation (TMS) set at 20% above the motor threshold were studied in six subjects suffering from writer's cramp, while performing dystonic movement and during voluntary isometric contraction of the muscles mostly involved in the dystonic movement. Dependency of SP duration on the intensity of preceding muscle contraction was compared on both affected and healthy side. In all subjects SP duration during dystonic contraction was shorter than during voluntary contraction of the similar strength performed with the same hand. Also, in five subjects, SP duration during dystonic contraction was shorter than during voluntary contraction of the similar strength performed with the healthy hand. In addition, the SP duration on the affected side was negatively associated with the intensity of the preceding contraction (i.e. the stronger contraction the shorter SP), while on the healthy side it was not the case. It is concluded that central inhibitory mechanisms are abnormal in writer's cramp.

Prolactin and cortisol responses to fenfluramine in Parkinson's disease

Dysfunction of the central serotonergic system has been associated with depression in Parkinson's disease. To evaluate central serotonergic function in Parkinson's disease in relation to depression, we examined prolactin and cortisol responses to a single-dose challenge with fenfluramine (60 mg orally), a serotonin releasing/uptake-inhibiting agent, in the course of 5 hours in 11 patients with Parkinson's disease associated with major depression (SADS-RDC), 22 nondepressed parkinsonians, and 20 age- and gender-matched healthy controls. No difference in cortisol responses were observed between the groups; however, prolactin responses to fenfluramine were significantly impaired in patients with Parkinson's disease compared to controls, and the response was significantly more blunted in parkinsonian patients with major depression in comparison with the nondepressed ones. These findings indicate that there is a diminished serotonergic responsivity in depression associated with Parkinson's disease.

Symptomatic dystonias associated with structural brain lesions: report of 16 cases

BACKGROUND

Symptomatic (secondary) dystonias associated isolated lesions in the brain provide insight into etiopathogenesis of the idiopathic form of dystonia and are a basis for establishing the possible correlation between the anatomy of a lesion and the type of dystonia according to muscles affected.

METHODS

In 358 patients with differently distributed dystonias, a group of 16 patients (4.5%) was encountered in whom dystonia was associated with focal brain lesions.

RESULTS

Of the 16 patients, 3 patients had generalized, 3 segmental and 4 hemidystonia, while the remaining 6 patients had focal dystonia. The most frequent etiologies were infarction in 7, and tumor in 4 patients. These lesions were usually found in the lenticular and caudate nucleus, thalamus, and in the case of blepharospasm in the upper brainstem.

CONCLUSIONS

Our results support the suggestion that dystonia is caused by a dysfunction of the basal ganglia.

A genetic study of idiopathic focal dystonias

The inheritance of focal dystonias was investigated in 43 families containing 43 index cases with torticollis (n = 21), blepharospasm (n = 18) and writer's cramp (n = 4). They generated a potential population of 235 first-degree relatives, and 168 out of 179 living first-degree relatives were examined. Ten relatives with dystonia were identified in ten families. Another two parents from two of the same group of ten families were affected according to the family history. The majority of the secondary cases (six patients, five siblings, and one child) were not aware of any dystonia. The tendency for affected relatives to have the same type of dystonia as index patients was observed only for torticollis. Overall, 23% of index patients had relatives with dystonia. Segregation analysis suggested the presence of an autosomal dominant gene or genes with reduced penetrance underlying focal dystonia.

Utility of auditory P300 in detection of presenile dementia

The significance of P300 in investigation of the cognitive changes characteristic of aging and dementia is well established. But some controversies about sensitivity and specificity of P300 latency prolongation in detection of dementia still exist, and its predictive value and specificity in "real" clinical situations (i.e., in mixed population of neurological patients, both demented and nondemented but potentially cognitively impaired) were seldom estimated. In order to elucidate these questions, we recorded auditory event-related potentials ("oddball" paradigm) in 40 demented patients, 58 nondemented neurological patients, and 39 healthy subjects aged < or = 65 years. In addition, for the qualitative analysis of the data, we calculated three normality ranges of different width (i.e., control group's mean +/- 3 SD, 2.5 SD, and 2 SD, respectively). Our results showed that P300 latency was significantly longer in demented patients as compared to both controls and nondemented patients. Sensitivity of the P300 latency prolongation in detection of dementia depends on the width of the selected normality range, and is greatest for the narrowest range (70%), and diminishes with its widening. Specificity of this parameter, when only demented patients and controls were considered (approach used in the majority of the previous studies) was 100%, regardless of the range used. However, when the assessment was done in a mixed population of neurological patients, the P300 latency prolongation showed smaller but still very high specificity (from 86.2 to 100%) and the predictive value (from 77.8 to 100%). Depending on the width of the normality range selected, the rise of sensitivity was associated with fall of specificity and predictive value (and vice versa).

Hemiballism: report of 25 cases

Twenty three patients with hemiballism and two with biballism were studied. Ischaemic and haemorrhagic strokes were the cause in most patients. Other causes were encephalitis, Sydenham's chorea, systemic lupus erythematosus, basal ganglia calcifications, non-ketotic hyperglycaemia, and tuberous sclerosis. Neuroimaging studies showed a lesion of the subthalamic nucleus in only six patients. In others, different subcortical structures were involved or the results were normal. Only two patients had "pure" hemiballism. The others had other types of dyskinesias, mainly chorea, which was present in 16 patients. The prognosis was usually good.

Sudden hearing loss as the initial monosymptom of multiple sclerosis

Hearing loss is an uncommon symptom in multiple sclerosis. We report two patients in whom unilateral sudden hearing loss was the first monosymptomatic manifestation of multiple sclerosis. We confirmed the initial central auditory dysfunction suggested by audiometric findings and brainstem auditory evoked potentials by MRI, which showed a unilateral pontine lesion in one patient and a lesion in the medulla oblongata in the other.

[Beta blockers in the treatment of neurological disorders]

The role of beta blockers (especially of propranolol, which has been most frequently used) in prophylaxis of migraine and treatment of essential tremor has been evidenced. These are two exceptionally common neurological entities, therefore detailed insight into indications, dose range and side-effects is necessary. Thus, the optimum therapeutical doses of propranolol for prophylaxis of migraine range from 160-240 mg a day, and for treatment of essential tremor from 240-320 mg a day, which, based on our experiences from practice, indicates that a large number of patients is receiving suboptimal doses, being, consequently, devoid of the best therapeutical effect.

[Gilles de la Tourette's syndrome]

Gilles de la Tourette's syndrome (GTS) is characterized with motor and vocal tics, initiating before 21 years of age, lasting for over a year and are associated with diverse behavioral disorders. The study analyzes features of 12 our GTS patients with mean age at the onset of the disease of 12.0 years, while the exact diagnosis was established only after 9.5 years (2-33 years). In 11 out of 12 patients the disease started with motor or vocal tics, while in completely developed clinical picture of GTS the permanently present tics were associated with coprolalia (6 patients), echolalia, copropraxia (in 2 patients, respectively), attention deficits (9 patients), obsessive-compulsive disorders (8 patients) etv. The role of neuroleptic therapy was discussed according to our experience and other reported studies. In our study, haloperidol had good therapeutical effect in 64% of the treated patients.

[The intrathecal manometric lumbar infusion test (Katzman Test) in the diagnosis of normotensive hydrocephalus]

Over 12-months 17 patients were admitted to the hospital for the presumed diagnosis of normal pressure hydrocephalus (NPH). Four patients had cardinal signs of the syndrome: gait disturbance, dementia and urinary incontinence. Six patients had gait disturbance and dementia. Five patients had gait disturbance and ventricular enlargement on CT scans of the brain, while the last two patients had only urinary incontinence and dementia. All patients underwent neurological examination and CT scans. Clinical and radiological results of these patients were compared with the results of the Katzman's test. Katzman's test was performed in all patients. Physiologic solution of 0.9% NaCl was infused in the lumbal subarachnoid space. The rate of infusion was 1 ml/min during 60 minutes. Cerebrospinal fluid (CSF) pressure was recorded simultaneously using metal aneroid. The test was considered positive if either CSF pressure over 300 mm H2 or undulating waves were recorded at any time of the test. Katzman's test was positive in 12 patients (9 of them with NPH). The undulating waves were recorded in 6 patients (5 with NPH). Four of them experienced tachycardia, hyperventilation, cephalea and mild confusion during the test. The test was positive in all 9 patients with NPH but also in 3 patients with different but pathophysiologically similar disorders. The test was positive in all 4 patients with the characteristic clinical triad of the syndrome and also in all 4 patients with periventricular hypodensity on their CT scans. No patient without gait disturbance had positive test. All except one patient with focal signs or pronounced cortical atrophy, besides with dramatic clinical improvement.(ABSTRACT TRUNCATED AT 250 WORDS)

Dexamethasone suppression test in patients with Parkinson's disease

The Dexamethasone Suppression Test (DST), supposed to effectively distinguish between endogenous and nonendogenous depression, was performed in a group of 34 patients with Parkinson's disease. Abnormal DST results were observed in 50% of the patients. The patients were clinically divided into subgroups of depressed and nondepressed parkinsonians. Abnormal DST results were significantly more frequent in depressed (75%) than in nondepressed parkinsonians (27.7%).

Auditory event-related potentials in different types of dementia

Auditory event-related potentials were recorded in demented, drug-free patients with Huntington's disease and Alzheimer's disease, as well as in demented and nondemented patients with Parkinson's disease, who were matched for age, duration and stage of the disease. The normal P3 latency at a given age was predicted by using an age regression equation that had been calculated on the basis of the findings in 42 normal adults. Using this procedure, a prolonged P3 latency was found in about two thirds of demented patients, irrespectively of the underlying disease. Although the prolonged P3 latency proved to be useful electrophysiological correlate of dementing illness, no differences were found between the observed groups in respect to other components of the auditory event-related potentials (N1 and P2).

Reduced rapid eye movement sleep latency in patients with Parkinson's disease

Rapid eye movement (REM) sleep latency (time from sleep onset to the first REM episode) was measured in 39 patients with idiopathic Parkinson's disease. Reduced REM sleep latency (less than or equal to 65.0 min) was found in a high proportion of patients (69%). Since reduced REM sleep latency may be a trait-like abnormality relatively specific to primary depression, we evaluated this parameter in two groups of parkinsonian patients: depressed (16 patients) and non-depressed (23 patients). Its incidence was significantly higher in depressed patients with Parkinson's disease.

Degenerative neurological disorders associated with deficiency of glutamate dehydrogenase

The activity of glutamate dehydrogenase, the enzyme of glutamate degradation, was measured in platelets of 27 healthy controls and 85 patients with different degenerative cerebellar and/or basal ganglia disorders. A group of 7 patients was selected with slowly progressive multiple-system atrophy, in whom a clinical diagnosis of olivopontocerebellar atrophy appeared tenable, with decreased activity of glutamate dehydrogenase (38% of the mean control value). In 4 patients data on inheritance were compatible with the genetic pattern of autosomal recessive inheritance, while 3 patients were sporadic cases. In an effort to define this group of patients more precisely, it is suggested that decreased activity of glutamate dehydrogenase induces an increase in extracellular glutamate levels in the central nervous system with subsequent development of excitotoxicity.

Depression and Parkinson's disease: possible role of serotonergic mechanisms

Depression is frequently encountered in Parkinson's disease and was seen to occur in 14 of 26 patients studied. The levels of 5-hydroxyindoleacetic acid (5-HIAA), the main metabolite of serotonin (5-HT), in CSF samples of the patients were significantly lower than in those of controls. However, within the group of patients the levels of 5-HIAA in CSF samples were significantly lower in the depressive subgroup compared with the non-depressive patients. Moreover, no correlation was recorded between motor disability and depression. The results indicate that disturbed 5-HT metabolism may possibly play a role in Parkinson's disease as a predisposing factor in the development of depression.

Cyclic nucleotides in cerebrospinal fluid of drug-free Parkinson patients

Concentrations of cyclic nucleotides--adenosine-3',5'-monophosphate (c-AMP) and guanosine-3',5'-monophosphate (c-GMP)--were measured in cerebrospinal fluid (CSF) of 17 drug-free Parkinson patients and 12 controls. No significant difference between the cyclic nucleotide contents (p greater than 0.05) in CSF of patients and controls was detected, nor was there a correlation between the content and the degree of neurological disability. Besides, no changes in the cyclic nucleotide contents were detected in the subgroups of patients according to the prominence of tremor or rigidity/akinesia as the main symptoms of the disease.

Cyclic AMP in the cerebrospinal fluid of patients with recent cerebral infarction

The concentrations of cyclic adenosine 3',5'-monophosphate (c-AMP) and glucose were measured in cerebrospinal fluid (CSF) of 43 patients with recent cerebral infarction divided into five groups in respect to the time (up to 24 h) elapsed between cerebrovascular insult and CSF sampling. 10 of the additionally studied subjects were (control group) neurologically normal. None of the investigated subjects was under therapy at the time of CSF sampling. The levels of c-AMP and glucose in patients with cerebral infarction were found not to be related to the degree of neurological deficit but to the duration of ischemia. CSF c-AMP was elevated (p less than 0.001) for 8-12 h following the cerebrovascular insult and subsequently reached the level of controls. The CSF glucose level was elevated during the whole period of observation.

Cerebrospinal fluid prostaglandin F2 alpha in stroke patients: no relationship to the degree of neurological deficit

The concentration of prostaglandin F2 alpha (PGF2 alpha) was measured in cerebrospinal fluid (CSF) of 50 patients with recent stroke divided into three groups in respect to the time (up to 24 h) that expired between cerebrovascular insult and CSF sampling. 10 of the additionally studied persons were neurologically normal (control group). None of the investigated subjects were undergoing any therapy at the time of CSF sampling. The estimation of the neurological score revealed that the stroke patients suffered from acute cerebral ischemic attacks of varying severity. No relationship between the CSF PGF2 alpha and neurological status was found. Within the first 4 h after the stroke a marked increase in PGF2 alpha was found, afterwards being diminished but still enhanced in comparison to the controls.

Insulin increases entrance of 2-deoxy-D-[3H]glucose in isolated rat brain microvessels

Insulin in a dose of 0.5 U ml-1 in the incubation medium did not change ATP and phosphocreatine contents in the isolated rat brain microvessels, when energy production was supported by 5.5 mmol l-1 glucose. However, the entrance of non-metabolizable glucose analogue, 2-deoxy-D-[3H]glucose into the microvessel cells was strongly enhanced, almost 18-fold.