KCNJ3 is a novel candidate gene for autosomal dominant pure hereditary spastic paraplegia identified using whole genome sequencing

Hereditary spastic paraplegia (HSP) is a group of familial diseases characterized by progressive corticospinal tract degeneration. Clinically, patients present with lower-limb spasticity and weakness. To date, more than 80 genetic HSP types have been identified. Despite advances in molecular genetics, novel HSP gene discoveries are ongoing, with a low genetic diagnostic yield. In this study, we aimed to determine pathogenic variants in a family with HSP, which was not diagnosed through conventional genetic testing. We clinically characterized a large family and conducted whole genome sequencing (WGS) analysis of four affected and three unaffected individuals in the family to identify the genetic cause of HSP. This family had autosomal dominant pure (uncomplicated) late childhood-onset HSP. The patients' symptoms accelerated between the ages of 20 and 30. Brain magnetic resonance images typically showed white matter changes, a thin corpus callosum, and cerebellar atrophy. We identified a heterozygous missense variant, KCNJ3 c.1297T>G (p.Leu433Val), through WGS and family genetic analysis, confirmed by Sanger sequencing. We suggest that the identification of KCNJ3 c.1297T>G (p.Leu433Val) constitutes the discovery of a potential novel gene responsible for HSP in this family. This is the first study to report the possible role of a KCNJ3 variant in HSP pathogenesis. Our findings further expand the phenotypic and genotypic spectrum of HSP.

Herpes simplex encephalitis initially presenting without fever or cerebrospinal fluid pleocytosis and with typical neuroimaging findings: a case report

Herpes simplex encephalitis (HSE) is a common viral encephalitis that can be fatal if not adequately treated. Fever, cerebrospinal fluid (CSF) pleocytosis, and typical neuroimaging findings are commonly observed in HSE cases. We encountered a patient with HSE who did not exhibit these classic clinical features. A 63-year-old male presented with his first-ever seizure. Fever did not develop until the fourth day of admission, and neither neuroimaging nor CSF analysis revealed abnormalities. Under suspicion of autoimmune encephalitis, methylprednisolone was administered. Subsequently, when the patient developed fever, a follow-up neuroimaging study was performed and revealed abnormalities consistent with HSE. The patient was promptly treated with acyclovir, which led to a full recovery. Diagnosing HSE in patients who present without fever or CSF pleocytosis and with typical neuroimaging findings poses a challenge. Therefore, prior to initiating immunosuppressive treatment, it is crucial to closely observe patients and to conduct follow-up tests, including neuroimaging and CSF analysis.

A Survey of Perspectives on Telemedicine for Patients With Parkinson's Disease

OBJECTIVE

Parkinson's disease (PD) patients often find it difficult to visit hospitals because of motor symptoms, distance to the hospital, or the absence of caregivers. Telemedicine is one way to solve this problem.

METHODS

We surveyed 554 PD patients from eight university hospitals in Korea. The questionnaire consisted of the clinical characteristics of the participants, possible teleconferencing.

METHODS

, and preferences for telemedicine.

RESULTS

A total of 385 patients (70%) expressed interest in receiving telemedicine. Among them, 174 preferred telemedicine whereas 211 preferred in-person visits. The longer the duration of disease, and the longer the time required to visit the hospital, the more patients were interested in receiving telemedicine.

CONCLUSION

This is the first study on PD patients' preferences regarding telemedicine in Korea. Although the majority of patients with PD have a positive view of telemedicine, their interest in receiving telemedicine depends on their different circumstances.

Aphasic Status Epilepticus Associated with Alzheimer's Disease: Clinical and Electrographic Characteristics

In aphasic status epilepticus (ASE), aphasia is the sole manifestation of seizure in patients with this disorder. Alzheimer's disease (AD) is one of neurological disorders causing ASE. Herein, we report two cases of ASE associated with AD, and discuss their clinical characteristics. Patient 1 presented Broca's aphasia, and patient 2 presented global aphasia during the ictal period. Both patients exhibited atypical ictal electroencephalographic (EEG) patterns, which improved after antiepileptic drug administration. ASE was the presenting symptom of AD in patient 1. ASE can develop at any stage of AD. Alterations in clinical symptoms and EEG patterns after treatment with antiepileptic drug are the key to diagnosis. Prompt diagnosis and treatment are critical for preventing further consciousness dysfunction.

A Role of β2-Adrenoreceptor Agonists Related to the Development of Parkinson's Disease

Background

Several studies have suggested the potential protective role of β2-adrenoreceptor agonist (β2AR-agonist) on the development of Parkinson's disease (PD). However, those could not reflect a different epidemiologic background in eastern countries. We explored β2AR-agonist's effect on PD development by controlling for smoking.

Materials and Methods

We used the Korean national sample cohort data (from 2002 to 2013) containing 1,025,340 participants (2.2% of the whole population). The subjects over 60 years were included. PD was defined based on the ICD-10 code, which should be diagnosed by neurologists. Atypical Parkinsonisms or ataxic disorders were excluded. We made Set 1 (from 2003 to 2007) and Set 2 (from 2003 to 2008) based on the exposure period for the sensitivity analysis. We observed whether PD had developed during the follow-up periods in each subset.

Results

The PD (Set 1, n = 742; Set 2, n = 699) and non-PD group (Set 1, n = 57,645; Set 2, n = 66,586) were collected. Old age, Medicaid, and asthma were risk factors, whereas smoking was a significant protective factor for PD development. The proportion of β2AR-agonist use was significantly higher in the PD group than in the non-PD group (Set 1, 3.6% vs. 2.4%; Set 2, 4.1% vs. 2.6%). β2AR-agonist use still was a risk factor in developing PD from the multiple logistic regression analysis.

Conclusions

β2-AR-agonist looked like a risk factor rather than a protective factor for PD development. Well-controlled studies reflecting various epidemiologic backgrounds are required to confirm the role of β2AR-agonist.

Patient with Epilepsy Showing Psychiatric Symptoms after Remission of Seizures and Normalization of Electroencephalography: The Phenomenon of Forced Normalization?

Psychiatric disorders are commonly observed in patients with epilepsy. Among them, the phenomenon known as forced normalization is scarce. Herein, we report the case of a 41-year-old patient who showed long-term first-onset psychiatric symptoms after seizure remission and normalization of electroencephalography. After changing the antiepileptic drug regimen and psychiatric treatment, the patient's symptoms regressed. However, the exact pathological mechanisms remain to be elucidated. Changing the regimen of antiepileptic drugs and long-term psychiatric treatment may help control this phenomenon.

Characteristic MR Imaging Features and Serial Changes in Adult-Onset Alexander Disease: A Case Report

Adult-onset Alexander Disease (AOAD) is a rare genetically determined leukoencephalopathy that presents with ataxia, spastic paraparesis, or brain stem signs including speech abnormalities, swallowing difficulties, and frequent vomiting. The diagnosis of AOAD is frequently proposed based on the findings on MRI. We demonstrate two cases (37-year-old female and 61-year-old female) with characteristic imaging findings and changes in follow-up MRI in patients with AOAD, which were confirmed via glial fibrillary acidic protein (GFAP) mutation analysis. On MRI, the typical tadpole-like brainstem atrophy and periventricular white matter abnormalities were noted. The presumptive diagnoses were made based on the typical MRI appearances and, subsequently, confirmed via GFAP mutation analysis. Follow-up MRI demonstrated the progression of atrophy in the medulla and upper cervical spinal cord. Our report could help raise awareness of characteristic MRI findings of AOAD, thus helping clinicians use GFAP analysis for AOAD diagnosis confirmation.

Diffusion tensor tractography of the corticobulbar tract in a dysphagic patient with progressive supranuclear palsy: A case report

RATIONALE

This paper reports the changes over time in the corticobulbar tract (CBT) analyzed using diffusion tensor tractography (DTT) in a dysphagic patient with progressive supranuclear palsy (PSP).

PATIENT CONCERNS

A 53-year-old man initially presented with dysarthria, gait disturbance, and bradykinesia, and approximately 1-year later, downward gaze paralysis appeared. Initially, there was no dysphagia; however, approximately 2 years after visiting the hospital, symptoms of dysphagia, including difficulty swallowing pills, aspiration, and oral movement impairments appeared. The symptoms gradually progressed, and finally, mouth opening was severely damaged to the extent that it was difficult to orally feed.

INTERVENTIONS

We performed diffusion tensor imaging 3 times; at 3-month, 20-month, and 41-month from onset.

OUTCOMES

On 3-month DTT, the left CBT was well reconstructed, whereas the right CBT showed partial tearing. In the 20-month DTT, both CBTs became thinner compared to the 3-month DTT. On 41-month DTT, both CBTs became much thinner than after 3-month and 20-month DTT.

LESSONS

We observed the degree of CBT injury over time in a dysphagic patient with PSP. These results suggest that the analysis of CBT using DTT is helpful in predicting the degree of dysphagia and prognosis in patients with PSP.

Long Short-Term Memory-Based Deep Learning Models for Screening Parkinson's Disease Using Sequential Diagnostic Codes

BACKGROUND AND PURPOSE

It is challenging to detect Parkinson's disease (PD) in its early stages, which has prompted researchers to develop techniques based on machine learning methods for detecting PD. However, previous studies did not fully incorporate the slow progression of PD over a long period of time nor consider that its symptoms occur in a time-sequential manner. Contributing to the literature on PD, which has relied heavily on cross-sectional data, this study aimed to develop a method for detecting PD early that can process time-series information using the long short-term memory (LSTM) algorithm.

METHODS

We sampled 926 patients with PD and 9,260 subjects without PD using medical-claims data. The LSTM algorithm was tested using diagnostic histories, which contained the diagnostic codes and their respective time information. We compared the prediction power of the 12-month diagnostic codes under two different settings over the 4 years prior to the first PD diagnosis.

RESULTS

The model that was trained using the most-recent 12-month diagnostic codes had the best performance, with an accuracy of 94.25%, a sensitivity of 82.91%, and a specificity of 95.26%. The other three models (12-month codes from 2, 3, and 4 years prior) were found to have comparable performances, with accuracies of 92.27%, 91.86%, and 91.81%, respectively. The areas under the curve from our data settings ranged from 0.839 to 0.923.

CONCLUSIONS

We explored the possibility that PD specialists could benefit from our proposed machine learning method as an early detection method for PD.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis after BNT162b2 COVID-19 Vaccination

After the coronavirus disease 2019 (COVID-19) pandemic emerged, the development of vaccines was accelerated. Neurologic complications of COVID-19 vaccination had been reported, which included encephalitis. In this study, we report a very rare case of a female with anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma that would be triggered by BNT162b2 m-RNA COVID-19 vaccination.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis after BNT162b2 COVID-19 Vaccination

After the coronavirus disease 2019 (COVID-19) pandemic emerged, the development of vaccines was accelerated. Neurologic complications of COVID-19 vaccination had been reported, which included encephalitis. In this study, we report a very rare case of a female with anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma that would be triggered by BNT162b2 m-RNA COVID-19 vaccination.

Semiautomated Algorithm for the Diagnosis of Multiple System Atrophy With Predominant Parkinsonism

Objective

Putaminal iron deposition is an important feature that helps differentiate multiple system atrophy with predominant parkinsonism (MSA-p) from Parkinson’s disease (PD). Most previous studies used visual inspection or quantitative methods with manual manipulation to perform this differentiation. We investigated the value of a new semiautomated diagnostic algorithm using 3T-MR susceptibility-weighted imaging for MSA-p.

Methods

This study included 26 MSA-p, 68 PD, and 41 normal control (NC) subjects. The algorithm was developed in 2 steps: 1) determine the image containing the remarkable putaminal margin and 2) calculate the phase-shift values, which reflect the iron concentration. The next step was to identify the best differentiating conditions among several combinations. The highest phase-shift value of each subject was used to assess the most effective diagnostic set.

Results

The raw phase-shift values were present along the lateral margin of the putamen in each group. It demonstrates an anterior-to-posterior gradient that was identified most frequently in MSA-p. The average of anterior 5 phase shift values were used for normalization. The highest area under the receiver operating characteristic curve (0.874, 80.8% sensitivity, and 86.7% specificity) of MSA-p versus PD was obtained under the combination of 3 or 4 vertical pixels and one dominant side when the normalization methods were applied. In the subanalysis for the MSA-p patients with a longer disease duration, the performance of the algorithm improved.

Conclusion

This algorithm detected the putaminal lateral margin well, provided insight into the iron distribution of the putaminal rim of MSA-p, and demonstrated good performance in differentiating MSA-p from PD.

Recurrent Altered Mental State Associated with Nonhepatic Hyperammonemia Presented in an Elderly Female Patient: Probable Late-Onset Urea Cycle Disorder

Altered mentality associated with hyperammonemia is usually diagnosed in patients with liver disease. Nonhepatic hyperammonemia may be present in critically ill patients or may be caused by high protein diets or certain drugs. Urea cycle disorders (UCDs) rarely present with altered mentality with hyperammonemia in adult patients. An 82-year-old female visited our hospital with complaints of abnormal behavior and confusion. Routine blood tests revealed elevated serum ammonia. Her mentality and serum ammonia level normalized after lactulose enema and she was discharged thereafter. However, she was later re-admitted because of recurrent altered mentality. Amino acid analysis revealed that serum levels of ornithine and glutamine increased significantly, whereas the levels of alanine and glutamic acid increased slightly, and the levels of arginine, lysine, and citrulline were normal, which were probably caused by reduced activity of the mitochondrial ornithine carrier-1. Although our patient was not diagnosed genetically, this case illustrates the under-recognized fact that UCD can occur in a senile age. Clinical suspicion of UCDs in patients with hyperammonemia is critical for early diagnosis and to prevent the significant neurologic sequelae.

Three Cases of Aphasic Status Epilepticus: Clinical and Electrographic Characteristics

Aphasic status epilepticus (ASE) is unusual and has clinical characteristics similar to those of other disorders. Herein, we report 3 cases of ASE. A left-handed man (patient 1) showed continuous aphasia after the administration of flumazenil. He had underlying alcoholic liver cirrhosis and traumatic brain lesions in the right hemisphere. Electroencephalography (EEG) revealed periodic epileptiform discharges in the right frontotemporal area, which were intervened by rhythmic activity with spatiotemporal evolutions. A right-handed woman (patient 2) showed recurrent aphasia. Blood tests revealed a high blood glucose level (546 mg/dL) and high serum osmolality (309 mMol/L). Her EEG showed rhythmic activity in the left frontotemporal area with spatiotemporal evolutions on a normal background rhythm. She became seizure-free after the administration of an antiepileptic drug and strict glucose regulation. A right-handed woman (patient 3) developed subacute aphasia a week before hospital admission. She had a gradual decline of cognition 1 year before. Her EEG showed intermittent quasi-rhythmic fast activity in the frontotemporal area bilaterally, with fluctuating frequency and amplitude. The patient became seizure-free after the administration of an antiepileptic drug. Brain single-photon emission tomography performed after seizure control showed decreased perfusion in the left frontotemporal area. After discharge, her cognitive function gradually declined to a severe state of dementia. ASE can be caused by diverse etiologies; it is usually caused by cerebral lesions and less frequently by non-lesional etiologies or degenerative disorders. Adequate treatment of underlying disorders and seizures is critical for curing the symptoms of ASE.

Determining the Degree of Dopaminergic Denervation Based on the Loss of Nigral Hyperintensity on SMWI in Parkinsonism

BACKGROUND AND PURPOSE

Nigrostriatal dopaminergic function in patients with Parkinson disease can be assessed using ¹²³I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl)-nortropan dopamine transporter (¹²³I-FP-CIT) SPECT, and a good correlation has been demonstrated between nigral status on SWI and dopaminergic denervation on ¹²³I-FP-CIT SPECT. Here, we aim to correlate quantified dopamine transporter attenuation on ¹²³I-FP-CIT SPECT with nigrosome-1 status using susceptibility map-weighted imaging (SMWI).

MATERIALS AND METHODS

Between May 2017 and January 2018, consecutive patients with idiopathic Parkinson disease (n = 109) and control participants (n = 29) who underwent ¹²³I-FP-CIT SPECT with concurrent 3T SWI were included. SMWI was generated from SWI. Two neuroradiologists evaluated nigral hyperintensity from nigrosome-1 on each side of the substantia nigra. Using consensus reading, we compared the ¹²³I-FP-CIT-specific binding ratio according to nigral hyperintensity status and the ¹²³I-FP-CIT specific binding ratio threshold to confirm the loss of nigral hyperintensity was determined using receiver operating characteristic curve analysis.

RESULTS

The concordance rate between SMWI and ¹²³I-FP-CIT SPECT was 65.9%. The ¹²³I-FP-CIT-specific binding ratios in the striatum, caudate nucleus, and putamen were significantly lower when nigral hyperintensity in the ipsilateral substantia nigra was absent than when present (all, P < .001). The ¹²³I-FP-CIT-specific binding ratio threshold values for the determination of nigral hyperintensity loss were 2.56 in the striatum (area under the curve, 0.890), 3.07 in the caudate nucleus (0.830), and 2.36 in the putamen (0.887).

CONCLUSIONS

Nigral hyperintensity on SMWI showed high positive predictive value and low negative predictive value with dopaminergic degeneration on ¹²³I-FP-CIT SPECT. In patients with Parkinson disease, the loss of nigral hyperintensity is prominent in patients with lower striatal specific binding ratios.

Cerebral Toxocara canis larval infection presenting as delayed encephalopathy and nonconvulsive status epilepticus: a case report

Adult cerebral Toxocara canis larval infections are rare. Humans are infected by contacting soil that contains infectious eggs or by eating undercooked meat. We encountered a patient with cerebral T. canis infection who showed recurrent altered mentality with nonconvulsive status epilepticus (NCSE). A 71-year-old male was admitted with complaints of drowsy mentality and abnormal behavior. Magnetic resonance imaging revealed non-enhanced multiple gliosis and calcified lesions. Electroencephalography revealed NCSE, which was cured with valproate. However, he was readmitted because of recurrence of symptoms. On cerebrospinal fluid examination, T. canis antibodies were observed. Subsequently, he was treated with albendazole and corticosteroids. Although corticosteroid improved his symptoms, the therapy could not be continued because the patient developed septic shock. This is the first report of cerebral T. canis larval infection presenting as delayed encephalopathy and NCSE. In patients with unexplainable progressive encephalopathy, particularly when gliosis or calcified lesions are observed on neuroimaging, cerebral T. canis larval infection should be considered and treated promptly.

Bilateral Subthalamic Nucleus Deep Brain Stimulation under General Anesthesia: Literature Review and Single Center Experience

Bilateral subthalamic nucleus (STN) Deep brain stimulation (DBS) is a well-established treatment in patients with Parkinson's disease (PD). Traditionally, STN DBS for PD is performed by using microelectrode recording (MER) and/or intraoperative macrostimulation under local anesthesia (LA). However, many patients cannot tolerate the long operation time under LA without medication. In addition, it cannot be even be performed on PD patients with poor physical and neurological condition. Recently, it has been reported that STN DBS under general anesthesia (GA) can be successfully performed due to the feasible MER under GA, as well as the technical advancement in direct targeting and intraoperative imaging. The authors reviewed the previously published literature on STN DBS under GA using intraoperative imaging and MER, focused on discussing the technique, clinical outcome, and the complication, as well as introducing our single-center experience. Based on the reports of previously published studies and ours, GA did not interfere with the MER signal from STN. STN DBS under GA without intraoperative stimulation shows similar or better clinical outcome without any additional complication compared to STN DBS under LA. Long-term follow-up with a large number of the patients would be necessary to validate the safety and efficacy of STN DBS under GA.

Patient selected goals and satisfaction after bilateral subthalamic nucleus deep brain stimulation in Parkinson's disease

Assessing patient goals is crucial in understanding patient centered outcomes and satisfaction. However, patient goals may change throughout treatment. Our objective is to identify the changes in patient-selected goals of Parkinson's disease (PD) patients undergoing bilateral subthalamic nucleus deep brain stimulation (STN-DBS) and examine the relationship among patient-selected goal achievement, standard DBS outcome measures, and overall patient satisfaction. Seventy-five patients undergoing bilateral STN-DBS listed three patient-selected goals before surgery. After six months, patients were asked to restate the three goals and to rate the degree of goal achievement and the overall satisfaction of surgery. The three most frequently selected goals were "dyskinesia", "gait disorder", and "medication off duration". After six months, 80.0% of patients could not accurately recall their pre-DBS goals. "Dyskinesia" was the most consistently selected goal, more patients selected "tremor" and "less medication" at post-DBS compared to pre-DBS, and less patients selected "gait disorder" at post-DBS compared to pre-DBS. 74.7% of patients reported overall satisfaction by stating they were "very much" or "much better after surgery". Patient satisfaction significantly correlated with goal achievement (r = 0.640; p < 0.001). Interestingly, change in UPDRS motor scores did not correlate with patient satisfaction (r = 0.100; p = 0.395). Although recalled goals do not accurately represent the pre-surgical goals, the achievement score for recalled goals significantly correlated with patient satisfaction. Patient goals change due to many reasons. Therefore, follow-up patient counseling to discuss goals and outcomes is important in improving patient satisfaction after STN-DBS.

GCH-1 genetic variant may cause Parkinsonism by unmasking the subclinical nigral pathology

BACKGROUND

Recent studies suggest that GTP cyclohydrolase 1 (GCH-1) variant may be a risk factor for nigral degeneration causing PD.

METHODS

A 49-year-old Korean woman visited our movement disorder clinic with the initial presentation of Parkinsonism starting at age 47. We monitored the degree of nigral degeneration with serial FP-CIT PET throughout the course of her disease (2, 8 and 11 years from disease onset).

RESULTS

The initial clinical presentation was consistent with intrinsic dopamine deficiency caused by GCH-1 variant. However, her follow-up disease course was consistent with Parkinsonism caused by nigral neurodegeneration. We found a novel GCH-1 variant in the current case. The disease course of the patient was overall benign in motor and non-motor aspects, corresponding to previously reported GCH-1 cases with PD. Serial FP-CIT PET scans showed normal initial FP-CIT binding followed by a continuous decline of the putaminal binding ratio. However, the decreased binding ratio could not sufficiently explain the corresponding clinical duration of the patient. Therefore, dopamine deficiency by GCH-1 genetic variant contributed to Parkinsonism in the current case with subclinical nigral degeneration.

CONCLUSION

Our case suggests that GCH-1 variant causes Parkinsonism by unmasking the subclinical nigral pathology, not by causing the nigral neurodegeneration.

Epilepsy Mimicking Affective Disorder in a Patient with Amygdala Enlargement

Affective disorders are commonly associated with epilepsy. Affective symptoms rarely occur concomitantly with seizure occurrence, which can lead to misdiagnosis. Here, we describe a 69-year-old man who experiencedintermittent manifestations of unpleasant mood and aggressive behavior. He had temporal lobe epilepsy with amygdala enlargement. After successful treatment with an antiepileptic drug, hissymptoms resolved. Additionally, the amygdala enlargement decreased when checked at 5 years after treatment. We discuss the clinical characteristics and differential points of the case.

Determinants of Functional Independence or Its Loss following Subthalamic Nucleus Stimulation in Parkinson's Disease

OBJECTIVE

This study aimed to describe the change in functional status following bilateral subthalamic nucleus stimulation (STN-DBS) in Parkinson's disease (PD) and to identify predictors of postoperative functional dependence.

METHODS

We included PD patients with bilateral STN-DBS who had complete Schwab &amp; England Activities of Daily Living (S&amp;E ADL) Scale data at baseline and 6 months after surgery from our prospective registry. Functional dependence was defined as an S&amp;E ADL score of less than 80%. All data were collected from the on-medication state and on-stimulation state (after surgery). Logistic regression analyses were performed to determine the factors predictive of functional dependence after surgery.

RESULTS

A total of 196 patients were included. At baseline, 41 patients were functionally dependent and the other 155 were functionally independent. Among the patients with preoperative dependence, 32 (78%) became functionally independent after surgery, and this conversion was associated with a lower baseline axial score (p = 0.012). Among the patients with preoperative independence, 21 (14%) developed postoperative dependence, and this conversion was associated with a higher baseline axial score (p = 0.013) and its smaller improvement (p < 0.001). Female sex (odds ratio [OR] 3.214; 95% confidence interval [CI] 1.210-8.542; p = 0.019) and a higher baseline axial score (OR 1.184; 95% CI 1.056-1.327; p = 0.004) significantly predicted the risk of postoperative functional dependence.

CONCLUSIONS

We found that functional status following bilateral STN-DBS is closely related to preoperative axial symptoms. When loss of independence is a potential target for STN-DBS, clinicians should take into consideration the severity of axial impairment before surgery.

Clonazepam for probable REM sleep behavior disorder in Parkinson's disease: A randomized placebo-controlled trial

BACKGROUND

Clonazepam is considered to be a first-line treatment for rapid eye movement sleep-related behavior disorder (RBD) in Parkinson's disease (PD). The purpose of this study was to determine the short-term efficacy and safety of clonazepam for the treatment of probable RBD (pRBD) in patients with PD.

METHODS

We conducted a four-week, randomized, double-blind, placebo-controlled trial of clonazepam (0.5 mg/day at bedtime) compared to a placebo for RBD symptoms in patients with PD. Patients aged 30 years or older who had a caregiver that could observe RBD symptoms were recruited between April 2015 and February 2016. The primary outcome was the Clinical Global Impressions-Improvement (CGII) score at week four, and we compared scores between the clonazepam and placebo groups.

RESULTS

A total of 40 patients were enrolled, with 20 assigned to receive clonazepam and 20 to receive the placebo. The CGI-I score at four weeks indicated an improvement in RBD symptoms in both the clonazepam (median score [minimum, maximum] = 2 [1,5]) and placebo (3 [1,6]) groups, with no significant difference between the groups (p = .253). The secondary outcomes were not significantly different between the clonazepam and placebo groups.

CONCLUSIONS

Both clonazepam and placebo tended toward improvement on pRBD symptoms in patients with PD. No firm conclusion on efficacy of clonazepam was drawn due to limitations in the study design. This study emphasized the importance of conducting future large-scale, randomized trials with better assessment tools and polysomnography to provide evidence for the benefit of clonazepam.

Clinical differences in patients with Parkinson's disease according to tandem gait performance

Some of patients with Parkinson's disease (PD) have abnormal tandem gait (TG) performance without any symptoms and signs of cerebellar dysfunction. Clinical difference between patients with good and poor TG performance has not yet been studied. We report the relationship between tandem gait performance and clinical characteristics including 37 patients with PD who had no evidence of cerebellar dysfunction. Using tandem gait test, the patients were divided into two groups (good-TG and poor-TG). We evaluated the two groups with Montreal Cognitive Assessment (MoCA), Mini Mental Status Examination (MMSE), Frontal Assessment Batter (FAB), Beck Depression Index (BDI-II), REM Sleep Behavior Disorder Single-Question Screen (RBD1Q), MDS-UPDRS items related to axial disability and freezing. Fifteen participants were classified as good-TG group and 22 were as poor-TG group. Participants in good-TG group had higher MoCA score and lower BDI-II score. The proportion of participants who answered "yes" to RBD1Q was lower in good-TG group (27%, 4 of 15) than that in poor-TG group (55%, 12 of 22). All participants in good-TG group marked "0" for the MDS-UPDRS item 2.13 which addresses freezing event over the past week, whereas 18% (4 of 22) of participants in poor-TG group marked "1". In conclusion, tandem gait performance may be related to various clinical characteristics including cognitive function, mood, RBD, and freezing in patients with PD.

Musculoskeletal Problems Affect the Quality of Life of Patients with Parkinson's Disease

Objective

Musculoskeletal problems are more common in patients with Parkinson’s disease (PD) than in normal elderly, but the impact of musculoskeletal problems on health-related quality of life (HRQoL) in patients with PD is unknown.

Methods

Four hundred consecutive patients with PD were enrolled for the evaluation of musculoskeletal problems and HRQoL. HRQoL was assessed by the 36-Item Short Form Health Survey, which comprised physical health and mental health.

Results

Of the total patients, 265 patients had musculoskeletal problems, and 135 patients did not have musculoskeletal problems. Patients with musculoskeletal problems reported lower levels of HRQoL in terms of physical health than did patients without musculoskeletal problems (p < 0.05). In women, all components of physical health were lower in patients with musculoskeletal problems than in patients without musculoskeletal problems (p < 0.05). Meanwhile, in men, only the bodily pain score of physical health was lower in patients with musculoskeletal problems than in patients without musculoskeletal problems. Mental health and physical health were negatively correlated with depression, Unified Parkinson’s Disease Rating Scale I & II scores, and pain severity from musculoskeletal problems, in that order (p < 0.01 for all).

Conclusion

These results suggest that musculoskeletal problems in patients with PD affect HRQoL significantly, mainly in terms of physical health rather than mental health and especially in women rather than men. Musculoskeletal problems should not be overlooked in the care of patients with PD.

Expanding the Spectrum of Dopa-Responsive Dystonia (DRD) and Proposal for New Definition: DRD, DRD-plus, and DRD Look-alike

Previously, we defined DRD as a syndrome of selective nigrostriatal dopamine deficiency caused by genetic defects in the dopamine synthetic pathway without nigral cell loss. DRD-plus also has the same etiologic background with DRD, but DRD-plus patients have more severe features that are not seen in DRD because of the severity of the genetic defect. However, there have been many reports of dystonia responsive to dopaminergic drugs that do not fit into DRD or DRD-plus (genetic defects in the dopamine synthetic pathway without nigral cell loss). We reframed the concept of DRD/DRD-plus and proposed the concept of DRD look-alike to include the additional cases described above. Examples of dystonia that is responsive to dopaminergic drugs include the following: transportopathies (dopamine transporter deficiency; vesicular monoamine transporter 2 deficiency); SOX6 mutation resulting in a developmentally decreased number of nigral cells; degenerative disorders with progressive loss of nigral cells (juvenile Parkinson's disease; pallidopyramidal syndrome; spinocerebellar ataxia type 3), and disorders that are not known to affect the nigrostriatal dopaminergic system (DYT1; GLUT1 deficiency; myoclonus-dystonia; ataxia telangiectasia). This classification will help with an etiologic diagnosis as well as planning the work up and guiding the therapy.

Amantadine and the Risk of Dyskinesia in Patients with Early Parkinson's Disease: An Open-Label, Pragmatic Trial

Objective

We examined whether amantadine can prevent the development of dyskinesia.

Methods

Patients with drug-naïve Parkinson’s disease (PD), younger than 70 years of age and in the early stage of PD (Hoehn and Yahr scale < 3), were recruited from April 2011 to December 2014. The exclusion criteria included the previous use of antiparkinsonian medication, the presence of dyskinesia, significant psychological disorders, and previous history of a hypersensitivity reaction. Patients were consecutively assigned to one of 3 treatment groups in an open label fashion: Group A-1, amantadine first and then levodopa when needed; Group A-2, amantadine first, dopamine agonist when needed, and then levodopa; and Group B, dopamine agonist first and then levodopa when needed. The primary endpoint was the development of dyskinesia, which was analyzed by the Kaplan-Meier survival rate.

Results

A total of 80 patients were enrolled: Group A-1 (n = 27), Group A-2 (n = 27), and Group B (n = 26). Twenty-four patients were excluded from the analysis due to the following: withdrawal of amantadine or dopamine agonist (n = 9), alternative diagnosis (n = 2), withdrawal of consent (n = 1), and breach in the protocol (n = 12). After exclusion, 5 of the 56 (8.93%) patients developed dyskinesia. Patients in Group A-1 and A-2 tended to develop dyskinesia less often than those in Group B (cumulative survival rates of 0.933, 0.929, and 0.700 for A-1, A-2, and B, respectively; p = 0.453).

Conclusion

Amantadine as an initial treatment may decrease the incidence of dyskinesia in patients with drug-naïve PD.

Emergence of non-motor fluctuations with reference to motor fluctuations in Parkinson's disease

INTRODUCTION

Non-motor fluctuations (NMF) and motor fluctuations (MF) are frequent in patients with Parkinson's disease (PD) with long-term medical treatment. We aimed to examine the timing of the emergence of NMF with reference to MF in a prospective cohort of patients with PD without symptom fluctuations.

METHODS

A total of 334 patients with PD who had neither MF nor NMF were recruited. The exclusion criteria included a Mini-Mental State Examination score of less than 26 points at baseline and an alternative diagnosis or significant comorbidity during follow-up. The "SNUH-Fluctuation Questionnaire" consisting of 29 items (9 on MF and 20 on NMF) was administered on a semi-annually basis for 3 years.

RESULTS

Three hundred seven out of 334 patients were analyzed for symptom fluctuations with the Kaplan-Meier survival analysis. MF were observed in more patients and developed earlier than NMF (cumulative survival of 0.572 for MF and 0.619 for NMF at 36 months of follow-up). In 212 patients who finished the follow-up for 36 months, MF and NMF developed simultaneously in 58 (27.4%), MF developed first in 45 (21.2%), and NMF developed first in only 3 (1.4%). The remaining 106 patients (50.0%) did not develop either MF or NMF.

CONCLUSION

NMF developed simultaneously with or later than MF. From these data, we hypothesize that NMF develop in the disease state where the pathology in the brain has been severe enough to develop MF. Hence, pharmacologic management should consider targeting both dopaminergic and non-dopaminergic systems to treat NMF.

Characteristics of Early Oropharyngeal Dysphagia in Patients with Multiple System Atrophy

BACKGROUND/AIMS

Dysphagia, a symptom of multiple system atrophy (MSA), is a major clinical concern. In this study, we investigate the characteristics of early oropharyngeal dysphagia (OD) in patients with MSA, and the differences between MSA subtypes.

METHODS

Patients enrolled in the study had previously been diagnosed with MSA at the clinic of the Department of Neurology, and had been referred for a videofluoroscopic swallowing study (VFSS), between 2005 and 2014, to check for dysphagia. The clinical characteristics and VFSS findings were analyzed and compared between the MSA subtypes.

RESULTS

This study enrolled 59 patients with MSA (24 men; 31 with MSA-P, 21 with MSA-C, and 7 with MSA-PC). Dysphagia symptoms were mostly limited to aspiration symptoms (90.48%) in patients with MSA-C, while difficulty in swallowing, increased mealtime, and drooling were frequent in those with MSA-P. The most common VFSS finding amongst patients was vallecular residue (n = 53, 89.8%), followed by penetration/aspiration (n = 40, 67.8%), and coating of the pharyngeal wall (n = 39, 66.1%). Comparison analysis between subtypes showed that apraxia and vallecular residue were more frequent and severe in MSA-P than in MSA-C (p = 0.033 and p = 0.010, respectively).

CONCLUSION

Understanding early OD characteristics in patients with MSA and the differences between MSA subtypes could be helpful in managing dysphagia in patients with MSA. Several dysphagia symptoms similar to those of Parkinson disease were frequently observed in MSA-P, but not in MSA-C. A follow-up study is needed to elucidate the natural course of OD in MSA patients and the difference between MSA subtypes.

Aphasic Status Epilepticus Associated with Uremia

Aphasic status epilepticus (ASE) is a rare disorder characterized by recurrent aphasia without impairment of other cognitive functions. A 76-year-old woman with chronic kidney disease developed ASE after neglecting peritoneal dialysis. Magnetic resonance imaging failed to demonstrate an appropriate lesion. Electroencephalography demonstrated ictal discharges in the left frontotemporal leads. ASE disappeared after intravenous valproic acid and correction of uremia. This is the first case report of ASE in a patient with acute aggravation of uremia.

A Death Case of Bulimia Nervosa Presented with Abdominal Distention

Bulimia nervosa is one of the eating disorders. Psychological manifestations of this disease, such as guilt or denial, may interfere with patient communication. The patients with bulimia nervosa are most commonly between ages of 17 and 25 years old, and often maintain normal body weight. It is not easy to screen out and diagnose bulimia nervosa patients at the emergency department. We reported two bulimia nervosa patients who visited our emergency department with abdominal distension, and one of them died of abdominal compartment syndrome. We confirmed collapse of the abdominal aorta and key arteries in enhanced abdominal computed tomography. Promptly, we performed gastrostomy for reduction of abdominal pressure, but she finally succumbed due to multiple organ failure 12 hours after the surgery.

18F-NaF PET/CT for the evaluation of temporomandibular joint disorder

AIM

To investigate the usefulness of a quantitative parameter (maximum standardised uptake value [SUVmax]) of ¹⁸F-sodium fluoride (NaF) positron-emission tomography (PET)/computed tomography (CT) for the evaluation of temporomandibular joint (TMJ) disorder (TMD).

MATERIALS AND METHODS

Seventy-six TMD patients (male: female=14:62, age=40.3±17.1 years, bilateral: unilateral=40:36) with 152 TMJs were enrolled. The ¹⁸F-NaF PET/CT parameter (SUVmax) was compared with the presence of TMJ arthralgia (arthralgic=86, non-arthralgic=66) and clinical subtypes based on the Research Diagnostic Criteria for TMD Axis I (TMD osteoarthritis=49, non-TMD osteoarthritis=67, and asymptomatic TMJ=36). Splint therapy was applied to 48 patients for 6 months without considering ¹⁸F-NaF PET/CT findings. Post-splint therapy ¹⁸F-NaF PET/CT was performed in 32 patients and clinical responses to the therapy were classified into improvement (n=33), no change (n=10), or aggravation (n=7) for 50 TMJs excluding asymptomatic TMJs (n=14).

RESULTS

SUVmax was significantly greater in arthralgic TMJs than in non-arthralgic TMJs (6.62±3.56 versus 4.32±1.53, p<0.0001). SUVmax was also significantly greater in TMD osteoarthritis (6.75±3.85) than in non-TMD osteoarthritis (5.21±2.70) and asymptomatic TMJs (4.86±1.99; p=0.0386). After splint therapy, SUVmax was significantly increased in aggravated TMJs (from 7.80±3.72 to 11.00±5.74, p=0.0156), whereas no significant change in SUVmax was observed in improved (from 6.16±2.68 to 6.09±2.60, p=0.4915) and unchanged (from 6.46±4.19 to 6.77±4.32, p=0.3223) TMJs.

CONCLUSIONS

¹⁸F-NaF PET/CT is a useful imaging tool for TMD evaluation because SUVmax showed a fair diagnostic performance for arthralgic TMJ and TMD osteoarthritis, and a correlation with the therapeutic response.

Validation of the Vectra H1 portable three-dimensional photogrammetry system for facial imaging

Three-dimensional (3D) surface imaging using stereophotogrammetry has become increasingly popular in clinical settings, offering advantages for surgical planning and outcome evaluation. The handheld Vectra H1 is a low-cost, highly portable system that offers several advantages over larger stationary cameras, but independent technical validation is currently lacking. In this study, 3D facial images of 26 adult participants were captured with the Vectra H1 system and the previously validated 3dMDface system. Using error magnitude statistics, 136 linear distances were compared between cameras. In addition, 3D facial surfaces from each system were registered, heat maps generated, and global root mean square (RMS) error calculated. The 136 distances were highly comparable across the two cameras, with an average technical error of measurement (TEM) value of 0.84mm (range 0.19-1.54mm). The average RMS value of the 26 surface-to-surface comparisons was 0.43mm (range 0.33-0.59mm). In each case, the vast majority of the facial surface differences were within a ±1mm threshold. Areas exceeding ±1mm were generally limited to facial regions containing hair or subject to facial microexpressions. These results indicate that 3D facial surface images acquired with the Vectra H1 system are sufficiently accurate for most clinical applications.

Correlation of electrode position and clinical outcomes in globus pallidus stimulation for dystonia

BACKGROUND

The correlation between the electrode location and the clinical outcome for internal globus pallidus (GPi) deep brain stimulation (DBS) has not been fully elucidated.

OBJECTIVE

The aim of this study was to determine the discrepancies between the theoretical target planned by magnetic resonance imaging (MRI) and the actual electrode location in postoperative MRI, as well as to find the correlation between the final electrode locations and the clinical outcome after GPi DBS.

METHODS

Thirty-six patients who underwent GPi DBS for dystonia were included in this retrospective study. The X coordinate was defined as the lateral distance from the midline, the Y coordinate as the anterior distance from the midcommissural point, and the Z coordinate as the inferior distance from the intercommissural line.

RESULTS

All coordinates showed a significant difference between theoretical and actual values for all electrode locations (p < 0.05). In particular, greater differences were exhibited for Y than for the X and Z coordinates. There was no significant difference in the accuracy of the localization of the left-side versus the right-side electrode for any coordinates. The patients whose electrodes were located within or near the posteroventral GPi showed better clinical outcomes.

CONCLUSIONS

The actual electrode location was slightly more posterior to the theoretically planned target. Electrodes concentrated near the posteroventral GPi tended to yield favorable outcomes.

Maximum standardised uptake value of quantitative bone SPECT/CT in patients with medial compartment osteoarthritis of the knee

AIM

To evaluate the correlation between the maximum standardised uptake value (SUVmax) from bone single-photon-emission computed tomography/computed tomography (SPECT/CT) and other imaging parameters for medial compartment osteoarthritis (OA) of the knee.

MATERIALS AND METHODS

Patients (n=26; male:female=2:24; age, 55.3±5.8 years) underwent quantitative knee SPECT/CT using technetium-99m (Tc-99m) hydroxymethylene diphosphonate (HDP) before surgical operation for medial OA of the knee. SUVmax was calculated using dedicated quantitative software. Visual grades of tracer uptake on bone SPECT/CT and Kellgren-Lawrence (KL) OA scores on plain radiographs were assessed using a five-point scale. Magnetic resonance imaging (MRI) scores (n=22) and patient symptom scores were also assessed.

RESULTS

The operated knees (n=34) had a greater SUVmax than the non-operated knees (n=18) in the medial compartment (14.1±6.1 versus 5.3±4.4, p<0.0001). In the medial compartment, the SUVmax was significantly correlated with SPECT/CT visual grades (rho=0.794, p<0.0001), KL scores (rho=0.703, p<0.0001), and MRI scores (rho=0.714-0.808, p≤0.0002); however, SUVmax and other imaging parameters were not correlated with patient symptom scores (p>0.05).

CONCLUSIONS

The SUVmax of quantitative bone SPECT/CT was highly correlated with traditional imaging parameters for medial compartment OA severity of the knee. Quantitative bone SPECT/CT is a promising imaging technique for the objective assessment of knee OA.

Liquid levodopa-carbidopa in advanced Parkinson's disease with motor complications

While levodopa, carbidopa, ascorbic acid solution (LCAS) therapy has been used in patients with advanced Parkinson's disease (PD) for many years, long-term follow-up data is scarce. The present study aimed to determine the long-term retention rate for LCAS therapy, and to identify the causes of LCAS therapy withdrawal. Our study included a series of 38 patients with PD (14 men and 24 women) who underwent LCAS treatment between 2011 and 2013 to alleviate motor complications that were not satisfactorily controlled by optimized conventional anti-parkinsonian treatment at the Seoul National University Hospital. All patients were admitted to educate them about and initiate LCAS treatment for 2-5days, and were then followed up as outpatients. The mean follow-up duration was 12.8months, and three main reasons for LCAS treatment discontinuation were worsening of wearing-off symptoms (8 patients), persistent dyskinesia (4 patients), and poor drug adherence (4 patients). Fourteen patients (36.8%) maintained the LCAS treatment after 12months, and were categorized as the treatment-retention group. The mean percentage of on time without dyskinesia significantly increased from 33.6±17.6% to 57.0±27.7% after LCAS initiation (p=0.016) in the treatment-retention group. Twelve patients (31.6%) were still receiving LCAS treatment after 30months. LCAS treatment can be a non-device assisted therapeutic option for patients who have no access to advanced therapies such as deep brain stimulation and infusional treatments.

Visual Hallucination and Pattern of Brain Degeneration in Parkinson's Disease

BACKGROUND AND OBJECTIVES

The incidence of visual hallucination (VH) increases with Parkinson's disease (PD) progression, and its development is thought to be related to a specific neurodegenerative process in PD. This study aimed to reveal brain degeneration related to VH in PD by analyzing neuroimaging data obtained from patients in their different stages of PD.

METHODS

Data from 48 PD patients - 21 nondemented without VH (PNV group), 10 nondemented with VH (PV group), and 17 demented with VH (PVD group) - and 30 age-matched healthy controls (HC group) were analyzed. Voxel-based morphometry and tract-based spatial statistics were conducted. Previous magnetic resonance volumetric studies on VH in PD were collectively reviewed.

RESULTS

The PV group showed gray matter atrophy in the right inferior parietal lobule and supramarginal gyrus compared with the HC and PNV groups. The PVD group showed a wider range of gray matter atrophies in the temporo-parieto-occipital regions than those in the PV group. White matter changes seemed to be an earlier event than gray matter changes. Fractional anisotropy values diffusely decreased in all three PD subgroups compared with the HC group without significant differences between the PD subgroups. Mean diffusivity was not different between the PNV and HC groups but increased in the parieto-temporal region in the PV group and increased diffusely in the PVD group, additionally including the fronto-occipital regions. A review of previous studies supported our observations.

CONCLUSIONS

Gray matter degenerations from the parieto-temporal junction to the parieto-occipital and temporo-occipital regions may be responsible for VH on the typical timeline of PD progression.

An Atypical Presentation of Subacute Encephalopathy with Seizures in Chronic Alcoholism Syndrome

Subacute encephalopathy with seizures in chronic alcoholism syndrome is a rare clinical manifestation in patients with chronic alcohol abuse. We report the case of a patient with chronic alcoholism who presented with partial nonconvulsive status epilepticus associated with a thalamic lesion.

A Systematic Review of Treatment Outcome in Patients with Dopa-responsive Dystonia (DRD) and DRD-Plus

Background

Dopa-responsive dystonia (DRD) and DRD-plus are inherited metabolic disorders of the dopamine synthetic pathway that have considerable clinical, biochemical, and genetic heterogeneity. Dopamine is the main deficient neurotransmitter; however, a deficiency in norepinephrine and serotonin can coexist, depending on the gene and its degree of defect. Therefore, even though levodopa is the mainstay of therapy, response to levodopa can be suboptimal and, thus, other drugs are tried.

Methods and Results

The authors searched for reports of DRD and DRD-plus and reviewed the drugs used, their response and side effects, and neurologic outcomes, including motor and cognition. Based on the current results, a recommended treatment plan is presented according to the type of enzyme defect in patients with DRD and DRD-plus.

Conclusions

It is important to recognize the features of DRD and DRD-plus, because many of them have a good clinical response to the appropriate treatment. The aim of this review is to help guide clinicians with planning treatment for patients with DRD and DRD-plus.

Bilateral Deep Brain Stimulation of the Subthalamic Nucleus under Sedation with Propofol and Fentanyl

Awakening during deep brain stimulation (DBS) surgery may be stressful to patients. The aim of the current study was to evaluate the effect on MER signals and their applicability to subthalmic nucleus (STN) DBS surgery for patients with Parkinson’s disease (PD) under sedation with propofol and fentanyl. Sixteen consecutive patients with PD underwent STN-DBS surgery with propofol and fentanyl. Their MER signals were achieved during the surgery. To identify the microelectrodes positions, the preoperative MRI and postoperative CT were used. Clinical profiles were also collected at the baseline and at 6 months after surgery. All the signals were slightly attenuated and contained only bursting patterns, compared with our previous report. All electrodes were mostly located in the middle one third part of the STN on both sides of the brain in the fused images. Six months later, the patients were improved significantly in the medication-off state and they met with less dyskinesia and less off-duration. Our study revealed that the sedation with propofol and fentanyl was applicable to STN-DBS surgery. There were no significant problems in precise positioning of bilateral electrodes. The surgery also improved significantly clinical outcomes in 6-month follow-up.

Does serum uric acid act as a modulator of cerebrospinal fluid Alzheimer's disease biomarker related cognitive decline?

BACKGROUND AND PURPOSE

The association of serum uric acid, cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD) and longitudinal cognitive decline was evaluated using the AD Neuroimaging Initiative database.

METHODS

In 271 healthy subjects, 596 mild cognitive impairment patients and 197 AD patients, serum uric acid and CSF AD biomarkers were measured at baseline, and Mini-Mental State Examination and AD Assessment Scale - Cognitive Subscale (ADAS-cog) were assessed serially (mean duration, 2.9 years). The effect of uric acid on longitudinal cognitive decline was evaluated using linear mixed effect models for Mini-Mental State Examination and ADAS-cog scores in female and male subjects separately, with possible confounders controlled (model 1). To determine the effects of uric acid independent of CSF biomarker (Aβ1-42 or tau) and to test whether the detrimental effects of CSF biomarker differ according to uric acid, CSF biomarker and its interaction with uric acid were further included in model 1 (model 2).

RESULTS

Higher levels of uric acid were associated with slower cognitive decline, particularly in the mild cognitive impairment and dementia subgroups, and more prominently in female subjects. Model 2 with CSF Aβ1-42 showed that higher levels of uric acid were associated with a slower cognitive decline and alleviated the detrimental effect of Aβ1-42 on cognitive decline. Model 2 with CSF tau showed that higher levels of uric acid alleviated the detrimental effect of tau on cognitive decline in female subjects but not in male subjects.

CONCLUSION

Higher levels of uric acid had protective effects on longitudinal cognitive decline independent of and interactively with CSF AD biomarkers.

Prevalence of antineuronal antibodies in patients with encephalopathy of unknown etiology: Data from a nationwide registry in Korea

We aimed to evaluate the prevalence of antineuronal antibodies in a nationwide cohort of patients with encephalopathy of unknown etiology. We screened 1699 patients with idiopathic encephalopathy who were referred from 70 hospitals across Korea for autoimmune synaptic and classic paraneoplastic antibodies. Those with cerebellar degeneration, sensory polyneuropathy or other paraneoplastic syndromes without encephalopathy were not included in this study. One-hundred and four patients (6.12%) had antibody-associated autoimmune encephalopathy. Autoimmune synaptic antibodies were identified in 89 patients (5.24%) and classic paraneoplastic antibodies were identified in 16 patients (0.94%). The patients with antibody-associated autoimmune encephalopathy comprised a small but significant portion of the total number of patients with encephalopathy of unknown cause.

Long-Term Clinical Outcome of Internal Globus Pallidus Deep Brain Stimulation for Dystonia

Background

GPi (Internal globus pallidus) DBS (deep brain stimulation) is recognized as a safe, reliable, reversible and adjustable treatment in patients with medically refractory dystonia.

Objectives

This report describes the long-term clinical outcome of 36 patients implanted with GPi DBS at the Neurosurgery Department of Seoul National University Hospital.

Methods

Nine patients with a known genetic cause, 12 patients with acquired dystonia, and 15 patients with isolated dystonia without a known genetic cause were included. When categorized by phenomenology, 29 patients had generalized, 5 patients had segmental, and 2 patients had multifocal dystonia. Patients were assessed preoperatively and at defined follow-up examinations postoperatively, using the Burke-Fahn-Marsden dystonia rating scale (BFMDRS) for movement and functional disability assessment. The mean follow-up duration was 47 months (range, 12–84)

Results

The mean movement scores significantly decreased from 44.88 points preoperatively to 26.45 points at 60-month follow up (N = 19, P = 0.006). The mean disability score was also decreased over time, from 11.54 points preoperatively to 8.26 points at 60-month follow up, despite no statistical significance (N = 19, P = 0.073). When analyzed the movement and disability improvement rates at 12-month follow up point, no significant difference was noted according to etiology, disease duration, age at surgery, age of onset, and phenomenology. However, the patients with DYT-1 dystonia and isolated dystonia without a known genetic cause showed marked improvement.

Conclusions

GPi DBS is a safe and efficient therapeutic method for treatment of dystonia patients to improve both movement and disability. However, this study has some limitations caused by the retrospective design with small sample size in a single-center.

Long-term control of diabetes in immunosuppressed nonhuman primates (NHP) by the transplantation of adult porcine islets

Pig islets are an alternative source for islet transplantation to treat type 1 diabetes (T1D), but reproducible curative potential in the pig-to-nonhuman primate (NHP) model has not been demonstrated. Here, we report that pig islet grafts survived and maintained normoglycemia for >6 months in four of five consecutive immunosuppressed NHPs. Pig islets were isolated from designated pathogen-free (DPF) miniature pigs and infused intraportally into streptozotocin-induced diabetic rhesus monkeys under pretreatment with cobra venom factor (CVF), anti-thymocyte globulin (ATG) induction and maintenance with anti-CD154 monoclonal antibody and low-dose sirolimus. Ex vivo expanded autologous regulatory T cells were adoptively transferred in three recipients. Blood glucose levels were promptly normalized in all five monkeys and normoglycemia (90-110 mg/dL) was maintained for >6 months in four cases, the longest currently up to 603 days. Intravenous glucose tolerance tests during the follow-up period showed excellent glucose disposal capacity and porcine C-peptide responses. Adoptive transfer of autologous regulatory T cells was likely to be associated with more stable and durable normoglycemia. Importantly, the recipients showed no serious adverse effects. Taken together, our results confirm the clinical feasibility of pig islet transplantation to treat T1D patients without the need for excessive immunosuppressive therapy.

Should genetic testing for SCAs be included in the diagnostic workup for MSA?

OBJECTIVE

To examine the prevalence of mutations in spinocerebellar ataxia (SCA) genes in patients who were clinically diagnosed with multiple system atrophy (MSA).

METHODS

Genetic tests for SCA were performed in 302 of 528 patients who met the diagnostic criteria for MSA based on clinical features. Generally, when a patient had cerebellar symptoms or cerebellar atrophy on neuroimaging, genetic tests for SCA types 1, 2, 3, 6, 7, and 17, and dentatorubropallidoluysian atrophy were done, and when a patient had parkinsonism without cerebellar symptoms, genetic tests for SCA types 2, 3, and 17 were done.

RESULTS

Mutations in SCA genes were found in 22 of the 302 patients (7.3%) with SCA17 comprising more than half of the mutation-positive cases. The age at disease onset in these 22 patients was not different compared with the 280 patients without mutations (55.9 ± 9.3 vs 59.2 ± 8.9, p = 0.102). All patients had urinary symptoms, and 10 patients also had orthostatic dizziness or orthostatic hypotension. A family history was reported in only 3 patients. Of note, dream enactment behavior suggesting REM sleep behavior disorder was reported in 9 of the 11 patients (81.8%) asked.

CONCLUSIONS

The high proportion of patients with SCA mutations in this study indicates that genetic testing for SCA should be included for patients with MSA, especially for patients with cerebellar dysfunctions.