Panic Attack, Severe Hypophosphatemia and Rhabdomyolysis in the Setting of a Motor Functional Neurological Disorder.

(1) Background: panic attack is often regarded as a benign disorder with variable physical and psychological symptoms. (2) Case Presentation: We here report the case of a 22-year-old patient known for an episode of motor functional neurological disorder a year earlier who presented a panic attack with hyperventilation causing severe hypophosphatemia and rhabdomyolysis, as well as mild tetraparesis. Electrolyte disturbances quickly resolved after phosphate substitution and rehydration. However, clinical signs suggesting a relapse of a motor functional neurological disorder appeared (improved walking with dual tasks). Diagnostic workup, including brain and spinal magnetic resonance imaging, as well as electroneuromyography and genetic testing for hypokalemic periodic paralysis, was unremarkable. Tetraparesis, lack of endurance, and fatigue eventually improved after several months. (3) Conclusions: the present case report highlights the intertwined relationship between a psychiatric disorder, leading to hyperventilation and acute metabolic disturbances, and functional neurological manifestations.

The ipsilateral silent period: an early diagnostic marker of callosal disconnection in ALS.

INTRODUCTION: Imaging studies showed affection of the corpus callosum (CC) in amyotrophic lateral sclerosis (ALS). Here, we sought to determine whether these structural alterations reflect on the functional level, using transcranial magnetic stimulation (TMS). METHODS: In 31 ALS patients and 12 controls, we studied mirror movements (MM) and transcallosal inhibition (TI) using TMS. Structural integrity of transcallosal fibres was assessed using diffusion tensor imaging. RESULTS: TI was pathologic in 25 patients (81%), 22 (71%) showed MM. Loss of TI was observed in very early stages (disease duration <4 months). No correlation was found between TI/MM and fractional anisotropy of transcallosal fibres. DISCUSSION: These results substantiate the body of evidence towards a functional involvement of the CC in early ALS beyond microstructural alterations. SIGNIFICANCE: TI may become a useful early diagnostic marker in ALS, even before descending tracts are affected. Diagnostic delay in ALS is high, often preventing patients from gaining access to therapeutic trials, and sensitive diagnostic tools are urgently needed. Our findings also provide insights into the pathophysiology of ALS, potentially supporting the so-called 'top-down' hypothesis, that is, corticoefferent (intracortical/corticospinal) propagation. Callosal affection in early stages might represent the 'missing link' to explain corticocortical disease-spreading.

Extrastriatal 123I-FP-CIT SPECT impairment in degenerative parkinsonisms.

INTRODUCTION: Neuropathological data and nuclear medicine imaging show extensive serotonergic impairment in Parkinson's disease (PD) and atypical parkinsonian syndromes (APS). The study aims at performing a case-controlled region-of-interest (ROI)-based analysis of 123I-N-ω-fluoropropyl-2ß-carbomethoxy-3ß-(4-iodophenyl) nortropane (123I-FP-CIT) images to measure extrastriatal regional deficits in PD and APS, and assess their added diagnostic value in discriminating degenerative parkinsonisms from other conditions. METHODS: We included 157 patients with early degenerative parkinsonism (mean age 72.6 years, 44% female, mean disease duration at scan 1.6 years), i.e. PD (n = 59), multiple system atrophy parkinsonian variant (MSA-P, n = 17), progressive supranuclear palsy (PSP, n = 28), corticobasal syndrome (CBS, n = 19), dementia with Lewy bodies (DLB, n = 34) as well as 58 similarly-aged control participants. 123I-FP-CIT SPECT images were processed with statistical parametric mapping 12 (SPM12)-based PETPVE12 software and subjected to partial volume effect correction for ROI-based group comparisons. RESULTS: Relative to controls, all forms of degenerative parkinsonism showed decreased 123I-FP-CIT uptake in caudate nucleus, putamen but also pallidum and insula. In addition, a significant uptake reduction was observed in thalamus for MSA-P and PSP, in midbrain for PD and PSP, and in the amygdala for PSP (ANCOVA controlling for age, sex and antidepressant medication, all Bonferroni-corrected p < 0.007). Receiver-operating characteristics area-under-the-curve showed that adding extrastriatal evaluation led to higher accuracies in separating degenerative conditions from control participants (96.1% vs 94.9% with striatal ROIs only, p = 0.045). CONCLUSION: This study provides evidence of a major extrastriatal 123I-FP-CIT impairment, and therefore of an altered serotonergic transmission in PD and APS, confirming previous neuropathological and SERT imaging findings.

A modern multidisciplinary approach to patients suffering from cervical spondylotic myelopathy.

BACKGROUND: The traditional approach to patients suffering from cervical spondylotic myelopathy (CSM) consists of mere assessment of radiological standard magnetic resonance (MR) images and evaluation of surgical indication, depending on clinical symptoms and degree of radiological stenosis. Identification of prognostic factors for surgery remains difficult. Surgery is thought to be able to stop the disease progression, while significant improvements of neurological symptoms are not predictable. METHODS: Authors present a modern approach to patients with CSM, that is comprehensive of clinical, electrophysiological and radiological findings, and that has been developed by a multidisciplinary team of experts (neurosurgeons, neurologists, neuroradiologists). Authors tried to identify the good responders to surgery, as those who really improved symptoms, by performing an integration of these data. This approach has been used in 11 consecutive patients suffering from and operated for CSM at our Institution. The multidisciplinary protocol included the complementary use of electrophysiological (motor and somatosensory evoked potentials), radiological (magnetic resonance, cervical plain and dynamic x-rays), and clinical (modified Japanese Orthopedic Association [mJOA] and Neck Disability Index [NDI] scores, Hirabayashi Recovery Ratio) values. These data were obtained at the preoperative period, and at 3 and 12 months follow-up. We defined as "good responders" those patients having had an improvement of the Hirabayashi Recovery Ratio of 50% and of the NDI of 30%. RESULTS: The mean preoperative mJOA was 12.79 (range 3-17), while the mean mJOA at 3 and 12 months was, respectively, 14.71 and 13.43. However, only the improvement at 3 months was statistically significant, while improvements from the preoperative assessment to 12 months and from 3 to 12 months were not significant. The mean preoperative NDI was 33.57%, while it was 32.43% and 24.36% at 3 and 12 months, respectively. None of these improvements was significant. Concerning response to surgery, we observed 7/11 (63.3%) good responders according to the Hirabayashi Recovery Ratio, and 6/11 (54.5%) good responders according to NDI results. CONCLUSIONS: A modern multidisciplinary approach to patients with CSM is mandatory to investigate the different aspects of the disease. Decompressive surgery was able, in our series, to improve or stabilize clinical symptoms. Further studies are necessary to allow for a proper selection of patients by cumulative analysis of multidisciplinary findings.