Freezing of gait: pharmacological and surgical options.

PURPOSE OF REVIEW: The primary aim of this review is to describe and update the pathophysiological and relevant therapeutic strategies for freezing of gait (FoG) in patients with Parkinson's disease (PD). RECENT FINDINGS: FoG presumably involves dysfunction of multiple cortical and subcortical components, including dopaminergic and nondopaminergic circuits. In this regard, levodopa and physical therapy represent the first-choice therapeutic options for PD patients with FoG. However, the relationship between FoG and levodopa is not fully predictable. For those patients with levodopa-resistant FoG, there is promising but still controversial data on the benefits of bilateral high-frequency transcranial magnetic stimulation and deep brain stimulation on the subthalamic nuclei, substantia nigra pars reticulata, pedunculopontine nucleus, and the Fields of Forel. On the other hand, general exercise, gait training with a treadmill, focus attention on gait training, and conventional physiotherapy have demonstrated moderate to large benefits in FoG. SUMMARY: FOG requires different treatment strategies. The inclusion of adequate detection and prediction of FoG combined with double-blind, and statistically powered protocols are needed to improve patients' quality of life, the motor and nonmotor symptoms and societal burden associated with FoG.

How can I assess my patients with Parkinson's disease during a busy clinic day?

BACKGROUND: The evaluation of motor impairment in Parkinson's disease (PD) is mainly assessed with the motor subdomain of the Unified Parkinson's Disease Rating scale (UPDRS part III) and, lately, with the MDS-UPDRS part III. To optimize efforts and special needs during specific circumstances in clinical practice, we sought to identify the most sensitive items to assess motor impairment in PD. METHODS: We included the COPPADIS-PD cohort and collected the UPDRS part III at baseline (V0), 12 months (V1), and 24 months (V2). Factor analysis and effect size using Cohen's d formula were performed in the Off and On states at V0, V1, and V2. RESULTS: We included 667 patients with PD, mean age of 62.59 ± 8.91 years, 410 (60.2%) males, with a median HY stage of 2.00 (1.00; 4.00) at baseline. Over time, the most discriminating items were postural stability and body bradykinesia ("arise from chair" and "gait") in the Off state, right and left upper extremity bradykinesia ("finger tap", "hand movements" and "prono/supination") in the On state. Body bradykinesia and right-left finger tapping were the items with the largest effect size (0.93, 0.84, 0.83, respectively) to assess motor improvement after receiving antiparkinsonian medications over time. CONCLUSION: Under specific circumstances, selecting a few items of the UPDRS part III, including postural stability, body bradykinesia, and upper extremity bradykinesia, could be used to create a quick clinical judgment of motor status and improvement in PD.

Impacto de las complicaciones neurológicas y médicas sobre la mortalidad y situación funcional de pacientes con ictus agudo / The impact of neurological and medical complications on the mortality and functional situation of acute stroke patients

Introducción. Los pacientes con ictus presentan un elevado riesgo de presentar complicaciones. Su aparición puede condicionar el pronóstico del ictus. Estudiamos la frecuencia y el impacto de la aparición de diversas complicaciones en el pronóstico precoz y a medio plazo en estos pacientes. Pacientes y métodos. Estudio observacional de los pacientes ingresados en una unidad de ictus. Se registraron las complicaciones durante su estancia, distinguiéndose entre complicaciones neurológicas y médicas. Se estudió la influencia de estas según subtipo de ictus en la mortalidad intrahospitalaria y a los 90 días, y en la situación funcional a los 90 días, analizándose los factores clínicos predictores para la aparición de complicaciones. Resultados. Muestra de 847 pacientes. Un 29,5% de los pacientes presento complicaciones, que fueron más frecuentes en el ictus hemorrágico (50,5% frente a 26,6%; p < 0,0001). Las complicaciones más habituales fueron las neurológicas (21%). Para ambos subtipos, la presencia de complicaciones se asoció a mayor mortalidad intrahospitalaria (2,1% frente a 12,6%; p < 0,0001) y a 90 días (5,7% frente a 29,6%; p < 0,0001), y menor probabilidad de independencia a 90 días (72,9% frente a 30,4%; p < 0,0001). La gravedad del ictus al ingreso se mostró como el predictor más potente en la aparición de cualquier tipo de complicación. Conclusiones. La aparición de complicaciones durante la fase aguda del ictus influye de forma diversa en la mortalidad y en el pronóstico funcional. La identificación de factores predictores podría disminuir el impacto sobre la evolución del paciente con un ictus agudo (AU)

Introduction. Stroke patients have a high risk of presenting complications, the appearance of which can condition the prognosis of the stroke. We studied the frequency and impact of the onset of several different complications on the early and mid-term prognosis of these patients. Patients and methods. We conducted an observation-based study of the patients admitted to a stroke unit. The complications that occurred while hospitalised were recorded, a distinction being drawn between neurological and medical complications. The study examined their influence, according to the subtype of stroke, on intra-hospital mortality and that at 90 days, as well as on the functional situation at 90 days, by analysing the clinical factors that are predictive for the appearance of complications. Results. The sample consisted of 847 patients. Altogether, 29.5% of the patients presented complications, which were more frequent in haemorrhagic stroke (50.5% versus 26.6%; p < 0.0001). The most usual complications were of a neurological nature (21%). For both subtypes, the presence of complications was associated with a higher rate of mortality both in hospital (2.1% versus 12.6%; p < 0.0001) and at 90 days (5.7% versus 29.6%; p < 0.0001), and a lower probability of independence at 90 days (72.9% versus 30.4%; p < 0.0001). The severity of the stroke on admission revealed itself as the most powerful predictor of the onset of any type of complication. Conclusions. The appearance of complications during the acute phase of the stroke has an adverse influence on mortality and on the functional prognosis. The identification of predictive factors could reduce the impact upon the progress of acute stroke patients (AU)

Atención extrahospitalaria del ictus. Réplica 2 / Extra-hospital stroke care. Reply 2

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[Description of a series of cases of hypnic headache. Differentiation between sexes]. / Descripcion de una serie de casos de cefalea hipnica. Diferenciacion entre sexos.

INTRODUCTION: Hypnic headache is an infrequent type of primary headache characterised by appearing almost exclusively during sleep and by waking the patient up. The pain is dull (generally bilateral), is not associated to autonomic signs and usually appears from the age of 50 onwards. PATIENTS AND METHODS: A 10-year prospective study was conducted which describes the patients with hypnic headache who were attended in a specialised headache clinic. Data collected include demographic variables, the characteristics of the pain and response to treatment. Data from males and from females were compared. RESULTS: Twenty-four patients were diagnosed with hypnic headache: 15 females and 9 males. There were no differences between sexes as regards the age at onset of the pain, the time elapsed until diagnosis, the number of episodes per month or the amount of time the pain lasted. The males reported a more intense pain (measured by means of the analogical visual scale) than the females. Neither were there any differences in terms of the presence of arterial hypertension or obstructive sleep apnoea syndrome. Response to different symptomatic and preventive treatments was scarce and with no differences between sexes. CONCLUSIONS: The pain in hypnic headaches is more intense in males, although this needs to be corroborated in longer series. Further advances need to be made in the pathophysiology of this kind of headache so as to be able to find more efficient preventive pharmacological agents.

[Development and response to intravenous treatment with tissue plasminogen activator with regard to referral hospitals. The experience of a stroke referral unit]. / Evolución y respuesta al tratamiento intravenoso conactivador del plasminógeno tisular en relación con el hospitalde derivación. Experiencia de una unidad de ictus de referencia.

INTRODUCTION: The intravenous administration of tissue plasminogen inhibitor is a safe and effective treatment for patients with an acute ischaemic stroke. The prognosis depends on a number of factors, the time that elapses between the onset of the stroke and its administration being one of those with the greatest impact. PATIENTS AND METHODS: This is a prospective observational study of the patients who received intravenous fibrinolysis in our stroke unit between June 2007 and December 2010. The patients were divided into two groups, a distinction being made between those who went directly to AE at our hospital and those who were referred from other hospitals in Extremadura. The baseline characteristics, response to treatment and development in each group were compared. RESULTS: The patients who came from outside our health district were mainly males, with a TACI-type stroke and they presented higher scores on the National Institutes of Health Stroke Scale (NIHSS). The time elapsed prior to administration of the fibrinolysis was shorter in the patients from our health district. The NIHSS score on discharge was higher in patients who came from another health district, but there were no differences in the Rankin scale at three months or in the mortality rate. CONCLUSIONS: Patients submitted to fibrinolysis who come from another hospital score higher on the NIHSS on discharge. This is probably due to a bias in the selection of the patients, since those referred are mainly males, who have a poorer clinical situation on admission and receive treatment in a significantly longer time interval following the onset of symptoms.

Nuevo caso de encefalitis antirreceptor de NMDA sin tumor asociado / A novel case of anti-NMDA receptor encephalitis with no associated tumour

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[Encephalitis due to antibodies against the NMDA receptor. A case report of a female patient with no associated tumour and a literature review]. / Encefalitis por anticuerpos contra el receptor NMDA. Descripción de una paciente sin tumor asociado y revisión de la bibliografía.

INTRODUCTION: A severe form of acute encephalitis associated to antibodies against the N-methyl D-aspartate (NMDA) receptor has recently been reported. This clinical picture occurs in young people, not always with an underlying tumour and, despite the initial severity, if identified and treated at an early stage, complete recovery without any kind of sequelae can be achieved. We report on a new case and review the body of knowledge currently available on this recently identified condition. CASE REPORT: A 22-year-old female who visited our centre due to a progressive conduct disorder. Over the days that followed, deterioration in the level of consciousness made it necessary to put her on assisted respiration. Magnetic resonance imaging of the head showed hyperintense lesions mainly in deep temporal regions. A study of the cerebrospinal fluid revealed pleocytosis with a predominance of lymphocytes and antibodies against the NMDA receptor. In the complementary study no underlying tumour was observed. Treatment with corticosteroids and immunoglobulins brought about a slow but steady improvement. After a one-year follow-up there have been no recurrences, no tumours have appeared and the patient has gone back to her usual day-to-day activities. Even a significant temporal atrophy that developed at the beginning of the clinical picture has gradually been seen to resolve itself in neuroimaging studies performed as a control measure. CONCLUSION: Encephalitis due to anti-NMDA antibodies is a disease that has only recently been characterised, but which, according to currently available data, is relatively frequent. Clinically well defined, suspicion of this condition will make it possible to reach a definitive diagnosis and to establish early treatment.

Encefalitis por anticuerpos contra el receptor NMDA. Descripción de una paciente sin tumor asociado y revisión de la bibliografía / Encephalitis due to antibodies against the NMDA receptor. A case report of a female patient with no associated tumour and a literature review

Introducción. Recientemente se ha descrito una forma grave de encefalitis aguda asociada a anticuerpos contra el receptor N-metil-D-aspartato (NMDA). Este cuadro ocurre en jóvenes, no siempre con un tumor subyacente y, pese a la gravedad inicial, su identificación y tratamiento precoz pueden llevar a recuperaciones sin secuelas. Presentamos un nuevo caso y revisamos los conocimientos disponibles acerca de esta nueva entidad. Caso clínico. Mujer de 22 años de edad que acudió a nuestro centro como consecuencia de un trastorno progresivo del comportamiento. Durante los días siguientes, un deterioro del nivel de conciencia hizo necesario el soporte respiratorio. Una resonancia magnética craneal mostró lesiones hiperintensas principalmente en regiones temporales profundas. El estudio de líquido cefalorraquídeo reveló pleocitosis con predominio linfocitario y anticuerpos contra el receptor NMDA. En el estudio complementario no se apreció tumor subyacente. El tratamiento con corticoesteroides e inmunoglobulinas dio lugar a una lenta pero continua mejoría. Al cabo de un año de seguimiento no ha presentado recidivas, no ha aparecido tumor alguno y la paciente se ha reintegrado a sus actividades habituales. Incluso una atrofia temporal llamativa desarrollada al inicio del cuadro se ha ido resolviendo en estudios de neuroimagen de control. Conclusión. La encefalitis por anticuerpos anti-NMDA es una enfermedad recientemente caracterizada, pero, de acuerdo con los datos disponibles hasta la fecha, relativamente frecuente. Clínicamente bien definida, la sospecha de esta entidad hará posible un diagnóstico definitivo y la instauración de un tratamiento precoz (AU)

Introduction. A severe form of acute encephalitis associated to antibodies against the N-methyl D-aspartate (NMDA) receptor has recently been reported. This clinical picture occurs in young people, not always with an underlying tumour and, despite the initial severity, if identified and treated at an early stage, complete recovery without any kind of sequelae can be achieved. We report on a new case and review the body of knowledge currently available on this recently identified condition. Case report. A 22-year-old female who visited our centre due to a progressive conduct disorder. Over the days that followed, deterioration in the level of consciousness made it necessary to put her on assisted respiration. Magnetic resonance imaging of the head showed hyperintense lesions mainly in deep temporal regions. A study of the cerebrospinal fluid revealed pleocytosis with a predominance of lymphocytes and antibodies against the NMDA receptor. In the complementary study no underlying tumour was observed. Treatment with corticosteroids and immunoglobulins brought about a slow but steady improvement. After a one-year follow-up there have been no recurrences, no tumours have appeared and the patient has gone back to her usual day-to-day activities. Even a significant temporal atrophy that developed at the beginning of the clinical picture has gradually been seen to resolve itself in neuroimaging studies performed as a control measure. Conclusion. Encephalitis due to anti-NMDA antibodies is a disease that has only recently been characterised, but which, according to currently available data, is relatively frequent. Clinically well defined, suspicion of this condition will make it possible to reach a definitive diagnosis and to establish early treatment (AU)

Experience with intravenous levetiracetam in status epilepticus: a retrospective case series.

BACKGROUND: Status epilepticus is a medical emergency associated with significant morbidity and mortality. OBJECTIVE: To report our experience with the use of intravenous (IV) levetiracetam in patients with status epilepticus who had not responded to IV benzodiazepines. METHODS: A retrospective review of the clinical charts of patients with status epilepticus who were treated with IV levetiracetam from July 2007 to July 2008 in our department was performed. Data on demographics, epileptic syndrome, aetiology, treatment dosage and adverse effects were analysed. IV levetiracetam was administered over a period of 15-30 minutes; each 500 mg of levetiracetam was diluted in 100 mL of normal saline. RESULTS: Thirty-four patients (19 men and 15 women, 11-90 years old) with status epilepticus were treated with IV levetiracetam. Six patients (18%) had primarily generalized status epilepticus and 28 (82%) had focal status epilepticus. The aetiologies were: vascular (47%), cryptogenic (24%), tumours (12%), metabolic (12%) and brain anoxia (6%). The indications for administering IV levetiracetam were: no response to IV phenytoin and/or IV valproic acid (53% of patients) or to avoid adverse effects, contraindications or potential interactions (47% of patients). The median loading dose of IV levetiracetam was 1000 mg and the maintenance dosage ranged from 500 to 1500 mg/12 hours (median 1000 mg/12 hours). Status epilepticus stopped in a clear temporal relationship with IV levetiracetam in 71% of patients. IV levetiracetam was especially effective in older patients with vascular status epilepticus, while cryptogenic status epilepticus, primarily generalized status epilepticus, previous therapy with IV phenytoin and/or valproic acid and status epilepticus due to brain anoxia were associated with a poor response. There were no serious adverse events documented in the patients' charts. CONCLUSIONS: While waiting for large, controlled studies, our data suggest that IV levetiracetam might be an alternative for the treatment of status epilepticus, especially in elderly patients with vascular status epilepticus and concomitant medical conditions.