TEMPORAL LOBE HERNIATION AND CHIASMOPATHY DURING DOPAMINE AGONIST THERAPY FOR PROLACTINOMA.

Background: Dopamine agonists (DA) are first line treatment for prolactinomas. Optic chiasm herniation can rarely occur during therapy, while brain herniation is very uncommon. Case Reports: A 34 yo woman presented with headaches and vision changes. Prolactin (PRL) was 4300 ng/mL. MRI showed a 4.5 cm pituitary adenoma with chiasm compression. After 3 months, PRL decreased to 201 ng/mL while patient was taking CAB 0.75 mg twice a week. MRI showed ~30% tumor reduction with medial temporal lobe herniation and encephalocele. CAB was stopped and she underwent surgical debulking and encephalocele repair. Histopathology confirmed prolactin tumor. CAB 0.75 mg twice a week was resumed.A 50 yo man had incidental detection of a sellar mass after trauma. MRI showed 3.6 cm tumor with minimal contact of right optic nerve, and PRL 3,318 ng/ml. He received CAB 0.5mg twice a week with PRL improvement to 26 ng/mL after 1 month. After 2 months ophthalmology exam showed new left superotemporal depression. PRL was 68 ng/mL and MRI showed 35% mass reduction and new inferior displacement tethering of the chiasm. CAB dose was decreased to 0.25 mg twice a week. Conclusion: Our cases illustrate that rapid biochemical and radiographic response to DA therapy in large prolactinomas warrants close clinical and neuro-ophthalmologic follow-up. We recommend repeating the MRI 3 months after initiation of DA therapy or sooner in case of new mass effect manifestations. Decision regarding DA dose reduction or chiasmopexy for visual field deficits needs to be multi-disciplinary and on a case-to-case basis.

[Neuroepidemiology in the eastern region of Colombia]. / Neuroepidemiologia en el Oriente colombiano.

OBJECTIVE: To determine the presence of eight neurological disorders (migraine, cerebrovascular disease, disorders of movement, peripheral neuropathy, mental retardation, epilepsy, dementia and the sequelas of head injuries) in the eastern region of Colombia. PATIENTS AND METHODS: Using the neuro epidemiological protocol of the World Health Organization (WHO), modified by our group, together with a questionnaire to determine the sequelas of head injuries and the abbreviated mental test (Mini mental), we interviewed people in the municipalities of Bucaramanga, Piedecuesta and Aratoca. The persons suspected of having neurological disorders, who were over 12 years old, were evaluated by neurologists and those under 12 years old by a neuropaediatrician. RESULTS: In the eastern region, 1,454 persons altogether were interviewed. Neurological conditions were suspected in 454 of these (31.2%), and confirmed in 437 (30.1%). The specific results for these neurological disorders and their respective confidence intervals (in brackets) were: migraine 198.8 (178.7 220.4); peripheral neuropathy: 26.8 (19.4 36.9); epilepsy: 22.7 (15.9 32.1); dementia: 17.9 (11.9 26.5); cerebrovascular disease: 17.2 (11.4 25.7); mental retardation and delayed nervous system development: 15.1 (9.7 23.2); extrapyramidal disorders: 8.3 (4.5 14.8); sequelas of head injuries: 6.9 (3.5 13.1). RESULTS: These results, obtained using a modified version of a WHO protocol, together with dementia and the sequelas of head injuries, will permit the development of health policies and programmes for the control and treatment of neurological disorders prevalent in this region of Colombia

Neuroepidemiología en el oriente colombiano / Neuro-epidemiology in the eastern region of Colombia

Objetivo. Determinar la prevalencia de ocho enfermedades neurológicas (migraña, enfermedad cerebrovascular, trastornos del movimiento, neuropatías periféricas, retraso mental, epilepsia, demencia y secuelas de trauma craneoencefálico) en el oriente colombiano. Pacientes y métodos. Mediante la aplicación del protocolo neuroepidemiológico de la Organización Mundial de la Salud (OMS), modificado por nuestro grupo, junto a una encuesta para determinar secuelas de trauma craneoencefálico y el examen mental abreviado ( Minimental), se entrevistó a personas ubicadas en los municipios de Bucaramanga, Piedecuesta y Aratoca. A los individuos sospechosos de padecer enfermedad neurológica y los mayores de 12 años, los evaluaron neurólogos de adultos, y a los menores de 12 años, los examinó un neuropediatra. Resultados. En la región oriental se encuestó a un total de 1.454 individuos, de los que 454 fueron sospechosos de padecer enfermedad neurológica (31,2 por ciento); se confirmó la misma en 437 (30,1 por ciento) de ellos. Los resultados específicos por enfermedad neurológica con sus respectivos intervalos de confianza, anotados entre paréntesis, fueron: migraña, 198,8 (178,7-220,4); neuropatías perifé ricas, 26,8 (19,4-36,9); epilepsia, 22,7 (15,9-32,1); demencia, 17,9 (11,9-26,5); enfermedad cerebrovascular, 17,2 (11,4-25,7); retraso mental y del neurodesarrollo, 15,1 (9,7-23,2); enfermedades extrapiramidales, 8,3 (4,5-14,8), y secuelas de traumatismo craneoencefálico, 6,9 (3,5-13,1). Conclusiones. Estos resultados, obtenidos con una versión modificada del protocolo de la OMS, con la adición de demencia y secuelas de traumatismo craneoencefálico, nos permitirán definir políticas y programas de salud dirigidos al control y tratamiento de las enfermedades neurológicas prevalentes en este sector del oriente colombiano (AU)

Prevalencia de la esclerosis múltiple en Colombia / Prevalence of multiple sclerosis in Colombia

Introducción. La esclerosis múltiple (EM) es la enfermedad desmielinizante más común del sistema nervioso. Se caracteriza por numerosas áreas desmielinizantes o placas de desmielinización que se encuentran dispersas en el sistema nervioso. Se ha demostrado que la EM es menos frecuente en las regiones tropicales que en aquellas localizadas en el subtrópico, En Latinoamérica, particularmente, existen algunos estudios que evidencian dicho fenómeno.Sin embargo, en Colombia no se han realizado estudios de prevalencia de EM. Objetivo. Determinar la prevalencia de la esclerosis múltiple en cinco provincias colombianas (Antioquia, Caldas, Santander, Risaralda y Bolívar). Pacientes y métodos. Se utilizó el método de captura-recaptura de dos fuentes para estimar el número de casos de EM definida según los criterios de Poser et al, durante el período comprendido entre julio de 1995 y junio de 2000. Resultados. La prevalencia (casos de EM por 100.000 habitantes) varió entre 1,48 en Antioquia (IC95 por ciento 1,12; 1,78) a 4,98 en Risaralda (IC95 por ciento 3,52; 6,43). El 72 por ciento de los individuos identificados eran mujeres. Las regiones incluidas en este estudio comprenden al 25 por ciento de la población de Colombia. Conclusiones. La prevalencia de EM estimada es baja y está de acuerdo a lo esperado para las áreas tropicales. Los individuos con EM de estas regiones pueden ser muy útiles para el estudio de otros factores involucrados en la etiología de la EM (genético). El método de captura- recaptura es una excelente herramienta para la realización de estudios de prevalencia porque consume poco tiempo y es muy barato (AU)

[The Mini-Mental State Examination as a selected diagnostic test for dementia: a Colombian population study. GENECO]. / El examen mental abreviado (Mini-Mental State Examination) como prueba de selección para el diagnóstico de demencia: estudio poblacional colombiano. GENECO.

INTRODUCTION: Folstein's Mini Mental State Examination (MMSE) is widely used as screening test for cognitive impairment. OBJECTIVE: To test a Spanish version of the MMSE in a population of high illiteracy rate. MATERIAL AND METHODS: Population-based survey of a stratified random sample of urban and rural residents of five regions of Colombia, followed by neurological and neuropsychological evaluation of suspect cases (phase 2). Dementia was diagnosed using DSM-IV criteria. RESULTS: 1,611 subjects age 50 or older filled out both the WHO Protocol for Epidemiologic Studies of Neurological Disorders and a Spanish version of the MMSE; 55.2% of them had three or less years of schooling; 536 individuals with scores below cutoff points were sent to phase 2. Of the population with satisfactory scores in MMSE 366 (34.0%) were evaluated by neurologists to exclude other neurological conditions. Twelve cases of dementia were diagnosed among individuals with scores below cutoff point and one among subjects with high scores. Age-adjusted prevalence was 8.1 per thousand subjects age 50 or over (95% CI: 3.7-12.5); and 34.2 per thousand for ages 75 or over (95% CI: 12.2-56.2). Sensitivity and specificity were 92.3 and 53.7%; 16 of the 19 questions show significant differences (p < 0.001) according to educational level. A gender gap is significant in low educational levels (p < 0.001) but not in subjects with more than five years of schooling. CONCLUSIONS: MMSE scores correlated closely with level of education. Low specificity leads to many non-demented subjects with low educational status requiring further investigation.

El examen mental abreviado (Mini-Mental State Examination) como prueba de selección para el diagnóstico de demencia: estudio poblacional colombiano / The mini-mental state examination as a diagnostic selection test for dementia. A Colombian population study

Introducción. El examen mental abreviado (EMA) o Mini Mental State Examination (MMSE) se emplea masivamente para detectar déficit cognoscitivo. Objetivo. Probar una versión en castellano del EMA en población colombiana con baja escolaridad. Material y métodos. Estudio poblacional puerta a puerta, en muestra aleatoria estratificada de habitantes urbanos y rurales de cinco regiones de Colombia, seguido por evaluación neurológica y neuropsicológica de casos sospechosos (fase 2). Para diagnosticar demencia se emplearon criterios del DSM-IV. Resultados. 1.611 sujetos de 50 o más años respondieron el formato de la OMS para el estudio epidemiológico de enfermedades neurológicas y la versión en castellano del EMA; el 55,2% de ellos tenían tres o menos años de escolaridad; 536 individuos fueron remitidos a la fase 2 y otros 366 fueron evaluados por un neurólogo para descartar otras condiciones neurológicas: se diagnosticaron 12 casos de demencia entre los primeros y uno entre los últimos. La prevalencia ajustada por edad fue de 8,1 por mil sujetos mayores de 50 (IC 95%: 3,7-12,5); y 34,2 por mil mayores de 75 (IC 95%: 12,2-56,2). La sensibilidad y especificidad fueron del 92,3 y 53,7%; 16 de las 19 preguntas de la prueba mostraron diferencias significativas (p< 0,001) según la escolaridad. La diferencia entre los sexos a favor de los hombres es significativa en niveles educativos bajos (p< 0,001) pero no en sujetos con más de cinco años de estudio. Conclusiones. Las puntuaciones del MMSE poseen una alta correlación con el nivel educativo. Su baja especificidad lleva a que una gran cantidad de sujetos de baja escolaridad, no demenciados, requieran posteriores evaluaciones (AU)

Introduction. Folstein’s Mini Mental State Examination (MMSE) is widely used as screening test for cognitive impairment. Objective. To test a Spanish version of the MMSE in a population of high illiteracy rate. Material and methods. Population-based survey of a stratified random sample of urban and rural residents of five regions of Colombia, followed by neurological and neuropsychological evaluation of suspect cases (phase 2). Dementia was diagnosed using DSM-IV criteria. Results. 1,611 subjects age 50 or older filled out both the WHO Protocol for Epidemiologic Studies of Neurological Disorders and a Spanish version of the MMSE; 55.2% of them had three or less years of schooling; 536 individuals with scores below cutoff points were sent to phase 2. Of the population with satisfactory scores in MMSE 366 (34.0%) were evaluated by neurologists to exclude other neurological conditions. Twelve cases of dementia were diagnosed among individuals with scores below cutoff point and one among subjects with high scores. Age-adjusted prevalence was 8.1 per thousand subjects age 50 or over (95% CI: 3.7-12.5); and 34.2 per thousand for ages 75 or over (95% CI: 12.2-56.2). Sensitivity and specificity were 92.3 and 53.7%; 16 of the 19 questions show significant differences (p< 0.001) according to educational level. A gender gap is significant in low educational levels (p< 0.001) but not in subjects with more than five years of schooling. Conclusions. MMSE scores correlated closely with level of education. Low specificity leads to many non-demented subjects with low educational status requiring further investigation (AU)

[Prevalence of multiple sclerosis in Colombia]. / Prevalencia de la esclerosis múltiple en Colombia.

INTRODUCTION: Multiple sclerosis (MS) is the commonest demyelinating condition of the nervous system. It is characterized by numerous demyelinating areas or plaques of demyelination which are found dispersed throughout the nervous system. It has been shown that MS is less frequent in tropical regions than in subtropical regions. In Latin America particularly, there are some studies which show this phenomenon. However, in Colombia no studies of prevalence of MS have been done. OBJECTIVE: To determine the prevalence of multiple sclerosis in five provinces of Colombia (Antioquia, Caldas, Santander, Risaralda and Bolivar). PATIENTS AND METHODS: The capture-recapture method was used for two sources to determine the number of cases defined on the criteria of Poser et al seen between July 1995 and June 2000. RESULTS: The prevalence (cases of MS per 100,000 inhabitants) varied between 1.48 in Antioquia (95% CI 1.12; 1.78) and 4.98 in Risaralda (95% CI 3.52; 6.43). Seventy two percent were women. The regions included in this study represented 25% of the population of Colombia. CONCLUSIONS: There is a low prevalence of MS which is as expected in tropical areas. Persons with MS in these regions may be very useful in the study of other factors involved in the aetiology of MS (genetic). The capture-recapture method is an excellent tool for carrying out prevalence studies since it is cheap and requires little time.

Contralateral early blink reflex in multifocal motor neuropathy.

Multifocal motor neuropathy (MMN) is a clinical entity affecting the peripheral nerve system mainly. We present here a Colombian man, 37 year-old, who presented MMN, and interestingly, displayed abnormal responses in the blink reflex after electrical stimulation of the supraorbital nerves. These findings allow us to suggest that the lesion distribution in MMN mostly the subclinical one, seems to be more widespread than usually thought.