Intravenous lacosamide in clinical practice-Results from an independent registry.

PURPOSE: This non-interventional study was conducted to evaluate the efficacy and tolerability of intravenous lacosamide (LCM-iv) under routine conditions in daily clinical practice as a prospective registry. METHODS: Patients with any type of seizure or epilepsy syndrome were recruited in 16 neurological and neuropediatric centers in Germany if the treating physician decided to administer LCM-iv for any reason. Observation time per patient was 10 days with daily documentation of LCM-iv administration, type and frequency of seizures, currently used drugs and doses, and adverse events. Treatment efficacy, tolerability, and handling of LCM-iv were assessed using a five-step scale. RESULTS: In 119 patients treating physicians classified epilepsies as focal in 66.1% and generalized in 17.4% (16.5% unclassifiable). Most common etiologies of seizures were tumors (36.1%) and cerebrovascular diseases (21.8%). Reasons for LCM-iv treatment included preparation for surgery (25.2%), convulsive (24.4%) and non-convulsive (18.5%) status epilepticus (SE), series of seizures (16.0%), gastrointestinal causes (5.9%), and acute seizures (4.2%). The median dose of LCM-iv was 300mg per day. In 45 of 64 patients (70.3%) with SE or series of seizures, epileptic activity ceased during observation time. Five patients showed abnormalities in ECG prior to the infusion and one patient afterwards, but during infusion no abnormalities were reported. Treating physicians rated efficacy and tolerability as very good or good in 77.6% and 93.1% of patients, respectively. CONCLUSIONS: This large and independent multicenter registry on the use of LCM-iv in clinical practice demonstrates that LCM-iv is well-tolerated and highly efficacious when given in emergency situations, including patients experiencing SE. It is advisable to perform an electrocardiogram prior to LCM-iv administration.

Valproic acid in normal therapeutic concentration has no neuroprotective or differentiation influencing effects on long term expanded murine neural stem cells.

The antiepileptic drug valproic acid (VPA) has shown neuroprotective effects in different cell types including mesencephalic neural primary cultures. Furthermore, an influence on neural differentiation and neurite outgrowth has been described. Nevertheless, results in this regard are contradictory and data on long term expanded neural stem cells are missing. This is why we investigated possible neuroprotective effects of VPA on fetal mesencephalic neural stem cells (fmNSCs) in vitro, using the neurotoxic agent 1-methyl-4-phenyl-pyridin (MPP+). We also examined potential VPA effects on cell expansion and differentiation and the underlying signaling pathways. In our study, we could exclude any relevant toxic effects of 100 µg/ml and 200 µg/ml VPA on fmNSCs during expansion and differentiation for up to 96 h. MPP+ treatment in concentrations of 30 and 60 µM MPP+ significantly decreased the survival rate of fmNSCs during expansion and differentiation. In all used concentrations, VPA did neither reverse these MPP+ effects when applied simultaneously with MPP+ nor after pre-treatment with VPA for 24 h. In contrast, MPP+ effects were emphasized by VPA pretreatment for 24h when applied during cell expansion. Concerning the self-renewing capacity of fmNSCs, measured by BrdU and Ki67 staining, we did not find any significant influence of VPA. Additionally there was no significant influence of therapeutic VPA dosages on astroglial (GFAP), oligodendroglial (GalC) and neuronal (MAP2) differentiation, measured by immunostaining after 10 days of differentiation. Summing up, we did not find any neuroprotective effects of VPA on fmNSCs in vitro, neither during expansion nor during cell differentiation. Also the self-renewing and differentiation potential of the used fmNSCs was not altered. These findings have implications for the large community of patients having to take VPA on a chronic base, especially in the light of knowledge that a regular cell replacement out of hippocampal adult stem cells is mandatory for the maintenance of normal cognition through adulthood.

Parkinson's disease risk score: moving to a premotor diagnosis.

Early pre-motor symptoms (also frequently termed "non-motor" symptoms) in Parkinson's disease (PD), which precede the onset of motor symptoms, are being increasingly recognized by clinicians. Non-motor symptoms in the pre-motor phase of PD include impaired olfaction (hyposmia), sleep disturbances (i.e., radid eye movement sleep behavior disorder, daytime sleepiness), behavioral/emotional dysfunction (i.e., change of personality or change of core personal characteristics), dysautonomia (i.e., constipation, urinary dysfunction, orthostatic hypotension), depressive symptoms (i.e., fatigue, apathy, anxiety), and chronic pain (joint and muscle). The pre-motor phase of PD is based on current pathophysiological concepts that relate these symptoms to early structural changes within lower brainstem nuclei and the peripheral nervous system including the autonomic and enteric ganglia. The perspective to identify these symptoms as early as possible will enable neurologists to make a diagnosis at the pre-motor stage of PD. Thus, the development of a PD risk score will be the first means to identify individuals at risk who are most likely to develop the prototypical motor symptoms of PD later in life. More importantly, these individuals at risk will be the first to benefit from disease-modifying strategies. In this workshop report, the elements of a PD risk score are proposed, including the stepwise sequence of escalating diagnostic measures to diagnose the pre-motor stage in PD.

Cerebrospinal fluid promotes survival and astroglial differentiation of adult human neural progenitor cells but inhibits proliferation and neuronal differentiation.

BACKGROUND: Neural stem cells (NSCs) are a promising source for cell replacement therapies for neurological diseases. Growing evidence suggests an important role of cerebrospinal fluid (CSF) not only on neuroectodermal cells during brain development but also on the survival, proliferation and fate specification of NSCs in the adult brain. Existing in vitro studies focused on embryonic cell lines and embryonic CSF. We therefore studied the effects of adult human leptomeningeal CSF on the behaviour of adult human NSCs (ahNSCs). RESULTS: Adult CSF increased the survival rate of adult human NSCs compared to standard serum free culture media during both stem cell maintenance and differentiation. The presence of CSF promoted differentiation of NSCs leading to a faster loss of their self-renewal capacity as it is measured by the proliferation markers Ki67 and BrdU and stronger cell extension outgrowth with longer and more cell extensions per cell. After differentiation in CSF, we found a larger number of GFAP+ astroglial cells compared to differentiation in standard culture media and a lower number of beta-tubulin III+ neuronal cells. CONCLUSIONS: Our data demonstrate that adult human leptomeningeal CSF creates a beneficial environment for the survival and differentiation of adult human NSCs. Adult CSF is in vitro a strong glial differentiation stimulus and leads to a rapid loss of stem cell potential.

Histopathological analysis of skeletal muscle in patients with Parkinson's disease and 'dropped head'/'bent spine' syndrome.

BACKGROUND: 'Dropped head' and 'bent spine' phenomena are recognized clinical presentations of neuromuscular disorders. Similar symptoms are known in patients with parkinsonian syndromes, but their pathophysiology remains unclear. One hypothesis is a relation between the movement disorder and the skeletal muscle pathology. METHODS: We describe detailed histopathological data from 19 consecutive skeletal muscle biopsies in patients with idiopathic Parkinson's disease (PD) and concomitant 'dropped head' or 'bent spine' syndrome. A biochemical analysis of the respiratory chain complexes was also performed, and clinical, electrophysiological, and imaging data were analyzed. RESULTS: The subjects developed neuromuscular symptoms 2.7 +/- 2.4 years after onset of PD. We found no correlation with the age at onset of the disease, disease duration, or severity. We found no evidence for dystonia nor did we find any relationship between their anti-parkinsonian medication, and possible drug side effects. Muscle biopsies were abnormal in all patients. Based on histopathological criteria we divided the muscle pathology into three different groups, i.e. necrotizing myopathy, inflammatory myopathy, and myopathy with mitochondrial abnormalities. Biochemical analysis of respiratory chain complexes revealed abnormalities in nine patients. CONCLUSIONS: 'Dropped head' and 'bent spine' symptoms in association with PD appear to be accompanied by a wide spectrum of histopathological abnormalities in skeletal muscle. A muscle biopsy should be performed to identify potentially treatable conditions (i.e. inflammatory myopathies).

Dopamine Agonists and their risk to induce psychotic episodes in Parkinson's disease: a case-control study.

BACKGROUND: Psychosis is rare in untreated patients with Parkinson's disease (PD) but the prevalence rises to 40% during dopaminergic treatment. So far, no systematic comparison of the psychogenic potential of different dopaminergic drugs had been performed. METHODS: Eighty PD patients with psychotic episodes were compared to an age-matched control group of PD patients without psychotic episodes (n = 120) in a cross-sectional retrospective study. RESULTS: We found a positive correlation between psychotic episodes and dementia, number of concomitant medication, and pergolide intake. Odds ratio calculation confirmed the association with dementia. With respect to dopaminergic treatment, pergolide showed the highest odds ratio, levodopa the lowest. An adjusted logistic regression model confirmed the strong association with psychotic episodes and pergolide and no association with levodopa (adjusted odds ratio 2.01 and 0.11, respectively). CONCLUSION: The analysis indicates that dementia and concomitant medication are factors in PD associated with psychotic symptoms. Furthermore, different dopaminergic drugs showed markedly different associations with psychotic symptoms.

Initiation of dopaminergic differentiation of Nurr1(-) mesencephalic precursor cells depends on activation of multiple mitogen-activated protein kinase pathways.

Interleukin-1 (IL-1) plays a pivotal role in terminal dopaminergic differentiation of midbrain-derived neural precursor cells already committed to the mesencephalic dopaminergic phenotype (named mdNPCs for mesencephalic dopaminergic neural precursor cells). Here we characterized the molecular events in long-term expanded rat nuclear receptor related-1(-) (Nurr1(-)) mdNPCs in response to IL-1beta during their terminal dopaminergic specification. We showed that IL-1beta induced a rapid induction of mRNA of dopaminergic key fate-determining transcription factors, such as Nurr1 and Pitx3, and a subsequent increase of tyrosine hydroxylase protein as an early marker for dopaminergic neurons in vitro. These effects of IL-1beta were specific for mdNPCs and were not observed in striatal neural precursor cells (NPCs). Surprisingly, IL-1beta did not activate the NF-kappaB pathway or the transcription factor activating protein 1 (AP-1), but inhibition of nuclear translocation of NF-kappaB by SN50 facilitated IL-1beta-induced Nurr1 expression and dopaminergic differentiation of mdNPCs. Incubation of mdNPCs with IL-1beta led to a rapid phosphorylation of ERK1/2 and p38 mitogen-activated protein (MAP) kinases within 1 to 3 hours, whereas Jun kinase was not phosphorylated in response to IL-1beta. Consistently, inhibition of the ERK1/2 pathway or p38 MAP kinase blocked Nurr1 upregulation and further dopaminergic specification of mdNPCs, but not differentiation into MAP2ab(+) neurons. IL-1 receptor antagonist did not block early dopaminergic differentiation events, suggesting that the effects of IL-1beta are not mediated through activation of IL-1 receptor type I. Our results indicate that induction of terminal dopaminergic specification of Nurr1(-) mdNPCs by IL-1beta depends on activation of the ERK1/2 and p38 MAP kinase pathway.

Adult cerebrospinal fluid inhibits neurogenesis but facilitates gliogenesis from fetal rat neural stem cells.

Neural stem cells (NSCs) are a promising source for cell replacement therapies for neurological diseases. Administration of NSCs into the cerebrospinal fluid (CSF) offers a nontraumatic transplantation method into the brain. However, cell survival and intraparenchymal migration of the transplants are limited. Furthermore, CSF was recently reported to be an important milieu for controlling stem cell processes in the brain. We studied the effects of adult human leptomeningeal CSF on the behavior of fetal rat NSCs. CSF increased survival of NSCs compared with standard culture media during stem cell maintenance and differentiation. The presence of CSF enhanced NSC differentiation, leading to a faster loss of self-renewal capacity and faster and stronger neurite outgrowth. Some of these effects (mainly cell survival, neurite brancing) were blocked by addition of the bone morphogenic protein (BMP) inhibitor noggin. After differentiation in CSF, significantly fewer MAP2ab(+) neurons were found, but there were more GFAP(+) astroglia compared with standard media. By RT-PCR analysis, we determined a decrease of mRNA of the NSC marker gene Nestin but an increase of Gfap mRNA during differentiation up to 72 hr in CSF compared with standard media. Our data demonstrate that adult human leptomeningeal CSF enhances cell survival of fetal rat NSCs during proliferation and differentiation. Furthermore, CSF provides a stimulus for gliogenesis but inhibits neurogenesis from fetal NSCs. Our data suggest that CSF contains factors such as BMPs regulating NSC behavior, and we hypothesize that fast differentiation of NSCs in CSF leads to a rapid loss of migration capacity of intrathecally transplanted NSCs.

Stage-dependent vulnerability of fetal mesencephalic neuroprogenitors towards dopaminergic neurotoxins.

Although extensive knowledge exists on selective vulnerability of dopaminergic neurons against parkinsonism-inducing neurotoxins, there is a complete lack of such data on immature neuroprogenitors. Here we investigated the toxicity of 1-methyl-4-phenylpyridinium (MPP+), 6-hydroxydopamine (6-OHDA) and the free radical generator H2O2 on various developmental stages of predopaminergic mesencephalic neuroprogenitors (mNPCs) to evaluate stage-dependency of selective dopaminergic neurotoxicity. Striatal NPCs (sNPCs) without dopaminergic differentiation potential served as controls. Exposure of both undifferentiated NPCs to MPP+ resulted in concentration-dependent cell death at concentrations of >10 microM after 72 h without differences between both cell types, while 6-OHDA led to relevant cell death at 1000 microM after 24h with significant higher sensitivity of mNPCs compared to sNPCs. H2O2 did not induce relevant cell death in all cell types. In NPC cultures differentiated for 14 days, MPP+ showed enhanced toxicity compared to the undifferentiated counterparts, but no significant differences between both NPC type and differentiation conditions. 6-OHDA showed similar toxicity pattern in differentiated compared to undifferentiated NPCs. By evaluating the toxicity of MPP+ on MAP2ab+ neurons derived from both mNPCs and sNPCs as well as tyrosine hydroxylase (TH)+ dopaminergic cells from mNPCs, we found concentration-dependent cell death of all cell types with no increased vulnerability of TH+ cells. Primary TH+ neurons showed significantly higher vulnerability to MPP+. Together, we demonstrated stage-dependent vulnerability of NPCs towards dopaminergic neurotoxins, but no selective vulnerability of NPC-derived TH+ dopaminergic cells towards MPP+. This cell system seems not suitable as a screening tool for selective dopaminergic toxicity.

[Rofecoxib-induced psychosis]. / Psychotische Störung unter Rofecoxib.

Acute psychosis is a possible side effect of many centrally acting drugs. Its appearance is facilitated by certain conditions like advanced age, comedication, or comorbidity. We report two cases of acute psychotic syndromes with visual (Case 1 + 2) and auditory (Case 1) hallucinations under rofecoxib, a cyclooxygenase-2-inhibitor. This is one of the first reports of psychotic disorders under rofecoxib intake. We present a review of the literature on mental side effects of NSAID and on the pharmacological basis of the association of cyclooxygenase-inhibitors and mental disorders.

Dexamethasone blocks astroglial differentiation from neural precursor cells.

In previous studies, we demonstrated functional neuronal and dopaminergic differentiation of fetal mesencephalic neural precursor cells. The major factors for orienting their progeny towards a dopaminergic phenotype are forskolin and interleukin-1beta. Here, we investigated the effects of dexamethasone (10 microM) on neuronal and glial differentiation. Exposure of mesencephalic neural precursor cells to dexamethasone significantly reduces the amount of glial fibrillary acidic protein astroglia, but not of galactocerebrosidase C oligodendroglia, MAP2ab neurons and tyrosine hydroxylase dopaminergic cells. Presuming a possible involvement of the nuclear factor-kappaB pathway, we examined the effects of wortmannin (phosphatidylinositol 3'-kinase inhibitor) and SN50 (nuclear factor-kappaB inhibitor) on gliogenesis. Both wortmannin and SN50 mimicked the effects of dexamethasone suggesting that dexamethasone specifically blocks astroglial differentiation from mesencephalic neural precursor cells most likely via inhibition of the nuclear factor-kappaB pathway.

[Rabbit syndrome due to olanzapine]. / Rabbit-Syndrom unter Olanzapineinnahme.

Rabbit syndrome (RS) is a rare extrapyramidal side effect of antipsychotic treatment. It is characterized by involuntary, rhythmic dyskinesias of mouth and lips excluding the tongue, and is most common under typical neuroleptics. There are also several reports of the syndrome in patients with the atypical antipsychotics risperidone and aripiprazole. We report a 74 year-old patient suffering from a bipolar affective disorder, who developed a rabbit syndrome following the intake of 20 mg/d olanzapine. To our knowledge this is the first case report of a RS due to olanzapine.

Midbrain-derived neural stem cells: from basic science to therapeutic approaches.

Neural stem cells (NSCs) are a subtype of tissue-specific progenitor cells capable of extended self-renewal and the ability to generate all major cell types of nervous tissue, such as neurons, astroglia and oligodendroglial cells. Recent studies suggest that salient patterning in anterior-posterior and dorsal-ventral axes occurs early, concomitantly with neural induction and therefore stem cells and restricted precursors exhibit regionalization. Fetal mesencephalic NSCs can be isolated and expanded in vitro for many months while retaining their potential to differentiate into glia and neurons, with a subset of neurons displaying all the major properties of mature functional dopaminergic neurons. Since Parkinson's disease (PD) is characterized by the loss of a specific type of dopaminergic cells, the prospect of replacing the missing or damaged cells is very attractive in PD. Thus, mesencephalic NSCs might serve as a new and continuous source of dopaminergic neurons for regenerative strategies in this neurodegenerative disorder. This review discusses new data concerning the cell biology and therapeutic potential of NSCs derived from the midbrain region of the central nervous system.