Ability and fitness to drive of Parkinson's disease patients.

The authors review reports in the literature on the fitness and ability to drive of neurosurgical patients and subjects afflicted by neurological disorders, before focusing on their own series of 204 idiopathic Parkinson's disease (PD) patients. The study sample comprised 173 men and 31 women (average age 70.6 and 74.2 years, respectively) of whom 51, for various reasons, still drove (albeit only short distances). Different variables were examined (Hoehn & Yahr scale values (of the total group and of the subgroup of active drivers), scores for various clinical diseases, and so on) looking for an association between these variables and the number of accidents incurred by PD patients as compared with the healthy population and with a control group of healthy age-matched subjects (ISTAT data). The need for adequate legislation on driving in PD emerges clearly and recommendations are given on which such legislation might be based.

Elective neurotraumatology and therapeutic strategies in early post-trauma.

The aim of elective neurotraumatology is to outline new and valid therapeutic strategies in early post-trauma in order to obtain a more favourable long-term outcome for cranial and spinal trauma patients than usually achieved with conventional intensive therapies. After a critical review of all drugs and measures currently used for the treatment of damage due to cerebral trauma and a brief mention of new agents still being studied, the results of a retrospective study of 128 patients with severe head injury are reported. For all patients a complete clinical and pharmacological history of their traumatic event, which had occurred from 5 to 14 years before the present evaluation, was available. Eighty-nine had undergone traditional therapies and 39 had been given complementary neuroprotective drugs, variously associated with traditional therapies. There was no statistically significant difference between the groups in terms of the global clinical outcome, (assessed by a 5-point scale: death, worsening, unchanged condition, improvement, recovery), and some sequelae, such as decubitus, impairment of sphincter control, neurological focal deficits and post-traumatic epilepsy. On the contrary, cognitive impairment and depression resulted statistically less frequent in patients who underwent conventional therapies and early complementary neuroprotective treatments than in the controls. In conclusion it would be very interesting to perform controlled clinical studies to confirm these preliminary results and the effectiveness of early neuroprotection on the long-term clinical outcome of patients with severe head injury. The therapeutic approach in early post-trauma is still not completely standardised and the purpose of elective neurotraumatology is to emphasise and promote the importance of such a standardisation.

Long-Term Nicergoline Treatment of Mild to Moderate Senile Dementia : Results of a Multicentre, Double-Blind, Placebo-Controlled Study.

The efficacy and tolerability of nicergoline were evaluated in a long-term, double-blind, placebo-controlled trial. 108 patients, fulfilling DSM III-R criteria for mild to moderate senile dementia of degenerative, vascular or mixed origin, were selected from a pool of outpatients attending five Italian neurological centres and randomised to receive nicergoline 30mg twice daily (54 patients) or placebo (54 patients) for 12 months. Treatment efficacy on cognitive and behavioural performances was assessed by the Sandoz Clinical Assessment Geriatric scale (SCAG) and Mini Mental State Examination (MMSE), at baseline and after 3, 6, 9 and 12 months of treatment. Investigators and patients or caregivers provided a global evaluation of treatment outcome at study end. The efficacy analysis was carried out on 101 patients (51 nicergoline; 50 placebo) who completed the 12-month study. At study end, the SCAG total score and its clusters showed statistically significant improvement in the nicergoline-treated group compared with placebo-treated patients. The MMSE total score was maintained with nicergoline treatment. Global treatment evaluations, both by physician and patients, were consistently in favour of nicergoline (p < 0.001). Nicergoline was well tolerated; incidence of adverse events (7% in the nicergoline and 2% in the placebo group), withdrawals and haemodynamic changes were comparable with placebo.

[Multiple sclerosis. A report of a case treated with thymopentin]. / Sclerosi multipla. Presentazione di un caso trattato con timopentina.

The authors analyse the case of a 58-year-old male suffering from substantially "atypical" multiple sclerosis (MS), both in terms of the late onset and because of some characteristics of the course of disease. The patient was treated with a subcutaneous immunomodulator (thymopentin) at a dose of 50 mg/day in 3-monthly cycles with intervals of 2 months between cycles, for a total of 3 cycles. Instrumental (CAT-NMR) and laboratory (immunological) tests were not significant, whereas others provided complex responses that allowed the presence of a demyelinating syndrome to be ascertained, above all due to the positivity of isoelectrofocusing. Treatment with thymopentin, commenced 12 years after the clinical onset of disease and after numerous cycles of cortisone and ACTH therapy, led to a major improvement in clinical conditions, especially of "sthenia" and movement, with consequent recovery of personal autonomy and working capacity which had previously been totally lost. Immunological tests performed at the end of each treatment cycle showed some slight but interesting modifications in parameters relating to DNA and the percentage of HLA antigens bound to lymphocytes. These findings suggest that the patient's immune system was sensitive to treatment with the thymic hormone responsible for the objective clinical improvement. These results appear to open the way to the possible treatment with immunomodulators.

Angiopathic parkinsonism: does it exist?

The Authors report on 150 cases of patients suffering from Parkinson's disease. The patients represent 8.3% of total parkinsonian patients and are selected on the basis of clinical and laboratory criteria that allow the diagnosis of "angiopathic parkinsonism" as an autonomous entity. Cerebral blood flow alterations in Parkinson's disease and associated dementing symptoms are also discussed. In conclusion, the Authors emphasize the usefulness of recognizing the "angiopathic parkinsonism" in view of therapeutical implications.

[Nonpsychotic involutional inhibited depressions and psycho-organic deteriorations: treatment with Viloxazine and piracetam]. / Depressioni involutive, inibite, non psicotiche e decadimenti psico-organici: trattamento con viloxazina e piracetam.

Involutional depression is often the first symptom of a psycho-organic syndrome or dementia and may not present overt symptoms itself; these depressive states have been variously classified by different schools in various countries. The hypothesis of catecholamine and indolamine in the aetiopathogenic agent is oversimplistic and the theory that abnormal receptor hypersensitivity is the cause of the condition is more convincing. On the basis of this hypothesis numerous studies have been conducted into the efficacy of various antidepressants in the treatment of this hypersensitivity. Involutional depressions are more common among women and are found in about 10% of 60-65 year olds. This report claims that combined viloxazine-piracetam is the most appropriate treatment for involutional depression. This approach (200 mg oral viloxazine and 9 g oral piracetam a day) was adopted for 3 months in 33 out patients about 64 years old who were subsequently put on maintenance doses (100 mg viloxazine, 3 g piracetam a day). The various Hamilton scale parameters were assessed as were reaction times to auditory and visual simple stimuli. Result sat the start and end of treatment were then compared. About three quarters of the patients showed improvement in both depression and psycho-organic syndrome symptoms, while total remission or lasting improvement in both pathologies was obtained in about 50%.

Long-term evaluation of cervical spine disorders following laminectomy.

The Authors report the results obtained by long-term clinical and radiological evaluation of patients who had undergone cervical multiple bilateral laminectomy to relieve the compression exerted on the cord by different diseases (spondylarthrosis, syringohydromyelia, intramedullary and extramedullary tumours, leptomeningeal cysts and extradural tumours). 98 patients were reviewed, the follow-up ranging from 8 to 24 years (mean 14 years). The results demonstrate that the most severe post-laminectomy changes are recorded in patients with intramedullary lesions and when middle-low cervical spine levels (C4-C7) are affected. The significance of spinal deformities such as kyphosis, spondylolisthesis and swan-neck is also discussed.

Operatory indications and licence of craniostenosis.

On average 0.04% of the population is affected by craniostenosis. It is believed there are anatomo-clinical forms at moderate risk and others at high risk. The neurosurgical indications are very different according to various Authors. The forms at high risk which are caused by an isolated synostosis of the coronal system with brachicephalia are either associated to other synostosis (oxicephalia) or to facial synostosis should always be operated, with various techniques, within the first 6 months of life. Basing on the experience of 3 cases of craniostenosis, deliberately not operated on, followed and controlled for over 20 years from the decision of not to operate, all in excellent general condition both neurological and psychiatric, the Authors consider and discuss the criteria of surgical indications with particular regard to clinical objectivity (implicity disregarding a precise value of the craniometric data).

[Neurotraumatology and post-traumatic epilepsy. Prevention, treatment and long-term follow-up. Barbexaclone + phenobarbital (maliasin) versus diphenylhydantoin, phenobarbital, primidone, carbamazepine]. / Neurotraumatologia ed epilessia post-traumatica. Profilassi, trattamento e follow-up a lunga distanza. Barbesaclone + PB ("maliasin") vs difenilidantoina, phenobarbital, primidone, carbamazepina.

A report is presented on 58 patients (46 males, 12 females) all suffering from post-traumatic epilepsy (PTE) and followed up for a minimum of 1 year to maximum of 23 years after the injury (mean 6.3 years). The type and site of the head injury, the nature of the brain lesions, the time elapsing before the first critical manifestation, the clinical character of the epileptic attacks, EEG, cerebral CAT and RMN data were performed are given for all patients. The therapeutic and prophylactic strategies adopted are then described in detail with particular emphasis on the use of diphenylhydantoin (DPH) and barbexaclone. The latter drug, used for the last 3 years was found to be particularly useful in the treatment of patients suffering from a post-traumatic psycho-organic syndrome in addition to the PTE.

Involutional dementias: new perspectives.

13 patients with psycho-organic syndrome (POS) and 10 patients with dementia (senile, Alzheimer, multi-infarct) were treated with drugs considered to influence the neuronal turnover of acetylcholine (Phosphatidylcholine, piracetam, S-adenosylmethionine) for 30 days and compared in respect of CSF ACh levels, reaction times to simple visual stimuli (TRS-V) and to simple hearing stimuli (TRS-H) and scores on the Sandoz Clinical Assessment Geriatric (SCAG) rating scale. The POS patients presented higher CSF ACh levels, shorter TRS-V and TRS-H times and lower SCAG scores than the demented patients before treatment. During treatment the CSF ACh values fell in the POS but not in the demented patients. All the other values improved in both groups but more markedly in the POS group. The CSF ACh variations in the latter appear to correlate with the variations in TRS-V and TRS-H times and SCAG scores. The monitoring of CSF ACh would seem to be useful in assessing both the degree of decline in dementia and the possibilities of treatment in individual patients.

[Rational medical and surgical therapy of essential facial hemispasm. Experiences in 21 cases]. / Terapia razionale medica e chirurgica dell'emispasmo facciale essenziale. Esperienze su 21 casi.

After a brief review of the definition, aetiopathogenetic hypotheses and various medical and surgical treatment of idiopathic hemifacial spasm, 21 personal cases are reported. It is concluded that the most effective treatment is surgical release of the compressed nerve with various types of vascular loop. The most effective medical treatment is large doses of carbamazepine, though it does not always produce a lasting improvement.

[Tetraventricular ependymoma. Presentation of a case]. / Ependimoma tetraventricolare. Presentazione di un caso.

The clinical study of encephalic ependymoma shows that cases present with polymorphous clinical pictures depending on intra and/or periventricular tumoural growth, generally such as to hinder precise diagnosis during life, unless under direct control, or, currently, using computerized axial tomography. The reported case, completed by macro and microscopic autoptic study, takes on particular importance because the neoplasia involved all encephalic ventricular cavities. This exceptional localisation and extension, only gave an aspecific clinical picture, dominated by the presence of a slight internal communicating type hydrocephalus and immediate general convulsive signs.

Usefulness of gamma-aminobutyric acid (GABA) therapy in pathologies of neurosurgical competence.

The Authors, after giving some theoretical and pharmacodynamic opinions on GABA, report their clinical experience for 18 consecutive years with the use of gamma-aminobutyric acid in cases of central comas, psycho-organic post-operative syndromes, Parkinson's Disease. The drug, in the various above listed pathologies, shows respectively a wakening effect, with actual rising of the level of consciousness, a re-equilibrating action towards psycho-organic involutions, especially acute ones, and a considerable antiakinetic activity. After analyzing the original results obtained, considered especially in the light of the most modern researches on the importance of GABA-ergic mediation on the basal ganglia, some interesting neurofunctional hypotheses are put forward, which are connected with the problem of nervous conduction in human pathology. According to said hypotheses the aminoacid works clinically, owing to its role of inhibiting mediator (rather than of oxidable substrata), and is involved in extrapyramidal nigro-striatal lesions.

[EEG screening of candidates for underwater activity]. / Screening EEG per candidati ad attività subacquee

Following a review of a number of EEC recording technique, a screening technique for candidates for sporting and/or professional underwater activities is proposed in replacement of the routine examinations which are considered unsuitable. Modalities are described involving basic recordings in hyperpnoea and 12 tests in apnoea. Examples are given and the practical advantages of the proposed technique are discussed in the light of experience.