- Email: [email protected]
Transcranial direct current stimulation for treatment of freezing of gait in Parkinson's disease. A cross-over study
Abstracts / Journal of the Neurological Sciences 333 (2013) e65–e108
by nervous system dysfunctions. Here, we present a patient in whom biballism occurred d thyrotoxicosis. Case: A 62-year old right-handed male with mild tachycardia has noted abrupt onset of involuntary movements 1 week prior to admission. He was alert and well orientated. Constant ballistic movements involving proximal musculature were seen on both arms and legs. These movements disappeared during sleep. No involuntary movements were seen in his face. Cranial nerve examination and strength of extremities were normal. Tendon reflexes were symmetric and slightly brisk. The hematological examination, biochemical examination including blood glucose, electrolytes, renal and liver function tests, copper studies were normal. Laboratory tests for thyroid function were as follows: total serum T3:3.72 ng/ml, total serum T4:14.5 ng/ml, free T3:8.5 pg/ml, free T4:4.3 ng/dl, TSH: 0.001 mu/ml, thyroglobulin: 230 ng/nl. Cranial MRI demonstrated no abnormalities. The abnormal movements suppressed over the next week following administration of propylthiouracil 100 mg three times a day. Two weeks later when free T3 and T4 were decreased, the ballistic movements dramatically resolved. Another episode occurred during a 9-month follow up. Since the biballism disappeared with euthyroidism but reappeared whenever there was a further increase in T3 and T4, its relationship on hyperthyroidism and its reversibility are clearly demonstrated. Conclusion: Hyperthyroidism-related biballismus was thought to be a result of a transient metabolic disturbance of the basal ganglia circuits rather than a permanent and irreversible change. doi:10.1016/j.jns.2013.07.562
Abstract — WCN 2013 No: 2387 Topic: 2 — Movement Disorders Psychotic symptoms overshadow motor dysfunction and dementia in normal pressure hydrozephalus — A case report S. Niaa, C. Sedlacekb, A. Baumgartnera, C. Baumgartnera. aKarl Landsteiner Institute Cognitive Neurology and Epilepsy Research, Vienna, Austria; b Neurologische Abteilung Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel, Karl Landsteiner Institute Cognitive Neurology and Epilepsy Research, Vienna, Austria Background: The characteristic symptoms of normal pressure hydrocephalus are dementia, urinary incontinence and gait disturbance. Psychiatric symptoms may also occur but appear usually after the characteristic symptoms. Objective and methods: In our case report we present a 63 year old woman that had been diagnosed with a bipolar affective disorder at the age of 61 with an acute onset of psychosis. She had been treated with several neuroleptics and anticonvulsants before being admitted to a neurological department. The reason for the admission was extrapyramidal signs, which had been explained as a side effect of the neuroleptic use. In the physical examination the patient showed in addition to the motor dysfunction, a massive cognitive decline. Although a MRI of the brain and a lumbar puncture had been already preformed in the past, we decided to repeat those. Now signs of normal pressure hydrocephalus were visible in the MRI. Also the patient significantly improved in walking and in cognitive testing after the second spinal tab. Results: A surgically implanted ventriculoperitoneal shunt to drain excess cerebrospinal fluid has stabilized the patient. Neuroleptics and anticonvulsant medications have been stopped. No further signs of a psychosis have been reported since then. Conclusion: This case demonstrates the need to consider NPH when older patients present with psychotic symptoms, particularly in the presence of cognitive impairment, gait disturbance, or incontinence. doi:10.1016/j.jns.2013.07.563
e83
Abstract — WCN 2013 No: 2395 Topic: 2 — Movement Disorders Transcranial direct current stimulation for treatment of freezing of gait in Parkinson's disease. A cross-over study G. Cosentinoa, F. Valentinoa, N.G. Pozzib, F. Brighinaa, B. Fierroa, G. Savettieria, G. Sandrinib, C. Pacchettib, M. D'Amelioa. aUniversity of Palermo, Palermo, Italy; bNational Institute of Neurology Foundation ‘C. Mondino’, Pavia, Italy Background: Progression of Parkinson's disease (PD) is frequently characterized by the occurrence of freezing of gait (FOG), a disabling motor complication which generally does not improve with dopaminergic therapy. Recent evidence shows that non-invasive brain stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial current direct stimulation (tDCS), could improve motor performances in PD patients. Methods: In this cross-over, double-blind, sham-controlled study we investigated the safety and efficacy of tDCS of the primary motor cortex of ten PD patients with FOG in “on” state. The patients underwent anodal and sham stimulation in a randomized balanced order for five consecutive days. Clinical assessment over a 1-month period included the revised version of the UPDRS (MDS-UPDRS), Stand Walk Sit (SWS) test, video-analysis of gait, Freezing of Gait Questionnaire (FOG-Q) and Gait and Falls Questionnaire (GFQ). Results: A significant improvement of MDS-UPDRS score and gait, with reduction in the number and duration of FOG episodes, was observed in patients who received anodal tDCS as compared to the sham intervention. The beneficial effects were observed after the first tDCS intervention, became more evident after the end of the whole session, and persisted for all the observation period. Conclusion: Anodal tDCS of the motor cortex is safe and has therapeutic potential in PD patients with FOG in “on” state. Induction of dopamine release in the basal ganglia and modulatory effects on abnormal patterns of cortical activation in PD may account for the observed effects. doi:10.1016/j.jns.2013.07.564
Abstract — WCN 2013 No: 2409 Topic: 2 — Movement Disorders Myocardial 131 I-meta-iodobenzylguanidine (MIBG) scintigraphy in the differential diagnosis of Parkinson's disease R. Petrovic, T. Samardzic, M. Relja, S. Telarovic, V. Miletic, S. Tezak. Clinical Hospital Centre Zagreb, Medical School University of Zagreb, Zagreb, Croatia The aim of our investigation is to evaluate how myocardial 131 Imeta-iodobenzylguanidine (MIBG) scintigraphy may assist in the establishment of final diagnosis in PD. Materials and methods: Eighteen patients clinically diagnosed as idiopathic PD (IPD) and fourteen patients with extrapyramidal symptoms (EPS) underwent MIBG scintigraphy. Planar chest MIBG imaging was performed 15 min, 2, 3, 4 and 24 h after tracer injection. Myocardial MIBG activity was quantified by means of a heart to mediastinum ratio (H/M ratio). A ratio over 1.8 was considered normal, between 1.31–1.79 decreased, and less than 1.3 severely decreased. Results showed that the H/M ratio from early and delayed MIBG scintigraphy was pathologically decreased (b1.3) in fourteen patients diagnosed as IPD and in six patients with EPS. One patient with EST had decreased H/M ratio (1.3–1.79). Three patients initially diagnosed with IPD as well as seven patients with EPS had normal H/M ratios. In total, we confirmed initially established clinical diagnoses of IPD in 14 of 18
by nervous system dysfunctions. Here, we present a patient in whom biballism occurred d thyrotoxicosis. Case: A 62-year old right-handed male with mild tachycardia has noted abrupt onset of involuntary movements 1 week prior to admission. He was alert and well orientated. Constant ballistic movements involving proximal musculature were seen on both arms and legs. These movements disappeared during sleep. No involuntary movements were seen in his face. Cranial nerve examination and strength of extremities were normal. Tendon reflexes were symmetric and slightly brisk. The hematological examination, biochemical examination including blood glucose, electrolytes, renal and liver function tests, copper studies were normal. Laboratory tests for thyroid function were as follows: total serum T3:3.72 ng/ml, total serum T4:14.5 ng/ml, free T3:8.5 pg/ml, free T4:4.3 ng/dl, TSH: 0.001 mu/ml, thyroglobulin: 230 ng/nl. Cranial MRI demonstrated no abnormalities. The abnormal movements suppressed over the next week following administration of propylthiouracil 100 mg three times a day. Two weeks later when free T3 and T4 were decreased, the ballistic movements dramatically resolved. Another episode occurred during a 9-month follow up. Since the biballism disappeared with euthyroidism but reappeared whenever there was a further increase in T3 and T4, its relationship on hyperthyroidism and its reversibility are clearly demonstrated. Conclusion: Hyperthyroidism-related biballismus was thought to be a result of a transient metabolic disturbance of the basal ganglia circuits rather than a permanent and irreversible change. doi:10.1016/j.jns.2013.07.562
Abstract — WCN 2013 No: 2387 Topic: 2 — Movement Disorders Psychotic symptoms overshadow motor dysfunction and dementia in normal pressure hydrozephalus — A case report S. Niaa, C. Sedlacekb, A. Baumgartnera, C. Baumgartnera. aKarl Landsteiner Institute Cognitive Neurology and Epilepsy Research, Vienna, Austria; b Neurologische Abteilung Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel, Karl Landsteiner Institute Cognitive Neurology and Epilepsy Research, Vienna, Austria Background: The characteristic symptoms of normal pressure hydrocephalus are dementia, urinary incontinence and gait disturbance. Psychiatric symptoms may also occur but appear usually after the characteristic symptoms. Objective and methods: In our case report we present a 63 year old woman that had been diagnosed with a bipolar affective disorder at the age of 61 with an acute onset of psychosis. She had been treated with several neuroleptics and anticonvulsants before being admitted to a neurological department. The reason for the admission was extrapyramidal signs, which had been explained as a side effect of the neuroleptic use. In the physical examination the patient showed in addition to the motor dysfunction, a massive cognitive decline. Although a MRI of the brain and a lumbar puncture had been already preformed in the past, we decided to repeat those. Now signs of normal pressure hydrocephalus were visible in the MRI. Also the patient significantly improved in walking and in cognitive testing after the second spinal tab. Results: A surgically implanted ventriculoperitoneal shunt to drain excess cerebrospinal fluid has stabilized the patient. Neuroleptics and anticonvulsant medications have been stopped. No further signs of a psychosis have been reported since then. Conclusion: This case demonstrates the need to consider NPH when older patients present with psychotic symptoms, particularly in the presence of cognitive impairment, gait disturbance, or incontinence. doi:10.1016/j.jns.2013.07.563
e83
Abstract — WCN 2013 No: 2395 Topic: 2 — Movement Disorders Transcranial direct current stimulation for treatment of freezing of gait in Parkinson's disease. A cross-over study G. Cosentinoa, F. Valentinoa, N.G. Pozzib, F. Brighinaa, B. Fierroa, G. Savettieria, G. Sandrinib, C. Pacchettib, M. D'Amelioa. aUniversity of Palermo, Palermo, Italy; bNational Institute of Neurology Foundation ‘C. Mondino’, Pavia, Italy Background: Progression of Parkinson's disease (PD) is frequently characterized by the occurrence of freezing of gait (FOG), a disabling motor complication which generally does not improve with dopaminergic therapy. Recent evidence shows that non-invasive brain stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial current direct stimulation (tDCS), could improve motor performances in PD patients. Methods: In this cross-over, double-blind, sham-controlled study we investigated the safety and efficacy of tDCS of the primary motor cortex of ten PD patients with FOG in “on” state. The patients underwent anodal and sham stimulation in a randomized balanced order for five consecutive days. Clinical assessment over a 1-month period included the revised version of the UPDRS (MDS-UPDRS), Stand Walk Sit (SWS) test, video-analysis of gait, Freezing of Gait Questionnaire (FOG-Q) and Gait and Falls Questionnaire (GFQ). Results: A significant improvement of MDS-UPDRS score and gait, with reduction in the number and duration of FOG episodes, was observed in patients who received anodal tDCS as compared to the sham intervention. The beneficial effects were observed after the first tDCS intervention, became more evident after the end of the whole session, and persisted for all the observation period. Conclusion: Anodal tDCS of the motor cortex is safe and has therapeutic potential in PD patients with FOG in “on” state. Induction of dopamine release in the basal ganglia and modulatory effects on abnormal patterns of cortical activation in PD may account for the observed effects. doi:10.1016/j.jns.2013.07.564
Abstract — WCN 2013 No: 2409 Topic: 2 — Movement Disorders Myocardial 131 I-meta-iodobenzylguanidine (MIBG) scintigraphy in the differential diagnosis of Parkinson's disease R. Petrovic, T. Samardzic, M. Relja, S. Telarovic, V. Miletic, S. Tezak. Clinical Hospital Centre Zagreb, Medical School University of Zagreb, Zagreb, Croatia The aim of our investigation is to evaluate how myocardial 131 Imeta-iodobenzylguanidine (MIBG) scintigraphy may assist in the establishment of final diagnosis in PD. Materials and methods: Eighteen patients clinically diagnosed as idiopathic PD (IPD) and fourteen patients with extrapyramidal symptoms (EPS) underwent MIBG scintigraphy. Planar chest MIBG imaging was performed 15 min, 2, 3, 4 and 24 h after tracer injection. Myocardial MIBG activity was quantified by means of a heart to mediastinum ratio (H/M ratio). A ratio over 1.8 was considered normal, between 1.31–1.79 decreased, and less than 1.3 severely decreased. Results showed that the H/M ratio from early and delayed MIBG scintigraphy was pathologically decreased (b1.3) in fourteen patients diagnosed as IPD and in six patients with EPS. One patient with EST had decreased H/M ratio (1.3–1.79). Three patients initially diagnosed with IPD as well as seven patients with EPS had normal H/M ratios. In total, we confirmed initially established clinical diagnoses of IPD in 14 of 18