The lowest effective dose of botulinum A toxin in adult patients with upper limb spasticity

Objective: To define the lowest effective dose of botulinum toxin type A (Dysport®) and safety in the treatment of adult patients with upper limb spasticity.

Design: This was a prospective, randomized, double-blind, dose-ranging study. Patients received either a placebo or one of three doses of Dysport® (350, 500, 1000 U) into five muscles of affected arm by anatomical and electromyography guidance. Efficacy was assessed periodically throughout the 6-month study period by the Modified Ashworth Scale (MAS), the Action Research Arm Test (ARA), the Barthel Index (BI) and the Visual Analogue Pain Scale (VAS).

Results: Fifty patients were recruited. The four study groups were comparable at baseline with respect to their demographical characteristics and severity of spasticity. All doses of Dysport® studied showed a significant reduction from baseline of muscle tone and pain compared to placebo. However, the effect of functional disability was best at a dose of 500 U and the peak improvement was at week 8 after injection. A dose of 1000 U Dysport produced such an excess degree of muscle weakening that the number of randomized patients was reduced to five. BI and ARA of all patients were decrease after injection. No other adverse event was considered related to the study medication.

Conclusion: This study suggests that treatment with Dysport® reduces muscle tone in adult patients with upper limb spasticity. The optimal dose for treatment of patients with residual voluntary movement in the upper limb appears to be 500 U.     

Comparison of transcranial Doppler ultrasound and computed tomography angiography in symptomatic middle cerebral artery stenosis

Transcranial Doppler ultrasound (TCD) and computed tomography angiography (CTA) of 10 patients with middle cerebral artery territory stroke were studied. To obtain data from patients with presumed in situ middle cerebral artery (MCA) stenosis, the study excluded patients with a known source of cardiac emboli, significant carotid stenosis and classical lacunar syndrome. As the gold standard for this study, CTA demonstrated MCA stenosis in all patients (100%), while abnormal TCDs suggesting MCA stenoses were found in only six patients (60%). The stenotic sites differed among patients with normal and abnormal TCDs. Patients with false negative TCDs were found to have more distal lesions (distal M1 or M2 segment) whereas patients with TCD abnormalities tend to have more proximal lesions as demonstrated by CTA. It is concluded that an abnormal TCD is highly suggestive of stenosis of MCA. A normal TCD, however, does not exclude such a lesion, especially in patients with distal M1 or M2 stenoses. Therefore, TCD may not be the best screening test for intracranial vascular stenotic lesion in MCA territory stroke.     

Elevation of serum transcobalamin II in patients with scrub typhus

Serum transcobalamin II levels were measured in scrub typhus patients. Eighteen out of fifty-two patients admitted to Maharat Nakhon Ratchasima Hospital were diagnosed with scrub typhus infection. The serum unsaturated vitamin B12 binding protein (UBBC) and total vitamin B12 binding protein (TBBC) levels in these patients were significantly higher than in normal subjects (p < 0.001). The mean serum transcobalamin II level in the typhus patients was also significantly higher than in the normal subjects (p=0.004). There was a significant correlation between serum TCII levels and typhus IgM or IgG titers (p < 0.05), but not to total IgM levels. These findings indicate that patients with scrub typhus had stimulation of the recticuloendothelial system as a result of a considerable increase in transcobalamin II levels.     

Posterior leukoencephalopathy following cisplatin,bleomycin and vinblastine therapy for germ cell tumor of the ovary

A 31-year-old female developed multiple episodes of grand mal seizures after combination chemotherapy with cisplatin, vinblastine and bleomycin for germ cell ovarian cancer stage Ic. The clinicoradiologic features in this patient were consistent with posterior leukoencephalopathy, which is a rare complication of chemotherapy. Seizures were controlled by the anticonvulsive agent Dilantin (Pfizer, Khet Klongtoey, Bangkok) and she returned home without any permanent neurologic deficits. Follow-up magnetic resonance imaging 2 weeks later showed complete resolution of the abnormalities. This syndrome has been previously reported following cisplatin-based chemotherapy. Physicians should remain alert to the potential hazards of chemotherapy to the central nervous system. Risks and benefits should be seriously considered before starting treatment.     

Spontaneous penetration of dura mater and bone by glioblastoma multiforme

Three patients are reported whose cranial dura mater and bones were penetrated by intracranial glioblastomas in the absence of previous craniotomy or radiotherapy. The gliomatous nature of the tumors was confirmed by localization of cytoplasmic glial fibrillary acidic protein (GFAP) of the neoplastic cells. Review of the literature disclosed only 15 glioblastomas, including the three cases, spontaneously penetrating the cranial dura mater and bones. These patients ranged in age from 3.5 to 70 years with an average age of 40 years. The male/female ratio was 5/8. Five glioblastomas were in the temporal lobes, three were in the frontal lobes, three were in the frontotemporal regions, two were in the occipital lobes, one was in the frontoparietal region, and one was in the temporoparietooccipital region. Six glioblastomas also had spontaneous distant metastases. In the absence of previous craniotomy and radiotherapy, rapid growth of the glioblastomas may promote such spontaneous penetration into the cranial dura mater and bones.     

The lowest effective dose of botulinum A toxin in adult patients with upper limb spasticity

Objective: To define the lowest effective dose of botulinum toxin type A (Dysport®) and safety in the treatment of adult patients with upper limb spasticity.

Design: This was a prospective, randomized, double-blind, dose-ranging study. Patients received either a placebo or one of three doses of Dysport® (350, 500, 1000?U) into five muscles of affected arm by anatomical and electromyography guidance. Efficacy was assessed periodically throughout the 6-month study period by the Modified Ashworth Scale (MAS), the Action Research Arm Test (ARA), the Barthel Index (BI) and the Visual Analogue Pain Scale (VAS).

Results: Fifty patients were recruited. The four study groups were comparable at baseline with respect to their demographical characteristics and severity of spasticity. All doses of Dysport® studied showed a significant reduction from baseline of muscle tone and pain compared to placebo. However, the effect of functional disability was best at a dose of 500?U and the peak improvement was at week 8 after injection. A dose of 1000?U Dysport produced such an excess degree of muscle weakening that the number of randomized patients was reduced to five. BI and ARA of all patients were decrease after injection. No other adverse event was considered related to the study medication.

Conclusion: This study suggests that treatment with Dysport® reduces muscle tone in adult patients with upper limb spasticity. The optimal dose for treatment of patients with residual voluntary movement in the upper limb appears to be 500?U.     

Headache in Brain Tumor: A Cross-Sectional Study

SYNOPSIS
Headache is one of the cardinal features of intracranial neoplasm. However, there is little published information on the prevalence and clinical profiles of headache in patients with brain tumor. This cross-sectional study recruited 171 cases of brain tumor. The average age was 39 years (range from 4 to 75 years). The female to male ratio was 1.2:1. The prevalence of headache was 71%. The duration of headache ranged from 3 days to 10 years with an average of 15.7 months. Most prominent headache profiles in this series were intermittent, nocturnal and early morning headache as well as headache upon arising. Most of the patients had mild to moderately severe headache. Headache is more common with tumors below the tentorium cerebelli. It is more prevalent in primary and intracerebral tumor than in metastatic and extracerebral tumor. Headache has lateralizing value, especially in patients with supratentorial lesions who have no obvious increased intracranial pressure.     

Combined paraganglioma and glioma of conus medullaris and cauda equina

A mixed paraganglioma and glioma occurred in the conus medullaris and cauda equina of a woman. The tumor was subdural, encapsulated, and vascular. It was first manifested with symptoms and signs of compression of the cauda equina when she was 19 years of age and was excised when she was 24. The tumor was attached to the conus medullaris, the dura mater, and a nerve root of the cauda equina. Striking light and dark cells with an organoid arrangement mingled with a few glial fibrillary acidic protein (GFAP)-positive neuroglia forming a combined paraganglioma and glioma. Twenty-three paragangliomas were reported in the literature including the present case. The sex and age of recorded 19 patients demonstrated ten males and nine females with an average age of 46.3 years. Twenty tumors were subdurally situated at the conus medullaris and cauda equina. Three neoplasms were epidural and thoracic in location.