Axial parkinsonian symptoms can be improved: the role of levodopa and bilateral subthalamic stimulation

OBJECTIVE: To assess the effects of high frequency stimulation of the subthalamic nucleus (STN) on axial symptoms occurring in advanced stages of Parkinson's disease (PD). METHODS: The efficacy of STN stimulation on total motor disability score (unified Parkinson's disease rating scale (UPDRS) part III) were evaluated in 10 patients with severe Parkinson's disease. The subscores were then studied separately for limb akinesia, rigidity, and tremor, which are known to respond to levodopa, and axial signs, including speech, neck rigidity, rising from a chair, posture, gait, and postural stability, which are known to respond less well to levodopa. Patients were clinically assessed in the "off" and "on" drug condition during a levodopa challenge test performed before surgical implantation of stimulation electrodes and repeated 6 months after surgery under continuous STN stimulation. A complementary score for axial symptoms from the "activities of daily living" (ADL)-that is, speech, swallowing, turning in bed, falling, walking, and freezing-was obtained from each patient's questionnaire (UPDRS, part II). RESULTS: Improvements in total motor disability score (62%), limb signs (62%), and axial signs (72%) obtained with STN stimulation were statistically comparable with those obtained with levodopa during the preoperative challenge (68%, 69%, and 59%, respectively). When levodopa and STN stimulation were combined there was a further improvement in total motor disability (80%) compared with preoperative levodopa administration. This consisted largely of an additional improvement in axial signs (84%) mainly for posture and postural stability, no further improvement in levodopa responsive signs being found. Axial symptoms from the ADL showed similar additional improvement when levodopa and STN stimulation were combined. CONCLUSION: These findings suggest that bilateral STN stimulation improves most axial features of Parkinson's disease and that a synergistic effect can be obtained when stimulation is used in conjunction with levodopa treatment.     

Post‐traumatic stress symptoms in Guillain–Barré syndrome patients after prolonged mechanical ventilation in ICU: a preliminary report

Thirty percent of Guillain–Barré syndrome (GBS) patients require mechanical ventilation (MV) in intensive care unit (ICU). Post‐traumatic stress disorder (PTSD) is found in ICU survivors, and the traumatic aspects of intubation and MV have been previously reported as risk factors for PTSD after ICU. Our objective was to determine long‐term PTSD or post‐traumatic stress symptoms (PTSS) in GBS patients after prolonged MV in ICU. We assessed GBS patients who had MV for more than 2 months. PTSD was assessed using Horowitz Impact of Event Scale (IES), IES‐Revisited (IES‐R), and the Post‐traumatic CheckList Scale; functional outcome using Rankin and Barthel scales; quality of life (QoL) using Nottingham Health Profile (NHP) and 36‐Item Short Form Health Survey (SF‐36) and depression using Hospital Anxiety and Depression Scale (HAD) and Beck questionnaire. Thirteen patients could be identified and analyzed. They had only mild disability. They were neither anxious nor depressed with an anxiety HAD at 5 (4–11.5), a depression HAD at 1 (0–3.5) and a Beck at 1 (0–5). QoL was mildly decreased in our population with a NHP at 78.5 (12.8–178.8) and mild decreased SF‐36. Compared with the French population, the SF‐36 sub‐categories were, however, not statistically different. Twenty‐two percentage of our 13 patients had PTSD and PTSS with a Horowitz IES at 12 (2–29), and an IES‐R at 16 (2–34.5). Although severe GBS patients requiring prolonged MV had good functional recovery and no difference in QoL, they had a high incidence of PTSS.     

Cerebral fat embolism: usefulness of magnetic resonance spectroscopy

We report a case of cerebral fat embolism which occurred in a 33-year-old man after a diaphyseal femoral fracture without cranial traumatism. The initial examination showed an incomplete picture of coma with tetrapyramidal syndrome and cutaneomucous purpura. There was no respiratory damage. We present a magnetic resonance spectroscopy analysis of the cerebral lesions observed in the initial phase of the embolism, as well as follow-up, which has strengthened the clinical and imaging features for the diagnosis.     

Physiopathology of ALS: therapeutic approach

The finding in 1993 of a mutation of the copper zinc super oxyde dismutase (SOD1) provides a major breakthrough in the understanding of the etiopathogenic mechanism of amyotrophic lateral sclerosis. Various mechanisms are commonly implied in the motor neurons degeneration. Excitotoxicity and calcium metabolism abnormalities are one of the most frequently confirmed hypotheses. It allowed proposing riluzole which remains the only one drug proved to be active in the disease. The role of growth factors remains controversial and all therapeutic trials performed with these molecules remained negative. Oxidative stress abnormalities are demonstrated by number of studies but their direct therapeutic application remains to be demonstrated. Apoptosis and the role of mitochondria has been definitely confirmed and open a new therapeutic avenue for the next few years.     

Encéphalites auto-immunes à anticorps antirécepteurs-NMDA, une cause fréquente d’encéphalite en réanimation

Paraneoplastic autoimmune encephalitis results in rapidly evolving symptoms encompassing behavior changes, mood disorders, seizures, memory deficits, and possible decline of consciousness associated to an inflammation of the cerebrospinal fluid (CSF) and abnormalities on cerebral imaging. Among these encephalitis, the recently described anti-NMDA-receptor encephalitis seems more common. According to an epidemiological prospective study, this encephalitis represents up to 4% of all causes of encephalitis; the 5th cause of encephalitis after Herpes simplex virus, Varicelle zona virus (VZV), Mycobacterium tuberculosis infections, and acute demyelinating encephalomyelitis (ADEM), and thus the second cause of autoimmune encephalitis after ADEM. Anti-NMDA-receptor encephalitis predominantly affects young people, especially women. The clinical presentation is characteristic and includes rapidly evolving behavioral changes, prominent psychiatric symptoms with delusion and psychosis, seizures, abnormal movements, autonomic instability, and central hypoventilation. Admission to the intensive care unit is common for hypoventilation or decreased consciousness. Presentation is associated with the presence of an ovarian teratoma in two-third of the cases. Diagnosis is assessed based on the identification of specific antibodies against NMDA-receptor in the CSF, as well as indirect data obtained using electroencephalography and cerebral imaging. Treatment relies on immunotherapy, corticosteroids associated to intravenous immunoglobulins or plasma exchange, and resection of the germinal tumor. If diagnosed and treated early, anti-NMDA-receptor encephalitis has a mortality rate of 4% and a favorable outcome in about two-third of the patients.