Long term mortality of patients with Parkinson's disease treated with deep brain stimulation in a reference center

INTRODUCTION

Parkinson's disease (PD) is a common neurodegenerative disorder, with a higher risk of death than general population. Deep Brain Stimulation (DBS) has been used to treat PD for more than 2 decades, but few studies exist concerning mortality in this subset of patients. Our goal is to analyse mortality in PD patients treated with DBS in our centre.

METHODS

retrospective evaluation of clinical files of patients with PD who underwent DBS surgery consecutively between October 2002 and May 2019.

RESULTS

346 patients were included in the analysis, 60 % male, with a mean age at disease onset of 48± 8 years (18-64), mean age at surgery of 60 ± 7 years (33-75), and mean disease duration until surgery of 14 ± 6 years (3-52). Mean follow-up after surgery was 7 ± 4 years (range 1-17). Overall mortality rate was 17.9 % and mean age at time of death was 71 ± 6 years. The main causes of death were pneumonia, dementia and acute myocardial infarction. In our series, male gender and disease duration until surgery were the only predictors of mortality in multivariate analysis.

CONCLUSION

Our study showed a long-term survival higher than previously described, and suggests that the treatment of patients with shorter disease evolution might have a survival benefit. The leading causes of death in PD patients treated with DBS seems unrelated to surgery, as the main causes of death are comparable to non-DBS patients.

Brain networks associated with anticipatory postural adjustments in Parkinson's disease patients with freezing of gait

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High hemodynamic response in the AI and SMA in the FoG when an APA was required.

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Connectivity between the right and left insulae was correlated with severity of FoG.

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Both groups showed different brain network organizations between SMA and bilateral AI.

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SMA was found to be a hub in patients with FoG when an APA was required.

Specific impairments of anticipatory postural adjustment (APA) during step initiation have been reported in patients with Parkinson’s disease (PD) and freezing of gait (FoG). Although APA disruption has been associated with FoG, there is scarce knowledge about its neural correlates. We sought to better understand the neural networks involved with APA in patients with FoG by assessing the level of hemodynamic response of specific brain regions and the functional connectivity during the leg lifting task. In the current investigation, APAs of patients with PD, with and without (nFoG) freezing were assessed during a leg lifting task in an event-related, functional magnetic resonance imaging (er-fMRI) protocol. Results identified a high hemodynamic response in the right anterior insula (AI) and supplementary motor area (SMA) in the FoG group when an APA was required. The nFoG had stronger connectivity between the right and left insulae than the FoG group. The strength of this connectivity was negatively correlated with the severity of FoG. Both groups showed different brain network organizations comprising the SMA and the bilateral AI. The SMA was found to be a hub in patients with FoG when an APA was required for the task. Our findings suggest that both groups used compensatory mechanism comprising the insulae during APA. Neither group used the entire network comprised of the insulae and SMA to accomplish the task. The FoG group relied more on SMA as a hub than as part of a broader network to exchange information during the APA.

Spinal direct current stimulation (tsDCS) in hereditary spastic paraplegias (HSP): A sham-controlled crossover study

Objective: Hereditary spastic paraplegia (HSP) represents a heterogeneous group of neurodegenerative diseases characterized by progressive spasticity and lower limb weakness. We assessed the effects of transcutaneous spinal direct current stimulation (tsDCS) in HSP.Design: A double-blind, randomized, crossover and sham-controlled study.Setting: Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan.Participants: eleven patients with HSP (six men, mean age ± SD: 37.3 ± 8.1 years), eight affected by spastin/SPG4,1 by atlastin1/SPG3a, 1 by paraplegin/SPG7 and 1 by ZFYVE26/SPG15.Interventions: tsDCS (anodal or sham, 2.0 mA, 20', five days) delivered over the thoracic spinal cord (T10-T12).Outcome measures: Motor-evoked potentials (MEPs), the H-reflex (Hr), F-waves, the Ashworth scale for clinical spasticity, the Five Minutes Walking test and the Spastic Paraplegia Rating Scale (SPRS) were assessed. Patients were evaluated before tsDCS (T₀), at the end of the stimulation (T₁), after one week (T₂), one month (T₃) and two months (T₄).Results: The score of the Ashworth scale improved in the anodal compared with sham group, up to two months following the end of stimulation (T₁, P = .0137; T₄, P = .0244), whereas the Five Minutes Walking test and SPRS did not differ between the two groups. Among neurophysiological measures, both anodal and sham tsDCS left Hr, F-waves and MEPs unchanged over time.Conclusions: Anodal tsDCS significantly decreases spasticity and might be a complementary strategy for the treatment of spasticity in HSP.

Mood and emotional disorders associated with parkinsonism, Huntington disease, and other movement disorders

This chapter provides a review of mood, emotional disorders, and emotion processing deficits associated with diseases that cause movement disorders, including Parkinson's disease, Lewy body dementia, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, frontotemporal dementia with parkinsonism, Huntington's disease, essential tremor, dystonia, and tardive dyskinesia. For each disorder, a clinical description of the common signs and symptoms, disease progression, and epidemiology is provided. Then the mood and emotional disorders associated with each of these diseases are described and discussed in terms of clinical presentation, incidence, prevalence, and alterations in quality of life. Alterations of emotion communication, such as affective speech prosody and facial emotional expression, associated with these disorders are also discussed. In addition, if applicable, deficits in gestural and lexical/verbal emotion are reviewed. Throughout the chapter, the relationships among mood and emotional disorders, alterations of emotional experiences, social communication, and quality of life, as well as treatment, are emphasized.

Gamma Knife Thalamotomy for a Medically Refractory Tremors: Longitudinal Evaluation of Clinical Effects and MRI Response Patterns

OBJECTIVE

The present longitudinal study evaluated the results of Gamma Knife surgery (GKS) for medically refractory tremors.

METHODS

The outcome after Gamma Knife thalamotomy targeting the ventral intermediate nucleus (VIM) was analyzed in 17 patients (9 men and 8 women; mean age 72 years) with either Parkinson's disease or an essential tremor, who were followed up for at least 2 years after treatment. Clinical and magnetic resonance imaging (MRI) examinations were done before and every 3 months after GKS.

RESULTS

The mean rates of symptom improvement (a decrease in the tremor frequency) were 6%, 39%, 63%, and 64% at 3, 6, 12, and 24 months after treatment, respectively. The defined MRI response patterns included a minimum reaction (in 3 patients), a normal reaction (in 11 patients), and a hyperreaction (in 3 patients). They were not associated with any evaluated pretreatment, radiosurgical, or outcome parameter, although 2 patients with a hyperreaction exhibited mild-to-moderate motor weakness in the contralateral limbs. Linear contrasting of the border between the thalamus and the internal capsule adjacent to the lesion site was noted on follow-up MRI in 13 cases and was associated with a higher symptom improvement rate.

CONCLUSION

GKS allows effective and safe management of medically refractory tremors. The treatment is characterized by variable MRI response patterns. Some imaging findings during follow-up may be associated with clinical effects.

Analysis of dynamic elbow flexion deformity in children with hemiplegic cerebral palsy

BACKGROUND

Cerebral palsy affects 1 per 1.000 children, and in 83% of the cases upper extremity is involved. Dynamic elbow flexion deformity is a movement disorder observed in individuals with hemiparesis secondary to cerebral palsy. We sought to determine whether children with hemiplegic cerebral palsy exhibit dynamic elbow flexion deformity during daily activities and its influence to reaching function.

METHODS

Sixteen children with upper limb hemiparesis and cerebral palsy (age 11y 7mo (SD 3y 2mo); 11 boys, 5 girls; Gross Motor Function Classification System level I or II) were included in this observational descriptive study. Manual Ability Classification System, Children's Hand-use Experience Questionnaire and Shriners Hospital for Children Upper Extremity Evaluation were used to evaluate affected upper extremity function. Spasticity was assessed with Modified Ashworth scale. Involuntary elbow flexion was recorded in eight daily activities. Elbow motion during reach function was measured.

FINDINGS

Fifteen out of 16 individuals showed dynamic elbow flexion deformity. There was a significative increase of involved median elbow flexion in all the activities studied, except for "high speed stairs climbing" evaluation. Children's Hand-use Experience Questionnaire showed that children were independent in most of the daily activities (21 out of 29). Correlation between dynamic elbow flexion deformity and Shriners Hospital for Children Upper Extremity Evaluation was observed only in sitting-standing activity (Spearman's ρ 0.549, P = 0.028).

INTERPRETATION

Dynamic elbow flexion deformity is very common in hemiplegic cerebral palsy and occurs proportionally to the degree of the effort demanded by the activities. Despite of presenting this movement disorder, it does not affect in children participation in daily activities.

Baclofen pump with pre-brainstem catheter tip placement: technical note and case series

PURPOSE

This study aims to describe a new baclofen pump implantation technique with pre-brainstem catheter placement and to demonstrate the benefits that this procedure has in treating spasticity and dystonia.

METHODS

We described a new technique to place a baclofen pump catheter anterior to the brainstem. To illustrate the technique, we presented five patients with both spasticity and dystonia in whom conventional treatment was not effective. They each received a baclofen pump with a pre-brainstem catheter. We evaluated the results using the Ashworth scale for spasticity, the Barry-Albright scale for dystonia, and the PedsQL for quality of life assessment. Each patient was evaluated before a surgery and after 6 months of follow-up.

RESULTS

There were statistically significant differences in all the physical examination evaluated areas using the Barry-Albright and modified Ashworth scales between the preoperative and the postoperative period. The same applies to the results of the PedsQL quality of life scale.

CONCLUSION

We presented an innovative baclofen pump implantation technique with pre-brainstem catheter placement that could be a therapeutic alternative in patients with dystonia and spastic quadriparesis for whom conventional therapy is not effective.

Determinants and impact of alexithymia on quality of life in Parkinson's disease

INTRODUCTION

Alexithymia is a neuropsychiatric symptom conceptualized as difficulty identifying and describing feelings. Although associated with other non-motor symptoms, mainly neuropsychiatric, alexithymia may present as an isolated symptom in persons with Parkinson's Disease (PwP). The objective of the study is to identify determinants of alexithymia and its association with quality of life (QoL) in Parkinson's disease.

METHODS

Subjects with Parkinson's disease were recruited. The following instruments were applied: Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Non-Motor Symptoms Scale (NMSS), Montreal Cognitive Assessment (MoCA), Toronto alexithymia scale (TAS-20) and Parkinson's Disease Questionnaire (PDQ-8). Matched healthy controls were screened using TAS-20. Clinical and demographical variables were compared between alexithymic and non-alexithymic. Regression models were used to find determinants of alexithymia. Impact of alexithymia on QoL was estimated with a linear regression model.

RESULTS

98 patients were included. 56.1% PwP and 28.8% controls were alexithymic (p<0.001). Education level (OR 0.86) and NMSS urinary score (OR 1.09) determined alexithymia as well as TAS-20 score. Alexithymia was an independent determinant of QoL.

CONCLUSIONS

Alexithymia is a prevalent independent non-motor symptom in PwP with impact on QoL. Low education level and urinary symptoms are important determinants of alexithymia.

O-Arm Stereotactic Imaging in Deep Brain Stimulation Surgery Workflow: A Utility and Cost-Effectiveness Analysis

INTRODUCTION

Deep brain stimulation (DBS) surgery is an established treatment for movement disorders. Advances in neuroimaging techniques have resulted in improved targeting accuracy that may improve clinical outcomes. This study aimed to evaluate the safety and feasibility of using the Medtronic O-arm device for the acquisition of intraoperative stereotactic imaging, targeting, and localization of DBS electrodes compared with standard stereotactic MRI or computed tomography (CT).

METHODS

Patients were recruited prospectively into the study. Routine frame-based stereotactic DBS surgery was performed. Intraoperative imaging was used to facilitate and verify the accurate placement of the intracranial electrodes. The acquisition of coordinates and verification of the position of the electrodes using the O-arm were evaluated and compared with conventional stereotactic MRI or CT. Additionally, a systematic review of the literature on the use of intraoperative imaging in DBS surgery was performed.

RESULTS

Eighty patients were included. The indications for DBS surgery were dystonia, Parkinson's disease, essential tremor, and epilepsy. The globus pallidus internus was the most commonly targeted region (43.7%), followed by the subthalamic nucleus (35%). Stereotactic O-arm imaging reduced the overall surgical time by 68 min, reduced the length of time of acquisition of stereotactic images by 77%, reduced patient exposure to ionizing radiation by 24.2%, significantly reduced operating room (OR) costs per procedure by 31%, and increased the OR and neuroradiology suite availability.

CONCLUSIONS

The use of the O-arm in DBS surgery workflow significantly reduced the duration of image acquisition, the exposure to ionizing radiation, and costs when compared with standard stereotactic MRI or CT, without reducing accuracy.

Is Fidgety Philip's ground truth also ours? The creation and application of a machine learning algorithm

BACKGROUND

Behavioral observations support clinical in-depth phenotyping but phenotyping and pattern recognition are affected by training background. As Attention Deficit Hyperactivity Disorder, Restless Legs syndrome/Willis Ekbom disease and medication induced activation syndromes (including increased irritability and/or akathisia), present with hyperactive-behaviors with hyper-arousability and/or hypermotor-restlessness (H-behaviors), we first developed a non-interpretative, neutral pictogram-guided phenotyping language (PG-PL) for describing body-segment movements during sitting.

METHODOLOGY & RESULTS

The PG-PL was applied for annotating 12 1-min sitting-videos (inter-observer agreements >85%->97%) and these manual annotations were used as a ground truth to develop an automated algorithm using OpenPose, which locates skeletal landmarks in 2D video. We evaluated the algorithm's performance against the ground truth by computing the area under the receiver operator curve (>0.79 for the legs, arms, and feet, but 0.65 for the head). While our pixel displacement algorithm performed well for the legs, arms, and feet, it predicted head motion less well, indicating the need for further investigations.

CONCLUSION

This first automated analysis algorithm allows to start the discussion about distinct phenotypical characteristics of H-behaviors during structured behavioral observations and may support differential diagnostic considerations via in-depth phenotyping of sitting behaviors and, in consequence, of better treatment concepts.

Neurons under genetic control: What are the next steps towards the treatment of movement disorders?

Since the implementation of deep-brain stimulation as a therapy for movement disorders, there has been little progress in the clinical application of novel alternative treatments. Movement disorders are a group of neurological conditions, which are characterised with impairment of voluntary movement and share similar anatomical loci across the basal ganglia. The focus of the current review is on Parkinson's disease and Huntington's disease as they are the most investigated hypokinetic and hyperkinetic movement disorders, respectively. The last decade has seen enormous advances in the development of laboratory techniques that control neuronal activity. The two major ways to genetically control the neuronal function are: 1) expression of light-sensitive proteins that allow for the optogenetic control of the neuronal spiking and 2) expression or suppression of genes that control the transcription and translation of proteins. However, the translation of these methodologies from the laboratories into the clinics still faces significant challenges. The article summarizes the latest developments in optogenetics and gene therapy. Here, I compare the physiological mechanisms of established electrical deep brain stimulation to the experimental optogenetical deep brain stimulation. I compare also the advantages of DNA- and RNA-based techniques for gene therapy of familial movement disorders. I highlight the benefits and the major issues of each technique and I discuss the translational potential and clinical feasibility of optogenetic stimulation and gene expression control. The review emphasises recent technical breakthroughs that could initiate a notable leap in the treatment of movement disorders.

Prospective Evaluation of the Time Course of White Matter Edema Associated with Implanted Deep Brain Stimulation Electrodes

INTRODUCTION

Deep brain stimulation (DBS) is commonly used in the treatment of medically refractory movement disorders. There have been several reports in the literature of edema developing around the implanted electrode. Most of these studies have been retrospective, suggesting that the time course and incidence of this edema are underestimated. An understanding of the incidence and time course of edema related to DBS leads is important to allow clinicians to better assess the correct course of action when edema following DBS implantation is observed.

METHODS

We examined both the time course and prevalence of edema following DBS implantation by obtaining a series of postoperative MRI scans from patients who underwent DBS surgery. Edema volume was quantified by a single neuroradiologist, measuring the peri-electrode T2 signal change.

RESULTS

We examined postoperative MRIs in thirteen patients with fifteen DBS electrode implants. Eleven patients exhibited white matter edema on at least 1 postoperative MRI, with none being symptomatic. Edema was completely resolved in 4 of the electrode implants through postoperative day 70, with the remaining cases still exhibiting edema at the last imaged time point.

DISCUSSION/CONCLUSION

In this study, we obtained a regimented series of postoperative MRIs in an effort to determine the time course and incidence of edema. Our results show that edema following DBS implant is not rare, is often asymptomatic, and may resolve over many weeks.

A novel use of inertial sensors to measure the craniocervical flexion range of motion associated to the craniocervical flexion test: an observational study

Background

The craniocervical flexion test (CCFT) is recommended when examining patients with neck pain related conditions and as a deep cervical retraining exercise option. During the execution of the CCFT the examiner should visually assess that the amount of craniocervical flexion range of motion (ROM) progressively increases. However, this task is very subjective. The use of inertial wearable sensors may be a user-friendly option to measure and objectively monitor the ROM. The objectives of our study were (1) to measure craniocervical flexion range of motion (ROM) associated with each stage of the CCFT using a wearable inertial sensor and to determine the reliability of the measurements and (2) to determine craniocervical flexion ROM targets associated with each stage of the CCFT to standardize their use for assessment and training of the deep cervical flexor (DCF) muscles.

Methods

Adults from a university community able to successfully perform the CCFT participated in this study. Two independent examiners evaluated the CCFT in two separate sessions. During the CCFT, a small wireless inertial sensor was adhered to the centre of the forehead to provide real-time monitoring and to record craniocervical flexion ROM. The intra- and inter-rater reliability of the assessment of craniocervical ROM was calculated. This study was approved by the Research Ethics Committee of CEU San Pablo University (236/17/08).

Results

Fifty-six participants (18 males, 23 females; mean [SD] age, 21.8 [3.45] years) were included in the study and successfully completed the study protocol. All interclass correlation coefficient (ICC) values indicated good or excellent reliability of the assessment of craniocervical ROM using a wearable inertial sensor. There was high variability between subjects on the amount of craniocervical ROM necessary to achieve each stage of the CCFT.

Conclusions

The use of inertial sensors is a reliable method to measure the craniocervical flexion ROM associated with the CCFT. The great variability in the ROM limits the possibility to standardize a set of targets of craniocervical flexion ROM equivalent to each of the pressure targets of the pressure biofeedback unit.

Movement Disorders in Chronic Kidney Disease - A Descriptive Review

OBJECTIVES

The objective of this study is to describe the mechanism of damage to subcortical structures in chronic kidney disease (CKD) and to describe the range of movement disorders associated with CKD.

MATERIALS AND METHODS

We have reviewed the Medline literature up to January of 2020 using key words movement disorders and chronic kidney disease. The reviewed articles were studied for mechanisms of subcortical damage in CKD as well as type of the reported movements, their frequency and updated treatment.

RESULTS

The search revealed 183 articles most of them dealing with restless legs syndrome. The damage to basal ganglia in CKD resulted from several mechanisms including accumulation of nitro tyrosine caused by reactive oxygen species and action of uremic toxins leading to endothelial damage and dysfunction of blood-brain barrier. Involuntary movements in CKD include restless legs syndrome (RLS), myoclonus, asterixis, dystonia, chorea, tremor, and Parkinsonism.

CONCLUSIONS

Chronic kidney disease can cause several abnormal involuntary movements via damaging basal ganglia and subcortical structures. The most common movement disorders in CKD are RLS, myoclonus and asterixis. Restless legs syndrome and myoclonus when severe, need and respond to treatment. Movement disorders in CKD improve with improvement of kidney function.

D1-mGlu5 heteromers mediate noncanonical dopamine signaling in Parkinson's disease

Dopamine receptor D1 modulates glutamatergic transmission in cortico-basal ganglia circuits and represents a major target of L-DOPA therapy in Parkinson's disease. Here we show that D1 and metabotropic glutamate type 5 (mGlu5) receptors can form previously unknown heteromeric entities with distinctive functional properties. Interacting with Gq proteins, cell-surface D1-mGlu5 heteromers exacerbated PLC signaling and intracellular calcium release in response to either glutamate or dopamine. In rodent models of Parkinson's disease, D1-mGlu5 nanocomplexes were strongly upregulated in the dopamine-denervated striatum, resulting in a synergistic activation of PLC signaling by D1 and mGlu5 receptor agonists. In turn, D1-mGlu5-dependent PLC signaling was causally linked with excessive activation of extracellular signal-regulated kinases in striatal neurons, leading to dyskinesia in animals treated with L-DOPA or D1 receptor agonists. The discovery of D1-mGlu5 functional heteromers mediating maladaptive molecular and motor responses in the dopamine-denervated striatum may prompt the development of new therapeutic principles for Parkinson's disease.

Treatment use among children with Tourette syndrome living in the United States, 2014

Treatment of Tourette syndrome (TS) can be complicated by changes over time in tic expression, severity, and co-occurring disorders. Using the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome, this study provides descriptive estimates of the use of behavioral interventions and medication among children living with TS. Parent-reported data on 115 children aged 5-17 years ever diagnosed with TS were analyzed to provide descriptive, unweighted results. Overall, 77.4% of children had current or past use of any TS treatment; 59.1% ever used behavioral interventions and 56.1% had ever taken TS medication. Children with "moderate" or "severe" versus "mild" TS, ≥1 co-occurring disorders, and tics that interfered with functioning were significantly more likely to have used one or more TS treatments. Side effects were reported for 84.4% of children who took TS medication. Most parents of children with current TS (87.2%) were satisfied with the management of their child's TS. However, parents of children with "moderate" or "severe" current TS were significantly more dissatisfied compared to parents of children with "mild" TS. Findings from this study could be used to inform efforts to support children living with TS and their families.

Modeling cerebellar limb dysmetria and impaired spatial memory in rats using lamivudine: A preliminary study

BACKGROUND AND AIM

Neurodegeneration has been associated with the use of combination antiretroviral therapy (cART). This study is aimed at determining if any constituent of cART can induce cerebellar limb dysmetria and spatial memory impairments.

MATERIALS AND METHODS

Forty adult male Wistar rats were randomly grouped into four (n = 10): control (distilled water 0.5 mL); Tenofovir (6 mg/kg); Lamivudine (6 mg/kg) and Efavirenz (12 mg/kg). The following neurobehavioral studies were conducted: open field, beam walk, and Morris water maze. Immunohistochemistry of CD 68 and GFAP were used to test for neuroinflammation and neurodegeneration.

RESULTS

There was marked increase in pyknotic pyramidal cells of the hippocampus and ghost Purkinje cells in the cerebellum of treatment groups. There was also a significant increase in oxidative stress in lamivudine and efavirenz groups. In addition, Lamivudine caused a significant increase of microglial and astrocytic activity (p < 0.001, 0.05 respectively) compared to control. The open field test showed a significant decrease (p < 0.0001) of the line crossing performance in the efavirenz, lamivudine and tenofovir (with means: 26.4, 4.6, 17.4 respectively) compared to control (50.6). There was also a significant decrease in the grooming (p < 0.05) and rearing (p < 0.01) in lamivudine group. Whereas, walk latency increased in efavirenz (p < 0.01), and lamivudine (p < 0.0001) compared to control. While hind limb slips significantly increased in efavirenz (p < 0.05) and lamivudine (p < 0.0001) compared with control group. Likewise, Lamivudine and Tenofovir exposed groups experienced a significant delay in the time to identify the hidden platform in compared to control (p < 0.05).

CONCLUSION

Lamivudine altered efferent stimuli along the cerebellospinal tracts thereby causing motor impairments. The degenerating Purkinje fibers may have induced marked neurodegeneration in the hippocampus resulting in impaired spatial memory.

Scientific impact of movement disorders research from Southeast Asia: A bibliometric analysis

BACKGROUND

The number of scientific publications on movement disorders from Southeast Asia (SEA) is thought to be low. Thus, we looked at the movement disorders research productivity among SEA countries and its associations with country-specific socioeconomic factors.

METHODS

We performed a systematic search for publications indexed in PubMed, Scopus, Embase and Cochrane Central Register of Controlled Trials from January 2000 to December 2019 with at least one author from SEA. Bibliometric indices were used to evaluate research impact. The country-specific socioeconomic characteristics were also obtained.

RESULTS

Of the 9488 identified articles, 1567 met the eligibility criteria. There was an increasing trend in the total number of publications on movement disorders during the last two decades. Singapore had the highest contribution in all aspects, which highlights the impact of knowledge-based economy type in research productivity. Parkinsonism remained the most studied condition, followed by dystonia, chorea, and tremor. Among the socioeconomic factors, only % gross domestic product (GDP) for research and development showed a positive correlation on the number of publications of a country. On the other hand, GDP per capita, population size and the number of neurologist size did not affect research productivity.

CONCLUSIONS

An increasing trend in the movement disorders research output over the last 20 years was seen. Singapore had the highest contribution in all aspects which highlights the impact of economy in research productivity. Among the socioeconomic factors, only % GDP for R&D showed a positive impact on the number of publications of a country.

Status Dystonicus, Oculogyric Crisis and Paroxysmal Dyskinesia in a 25 Year-Old Woman with a Novel KCNMA1 Variant, K457E

The diagnosis of a paroxysmal dyskinesia is difficult and status dystonicus is a rare life threatening movement disorder characterised by severe, frequent or continuous episodes of dystonic spasms. A 25 year old woman with chronic ataxia and paroxysmal dyskinesia presented with facial twitching, writhing of arms, oculogyric crisis and visual and auditory hallucinations. She developed respiratory failure and was ventilated. No cause was found so whole exome sequencing was performed and this revealed a novel, non-synonymous heterozygous variant in exon 11 of the KCNMA1 gene, K457E (c 1369A>G) in the patient but not her parents. This variant has not been previously reported in gnomAD or ClinVar. The finding of a de novo variant in a potassium channel gene guided a trial of the potassium channel antagonist 3,4 diaminopyridine resulting in significant improvement, discharge from the intensive care unit and ultimately home.

Lack of Accredited Clinical Training in Movement Disorders in Europe, Egypt, and Tunisia

BACKGROUND

Little information is available on the official postgraduate and subspecialty training programs in movement disorders (MD) in Europe and North Africa.

OBJECTIVE

To survey the accessible MD clinical training in these regions.

METHODS

We designed a survey on clinical training in MD in different medical fields, at postgraduate and specialized levels. We assessed the characteristics of the participants and the facilities for MD care in their respective countries. We examined whether there are structured, or even accredited postgraduate, or subspecialty MD training programs in neurology, neurosurgery, internal medicine, geriatrics, neuroradiology, neuropediatrics, and general practice. Participants also shared their suggestions and needs.

RESULTS

The survey was completed in 31/49 countries. Structured postgraduate MD programs in neurology exist in 20 countries; structured neurology subspecialty training exists in 14 countries and is being developed in two additional countries. Certified neurology subspecialty training was reported to exist in 7 countries. Recommended reading lists, printed books, and other materials are the most popular educational tools, while courses, lectures, webinars, and case presentations are the most popular learning formats. Mandatory activities and skills to be certified were not defined in 15/31 countries. Most participants expressed their need for a mandatory postgraduate MD program and for certified MD sub-specialization programs in neurology.

CONCLUSION

Certified postgraduate and subspecialty training exists only in a minority of European countries and was not found in the surveyed Egypt and Tunisia. MD training should be improved in many countries.

Bobble-head doll syndrome with supra-sellar arachnoid cyst

A 19-year-old woman reported progressively worsening involuntary head movements since the age of 7. She had visited multiple hospitals and been labelled as having a functional disorder. Detailed evaluation identified a large supra-sellar arachnoid cyst with hydrocephalus. We made a diagnosis of bobble-head doll syndrome, which is only very rarely associated with suprasellar arachnoid cyst. Her symptoms improved rapidly following endoscopic third ventriculostomy with cyst fenestration and gradual decompression of the ventricles. Clearly, not all suppressible movements should be labelled as psychogenic.

Essential tremor: Is the word "essential" really essential?

Essential tremor (ET) is among the common movement disorders. A surge in research in recent years has considerably improved our understanding of disease etiology and pathogenesis, and its associated clinical phenomenology and natural history. With this progress have emerged a multitude of new questions and conundrums and newly proposed terminologies. Amidst these various related discussions, it is worth revisiting the essence of the nomenclature, "essential tremor", to assess how well it continues to fit the growing understanding of this entity. Here we revisit the historical underpinnings of the nomenclature, its accuracy, pitfalls of eliminating the word, and advantages of removing the word. There are two primary historical bases for using the word "essential": (i) idiopathic or unclear etiology, (ii) a unitary (single-featured) trait perceived as a constitutional feature. Numerous studies indicate that ET is neither truly idiopathic nor is fully isolated, making the use of "essential" technically incorrect. There are pitfalls and advantages of eliminating the term "essential" and both are succinctly described in this article. Yet in the absence of any flawless alternatives at present, we conclude that it is preferable for now to persist with "essential" tremor, thereby respecting the historical continuity of this one-and-a-half-century old nomenclature.

Dystonic Storm in Consultation-Liaison Psychiatry

Dystonia is a movement disorder characterised by sustained muscle contractions that produce repetitive twisting movements or abnormal postures. It can be classified according to the aetiology as primary (idiopathic and genetic forms), or secondary. The presentation associated with generalised, intense episodes and with exacerbation of severe muscle contractures and usually refractory to traditional pharmacotherapy is known as dystonic status or dystonic storm. In the present article, a case is presented of a 33-year-old patient with a history of congenital deafness, stimulant use disorder and on psychopharmacological treatment with antipsychotics, who presented with a severe dystonic reaction that evolved to a status dystonicus.

Safety of Deep Brain Stimulation Lead Placement on Patients Requiring Anticlotting Therapies

BACKGROUND

Limited studies exist to support the safety of performing neuromodulation surgeries in patients whose anticlotting medication has been held. Here, we assess the safety of performing deep brain stimulation (DBS) in this patient population.

METHODS

All consecutive DBS patients who underwent lead and battery placement/revision at our institution between 2011 and 2020 were included in this Institutional Review Board-approved prospective outcomes database. We retrospectively recorded adverse events occurring within 90 days of surgery.

RESULTS

The study included 226 patients who underwent 381 lead placements in 267 surgeries. Of the 267 surgeries included in this study, 176 (66%) were performed on patients not on anticoagulants and 89 (33%) cases were on patients on 1 drug. Two (0.7%) cases involved a patient taking 2 drugs. A total of 49 adverse events were seen. Thirteen occurred in patients taking anticoagulants. There was no difference in adverse event rate between patients on anticlotting medication and those not (χ² [1] = 1.523, P = 0.2171). No clot-related sequelae occurred in any patient. Three hemorrhages occurred, all in patients not on anticoagulants.

CONCLUSIONS

We found no increased risk of complications in patients routinely on anticlotting medication undergoing DBS lead placement. We show that our protocol was successful in balancing increased risks of bleeding and of thromboembolic events in this patient group.