Is there a rationale for iron supplementation in the treatment of akathisia? A review of the evidence

BACKGROUND

An association found between akathisia and iron deficiency led to the suggestion that iron supplementation might be a useful therapeutic intervention for patients with akathisia. There is, however, a body of literature on the abnormal deposition of iron in the brain in several degenerative diseases like Hallervorden-Spatz syndrome, Parkinson's disease, and Alzheimer's disease. Given the ability of neuroleptics to chelate iron and promote its deposition in the brain, we questioned whether peripheral measures of iron are an accurate reflection of central iron levels and thus whether there was a rationale for iron supplementation in akathisia.

METHOD

A MEDLINE search for literature relating to iron and akathisia, tardive dyskinesia, and Parkinson's disease was carried out and critically reviewed.

RESULTS

Evidence is presented for the ability of neuroleptics to chelate iron, mobilize it from peripheral stores, and deposit it in the basal ganglia. The effect of iron on dopaminergic receptor activity in brain and the potential role of iron in degenerative and neuroleptic-induced movement disorders are reviewed. The preponderance of the evidence shows a relationship between iron excess in the basal ganglia and the movement disorders. We found no studies that have examined the regulation of central levels of iron in patients with akathisia.

CONCLUSION

The rationale for iron supplementation in the treatment of akathisia is relatively weak, and there are potentially adverse long-term consequences as outlined in our review. More research is required to directly measure the level of iron in the brain of patients with akathisia, e.g., using magnetic resonance imaging, before such therapeutic intervention can be recommended.

[Immobility syndrome in patients being care for in a home care unit]

OBJECTIVES

to asses in a group of elderly patients included in a Home Care Unit, the level of immobility, the functional status based on the Katz's index and the Red Cross scale, and their medical, psychological and social consequences.

METHODS

assessment of elderly patients visited during three consecutive months, through and standardized protocol with 14 items related with the previous aspects.

RESULTS

114 elderly patients (71% females) were visited during this time. The mean age was 82.4 years. 71 patients (65.7%) had immobility, with a mean age of 83.4 years and females predominance. Based on the level of immobility, 24 patients were in bed and 44 patients were able to be in bed-armchair. 74% of the patients were severely disabled on the activities daily living (Katz G); 85% of the patients had a severe physical disability (Red Cross scale 4-5), whereas a lower percentage (36%) had severe mental disability (Red Cross scale 4-5). Neurological disorders were the most frequent etiology of immobility (72%), with only one cause in 27 patients, two causes in 20 patients and more than three causes in 24 patients. Medical consequences were the most frequent, mainly urinary and chest infections, pressure sores and constipation.

CONCLUSIONS

Immobility's syndrome represents a common medical problem in the geriatric care, related specially with the neurological and osteo-articular disorders, conditioning a high mobility.

White matter lesions and disequilibrium in older people. II. Clinicopathologic correlation

OBJECTIVE

To identify the cause of subcortical white matter lesions seen on magnetic resonance imaging in older patients with progressive deterioration of gait and balance.

DESIGN

Postmortem examination of three patients with objective impairment of gait and balance thought to be due to subcortical white matter lesions identified on magnetic resonance imaging. Brain sections were stained with routine methods and for glial fibrillary acid protein using an immunoperoxidase technique.

PATIENTS

Part of a prospective study of gait and balance problems in older people. None had a history of hypertension or discrete strokelike episodes.

RESULTS

Other than a few small infarcts in the basal ganglia and internal capsule in the patient with the mildest gait disorder, there were no gross or microscopic features on routine examination post mortem to explain the white matter hyperintensities on magnetic resonance imaging or the progressive gait deterioration. By contrast, immunohistochemical staining with anti-glial fibrillary acid protein showed prominent astrocytosis T2-weighted high-intensity signal areas on magnetic resonance imaging.

CONCLUSIONS

The astrocytes presumably swell as they take up extravasated protein at the site of a breakdown in the blood-brain barrier, and the increased water content per unit volume increases the magnetic resonance imaging proton signal. We hypothesized that the astrocytes may have been initially activated by small infarcts or subclinical ischemia, but the process then became self-perpetuating, ultimately involving most of the white matter and producing the severe gait disorder.

Transient involuntary movement of the leg (monoballismus) during cerebral angiography

Transient involuntary movement of the leg developed during diagnostic or therapeutic angiography in five patients. The movement was jerky, brisk flexion/extension of the hip and knee joints on the side contralateral to acute ischemia. This movement may occur as a result of thromboembolic cerebral ischemia or as an ischemic complication of angiography.

White matter lesions and disequilibrium in older people. I. Case-control comparison

OBJECTIVE

To investigate the relationship between subcortical white matter lesions identified on magnetic resonance imaging and gait and balance problems in older people.

DESIGN

Magnetic resonance imaging scans of the brain in 27 community-dwelling older patients (> 75 years of age) who had subjective and objective abnormalities of gait and balance of unknown cause were compared with those of 27 age- and sex-matched control subjects. The T2-weighted intense lesions of the subcortical white matter were graded on a scale of 0 to 2.

SETTING

Outpatient clinic.

RESULTS

The patient had significantly (P < .01, chi 2) more severe subcortical white matter hyperintensities on magnetic resonance imaging than did the control group. Patients fell more frequently than did the control subjects and had slower motor responses and prolonged reaction times compared with the control subjects.

CONCLUSIONS

Subcortical white matter lesions identified on magnetic resonance imaging are associated with gait and balance dysfunction in ambulatory older people. These lesions probably interfere with central processing of sensorimotor signals leading to impaired postural responses.

Subarachnoid-pleural fistula after resection of a pancoast tumor with hyponatremia

Resection of superior sulcus neoplasms is associated with a number of complications resulting from the extensive nature of the resection and the necessity to sacrifice certain adjacent structures. One of the complications of resection is the development of subarachnoid-pleural fistula, with the subsequent appearance of air in the cerebrospinal fluid circulation. We report a case in which a subarachnoid-pleural fistula led to persistent pneumocephaly in a patient who exhibited postoperative hyponatremia, confusion, and gait disturbance.

[Drug-induced extrapyramidal disorders]

We analyze 402 drug-adverse events consisting of movement disorders or aggravation of parkinsonisms, submitted to Sistema Español de Farmacovigilancia until 1994. Our aim is to know patient characteristics and the drugs related with these submissions. Most of them (64) belong to calcium-entry blocker group (31%) and benzamides (27%). Case age intervals more frequent were 11-30 and 60-80 years-old and the events affect predominantly females. The percentage of serious adverse events were near 80%. We think that drug-related parkinsonisms have high prevalence rate and that the role of calcium-entry blockers in these events should be considered at the moment to prescribe groups.

Intrathecal baclofen for motor disorders

To test the efficacy of intrathecal baclofen in various movement disorders, 18 patients with dystonia, head trauma, cerebral palsy, rigidity, or painful spasms underwent a trial of intrathecal baclofen. Ten went on to permanent implantation with an infusion pump to provide long-term treatment. Patients with a component of spasticity, painful spasms, or focal dystonias did best, and no response was seen in patients with rigidity due to anoxic encephalopathy. A videotape of responses is provided.

Delayed neurological symptoms from the spontaneous migration of a bullet in the lumbosacral spinal canal. Case report

In a patient wounded by a gunshot in the abdomen, the bullet was radiologically located intradurally at S1 level. Although she had no neurological deficit at admission, she developed pain and motor weakness a few days later. At operation the bullet was found at L4 level and its removal resulted in complete neurological recovery.

Clinical features of progressive lacunar infarction--retrospective analysis of patients with motor syndromes

The clinical features of progressive lacunar infarction were analyzed in 20 patients with lacunar infarction. Seven of the 20 patients experienced paresis progression and the remaining 13 patients had a stable course. The mean age of progressive lacunar infarction patients (78.6 +/- 4.30 yrs) was significantly higher than that of stable lacunar infarction patients (65.1 +/- 7.68 yrs) (p < 0.01). Patients presenting with pure motor stroke were more likely to have progressive stroke (7/13) than those presenting with sensorimotor stroke (0/7) (p < 0.05). Paresis aggravation began on Day 1 and ceased on Day 2 in most patients. Progressive paresis began to improve after reaching the nadir. Hemiparesis was only slightly worse after 1 month compared with that on admission. Older patients are more likely to have a progressive course. Paresis progression in lacunar patients does not preclude the possibility of recovery and is not necessarily associated with a poor prognosis.

Cerebral gigantism (Sotos' syndrome). A rare cause of delayed walking and awkward gait

A case history of an 8-year-old girl with cerebral gigantism (Sotos' syndrome) has been presented. Throughout her life, this child has demonstrated all of the common features of Sotos' syndrome including large size at birth, excessive growth during childhood, dysmorphic craniofacial features, delay in motor and speech development, generalized clumsiness, and awkward gait. Family history was contributory with delays in early language development and the possibility that the child's father had Sotos' syndrome. When evaluating a pediatric patient for pes planus, delayed walking, and gait problems, the practitioner should consider the entire clinical profile and unusual etiologies.

[A case of astrocytoma of corpus callosum presented diagnostic dyspraxia]

A case of astrocytoma whose first clinical presentation was diagnostic dyspraxia was reported. A 38-year-old right-handed male experienced funny motion of his left hand triggered by voluntary movement of his right hand. One day, he tried to insert a coin into the vending machine with his right hand, then the left hand was against the other. One month after that event, he experienced headache and vertigo. On admission, there were no abnormal findings on neurological examination. On neuropsychological examination, he was cooperative, well orientated and attentive, and there were no callosal disconnection symptoms. Frontal lobe function tests were slightly impaired. T1-weighted MRI demonstrated irregular mixed signal intensity mass lesion extending from the genu to the body of the corpus callosum and the cingulate gyrus. This lesion was slightly enhanced with Gd-DTPA. Biopsy was performed and histological diagnosis was fibrillary astrocytoma. After irradiation and chemotherapy, he was discharged from the hospital without evident neurological deficit. About 20 cases of diagnostic dyspraxia have been reported and almost all of them were caused by cerebro-vascular disease. This is the first case of brain tumor who presented diagnostic dyspraxia.

[Neurological involvements with transient gait disturbance in subacute phase of Kawasaki disease; a case report]

A 1-year-and-9-months old boy with gait disturbance during the 3rd week of Kawasaki disease (KD) was described. He had been previously healthy, and developed high fever and rash. The diagnosis of KD was based on 5 of 6 major criteria on the 3rd clinical day. He was initially treated with intravenous gamma-globulin 400 mg/kg/day for five days. On the 17th clinical day, the patient developed gait disturbance after most clinical signs disappeared. His gait was wide- based and unstable. Generalized hypotonia with poor traction response was also seen. Pyramidal tract signs including exaggerated patellar and Achilles tendon reflexes and positive bilateral Mendel-Bechterew reflex were presented. Cerebrospinal fluid was normal. Brain CT, MRI, and 123I-IMP SPECT images were normal without broad hemorrhage or infarction of the cerebral parenchyma. Gait disturbance recovered spontaneously within one month without any sequelae.

The cardiovascular outcome of patients with motor impairment and extensive leukoaraiosis

BACKGROUND AND METHODS

The long-term outcome of patients with motor impairment and extensive leukoaraiosis on computed tomographic scan is unknown. We studied the incidence of stroke, myocardial infarction, and death in 31 such patients (cases) and in 68 neurologic patients without leukoaraiosis (controls). The patients in both groups had a routine neurologic and cardiovascular assessment and were followed up for 51.9 +/- 20.1 (mean +/- SD) months (cases) and 49.5 +/- 18.6 months (controls).

RESULTS

The 6-year risk of cumulative stroke, as determined by life table analysis, was 49% among cases and 16% among controls (hazard ratio, 3.0; 95% confidence interval, 1.2 to 7.5). The risk of stroke or myocardial infarction was 69% vs 36% (hazard ratio, 2.9; 95% confidence interval, 1.4 to 6.2). The stroke risk remained significantly increased among cases after adjustment for age, sex, and any conventional vascular risk factor, while it was reduced (hazard ratio, 2.5; 95% confidence interval, 0.8 to 7.4) after adjustment for history of lacunar stroke was corrected for and was almost halved (hazard ratio, 1.6; 95% confidence interval, 0.5 to 4.6) after adjustment for the presence of lacunar infarction images on computed tomographic scan.

CONCLUSIONS

Patients with motor impairment and extensive leukoaraiosis have a very poor cardiovascular outcome. Lacunar infarction might be the major determinant of the outcome in these patients.

Hemiballismus: CT and MR findings

OBJECTIVE

Our aim was to determine the frequency with which a lesion responsible for hemiballismus was detectable on CT and MR examinations.

MATERIALS AND METHODS

The CT and MR examinations of six patients with hemiballismus were reviewed. Three patients underwent MRI alone, two CT alone, and one underwent both CT and MRI. Sites considered as possible locations for a lesion causing hemiballismus included the subthalamic nucleus on the side contralateral to the movements, contralateral putamen, caudate nucleus, thalamus, corpus striatum, lenticular nucleus, substantia nigra, and the premotor and motor cortex.

RESULTS

A lesion likely to account for hemiballismus was found in five patients (contralateral subthalamic nucleus in four patients, contralateral putamen in one patient). Causes of hemiballismus included infarction (one patient), hemorrhage (two patients), trauma (one patient), and an abscess (one patient). A responsible lesion was detected in all five patients who underwent MRI. In one patient who underwent CT alone, a responsible lesion was not identified.

CONCLUSION

A lesion responsible for hemiballistic movements can generally be found on cross-sectional imaging examinations. Because the multiplanar imaging capability of MR appears to allow for sensitive detection of even small lesions in sites likely to cause hemiballismus, MRI offers the best means of imaging these patients.

Photic headshaking in the horse: 7 cases

Seven horses with headshaking are described. No physical abnormalities were detected in any of the cases. Six of these horses had onset of clinical signs in the spring. The role of light was assessed by application of a blindfold or dark grey lens to the eyes, covering the eyes with a face mask and observing the horse in total darkness outdoors. Cessation of headshaking was observed with blindfolding (5/5 horses), night darkness outdoors (4/4 horses) and use of grey lenses (2/3 horses). Outdoor behaviour suggested efforts to avoid light in 4/4 cases. The photic sneeze in man is suggested as a putative mechanism for equine headshaking. Five of 7 horses had improvement with cyproheptadine treatment (0.3 mg/kg bwt b.i.d.). Headshaking developed within 2 calendar weeks of the same date for 3 consecutive years in one horse. Neuropharmacological alterations associated with photoperiod mechanisms leading to optic trigeminal summation are suggested as possible reasons for spring onset of headshaking.

Intracranial haemorrhage in a dobermann puppy with von Willebrand's disease

Neurological examination of a lethargic, ataxic 12-week-old dobermann revealed decreased conscious proprioception in all its limbs. Haematological examination revealed a low platelet count. Cytological examination of a sample of cerebrospinal fluid revealed evidence of haemorrhage and chronic inflammation. The levels of von Willebrand's factor antigen were extremely low. Skull radiographs were consistent with mild hydrocephalus. Treatment resulted in little clinical improvement and the animal was euthanased. Post mortem examination of the brain revealed an internal hydrocephalus with haemorrhage into the ventricles. It was considered that the animal had suffered severe intracranial haemorrhage as a result of its low level of von Willebrand's factor antigen and that the bleeding may have been potentiated by the low platelet count.

[Hemorrhage in cerebral cavernous hemangioma as a cause of hemiballismus]

A 19 year old righthanded woman, without previous neurological symptoms, was examined in April 1993, because of involuntary movements affecting especially the right hand, but also her right leg and the right side of her face. Magnetic Resonance Imagning (MRI), showed a process located in the area of the left subthalamic nucleus, which was recognized as a cavernous haemangioma. A left carotic arteriography in August was normal. The patient had a complete regression of her symptoms, wherefore there was no indication for neurosurgical intervention. The patient is still being followed without treatment.

Alien hand syndrome without a corpus callosum lesion

A 58 year old right handed woman developed a left alien hand syndrome after a right capsulothalamic haemorrhage with mesencephalic extension. No lesion was detected in the corpus callosum. Positron emission tomography suggested that right cortical dysfunction might account for the absence of recognition of the left hand whereas involuntary motor activity was attributed to the lesion itself. This case shows that the alien hand syndrome is not always the expression of a disconnection syndrome and may occur after a large, strategically located, posterior lesion.