551
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Huang YS, Tafti M, Guilleminault C. Daytime sleepiness with and without cataplexy in Chinese–Taiwanese patients. Sleep Med 2006; 7:454-7. [PMID: 16815745 DOI: 10.1016/j.sleep.2006.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Revised: 05/08/2006] [Accepted: 05/16/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Investigation of Chinese-Taiwanese patients with excessive sleepiness, but no association with other sleep disorders, and with the presence or absence of cataplexy. PATIENTS AND METHODS Thirty-five patients, successively referred between 2002 and 2004, underwent polysomnography (PSG), repeat multiple sleep latency test (MSLT), and human leukocyte antigen (HLA) typing. Three patients without cataplexy also had cerebrospinal fluid (CSF) hypocretin measurements. RESULTS DQB1*0602 was associated with cataplexy in over 90% of Chinese-Taiwanese cases. Absence of cataplexy and <2 sleep-onset REM periods (SOREMPs) was seen in only two subjects, but presence of two SOREMPs did not dissociate DQB1*0602 positive and negative or cataplexy positive and negative subjects. As a group, narcoleptics with cataplexy had a higher number of SOREMPs, and the mean sleep latency was much shorter in narcoleptics with cataplexy than in the non-cataplectic patients, independent of the number of SOREMPs. CONCLUSIONS Chinese-Taiwanese patients with cataplexy present with similar HLA findings as Black and Caucasian patients, but the presence of two or more SOREMPs in Chinese-Taiwanese patients is not a sufficient diagnostic tool to identify narcolepsy. When cataplexy is not present, description of PSG nd HLA findings may be a better approach than using a label with little scientific significance, allowing for better collection of patients' phenotype.
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Affiliation(s)
- Yu-shu Huang
- Sleep Disorders Clinic, Chang-Gung University Hospital, Taipei, Taiwan, ROC
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552
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Faraco JH, Appelbaum L, Marin W, Gaus SE, Mourrain P, Mignot E. Regulation of hypocretin (orexin) expression in embryonic zebrafish. J Biol Chem 2006; 281:29753-61. [PMID: 16867991 DOI: 10.1074/jbc.m605811200] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hypocretins/orexins are neuropeptides involved in the regulation of sleep and energy balance in mammals. Conservation of gene sequence, hypothalamic localization of cell bodies, and projection patterns in adult zebrafish suggest that the architecture and function of the hypocretin system are conserved in fish. We report on the complete genomic structure of the zebrafish and Tetraodon hypocretin genes and the complete predicted hypocretin protein sequences from five teleosts. Using whole mount in situ hybridization, we have traced the development of hypocretin cells in zebrafish from onset of expression at 22 h post-fertilization through the first week of development. Promoter elements of similar size from zebrafish and Tetraodon were capable of driving efficient and specific expression of enhanced green fluorescent protein in developing zebrafish embryos, thus defining a minimal promoter region able to accurately mimic the native hypocretin pattern. This enhanced green fluorescent protein expression also revealed a complex pattern of projections within the hypothalamus, to the midbrain, and to the spinal cord. To further analyze the promoter, a series of deletion and substitution constructs were injected into embryos, and resulting promoter activity was monitored in the first week of development. A critical region of 250 base pairs was identified containing a core 13-base pair element essential for hypocretin expression.
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Affiliation(s)
- Juliette H Faraco
- Stanford University Center for Narcolepsy, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California 94305, USA
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553
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Smit LS, Lammers GJ, Catsman-Berrevoets CE. Cataplexy leading to the diagnosis of Niemann-Pick disease type C. Pediatr Neurol 2006; 35:82-4. [PMID: 16814094 DOI: 10.1016/j.pediatrneurol.2005.12.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Revised: 11/17/2005] [Accepted: 12/28/2005] [Indexed: 10/24/2022]
Abstract
Cataplexy in childhood is a rare and often misdiagnosed symptom. It is described as a brief episode of bilateral loss of muscle tone with intact consciousness, triggered by a variety of strong emotions and in particular with unexpected laughter. This report presents a 9-year old male with progressive cerebellar and pyramidal symptoms and a cognitive decline since the age of 4. His recently developed "drop attacks" on laughter were recognized as cataplexy and led to the diagnosis of Niemann-Pick type C disease. With biochemical studies this diagnosis, a lysosomal storage disease, was confirmed. With cataplexy narcolepsy, Niemann-Pick type C disease, Norrie disease, Prader-Willi syndrome, and Coffin-Lowry syndrome are associated disorders. Recognition of cataplexy in children with concomitant neurologic symptoms may lead to an early and straight diagnosis of one of these disorders.
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Affiliation(s)
- Liesbeth S Smit
- Department of Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.
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554
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Ferracci F, Carnevale A. The neurological disorder associated with thyroid autoimmunity. J Neurol 2006; 253:975-84. [PMID: 16786216 DOI: 10.1007/s00415-006-0170-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 01/30/2006] [Indexed: 01/18/2023]
Abstract
The neurological disorder associated with thyroid autoimmunity is an elusive disease that neurologists have learned to recognize in the last few years. The diagnosis is made, after excluding more common diseases, when neuropsychiatric symptoms develop in a patient with high serum concentrations of anti-thyroid antibodies. The clinical presentations of the disease and the many controversial issues surrounding the diagnosis, the pathogenesis, the role of thyroid autoantibodies, and the choice of therapy are reviewed and discussed in the light of the medical literature in English.
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Affiliation(s)
- Franco Ferracci
- Divisione di Neurologia, Ospedale San Martino, Viale Europa, 32100 Belluno, Italy.
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555
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Arias-Carrión O, Drucker-Colín R, Murillo-Rodríguez E. Survival rates through time of hypocretin grafted neurons within their projection site. Neurosci Lett 2006; 404:93-7. [PMID: 16762505 DOI: 10.1016/j.neulet.2006.05.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 04/07/2006] [Accepted: 05/08/2006] [Indexed: 11/16/2022]
Abstract
Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness, inadvertent transitions from wakefulness to rapid eye movement sleep (so called "sleep-onset REMS period") and cataplexy (sudden bilateral skeletal muscle weakness during waking without impairment of consciousness). This disorder has been recently linked to a loss of hypocretin (HCRT) neurons making narcolepsy a neurodegenerative disease. Neuronal replacement could be used to reverse the symptoms of narcolepsy. Towards this end, we have recently reported that HCRT neurons from rat pups can survive when grafted into the pons of adult rats. Here, we investigate the time-course of survival of grafted HCRT neurons into the pons of adult rats. The HCRT neurons are present only in the lateral hypothalamus, and therefore suspension of cells from this region was derived from 8- to 10-day-old rat pups (donor), and grafted into the pons of adult (60 days old) host rats. Control rats received a transplant that consisted of cells from the cerebellum where no HCRT neurons are present. All adult host rats were sacrificed 1, 3, 6, 9, 12, 24, or 36 days after grafting. Immunohistochemistry was used to identify and count the presence of the HCRT grafted neurons in the target area. The tally of HCRT neurons present in the graft zone 1 day post-grafting was considered to be the baseline. From day 3 to 36 post-transplant there was a steady decline in the number of HCRT neurons. We also noted that on day 36, the HCRT neurons that survived in the pons had morphological features that were similar to mature HCRT neurons in the adult lateral hypothalamus, suggesting that these neurons might be functionally active. Control rats that received grafts of cerebellar tissue did not show HCRT neurons in the target area. These results demonstrate that there is a progressive decline in the number of transplanted neurons, but a significant percentage of HCRT neurons do survive until day 36. This study highlights the potential use of transplants as a therapeutical tool in order to treat narcolepsy.
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Affiliation(s)
- Oscar Arias-Carrión
- Depto. de Neurociencias/Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Circuito Interior, Ciudad Universitaria, México DF, México
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556
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Paquereau J. Comment différencier le SAS des autres causes de somnolence ? Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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557
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KANEKO Y, KANBAYASHI T, ARII J, KONDO H, KUBOTA H, HAYASHI-OGAWA Y, MIYAKOSHI N, YANO T, MISHIMA K, SHIMIZU T. CSF hypocretin-1 measurement in pediatric and teenage patients with sleep disorders. Sleep Biol Rhythms 2006. [DOI: 10.1111/j.1479-8425.2006.00217.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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558
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Abstract
SUMMARY A young man, in whom narcolepsy was subsequently diagnosed, had the simultaneous onset of quadriparesis and a rapid eye movement (REM)-sleep polysomnographic pattern. During this REM-sleep pattern, a waking alpha EEG rhythm, appearing when he was asked to close his eyes, immediately attenuated when he was instructed to open his eyes, after which the REM-sleep pattern persisted. The juxtaposition of REM sleep patterns and reactive alpha rhythms are likely unique to sleep paralysis and may prove valuable in diagnosing narcolepsy.
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Affiliation(s)
- Mark Eric Dyken
- Department of Neurology, Sleep Disorders Center, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA.
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559
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MIYATA R, HASEGAWA T, SHIMOHIRA M, KOHYAMA J, KANBAYASHI T. Hypocretin-1 levels in Angelman syndrome. Sleep Biol Rhythms 2006. [DOI: 10.1111/j.1479-8425.2006.00215.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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560
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Abstract
This article reviews nine case studies of patients presenting with sleep complaints.
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Affiliation(s)
- Mark W Mahowald
- Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
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561
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Abstract
Narcolepsy is a rare neurologic sleep disorder with morbidity associated with functional impairment and frequent delay in diagnosis. Symptoms typically manifest in adolescence or early adulthood, but diagnosis of narcolepsy has been reported in early childhood. Diagnosis rates are as low as 50% of the total population of patients with narcolepsy and are delayed as much as 10 years after disease onset due to inadequate patient-physician communication and/or misdiagnosis. I present the complexity of diagnosing narcolepsy in early childhood in a patient with cataplexy that started soon after independent ambulation at age 10 months.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, University of Wisconsin Medical School, Clinical Sciences Center, Madison, WI 53792, USA
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562
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Bassetti CL, Hersberger M, Baumann CR. CSF prostaglandin D synthase is reduced in excessive daytime sleepiness. J Neurol 2006; 253:1030-3. [PMID: 16598611 DOI: 10.1007/s00415-006-0153-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 01/06/2006] [Accepted: 01/24/2006] [Indexed: 01/12/2023]
Abstract
Lipocalin-type prostaglandin D synthase (L-PGDS) is a brain enzyme, which produces prostaglandin D(2), a substance with endogenous somnogenic effects. Using a standardized protocol for immunonephelometric determination of cerebrospinal fluid (CSF) L-PGDS levels, we show that CSF L-PGDS levels are significantly lower in 34 patients with excessive daytime sleepiness when compared with levels in 22 healthy controls. Thus, L-PGDS may represent the first neurochemical measure of excessive daytime sleepiness.
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Affiliation(s)
- Claudio L Bassetti
- Department of Neurology, Universitätsspital Zürich, Frauenklinikstrasse 26, 8091 Zürich, Switzerland.
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563
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Abstract
Hypersomnia includes a group of disorders in which the primary complaint is excessive daytime sleepiness. Chronic hypersomnia is characterized by at least 3 months of excessive sleepiness prior to diagnosis and may affect 4% to 6% of the population. The severity of daytime sleepiness needs to be quantified by subjective scales (at least the Epworth sleepiness scale) and objective tests such as the multiple sleep latency test. Chronic hypersomnia does not correspond to an individual clinical entity but includes numerous different etiologies of hypersomnia as recently reported in the revised International Classification of Sleep Disorders. This review details most of those disorders, including narcolepsy with and without cataplexy, idiopathic hypersomnia with and without long sleep time, recurrent hypersomnia, behaviorally induced insufficient sleep syndrome, hypersomnia due to medical condition, hypersomnia due to drug or substance, hypersomnia not due to a substance or known physiologic condition, and also sleep-related disordered breathing and periodic leg movement disorders.
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Affiliation(s)
- Yves Dauvilliers
- Neurology Department, Gui de Chauliac Hospital, 80 Avenue Augustin Fliche, INSERM E0361 34295, Montpellier, Cedex 5, France.
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564
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Xi MC, Chase MH. Neuronal mechanisms of active (rapid eye movement) sleep induced by microinjections of hypocretin into the nucleus pontis oralis of the cat. Neuroscience 2006; 140:335-42. [PMID: 16533574 DOI: 10.1016/j.neuroscience.2006.01.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 01/18/2006] [Accepted: 01/26/2006] [Indexed: 10/24/2022]
Abstract
Hypocretinergic (orexinergic) neurons in the hypothalamus project to the nucleus pontis oralis, a nucleus which plays a crucial role in the generation of active (rapid eye movement) sleep. We recently reported that the microinjection of hypocretin into the nucleus pontis oralis of chronically-instrumented, unanesthetized cats induces a behavioral state that is comparable to naturally-occurring active sleep. The present study examined the intracellular signaling pathways underlying the active sleep-inducing effects of hypocretin. Accordingly, hypocretin-1, a protein kinase C inhibitor and a protein kinase A inhibitor were injected into the nucleus pontis oralis in selected combinations in order to determine their effects on sleep and waking states of chronically instrumented, unanesthetized cats. Microinjections of hypocretin-1 into the nucleus pontis oralis elicited active sleep with a short latency. However, a pre-injection of bisindolylmaleimide-I, a protein kinase C-specific inhibitor, completely blocked the active sleep-inducing effects of hypocretin-1. The combined injection of bisindolylmaleimide-I and hypocretin-1 significantly increased the latency to active sleep induced by hypocretin-1; it also abolished the increase in the time spent in active sleep induced by hypocretin-1. On the other hand, the injection of 2'5'-dideoxyadenosine, an adenylyl cyclase inhibitor, did not block the occurrence of active sleep by hypocretin-1. We conclude that the active sleep-inducing effect of hypocretin in the nucleus pontis oralis is mediated by intracellular signaling pathways that act via G-protein stimulation of protein kinase C.
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Affiliation(s)
- M-C Xi
- WebSciences International, 1251 Westwood Boulevard, Los Angeles, CA 90024, USA
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565
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566
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Baumann CR, Khatami R, Werth E, Bassetti CL. Hypocretin (orexin) deficiency predicts severe objective excessive daytime sleepiness in narcolepsy with cataplexy. J Neurol Neurosurg Psychiatry 2006; 77:402-4. [PMID: 16484654 PMCID: PMC2077721 DOI: 10.1136/jnnp.2005.067207] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cerebrospinal fluid (CSF) hypocretin-1 deficiency is associated with definite ("clear cut") cataplexy in patients with narcolepsy. The relationship between CSF hypocretin-1 levels and other narcoleptic symptoms (including excessive daytime sleepiness, EDS) is not properly understood. In a consecutive series of 18 subjects with narcolepsy and definite cataplexy, patients with undetectable CSF hypocretin-1 (n = 12) were found to have significantly lower mean sleep latencies (p = 0.045) and a higher frequency of sleep onset REM periods (SOREMPs, p = 0.025) on multiple sleep latency test than patients (n = 6) with detectable levels. Conversely, Epworth sleepiness scale scores, the frequency of hallucinations/sleep paralysis, and the frequency and severity of cataplexy were similar in both groups. These results suggest that hypocretin deficiency identifies a homogenous group of patients with narcolepsy characterised by the presence of definite cataplexy, severe EDS, and frequent SOREMPs.
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Affiliation(s)
- C R Baumann
- Department of Neurology, University Hospital Zürich, Frauenklinikstrasse 26, 8091 Zürich, Switzerland
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567
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568
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569
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Abstract
Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness and cataplexy. The hypocretin/orexin deficiency is likely to be the key to its pathophysiology in most of cases although the cause of human narcolepsy remains elusive. Acting on a specific genetic background, an autoimmune process targeting hypocretin neurons in response to yet unknown environmental factors is the most probable hypothesis in most cases of human narcolepsy with cataplexy. Although narcolepsy presents one of the tightest associations with a specific human leukocyte antigen (HLA) (DQB1*0602), there is strong evidence that non-HLA genes also confer susceptibility. In addition to a point mutation in the prepro-hypocretin gene discovered in an atypical case, a few polymorphisms in monoaminergic and immune-related genes have been reported associated with narcolepsy. The treatment of narcolepsy has evolved significantly over the last few years. Available treatments include stimulants for hypersomnia with the quite recent widespread use of modafinil, antidepressants for cataplexy, and gamma-hydroxybutyrate for both symptoms. Recent pilot open trials with intravenous immunoglobulins appear an effective treatment of cataplexy if applied at early stages of narcolepsy. Finally, the discovery of hypocretin deficiency might open up new treatment perspectives.
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Affiliation(s)
- Yves Dauvilliers
- Service de Neurologie B, Hôpital Gui-de-Chauliac and INSERM E0361, Montpellier-France, and Center for Integrative Genomics, University of Lausanne, Lausanne-Dorigny, Switzerland.
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570
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Verhoeven WMA, Tuinier S. Prader–willi Syndrome: Atypical Psychoses and Motor Dysfunctions. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2006; 72:119-30. [PMID: 16697294 DOI: 10.1016/s0074-7742(05)72007-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Prader-Willi syndrome (PWS) is the result of a lack of expression of genes on the paternally derived chromosome 15q11-q13 and can be considered as a hypothalamic disorder. Its behavioral phenotype is characterized by ritualistic, stereotyped, and compulsive behaviors as well as motor abnormalities. After adolescence, recurrent affective psychoses are relatively frequent, especially in patients with uniparental disomy. These psychotic states have a subacute onset with complete recovery and comprise an increase of psychomotor symptoms that show resemblance with catatonia. Some evidence has emerged that gamma-aminobutyric acid (GABA) dysfunctionality is involved in both PWS and catatonia. Treatment of these atypical psychoses should preferably include GABA mimetic compounds like lorazepam, valproic acid, and possibly topiramate.
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571
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Abstract
Hypersomnia, a complaint of excessive daytime sleep or sleepiness, affects 4% to 6% of the population, with an impact on the everyday life of the patient Methodological tools to explore sleep and wakefulness (interview, questionnaires, sleep diary, polysomnography Multiple Sleep Latency Test, Maintenance of Wakefulness Test) and psy-chomotor tests (for example, psychomotor vigilance task and Oxford Sleep Resistance or Osier Test) help distinguish between the causes of hypersomnia. In this article, the causes of hypersomnia are detailed following the conventional classification of hypersomnic syndromes: narcolepsy, idiopathic hypersomnia, recurrent hypersomnia, insufficient sleep syndrome, medication- and toxin-dependent sleepiness, hypersomnia associated with psychiatric disorders, hypersomnia associated with neurological disorders, posttraumatic hypersomnia, infection (with a special emphasis on the differences between bacterial and viral diseases compared with parasitic diseases, such as sleeping sickness) and hypersomnia, hypersomnia associated with metabolic or endocrine diseases, breathing-related sleep disorders and sleep apnea syndromes, and periodic limb movements in sleep.
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Affiliation(s)
- Yves Dauvilliers
- Service de Neurologie B, Hôpital Gui-de-Chauliac, INSERM E0361, Montpellier, France
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572
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Abstract
The finding of orexin (hypocretin) deficiency in patients with narcolepsy suggests that this hypothalamic neuropeptide plays a crucial role in regulating and maintaining sleep/wakefulness states and energy homeostasis. Orexin might be especially important for stabilization of behavioral states, because the major symptom in narcolepsy is instability of each behavioral state, which results in sleep/wakefulness fragmentation. The efferent and afferent systems of orexin neurons suggest interactions between these cells and arousal/sleep-wakefulness centers in the brainstem as well as important feeding centers in the hypothalamus. Electrophysiological studies have shown that orexin neurons are regulated by monoamines and acetylcholine as well as metabolic cues, including leptin, glucose, and ghrelin. Thus, orexin neurons have the requisite functional interactions with hypothalamic feeding pathways and monoaminergic/cholinergic centers, and provide a critical link between peripheral energy balance and the central mechanisms that coordinate sleep/wakefulness and motivated behavior such as food seeking.
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Affiliation(s)
- Takeshi Sakurai
- Department of Pharmacology, Institute of Basic Medical Sciences, University of Tsukuba, Ibaraki 305-8575, Japan.
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573
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Martínez-Rodríguez JE, Santamaria J. CSF markers in sleep neurobiology. Clin Chim Acta 2005; 362:12-25. [PMID: 15992787 DOI: 10.1016/j.cccn.2005.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Revised: 05/23/2005] [Accepted: 05/24/2005] [Indexed: 11/19/2022]
Abstract
The cerebrospinal fluid has been used in the study of normal and pathological conditions of the central nervous system for more than a century. CSF analysis has also been applied to the study of sleep and its disorders but methodological aspects have often limited the results. The discovery of the hypocretin system (also known as orexin system) and its involvement in the pathophysiology of narcolepsy has opened a new field in the diagnosis of hypersomnia by CSF analysis and has revived the interest on this subject in sleep medicine. Older and new lines of research involving CSF measurement of hypocretin and other neurotransmitters in sleep and its disorders are reviewed.
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Affiliation(s)
- Jose E Martínez-Rodríguez
- Neurology Service, Hospital Clínic de Barcelona and Institut d'Investigació Biomédica August Pi i Sunyer (IDIBAPS), C/Villarroel 170, Spain.
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574
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Abstract
Problems with sleep are one of the commonest reasons for seeking medical attention. Knowledge gained from basic research into sleep in animals has led to marked advances in the understanding of human sleep, with important diagnostic and therapeutic implications. At the same time, research guided by human sleep disorders is leading to important basic sleep concepts. For example, sleep may not be a global, but rather a local, brain phenomenon. Furthermore, contrary to common assumptions, wakefulness, rapid eye movement (REM) and non-REM sleep are not mutually exclusive states. This striking realization explains a fascinating range of clinical phenomena.
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Affiliation(s)
- Mark W Mahowald
- Minnesota Regional Sleep Disorders Center, and Department of Neurology, Hennepin County Medical Center, and University of MN Medical School, Minneapolis, Minnesota 55415, USA.
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575
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Abstract
The hypocretins (also called the orexins) are two neuropeptides derived from the same precursor whose expression is restricted to a few thousand neurons of the lateral hypothalamus. Two G-protein coupled receptors for the hypocretins have been identified, and these show different distributions within the central nervous system and differential affinities for the two hypocretins. Hypocretin fibers project throughout the brain, including several areas implicated in regulation of the sleep/wakefulness cycle. Central administration of synthetic hypocretin-1 affects blood pressure, hormone secretion and locomotor activity, and increases wakefulness while suppressing rapid eye movement sleep. Most human patients with narcolepsy have greatly reduced levels of hypocretin peptides in their cerebral spinal fluid and no or barely detectable hypocretin-containing neurons in their hypothalamus. Multiple lines of evidence suggest that the hypocretinergic system integrates homeostatic, metabolic and limbic information and provides a coherent output that results in stability of the states of vigilance.
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Affiliation(s)
- Luis de Lecea
- Department of Molecular Biology, The Scripps Research Institute, La Jolla, CA 92037, USA.
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576
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Abstract
Excessive daytime somnolence is a prevalent problem in medical practice and in society. It exacts a great toll in quality of life, personal and public safety, and productivity. The causes of EDS are myriad, and careful evaluation is needed to determine the cause in each case. Although much progress has been made in discovering the pathophysiology of narcolepsy, much more remains to be understood, and far less is known about other primary conditions of EDS. Several methods have been developed to assess EDS, although each of them has limitations. Treatment is available for the great majority of cases.
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Affiliation(s)
- Jed E Black
- Stanford Sleep Disorders Center, Sleep Medicine Division, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
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577
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Meier A, Mollenhauer B, Cohrs S, Rodenbeck A, Jordan W, Meller J, Otto M. Normal hypocretin-1 (orexin-A) levels in the cerebrospinal fluid of patients with Huntington's disease. Brain Res 2005; 1063:201-3. [PMID: 16263095 DOI: 10.1016/j.brainres.2005.09.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 09/20/2005] [Accepted: 09/25/2005] [Indexed: 10/25/2022]
Abstract
A significant atrophy and loss of hypocretin neurons in the brains of human patients with Huntington's disease (HD) and in R6/2 mice have been reported. We included 10 patients with HD and 12 patients with chorea-like hyperkinetic movement disorders (non-HD). All patients of the HD group and eleven patients of the non-HD group showed normal hypocretin-1 levels. Thus, hypocretin-1 may not serve as an additional diagnostic marker for HD.
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Affiliation(s)
- Andreas Meier
- Department of Psychiatry and Psychotherapy, Sleep Disorders Center, Georg-August-University, von-Siebold-Strasse 5, 37075 Goettingen, Germany.
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578
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Arnulf I, Zeitzer JM, File J, Farber N, Mignot E. Kleine-Levin syndrome: a systematic review of 186 cases in the literature. ACTA ACUST UNITED AC 2005; 128:2763-76. [PMID: 16230322 DOI: 10.1093/brain/awh620] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Kleine-Levin syndrome (KLS) is a rare disorder with symptoms that include periodic hypersomnia, cognitive and behavioural disturbances. Large series of patients are lacking. In order to report on various KLS symptoms, identify risk factors and analyse treatment response, we performed a systematic review of 195 articles, written in English and non-English languages, which are available on Medline dating from 1962 to 2004. Doubtful or duplicate cases, case series without individual details and reviews (n = 56 articles) were excluded. In addition, the details of 186 patients from 139 articles were compiled. Primary KLS cases (n = 168) were found mostly in men (68%) and occurred sporadically worldwide. The median age of onset was 15 years (range 4-82 years, 81% during the second decade) and the syndrome lasted 8 years, with seven episodes of 10 days, recurring every 3.5 months (median values) with the disease lasting longer in women and in patients with less frequent episodes during the first year. It was precipitated most frequently by infections (38.2%), head trauma (9%), or alcohol consumption (5.4%). Common symptoms were hypersomnia (100%), cognitive changes (96%, including a specific feeling of derealization), eating disturbances (80%), hypersexuality (43%), compulsions (29%), and depressed mood (48%). In 75 treated patients (213 trials), somnolence decreased using stimulants (mainly amphetamines) in 40% of cases, while neuroleptics and antidepressants were of poor benefit. Only lithium (but not carbamazepine or other antiepileptics) had a higher reported response rate (41%) for stopping relapses when compared to medical abstention (19%). Secondary KLS (n = 18) patients were older and had more frequent and longer episodes, but had clinical symptoms and treatment responses similar to primary cases. In conclusion, KLS is a unique disease which may be more severe in female and secondary cases.
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Affiliation(s)
- I Arnulf
- Stanford University Center for Narcolepsy, Palo Alto, CA, USA.
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579
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Mahmood M, Black J. Narcolepsy-cataplexy: how does recent understanding help in evaluation and treatment. Curr Treat Options Neurol 2005; 7:363-71. [PMID: 16079041 DOI: 10.1007/s11940-005-0029-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Narcolepsy is a substantially disabling disease with profound physical, mental, and social effects. The burden on patients is compounded by delayed and missed diagnoses and by the subsequent undertreatment of narcolepsy and associated symptoms such as cataplexy. The recent advances in the elucidation of the genetics of canine narcolepsy and the pathophysiologic role of hypocretin, in animals and humans, enhances current diagnostic capability and will provide better treatment modalities in the future. The varied symptoms of narcolepsy are challenging to manage and may require treatment with a combination of agents. The recent development of a markedly enhanced characterization of sodium oxybate in the treatment of the excessive daytime sleepiness, nocturnal sleep fragmentation, and cataplexy of narcolepsy offers the potential of treating multiple symptoms simultaneously and marks a dramatic advance in the treatment of narcolepsy.
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Affiliation(s)
- Mujahid Mahmood
- Stanford Sleep Disorders Clinic, 401 Quarry Road, 3301, Stanford, CA 94305, USA.
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580
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Abstract
Since their discovery in 1998, the hypocretins (orexins)-peptides that are produced by a group of neurons situated in the posterolateral hypothalamus--have been shown to excite many CNS areas including many neuronal systems that regulate sleep and wakefulness. Animal studies indicate that hypocretins play a part in the regulation of various functions including arousal, muscle tone, locomotion, regulation of feeding behaviour, and neuroendocrine and autonomic functions. A link between hypocretin deficiency and narcoleptic symptoms was first shown in canine and rodent models of narcolepsy. Hypocretin deficiency, as shown by low or absent concentrations in CSF, was subsequently found in 90% of patients with sporadic narcolepsy-cataplexy, and less commonly in familial narcolepsy. In most other sleep-wake and neurological disorders, hypocretin concentrations are normal. Low concentrations were also found in hypothalamic disorders, acute traumatic brain injury, and a few other disorders. The exact function of the hypocretin system in sleep-wake regulation and its pathophysiological role in hypocretin-deficient and non-deficient narcolepsy as well as in non-narcoleptic, hypocretin-deficiency syndromes remain unclear.
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Affiliation(s)
- Christian R Baumann
- Department of Neurology, University Hospital, Frauenklinikstrasse 26, 8091 Zürich, Switzerland
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581
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Crocker A, España RA, Papadopoulou M, Saper CB, Faraco J, Sakurai T, Honda M, Mignot E, Scammell TE. Concomitant loss of dynorphin, NARP, and orexin in narcolepsy. Neurology 2005; 65:1184-8. [PMID: 16247044 PMCID: PMC2254145 DOI: 10.1212/01.wnl.0000168173.71940.ab] [Citation(s) in RCA: 212] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Narcolepsy with cataplexy is associated with a loss of orexin/hypocretin. It is speculated that an autoimmune process kills the orexin-producing neurons, but these cells may survive yet fail to produce orexin. OBJECTIVE To examine whether other markers of the orexin neurons are lost in narcolepsy with cataplexy. METHODS We used immunohistochemistry and in situ hybridization to examine the expression of orexin, neuronal activity-regulated pentraxin (NARP), and prodynorphin in hypothalami from five control and two narcoleptic individuals. RESULTS In the control hypothalami, at least 80% of the orexin-producing neurons also contained prodynorphin mRNA and NARP. In the patients with narcolepsy, the number of cells producing these markers was reduced to about 5 to 10% of normal. CONCLUSIONS Narcolepsy with cataplexy is likely caused by a loss of the orexin-producing neurons. In addition, loss of dynorphin and neuronal activity-regulated pentraxin may contribute to the symptoms of narcolepsy.
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Affiliation(s)
- A Crocker
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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582
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Arii J, Kanbayashi T, Tanabe Y, Sawaishi Y, Kimura S, Watanabe A, Mishima K, Hishikawa Y, Shimizu T, Nishino S. CSF hypocretin-1 (orexin-A) levels in childhood narcolepsy and neurologic disorders. Neurology 2005; 63:2440-2. [PMID: 15623725 DOI: 10.1212/01.wnl.0000147328.15956.b4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- J Arii
- Department of Pediatrics, Chiba Rosai Hospital, 2-16 Tatsumidai-Higashi, Ichihara-shi, Chiba 290-0003, Japan.
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583
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Abstract
The role of hypocretin (orexin) neurotransmission in waking and arousal, though of intense interest, is poorly understood. In this issue of Neuron, demonstrate that, in general, hypocretin neurons are minimally active during both sleep and quiet waking. In contrast, these neurons display robust activity during periods of alert and/or active waking.
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Affiliation(s)
- Craig W Berridge
- Psychology Department, University of Wisconsin, Madison, Wisconsin 53706, USA
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584
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Baumann CR, Bassetti CL. Hypocretins (orexins): clinical impact of the discovery of a neurotransmitter. Sleep Med Rev 2005; 9:253-68. [PMID: 15979356 DOI: 10.1016/j.smrv.2005.01.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hypothalamic excitatory hypocretin (orexin) neurons have been discovered in 1998 and found to have widespread projections to basal forebrain, monoaminergic and cholinergic brainstem, and spinal cord regions. The hypocretin system is influenced both neuronally (e.g. suprachiasmatic nucleus, GABAergic, cholinergic and aminergic brainstem nuclei) as well as metabolically (e.g. glucose, ghrelin, and leptin). Physiologically the hypocretin system has been implicated in the regulation of behaviours that are associated with wakefulness, locomotion, and feeding. A role in REM sleep, neuroendocrine, autonomic and metabolic functions has also been suggested. Pathophysiologically a deficient hypocretin neurotransmission has been found in human narcolepsy and (engineered) animal models of the disorder. Different mechanisms are involved including (1) degeneration of hypocretin neurons (mice), (2) hypocretin ligand deficiency (humans, mice, dogs), (3) hypocretin receptor deficiency (mice, dogs). Reports of low hypocretin-1 cerebrospinal fluid levels in neurologic conditions (e.g. Guillain-Barré syndrome, traumatic brain injury, hypothalamic lesions) with and without sleep-wake disturbances and, on the other hand, observations of normal levels in about 11% of narcoleptics raise questions about the exact nature and pathophysiological base of the link between hypocretin deficiency and clinical manifestations in human narcolepsy.
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Affiliation(s)
- Christian R Baumann
- Neurologische Klinik, Universitätsspital Zürich, Frauenklinikstrasse 26, CH-8091 Zürich, Switzerland
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585
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Nishino S, Kanbayashi T. Symptomatic narcolepsy, cataplexy and hypersomnia, and their implications in the hypothalamic hypocretin/orexin system. Sleep Med Rev 2005; 9:269-310. [PMID: 16006155 DOI: 10.1016/j.smrv.2005.03.004] [Citation(s) in RCA: 184] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Human narcolepsy is a chronic sleep disorder affecting 1:2000 individuals. The disease is characterized by excessive daytime sleepiness, cataplexy and other abnormal manifestations of REM sleep, such as sleep paralysis and hypnagogic hallucinations. Recently, it was discovered that the pathophysiology of (idiopathic) narcolepsy-cataplexy is linked to hypocretin ligand deficiency in the brain and cerebrospinal fluid (CSF), as well as the positivity of the human leukocyte antigen (HLA) DR2/DQ6 (DQB1*0602). The symptoms of narcolepsy can also occur during the course of other neurological conditions (i.e. symptomatic narcolepsy). We define symptomatic narcolepsy as those cases that meet the International Sleep Disorders Narcolepsy Criteria, and which are also associated with a significant underlying neurological disorder that accounts for excessive daytime sleepiness (EDS) and temporal associations. To date, we have counted 116 symptomatic cases of narcolepsy reported in literature. As, several authors previously reported, inherited disorders (n=38), tumors (n=33), and head trauma (n=19) are the three most frequent causes for symptomatic narcolepsy. Of the 116 cases, 10 are associated with multiple sclerosis, one case of acute disseminated encephalomyelitis, and relatively rare cases were reported with vascular disorders (n=6), encephalitis (n=4) and degeneration (n=1), and hererodegenerative disorder (three cases in a family). EDS without cataplexy or any REM sleep abnormalities is also often associated with these neurological conditions, and defined as symptomatic cases of EDS. Although it is difficult to rule out the comorbidity of idiopathic narcolepsy in some cases, review of the literature reveals numerous unquestionable cases of symptomatic narcolepsy. These include cases with HLA negative and/or late onset, and cases in which the occurrences of the narcoleptic symptoms are parallel with the rise and fall of the causative disease. A review of these cases (especially those with brain tumors), illustrates a clear picture that the hypothalamus is most often involved. Several cases of symptomatic cataplexy (without EDS) were also reported and in contrast, these cases appear to be often associated with non-hypothalamic structures. CSF hypocretin-1 measurement were also carried out in a limited number of symptomatic cases of narcolepsy/EDS, including narcolepsy/EDS associated with tumors (n=5), head trauma (n=3), vascular disorders (n=5), encephalopathies (n=3), degeneration (n=30), demyelinating disorder (n=7), genetic/congenital disorders (n=11) and others (n=2). Reduced CSF hypocretin-1 levels were seen in most symptomatic narcolepsy cases of EDS with various etiologies and EDS in these cases is sometimes reversible with an improvement of the causative neurological disorder and an improvement of the hypocretin status. It is also noted that some symptomatic EDS cases (with Parkinson diseases and the thalamic infarction) appeared, but they are not linked with hypocretin ligand deficiency. In contrast to idiopathic narcolepsy cases, an occurrence of cataplexy is not tightly associated with hypocretin ligand deficiency in symptomatic cases. Since CSF hypocretin measures are still experimental, cases with sleep abnormalities/cataplexy are habitually selected for CSF hypocretin measures. Therefore, it is still not known whether all or a large majority of cases with low CSF hypocretin-1 levels with CNS interventions, exhibit EDS/cataplexy. It appears that further studies of the involvement of the hypocretin system in symptomatic narcolepsy and EDS are helpful to understand the pathophysiological mechanisms for the occurrence of EDS and cataplexy.
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Affiliation(s)
- Seiji Nishino
- Center for Narcolepsy, Stanford University, Palo Alto, CA 94304, USA.
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586
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Cochen V, Arnulf I, Demeret S, Neulat ML, Gourlet V, Drouot X, Moutereau S, Derenne JP, Similowski T, Willer JC, Pierrot-Deseiligny C, Bolgert F. Vivid dreams, hallucinations, psychosis and REM sleep in Guillain–Barré syndrome. Brain 2005; 128:2535-45. [PMID: 16000335 DOI: 10.1093/brain/awh585] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We conducted a prospective controlled study of the clinical and biological determinants of the mental status abnormalities in 139 patients with Guillain-Barré syndrome (GBS) and 55 patients without GBS placed in the intensive care unit (ICU controls). There were mental status changes in 31% of GBS patients and in 16% of controls (odds ratio = 2.3; P = 0.04). In GBS patients, they included vivid dreams (19%), illusions (30%, including an illusory body tilt), hallucinations (60%, mainly visual) and delusions (70%, mostly paranoid). They appeared a median 9 days after disease onset (range 1-40 days, during the progression or the plateau of the disease), and lasted a median 8 days. Seven (16%) patients experienced the symptoms before their admission to the ICU. Hallucinations were frequently hypnagogic, occurring as soon as the patients closed their eyes. Autonomic dysfunction, assisted ventilation and high CSF protein levels were significant risk factors for abnormal mental status in GBS patients. CSF hypocretin-1 (a hypothalamic neuropeptide deficient in narcolepsy) levels, measured in 20 patients, were lower in GBS patients with hallucinations (555 +/- 132 pg/ml) than in those without (664 +/- 71 pg/ml, P = 0.03). Since the mental status abnormalities had dream-like aspects, we examined their association with rapid eye movement sleep (REM sleep) using continuous sleep monitoring in 13 GBS patients with (n = 7) and without (n = 6) hallucinations and 6 tetraplegic ICU controls without hallucinations. Although sleep was short and fragmented in all groups, REM sleep latency was shorter in GBS patients with hallucinations (56 +/- 115 min) than in GBS patients without hallucinations (153 +/- 130 min) and in controls (207 +/- 179 min, P < 0.05). In addition, sleep structure was highly abnormal in hallucinators, with sleep onset in REM sleep periods (83%), abnormal eye movements during non-REM sleep (57%), high percentages of REM sleep without atonia (92 +/- 22%), REM sleep behaviour disorders and autonomic dysfunction (100%), reminiscent of a status dissociatus. The sleep abnormalities, that were almost absent in non-hallucinated GBS patients, were not exclusively related to ICU conditions, since they also appeared out of ICU, and were reversible, disappearing when the mental status abnormalities vanished while the patients were still in ICU. In conclusion, the mental status abnormalities experienced by GBS patients are different from the ICU delirium, are strongly associated with autonomic dysfunction, severe forms of the disease and possibly with a transitory hypocretin-1 transmission decrease. Sleep studies suggest that mental status abnormalities are wakeful dreams caused by a sleep and dream-associated disorder (status dissociatus).
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Affiliation(s)
- V Cochen
- Fédération de Neurologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
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587
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Abstract
Pediatric sleep disorders represent a heterogeneous collection of disturbances that require varied intervention strategies. The diagnosis of some sleep disorders (eg, OSAS, narcolepsy, PLMD) require PSG, whereas others can be diagnosed during an office visit with a thorough medical,psychiatric, and sleep history. Sleep disorders place children at risk for school failure, accidents, and social problems, and can place a significant burden on families and the parent-child relationship.
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Affiliation(s)
- Philip K Capp
- Department of Neurology, Children's National Medical Center, 111 Michigan Avenue NW, George Washington University School of Medicine and Health Sciences, Washington, DC 20010-2970, USA
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588
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Abstract
Recent studies provide valid criteria that help differentiate idiopathic narcolepsy from other disorders of excessive daytime somnolence [3]. Research to date suggests that idiopathic narcolepsy might properly be considered a disorder of excessive sleepiness with dysfunctional REM-sleep mechanisms, clinically evidenced as cataplexy and electrophysiologically recognized as SOREMPs. Given these criteria, a diagnosis can generally be made using a combination of history, PSG, and MSLT. Traditionally, the medical treatment of idiopathic narcolepsy has centered on a two-drug regimen (stimulants for sleepiness and TCAs for cataplexy and auxiliary symptoms). Some newer medications are proving efficacious for sleepiness with minimal adverse effects, whereas others may provide a single-drug regimen that simultaneously addresses sleepiness and cataplexy [18]. New research has allowed some experts to hypothesize that idiopathic narcolepsy may be the result of a genetic predisposition to autoimmune disease [176]. It is possible that aberrant genetic coding of elements in the hypocretin/orexin systems allows a sensitivity to inducible and possibly virally mediated changes, which leave cells in the lateral hypothalamus susceptible to autoimmune attack [96]. As such, genetic screening of high-risk individuals might eventually rationalize the prophylactic use of immunosuppressants in some instances. In the future, for atypical cases(poorly responsive to therapy), genetic, CSF, and brain imaging studies, and possibly even neuronal transplantation may prove beneficial in the assessment and treatment of idiopathic narcolepsy.
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Affiliation(s)
- Mark E Dyken
- Department of Neurology, Sleep Disorders Center, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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589
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Stiller JW, Postolache TT. Sleep-wake and Other Biological Rhythms: Functional Neuroanatomy. Clin Sports Med 2005; 24:205-35, vii. [DOI: 10.1016/j.csm.2004.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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590
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Abstract
Orexins, which were initially identified as endogenous peptide ligands for two orphan G-protein coupled receptors (GPCRs), have been shown to have an important role in the regulation of energy homeostasis. Furthermore, the discovery of orexin deficiency in narcolepsy patients indicated that orexins are highly important factors for the sleep/wakefulness regulation. The efferent and afferent systems of orexin-producing neurons suggest interactions between these cells and arousal centers in the brainstem as well as important feeding centers in the hypothalamus. Electrophysiological studies have shown that orexin neurons are regulated by humoral factors, including leptin, glucose, and ghrelin as well as monoamines and acetylcholin. Thus, orexin neurons have functional interactions with hypothalamic feeding pathways and monoaminergic/cholinergic centers to provide a link between peripheral energy balance and the CNS mechanisms that coordinate sleep/wakefulness states and motivated behavior such as food seeking.
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Affiliation(s)
- Takeshi Sakurai
- Department of Pharmacology, Institute of Basic Medical Science, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan.
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591
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Abstract
Narcolepsy is characterised by excessive daytime sleepiness, usually associated with cataplexy, hypnagogic hallucinations, sleep paralysis and fragmented nocturnal sleep. Although uncommon, it results in significant disability. Most cases occur sporadically, but genetic factors probably form a susceptibility background on which unknown environmental triggers act. The hypocretin system is strongly implicated in the development of narcolepsy. Cerebrospinal fluid levels of hypocretin-1 are significantly reduced in narcoleptic subjects with cataplexy. Despite the advances in our understanding of narcolepsy, current therapy is primarily symptomatic. Stimulants (standard and novel) combat excessive daytime sleepiness. Antidepressants (tricyclics, dual-action or selective serotonin re-uptake inhibitors) and sodium oxybate are anticataplexy agents. Hypnagogic hallucinations and sleep paralysis respond to antidepressants. Sodium oxybate consolidates sleep. Novel and experimental treatments include histamine antagonists, hypocretin agonists, slow-wave sleep enhancers, intravenous gamma-globulin, tramadol and corticosteroids.
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Affiliation(s)
- Vivien C Abad
- Clinical Monitoring Sleep Disorders Center, Camino Medical Group, Cupertino, California, USA
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592
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Baumann C, Ferini-Strambi L, Waldvogel D, Werth E, Bassetti CL. Parkinsonism with excessive daytime sleepiness. J Neurol 2005; 252:139-45. [PMID: 15729517 DOI: 10.1007/s00415-005-0614-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Revised: 06/30/2004] [Accepted: 07/19/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Parkinsonian patients with excessive daytime sleepiness (EDS), hallucinations, REM sleep behavior disorder (RBD), short mean sleep latencies, and sleep-onset REM periods (SOREMP) on multiple sleep latency tests (MSLT) have been reported. In these patients a narcolepsy-like pathophysiology of sleep-wake disturbances has been suggested. PATIENTS AND METHODS We studied 14 consecutive patients with Parkinsonism and EDS. Standard studies included assessment of duration and severity of Parkinsonism (Hoehn & Yahr score), Epworth sleepiness score (ESS), history of "REM-symptoms" (RBD/hallucinations/sleep paralysis/cataplexy-like episodes), polysomnography (PSG), MSLT, and measurement of cerebrospinal fluid (CSF) levels of hypocretin-1 (orexin A). RESULTS There were 12 men and 2 women (mean age 69 years; range 54-82). The mean duration and the Hoehn&Yahr score were 6.3 years and 2.2, respectively. Diagnoses included idiopathic Parkinson's disease (IPD, n = 10), dementia with diffuse Lewy bodies (n = 3), and multisystem atrophy (n = 1). The ESS was > or = 10 in all patients (mean 12; range 10-18). "REM-symptoms" were reported by all but two patients (hallucinations: n = 9; RBD: n = 9). None of the patients reported cataplexy-like symptoms or sleep paralysis. On PSG sleep apnea (apnea hypopnea index > 10/h, n = 7), periodic limb movements during sleep (PLMS-index > 10/h, n = 6), and features of RBD (n = 5) were found. On MSLT mean sleep latency was < 5 minutes in 10 patients, and SOREMP were found in two patients. When compared with controls (n = 20, mean 497 pg/ml; range 350-603), CSF hypocretin-1 levels were normal in 8 patients and low in 2 patients (221 and 307 pg/ml, respectively). CONCLUSION These findings do not support the hypothesis of a "final common pathway" in the pathophysiology of narcolepsy and Parkinsonism with EDS. Sleep apnea and PLMS may play a so-far underestimated role in the pathogenesis of EDS in Parkinsonian patients.
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Affiliation(s)
- Christian Baumann
- Neurologische Poliklinik, Universitätsspital Zürich, Frauenklinikstrasse 26, 8091 Zürich, Switzerland
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593
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Iranzo A, Graus F, Clover L, Morera J, Bruna J, Vilar C, Martínez-Rodriguez JE, Vincent A, Santamaría J. Rapid eye movement sleep behavior disorder and potassium channel antibody-associated limbic encephalitis. Ann Neurol 2005; 59:178-81. [PMID: 16278841 DOI: 10.1002/ana.20693] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Of six patients registered in our center with nonparaneoplastic limbic encephalitis associated with antibodies to voltage-gated potassium channels, the five men had rapid eye movement sleep behavior disorder (RBD) coincident with voltage-gated potassium channel antibody-associated limbic encephalitis onset. In three patients, immunosuppression resulted in resolution of RBD in parallel with remission of the limbic syndrome. RBD persisted in two patients with partial resolution of the limbic syndrome. Our findings suggest that RBD is frequent in the setting of voltage-gated potassium channel antibody-associated limbic encephalitis and can be related to autoimmune-mediated mechanisms. In addition, these observations suggest that impairment of the limbic system may play a role in the pathogenesis of RBD.
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Affiliation(s)
- Alex Iranzo
- Neurology Service, Hospital Clínic and Institut d'Investigació Biomèdiques August Pi i Sunyer, C/Villaroel 170, 08036 Barcelona, Spain.
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594
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Nevsimalova S, Vankova J, Stepanova I, Seemanova E, Mignot E, Nishino S. Hypocretin deficiency in Prader-Willi syndrome. Eur J Neurol 2005; 12:70-2. [PMID: 15613151 DOI: 10.1111/j.1468-1331.2004.00969.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Four patients with clinically and genetically confirmed Prader-Willi syndrome (PWS) underwent nocturnal polysomnograpy (PSG), multiple sleep latency test (MSLT), human leukocyte antigens (HLA) typing and estimation of cerebrospinal fluid (CSF) hypocretin-1 (Hcrt-1) level to investigate if a role of hypothalamic dysfunction and sleep disturbance might be functionally connected through the hypocretin (orexin) system. In all four patients physical examination confirmed extreme obesity (increasing with age) with dysmorphogenetic features. Excessive daytime sleepiness (EDS) was manifested in only two subjects without any imperative feature. None of the patients under study suffered from cataplexy. Nocturnal PSG revealed fragmented sleep with low efficiency, the hypopnea and apnea indexes increasing from borderline up to very high values in direct proportion to the patients' age. MSLT latency was shortened in two patients with clinically expressed EDS, only one sleep onset rapid eye movements (REM) period (SOREM) was found. HLA typing showed DQB1*0602 positivity in two patients; the further two were negative. Mean value of CSF Hcrt-1 in the patients group was down to 164 +/- 46.8 pg/ml (in comparison with 265.8 +/- 48.8 pg/ml in 10 young healthy subjects, P=0.02). The deficiency of CSF Hcrt-1 level correlated in PWS patients with their EDS severity.
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Affiliation(s)
- S Nevsimalova
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic.
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595
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Dauvilliers Y, Cervena K, Carlander B, Espa F, Bassetti C, Claustrat B, Laplanche JL, Billiard M, Touchon J. Dissociation in circadian rhythms in a pseudohypersomnia form of fatal familial insomnia. Neurology 2004; 63:2416-8. [PMID: 15623717 DOI: 10.1212/01.wnl.0000147337.07987.ec] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors present clinical, sleep, and neuroendocrine features of a patient with genetically confirmed fatal familial insomnia (D178N mutation with heterozygosity at codon 129 of the prion protein gene). The patient exhibited pseudohypersomnia behavior instead of insomnia. There was profound alteration in the sleep-wake cycle with a clear dissociation in the disappearance of circadian and neuroendocrine rhythms, findings unrelated to abnormalities in the hypocretinergic system.
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Affiliation(s)
- Y Dauvilliers
- Service de Neurologie B, Hôpital Gui-de-Chauliac, 80 avenue Augustin Fliche, 34295 Montpellier Cedex 5, France.
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596
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Mochizuki T, Crocker A, McCormack S, Yanagisawa M, Sakurai T, Scammell TE. Behavioral state instability in orexin knock-out mice. J Neurosci 2004; 24:6291-300. [PMID: 15254084 PMCID: PMC6729542 DOI: 10.1523/jneurosci.0586-04.2004] [Citation(s) in RCA: 272] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Narcolepsy is caused by a lack of orexin (hypocretin), but the physiologic process that underlies the sleepiness of narcolepsy is unknown. Using orexin knock-out (KO) mice as a model of narcolepsy, we critically tested the three leading hypotheses: poor circadian control of sleep and wakefulness, inadequate activation of arousal regions, or abnormal sleep homeostasis. Compared with wild-type (WT) littermates, orexin KO mice had essentially normal amounts of sleep and wake, but wake and non-rapid eye movement (NREM) bouts were very brief, with many more transitions between all behavioral states. In constant darkness, orexin KO mice had normal amplitude and timing of sleep-wake rhythms, providing no evidence for disordered circadian control. When placed in a new, clean cage, both groups of mice remained awake for approximately 45 min, demonstrating that, even in the absence of orexin, fundamental arousal regions can be engaged to produce sustained wakefulness. After depriving mice of sleep for 2-8 hr, orexin KO mice recovered their NREM and rapid eye movement sleep deficits at comparable rates and to the same extent as WT mice, with similar increases in EEG delta power, suggesting that their homeostatic control of sleep is normal. These experiments demonstrate that the fragmented wakefulness of orexin deficiency is not a consequence of abnormal sleep homeostasis, poor circadian control, or defective fundamental arousal systems. Instead, the fragmented behavior of orexin KO mice may be best described as behavioral state instability, with apparently low thresholds to transition between states.
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Affiliation(s)
- Takatoshi Mochizuki
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02115, USA
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597
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Dauvilliers Y, Carlander B, Billiard M. La narcolepsie, de Westphal à l’hypocrétine. Presse Med 2004; 33:1593-600. [PMID: 15685112 DOI: 10.1016/s0755-4982(04)99000-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CLINICAL DATA Narcolepsy is a poorly known disease, though not exceptional, with a prevalence of 25 to 35 per 100,000 according to various surveys. Its onset can be anytime from childhood to the fifties with a peak in the second decade. It is characterized by two cardinal symptoms, irresistible sleep episodes and cataplexy or sudden loss of muscle tone triggered by emotional situations. The other symptoms, referred to as accessory due to their inconstancy, are hypnagogic hallucinations, sleep paralysis and disturbed nocturnal sleep. Its diagnosis relies on the identification of the cardinal symptoms. Laboratory tests are required to confirm the diagnosis before initiation of a life-long treatment. Theses test include: all-night and daytime polysomnography documenting sleep-onset REM periods, HLA typing, showing the association with HLA DQB1*0602, and, in unclear cases only, measurement of cerebro-spinal fluid (CSF) hypocretine-1 showing values below 110pg/ml, highly specific of narcolepsy with cataplexy. Pathophysiology owes a lot to the existence of a natural canine model, the narcoleptic dog. Irresistible sleep episodes and cataplexy exhibit different pharmacological control, the former depending on dopaminergic systems and the latter on noradrenergic systems. The most remarkable findings of the last twenty years are the close association with HLA DQB1*0602, the identification of a mutation of hypocretin receptor 2 in the narcoleptic dog and the absence of CSF hypocretin-1 in 90% of patients. An autoimmune mechanism is suggested but not evidenced. THREE-FOLD TREATMENT: First line treatment of irresistible sleep episodes in modafinil, Cataplexy or tricyclic antidepressants or sodium oxybate, and disturbed nocturnal sleep by hypnotics or sodium oxybate. Current therapeutic research is oriented towards hypocretin agonists and immunosuppressors.
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598
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Abstract
In the absence of a golden standard for the diagnosis of narcolepsy, the clinical spectrum of disorder remains controversial. The aims of this study were (1) to determine frequency and characteristics of sleep-wake symptoms in patients with narcolepsy with cataplexy, (2) to compare clinical characteristics with results of ancillary tests, and (3) to identify factors that discriminate narcolepsy from other conditions with excessive daytime sleepiness (EDS). We prospectively studied 57 narcoleptics with cataplexy, 56 patients with non-narcoleptic hypersomnia (H), and 40 normal controls (No). Based on suggested and published criteria, we differentiated between narcoleptics with definite cataplexy (N) and narcoleptics without definite cataplexy (possible cataplexy, NpC). Assessment consisted of questionnaires [all patients and controls, including the Ullanlinna Narcolepsy Score (UNS)], polysomnography (all patients), multiple sleep latency test (MSLT) and human leukocyte antigen typing (in most narcoleptics). A new narcolepsy score based on five questions was developed. Data were compared with those of 12 hypocretin-deficient narcoleptics (N-hd). There were significant differences between N and NpC (including mean sleep latency on MSLT), but none between N and N-hd. A score of sleep propensity during active situations (SPAS) and the frequency of sleep paralysis/hallucinations at sleep onset, dreams of flying, and history of sleep shouting discriminated N from H and No (P < 0.001). Cataplexy-like symptoms in H (18%) and No (8%) could be discriminated from 'true' cataplexy in N on the basis of topography of motor effects, triggering emotions and triggering situations (P < 0.001). Our narcolepsy score had a similar sensitivity (96% versus 98%) but a higher specificity (98% versus 56%) than the UNS. Analysis of co-occurring symptoms in narcolepsy revealed two symptom complexes: EDS, cataplexy, automatic behaviors; and sleep paralysis, hallucinations, parasomnias. Low/undetectable cerebrospinal fluid hypocretin-1 levels and a history of definite cataplexy identify similar subgroups of narcoleptics. Specific questions on severity of EDS (SPAS score) and characteristics of cataplexy allow the recognition of subgroups of narcoleptics and their differentiation from non-narcoleptic EDS patients, including those reporting cataplexy-like episodes. The existence of co-occurring symptoms supports the hypothesis of a distinct pathophysiology of single narcoleptic symptoms.
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599
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Dauvilliers Y, Carlander B, Rivier F, Touchon J, Tafti M. Successful management of cataplexy with intravenous immunoglobulins at narcolepsy onset. Ann Neurol 2004; 56:905-8. [PMID: 15562415 DOI: 10.1002/ana.20339] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hypocretin/orexin deficiency appears to be a consistent feature of narcolepsy with a putative autoimmune mechanism involved. We treated four hypocretin/orexin-deficient narcolepsy patients with intravenous immunoglobulins and assessed the efficacy by repeated polysomnographies and questionnaires. Three patients received the treatment within a few months after acute onset of narcolepsy. A clear improvement in the frequency and severity of cataplexy was obtained with a benefic effect up to 7 months without any anticataplectics drugs at follow-up. Our findings point to the importance of early diagnosis of narcolepsy, which once treated quickly may modify its long-term outlook.
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Affiliation(s)
- Yves Dauvilliers
- Service de Neurologie B, Hôpital Gui-de-Chauliac, Montpellier, France.
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600
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Petersén A, Gil J, Maat-Schieman MLC, Björkqvist M, Tanila H, Araújo IM, Smith R, Popovic N, Wierup N, Norlén P, Li JY, Roos RAC, Sundler F, Mulder H, Brundin P. Orexin loss in Huntington's disease. Hum Mol Genet 2004; 14:39-47. [PMID: 15525658 DOI: 10.1093/hmg/ddi004] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Huntington's disease (HD) is a devastating neurodegenerative disorder caused by an expanded CAG repeat in the gene encoding huntingtin, a protein of unknown function. Mutant huntingtin forms intracellular aggregates and is associated with neuronal death in select brain regions. The most studied mouse model (R6/2) of HD replicates many features of the disease, but has been reported to exhibit only very little neuronal death. We describe for the first time a dramatic atrophy and loss of orexin neurons in the lateral hypothalamus of R6/2 mice. Importantly, we also found a significant atrophy and loss of orexin neurons in Huntington patients. Like animal models and patients with impaired orexin function, the R6/2 mice were narcoleptic. Both the number of orexin neurons in the lateral hypothalamus and the levels of orexin in the cerebrospinal fluid were reduced by 72% in end-stage R6/2 mice compared with wild-type littermates, suggesting that orexin could be used as a biomarker reflecting neurodegeneration. Our results show that the loss of orexin is a novel and potentially very important pathology in HD.
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Affiliation(s)
- Asa Petersén
- Department of Physiological Sciences, Section for Neuronal Survival, Lund, Sweden.
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