Vecuronium dose requirement and pupillary response in a patient with olivopontocerebellar atrophy (OPCA)

Eye tracking identifies biomarkers in α-synucleinopathies versus progressive supranuclear palsy

Objectives

This study (1) describes and compares saccade and pupil abnormalities in patients with manifest alpha-synucleinopathies (αSYN: Parkinson’s disease (PD), Multiple System Atrophy (MSA)) and a tauopathy (progressive supranuclear palsy (PSP)); (2) determines whether patients with rapid-eye-movement sleep behaviour disorder (RBD), a prodromal stage of αSYN, already have abnormal responses that may indicate a risk for developing PD or MSA.

Methods

Ninety (46 RBD, 27 PD, 17 MSA) patients with an αSYN, 10 PSP patients, and 132 healthy age-matched controls (CTRL) were examined with a 10-min video-based eye-tracking task (Free Viewing). Participants were free to look anywhere on the screen while saccade and pupil behaviours were measured.

Results

PD, MSA, and PSP spent more time fixating the centre of the screen than CTRL. All patient groups made fewer macro-saccades (> 2^◦ amplitude) with smaller amplitude than CTRL. Saccade frequency was greater in RBD than in other patients. Following clip change, saccades were temporarily suppressed, then rebounded at a slower pace than CTRL in all patient groups. RBD had distinct, although discrete saccade abnormalities that were more marked in PD, MSA, and even more in PSP. The vertical saccade rate was reduced in all patients and decreased most in PSP. Clip changes produced large increases or decreases in screen luminance requiring pupil constriction or dilation, respectively. PSP elicited smaller pupil constriction/dilation responses than CTRL, while MSA elicited the opposite.

Conclusion

RBD patients already have discrete but less pronounced saccade abnormalities than PD and MSA patients. Vertical gaze palsy and altered pupil control differentiate PSP from αSYN.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11136-5.

Anesthesia in a patient with multiple-system atrophy using a combination of rocuronium and sugammadex

Multiple-system atrophy is an adult-onset progressive neurodegenerative disease affecting the central nervous system, including the spinal cord. There has been no perioperative guideline of the muscle relaxants used in multiple-system atrophy, although a recent article recommends anesthesiologists to use shorter-acting drugs at the lowest possible doses in the patients. Here, we document the first case with multiple-system atrophy undergoing surgery managed with a combination of rocuronium and sugammadex. The recovery time to the train-of-four count 2 after intravenous rocuronium 0.6 mg / kg, or the time from the start of sugammadex 2 mg / kg intravenously to the train-of-four ratio over 0.9 was prolonged in our case more than 20 and 2 minutes compared with those in healthy subjects, respectively. Neuromuscular monitoring, in addition to the careful vigilance in the perioperative period, seems mandatory in the patients. J. Med. Invest. 68 : 381-382, August, 2021.

Pupillary dysfunction of multiple system atrophy: Dynamic pupillometric findings and clinical correlations

INTRODUCTION

Although autonomic dysfunction is the prominent clinical feature in multiple system atrophy (MSA), little is known about the pupillary autonomic aspect of MSA. We aimed to evaluate pupillary autonomic function in MSA patients using dynamic pupillometry, which can quantify the pupillary light reflex.

METHODS

Dynamic pupillometry parameters were compared in 21 MSA patients and 21 healthy controls. Pupillometric parameters were correlated with total Unified Multiple System Atrophy Rating Scale (UMSARS) scores and autonomic symptom severity.

RESULTS

Average constriction (p = 0.034) and dilation (p = 0.003) velocities were significantly slowed in MSA patients compared with controls. Total UMSARS correlated with the average constriction (r = -0.527, p = 0.017) and maximum constriction (r = -0.658, p = 0.003) velocities. Autonomic symptom severity correlated with average constriction (r = -0.544, p = 0.013), maximum constriction (r = -0.607, p = 0.005) and average dilation (r = -0.499, p = 0.025) velocities.

CONCLUSION

Dynamic pupillometry may provide useful information about pupillary autonomic dysfunction, which correlated with the clinical severity, in patients with MSA.

Visual signs and symptoms of multiple system atrophy

Multiple system atrophy (MSA) is a rare movement disorder and a member of the 'parkinsonian syndromes', which also include Parkinson's disease (PD), progressive supranuclear palsy (PSP), dementia with Lewy bodies (DLB) and corticobasal degeneration (CBD). Multiple system atrophy is a complex syndrome, in which patients exhibit a variety of signs and symptoms, including parkinsonism, ataxia and autonomic dysfunction. It can be difficult to separate MSA from the other parkinsonian syndromes but if ocular signs and symptoms are present, they may aid differential diagnosis. Typical ocular features of MSA include blepharospasm, excessive square-wave jerks, mild to moderate hypometria of saccades, impaired vestibular-ocular reflex (VOR), nystagmus and impaired event-related evoked potentials. Less typical features include slowing of saccadic eye movements, the presence of vertical gaze palsy, visual hallucinations and an impaired electroretinogram (ERG). Aspects of primary vision such as visual acuity, colour vision or visual fields are usually unaffected. Management of the disease to deal with problems of walking, movement, daily tasks and speech problems is important in MSA. Optometrists can work in collaboration with the patient and health-care providers to identify and manage the patient's visual deficits. A more specific role for the optometrist is to correct vision to prevent falls and to monitor the anterior eye to prevent dry eye and control blepharospasm.

Vecuronium in a patient with late cerebellar cortical atrophy

Little information is available regarding the sensitivity to neuromuscular blocking drugs in patients with spinocerebellar degeneration and associated diseases. We report the response to vecuronium in a patient with late cerebellar cortical atrophy, a nonhereditary type of cerebellar ataxia. Onset time and time to 25% recovery of T1/T0 after vecuronium 0.1 mg.kg(-1) under sevoflurane anesthesia were 156 seconds and 43 minutes, respectively. Recovery index was 27 minutes. We believe this is the first report describing a response to neuromuscular blocking drugs in this disease.

Movement disorder emergencies in the perioperative period

Movement disorder emergencies are uncommon in the perioperative period; however, when they occur, then carry significant morbidity. By paying attention to the phenomenology of the movement disorder, the effects of medications administered in the operating room, and unusual sequelae of surgery, neurologists can have a positive impact on the outcome of these patients.