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Tanimura J, Hashimoto T. Case of tizanidine withdrawal showing hallucination, decorticate posture and tremor, with hypersympathetic vital signs. BMJ Case Rep 2024; 17:e254966. [PMID: 38453230 PMCID: PMC10921490 DOI: 10.1136/bcr-2023-254966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
Tizanidine, an α2-adrenergic receptor agonist commonly prescribed as a muscle relaxant, has been associated with limited cases of acute intoxication or withdrawal. Here, we present a case of tizanidine withdrawal in a woman in her 40s who presented with an unusual combination of systemic and neurological symptoms. These included hallucinations, decorticate posture, limb and eyelid tremors, along with hypertension, tachycardia and tachypnoea. The diagnosis of tizanidine withdrawal was established by a comprehensive assessment of the patient's medical history and the systematic exclusion of other potential diseases. Our approach to managing the withdrawal symptoms was to initiate symptomatic treatment with a combination of a beta-blocker and a calcium channel blocker. Remarkably, this intervention successfully resolved both vital signs and neurological manifestations by the following day. In conclusion, tizanidine withdrawal is associated with a distinct and diagnostically significant neurological syndrome characterised by hallucinations, decorticate posture, tremors and hypersympathetic vital signs.
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Affiliation(s)
- Jun Tanimura
- Department of Neurology, Aizawa Hospital, Matsumoto, Japan
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Tsuda S, Golam M, Hou J, Nelson R, Bernavil P, Richardson K, Wang KKW, Thompson F, Bose P. Altered monoaminergic levels, spasticity, and balance disability following repetitive blast-induced traumatic brain injury in rats. Brain Res 2020; 1747:147060. [PMID: 32828734 PMCID: PMC10424094 DOI: 10.1016/j.brainres.2020.147060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/28/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022]
Abstract
Spasticity and balance disability are major complications following traumatic brain injury (TBI). Although monoaminergic inputs provide critical adaptive neuromodulations to the motor system, data are not available regarding the levels of monoamines in the brain regions related to motor functions following repetitive blast TBI (bTBI). The objective of this study was to determine if mild, repetitive bTBI results in spasticity/balance deficits and if these are correlated with altered levels of norepinephrine, dopamine, and serotonin in the brain regions related to the motor system. Repetitive bTBI was induced by a blast overpressure wave in male rats on days 1, 4, and 7. Following bTBI, physiological/behavioral tests were conducted and tissues in the central motor system (i.e., motor cortex, locus coeruleus, vestibular nuclei, and lumbar spinal cord) were collected for electrochemical detection of norepinephrine, dopamine, and serotonin by high-performance liquid chromatography. The results showed that norepinephrine was significantly increased in the locus coeruleus and decreased in the vestibular nuclei, while dopamine was significantly decreased in the vestibular nuclei. On the other hand, serotonin was significantly increased in the motor cortex and the lumbar spinal cord. Because these monoamines play important roles in regulating the excitability of neurons, these results suggest that mild, repetitive bTBI-induced dysregulation of monoaminergic inputs in the central motor system could contribute to spasticity and balance disability. This is the first study to report altered levels of multiple monoamines in the central motor system following acute mild, repetitive bTBI.
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Affiliation(s)
- Shigeharu Tsuda
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA; Department of Anesthesiology, College of Medicine, University of Florida, 1600 SW Archer Rd m509, Gainesville, FL 32610-0254, USA
| | - Mustafa Golam
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA; Department of Physiological Sciences, University of Florida, 1333 Center Dr, Gainesville, FL 32603, USA
| | - Jiamei Hou
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA; Department of Anesthesiology, College of Medicine, University of Florida, 1600 SW Archer Rd m509, Gainesville, FL 32610-0254, USA
| | - Rachel Nelson
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA
| | - Phillip Bernavil
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA
| | - Kenneth Richardson
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA
| | - Kevin K W Wang
- Department of Emergency Medicine, University of Florida, 1329 SW 16th Street, Suite 5270, Gainesville, FL 32610, USA
| | - Floyd Thompson
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA; Department of Physiological Sciences, University of Florida, 1333 Center Dr, Gainesville, FL 32603, USA; Department of Neuroscience, University of Florida, 1149 Newell Dr, Gainesville, FL 32610, USA
| | - Prodip Bose
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Rd, Gainesville 32608-1197, USA; Department of Anesthesiology, College of Medicine, University of Florida, 1600 SW Archer Rd m509, Gainesville, FL 32610-0254, USA; Department of Neurology, University of Florida, 1149 Newell Dr, Gainesville, FL 32611, USA.
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de Natale ER, Ginatempo F, Laccu I, Figorilli M, Manca A, Mercante B, Puligheddu M, Deriu F. Vestibular Evoked Myogenic Potentials Are Abnormal in Idiopathic REM Sleep Behavior Disorder. Front Neurol 2018; 9:911. [PMID: 30420831 PMCID: PMC6215837 DOI: 10.3389/fneur.2018.00911] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 10/09/2018] [Indexed: 11/30/2022] Open
Abstract
Objectives: To investigate brainstem function in idiopathic REM sleep Behavior Disorder (iRBD), a condition occurring as a result of a derangement of connections within brainstem structures, with a battery of Vestibular Evoked Myogenic Potentials (VEMPs), neurophysiological tools suited for the functional investigation of the brainstem. Neurophysiological data were correlated with clinical characteristics of patients. Methods: Twenty patients with iRBD and 22 healthy controls underwent cervical (cVEMP), masseter (mVEMP) and ocular (oVEMP) VEMP recording. Patients were assessed clinically according to presence of motor as well as non-motor symptoms such as constipation, depression, and hyposmia. Also, they were screened for postural instability through the Berg Balance Scale (BBS). VEMPs were categorized as for increasing degrees of abnormalities, namely latency delay, amplitude reduction and absence; a VEMP score was built accordingly. Results: Compared with controls, iRBD had higher rates of abnormalities both in the VEMP battery (iRBD 75%, Controls 23%; p < 0.01) as well as in each single VEMP (cVEMP: 45 vs. 5%; mVEMP: 65 vs. 13.6%; oVEMP: 50 vs. 5%; p < 0.01), which exhibited significantly lower amplitudes (cVEMP and oVEMP: p < 0.0001; mVEMP: p = 0.001) in iRBD. Within altered reflexes, absence was predominant in oVEMP (81%), amplitude reduction in mVEMP (50%) and cVEMP (70%). Severity of VEMP alterations was significantly higher in iRBD compared with controls (p < 0.05 for all VEMPs), as indicated by the larger VEMP scores in the former. The oVEMP score correlated inversely with poor performances on the BBS. Conclusion: VEMPs unveil consistent and extensive brainstem abnormalities in iRBD patients. Further studies are warranted for testing the potential of VEMPs in the monitoring of the evolution of iRBD over time.
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Affiliation(s)
| | | | - Ilaria Laccu
- Department of Medical Sciences and Public Health, Sleep Disorder Research Center, University of Cagliari, Cagliari, Italy
| | - Michela Figorilli
- Department of Medical Sciences and Public Health, Sleep Disorder Research Center, University of Cagliari, Cagliari, Italy
| | - Andrea Manca
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Beniamina Mercante
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Monica Puligheddu
- Department of Medical Sciences and Public Health, Sleep Disorder Research Center, University of Cagliari, Cagliari, Italy
| | - Franca Deriu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
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Barresi M, Grasso C, Licata F, Li Volsi G. Noradrenergic modulation of neuronal responses to n-methyl-d-aspartate in the vestibular nuclei: an electrophysiological and immunohistochemical study. Neuroscience 2014; 265:172-83. [PMID: 24508745 DOI: 10.1016/j.neuroscience.2014.01.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 01/23/2014] [Accepted: 01/29/2014] [Indexed: 01/06/2023]
Abstract
Excitatory responses evoked by N-methyl-d-aspartate (NMDA) in the vestibular nuclei (VN) of the rat were studied in vivo during microiontophoretic application of noradrenaline (NA) and/or its agonists and antagonists. Ejection of NA-modified excitatory responses mediated by NMDA receptors (NMDAR) in all neurons tested; the effect was enhancement in 59% of cases and depression in the remaining 41%. Enhancements prevailed in all VN with the exception of the lateral vestibular nucleus, where both effects were recorded in an equal number of cases. The enhancing action of NA on NMDAR-mediated responses was mimicked by the noradrenergic beta-receptor agonist isoproterenol, the beta1 specific agonist denopamine and the alpha2 agonist clonidine. These effects were blocked respectively by the generic beta-receptor antagonist timolol, the beta1 antagonist atenolol and the alpha2 antagonist yohimbine. In contrast, application of the alpha1 receptor agonist cirazoline and the specific alpha1 antagonist prazosin respectively mimicked and partially antagonized the depression of NMDAR-mediated excitations induced by NA. Double-labeling immunohistochemical techniques demonstrated broad colocalization of NMDAR (specifically NR1 and NR2 subunits) with noradrenergic receptors (alpha1, alpha2 and beta1) in many VN neurons; only minor differences were found between nuclei. These results indicate that NA can produce generalized modulation of NMDAR-mediated excitatory neurotransmission in VN, which may in turn modify synaptic plasticity within the nuclei.
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Affiliation(s)
- M Barresi
- Department of Biomedical Sciences, Section of Physiology, University of Catania, Italy.
| | - C Grasso
- Department of Biomedical Sciences, Section of Physiology, University of Catania, Italy.
| | - F Licata
- Department of Biomedical Sciences, Section of Physiology, University of Catania, Italy.
| | - G Li Volsi
- Department of Biomedical Sciences, Section of Physiology, University of Catania, Italy.
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