Movement Disorders Following Cerebrovascular Lesion in the Basal Ganglia Circuit

Movement disorders following mechanical thrombectomy resulting in ischemic lesions of the basal ganglia: An emerging clinical entity

BACKGROUND AND PURPOSE

Post-stroke movement disorders (PMDs) following ischemic lesions of the basal ganglia (BG) are a known entity, but data regarding their incidence are lacking. Ischemic strokes secondary to proximal middle cerebral artery (MCA) occlusion treated with thrombectomy represent a model of selective damage to the BG. The aim of this study was to assess the prevalence and features of movement disorders after selective BG ischemia in patients with successfully reperfused acute ischemic stroke (AIS).

METHODS

We enrolled 64 consecutive subjects with AIS due to proximal MCA occlusion treated with thrombectomy. Patients were clinically evaluated by a movement disorders specialist for PMDs onset at baseline, and after 6 and 12 months.

RESULTS

None of the patients showed an identifiable movement disorder in the subacute phase of the stroke. At 6 and 12 months, respectively, 7/25 (28%) and 7/13 (53.8%) evaluated patients developed PMDs. The clinical spectrum of PMDs encompassed parkinsonism, dystonia and chorea, either isolated or combined. In most patients, symptoms were contralateral to the lesion, although a subset of patients presented with bilateral involvement and prominent axial signs.

CONCLUSION

Post-stroke movement disorders are not uncommon in long-term follow-up of successfully reperfused AIS. Follow-up conducted by a multidisciplinary team is strongly advisable in patients with selective lesions of the BG after AIS, even if asymptomatic at discharge.

Glucocorticoid receptor antagonist CORT113176 attenuates motor and neuropathological symptoms of Huntington's disease in R6/2 mice

Huntington's Disease (HD) is a progressive neurodegenerative disease caused by a mutation in the huntingtin gene. The mutation leads to a toxic gain of function of the mutant huntingtin (mHtt) protein resulting in cellular malfunction, aberrant huntingtin aggregation and eventually neuronal cell death. Patients with HD show impaired motor functions and cognitive decline. Elevated levels of glucocorticoids have been found in HD patients and in HD mouse models, and there is a positive correlation between increased glucocorticoid levels and the progression of HD. Therefore, antagonism of the glucocorticoid receptor (GR) may be an interesting strategy for the treatment of HD. In this study, we evaluated the efficacy of the selective GR antagonist CORT113176 in the commonly used R6/2 mouse model. In male mice, CORT113176 treatment significantly delayed the loss of grip strength, the development of hindlimb clasping, gait abnormalities, and the occurrence of epileptic seizures. CORT113176 treatment delayed loss of DARPP-32 immunoreactivity in the dorsolateral striatum. It also restored HD-related parameters including astrocyte markers in both the dorsolateral striatum and the hippocampus, and microglia markers in the hippocampus. This suggests that CORT113176 has both cell-type and brain region-specific effects. CORT113176 delayed the formation of mHtt aggregates in the striatum and the hippocampus. In female mice, we did not observe major effects of CORT113176 treatment on HD-related symptoms, with the exception of the anti-epileptic effects. We conclude that CORT113176 effectively delays several key symptoms related to the HD phenotype in male R6/2 mice and believe that GR antagonism may be a possible treatment option.

Hemichorea in patients with temporal lobe infarcts: Two case reports

BACKGROUND

Hemichorea and other hyperkinetic movement disorders are uncommon presentations of stroke and are usually secondary to deep infarctions affecting the basal ganglia and thalamus. Therefore, temporal ischemic lesions causing hemichorea are rare. We report the cases of two patients with acute ischemic temporal lobe infarct strokes that presented as hemichorea.

CASE SUMMARY

Patient 1: An 82-year-old woman presented with a 1-mo history of involuntary movement of the left extremity, which was consistent with hemichorea. Her diffusion-weighted imaging (DWI) revealed an acute ischemic stroke that predominantly affected the right temporal cortex, and magnetic resonance angiography of the head showed significant stenosis of the right middle cerebral artery (MCA). Treatment with 2.5 mg of olanzapine per day was initiated. When she was discharged from the hospital, her symptoms appeared to have improved compared with those previously observed. Twenty-seven days after the first admission, she was readmitted due to acute ischemic stroke. Computed tomography perfusion showed marked hypoperfusion in the right MCA territory. An emergency transfemoral cerebral angiogram was performed and showed severe stenosis in the M1 segment of the right MCA. After percutaneous transluminal angioplasty was successfully performed, abnormal movements or other neurologic problems did not occur. Patient 2: A 76-year-old man was admitted to our hospital for a 7-d history of right-upper-sided involuntary movements. DWI showed an acute patchy ischemic stroke in the left temporal lobe without basal ganglia involvement. Subsequent diffusion tensor imaging confirmed fewer white matter fiber tracts on the left side than on the opposite side. Treatment with 2.5 mg of olanzapine per day improved his condition, and he was discharged.

CONCLUSION

When acute hemichorea suddenly appears, temporal cortical ischemic stroke should be considered a possible diagnosis. In addition, hemichorea may be a sign of impending cerebral infarction with MCA stenosis.

Late-onset, first-ever involuntary movement after successful surgical revascularization for pediatric moyamoya disease - Report of two cases

Background

A small number of children with Moyamoya disease develop involuntary movements as an initial presentation at the onset, which usually resolves after effective surgical revascularization. However, involuntary movements that did not occur at the onset first occur after surgery in very rare cases. In this report, we describe two pediatric cases that developed involuntary movements during the stable postoperative period after successful surgical revascularization.

Case Description

A 10-year-old boy developed an ischemic stroke and successfully underwent combined bypass surgery. However, he developed chorea six months later. Another 8-year-old boy developed a transient ischemic attack and successfully underwent combined bypass surgery. However, he developed chorea three years later. In both cases, temporary use of haloperidol was quite effective in resolving the symptoms, and involuntary movements did not recur without any medication during follow-up periods of up to 10 years.

Conclusion

Postoperative first-ever involuntary movement is very rare in pediatric moyamoya disease, and the underlying mechanisms are still unclear, but a temporary, reversible imbalance of excitatory and inhibitory circuits in the basal ganglia may trigger the occurrence of these rare symptoms. Careful follow-up would be mandatory.

Lesion network mapping of eye-opening apraxia

Apraxia of eyelid opening (or eye-opening apraxia) is characterized by the inability to voluntarily open the eyes because of impaired supranuclear control. Here, we examined the neural substrates implicated in eye-opening apraxia through lesion network mapping. We analysed brain lesions from 27 eye-opening apraxia stroke patients and compared them with lesions from 20 aphasia and 45 hemiballismus patients serving as controls. Lesions were mapped onto a standard brain atlas using resting-state functional MRI data derived from 966 healthy adults in the Harvard Dataverse. Our analyses revealed that most eye-opening apraxia-associated lesions occurred in the right hemisphere, with subcortical or mixed cortical/subcortical involvement. Despite their anatomical heterogeneity, these lesions functionally converged on the bilateral dorsal anterior and posterior insula. The functional connectivity map for eye-opening apraxia was distinct from those for aphasia and hemiballismus. Hemiballismus lesions predominantly mapped onto the putamen, particularly the posterolateral region, while aphasia lesions were localized to language-processing regions, primarily within the frontal operculum. In summary, in patients with eye-opening apraxia, disruptions in the dorsal anterior and posterior insula may compromise their capacity to initiate the appropriate eyelid-opening response to relevant interoceptive and exteroceptive stimuli, implicating a complex interplay between salience detection and motor execution.

Functional and structural brain reorganization in patients with ischemic stroke: a multimodality MRI fusion study

Understanding how structural and functional reorganization occurs is crucial for stroke diagnosis and prognosis. Previous magnetic resonance imaging (MRI) studies focused on the analyses of a single modality and demonstrated abnormalities in both lesion regions and their associated distal regions. However, the relationships of multimodality alterations and their associations with poststroke motor deficits are still unclear. In this study, 71 hemiplegia patients and 41 matched healthy controls (HCs) were recruited and underwent MRI examination at baseline and at 2-week follow-up sessions. A multimodal fusion approach (multimodal canonical correlation analysis + joint independent component analysis), with amplitude of low-frequency fluctuation (ALFF) and gray matter volume (GMV) as features, was used to extract the co-altered patterns of brain structure and function. Then compared the changes in patients' brain structure and function between baseline and follow-up sessions. Compared with HCs, the brain structure and function of stroke patients decreased synchronously in the local lesions and their associated distal regions. Damage to structure and function in the local lesion regions was associated with motor function. After 2 weeks, ALFF in the local lesion regions was increased, while GMV did not improve. Taken together, the brain structure and function in the local lesions and their associated distal regions were damaged synchronously after ischemic stroke, while during motor recovery, the 2 modalities were changed separately.

[Frontal-subcortical syndrome: When the network fails, about a case]

Depression and parkinsonism are direct consequences of a lesion, usually vascular, that affects some structure of the frontal-subcortical circuit. Their detection represents a diagnostic challenge and has important repercussions in therapeutic management. The case is presented of a 79-year-old male patient with good overall baseline status, who was admitted to a Psychogeriatric Unit after an autolytic attempt. Initially, a non-psychotic frank depression is observed, and an increase in the base of support for walking and bradykinesia is noted. After adjustment of antidepressant treatment, a notable improvement in affective symptoms is evidenced but not in motor symptoms, so it is decided to request a magnetic resonance imaging that shows ischemic lesions in the basal ganglia. This case provides clear support for the frontal-subcortical circuit model, in which the clinical presentation, neuropsychiatric evaluation, neuroimaging data and therapeutic response contribute to understanding the deficits following these types of lesions. We believe that this article will provide brief and accurate information on the pathophysiological mechanisms, evaluation, diagnostic approach, and treatment of the frontal-subcortical syndrome.

Constraint-induced movement therapy alleviates motor impairment by inhibiting the accumulation of neutrophil extracellular traps in ischemic cortex

Stroke is a major cause of mortality and morbidity and most acute strokes are ischemic. Evidence-based medicine has demonstrated the effectiveness of constraint-induced movement therapy (CIMT) in the recovery of motor function in patients after ischemic stroke, but the specific treatment mechanism remains unclear. Herein, our integrated transcriptomics and multiple enrichment analysis studies, including Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and gene set enrichment analysis (GSEA) studies show that CIMT conduction broadly curtails immune response, neutrophil chemotaxis, and chemokine-mediated signaling pathway, CCR chemokine receptor binding. Those suggest the potential effect of CIMT on neutrophils in ischemic mice brain parenchyma. Recent studies have found that accumulating granulocytes release extracellular web-like structures composed of DNA and proteins called neutrophil extracellular traps (NETs), which destruct neurological function primarily by disrupting the blood-brain barrier and promoting thrombosis. However, the temporal and spatial distribution of neutrophils and their released NETs in parenchyma and their damaging effects on nerve cells remain unclear. Thus, utilizing immunofluorescence and flow cytometry, our analyses uncovered that NETs erode multiple regions such as primary motor cortex (M1), striatum (Str), nucleus of the vertical limb of the diagonal band (VDB), nucleus of the horizontal limb of the diagonal band (HDB) and medial septal nucleus (MS), and persist in the brain parenchyma for at least 14 days, while CIMT can reduce the content of NETs and chemokines CCL2 and CCL5 in M1. Intriguingly, CIMT failed to further reduce neurological deficits after inhibiting the NET formation by pharmacologic inhibition of peptidylarginine deiminase 4 (PAD4). Collectively, these results demonstrate that CIMT could alleviate cerebral ischemic injury induced locomotor deficits by modulating the activation of neutrophils. These data are expected to provide direct evidence for the expression of NETs in ischemic brain parenchyma and novel insights into the mechanisms of CIMT protecting against ischemic brain injury.

Striatal fibrinogen extravasation and vascular degeneration correlate with motor dysfunction in an aging mouse model of Alzheimer’s disease

Introduction: Alzheimer’s Disease (AD) patients exhibit signs of motor dysfunction, including gait, locomotion, and balance deficits. Changes in motor function often precede other symptoms of AD as well as correlate with increased severity and mortality. Despite the frequent occurrence of motor dysfunction in AD patients, little is known about the mechanisms by which this behavior is altered.

Methods and Results: In the present study, we investigated the relationship between cerebrovascular impairment and motor dysfunction in a mouse model of AD (Tg6799). We found an age-dependent increase of extravasated fibrinogen deposits in the cortex and striatum of AD mice. Interestingly, there was significantly decreased cerebrovascular density in the striatum of the 15-month-old as compared to 7-month-old AD mice. We also found significant demyelination and axonal damage in the striatum of aged AD mice. We analyzed striatum-related motor function and anxiety levels of AD mice at both ages and found that aged AD mice exhibited significant impairment of motor function but not in the younger AD mice.

Discussion: Our finding suggests an enticing correlation between extravasated fibrinogen, cerebrovascular damage of the striatum, and motor dysfunction in an AD mouse model, suggesting a possible mechanism underlying motor dysfunction in AD.

Post-stroke Chorea in the Neurology Department of Ignace Deen Hospital of Conakry, Guinea

INTRODUCTION

Chorea is an uncommon complication of stroke. The pathophysiology, the exact location of the lesions, and the evolution of this type of chorea are still poorly understood. The objective was to describe the epidemiological, clinical, and imaging profile of post-stroke chorea in a tropical environment in the context of a stroke epidemic.

MATERIAL AND METHODS

We conducted a five-year retrospective observational study from 2015 to 2020 on stroke patients who presented with chorea in our department. Epidemiological, clinical, and imaging data were registered.

RESULTS

Fourteen patients presented with chorea after their stroke, a frequency of 0.6%. The average age was 57.1 years with a male predominance. Hypertension was the cardiovascular risk factor in half of the patients; three patients (21.4) were diabetic. Chorea was the initial manifestation of the stroke in eight patients (57.1%). Thirteen patients (92.9%) had an ischaemic stroke and one had a cerebral haemorrhage. The middle cerebral artery (MCA) was involved in nine patients (64.3%), the anterior cerebral artery (ACA) in three patients (21.4%), and two patients (14.3%) had posterior cerebral artery (PCA) involvement. The lesions were cortical in five patients (35.7%), five other patients (35.7%) had a deep location, and four patients (28.6%) had both deep and cortical locations of their lesions. The structures affected were the lentiform nucleus (50%), the insula (35.7%), the caudate nucleus (14.3%), and the thalamus (14.3%).

CONCLUSION

Post-stroke chorea is poorly studied in the tropics. In the presence of any acute abnormal movement associated with cardiovascular risk factors, post-stroke chorea should be considered. Recovery is rapid when treated early.

Hypoglycemic Encephalopathy Manifesting with Cortical Hemichorea-Hemiballismus Syndrome: A Case Report

Hyper-/hypoglycemic states are rare but well-established causes of hyperkinetic movements, including chorea and ballismus, usually associated with brain lesions in the basal ganglia. We report a case of hemichorea-hemiballismus (HCHB) syndrome that developed after a severe hypoglycemic episode in a 71-year-old man with poorly controlled type 2 diabetes mellitus. Uncommonly, brain MRI showed contralateral cortical-subcortical T2 and T2-FLAIR-hyperintense frontoparietal lesions, with cingulate gyrus involved, while the basal ganglia were unaffected. In patients with hypoglycemic encephalopathy associated with cortical lesions, the long-term prognosis is usually poor. Nevertheless, in our patient, the dyskinesias and the cerebral lesions progressively regressed by achieving good glycemic control. After four and 12 months, the patient's neurological examination was normal. To our knowledge, this is the first evidence of hypoglycemic etiology of cortical HCHB syndrome, supporting recent theories that cortical circuitries may independently contribute to the pathogenesis of chorea and ballismus. This is also the first report of cingulate gyrus involvement in hypoglycemic encephalopathy. Finally, this case may indicate that a subset of patients with cortical lesions due to hypoglycemia could present a good clinical outcome, likely depending on the size of the lesions and the duration and severity of the hypoglycemic episode.

Monochorea after acute contralateral pontine infarction: A case report

RATIONALE

Chorea is a hyperkinetic movement characterized by random, brief, and involuntary muscle contractions. In stroke, a common cause of chorea, basal ganglia are anatomical locations that can cause chorea when a stroke occurs, and chorea is less frequently triggered by a stroke in other anatomical brain regions. Herein, we report a rare case of monochorea after acute contralateral pontine infarction.

PATIENT CONCERNS

A 32-year-old man visited the emergency room due to dysarthria and right hemiparesis that occurred approximately 6 hours and 30 minutes before the visit. A brain magnetic resonance image confirmed a diffusion restriction lesion in the left pons. The patient was initially diagnosed with acute infarction at the left pons and began to receive medical treatment with an antiplatelet agent and statin with admission.

DIAGNOSIS

Approximately 14 hours after the onset of the initial stroke symptoms, the patient complained of involuntary movement in the right arm for the first time. Intermittent, irregular involuntary movements were observed in the distal part of the right arm. This symptom was unpredictable and random, and a similar symptom was not observed in other parts of the patient's body. Clinically, post-stroke monochorea was suspected.

INTERVENTIONS AND OUTCOMES

The symptom improved from day 5 without specific medical treatment for chorea.

LESSONS

The monochorea caused by the pontine lesion in this case was triggered by the direct lesions of the corticospinal tract, and its underlying pathophysiology remains unclear. However, abnormal movements can occur due to inadequate downstream activation or inhibition of the corticospinal tract, which is induced by functional abnormalities of the motor cortex. This case suggests that further investigation is needed on the mechanisms of direct corticospinal tract lesions for chorea.

Dystonic posturing with athetoid movements in stroke without thalamic lesion

Complex hyperkinetic movement disorders are a rare complication of stroke, frequently involving posterolateral contralateral thalamic lesions. One of the proposed mechanisms for these presentations is proprioceptive impairment, hence not involving deregulation of the basal ganglia-thalamocortical circuits. We report a patient who presented with dystonic posturing and athetoid movements with onset 2 years after right frontoparietotemporal stroke. Brain MRI showed no thalamic lesion. Based on the phenomenology, a diagnosis of pseudochoreoathetosis was proposed. To our knowledge, this is the first case report of poststroke pseudochoreoathetosis without thalamic involvement.

Deep brain stimulation in posterior subthalamic area for Holmes tremor: Case reports with review of the literature

Background

Holmes tremor (HT) is a refractory tremor associated with cortico-basal ganglia loops and cerebellothalamic tract abnormalities. Various drug treatments have been attempted; however, no treatment method has yet been established. Historically, thalamic deep brain stimulation (DBS) has been performed in medically refractory cases. Recently, the posterior subthalamic area (PSA) has been used for HT. Here, we report cases of HT and review the effectiveness and safety of PSA-DBS for HT.

Cases

We conducted a retrospective chart review of two patients with HT who underwent PSA-DBS. Improvement in tremors was observed 1 year after surgery without apparent complications.

Literature review

We identified 12 patients who underwent PSA-DBS for HT, including our cases. In six patients, PSA was targeted alone; for the rest, the ventralis intermediate nucleus (Vim) of the thalamus and PSA were simultaneously targeted. The Fahn-Tolosa-Marin Tremor Rating Scale improvement rates were 56.8% (range, 33.9-82.1%; n = 6) and 77.8% (range, 42.6-100%; n = 5) for the PSA-DBS and PSA+Vim-DBS, respectively.

Conclusion

Reasonable improvements in HT were observed after PSA-DBS. PSA might be an appropriate target for improving the symptoms of HT. Long-term observations, accumulation of cases, and randomized studies are required in future.

Adult-Onset Idiopathic Cervical Dystonia

Adult-onset idiopathic focal dystonia is the most common type of primary dystonia, and adult-onset idiopathic cervical dystonia (AOICD) is its most prevalent phenotype. AOICD is an autosomal-dominant disorder with markedly reduced penetrance; clinical expression is dependent on age, sex, and environmental exposure. Motor symptoms at presentation are poorly recognised by non-specialists, leading to long delays in diagnosis. Certain features of history and examination can help diagnose cervical dystonia. There is a relatively high prevalence of anxiety and/or depression, which adversely affects health-related quality of life. Recent studies indicate that patients with AOICD also have disordered social cognition, particularly affecting emotional sensory processing. AOICD can be treated reasonably effectively with botulinum toxin injections, given at 3-month intervals. Oral antidystonic medications are often trialled initially, but are largely ineffective. Comprehensive modern management of patients with AOICD requires recognition of presence of mood disorders, and actively treating the endogenous mood disorder with antidepressant therapy. Botulinum toxin injections alone, no matter how expertly given, will not provide optimal therapy and improved health-related quality of life without an holistic approach to patient management. Increasing evidence indicates that AOICD is a neurophysiological network disorder of GABAergic inhibition, causing a syndrome of dystonia, mood disturbance, and social cognitive dysfunction, with the superior colliculus playing a central role.

Case Report: Dystonic Storm Following Japanese Encephalitis Virus Infection

Dystonic storm (also called status dystonicus) is a neurological emergency characterized by sustained/intermittent involuntary generalized muscle contractions resulting in repetitive painful twisting movements and abnormal postures. It is commonly documented in patients with diagnosed primary dystonic syndromes or secondary dystonic states (i.e., patients with inborn errors of metabolism, dystonic cerebral palsy, Wilson's disease, pantothenate kinase-associated neurodegeneration, and exposure to drugs). However, viral-induced dystonic storm cases have rarely been reported. We describe the case of an 11-year-old girl from rural West Bengal (India) with a dystonic storm after Japanese encephalitis. Generalized dystonic spasms lasted for about 10-20 minutes and occurred 20-30 times/day. They were associated with extreme pain, fever, exhaustion, sweating, tachycardia, tachypnea, pupillary dilatation, arterial hypertension, and mutism and were precipitated by a full bladder and relieved somewhat during sleep. When dystonic spasms abated, she had high-grade generalized rigidity of all four limbs and fixed cervical and truncal dystonia. She was put on invasive ventilation and deep intravenous sedation with continuous midazolam infusion and other supportive measures and had a good clinical recovery. During the 12 months of follow-up, she did not have any other episode of a dystonic storm. However, axial rigidity and intermittent appendicular (upper limb) dystonic posturing were observed. The authors also have briefly discussed the differential diagnoses and treatment plans for such a neurological emergency.

Hyperkinetic Choreiform Movements Secondary to Basal Ganglia Calcification and Underlying Developmental Venous Anomaly

Chorea is irregular, involuntary movements that are associated with a variety of conditions and can encompass a wide differential. Unilateral hyperkinetic choreiform movements represent a rare subset characterized by the acute and sudden onset of progressive, uncontrollable body movements. We present a patient presenting with left-sided arm and leg arrhythmic movements caused by right-sided basal ganglia calcifications associated with an underlying developmental venous anomaly (DVA). To the author’s knowledge, this is only the second reported case of such a presentation, and it should be on the differential in patients presenting with unilateral movement abnormalities.

Rare coexistence of multiple manifestations secondary to thalamic hemorrhage: A case report

BACKGROUND

A growing body of literature indicates that the occurrence of thalamic lesions could lead to various dysfunctions, such as somatosensory disturbances, hemiparesis, language deficits, and movement disorders. However, clinical cases describing the coexistence of these types of manifestations have not been reported. Herein, we report a patient who exhibited these rare complications secondary to thalamic hemorrhage.

CASE SUMMARY

A 53-year-old right-handed man experienced sudden left hemiparesis, numbness of the left side of body, and language alterations due to an acute hemorrhage located in the right basal ganglia and thalamus 18 mo ago. Approximately 17 mo after the onset of stroke, he exhibited rare complications including dysphasia, kinetic tremor confined to the left calf, and mirror movement of the left arm which are unique and interesting, and a follow-up computed tomography scan revealed an old hemorrhagic lesion in the right thalamus and posterior limb of the internal capsule.

CONCLUSION

Hypophonia may be a recognizable clinical sign of thalamus lesions; thalamus injury could cause tremor confined to the lower extremity and mimicking extremity movements.

Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management

Involuntary movements develop after 1-4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.

Ischemic stroke-induced polyaxonal innervation at the neuromuscular junction is attenuated by robot-assisted mechanical therapy

Ischemic stroke is a leading cause of disability world-wide. Mounting evidence supports neuromuscular pathology following stroke, yet mechanisms of dysfunction and therapeutic action remain undefined. The objectives of our study were to investigate neuromuscular pathophysiology following ischemic stroke and to evaluate the therapeutic effect of Robot-Assisted Mechanical massage Therapy (RAMT) on neuromuscular junction (NMJ) morphology. Using an ischemic stroke model in male rats, we demonstrated longitudinal losses of muscle contractility and electrophysiological estimates of motor unit number in paretic hindlimb muscles within 21 days of stroke. Histological characterization demonstrated striking pre- and postsynaptic alterations at the NMJ. Stroke prompted enlargement of motor axon terminals, acetylcholine receptor (AChR) area, and motor endplate size. Paretic muscle AChRs were also more homogenously distributed across motor endplates, exhibiting fewer clusters and less fragmentation. Most interestingly, NMJs in paretic muscle exhibited increased frequency of polyaxonal innervation. This finding of increased polyaxonal innervation in stroke-affected skeletal muscle suggests that reduction of motor unit number following stroke may be a spurious artifact due to overlapping of motor units rather than losses. Furthermore, we tested the effects of RAMT - which we recently showed to improve motor function and protect against subacute myokine disturbance - and found significant attenuation of stroke-induced NMJ alterations. RAMT not only normalized the post-stroke presentation of polyaxonal innervation but also mitigated postsynaptic expansion. These findings confirm complex neuromuscular pathophysiology after stroke, provide mechanistic direction for ongoing research, and inform development of future therapeutic strategies. SIGNIFICANCE: Ischemic stroke is a leading contributor to chronic disability, and there is growing evidence that neuromuscular pathology may contribute to the impact of stroke on physical function. Following ischemic stroke in a rat model, there are progressive declines of motor unit number estimates and muscle contractility. These changes are paralleled by striking pre- and postsynaptic maladaptive changes at the neuromuscular junction, including polyaxonal innervation. When administered to paretic hindlimb muscle, Robot-Assisted Mechanical massage Therapy - previously shown to improve motor function and protect against subacute myokine disturbance - prevents stroke-induced neuromuscular junction alterations. These novel observations provide insight into the neuromuscular response to cerebral ischemia, identify peripheral mechanisms of functional disability, and present a therapeutic rehabilitation strategy with clinical relevance.

A neuroanatomical study of the feline brain using MRI and mulligan staining: functional and pathological considerations

BACKGROUND

Despite multiple studies describing accurate diagnoses using advanced neuroimaging techniques, low and mid-field magnetic resonance imaging (MRI) are still the most frequent scanners in veterinary clinics. To date, these studies in cats do not show a clear distinction of nerve centres in MRI data.

AIMS

The objective of this study is to determine the efficacy of Mulligan histological staining as a tool in facilitating the location and identification of the main structures of the feline brain in MRI. This study aims to facilitate the interpretation of MRI obtained with these types of scanners.

METHODS

A total of 10 feline brains were used. One specimen was used for MRI (T2 sequence using a 1.5T scanner). The other 9 brains were sectioned and stained with the three Mulligan staining techniques (Mulligan, Le Masurier and Robert).

RESULTS

The uptake of stain by the grey matter in these sections allowed the determination of the location and the limits of these nervous structures within the brain. The histological location of these structures was correlated with the MRI scans, leading to the successful identification of many small, indistinct nuclei.

CONCLUSION

Mulligan staining is proposed as a tool that facilitates the location of nerve structures in comparison with data from the most frequently-used MRI scanners in veterinary clinics.

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic time-outs into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.

Deficits in motor and cognitive functions in an adult mouse model of hypoxia-ischemia induced stroke

Ischemic strokes cause devastating brain damage and functional deficits with few treatments available. Previous studies have shown that the ischemia-hypoxia rapidly induces clinically similar thrombosis and neuronal loss, but any resulting behavioral changes are largely unknown. The goal of this study was to evaluate motor and cognitive deficits in adult HI mice. Following a previously established procedure, HI mouse models were induced by first ligating the right common carotid artery and followed by hypoxia. Histological data showed significant long-term neuronal losses and reactive glial cells in the ipsilateral striatum and hippocampus of the HI mice. Whereas the open field test and the rotarod test could not reliably distinguish between the sham and HI mice, in the tapered beam and wire-hanging tests, the HI mice showed short-term and long-term deficits, as evidenced by the increased number of foot faults and decreased hanging time respectively. In cognitive tests, the HI mice swam longer distances and needed more time to find the platform in the Morris water maze test and showed shorter freezing time in fear contextual tests after fear training. In conclusion, this study demonstrates that adult HI mice have motor and cognitive deficits and could be useful models for preclinical stroke research.

Differentiating the Brain's involvement in Executed and Imagined Stepping using fMRI

The purpose of this study was to extend the extant literature regarding brain areas that are activated during executed and imagined lower limb movement. Past research suggests that stepping, as a cyclical movement, should activate the motor control areas of the brain that integrates smooth movements with spinal cord nerves. The neuronal activity needed to imagine that same activity is likely to recruit additional sensory-motor areas that provide initiation and inhibition signals, making this task take on a neuronal activity pattern that is more similar to discrete movements. To assess this research question, 16 participants took part in the current study where they executed and imagined stepping, with movement at the hip, knee, and ankle joints, while viewing a computer-generated image of a human walking. A block design with a total of 10 blocks for rest and task for each condition was used. Rest blocks lasted 18 seconds, followed by an 18-second display of the visual stimulus. Results showed that in the executed condition, areas of the brain that are most prominently associated with sensory-motor activity were activated. In the imagined condition areas of the brain associated with movement control, inhibition of movement, and the integration of sensory input and motor output (parietal and occipital) were also activated. These findings contribute to the literature identifying brain areas that are activated in lower limb locomotion.

Hemichorea as Presentation of Acute Cortical Ischemic Stroke. Case Series and Review of the Literature

Hemichorea and other hyperkinetic movement disorders are a rare presentation of stroke, usually secondary to deep infarctions affecting the basal ganglia and the thalamus. Chorea can also result from lesions limited to the cortex, as shown in recent reports. Still, the pathophysiology of this form of cortical stroke-related chorea remains unknown. We report 4 cases of acute ischemic cortical strokes presenting as hemichorea, with the infarction being limited to the parietal and insular cortex in perfusion computed tomography scans and magnetic resonance imaging. These cases suggest potential dysfunction of pathways connecting these cortical regions with the basal ganglia.

Hemichorea-hemiballismus as the initial manifestation of symptomatic middle cerebral artery dissection: A case report

INTRODUCTION

Hemichorea-hemiballismus, which spans a spectrum of involuntary, continuous, nonpatterned movement involving one side of the body, can emerge as the initial manifestation of acute ischemic stroke. However, because of its rarity in the community, the diagnosis and treatment are often delayed.

PATIENT CONCERNS

We report a unique case of a 47-year-old female who presented with acute onset hemichorea-hemiballismus. No obvious focal sign apart from involuntary, continuous, nonpatterned movement of her left arm and leg was presented.

DIAGNOSIS

Initial diffusion-weighted magnetic resonance imaging (MRI) was negative but significant increase of blood flow velocity in the right middle cerebral artery (MCA) stem was revealed by transcranial doppler sonography. Repeated MRI showed acute infarction in the contralateral globus pallidus. Isolated dissection of the right MCA typified by intimal flap with double lumen was identified by digital subtraction angiography and high-resolution magnetic resonance imaging (HR-MRI).

INTERVENTIONS

The patient was initially treated with dual antiplatelet agents but the uncontrollable movement deteriorated during hospitalization. Antithrombotic therapy was then intensified with combination of tirofiban and low-molecular-weight heparin. Other symptomatic treatment included volume expansion with colloidal fluid to improve cerebral perfusion. Her involuntary movement gradually diminished and the patient was discharged with rivaroxaban 15 mg/daily.

OUTCOMES

The patient had recovered with significant reduction in her hemichorea-hemiballismus. Three-month follow-up HR-MRI showed complete resolution of the MCA dissection lesions.

CONCLUSION

Prompt recognition of acute onset hemichorea-hemiballismus as the manifestation of acute ischemic stroke in appropriate clinical setting may reduce diagnostic delay. Multiple imaging techniques including cerebral digital subtraction angiography and HR-MRI can be applied to diagnosis and further clarify the mechanism of stroke, which facilitate in selection of secondary prevention therapies.

Neurovascular Unit as a Source of Ischemic Stroke Biomarkers-Limitations of Experimental Studies and Perspectives for Clinical Application

Cerebral stroke, which is one of the most frequent causes of mortality and leading cause of disability in developed countries, often leads to devastating and irreversible brain damage. Neurological and neuroradiological diagnosis of stroke, especially in its acute phase, is frequently uncertain or inconclusive. This results in difficulties in identification of patients with poor prognosis or being at high risk for complications. It also makes difficult identification of these stroke patients who could benefit from more aggressive therapies. In contrary to the cardiovascular disease, no single biomarker is available for the ischemic stroke, addressing the abovementioned issues. This justifies the need for identifying of effective diagnostic measures characterized by high specificity and sensitivity. One of the promising avenues in this area is studies on the panels of biomarkers characteristic for processes which occur in different types and phases of ischemic stroke and represent all morphological constituents of the brains' neurovascular unit (NVU). In this review, we present the current state of knowledge concerning already-used or potentially applicable biomarkers of the ischemic stroke. We also discuss the perspectives for identification of biomarkers representative for different types and phases of the ischemic stroke, as well as for different constituents of NVU, which concentration levels correlate with extent of brain damage and patients' neurological status. Finally, a critical analysis of perspectives on further improvement of the ischemic stroke diagnosis is presented.

Interaction between ventricular expansion and structural changes in the corpus callosum and putamen in males with FMR1 normal and premutation alleles

Ventricular enlargement (VE) is commonly observed in aging and fragile X-associated tremor/ataxia syndrome (FXTAS), a late-onset neurodegenerative disorder. VE may generate a mechanical force causing structural deformation. In this longitudinal study, we examined the relationships between VE and structural changes in the corpus callosum (CC) and putamen. MRI scans (2-7/person over 0.2-7.5 years) were acquired from 22 healthy controls, 26 unaffected premutation carriers (PFX-), and 39 carriers affected with FXTAS (PFX+). Compared with controls, PFX- demonstrated enlarged fourth ventricles, whereas PFX+ displayed enlargement in both third and fourth ventricles, CC thinning, putamen atrophy/deformation (thinning and increased distance), and accelerated expansions in lateral ventricles. Common for all groups, baseline VE predicted accelerated CC thinning and putamen atrophy/deformation and conversely, baseline CC and putamen atrophy/deformation and enlarged third and fourth ventricles predicted accelerated lateral ventricular expansion. The results suggest a progressive VE within the 4 ventricles as FXTAS develops and a deleterious cycle between VE and brain deformation that may commonly occur during aging and FXTAS progression but become accelerated in FXTAS.

Vascularization of the Subthalamic Nucleus: Highlighting the Significance of the Premamillary Artery

BACKGROUND

The need for a better understanding of the subthalamic nucleus (STN)'s vascular anatomy is still evident because revealing its vascular supply may increase insight in the pathogenesis of related disorders, such as STN ischemia. The mechanisms under motor, behavioral, and cognitive changes following deep brain stimulation treatment may also be explained by its pattern of vascularization. The primary goal of this study was to delineate the vascularization of the STN and highlight the predominant perforating arteries supplying its territory.

METHODS

Fiber dissections were performed with the modified Klingler technique under 6-40× magnification by preserving all vascular structures.

RESULTS

The thalamic and subthalamic regions were dissected from medial to lateral in silicone-injected cadavers. The STN was revealed as a biconvex-shaped structure surrounded by dense inferolateral bundles of myelinated fibers, the zona incerta, bordering the superolateral portion of the red nucleus. The ventral limit of the STN was the substantia nigra, and the internal capsule traversed from its inferior to anterolateral side. The premamillary artery, a large perforator arising from the posterior communicating artery, constantly supplied the STN and was followed proximally along the anterior third ventricular floor toward its origin. The premamillary artery was found to be one of the posterior perforators of the posterior communicating artery in all hemispheres.

CONCLUSIONS

The 3-dimensional microsurgical anatomy of the deep-seated STN region is complex, and the additional knowledge on its vascularization should improve our understanding of its surgical anatomy.

Activity-dependent cleavage of dyskinesia-related proline-rich transmembrane protein 2 (PRRT2) by calpain in mouse primary cortical neurons

Mutations of PRRT2 (proline-rich transmembrane protein 2) cause several neurological disorders, represented by paroxysmal kinesigenic dyskinesia (PKD), which is characterized by attacks of involuntary movements triggered by sudden voluntary movements. PRRT2 is reported to suppress neuronal excitation, but it is unclear how the function of PRRT2 is modulated during neuronal excitation. We found that PRRT2 is processed to a 12 kDa carboxy-terminal fragment (12K-CTF) by calpain, a calcium-activated cysteine protease, in a neuronal activity-dependent manner, predominantly via NMDA receptors or voltage-gated calcium channels. Furthermore, we clarified that 12K-CTF is generated by sequential cleavages at Q220 and S244. The amino-terminal fragment (NTF) of PRRT2, which corresponds to PKD-related truncated mutants, is not detected, probably due to rapid cleavage at multiple positions. Given that 12K-CTF lacks most of the proline-rich domain, this cleavage might be involved in the activity-dependent enhancement of neuronal excitation perhaps through transient retraction of PRRT2's function. Therefore, PRRT2 might serve as a buffer for neuronal excitation, and lack of this function in PKD patients might cause neuronal hyperexcitability in their motor circuits.

['Stroke chameleons']

The diagnosis of acute stroke should be correct and early that allows physician planning the most effective treatment strategies (reperfusion therapy, undifferentiated (basic) treatment, early secondary prevention). However, stroke symptoms can be atypical and similar to some other (non-vascular) event. It can significantly complicate the clinical diagnosis of stroke and decrease the patient's chances for effective treatment. A stroke should be suspected in every patient with acute onset of neurological symptoms, especially when the patient has the 'vascular' risk factors. Furthermore it is important to remember that negative CT-scan data and/or MRI data do not exclude the presence of not only ischemic stroke but also hemorrhagic stroke. The article describes the main variants of strokes with atypical symptoms (strokes-chameleons), emphasizes the importance of careful clinical examination, provides supportive differential diagnostic criteria and discusses limitations of neuroimaging methods.

Vascular Parkinsonism: A Review on Management updates

"Vascular parkinsonism (VP)" is a condition which presents with the clinical features of parkinsonism that are presumably caused by cerebrovascular disease. It is classically described as symmetrical lower-body parkinsonism with gait unsteadiness and absence of tremors and is usually associated with pyramidal signs. Treatment for VP remains challenging as available data on the efficacy of current treatment options are contentious. VP is generally considered to be poorly responsive to levodopa, the most effective of the current treatment modalities for parkinsonism. However, there is evidence that some patients benefit from therapy with levodopa. This article reviews the place of levodopa in the treatment of VP.

Post-Stroke Lingual Dystonia: Clinical Description and Neuroimaging Findings

Background

Lingual dystonia is extremely rare following stroke. We describe clinical features and neuroimaging findings in a series of 11 patients (seven acute and four chronic) with post-stroke lingual dystonia and review the literature.

Methods

This was a case series using a preformed structured proforma and review of literature using a PubMed search.

Results

In our case series, all patients had dysarthria as a presenting symptom. Seven patients had acute presentation (six had an ischemic infarct and one had thalamic hemorrhage) and four had chronic presentation (all had infarct). All patients except one had small infarcts, with the majority of them in the basal ganglia and subcortical white matter regions. Additional chronic ischemic lesions were seen in all patients with acute presentation. The majority of the patients with acute (five out of seven; 71.42%) presentation had left-sided involvement on imaging. We could identify only one case of acute post-stroke lingual dystonia following the PubMed search. Three other cases of post-stroke lingual dystonia with chronic presentation have been described; however, these were associated with oromandibular or cranial dystonia.

Discussion

Our results, based on brain lesions, suggest that all lingual dystonia patients with acute infarcts had underlying chronic infarcts. Overall, more left-sided than right-sided strokes were observed with post-stroke lingual movement disorders including dystonia; however, the data were not significant (p = 1). All patients had dysarthria, with only one having mild tongue weakness and only four having facial weakness. This suggests that the lingual dystonia was responsible for the dysarthria rather than weakness in these patients.

The Caudal Part of Putamen Represents the Historical Object Value Information

The basal ganglia, especially the circuits originating from the putamen, are essential for controlling normal body movements. Notably, the putamen receives inputs not only from motor cortical areas but also from multiple sensory cortices. However, how these sensory signals are processed in the putamen remains unclear. We recorded the activity of tentative medium spiny neurons in the caudal part of the putamen when the monkey viewed many fractal objects. We found many neurons that responded to these objects, mostly in the ventral region. We called this region "putamen tail" (PUTt), as it is dorsally adjacent to "caudate tail" (CDt). Although PUTt and CDt are mostly separated by a thin layer of white matter, their neurons shared several features. Almost all of them had receptive fields in the contralateral hemifield. Moreover, their responses were object selective (i.e., variable across objects). The object selectivity was higher in the ventral region (i.e., CDt > PUTt). Some neurons above PUTt, which we called the caudal-dorsal putamen (cdPUT), also responded to objects, but less selectively than PUTt. Next, we examined whether these visual neurons changed their responses based on the reward outcome. We found that many neurons encoded the values of many objects based on long-term memory, but not based on short-term memory. Such stable value responses were stronger in PUTt and CDt than in cdPUT. These results suggest that PUTt, together with CDt, controls saccade/attention among objects with different historical values, and may control other motor actions as well.SIGNIFICANCE STATEMENT Although the putamen receives inputs not only from motor cortical areas but also from sensory cortical areas, how these sensory signals are processed remains unclear. Here we found that neurons in the caudal-ventral part of the putamen (putamen tail) process visual information including spatial and object features. These neurons discriminate many objects, first by their visual features and later by their reward values as well. Importantly, the value discrimination was based on long-term memory, but not on short-term memory. These results suggest that the putamen tail controls saccade/attention among objects with different historical values and might control other motor actions as well.

A phase IIb, randomised, double-blind, placebo-controlled, dose-ranging investigation of the safety and efficacy of NTCELL® [immunoprotected (alginate-encapsulated) porcine choroid plexus cells for xenotransplantation] in patients with Parkinson's disease

INTRODUCTION

Regenerative therapies in Parkinson's disease aim to slow neurodegeneration and re-establish damaged neuronal circuitry. Neurotrophins are potent endogenous regulators of neuronal survival, development and regeneration. They represent an attractive regenerative treatment option in Parkinson's disease. Porcine choroid plexus produces a number of neurotrophins, and can be safely delivered to the striatum in an encapsulated formulation (termed NTCELL^®) to protect them from immune attack. NTCELL^® has shown regenerative potential in animal models of stroke, Huntington's disease and Parkinson's disease. Following promising results from an initial open label safety study of intra-striatal delivery of NTCELL^® in human subjects, we sought to specifically investigate the safety and efficacy of NTCELL^® for the treatment of Parkinson's disease.

METHODS

18 patients aged 56-65 years with idiopathic Parkinson's disease of at least 5 years duration were randomised to receive either sham surgery (general anaesthesia and partial thickness burr holes) or intra-striatal delivery of NTCELL^® (the 3 groups in the treatment arm receiving incremental NTCELL^® doses).

RESULTS

At 26 weeks, we found no significant difference in total UPDRS scores ('on' and 'off'), UPDRS motor scores ('on' and 'off'), PDQ-39, UDysRS, timed walk or modified Hoehn and Yahr stage between patients implanted with NTCELL^® and patients undergoing sham procedure. There were no serious adverse events or xenogeneic viral transmission during the study.

CONCLUSION

The study did not meet its primary efficacy end-point of a change in UPDRS at 26 weeks post-intervention compared with baseline. Stereotactic NTCELL^® implantation was safe and well tolerated.

Vascular Pathology Causing Late Onset Generalized Chorea: A Clinico-Pathological Case Report

Background

Chorea may occur as a manifestation of an acute stroke. Patients with vascular-related chorea typically present with an acute or subacute onset of hemichorea, contralateral to the lesion.

Methods and Findings

In this clinico-pathological case, we report a 90-year-old female who presented, at age 81, with a transient episode of generalized chorea. Over the years, the patient continued to have intermittent episodes of generalized chorea or hemichorea, followed by a progressive dementia syndrome with gait and sphincter disturbance. There was no family history of chorea or dementia. Laboratory tests for paraneoplastic or autoimmune disorders and genetic testing for Huntington's disease were normal or negative. Magnetic resonance imaging showed subcortical and basal ganglia atrophy associated with ischemic leukoencephalopathy and lacunar infarcts. The post-mortem examination identified multiple lacunar infarcts (cortex, white matter, thalamus, basal ganglia) and minor Alzheimer's disease neuropathological changes.

Conclusions

Vascular disease, affecting the basal ganglia, is included in most lists of causes of generalized chorea. Proven cases are difficult to find. We present a rare case of vascular pathology causing late onset generalized and intermittent chorea. We highlight the intermittent nature of the chorea that could be explained by cumulative vascular lesions or functional disconnection in a previous deficient circuit.

Individualized Immunological Data for Precise Classification of OCD Patients

Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.

Jaw tremor: a manifestation of vascular parkinsonism? - a case report

Background

Vascular Parkinsonism (VP) is a heterogeneous group of conditions that manifest clinically in parkinsonian features, but are presumably of vascular cause. It is usually bilateral, non-tremulous, and frequently associated with pyramidal signs. Classically VP is described as lower body parkinsonism affecting predominantly the legs.

Case presentation

A 67 years old lady presented with a history of acute onset jaw tremor, with tremor predominantly in both upper limbs. Neurological examination revealed hypomimia of the face with cogwheel rigidity and bradykinesia bilaterally, predominantly in the upper limbs without pyramidal signs. She had a marked tremor of the jaw at rest. When she was asked to open her mouth the tremor was re-emergent. Non contrast CT scan of her brain revealed an infarction in the region of putamen on the left with no evidence of diffuse subcortical white matter ischemia or extension to the caudate nucleus. She was treated with levodopa and responded well to medication.

Conclusions

This case describes atypical clinical features which could be associated with VP including jaw tremor. This case also stresses the importance of initiating a trial of levodopa as certain patients may respond well to medication.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1093-5) contains supplementary material, which is available to authorized users.

Post-Thalamic Stroke Movement Disorders: A Systematic Review

BACKGROUND

After a stroke, movement disorders are rare manifestations mainly affecting the deep structures of the brain like the basal ganglia (44%) and thalamus (37%), although there have been case studies of movement disorders in strokes affecting the cerebral cortex also.

SUMMARY

This review aims to delineate the various movement disorders seen in association with thalamic strokes and tries to identify the location of the nuclei affected in each of the described movement disorders. Cases were identified through a search of PubMed database using different search terms related to post-thalamic stroke movement disorders and a secondary search of references of identified articles. We reviewed 2,520 research articles and only 86 papers met the inclusion criteria. Cases were included if they met criteria for post-thalamic stroke movement disorders. Case-cohort studies were also reviewed and will be discussed further. Key Messages: The most common post-stroke abnormal movement disorder reported in our review was dystonia followed by hemiataxia. There was a higher association between ischaemic stroke and movement disorder. Acute onset movement disorders were more common than delayed. The posterolateral thalamus was most commonly involved in post-thalamic stroke movement disorders.

Acute-onset Restless legs syndrome in acute neurological conditions-a prospective study on patients with the Guillain-Barre syndrome and acute stroke

OBJECTIVES

While the Restless legs syndrome (RLS) is usually recognized as a chronic condition, it has often been diagnosed among patients with acute neurological illnesses, in which limb discomfort is reported. This study was conducted to determine how many among these, actually have acute-onset RLS, and also to evaluate characteristics of this subgroup of patients with Guillain-Barre syndrome (GBS) and stroke developing acute-onset RLS.

METHODS

Consecutive patients diagnosed with GBS and eligible stroke patients, admitted to our Neurology services over a 1-year period, were enrolled. They were evaluated for symptoms of RLS based on IRLSSG consensus criteria and the AIIMS RLS Questionnaire for Indian patients (ARQIP).

RESULTS

Forty adults with GBS and 58 with stroke were included. A total of 10 of the 40 (25%) patients with GBS developed definite acute RLS, which was mostly monophasic. Seven (70%) of these had demyelinating type of GBS, a significant association with acute RLS (P = .024). Six of the 58 stroke patients (10%) developed definite acute-onset, often persistent RLS. Subcortical location showed significant association with increased risk of developing acute RLS (P < .001). All patients diagnosed with acute-onset RLS had an immediate and good response to dopamine agonists.

CONCLUSION

This is the first study showing that acute-onset RLS is common, affecting nearly 25% of patients with GBS and 10% patients with acute stroke. Recognizing and treating it can majorly contribute toward symptom relief and early improvement in the quality of life for this population.

Poststroke Choreodystonia Responsive to Zopiclone: Further Evidence of a Role for the "Z-Drugs" in Hyperkinetic Movement Disorders

View Supplementary Video 1