Subcutaneous apomorphine in Parkinson's disease: response to chronic administration for up to five years

Subcutaneous apomorphine, administered by continuous waking-day infusion with boluses, or by repeated intermittent injection, was given to 71 parkinsonian patients with severe refractory levodopa related on-off fluctuations for 1-5 years. A mean reduction in daily off period time of approximately 50% was maintained, and the incidence of neuropsychiatric toxicity remained low on long-term follow-up. No clinically significant tolerance or loss of therapeutic effect was seen, although increasingly severe on-phase dyskinesias and postural instability marred the long-term therapeutic response in many patients. Despite these drawbacks, apomorphine, when combined with the peripheral dopamine receptor agonist domperidone, represents a significant therapeutic advance in the management of late-stage Parkinson's disease and should certainly be considered before experimental implantation procedures.

The dopaminergic response in multiple system atrophy

Fifteen of 23 pathologically confirmed cases of multiple system atrophy (MSA) showed some initial response to levodopa and eight of these remained at least partially responsive at the time of death. Eleven developed motor oscillations, and drug-induced dyskinesias, often involving the face and jaw, were also seen in 11 cases. Acute levodopa and apomorphine challenges were administered to 11 patients with clinical MSA who were considered levodopa responsive. A short duration relatively small amplitude response with associated dyskinesias occurred in six and a further three developed dyskinesias without any motor response. Following levodopa withdrawal, a delayed deterioration occurred after three to six days in six patients, five of whom had shown no short duration motor response to the acute challenges. The occurrence of levodopa-induced dyskinesias without a concomitant motor response and delayed deterioration several days after levodopa withdrawal may be more typical of patients with MSA than Parkinson's disease.

Comparative efficacy of two oral sustained-release preparations of L-dopa in fluctuating Parkinson's disease. Preliminary findings in 20 patients

20 patients with Parkinson's disease and a fluctuating response to chronic treatment with conventional L-dopa preparations participated in an open randomized trial comparing two sustained-release L-dopa preparations (Madopar HBS, Sinemet CR4). While a majority (15 patients, 7 on Madopar HBS and 8 on Sinemet CR4) showed a favourable response after 2 months of slow-release L-dopa treatment the clinical benefit remained stable in only 2 patients on Madopar HBS and 3 patients on Sinemet CR4 over the entire follow-up period of 12 months. Reasons for treatment failure were increased peak-dose or biphasic dyskinesias or prolonged "off"-periods. This preliminary study failed to demonstrate clinically significant advantages of one slow-release principle over the other.

Treatment of spasmodic torticollis with local injections of botulinum toxin. One-year follow-up in 37 patients

Thirty-seven patients with spasmodic torticollis (cervical dystonia) who received repeated local injections of botulinum toxin have been followed up for a mean period of 12.3 (10-29) months, during which time 138 treatment sessions were performed. Mean doses per muscle averaged 320 mouse units (mu; range 160-1000 mu botulinum toxin A prepared by CAMR, Porton Down, UK). Eighty-six per cent of patients experienced significant improvement of posture and 84% of those with pain had relief following the first injection. Muscular patterns of recurrent torticollis were relatively constant and in most patients efficacy was maintained with subsequent injections, while 15% of all follow-up sessions failed. Only 2 of 37 patients were consistent nonresponders; 22% and 10% of all sessions were complicated by transient dysphagia and weakness of neck muscles, respectively. It is concluded that local botulinum toxin injections can be a safe and efficaceous long-term treatment of spasmodic torticollis and that optimal doses should be between 200 and 400 mu/muscle.

Clinical and polymyographic investigation of spasmodic torticollis

Polymyographic recordings were used to identify the most dystonic muscles suitable for local injection with botulinum toxin in 100 patients with spasmodic torticollis (TS). Rotating TS (72% of the patients) was due to dystonic activity of the splenius muscle ipsilateral to and/or the sternocleidomastoid muscle contralateral to the side of chin deviation. One-third of these patients had also dystonic activation of the contralateral splenius muscle and, rarely, the contralateral trapezius muscle. Ten patients had laterocollis due to dystonic activation of all recorded muscles on one side of the neck. Nine patients had retrocollis due to activity of both splenius muscles and rarely additional activity in both trapezius muscles. The type of dystonic muscle activity was found to be tonic, phasic or tremulous. Besides the evaluation of spontaneous dystonic EMG activity further examination during the "geste antagoniste" or the muscle activity during rotating head movements can provide additional information. It is concluded that polymyography may provide a rationale for identifying the dystonic muscles underlying the different forms of TS. It may prove to be helpful for the successful therapy with botulinum toxin and may be useful in differentiating tremulous torticollis from other types of head tremor.

Antiparkinsonian activity of a non-ergot dopamine agonist, CV 205-502, in patients with fluctuating Parkinson's disease

Six patients with fluctuating Parkinson's disease received single rising oral doses of the nonergot dopamine agonist CV 205-502 in an open experimental study. Doses of 0.5 mg produced antiparkinsonian effects of comparable intensity but longer duration than 200 mg of L-DOPA. CV 205-502, which combines structural features common to both ergolines and apomorphine, thus revealed interesting antiparkinsonian properties, but nausea and vomiting were dose-limiting side effects in all patients tested.

Pharmacological study in Meige's syndrome with predominant blepharospasm

Objective quantification of the symptoms of Meige's syndrome is difficult and has not been performed in the majority of pharmacological studies of Meige's syndrome published so far. The aim of the present study was to reexamine the therapeutic potential of biperiden, clonazepam, haloperidol, and lisuride using an objective method of quantification of the symptoms. Eleven patients received daily i.v. injections of biperiden, 5.0 mg; clonazepam, 1.0 mg; haloperidol, 2.5 mg; lisuride, 0.05 mg; and placebo in randomized order. The symptoms of the patients [idiopathic blepharospasm (IB), in 11 patients, oromandibular dystonia (OMD) in four patients] were quantified by a blind observer counting the frequencies and recording the cumulative duration of sustained spasms of IB and OMD over periods of 4 min before, and 15, 30, 60, 90, and 120 min after the i.v. challenges. Baseline quantification of IB and OMD was performed at identical intervals on randomized days of the trial. Significant improvement of the IB scores was found in response to biperiden and clonazepam and a trend toward improvement in response to lisuride (Wilcoxon test). Evaluation of the individual IB scores of each patient following the various drug challenges failed to predict the therapeutic potential of these drugs for subsequent oral treatment.

Primary CNS lymphoma presenting as a choreic movement disorder followed by segmental dystonia

Clinical presentation of primary CNS lymphoma with an extrapyramidal movement disorder has not been recorded. A 66-year-old woman presented with chorea involving her left arm and subsequently developed right-sided segmental dystonia with prominent hemifacial dystonic spasms, milder torticollis and dystonia of the right arm. Investigations revealed primary CNS lymphoma with extensive involvement of the right-sided basal ganglia as well as lesions confined to the head of the left caudate nucleus and the corpus callosum. Chorea of her left arm subsided with progressing disease while remission of right-sided segmental dystonia was observed following radiotherapy of the brain. This patient's findings and a review of the literature suggest a possible relation between cranio-cervical dystonia and pathology affecting the head of the caudate nucleus.