KCNMA1-related refractory status epilepticus responding to vagal nerve stimulation: Case report and literature review

Epilepsy, one of the most prevalent chronic neurological diseases, can cause severe morbidity as well as mortality. A mutation of the KCNMA1 gene results in a rare genetic disease that causes epilepsy as its core presentation. Both neurological and non-neurological manifestations have been reported in patients with KCNMA1 gene mutation. We are reporting a KCNMA1 gene variant referred to as c.2369C>T (p. Pro790Leu), which encodes the subunit of alpha of calcium-sensitive potassium channels, which causes epilepsy but not dyskinesia in a young Saudi female who is the daughter of consanguineous parents. Our case shows that calcium-sensitive potassium channels can cause an isolated generalized epilepsy as reported previously in a single case. Moreover, this case aids in delineating the clinical and structural picture and the treatment of the KCNMA1 gene mutation in patients.

Klüver-Bucy syndrome secondary to a nondominant middle cerebral artery ischemic stroke: a case report and review of the literature

Background

Klüver–Bucy syndrome is a rare and complex neurobehavioral cluster that occurs in humans and results from a temporal lobe lesion. It can be associated with a variety of causes. Stroke is a rarely reported cause of this syndrome.

Case presentation

In this report, we present the case of a 68-year-old Saudi male who developed Klüver–Bucy syndrome subsequent to a nondominant middle cerebral artery ischemic stroke involving right temporal lobe. The patient manifested most of the Klüver–Bucy syndrome clinical features, including hypersexuality, hyperphagia, hyperorality, and visual hypermetamorphosis (excessive tendency to react to every visual stimulation with a tendency to touch every such stimulus). These neurobehavioral manifestations improved after he was started on treatment.

Conclusions

The clinical course, anatomical association relying on pathophysiology, and potential treatment have all been deliberated in regard to the rare occurrence of Klüver–Bucy syndrome resulting from temporal lobe pathology.

Biotin-responsive basal ganglia disease revisited: clinical, radiologic, and genetic findings

OBJECTIVE

To investigate the clinical, genetic, and neuroradiologic data of biotin-responsive basal ganglia disease (BBGD) and clarify the disease spectrum.

METHODS

We first investigated all patients attending our Division of Pediatric Neurology with a genetically proven diagnosis of BBGD between 2009 and 2011. All patients underwent a detailed medical history and clinical examination, extensive laboratory investigations including genetic tests, and brain MRI. Finally, we conducted a systematic review of the literature.

RESULTS

We enrolled 10 patients meeting the diagnostic criteria for BBGD, and analyzed the data on 14 patients from 4 previous reports. The BBGD occurred predominantly in preschool/school-aged patients in the Saudi population, but it was also observed in other ethnic groups. The typical clinical picture consisted of recurrent subacute encephalopathy leading to coma, seizures, and extrapyramidal manifestations. The brain MRI typically showed symmetric and bilateral lesions in the caudate nucleus and putamen, infra- and supratentorial brain cortex, and in the brainstem. Vasogenic edema characterized the acute crises as demonstrated by diffusion-weighted imaging/apparent diffusion coefficient MRI. Atrophy and gliosis in the affected regions were observed in patients with chronic disease. Early treatment with a combination of biotin and thiamine resulted in clinical and neuroradiologic improvement. Death and neurologic sequelae including dystonia, mental retardation, and epilepsy were observed in those who were not treated or were treated late.

CONCLUSION

BBGD is an underdiagnosed pan-ethnic treatable condition. Clinicians caring for patients with unexplained encephalopathy and neuroimaging showing vasogenic edema in the bilateral putamen and caudate nuclei, infra- and supratentorial cortex, and brainstem should consider this disorder early in the hospital course because a therapeutic trial with biotin and thiamine can be lifesaving.

Citalopram, a selective serotonin reuptake inhibitor augments harmaline-induced tremor in rats

Citalopram, a serotonin reuptake inhibitor (SSRI) is one of the widely used antidepressants. Apart from its antidepressant activity citalopram is also used for anxiety, panic disorders, obsessive-compulsive disorder and behavioral disturbances of dementia. Tremor is the second most common neurological adverse effect in patients receiving treatment with SSRIs. Use of these agents in depressed patients with essential tremor has not been studied. The present study was undertaken to investigate the effect of chronic citalopram treatment on harmaline-induced tremors in rats. Female Sprague-Dawley rats weighing 70+/-2 g were given citalopram in doses of 0, 10, 20 and 40 mg/kg by gavage for 2 weeks. On the 15th day, the rats were given harmaline (10 mg/kg, i.p.) 30 min after the last dose of citalopram. The latency of onset, intensity and duration of tremor and EMG were recorded. Serotonin (5HT) and 5-hydroxy indole acetic acid (5HIAA) were measured in brain stem. Citalopram dose dependently exacerbated the duration, intensity and amplitude of EMG of harmaline-induced tremor. A significant decrease in 5HT turnover (5HIAA/5HT ratio) in the brain stem was observed suggesting a possible role of serotoninergic impairment in citalopram-induced augmentation of harmaline-induced tremor. Clinical implications of these observations warrant further investigation.

2-deoxy-D-glucose attenuates harmaline induced tremors in rats

Neuronal hyperactivity in essential tremor is accompanied by high energy demand in cerebellum, medulla and the thalamus. It has been suggested that brain regions that have increased metabolic demands are highly vulnerable to interruptions in glucose metabolism. In the present investigation attempt was made to study the effect of 2-deoxyglucose (2DG) a glycolytic pathway inhibitor on harmaline induced tremor in rats. Wistar rats of either sex weighing 100+/-3 g were given harmaline (10 mg/kg, i.p.) alone or along with 2DG (15 min before harmaline) in doses of 300, 600 and 900 mg/kg, respectively. The latency of onset, intensity and duration of tremor following harmaline administration were recorded. Neurobehavioral responses, electromyography (EMG) and levels of blood glucose and cerebellar serotonin (5HT) were determined after 40 min of harmaline administration. 2DG significantly and dose dependently attenuated severity of harmaline induced tremors and amplitude of EMG. Treatment of rats with 2DG alone reduced the locomotor activity, however, no significant change was observed in grip strength, landing foot splay, air righting reflex and response to tactile stimuli. Harmaline alone and along with 2DG had no effect on behavioral parameters except a decrease in landing foot splay. 2DG produced a dose-dependent hyperglycemia and attenuated harmaline induced increase in cerebellar 5HT levels. Our results clearly suggest the protective effect of 2DG in harmaline induced tremor. Further studies are warranted to assess the role of glucoprivation in the suppression of neuronal excitability in tremors.

Effect of acute caffeine on severity of harmaline induced tremor in rats

Recent studies suggest an association between caffeine consumption and tremor. However, the available literature is scanty and inconclusive. The present study was undertaken to investigate the effect of acute caffeine treatment on harmaline induced tremors in the rat. Four groups of male Sprague-Dawley rats (six animals in each group) weighing 88+/-2 g were administered harmaline (10 mg/kg, intraperitoneally (i.p.)) for inducing experimental tremors. The rats in group 1 served as controls and received normal saline, whereas the animals in groups 2, 3 and 4 were given caffeine (i.p.) at doses of 50, 100 and 150 mg/kg, respectively 60 min after harmaline administration. The latency of onset, intensity and duration of tremor and electromyographic (EMG) responses were recorded. Treatment of rats with caffeine resulted in a significant increase in the intensity and duration of harmaline induced tremors. Caffeine also enhanced the EMG amplitude in harmaline treated animals. In conclusion, the results of this study suggest that acute treatment with caffeine significantly potentiates the severity of harmaline induced tremors in rats.

Baclofen attenuates harmaline induced tremors in rats

Recent experimental and clinical studies clearly suggest the role of gamma-aminobutyric acid (GABA) in the pathogenesis of tremors. The present study was undertaken to investigate the effect of baclofen, a GABA B receptor agonist on harmaline induced tremors. Four groups of female Wistar rats weighing 100+/-15 g were injected with harmaline (10 mg/kg, intraperitoneally) for inducing experimental tremors. The animals in groups 2, 3 and 4 were given baclofen by gavage at doses of 2.5, 5 and 10 mg/kg, respectively, half an hour before harmaline administration, whereas, the rats in group 1 served as control and received water. The latency of onset, intensity and duration of tremor and electromyographic (EMG) responses were recorded. Treatment with baclofen resulted in a dose dependent decrease in the intensity of tremor. Our EMG study also revealed a significant decrease in the amplitude of tremors in baclofen treated rats. A highly significant increase in latency of onset of tremor was observed in the rats treated with high dose (10 mg/kg) of baclofen only. This study clearly suggests beneficial effects of baclofen in harmaline induced tremors.

Diethyldithiocarbamate (DEDC) impairs neuronal recovery following sciatic nerve injury in rats

Purpose: Diethyldithiocarbamate (DEDC) is a substituted dithiocarbamate that is metabolically interconvertible with disulfiram (Ant-abuse). In recent years DEDC has received considerable attention because of its clinical applications and potential role in mediating both the toxic and therapeutic actions of disulfiram which is frequently used for alcohol aversion therapy. DEDC is known for its multiplicity of action that exerts both pro- and antioxidant effects. In rodents DEDC has been shown to produce neuroprotective as well as neurotoxic effects. The purpose of this study was to examine the effect of DEDC on neurological recovery following sciatic nerve crush injury (SNCI) in rats. Methods: Adult female Wistar rats were subjected to SNCI with a haemostat under deep anaesthesia. The animals were orally treated with DEDC at the doses of 250 mg/kg, 500 mg/kg and 750 mg/kg body weight 1 hr before SNCI and then once daily for 60 days. The animals were observed for sciatic functional index (walking deficit), electrophysiological and histological changes. Vitamin E level was measured to deter-mine antioxidant status of sciatic nerve. Results: Crush injury to the sciatic nerve resulted in a significant impairment of functional response which gradually recovered over a period of 22 days. Treatment of animals with DEDC caused a significant delay in functional recovery which was accompanied by poor histo-logical and electrophysiological outcome. Prooxidant effect of DEDC is quite evident from a significant decrease in vitamin E levels in both injured and uninjured sciatic nerves. Conclusions: Our results demonstrate that exposure to DEDC adversely affects recovery from peripheral nerve injury. The delay may to some extent be attributed to DEDC induced oxidative stress.

Effect of aluminum on neurological recovery in rats following spinal cord injury

OBJECT

This investigation was undertaken to study the effect of aluminum on neurobehavioral, electrophysiological, structural, and biochemical changes in rats following spinal cord injury (SCI).

METHODS

Adult male Sprague-Dawley rats classified into different groups were given aluminum sulfate-dosed drinking water in the concentrations of 0%, 0.25%, 0.5% and 1%, respectively. After 30 days of aluminum treatment, the animals were subjected to spinal cord trauma. Laminectomy was performed at T7-8 in anesthetized rats, followed by placement of a compression plate (2.2 x 5 mm) loaded with a 35-g weight over the exposed spinal cord for 5 minutes. Control animals underwent the same surgical procedure, but the compression injury was not induced (sham). Postoperative neurological function was assessed using the inclined-plane test and by obtaining a modified Tarlov score and vocal/sensory score daily for 10 days. Electrophysiological changes were assessed using corticomotor evoked potentials, whereas pathological changes were assessed by light microscopy. The level of vitamin E in the spinal cord was measured as an index of antioxidant defense. The behavioral, biochemical, and histological analyses were performed in a blinded fashion.

CONCLUSIONS

Analysis of results obtained in the behavioral studies revealed that the compression of spinal cord produced transient paraparesis in which a maximum motor deficit occurred at Day 1 following SCI and resolved over a period of 10 days. Administration of aluminum significantly impaired the recovery following SCI. Analysis of the results of the biochemical, electrophysiological, and histopathological studies also confirmed the deleterious effects of aluminum on recovery from SCI in rats.

Attenuation of acrylamide-induced neurotoxicity in diabetic rats

In recent years, an increasing number of cases of neuropathy have been reported as a result of accidental or occupational exposure to chemicals. Acrylamide (Acr), a widely used industrial chemical, is known to produce peripheral neuropathy that resembles diabetic neuropathy in many ways. However, the interaction between diabetes and Acr has not been studied. The present study was undertaken to examine the effect of streptozotocin (STZ)-induced diabetes on Acr-induced neurotoxicity in rats. Male Sprague-Dawley rats weighing 300 +/- 10 g were divided into four groups of 10 animals each. The rats in group 1 served as control, and received normal saline. The animals in group 2 were given Acr dissolved in physiological saline (50 mg/kg IP 3 days/week) for 2 weeks. The rats in group 3 and 4 were made diabetic by administering a single IP injection of STZ (50 mg/kg). The animals in group 3 served as diabetic control, whereas the rats in group 4 received Acr in the same dose regimen as in group 2, a week after induction of diabetes. Neurobehavioral responses including foot print length, hind limb function, landing foot splay, and the ability to stay on an inclined plane were assessed 48 h after the last dose of Acr followed by electrophysiological measurements. The animals were then sacrificed, and sciatic nerves were collected for biochemical analysis. The results of this study clearly showed a significant deterioration of neurobehavioral and electrophysiological responses in Acr-treated rats. Although no significant change in these parameters was observed in the diabetic (only) group, Acr-induced functional deficiency was significantly reduced in diabetic animals. However, the difference in electrophysiological response in Acr-treated diabetic and nondiabetic rats was not found to be statistically significant (p 0.05). The precise mechanism by which Acr induced neurobehavioral toxicity is reduced in diabetic animals warrants further investigations.

Effect of lidocaine on harmaline-induced tremors in the rat

The present study was undertaken to investigate the effect of lidocaine on harmaline-induced tremors in the rat. Four groups of Wistar rats weighing 45-50 g were injected with harmaline (50 mg/kg i.p.) for inducing experimental tremors. The rats in group 1 served as control, whereas the animals in groups 2, 3, and 4 were also given lidocaine i.p. at doses of 12.5, 25, and 50 mg/kg, respectively, 10 min after the onset of tremors (therapeutic study). In a separate four groups of animals intraperitoneal lidocaine injection was given 10 min before harmaline (prophylactic study) in the same dose regimen as mentioned above. The latency of onset, intensity, and duration of tremor and electromyographic responses were recorded. Lidocaine dose dependently attenuated harmaline-induced tremors in rats. The latency period was increased, and duration and intensity of harmaline-induced tremors was reduced by lidocaine. Our electromyography (EMG) study also revealed a decrease in the amplitude of harmaline-induced tremors in lidocaine-treated rats. In conclusion, the results of this study clearly suggest beneficial effects of lidocaine in harmaline-induced tremors.

Diethyldithiocarbamate (DEDC) impairs neuronal recovery following sciatic nerve injury in rats

PURPOSE

Diethyldithiocarbamate (DEDC) is a substituted dithiocarbamate that is metabolically interconvertible with disulfiram (Ant-abuse). In recent years DEDC has received considerable attention because of its clinical applications and potential role in mediating both the toxic and therapeutic actions of disulfiram which is frequently used for alcohol aversion therapy. DEDC is known for its multiplicity of action that exerts both pro- and antioxidant effects. In rodents DEDC has been shown to produce neuroprotective as well as neurotoxic effects. The purpose of this study was to examine the effect of DEDC on neurological recovery following sciatic nerve crush injury (SNCI) in rats.

METHODS

Adult female Wistar rats were subjected to SNCI with a haemostat under deep anaesthesia. The animals were orally treated with DEDC at the doses of 250 mg/kg, 500 mg/kg and 750 mg/kg body weight 1 hr before SNCI and then once daily for 60 days. The animals were observed for sciatic functional index (walking deficit), electrophysiological and histological changes. Vitamin E level was measured to deter-mine antioxidant status of sciatic nerve.

RESULTS

Crush injury to the sciatic nerve resulted in a significant impairment of functional response which gradually recovered over a period of 22 days. Treatment of animals with DEDC caused a significant delay in functional recovery which was accompanied by poor histo-logical and electrophysiological outcome. Prooxidant effect of DEDC is quite evident from a significant decrease in vitamin E levels in both injured and uninjured sciatic nerves.

CONCLUSIONS

Our results demonstrate that exposure to DEDC adversely affects recovery from peripheral nerve injury. The delay may to some extent be attributed to DEDC induced oxidative stress.

Effect of acrylamide on neurological recovery following spinal cord injury in rats

Acrylamide (ACR) is a cumulative neurotoxin which causes axonal degeneration in animals and man. Industrial workers exposed to ACR have been reported to suffer from a variety of central and peripheral neuropathological symptoms including numbness of hands and feet, skin peeling and muscular weakness of legs. These reports suggest that the body burden of ACR may be a risk factor in recovery patterns following neurotrauma. The present study was designed to assess the effect of ACR on neurological recovery following spinal cord injury (SCI) in rats. Male Sprague-Dawley rats weighing 200-230 g were anaesthetised with chloral hydrate and laminectomy was performed at T 7-8 level leaving the dura intact. A compression plate (2.2 x 5.0 mm) loaded with a weight of 35 g was placed on the exposed cord for 5 minutes. Animals were divided into seven groups of eight rats each. The animals in Group 1 served as control whereas rats in Group 2 underwent laminectomy alone (sham). The rats in Group 3 to 6 were subjected to SCI as mentioned above. Animals in Groups 4, 5 and 6 also received ACR in the doses of 10 mg/kg, 20 mg/kg and 40 mg/kg, i.p., respectively in addition to SCI, whereas the rats in Group 7 received ACR alone at a dose of 40 mg/kg body weight. The first dose of ACR was given 30 minutes before SCI, followed by daily administration of drug for 7 days. Post traumatic neurological recovery was recorded daily for 10 days using a modified Tarlov score, inclined plane test and sensory and vocal score. Electrophysiological changes were assessed using somatosensory and corticomotor evoked potentials. The animals were sacrificed at different time intervals and the injured site of the spinal cord was analysed for lipid hydroperoxides (LPH), conjugated dienes (CD) and glutathione (GSH). Neuropathological changes in the spinal cord were assessed using light microscopy. The rats exposed to compression injury alone showed a maximum neurological deficit at 24 hr and then a gradual recovery was observed over a period of 10 days. The rats treated with ACR along with SCI showed poor or no recovery over a period of 10 days. Our electrophysiological and histopathological studies also confirmed that concomitant exposure to ACR produces a significant deleterious effect on the recovery from SCI. SCI induced increase in oxidative stress (increase in LPH and CD and decrease in GSH) is also exacerbated by ACR suggesting a role of free radicals. The results of this study suggest that increased body burden of ACR may retard the recovery from neurotrauma or even lead to permanent disability.

Neurological recovery in diabetic rats following spinal cord injury

This study was designed to assess the effect of spinal cord injury on neurobehavioral, electrophysiological, structural, and biochemical changes in normal and diabetic rats. Experimental diabetes was induced in Sprague-Dawley male rats (weighing 250-280 g) with streptozotocin (50 mg/kg i.p.). Eight weeks after the treatment with streptozotocin the animals were anaesthetized with chloral hydrate and laminectomy was performed at T 7-8 level leaving the dura intact. A compression plate (2.2 x 5.0 mm) loaded with a weight of 35 g was placed on the exposed spinal cord for 5 min. Postoperative neurological function was assessed using inclined plane test, modified Tarlov score, and vocal and sensory score daily for 10 days. Electrophysiological changes were assessed using somatosensory and corticomotor evoked-potentials. The animals were sacrificed at different time intervals and injured site of the spinal cord was analyzed for changes in vitamin E and glutathione levels (as markers of oxidative stress). Pathological changes in spinal cord were also studied using light microscopy. The data on neurobehavioral study clearly indicated that the compression of spinal cord produced highly significant neurological deficit and poor recovery in diabetic rats as compared to nondiabetic rats. Our histopathological and electrophysiological results also confirmed that diabetic animals are more susceptible to compressive spinal cord injury as compared to nondiabetic animals. A higher depletion of antioxidant defense markers (vitamin E and glutathione) was observed in diabetic rats as compared to nondiabetic rats. These results point toward the role of free radicals in poor recovery in diabetic rats following neurotrauma. Further studies are warranted to assess the neuroprotective potential of antioxidants to retard the secondary pathophysiological events following neurotrauma and to enhance the recovery.

Schwartz-Jampel syndrome: evidence of central nervous system dysfunction

We report four patients with Schwartz-Jampel syndrome showing evidence of central conduction impairment documented by somatosensory evoked potentials. Median nerve somatosensory evoked potential showed normal latencies to Erb's point and N13 in all patients. Interpeak latencies between N13 and N19 were prolonged in five nerves, with complete block in three nerves. Posterior tibial nerve somatosensory evoked potentials were performed in three patients. Peripheral latencies were normal in all patients. Interpeak latencies between lumbar and cervical potentials were prolonged in two patients, with conduction delay between cervical and cortical potentials in five of the six nerves tested. Visually evoked potentials, brainstem auditory evoked potentials, electromyography, and nerve conduction velocity studies were normal in all patients. Parents' median nerve and posterior tibial nerve somatosensory evoked potentials were normal.

Guillain-Barre syndrome: a series observed at Riyadh Armed Forces Hospital January 1984--January 1994

A consecutive series of 47 hospitalized cases of Guillain-Barre syndrome seen over a 10-year period was analysed with respect to: (1) age and sex; (2) antecedent events and seasonal distribution; (3) patterns of clinical presentation; (4) CSF and neurophysiological findings; (5) results of treatment with plasma exchange; and (6) outcome. Twenty-two were children, 20 middle-aged and 5 aged; 37 were male and 10 were female. The most frequent antecedent event was upper respiratory tract infections; a seasonal peak incidence was found in winter. Clinical, CSF and neurophysiological findings concurred with those in the Western literature; 79% of the cases were severe. Plasma exchange performed within the first 2 weeks of onset benefitted in the short-term outcome, i.e. improvement by 1 grade at 4 weeks, but the long-term benefit, i.e. the ability to regain independent locomotion, was questionable. Plasma exchange helped in curtailing the time to walking unaided but had no benefit on the duration of artificial ventilation. Factors associated with an adverse outcome were: age over 15 years, severity of motor electrodiagnostic findings (especially a decreased distal CMAP amplitude and EMG signs of acute denervation), requirement for ventilation and slow progression (>3 weeks) to maximum deficit. After a mean follow-up of 11 months, 55% of the patients regained independent locomotion, which is a comparatively low proportion.

The effect of nimodipine on essential tremor

We investigated the effect of nimodipine (30 mg qid) in 16 de novo patients with essential tremor in a double-blind placebo-controlled study in which we assessed tremor by clinical scorings, tremorgraphic recordings, and patient self-evaluation. Of the 15 patients who completed the study, eight improved. We conclude that nimodipine is effective in some patients with essential tremor.

Post-heatstroke parkinsonism and cerebellar dysfunction

A case is presented of a 45-year-old woman who developed parkinsonism, cerebellar dysfunction, aphasia and flaccid paralysis secondary to heat stroke. Magnetic resonance imaging revealed irregular patchy areas of increased signal intensity in the white matter of both cerebral hemispheres and the left striatum, remaining unchanged over a follow-up period of two years. Cerebellar atrophy, while not seen on initial examination, was present on the follow-up study done one year later and became more marked after two years.

Long-term therapy of essential tremor with flunarizine

We investigated the effect of long-term treatment of essential tremor (ET) with flunarizine (Fz) (10 mg/day) in 17 subjects who had a favorable response to 1 month of treatment. Side effects (dystonia, parkinsonism, weight gain and depression) occurred in 29.4% (5/17) of patients, leading to drug discontinuation. Fz was still effective at the end of 30 months of treatment in 41% (7/17) of patients. Loss of efficacy was observed in 29.4% (5/17) of patients. It is concluded that Fz is an alternative for long-term treatment of patients with ET; however, loss of efficacy and side effects are common.

Posttraumatic paroxysmal nocturnal hemidystonia

The term "nocturnal paroxysmal dystonia" has been used to describe patients who display paroxysmal episodes of dystonic-dyskinetic movements arising during nonrapid eye movement sleep, in particular stages 2-3 (Lugaresi E, Cirignotta F. Hypnogenic paroxysmal dystonia: epileptic seizure or a new syndrome. Sleep 1981;4: 129-138). The pathogenesis of these attacks has remained controversial. We describe a patient with posttraumatic paroxysmal nocturnal hemidystonia. Acetazolamide led to improvement.

Choroido-cerebral calcification syndrome with retardation

We present a sibship with a rare syndrome characterized by mental retardation, dense calcification of the lateral ventricular choroid plexus, and increased CSF protein. Neurophysiologic studies yielded nonspecific results, and endocrine studies, including parathormone levels, were normal. Simultaneous measurements of CSF and serum calcium, magnesium, and other electrolytes were normal, but the CSF/serum ratio of phosphate was low, suggesting a possible role in the pathogenesis of this syndrome.

Idiopathic long QT syndrome: asking the right question

Infants and young children cannot describe symptoms of cardiogenic syncope accurately. If the attention in such cases is focused on the seizure activity that may follow, the patient will be treated inappropriately with anticonvulsants. We report such a presentation in 4 infants and young children (ages 6 to 48 months) with idiopathic long QT syndrome. All patients presented with recurrent seizures. All patients had a corrected QT interval (QTc) > or = 0.44 s and none had deafness. The diagnosis was suspected by careful history-taking which revealed episodes of loss of consciousness before convulsions in all patients. All patients were treated successfully with propranolol and remained free of symptoms during the follow-up period of 1-2 years. Screening the other family members revealed a prolonged QTc in 9 out of 16, and a history of 3 sudden and unexplained deaths in two families.

Flunarizine in migraine: a double-blind placebo-controlled study (in a Saudi population)

We evaluated the effect of flunarizine (Fz) (10 mg/d) on migraine in a double-blind placebo-controlled design. The attacks' frequency, duration, severity and associated symptoms were compared before and after treatment. Forty-two patients completed a three-month trial period; 21 patients received Fz and 21 placebo. Statistical analysis showed no significant difference between Fz and placebo (p > 0.05). In this study Fz was not more efficient than placebo in migraine.

Intractable hiccup induced by brainstem lesion

Four patients with brainstem lesions presented with intractable hiccup and mild to moderate neurological signs. Two of the patients had been initially diagnosed as having a psychogenic cause for their hiccup. Magnetic resonance imaging (MRI) demonstrated brainstem infarction in one case, tuberculoma at the junction of the medulla oblongata and the cervical spinal cord in two, and a vermian tuberculoma compressing the brainstem in one. The brainstem infarct and one of the medullary tuberculoma were not detected on high resolution enhanced computed tomography. The 3 patients with CNS tuberculoma were free of hiccup 1-5 months after antituberculous chemotherapy. It is proposed that hiccup is not an abnormal reflex, but a myoclonus generated by repetitive activity of the "inspiratory solitary nucleus" due to release of higher nervous system inhibitory/-regulatory control. The neuroanatomical network and the mechanisms underlying the formation of intractable hiccup are outlined. The value of MRI in the initial diagnosis and follow-up of patients with intractable hiccup due to brainstem lesions is emphasised.

The effect of flunarizine on essential tremor

We investigated the effect of flunarizine treatment (10 mg/d) in 17 subjects with essential tremor in a double-blind placebo-controlled design. Tremor was assessed by clinical scoring, tremographic recordings, and subjective rating by subjects. Of the 15 subjects who completed the study, 13 showed improvement. We conclude that flunarizine is effective treatment for essential tremor.

Correlation between essential tremor and migraine headache

The relationship between essential tremor (ET) and migraine was investigated in a prospective study. In a group of 74 ET patients 36.5% had migraine compared with 17.7% of 102 control subjects without tremor. In a group of 58 patients with migraine 17.2% had ET compared with 1.2% of 85 controls without migraine. The prevalence of ET in migraine controls was greater than controls without migraine (22% compared with 1%; p = 0.002). It is concluded that there is an association between essential tremor and migraine.

Post-traumatic tremor

We present seven cases of tremor caused by mild head injury without loss of consciousness. The interval between head trauma to onset of symptoms was 1 to 4 weeks. A posture and kinetic tremor of the hands and head occurred unassociated with other neurologic signs. Myoclonic-like jerking was frequently present. Neuroimaging studies were normal. Clonazepam administration resulted in tremor reduction in three patients and propranolol decreased tremor in one patient. A tremor, similar to essential tremor, can be a rare complication of head trauma.

A double-blind trial of clonazepam in the treatment of parkinsonian dysarthria

We studied the effect of clonazepam in a double-blind trial on 12 parkinsonian patients with hypokinetic dysarthria. Speech samples were judged on 14 of the dimensions used in the Mayo Clinic dysarthria study. Of the 11 patients who completed the study, 10 showed improvement. The effective dosage of clonazepam was 0.25 to 0.5 mg/d with higher dosage than that less effective. Clonazepam has a definite role in the management of parkinsonian dysarthria.

Essential tremor variants: effect of treatment

Essential tremor may not represent a single condition. Subclassifications include kinetic predominant tremor; combined resting-postural tremor; primary writing tremor; isolated voice, chin, or tongue tremor; and orthostatic truncal tremor. We report patients with these disorders. An association of these conditions with essential tremor is suggested by a high occurrence of a family history of essential tremor, frequent presence of a mild postural tremor, and tremor reduction with alcohol ingestion. Pharmacologic responsiveness is different for these disorders. Propranolol and primidone often have beneficial effects but clonazepam was the only drug effective in some cases of kinetic predominant tremor and in orthostatic truncal tremor. Combined resting-postural tremor and voice tremor were often unresponsive to treatment.

Kinetic predominant essential tremor: successful treatment with clonazepam

Fourteen patients with marked kinetic tremors of long duration but no other major neurologic signs are described. A positive family history of essential tremor, mild postural tremor, and tremor suppression with alcohol suggest that the condition is a variant of essential tremor. Kinetic tremors had a frequency of 3.5 to 6.0 Hz and an alternating EMG pattern. Propranolol caused improvement in some patients, but clonazepam treatment resulted in tremor suppression in all patients. Kinetic tremor without cerebellar signs is a subtype of essential tremor with pharmacologic responsiveness to clonazepam.

Essential tongue tremor

Twenty patients with tongue tremor associated with essential tremor are reported. Patients were unaware of the tongue tremor, and voice disturbance was a complaint in only one patient. Three patients had an isolated tongue tremor. Hand tremor was present in 16 patients. Dystonia, myoclonus, and tremor of other body parts were present in some patients. Three patients had a mild-to-moderate dysarthria. The frequency of tongue tremor (4-8 Hz) was identical to hand tremor. The intravenous infusion of ethanol suppressed tongue tremor. Therapy with propranolol, primidone, or clonazepam also reduced tongue tremor amplitude. Tongue tremor is a common finding in some essential tremor patients but often there are no symptoms.

Disability in essential tremor: effect of treatment

We studied 18 patients with essential tremor for difficulty with handwriting, drinking, eating, fine manipulations, and embarrassment. Propranolol and primidone reduced the amplitude of both postural and kinetic tremor. Handwriting, drinking, and eating were improved with therapy, but fine manipulations and motor performance on tapping and pegboard tests were unaltered. Embarrassment remained unchanged. Essential tremor is not a benign condition; disability can be only partly reversed with drug therapy.

Handedness and essential tremor

In patients with essential tremor, a direct relationship was found between hand dominance and severity of hand tremor. A higher incidence of left-handedness was found in patients with essential tremor than in controls.

Effect of alcohol on dystonia

An intravenous infusion of a 250-ml, 10% ethanol solution decreased dystonic scores in five of seven patients with spasmodic torticollis, but had no effect in patients with Meige syndrome, tardive dystonia, or generalized torsion dystonia. Alcohol may temporarily decrease some forms of dystonia.

Metoprolol compared with propranolol in the treatment of essential tremor

We analyzed effects of metoprolol tartrate and propranolol hydrochloride on 23 patients with essential tremor. Tremor was assessed by patient self-evaluation, clinical scoring, and tremorgrams. Ten of 20 patients had tremor reduction with propranolol. Metoprolol decreased tremor in 13 of 23 patients, including three patients with asthma in whom propranolol had caused respiratory distress. Adverse reactions were infrequent. Individual patients either responded to both propranolol and metoprolol or to neither drug. Patient age, duration of tremor, tremor frequency, family history, or response to intravenous ethyl alcohol did not distinguish responders from nonresponders.

Effect of alcohol on tremors: comparison with propranolol

Intravenous administration of alcohol decreased postural essential tremor but not parkinsonian resting or cerebellar intention tremor. The response to alcohol infusion occurred in all 15 patients studied, whereas only 11 of the 15 had a response to propranolol therapy. Furthermore, the response to ethanol was greater than that due to propranolol.

Estrogen treatment of dyskinetic disorders

Estrogen have been reported in animal studies to both enhance and block central dopaminergic activity and in one clinical report to improve tardive dyskinesia. In the present study estrogen (Premarin, 2.5 mg per day) administration caused varying degrees of improvement in less than one-third of 21 patients with chorea due to Huntington's disease and tardive dyskinesia and had no effect in eight patients with dystonia. Estrogens appear to have an antidopaminergic effect in humans but poses only limited efficacy in the treatment of dyskinetic disorders.