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Stereotactic and Functional Neurosurgery Jun 2024In tremor syndromes, pharmacological therapy is the primary treatment, but deep brain stimulation (DBS) is used when it is insufficient. We explore the use of DBS,...
INTRODUCTION
In tremor syndromes, pharmacological therapy is the primary treatment, but deep brain stimulation (DBS) is used when it is insufficient. We explore the use of DBS, focusing on the globus pallidus internus for dystonia and the ventral intermediate nucleus (VIM) for tremor conditions. We introduce the posterior subthalamic area (PSA) as a potential target, suggesting its efficacy in tremor reduction, particularly in rare tremor syndromes. We aim to evaluate the efficacy and safety of double targeting the VIM and PSA in rare tremor conditions, highlighting the limited existing data on this.
METHODS
Between 2019 and 2023, 22 patients with rare tremor syndromes were treated with bilateral DBS of the VIM and PSA. This case series consisted of 7 isolated head tremor, 1 hepatic encephalopathic tremor due to Abernethy syndrome, 2 voice tremor, 4 dystonic tremor, and 8 Holmes tremor (2 multiple sclerosis, 2 cerebellar insult, and 4 posttraumatic) patients. Patients' preoperative and 12-month postoperative tremor scores were compared, and the optimum VIM and PSA stimulation areas were investigated.
RESULTS
There was a significant reduction in the mean TRS score from 3.70 (±0.57) to 0.45 (±0.68) after 12 months of surgery. Specific outcomes for different indications were observed: for head tremor, 6 of 7 patients showed a reduction in TRS scores to 0 points; the vocal tremor patients demonstrated improvement; this change was not statistically significant, which is likely to be due to the low number of patients in this subgroup; the dystonic tremor patients showed either complete tremor abolition or a reduction in TRS scores; the Holmes tremor patients showed an 80% reduction in TRS scores; and the hepatic encephalopathy tremor and Abernethy syndrome patients showed a 75% improvement in TRS scores. The stimulation parameters converged on the VIM and dorsal PSA. Complications included the need for electrode repositioning, infections requiring electrode removal and re-implantation, dysarthria, and stimulation-induced ataxia, which was resolved by adjusting the stimulation parameters.
DISCUSSION
The literature on DBS for rare tremors is limited. Double targeting of the VIM and PSA appears to produce promising improvements on the outcomes reported in the existing literature on VIM-only DBS. The proximity of the VIM and PSA allows for flexible electrode placement, contributing to the potential success of the dual-target approach. We also discuss the theoretical advantages of targeting the PSA based on the distribution of tremor circuits, emphasizing the need for further research and electrophysiological studies.
PubMed: 38934181
DOI: 10.1159/000539162 -
Annals of Clinical and Translational... Jun 2024
PubMed: 38924327
DOI: 10.1002/acn3.52130 -
Expanded-access use of elamipretide in a patient with membrane protein-associated neurodegeneration.Clinical Case Reports Jul 2024This case report presents a progressively declining 17-year-old patient with membrane protein-associated neurodegeneration who demonstrated symptomatic improvements in...
This case report presents a progressively declining 17-year-old patient with membrane protein-associated neurodegeneration who demonstrated symptomatic improvements in her dysarthria, dysphagia, and gait, and objective improvements in her 6-minute walk test and 5 times sit-to-stand test during elamipretide treatment.
PubMed: 38919884
DOI: 10.1002/ccr3.9116 -
Pediatric Neurology Jun 2024Since the initial description of glucose transporter-1 deficiency syndrome (Glut1-DS) the phenotype of the condition has expanded, even leading to the recognition of...
BACKGROUND
Since the initial description of glucose transporter-1 deficiency syndrome (Glut1-DS) the phenotype of the condition has expanded, even leading to the recognition of atypical manifestations. We report on eight patients with Glut1-DS who experienced at least one episode of acute focal neurological deficits.
METHODS
We conducted a retrospective analysis, collecting clinical, electrophysiological, neuroradiological, and genetic information. We focused in particular on three well-documented cases.
RESULTS
Among 42 patients with Glut1-DS, eight individuals aged between six and 38 years presented with an acute onset of neurological disturbances: dysarthria/aphasia, oral dyskinesia, swallowing difficulties, paresthesia, facial palsy, hemi/monoplegia, vomiting, headache, and behavioral disturbances. When performed, magnetic resonance imaging (MRI) revealed signs of venous congestion and hypoperfusion and electroencephalography showed focal contralateral slowing. Deficits were transient in all patients but one. Four patients (50%) were on a ketogenic diet (KD), and two of these patients had lower than usual ketonemia levels during the episode. In two patients, MRI demonstrated the presence of an ischemic brain lesion.
CONCLUSIONS
In Glut1-DS, stroke-like episodes are a recurrent manifestation, particularly during early adulthood, and they were reported in 19% of the patients in our cohort. Stroke mimics should be considered a key feature of Glut1-DS, as other paroxysmal disorders. It remains to be established whether a KD can prevent the recurrence of episodes and, if so, at what level of ketosis. Further observations are needed to confirm the correlation between Glut1-DS and ischemic stroke.
PubMed: 38914025
DOI: 10.1016/j.pediatrneurol.2024.05.024 -
BMJ Neurology Open 2024Dystonia is a genetic or non-genetic movement disorder with typical patterned and twisting movements due to abnormal muscle contractions that may be associated with...
BACKGROUND
Dystonia is a genetic or non-genetic movement disorder with typical patterned and twisting movements due to abnormal muscle contractions that may be associated with tremor. Genetic and phenotypic heterogeneity leads to variable clinical presentation.
METHODOLOGY
Next-generation sequencing technologies are being currently used in the workup of patients with inherited dystonia to determine the specific cause in the individuals with autosomal dominant, recessive, X-linked or mitochondrial inheritance patterns. Calcium voltage-gated channel subunit alpha1 A (CACNA1A) gene variants are rare in dystonias.
RESULTS
We here present a 20-year-old man with a history of delayed milestones, flexor posturing, dysarthria, dysphagia and a negative family history from consanguineous parents. Neurological examination revealed right lateral scoliosis of the neck and generalised dystonic posturing affecting both upper and lower limbs. MRI of the brain was unremarkable. Molecular genetic results revealed a heterozygous variant in the CACNA1A gene (CHR19: NM_023035.2, c. 1602G>A; p. Met534Ile). Segregation analyses in both the parents revealed wild-type CACNA1A gene suggesting de novo nature of the variant with a likely pathogenic classification.
CONCLUSION
Dystonia is one of the clinical phenotypes that can be associated with CACNA1A gene mutations and we recommend that this gene either be included in the dystonia panel offered or tested when the initial primary genetic result is negative.
PubMed: 38912174
DOI: 10.1136/bmjno-2024-000710 -
NMC Case Report Journal 2024We present a case of pontine infarction caused by subclavian steal phenomenon (SSP) due to subclavian artery stenosis (SAS) and an arteriovenous shunt in the forearm in...
We present a case of pontine infarction caused by subclavian steal phenomenon (SSP) due to subclavian artery stenosis (SAS) and an arteriovenous shunt in the forearm in a 74-year-old man with hemodialysis and stenting for SAS with improvement of SSP. He developed dysarthria during dialysis. He was admitted to our hospital and diagnosed with a pontine infarction. As the basilar artery appeared to be occluded on magnetic resonance angiography, an emergency diagnostic angiography was performed. Aortagram showed severe stenosis of the left subclavian artery. Right vertebral artery (VA) angiogram revealed retrograde arterial blood flow from the right VA to the left VA via the VA union, which suggested SSP. In addition, the steal was augmented by an ipsilateral hemodialysis arteriovenous shunt. Percutaneous subclavian artery stenting was performed 12 days later, and there was no recurrence of symptoms in the follow-up period. To our knowledge, this study is the first to report a patient with SSP who developed a pontine infarction due to SAS and an arteriovenous shunt during hemodialysis and who underwent subclavian artery stenting and had a good outcome.
PubMed: 38911923
DOI: 10.2176/jns-nmc.2024-0004 -
Journal of Radiology Case Reports 2024Traumatic intracranial ICA dissections are not commonly seen in children. Dissection resulting in perfusion deficit warrants intervention. Here we encountered a patient...
BACKGROUND
Traumatic intracranial ICA dissections are not commonly seen in children. Dissection resulting in perfusion deficit warrants intervention. Here we encountered a patient who experienced traumatic ICA dissection, treated by endovascular stenting.
METHODS
A 10-year-old female presented with aphasia and right sided weakness following trauma. Imaging showed deficit in the left MCA territory without core. Further imaging showed dissection of the left supraclinoid ICA, confirmed by digital subtraction angiography.
RESULTS
A Neuroform Atlas stent was placed without complication. All dysarthria and weakness had resolved on follow-up 5 months post-stenting.
CONCLUSIONS
Acute stroke symptoms in children can result in lasting deficits if not treated quickly. Medical management is regarded to be first line, depending on presentation. Endovascular stenting may provide a promising means to treat pediatric ICA dissections involving perfusion deficits and mitigate permanent ischemic changes.
Topics: Humans; Female; Stents; Child; Carotid Artery, Internal, Dissection; Endovascular Procedures; Angiography, Digital Subtraction; Cerebral Infarction; Reperfusion
PubMed: 38910586
DOI: 10.3941/jrcr.v18i1.5217 -
The American Journal of Case Reports Jun 2024BACKGROUND Papillary fibroelastoma is the most common type of benign primary cardiac tumor and is usually asymptomatic. However, tumor fragments or surface thrombus can...
BACKGROUND Papillary fibroelastoma is the most common type of benign primary cardiac tumor and is usually asymptomatic. However, tumor fragments or surface thrombus can embolize and cause transient ischemic attacks, strokes, or myocardial infarction. This report describes a 76-year-old woman who presented with dysarthria and right-sided weakness due to a stroke associated with a left atrial papillary fibroelastoma. CASE REPORT A 76-year-old woman visited the Emergency Department because she had right-sided weakness and dysarthria from 12 h ago. Brain magnetic resonance image was done at the Emergency Department, showing multiple small embolic, acute infarction in left basal ganglia and fronto-temporo-parietal lobes. Transthoracic and transesophageal echocardiogram showed a hypermobile echogenic mass (0.8×1.5 cm) with villous surface on the orifice of left atrial appendage. Twenty-four-hour Holter monitoring was performed to evaluate the cause of cerebral infarction, and there was no paroxysmal atrial fibrillation. Thoracic computed tomography angiography also showed a sea anemone-shaped mass around the left atrial appendage. Cardiac tumor excision was done via a lower partial sternotomy. Histopathologic analysis showed multiple delicate fronds, and the avascular fibroelastic cores were lined by a single layer of CD31-positive endothelial cells. Histopathologic findings were consistent with papillary fibroelastoma. The patient was discharged without any other complications on day 30 of hospitalization. CONCLUSIONS This case highlights the importance of cardiac imaging in patients with acute stroke, including transthoracic and transesophageal echocardiography, which can show the typical imaging features of papillary fibroelastoma and other intracardiac sources of embolus.
Topics: Humans; Female; Aged; Cardiac Papillary Fibroelastoma; Stroke; Heart Neoplasms; Heart Atria; Echocardiography, Transesophageal
PubMed: 38909277
DOI: 10.12659/AJCR.943568 -
Medicine Jun 2024This study aimed to characterize the risk factors, etiology, clinical manifestations, anatomical characteristics, stroke mechanisms, imaging features, and prognosis of... (Observational Study)
Observational Study
This study aimed to characterize the risk factors, etiology, clinical manifestations, anatomical characteristics, stroke mechanisms, imaging features, and prognosis of bilateral medial medullary infarction (BMMI). A retrospective analysis was conducted on 11 patients with BMMI who met the inclusion criteria at the Affiliated Hospital of Xuzhou Medical University from January 2013 to January 2023. The patients' imaging and clinical features were analyzed and summarized. Eleven patients (7 male, 4 female), aged 46 to 62 years, met the inclusion criteria. Common clinical presentations included dysarthria (90.9%), dysphagia (90.9%), quadriplegia (81.8%), and so on. Within 72 hours of onset, 8 cases presented with quadriplegia, 2 cases with hemiplegia, and 1 case without limb paralysis. The main risk factor for BMMI was hypertension, followed by diabetes. "Heart appearance" infarcts occurred in 4 cases (36.4%), while "Y appearance" infarcts occurred in 7 cases (63.6%). Among the patients, 3 had unilateral vertebral artery stenosis or occlusion, 5 had bilateral vertebral artery stenosis or occlusion, 2 had normal vertebral basilar artery, and 1 did not undergo cerebrovascular examination. All patients received standardized treatment for cerebral infarction. The prognosis was poor, with 81.8% of patients having an unfavorable outcome, including 1 death, 9 cases of disability, and only 1 patient achieving self-care ability after recovery. BMMI is more prevalent in males aged 45 to 60 years. The main risk factors are hypertension and diabetes. Atherosclerosis is the primary etiological subtype. The main clinical manifestations are dyskinesia, dizziness, quadriplegia, and dysarthria. The prognosis of BMMI is poor. The specific imaging features of "heart appearance" or "Y appearance" infarcts aid in the diagnosis of BMMI.
Topics: Humans; Male; Female; Middle Aged; Retrospective Studies; Medulla Oblongata; Brain Stem Infarctions; Risk Factors; Prognosis; Quadriplegia; Hypertension
PubMed: 38905383
DOI: 10.1097/MD.0000000000038336 -
Neurology Jul 2024Amyotrophic lateral sclerosis (ALS) is predominantly associated with motor cortex, corticospinal tract (CST), brainstem, and spinal cord degeneration, and cerebellar...
BACKGROUND AND OBJECTIVES
Amyotrophic lateral sclerosis (ALS) is predominantly associated with motor cortex, corticospinal tract (CST), brainstem, and spinal cord degeneration, and cerebellar involvement is much less well characterized. However, some of the cardinal clinical features of ALS, such as dysarthria, dysphagia, gait impairment, falls, and impaired dexterity, are believed to be exacerbated by coexisting cerebellar pathology. Cerebellar pathology may also contribute to cognitive, behavioral, and pseudobulbar manifestations. Our objective was to systematically assess both intracerebellar pathology and cerebrocerebellar connectivity alterations in a genetically stratified cohort of ALS.
METHODS
A prospective, multimodal neuroimaging study was conducted to evaluate the longitudinal evolution of intracerebellar pathology and cerebrocerebellar connectivity, using structural and functional measures.
RESULTS
A total of 113 healthy controls and 212 genetically stratified individuals with ALS were included: (1) hexanucleotide carriers ("C9POS"), (2) sporadic patients who tested negative for ALS-associated genetic variants, and (3) intermediate-length CAG trinucleotide carriers in ("ATXN2"). Flocculonodular lobule ( = 0.014, 95% CI -5.06e-5 to -3.98e-6) and crura ( = 0.031, 95% CI -1.63e-3 to -5.55e-5) volume reductions were detected at baseline in sporadic patients. Cerebellofrontal and cerebelloparietal structural connectivity impairment was observed in both C9POS and sporadic patients at baseline, and both projections deteriorated further over time in sporadic patients ( = 0.003, (249) = 3.04 and = 0.05, (249) = 1.93). Functional cerebelloparietal uncoupling was evident in sporadic patients at baseline ( = 0.004, 95% CI -0.19 to -0.03). ATXN2 patients exhibited decreased cerebello-occipital functional connectivity at baseline ( = 0.004, 95% CI -0.63 to -0.06), progressive cerebellotemporal functional disconnection ( = 0.025, (199) = -2.26), and progressive flocculonodular lobule degeneration ( = 0.017, (249) = -2.24). C9POS patients showed progressive ventral dentate atrophy ( = 0.007, (249) = -2.75). The CSTs ( < 0.001, 95% CI 4.89e-5 to 1.14e-4) and transcallosal interhemispheric fibers ( < 0.001, 95% CI 5.21e-5 to 1.31e-4) were affected at baseline in C9POS and exhibited rapid degeneration over the 4 time points. The rate of decline in CST and corpus callosum integrity was faster than the rate of cerebrocerebellar disconnection ( = 0.001, (190) = 6.93).
DISCUSSION
ALS is associated with accruing intracerebellar disease burden as well as progressive corticocerebellar uncoupling. Contrary to previous suggestions, we have not detected evidence of compensatory structural or functional changes in response to supratentorial degeneration. The contribution of cerebellar disease burden to dysarthria, dysphagia, gait impairment, pseudobulbar affect, and cognitive deficits should be carefully considered in clinical assessments, monitoring, and multidisciplinary interventions.
Topics: Humans; Amyotrophic Lateral Sclerosis; Male; Female; Middle Aged; Cerebellum; Aged; C9orf72 Protein; Prospective Studies; Ataxin-2; Magnetic Resonance Imaging; Disease Progression; Cerebral Cortex; Adult; Longitudinal Studies
PubMed: 38900989
DOI: 10.1212/WNL.0000000000209623