Four Cases of Parkinson Disease Diagnosed During the Postpartum Period.

BACKGROUND: There is little experience with the effect of pregnancy on Parkinson disease because the number of women with Parkinson disease who are of childbearing age is small. We report four cases beginning during the postpartum period and discuss the potential contribution of different factors that may influence the occurrence of Parkinson disease in this time period. CASES: Four women aged 29-35 years developed arm tremor, shoulder pain, dizziness, or decreased dexterity of the hand in the first few days or months after childbirth. They were initially diagnosed with postpartum depression or psychogenic parkinsonism. Finally, dopamine transporter imaging confirmed the diagnosis of young-onset Parkinson disease. CONCLUSION: Early-onset Parkinson disease may present in postpartum women. In women with atypical motor symptoms in addition to depression, this diagnosis should be considered.

Subthalamic stimulation: toward a simplification of the electrophysiological procedure.

BACKGROUND: The aim of the present study was to assess the consequences of a simplification of the electrophysiological procedure on the post-operative clinical outcome after subthalamic nucleus implantation in Parkinson disease. METHODS: Microelectrode recordings were performed on 5 parallel trajectories in group 1 and less than 5 trajectories in group 2. Clinical evaluations were performed 1 month before and 6 months after surgery. RESULTS: After surgery, the UPDRS III score in the off-drug/on-stimulation and on-drug/on-stimulation conditions significantly improved by 66,9% and 82%, respectively in group 1, and by 65.8% and 82.3% in group 2 (P<0.05). Meanwhile, the total number of words (P<0.05) significantly decreased for fluency tasks in both groups. Motor disability improvement and medication reduction were similar in both groups. CONCLUSIONS: Our results suggest that the electrophysiological procedure should be simplified as the team's experience increases.

Age Limits for Deep Brain Stimulation of Subthalamic Nuclei in Parkinson's Disease.

BACKGROUND: Clinical pre-operative predictive factors of optimal STN-DBS motor outcome in Parkinson's disease (PD) have been previously reported. However, available data involving elderly patients are conflicting. OBJECTIVE: To compare early post-operative outcomes in parkinsonian patients younger than 65 years old (group 1) vs patients 65 years old or older (group 2) at the time of surgery. METHODS: The cognitive and motor effects of DBS were evaluated by comparison of different scores obtained before (baseline) and 6 months after surgery using a repeated measures analysis of variance. RESULTS: Post-operative motor improvement (UPDRS part III and UPDRS part IV scores) and drug reduction were not statistically different between groups 1 and 2 (P > 0.05). Axial motor score which was significantly worse in group 2 in the on-drug condition before surgery was also significantly worse both in off-drug/on-stimulation and on-drug/on-stimulation conditions (P < 0.05). Similarly, cognitive performances (Wisconsin Card Sorting Test, Stroop interference test, Free and Cued Selective Reminding Test with Immediate Recall, Verbal Fluency) significantly worsened post-operatively ingroup 2. CONCLUSIONS: Although effective and safe, STN-DBS has a more negative impact on cognitive functions in elderly patient, requiring a careful preoperative selection.

Subjective Perceived Motor Improvement after Acute Levodopa Challenge in Parkinson's Disease.

BACKGROUND: Previous studies found a poor association between parkinsonian patient's reported subjective improvement after commencing dopaminergic treatment and improvements in objective measures of motor impairment by clinician. OBJECTIVE: To compare PD patient's subjective perceived motor improvement after acute levodopa challenge test with objective motor improvement assessed by the clinician using the UPDRS part III. To analyze clinical characteristics, i.e. age, disease duration, cognitive performance or severity of axial features, that may have influenced patient's perception. METHODS: Fifty-seven consecutive PD patients (23 women, 34 men; mean age, 63.4±7.7 years) (Hoehn and Yahr off score, 2.5±0.7; mean disease duration, 11.4±4.1 years) completed the acute levodopa challenge. The percentage of improvement in motor disability, i.e. objective motor improvement, was determined with respect to the off-drug condition. RESULTS: Bland & Altman visual analysis reveals a high degree of correlation between objective and subjective perceived motor improvement. Both the axial sub-scores in the off- and on-state (respectively, P = 0.006 and P = 0.024) and the presence of peak-dose dyskinesia (P = 0.043) significantly influence the difference between objective and subjective perceived motor improvement. CONCLUSIONS: This is the first study reporting on how PD patients assessed their motor improvement after acute levodopa challenge. These findings suggest a strong correlation between objective motor improvement assessed by the clinician using the UPDRS part III and subjective perceived motor improvement reported by the patient.

Pre-operative obesity may influence subthalamic stimulation outcome in Parkinson's disease.

BACKGROUND: Pre-operative predictive factors for optimal post-operative effect of subthalamic nucleus (STN) stimulation in Parkinson's disease (PD) have been previously reported. No study has explicitly assessed the link between excess pre-operative body weight and STN stimulation outcome. METHODS: We retrospectively compared STN stimulation outcomes of 36 PD patients with excess pre-operative body weight (group 1) and 36 matched normal-weight pre-operative (group 2) PD patients. We focused on the post-operative outcomes in the sub-group of 12 obese (group 3) PD patients. RESULTS: The post-operative motor improvement and the reduction of severity of levodopa-related complications were not statistically different between groups 1 and 2 (P>0.05). In the obese group (group 3), the axial sub-score significantly improved by 29.8% in the on-drug/on-stimulation conditions whereas the improvement was not significant in the off-drug/on-stimulation condition (22.4%, P=0.20). The post-operative Mattis Dementia Rating Score was significantly reduced in group 1 and group 3. DISCUSSION: We considered that the post-operative axial impairment observed in the obese PD patients might be essentially consecutive to disease progression and/or post-operative DBS consequences, i.e. surgical procedure or electrical stimulation itself. Moreover, it could be argued that musculoskeletal disorders associated with obesity were responsible for the incomplete efficacy of STN stimulation on axial sub-scores, by increasing gait and balance impairment. CONCLUSION: Pre-operative obesity may be regarded as a predictive clinical factor of axial and cognitive impairment after STN-DBS.

Decline in verbal fluency after subthalamic nucleus deep brain stimulation in Parkinson's disease: a microlesion effect of the electrode trajectory?

BACKGROUND: Decline in verbal fluency (VF) is frequently reported after chronic deep brain stimulation (DBS) of the subthalamic nucleus (STN) in Parkinson disease (PD). OBJECTIVE: We investigated whether the trajectory of the implanted electrode correlate with the VF decline 6 months after surgery. METHODS: We retrospectively analysed 59 PD patients (mean age, 61.9 ± 7; mean disease duration, 13 ± 4.6) who underwent bilateral STN-DBS. The percentage of VF decline 6 months after STN-DBS in the on-drug/on-stimulation condition was determined in respect of the preoperative on-drug condition. The patients were categorised into two groups (decline and stable) for each VF. Cortical entry angles, intersection with deep grey nuclei (caudate, thalamic or pallidum), and anatomical extent of the STN affected by the electrode pathway, were compared between groups. RESULTS: A significant decline of both semantic and phonemic VF was found after surgery, respectively 14.9% ± 22.1 (P < 0.05) and 14.2% ± 30.3 (P < 0.05). Patients who declined in semantic VF (n = 44) had a left trajectory with a more anterior cortical entry point (56 ± 53 versus 60 ± 55 degree, P = 0.01) passing less frequently trough the thalamus (P = 0.03). CONCLUSIONS: Microlesion of left brain regions may contribute to subtle cognitive impairment following STN-DBS in PD.

Tendon rupture as an adverse effect of rasagiline.

A 66-year-old woman with advanced Parkinson disease (PD) was referred to our center for an adjustment of her antiparkinsonian medication. To reduce daily off-time, we introduced rasagiline 1 mg/d. Three days after starting this new treatment, she presented with intense arthralgia that symmetrically affected the shoulders, hands, and hips without myalgia. Ten days later, while walking, she experienced acute pain on the inner side of her right thigh, with the absence of any trauma. Findings of ultrasonography confirming the diagnosis of partial avulsion of the right harmstrings. Rasagiline was stopped immediately, and the arthralgia disappeared within 48 hours and did not recur. To our knowledge, this is the first reported case of a spontaneous tendon rupture possibly caused by rasagiline. Our observation emphasizes that, although often well tolerated, rasagiline may cause muscle and joint complications that could increase disability in patients with PD.

Does early verbal fluency decline after STN implantation predict long-term cognitive outcome after STN-DBS in Parkinson's disease?

BACKGROUNDS: An early and transient verbal fluency (VF) decline and impairment in frontal executive function, suggesting a cognitive microlesion effect may influence the cognitive repercussions related to subthalamic nucleus deep brain stimulation (STN-DBS). METHODS: Neuropsychological tests including semantic and phonemic verbal fluency were administered both before surgery (baseline), the third day after surgery (T3), at six months (T180), and at an endpoint multiple years after surgery (Tyears). RESULTS: Twenty-four patients (mean age, 63.5 ± 9.5 years; mean disease duration, 12 ± 5.8 years) were included. Both semantic and phonemic VF decreased significantly in the acute post-operative period (44.4 ± 28.2% and 34.3 ± 33.4%, respectively) and remained low at 6 months compared to pre-operative levels (decrease of 3.4 ± 47.8% and 10.8 ± 32.1%) (P < 0.05). Regression analysis showed phonemic VF to be an independent factor of decreased phonemic VF at six months. Age was the only independent predictive factor for incident Parkinson's disease dementia (PDD) (F (4,19)=3.4, P<0.03). CONCLUSION: An acute post-operative decline in phonemic VF can be predictive of a long-term phonemic VF deficit. The severity of this cognitive lesion effect does not predict the development of dementia which appears to be disease-related.

Non-motor fluctuations in Parkinson's disease: prevalence, characteristics and management in a large cohort of parkinsonian outpatients.

OBJECTIVE: To describe demographic and clinical characteristics in a group of Parkinson's disease (PD) patients with non-motor fluctuations (NMF) and to evaluate the management of medications proposed to treat NMF. METHODS: Three hundred and three PD patients (mean age, 66 ± 10.3 years; mean disease duration, 10.1 ± 6.5 years) were enrolled. Each patient was interviewed in a non-directed fashion about the main NMF manifestations, i.e. dysautonomic, mental, and sensory symptoms. Both groups of patients with and without NMF were compared. Dysautonomia, motor fluctuations, age, disease duration, and LEDD were included in a multiple regression to determine which were predictive of NMF. RESULTS: NMF were found in 57 (19%) patients, mean age 65 ± 10.1 years, mean age at onset of PD 53.7 ± 10.9 years, mean disease duration 12.5 ± 6.9 years. NMF occurred on average 9.8 ± 7.7 years after the onset of PD. Fifty patients (86%) with NMF had also MF and 10 (21%) had PDD. Twenty-five (44%) patients suffered from sensory, 28 (49%) from autonomic and 25 (44%) from neuropsychiatric symptoms. Both disease and L-Dopa treatment durations, and LEDD were significantly higher in NMF patient's group. Motor fluctuations (p = 0.0016) and presence of dysautonomia (p = 0.007) were found to be two independent predictors of NMF. CONCLUSION: The development of new instruments to assess NMF is crucial for optimized management of advanced PD.