Pharmacological treatment of deep brain stimulation-induced hypomania leads to clinical remission while preserving motor benefits.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for Parkinson's disease, but can lead to adverse effects including psychiatric disturbance. Little is known about the risk factors and treatment options for such effects. Here, we describe a patient who reproducibly developed stimulation-induced hypomania when using ventrally located electrodes and responded well to pharmacological intervention while leaving the stimulation parameters unchanged to preserve motor benefits. In spite of clinical remission, [¹5O]-positron-emission-tomography (PET) demonstrated activation patterns similar to those reported during mania. This case, therefore, highlights an important treatment option of adverse effects of DBS, but also points toward the need for investigations of its risk factors and their underlying neurobiological mechanisms.

[How to diagnose and treat limb apraxia]. / Diagnostik und Therapie der Gliedmabenapraxie.

Apraxia is a disorder of higher motor cognition. Deficits in imitating abstract and symbolic gestures as well as deficits in appropriate tool use are common apraxic symptoms which, importantly, cannot be explained by primary sensorimotor deficits alone. In spite of the relevance of apraxia for neurorehabilitation and the individual stroke patient's prognosis, apraxia is to date still too rarely diagnosed and treated. In this review the currently published assessments for the diagnosis of apraxia are evaluated. Based on this, an apraxia screening instrument as well as a diagnostic test for clinical use are recommended. In addition, different published approaches to the therapy for apraxia are described. Although current evidence is scarce, the gesture training suggested by Smania and co-workers can be recommended as a therapy for apraxia, because its effects were shown to extend to activities of daily living and to persist for at least two months after completion of the training. This review aims at directing the clinician's attention to the importance of apraxia. Moreover, it provides the interested reader with instruments for a reliable diagnosis and effective treatment of apraxia. These are also important prerequisites for further research into the neurobiological mechanisms underlying apraxia and the development of new therapy strategies leading to an evidence-based effective treatment of apraxia.

Dipyridamole/aspirin combination in secondary stroke prevention: effects on absolute myocardial blood flow and coronary vascular resistance.

OBJECTIVE: In the European Stroke Prevention Study (ESPS 2), oral administration of a fixed combination of 200 mg extended-release dipyridamole and 25 mg aspirin (twice daily) after ischemic stroke or transient ischemic attack, significantly reduced the risk of stroke compared to placebo as well as compared to aspirin or dipyridamole alone. However, the i.v. application of dipyridamole over 4 - 6 min is known to increase myocardial blood flow up to 6-fold, and thereby potentially provoke ischemic wall motion abnormalities in patients with coronary artery disease. We therefore assessed the cardiac side effects of the dipyridamole/aspirin combination on absolute myocardial blood flow (MBF) and coronary vascular resistance (CVR). METHODS: MBF and CVR were measured using 150-water positron emission tomography in 24 patients after stroke or transient ischemic attack, before and 6.7 +/- 1.9 days after starting the dipyridamole/aspirin combination (Aggrenox) therapy. RESULTS: Resting MBF increased by 39% (max. 112%), from 0.92 +/- 0.13 (ml x g(-1) x min(-1)) at baseline to 1.28 +/- 0.27 (ml x g(-1) x min(-1)) under ongoing dipyridamole/aspirin combination therapy (p < 0.0005). CVR consecutively decreased from 105.3 +/- 16.9 to 74.1 +/- 16.5 (mmHg x ml(-1) x g x min) (p < 0.0005). The relative increase in MBF correlated negatively with the body surface area. No correlation was found between relative MBF increase and duration of dipyridamole/aspirin combination therapy (range 4 - 10 days). CONCLUSIONS: Orally administered dipyridamole/aspirin combination therapy in secondary stroke prevention increases MBF and decreases CVR significantly. These cardiac side effects of the dipyridamole/aspirin combination should be taken into account in stroke patients with proven or suspected coronary artery disease, particularly in combination with a small body surface area.