[REM sleep behavior disorder as a prodromal stage of α-synucleinopathies: symptoms, epidemiology, pathophysiology, diagnosis and therapy]. / REM-Schlaf-Verhaltensstörung als prodromales Stadium von α-Synukleinopathien: Klinik, Epidemiologie, Pathophysiologie, Diagnose und Behandlung.

Rapid eye movement (REM) sleep behavior disorder (RBD) is defined as a parasomnia characterized by loss of REM sleep-associated atonia and the presence of motor activity during dreaming typically presenting with an aggressive dream content. Epidemiological data on the prevalence of RBD are insufficient but it can be idiopathic or symptomatic. A video-audio polysomnography is essential for diagnosis. Clonazepam and melatonin are available as pharmaceutical treatment. Recent studies demonstrated that individuals suffering from idiopathic RBD carry a high specific risk (up to 80 %) for developing a neurodegenerative disorder of the α-synucleinopathy type (e.g. Parkinson's disease, dementia with Lewy bodies and multiple system atrophy) within 10-20 years. The current article provides a short overview of symptoms, epidemiology, pathophysiology, diagnosis and therapy of RBD.

[Early recognition of Parkinson's disease. Objectifiable non-motor symptoms and biomarkers]. / Früherkennung der Parkinson-Krankheit. Objektivierbare nichtmotorische Symptome und Biomarker.

The clinical diagnosis of Parkinson's disease (PD) according to the UK Brain Bank criteria is based on the presence of motor symptoms and the response to dopaminergic medication. According to these criteria the clinical diagnosis is delineated too late when more than 50 % of the dopaminergic neurons are already degenerated. In recent years interest has shifted increasingly more towards non-motor symptoms (NMS), such as rapid eye movement (REM) sleep behavior disorder (RBD), constipation, hyposmia and neuropsychiatric as well as cognitive symptoms. It was shown that NMS can precede the motor symptoms by some years and may thus possibly enable support of an earlier clinical diagnosis. Furthermore, cerebrospinal fluid or blood biomarkers as well as brain imaging techniques can objectively support an earlier diagnosis of PD. This article reviews important NMSs (e.g. RBD, hyposmia and neuropsychiatric/cognitive symptoms) as well as the current status on biomarkers and brain imaging in early (premotor) phases of PD and their relevance for the early diagnosis.

Rapid eye movement sleep behavior disorder: devising controlled active treatment studies for symptomatic and neuroprotective therapy--a consensus statement from the International Rapid Eye Movement Sleep Behavior Disorder Study Group.

OBJECTIVES: We aimed to provide a consensus statement by the International Rapid Eye Movement Sleep Behavior Disorder Study Group (IRBD-SG) on devising controlled active treatment studies in rapid eye movement sleep behavior disorder (RBD) and devising studies of neuroprotection against Parkinson disease (PD) and related neurodegeneration in RBD. METHODS: The consensus statement was generated during the fourth IRBD-SG symposium in Marburg, Germany in 2011. The IRBD-SG identified essential methodologic components for a randomized trial in RBD, including potential screening and diagnostic criteria, inclusion and exclusion criteria, primary and secondary outcomes for symptomatic therapy trials (particularly for melatonin and clonazepam), and potential primary and secondary outcomes for eventual trials with disease-modifying and neuroprotective agents. The latter trials are considered urgent, given the high conversion rate from idiopathic RBD (iRBD) to Parkinsonian disorders (i.e., PD, dementia with Lewy bodies [DLB], multiple system atrophy [MSA]). RESULTS: Six inclusion criteria were identified for symptomatic therapy and neuroprotective trials: (1) diagnosis of RBD needs to satisfy the International Classification of Sleep Disorders, second edition, (ICSD-2) criteria; (2) minimum frequency of RBD episodes should preferably be ⩾2 times weekly to allow for assessment of change; (3) if the PD-RBD target population is included, it should be in the early stages of PD defined as Hoehn and Yahr stages 1-3 in Off (untreated); (4) iRBD patients with soft neurologic dysfunction and with operational criteria established by the consensus of study investigators; (5) patients with mild cognitive impairment (MCI); and (6) optimally treated comorbid OSA. Twenty-four exclusion criteria were identified. The primary outcome measure for RBD treatment trials was determined to be the Clinical Global Impression (CGI) efficacy index, consisting of a four-point scale with a four-point side-effect scale. Assessment of video-polysomnographic (vPSG) changes holds promise but is costly and needs further elaboration. Secondary outcome measures include sleep diaries; sleepiness scales; PD sleep scale 2 (PDSS-2); serial motor examinations; cognitive indices; mood and anxiety indices; assessment of frequency of falls, gait impairment, and apathy; fatigue severity scale; and actigraphy and customized bed alarm systems. Consensus also was established for evaluating the clinical and vPSG aspects of RBD. End points for neuroprotective trials in RBD, taking lessons from research in PD, should be focused on the ultimate goal of determining the performance of disease-modifying agents. To date no compound with convincing evidence of disease-modifying or neuroprotective efficacy has been identified in PD. Nevertheless, iRBD patients are considered ideal candidates for neuroprotective studies. CONCLUSIONS: The IRBD-SG provides an important platform for developing multinational collaborative studies on RBD such as on environmental risk factors for iRBD, as recently reported in a peer-reviewed journal article, and on controlled active treatment studies for symptomatic and neuroprotective therapy that emerged during the 2011 consensus conference in Marburg, Germany, as described in our report.

[Long-term care after deep brain stimulation of patients with Parkinson's disease]. / Nachsorge nach tiefer Hirnstimulation bei Patienten mit M. Parkinson.

Long-term care after deep brain stimulation for Parkinson's disease requires regular technical check-ups as well as clinical follow-up. Residual or emerging difficulties with gait, balance or speech should be addressed by specific rehabilitation programs. In cases of psychosocial maladjustment, psychotherapy or family counseling may prove helpful. After consolidation of stimulation parameters, pharmacotherapy can be tailored according to the individual needs, following the same guidelines as for Parkinson's disease patients without deep brain stimulation. In cases of clinical deterioration, malfunctioning of the stimulation system, comorbidity or disease progression has to be considered and treated accordingly. Structured long-term care programs may contribute to patient satisfaction and ensure quality of life.

[Deep brain stimulation for essential tremor. Consensus recommendations of the German Deep Brain Stimulation Association]. / Tiefe Hirnstimulation bei essenziellem Tremor. Empfehlungen der Deutschen Arbeitsgemeinschaft Tiefe Hirnstimulation.

In Germany, deep brain stimulation (DBS) of the thalamic ventralis intermedius nucleus (VIM) is licensed for treatment of essential tremor in cases unresponsive to pharmacotherapy. Especially a bothersome hand tremor interfering with activities of daily living will improve, whereas head, tongue or vocal tremor shows less response. DBS was proven to be superior to lesional thalamotomy with better functional outcome and less adverse effects. The consensus statement presented here reflects the current recommendations of the German Deep Brain Stimulation Study Group for inclusion and exclusion criteria as well as for peri-, intra- and postoperative neurological management.

[Deep brain stimulation for dystonia. Consensus recommendations of the German Deep Brain Stimulation Association]. / Tiefe Hirnstimulation bei Dystonie. Empfehlungen der Deutschen Arbeitsgemeinschaft Tiefe Hirnstimulation.

Medical treatment of dystonia, particularly generalised forms of the disorder, is often not satisfactory or causes intolerable side effects. In focal dystonia, a reasonable treatment option with botulinum toxin exists but some patients either do not respond well or develop neutralising antibodies with secondary therapy failure. Deep brain stimulation (DBS) of the globus pallidus internus has been shown to be effective in both generalised and focal dystonia. This paper gives recommendations regarding the use of DBS in different forms of dystonia based on the currently available scientific data as well as the longstanding personal experience of the authors. The inclusion criteria for DBS candidates as well as the peri- and postoperative patient management are addressed. These recommendations were developed in a consensus procedure in the German Deep Brain Stimulation Association.

[Deep brain stimulation for tremor in multiple sclerosis : consensus recommendations of the German Deep Brain Stimulation Association]. / Tiefe Hirnstimulation bei Multiple-Sklerose-Tremor : Empfehlungen der Arbeitsgemeinschaft Tiefe Hirnstimulation.

Deep brain stimulation (DBS) in the nucleus ventralis intermedius thalami (VIM) is a common procedure to treat disabling tremor in multiple sclerosis which is refractory to pharmacological treatment. The sparse studies on DBS in multiple sclerosis tremor remain controversial regarding the clinical effect on postural and action tremor of hands, trunk and head. Furthermore, it remains unclear whether DBS in multiple sclerosis tremor is superior to thalamotomy and whether patients show an overall improvement in quality of life and activities of daily living. Therefore, the consensus recommendations of the German Deep Brain Stimulation Study Group rely primarily on expert opinion and include (1) extensive preoperative characterisation of tremor, ataxia with accompanying disabilities, status of the multiple sclerosis, co-morbidities and burden of disease, (2) careful intraoperative testing of effects and side effects and (3) intensive postoperative testing and programming as well as regular re-evaluation of the therapeutic effect.

[Deep brain stimulation for Parkinson's disease. Consensus recommendations of the German Deep Brain Stimulation Association]. / Tiefe Hirnstimulation bei idiopathischem Parkinson-Syndrom. Empfehlungen der Deutschen Arbeitsgemeinschaft Tiefe Hirnstimulation.

Deep brain stimulation (DBS) has been shown to be effective for levodopa-responsive symptoms and tremor in Parkinson's disease (PD). The subthalamic nucleus (STN) is the preferred target for most patients suffering from late stage motor complications of the disorder. STN DBS is superior to best medical treatment concerning the control of motor fluctuations and the increase of on-time without dyskinesias. In contrast to DBS of the internal pallidum (GPi), STN stimulation also permits a reduction of the dopaminergic medication. Long-term data demonstrated sustained effectiveness of STN DBS despite progressive disease. DBS of the thalamic ventral intermediate nucleus (VIM) is an alternative target in older PD patients with severe PD tremor refractory to medication. In order to minimize potential risks and side effects, the use of DBS needs careful adherence to inclusion and exclusion criteria for eligible PD patients. This paper summarizes the current consensus recommendations of the German Deep Brain Stimulation Association for DBS in PD.

[Abscess at the implant site following apical parodontitis. Hardware-related complications of deep brain stimulation]. / Abszess in der Impulsgeneratortasche nach apikaler Parodontitis. Eine Hardware-assoziierte Komplikation nach tiefer Hirnstimulation Hardware-related complication of deep brain stimulation.

Deep brain stimulation of the subthalamic nucleus is an important treatment option for advanced stages of idiopathic Parkinson's disease, leading to significant improvement of motor symptoms in suited patients. Hardware-related complications such as technical malfunction, skin erosion, and infections however cause patient discomfort and additional expense. The patient presented here suffered a putrid infection of the impulse generator site following only local dental treatment of apical parodontitis. Therefore, prophylactic systemic antibiotic treatment is recommended for patients with implanted deep brain stimulation devices in case of operations, dental procedures, or infectious disease.