James Parkinson. On child abuse and other things.

James Parkinson, a general physician, was interested in all facets of medical care, and wrote two books for the lay public that contained comments on diverse things. He may have been one of the first physicians to publicly describe child abuse. Some of his advice to the public was of a neurologic nature, and included directions on the diagnosis and treatment of pseudoseizures, epilepsy, drowning, and stroke.

Possible risk factors in multiple sclerosis as found in a national twin study.

Fifty-one twin pairs, one or both members of each with multiple sclerosis (MS), were analyzed for extraneous events occurring prior to onset. Six patient groupings allowed comparison of events with and without the genetic factor. Comparison of monozygotic, discordant (one involved), and dizygotic discordant twins showed a difference. The affected members of the monozygotic pairs encountered prior to onset more birth anoxia, unusual infantile and childhood infections, major operations, and childbirth than did their unaffected twins, a difference not found when comparing dizygotic twins. The difference was most evident in the monozygotic discordant twins interviewed 30 years after onset of MS. If concordant (both involved) twins are analyzed by early vs late age of onset, these events occur at an older age in the late- and at younger age in the early-onset patients, suggesting that they may determine the age of onset of symptoms; they are suspected to be important in the causation of MS in genetically susceptible individuals, although the mechanism of their action is unknown.

California encephalitis virus causes subacute encephalomyelitis in an adult.

A 24-year-old man from rural Mississippi had a case of California encephalitis (CE) that evolved as a subacute encephalomyelitis. The incidence of CE in adults is low, especially in the southeastern United States, and to our knowledge the clinical profile of symptomatic disease in adults has not been established. The characteristics of CE and St Louis encephalitis, the usual cause of arboviral illness affecting adults in the Southeast, differ.

Morphometric studies in dominant olivopontocerebellar atrophy. Comparison of cell losses with amino acid decreases.

We present a correlation of the morphometric cell density analysis with previous biochemical findings for the inferior olivary nucleus and Purkinje cell layer of the cerebellum from 10 patients (three kindreds) with dominant olivopontocerebellar atrophy. We have analyzed brain amino compounds of these patients and found a decrease of aspartic acid and glutamic acid in the cerebellar cortex and of aspartic acid in the inferior olives. The cell density analysis revealed decreased cell counts, with a mean of 34% of olivary cells and 42% of Purkinje cells surviving when compared with 10 control brains. The cell counts were then correlated with the amino acid analyses. The correlation coefficient for aspartic acid content and surviving neurons in the inferior olive was .87 and that for aspartic acid content and Purkinje cell density was .86. Comparison of glutamic acid content and Purkinje cell density yielded a correlation coefficient of .75. The correlations appear to indicate a relationship between these particular cells or the area they occupy and the decreased content of the two amino acids.

Progression rate and age at onset are related in autosomal dominant neurologic diseases.

We found that the rate of progression of two adult hereditary neurologic disorders (dominant ataxia and Huntington disease) correlated inversely with the age at onset. The earlier the onset, the more rapid the course; the later the onset, the slower the course. Alzheimer disease/senile dementia followed a similar pattern. The rate of progression of a nonhereditary progressive neurologic disorder, ALS, showed the opposite trend.

Neurotransmitter amino acids in dominantly inherited cerebellar disorders.

We measured amino acid contents in the brains of 11 patients with dominantly inherited cerebellar disorders. Despite clinical similarities, three biochemically different disorders were found. One disorder, with demonstrated HLA linkage in one pedigree, was characterized by moderate reduction of aspartate and glutamate contents in cerebellar cortex alone. In a second disorder, aspartate and glutamate contents were reduced markedly in other brain areas as well as in cerebellar cortex. Aspartate and glutamate contents were normal in cerebellar cortex in the third disorder. GABA content in cerebellar cortex and dentate nucleus was reduced in some patients with each disorder, whereas cerebellar taurine content was normal in all patients. Aspartate deficiency in cerebellar cortex did not result from lack of aspartate aminotransferase or pyruvate carboxylase activity. These amino acid abnormalities probably imply loss of specific cerebellar neurons.

"Orthostatic tremor' in familial-essential tremor.

We studied a family with essential tremor of the arms. Some members also had tremor of the trunk and legs on standing, but not on walking, sitting, or reclining. Tremor was evoked, regardless of body or limb position, by strong tonic contraction of the appropriate muscles; it was a type of static postural tremor. Beta-adrenergic blockers had no effect on the tremor of the trunk or legs, but clonazepam was beneficial.

Aspartate-taurine imbalance in dominantly inherited olivopontocerebellar atrophy.

Amino acids were measured in autopsied brain from two patients who died with a dominantly inherited form of olivopontocerebellar atrophy. Neuropathologic changes found in the brain of these patients suggested a loss of cerebellar climbing fibers. The contents of aspartic acid, gamma-aminobutyric acid, and homocarnosine were reduced in the cerebellar cortex and the dentate nucleus, while taurine content was markedly elevated in the same brain regions. These findings are compatible with the possibility that aspartic acid is the excitatory synaptic transmitter of the climbing fibers and taurine is the inhibitory neurotransmitter of one or more types of interneurons in the cerebellum.

Hereditary adult-onset Alexander's disease with palatal myoclonus, spastic paraparesis, and cerebellar ataxia.

We describe a progressive neurologic disorder in three sisters characterized clinically by palatal myoclonus, spastic weakness, hyperreflexia, mild cerebellar dysfunction, and ocular motor abnormalities. Postmortem examination of one patient demonstrated widespread Rosenthal fiber deposition associated with demyelination. The father previously was reported to have similar pathologic findings and carried a clinical diagnosis of multiple sclerosis. These clinical and pathologic findings describe a rare familial leukodystrophy that corresponds most closely to cases reported as adult Alexander's disease. Although similar pathologically to the well-characterized infantile variant of Alexander's disease, it is not known whether this adult variant represents the same disease process.

Decreased parvalbumin immunoreactivity in surviving Purkinje cells of patients with spinocerebellar ataxia-1.

The distribution of two calcium-binding proteins, calbindin D28k (CaBP) and parvalbumin (PV), was investigated by immunohistochemistry in the brains of three individuals dying of nonneurologic illness and three patients with spinocerebellar ataxia-1 (SCA-1). SCA-1 has recently been proven to be due to an unstable CAG repeat mutation on chromosome 6. In the cerebellum of control individuals the Purkinje cells showed strong immunoreactivity to CaBP. Other cells were CaBP-negative. Parvalbumin was highly localized to Purkinje, basket, stellate, and Golgi cells. All surviving Purkinje cells in SCA-1 were strongly immunoreactive to CaBP. The number of PV-immunoreactive Purkinje cells was markedly reduced in SCA-1. In addition, there was a significant decrease in the intensity of PV immunostaining within the individual Purkinje cells compared with controls. However, in the hippocampus, temporal cortex, and lateral geniculate scattered PV-positive neurons were seen in SCA-1 patients, similar to those in controls. The present results suggest that the decreased PV-immunoreactivity in the surviving Purkinje cells in SCA-1 may reflect biochemical alterations preceding Purkinje cell degeneration.

Familial progressive subcortical gliosis.

We report clinical and pathologic findings from two kindreds afflicted with a familial form of progressive subcortical gliosis. The disorder segregated as an autosomal dominant trait. Onset was in the presenium and the course was slowly progressive. Affected individuals initially manifested personality change, degeneration of social ability, disinhibition, psychotic symptoms, memory impairment, or depression. Later, all developed progressive dementia, frequently associated with verbal stereotypy, decreased speech output, echolalia, or manifestations of the human Klüver-Bucy syndrome. Terminal clinical manifestations included profound dementia, frequently with mutism, dysphagia, and extrapyramidal signs. Autopsy of seven end-stage patients revealed generalized cerebral atrophy, predominantly involving the white matter of the frontal and temporal lobes. Microscopically, prominent fibrillary astrocytosis was present in the subcortical white matter and in the subpial and deep layers of the overlying cerebral cortex. These changes were most pronounced in the frontal and temporal lobes, especially in the cingulate gyri and insulae. Mild cortical neuronal loss accompanied the gliosis, but no myelin loss was evident. The claustra and substantia nigra also showed severe astrocytosis and degenerative changes. Amyloid deposits and neuronal cytoskeletal inclusions were absent.

Linkage studies in spinocerebellar ataxia (SCA).

Data are now available on 9 pedigrees in detail and 4 pedigrees as lod scores only. Linkage to HLA is significant (Z = 5.53 at recombination rates of 0.223 in males and 0.327 in females). Tight linkage is excluded. Nine pedigrees which appear to be typical olivopontocerebellar atrophy (OPCA I) have recombination rates of 0.150 in males and 0.300 in females. The remaining 4 pedigrees are clinically atypical or include discrepant data and give no evidence for linkage. The symbol SCA1 is proposed for a locus on chromosome 6 (loosely linked to HLA), at which at least one allele produces OPCA I (Menzel type). It is not yet clear whether other clinical types are determined by alleles at different loci, although this is suggested by several pedigrees, including a Danish pedigree of OPCA with dementia. Linkage evidence will be decisive in delineating the ataxias.

An ergot alkaloid preparation (Hydergine) in the treatment of dementia: critical review of the clinical literature.

A critical review is presented of 12 clinical trials with Hydergine (a hydrogenated ergot alkaloid preparation) in the treatment of dementia. Qualitative and quantitative comparisons of improvement in symptoms showed that Hydergine consistently produced statistically significant (p less than or equal to 0.05) improvement in 13 symptoms associated with dementia. However, because of the small magnitude of the improvement and the absence of indications of long-term benefit, Hydergine would seem to be of minor value in dementia therapy. Further research with better methodology and design might lead to a different conclusion.

Inositol 1,4,5-trisphosphate receptors and protein kinase C in olivopontocerebellar atrophy.

We examined protein kinase C (PKC) activity and inositol 1,4,5-trisphosphate (InsP3) binding in frontal cortex (FC) and cerebellar cortex (CC) of normal humans, patients with dominant ataxia ("C" kindred) and in Lurcher mutant mouse brain (LMB), a suggested animal model for olivopontocerebellar atrophy (OPCA). PKC activity and [3H]InsP3 binding were decreased in CC of human OPCA by 70% and 90% respectively. The decreases were specific to CC as there were no changes in FC. PKC activity and [3H]InsP3 binding in cerebellum (CB) of LMB were similarly decreased as compared to normal littermate controls. The LMB decrease of PKC and [3H]InsP3 binding was evident on the 15th day of age, the day of onset of ataxia. InsP3-mediated calcium release was also decreased significantly in the cerebellar microsomes of 25-day-old LMB and human OPCA when compared with their respective controls. These data indicate that the decrease of second messenger linked PKC activity and InsP3 receptor binding in CB may be a biochemical marker that reflects neuronal degeneration in dominant cerebellar ataxia.

Inositol 1,4,5-trisphosphate metabolism in the cerebella of Lurcher mutant mice and patients with olivopontocerebellar atrophy.

We have investigated inositol 1,4,5-trisphosphate (InsP3) metabolism in cerebellar membranes of normal humans and patients with dominant ataxia ('C' kindred), and also in cerebellar microsomes of Lurcher mutant mouse (a suggested model for cerebellar ataxia). Various [3H]InsP3 metabolites formed were separated by HPLC using 3 successive convex gradients of 1.7 M ammonium formate, pH 3.7. [3H]InsP3 metabolism was rapid and in 15- and 45-day-old control mice cerebella about 50% of [3H]InsP3 was metabolized within 20 s. In 15-day-old Lurcher mice the rate of [3H]InsP3 metabolism was significantly low (40% of normal). [3H]InsP3 metabolism was almost absent in 45-day-old Lurcher mice cerebellar microsomes. The decreased [3H]InsP3 metabolism was consistent with decreased recovery of the various inositol polyphosphates formed. Similarly, in cerebellar membranes of human patients with olivopontocerebellar atrophy (OPCA) a significant decrease in [3H]InsP3 metabolism was observed when compared with normal controls. These data suggest that altered phosphoinositide turnover may be associated with the onset of neuronal degeneration in human OPCA.

Decreased insulin-like growth factor I-mediated protein tyrosine phosphorylation in human olivopontocerebellar atrophy and lurcher mutant mouse.

We examined insulin-like growth factor I (IGF-I)-dependent phosphorylation and protein tyrosine kinase (PTK) activity in cerebellar cortex of normal humans, patients with olivopontocerebellar atrophy (OPCA) ("C" kindred) and in lurcher mutant mouse, a suggested animal model for OPCA. PTK activity and IGF-I-dependent protein tyrosine phosphorylation was significantly reduced in cerebellar cortex of human OPCA patients as compared to the normal controls. Immunoblot analysis also demonstrated a decrease in cerebellar 80 kDa phosphotyrosine protein in these patients. By autoradiography, IGF-I receptors were localized in the molecular layer of 30-day-old control and lurcher mutant mice cerebella. However, the lurcher mutant mice showed a decrease in [125I]-IGF-I binding in the molecular layer as compared to the littermate controls. The IGF-I receptor autophosphorylation was also markedly reduced in 15-day- and 22-day-old lurcher cerebella. These results suggest that the process of cerebellar degeneration in human OPCA and lurcher mutant mouse may be associated with altered IGF-I receptor binding and protein tyrosine phosphorylation.

International Cooperative Ataxia Rating Scale for pharmacological assessment of the cerebellar syndrome. The Ataxia Neuropharmacology Committee of the World Federation of Neurology.

Despite the involvement of cerebellar ataxia in a large variety of conditions and its frequent association with other neurological symptoms, the quantification of the specific core of the cerebellar syndrome is possible and useful in Neurology. Recent studies have shown that cerebellar ataxia might be sensitive to various types of pharmacological agents, but the scales used for assessment were all different. With the long-term goal of double-blind controlled trials-multicentric and international-an ad hoc Committee of the World Federation of Neurology has worked to propose a one-hundred-point semi-quantitative International Cooperative Ataxia Rating Scale (ICARS). The scale proposed involves a compartimentalized quantification of postural and stance disorders, limb ataxia, dysarthria and oculomotor disorders, in order that a subscore concerning these symptoms may be separately studied. The weight of each symptomatologic compartment has been carefully designed. The members of the Committee agreed upon precise definitions of the tests, to minimize interobserver variations. The validation of this scale is in progress.