Medical Treatment for Spontaneous Anticoagulation-Related Intracerebral Hemorrhage in the Netherlands.

BACKGROUND: Spontaneous anticoagulation-related intracerebral hemorrhage accounts for up to a quarter of spontaneous intracerebral hemorrhage cases and is associated with higher hematoma volume and a worse outcome. Guidelines recommend rapid anticoagulant reversal but mode and timing are not specified and optimal strategy is uncertain. Variability in everyday practice is unknown. METHODS: An invitation to a web-based survey was sent to 85 Dutch stroke neurologists in different hospitals, with questions about importance, timing, and medical management of spontaneous anticoagulation-related intracerebral hemorrhage. RESULTS: In total, 61 (72%) neurologists completed the survey. Nearly all (97%) deemed rapid anticoagulant reversal important. A local guideline for management of anticoagulant reversal was used in 80% of the hospitals. Most neurologists (56%) estimated anticoagulant reversal in anticoagulation-related intracerebral hemorrhage to start later than intravenous thrombolysis in ischemic stroke. Few (5%) thought it was quicker. A minority (28%) of the hospitals started anticoagulation reversal without waiting for laboratory test results or consulting a specialist in hemostasis. Prothrombin complex concentrate was used by all neurologists for vitamin K antagonist reversal and by most (74%) for reversal of thrombin inhibitors and factor Xa inhibitors (72%). Anticoagulation reversal was initiated at the emergency department according to 89% of the respondents. CONCLUSION: Variability in logistics in acute management of spontaneous anticoagulation-related intracerebral hemorrhage was demonstrated. Anticoagulant reversal is deemed important, but is estimated to have a longer door-to-needle time than alteplase in thrombolysis for ischemic stroke by most neurologists. Several delaying factors were found. These factors might have an impact on outcome.

Regional Structural Hippocampal Differences Between Dementia with Lewy Bodies and Parkinson's Disease.

BACKGROUND: Dementia with Lewy bodies (DLB) and Parkinson's disease (PD) are considered subtypes of the α-synucleinopathy continuum that show similar and dissimilar clinical and morphological features. OBJECTIVE: To further our understanding of brain abnormalities that might differentiate both disorders more clearly, we performed quantitative magnetic resonance (MR) imaging of the subcortical and cortical grey matter. METHODS: Three-dimensional T1 weighted 3 tesla MR images of 14 DLB and 62 age- and gender-matched PD patients were examined to study cortical and subcortical grey matter structure. We used volumetric measurements to study total grey matter, and volumes of the pallidum, amygdala, putamen, caudate nucleus, thalamus and hippocampus. Whole-brain and structural network-based methods were used to identify local differences in grey matter and vertex-based shape analysis was used to assess focal hippocampal changes. RESULTS: Volumetric, whole-brain and network-based analyses showed reduced hippocampal (p = 0.008) and right parahippocampal region volumes (p = 0.030) in DLB compared to PD patients. Shape analysis showed atrophy in the head and body of the right (p = 0.040) and in the head of the left (p = 0.030) hippocampus of DLB patients. CONCLUSION: DLB patients showed atrophy of the hippocampus and parahippocampal gyrus compared to PD patients with a differential involvement of the head and body of the hippocampus. Further studies should examine if these group-based findings can be used to differentiate both disorders on an individual level.

Age- and disease-related cerebral white matter changes in patients with Parkinson's disease.

As age and Parkinson's disease (PD) both play a role in the degeneration of brain white matter, we aimed to investigate a possible interaction effect of age and disease presence on white matter integrity in patients with PD. We studied white matter hyperintensity volume, global fractional anisotropy, mean diffusivity and mean magnetization transfer ratio of normal appearing white matter in 163 patients with PD and 218 age- and gender-matched healthy control subjects. We investigated the relationship between age and these parameters in both groups, and interaction between age and disease presence. Patients with PD had a higher load of white matter hyperintensities with a preferential periventricular and anterior distribution as compared with healthy control subjects. Visuospatial functioning was related to total and postural instability and gait difficulty was related to periventricular white matter hyperintensity volume in patients with PD. The age-related decline of white matter integrity was similar for both groups. Global microstructural integrity of the normal appearing white matter did not differ between patients and healthy control subjects, suggesting that PD-specific changes do not exceed normal age-associated change in white matter without lesions.

Altered Whole-Brain and Network-Based Functional Connectivity in Parkinson's Disease.

Background: Functional imaging methods, such as resting-state functional magnetic resonance imaging, reflect changes in neural connectivity and may help to assess the widespread consequences of disease-specific network changes in Parkinson's disease. In this study we used a relatively new graph analysis approach in functional imaging: eigenvector centrality mapping. This model-free method, applied to all voxels in the brain, identifies prominent regions in the brain network hierarchy and detects localized differences between patient populations. In other neurological disorders, eigenvector centrality mapping has been linked to changes in functional connectivity in certain nodes of brain networks. Objectives: Examining changes in functional brain connectivity architecture on a whole brain and network level in patients with Parkinson's disease. Methods: Whole brain resting-state functional architecture was studied with a recently introduced graph analysis approach (eigenvector centrality mapping). Functional connectivity was further investigated in relation to eight known resting-state networks. Cross-sectional analyses included group comparison of functional connectivity measures of Parkinson's disease patients (n = 107) with control subjects (n = 58) and correlations with clinical data, including motor and cognitive impairment and a composite measure of predominantly non-dopaminergic symptoms. Results: Eigenvector centrality mapping revealed that frontoparietal regions were more prominent in the whole-brain network function in patients compared to control subjects, while frontal and occipital brain areas were less prominent in patients. Using standard resting-state networks, we found predominantly increased functional connectivity, namely within sensorimotor system and visual networks in patients. Regional group differences in functional connectivity of both techniques between patients and control subjects partly overlapped for highly connected posterior brain regions, in particular in the posterior cingulate cortex and precuneus. Clinico-functional imaging relations were not found. Conclusions: Changes on the level of functional brain connectivity architecture might provide a different perspective of pathological consequences of Parkinson's disease. The involvement of specific, highly connected (hub) brain regions may influence whole brain functional network architecture in Parkinson's disease.

Loss of integrity and atrophy in cingulate structural covariance networks in Parkinson's disease.

BACKGROUND: In Parkinson's disease (PD), the relation between cortical brain atrophy on MRI and clinical progression is not straightforward. Determination of changes in structural covariance networks - patterns of covariance in grey matter density - has shown to be a valuable technique to detect subtle grey matter variations. We evaluated how structural network integrity in PD is related to clinical data. METHODS: 3 Tesla MRI was performed in 159 PD patients. We used nine standardized structural covariance networks identified in 370 healthy subjects as a template in the analysis of the PD data. Clinical assessment comprised motor features (Movement Disorder Society-Unified Parkinson's Disease Rating Scale; MDS-UPDRS motor scale) and predominantly non-dopaminergic features (SEverity of Non-dopaminergic Symptoms in Parkinson's Disease; SENS-PD scale: postural instability and gait difficulty, psychotic symptoms, excessive daytime sleepiness, autonomic dysfunction, cognitive impairment and depressive symptoms). Voxel-based analyses were performed within networks significantly associated with PD. RESULTS: The anterior and posterior cingulate network showed decreased integrity, associated with the SENS-PD score, p = 0.001 (ß = - 0.265, ηp2 = 0.070) and p = 0.001 (ß = - 0.264, ηp2 = 0.074), respectively. Of the components of the SENS-PD score, cognitive impairment and excessive daytime sleepiness were associated with atrophy within both networks. CONCLUSIONS: We identified loss of integrity and atrophy in the anterior and posterior cingulate networks in PD patients. Abnormalities of both networks were associated with predominantly non-dopaminergic features, specifically cognition and excessive daytime sleepiness. Our findings suggest that (components of) the cingulate networks display a specific vulnerability to the pathobiology of PD and may operate as interfaces between networks involved in cognition and alertness.

Diagnosis and management of functional neurological symptoms: The Dutch experience.

OBJECTIVES: Functional neurological symptoms (FNS) were considered as a psychiatric disorder at the beginning of the 20th century (conversion disorder). Psychiatrists performed diagnosis and treatment throughout most of the past century in the Netherlands, but in the latest decades patients were usually firstly referred to neurologists. The aim of this study was to investigate the opinions of today's neurologists, psychiatrists and rehabilitation physicians in the Netherlands, regarding pathogenesis, diagnosis and treatment of FNS. DESIGN: An electronic questionnaire was sent to all neurologists registered with the Dutch Society for Neurology and to the members of the Department for Consultation-liaison and General Hospital Psychiatry. RESULTS: 343 of 780 neurologists, 64 of 197 psychiatrists and 47 of 750 rehabilitation physicians completed the questionnaire. 60% of neurologists and 67% of psychiatrists considered disordered brain functioning together with psychogenic factors responsible for FNS. 29% of neurologists and 88% of psychiatrists felt a psychiatrist was needed for diagnosis. 55% of neurologists and 88% of psychiatrists preferred combined treatment consisting of explaining FNS to patients, psychotherapy and physiotherapy provided by a therapist trained in FNS. 15% of neurologists preferred only physiotherapy. CONCLUSION: Most neurologists and psychiatrists did not consider FNS as a mere psychiatric disorder, but counted disordered brain functioning together with psychogenic factors responsible for FNS. Subsequently, according to the majority of neurologists and psychiatrists FNS should not be solely diagnosed and treated by psychiatrists. These results can help to formulate treatment strategies.