Gamma knife thalamotomy in treating refractory tremor: initial clinical experience in Croatia.

Tremor refractory to pharmacological therapy significantly reduces the patient´s quality of life, often leading to early retirement and social isolation. Gamma knife (GK) stereotactic radiosurgery of the unilateral thalamic ventral intermediate nucleus is an advanced, minimally invasive surgical procedure for symptomatic tremor suppression. Due to the restricted availability of this type of treatment, literature data on its efficacy and safety are lacking. We present two patients with severe, disabling tremor (one with parkinsonian and one with essential tremor) successfully treated with GK thalamotomy, performed in Croatia for the first time. GK thalamotomy should be considered in patients with refractory tremors and contraindications for deep brain stimulation.

Impact of Donepezil and Memantine on Behavioral and Psychological Symptoms of Alzheimer Disease: Six-month Open-label Study.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are common in individuals with Alzheimer disease (AD). Donepezil and memantine are both widely used for the treatment of moderate AD. OBJECTIVE: To evaluate the effects of donepezil and memantine in relieving BPSD in individuals with moderate AD. METHOD: We conducted a prospective, randomized, 6-month clinical trial involving 85 individuals with moderate AD divided into two groups: group 1 (n = 42) was treated with donepezil; group 2 (n = 43) was treated with memantine. We used the Neuropsychiatric Inventory (NPI) to assess the prevalence and severity of BPSD at baseline and after 6 months of treatment with donepezil or memantine. RESULTS: The two groups' baseline characteristics, including age, sex, mean length of education, and disease duration, were comparable, as were their baseline Mini-Mental State Examination scores. The NPI Total score improved from baseline to month 6 in both groups (P < 0.0001). Analyses of the NPI subdomains revealed that both donepezil treatment and memantine treatment produced statistically significant improvement in all of the NPI domains except euphoria and apathy, for which no improvement was observed after memantine treatment. Both treatments were well tolerated, with mostly mild and transient adverse effects. CONCLUSION: Specific drugs for AD, including donepezil and memantine, may be effective in treating BPSD in individuals with moderate AD, with a favorable safety profile.

Hydroxyapatite ceramics in multilevel cervical interbody fusion - is there a role?

The aim of this study is to evaluate the efficacy of hydroxyapatite grafts in multilevel cervical interbody fusion during the one year follow-up. A total of 86 patients with degenerative cervical disc disease underwent all together 224 cervical interbody fusion procedures in which either Smith-Robinson or Cloward type hydroxyapatite grafts were used. The surgeries included radiculopathy in 38 cases, myelopathy in 20 cases and myeloradicuopathy in 28 patients. In 65 out of 86 patients, fusion was followed by an anterior instrumentation (plating). Postoperatively, patients were followed for a mean of 15.64 (range 11-23.3) months. All patients underwent radiography to evaluate fusion and the axis curvature. Excellent clinical results (86%), described as a complete or partial relief of symptoms with full return to preop activity, were obtained in patients with radiculopathy. There were 5 grafts mobilizations and one graft fracture. Two grafts extruded in non-instrumented patients and required repeated surgery. There were other three reoperations due to the hardware problems. One year fusion rate was obtained at 86% for two-level surgery, 80.1% for three-level surgery and 74% for four-level surgery. The mean (SD) hospital stay was 3.8 (0.7) days. A hydroxyapatite cheramic can be a very effective synthetic material for multilevel cervical interbody fusion. It is characterized by a high fusion rate and a small percentage of graft-related complications, especially when fusion procedure is followed by plating.

Paroxismal non-kinesigenic dyskinesia and hemidystonia associated with silent celiac disease.

Paroxismal non-kinesigenic dyskinesia (PNKD) is a rare movement disorder manifesting as choreatic/dystonic movements, usually lasting from minutes to up to 4 h, with perserved consciousness during attacks. Primary PNKD are idiopathic or genetic disorders while secondary PNKD are associated with various neurologic and medical conditions. We present a case with PNKD and right sided hemidystonia in association with celiac disease, responsive to gluten-free diet, not previously reported in available literature. In conclusion, diagnostic tests for celiac disease should be a part of etiological investigations in patients with otherwise unexplained movement disorders including PKND. Gluten free diet could produce a favorable clinical response in those patients.

Ventrolateral disc herniation causes psoas muscle compression: A case report.

We report a case of a 39-year old male patient who presented to us with several months of lower back pain. Following clinical assessment, the patient underwent a magnetic resonance imaging exam, which after using advanced imaging protocols showed a ventrolateral disc hernation toward the psoas muscle. Based upon the findings in the magnetic resonance and the electromyoneurographic examination, the decision was made to treat the patient conservatively. Coronal planes are useful for discerning changes of various origins not usually seen on the sagital and axial planes. If needed, additional advanced protocol is available for increased specificity and diagnostic accuracy.

High eradication rate of H. pylori with moxifloxacin-based treatment: a randomized controlled trial.

INTRODUCTION: Eradication of Helicobacter pylori remains a problematic treatment issue in clinical practice. The intention is to find a treatment that achieves a high rate of eradication at a low price and treatment options that are now used give us the opportunity to achieve this goal. Recently published results showing a low rate of resistance and better compliance with moxifloxacin-based treatment regimens indicate the need to investigate its efficacy in H. pylori eradication. This study is based on proving the efficacy of moxifloxacin in H. pylori eradication within the triple therapy. AIMS AND METHODS: The aim of the study was to compare the efficacy of one week of moxifloxacin-based treatment with the standard treatment for H. pylori eradication. Patients with H. pylori infection and non-ulcer dyspepsia (n = 277) were randomly divided into four groups to receive: moxifloxacin 400 mg/d, metronidazole 400 mg twice daily, lansoprazole 30 mg twice daily (MML group); moxifloxacin 400 mg/d, amoxicillin 1 g twice daily, lansoprazole 30 mg twice daily (MAL group); clarithromycin 500 mg twice daily, metronidazole 400 mg twice daily, lansoprazole 30 mg twice daily (CML group); clarithromycin 500 mg twice daily, amoxicillin 1 g twice daily, lansoprazole 30 mg twice daily (CAL group). The patients were assessed for prevalence of H. pylori using the CLO test, histology and culture on gastric biopsy samples obtained during upper gastrointestinal endoscopy before randomization and 4-6 weeks after completion of treatment. Bacterial sensitivity to clarithromycin and moxifloxacin was determined with the E-test. RESULTS: 265 (95.6%) patients completed the study forming the basis for PP analysis. Eradication rates of H. pylori in ITT and in PP analyses were: in the MML group 93.5% (58/62) and 96.7% (58/60), respectively; in the MAL group 86.4% (57/66) and 90.5% (57/63); in the CML group 70.4% (50/71) and 75.8% (50/66); and in the CAL group 78.2% (61/78) and 80.2% (61/76). Moxifloxacin treatment protocols were significantly more effective on both ITT and PP analyses than the clarithromycin based protocols with only one exception (MAL vs. CAL on ITT analysis). Among 238 patients (86% of the entire study group), strains showing primary resistance to clarithromycin were found in 10.8% and to moxifloxacin in 5.9%. Eradication of moxifloxacin sensitive/resistant strains was 98.1%/75% for MML (p < 0.01) and 91.1%/66.7% for MAL (p = n.s.); comparison of eradication of sensitive strains in MML and MAL regimens was 98.1%/91.1% (p < 0.05), and for resistant strains 75%/66.7% (p = n.s.). CML and CAL protocols did not differ in efficacy of eradication of clarithromycin sensitive or resistant strains. CONCLUSION: Moxifloxacin-based triple therapies showed higher eradication rates with few side effects and good drug compliance when compared with standard H. pylori treatments. Moreover, the increased prevalence of clarithromycin resistance suggests that moxifloxacin-based regimens could be safe and effective options in treatment of H. pylori infection.

Cervical Disk Replacement With Discover Versus Fusion in a Single-Level Cervical Disk Disease: A Prospective Single-Center Randomized Trial With a Minimum 2-Year Follow-up.

STUDY DESIGN: Prospective randomized study. OBJECTIVE: To compare the clinical outcome after Discover arthroplasty versus anterior cervical discectomy and fusion (ACDF) in patients treated for symptomatic single-level cervical disk disease. SUMMARY OF BACKGROUND DATA: ACDF is still the gold standard for surgical treatment of cervical spine degenerative disk disease. However, results of many studies suggest that it may cause degenerative changes at levels immediately above and below the fusion, known as adjacent segment degenerative disease. Cervical arthroplasty has recently been introduced as an alternative to standard procedure of ACDF. It showed decreased surgical morbidity, decreased complications from postoperative immobilization, and an earlier return to previous level of function. MATERIALS AND METHODS: A total of 105 consecutive patients with single-level cervical disk disease, producing radiculopathy and/or myelopathy were randomly divided into groups to undergo ACDF or Discover arthroplasty. All patients were evaluated with preoperative and postoperative serial radiographic studies and clinically, using Neck Disability Index, Visual Analog Scale and neurological status at 3, 6, 12, and 24 months. RESULTS: The results of our study indicate that cervical arthroplasty using Discover Artificial Cervical Disc provides favorable clinical and radiologic outcomes in a follow-up period of 24 months. There has been significant improvement in clinical parameters, Visual Analog Scale and Neck Disability Index, at 3, 6, 12, and 24 months in arthroplasty group comparing to control group. CONCLUSION: The Discover artificial cervical disc replacement offers favorable outcome compared with ACDF for a single-level cervical disk disease at short-term and long-term follow-up.

Nonmotor symptoms in de novo Parkinson disease comparing to normal aging.

OBJECTIVE: Nonmotor symptoms (NMSs) are common in Parkinson disease (PD), affecting patient's quality of life. The prevalence and domains of NMSs in untreated de novo PD remains unclear, especially comparing to normal aging. The objective was to determine NMSs in untreated de novo PD patients. PATIENTS AND METHODS: We performed a cross-sectional study to evaluate the frequency and severity of NMSs in untreated de novo PD patients (n=71) and age-matched normal controls (n=60) using the Non-Motor Symptoms Scale (NMSS). The motor section of the Unified Parkisnon Disease Rating Scale (mUPDRS) and the Hoehn and Yahr (HY) stage were also obtained in PD patients RESULTS: The number of NMSs and the NMSS scores were significantly higher in the PD patients than in controls (p<0.001). There was no correlation of the NMSS scores with age and sex in both group and additionally with mUPDRS score and HY stage in PD patients group. Mood/cognition, attention/memory and gastrointestinal domains are the most frequent in PD patients and rarely seen in controls. CONCLUSION: NMSs in untreated de novo PD patients are more prevalent and severe with different domain involvement comparing to normal aging.

Multiple cystic brain metastases from papillary thyroid carcinoma mimicking neurocysticercosis.

The papillary carcinoma of the thyroid gland is the most common type of tumor of the thyroid gland with good prognosis and low incidence of distant metastasis. The brain metastases of thyroid gland carcinoma are extremely rare. We report a patient with multiple cystic brain lesions and satisfying criteria for diagnosis of neurocysticercosis. Brain biopsy revealed brain metastases from papillary thyroid carcinoma. The tumor originated from mediastinal thyroid tissue. Even in cases when neuroimaging suggests neurocysticercosis with great accuracy, it is important to exclude metastasis. Extensive brain metastases of primary papillary thyroid carcinoma are extremely rare.