Management of seizures in patients with multiple sclerosis; an Iranian consensus.

PURPOSE: Cooccurrence of a seizure in a patient with multiple sclerosis (MS) may complicate the management process. Questions, which may complicate the management process of a patient with MS and seizure, include "how should we approach to the patient", "how should we treat the patient", "how should we modify the patient's MS treatment strategy", etc. METHODS: We searched the electronic database PubMed on March 30, 2018 for articles in English that included the following search terms: "epilepsy" AND "multiple sclerosis" or "seizure" AND "multiple sclerosis" since 2013, to obtain the best recent relevant scientific evidence on the topic. A working group of 6 epilepsy and 5 MS experts took part in two consensus workshops in Tehran, Iran, in 2018. The final consensus manuscript was prepared and approved by all participants. RESULTS: The search with words "seizure" and "multiple sclerosis" yielded 121 entries; 10 were relevant to the topic. The search with words "epilepsy" and "multiple sclerosis" yielded 400 entries; 7 were relevant to the topic. We reviewed these 17 articles and also some other references, derived from these articles or relevant to the topic, for the purpose of our review. CONCLUSION: Cooccurrence of a seizure in a patient with MS may complicate the management process. In this review, we tried to provide answers to the frequently asked questions, considering the best available scientific evidence and expert opinion.

Wegener's Granulomatosis Presenting as Wallenberg Syndrome: A Case Report.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, a vasculitis affecting small and medium sized vessels usually affects the upper and lower respiratory tract, the kidneys, and the eyes. Neurologic manifestation in central nervous system (CNS) is less frequent than the peripheral and usually is in form of stroke. Few cases of lateral medullary ischemic stroke (Wallenberg syndrome) due to GPA have been reported. A 41 year-old female, presented with acute vertigo, nausea/vomiting, hiccups, dysphagia. In physical examination she had a saddled nose, horner syndrome, soft palate paralysis, crossed hypoesthesia of face, and limbs and hemi-ataxia. Brain magnetic imaging revealed a left lateral medullary infarction and sinusitis confirmed by paranasal Sinus CT scans. Chest CT showed a cavitary mass. Laboratory findings were remarkable for anemia, elevated erythrocyte sedimentation rate, and C-reactive protein. Cytoplasmic antineutrophil cytoplasmic antibody (ANCA)/anti-proteinase 3 was positive. Diagnosis of GPA was established and treatment was started. During 6-month follow-up improvement was satisfying and no relapses occurred. Medullary infarct is reported in few GPA patients, especially at presentation. Definite diagnosis is based on tissue biopsy. Although in context of extra CNS involvement and positive ANCA diagnosis can be made confidently. Treatment of choice in CNS involvement is not clear, corticosteroids and immunosuppressives seem effective. CNS involvement, especially stroke may present GPA or accompany extra CNS symptoms. Prompt diagnosis and treatment is essential.

The novel mutation p.Asp251Asn in the ß-subunit of succinate-CoA ligase causes encephalomyopathy and elevated succinylcarnitine.

SUCLA2 is one of several nuclear-encoded genes that can cause encephalomyopathy accompanied by mitochondrial DNA depletion. The disorder usually manifests in early childhood and leads to early death. The gene encodes one of the subunits of succinyl-CoA synthase, the enzyme that catalyzes the reversible conversion of substrates succinyl-CoA and ADP to products succinate and ATP in the tricarboxylic acid pathway. Thirty-two individuals harboring mutations in SUCLA2 have so far been reported, and five different mutations were observed among these individuals. Here we report identification of a novel mutation in SUCLA2 in two cousins affected with encephalomyopathy. The novel mutation causes p.Asp251Asn; the affected amino acid is likely positioned within the ATP-grasp domain of the encoded protein. As previously reported in other patients, we did not observe elevation of methylmalonic acid, the biochemical hallmark of patients with mutations in SUCLA2. We instead found elevated levels of succinylcarnitine.

Uremic encephalopathy: A definite diagnosis by magnetic resonance imaging?

The aim of this study was to investigate the magnetic resonance imaging (MRI) findings for the diagnose uremic encephalopathy and describe the usefulness of MRI findings in the ultimate diagnosis of uremic encephalopathy (UE). A total of 20 patients with uremic encephalopathy admitted to the hospital were evaluated in this prospective study. The clinical manifestations, laboratory and MRI imaging findings, demographic information, and clinical outcome were analyzed for each patient. We observed that the 20 prospectively reviewed patients with UE had no involvement of the basal ganglia or the lentiform fork sign (LFS). However, two-thirds of the patients had white matter involvement, and 80% of the subjects had cerebral or cortical atrophy. The arterial blood gas (ABG) analysis revealed that 50% of the patients suffered from metabolic acidosis (n=10). The results of the present study demonstrated that although the observation of Lentiform Fork Sign and Basal Ganglia involvement in MRI of UE patients is a specific finding the absence of which does not rule out UE. Thus, simultaneous examination of clinical manifestation and laboratory test analyses, along with imaging findings, should also be taken into account.

Genome-wide linkage analysis of a Parkinsonian-pyramidal syndrome pedigree by 500 K SNP arrays.

Robust SNP genotyping technologies and data analysis programs have encouraged researchers in recent years to use SNPs for linkage studies. Platforms used to date have been 10 K chip arrays, but the possible value of interrogating SNPs at higher densities has been considered. Here, we present a genome-wide linkage analysis by means of a 500 K SNP platform. The analysis was done on a large pedigree affected with Parkinsonian-pyramidal syndrome (PPS), and the results showed linkage to chromosome 22. Sequencing of candidate genes revealed a disease-associated homozygous variation (R378G) in FBXO7. FBXO7 codes for a member of the F-box family of proteins, all of which may have a role in the ubiquitin-proteosome protein-degradation pathway. This pathway has been implicated in various neurodegenerative diseases, and identification of FBXO7 as the causative gene of PPS is expected to shed new light on its role. The performance of the array was assessed and systematic analysis of effects of SNP density reduction was performed with the real experimental data. Our results suggest that linkage in our pedigree may have been missed had we used chips containing less than 100,000 SNPs across the genome.

PRKN, DJ-1, and PINK1 screening identifies novel splice site mutation in PRKN and two novel DJ-1 mutations.

We present results of mutation screening of PRKN gene in 93 Iranian Parkinson's disease (PD) patients with average age at onset (AAO) of 42.2 years. The gene was screened by direct sequencing and by a semi-quantitative PCR protocol for detection of sequence rearrangements. Heterozygous rearrangements were tested by reverse transcription-polymerase chain reaction (RT-PCR). Nine different PRKN mutations were found. One of these, IVS9+1G>A, affects splicing and is novel. Two mutated PRKN alleles were observed in each of 6 patients whose average AAO was 25.7 years. Only 1 patient carried a single mutated allele and his AAO was 41 years. Among patients with AAO of <30 years, 31.3% had two mutated alleles, while only 2.6% with AAO of >30 years carried a PRKN mutation. Analysis of PRKN by RT-PCR led to identification of a novel exon expressed in leukocytes of control and PD individuals. The alternatively spliced transcript if translated would code a protein without a RING Finger 2 domain. Its functional relevance remains to be shown. DJ-I and PINK1 were also screened. Two novel DJ-1 mutations, c.91-2A>G affecting splicing and c.319G>C causing Ala107Pro, were observed among patients with AAO of <31 years, suggesting that PD in a high fraction (>12%) of this group of Iranian patients may be due to mutations in DJ-1. Mutations in PINK1 were not observed. Our results complement previous findings on LRRK2 mutations among Iranian PD patients.

Creutzfeldt-Jakob disease: A case report.

BACKGROUND: Creutzfeldt-Jakob disease (CJD) as a life-threatening neurodegenerative disorder is not usually diagnosed in early stages of the disease because of a variety in its clinical manifestations. This study aimed to present a middle-aged woman with psychiatric symptoms who ultimately was diagnosed as a CJD case. CASE PRESENTATION: This 48-year-old woman had progressive symptoms of depressed mood, decreased sleep and appetite and mutism which started two months before the first visit. Gradually, slowness in movements, dysarthria and decreased performance were observed. Subsequently, when antidepressant and antipsychotic drugs were prescribed other symptoms such as ataxia and rigidity manifested in the patient. The problem list which led to final confirmation of the disease included non-specific neuropsychological presentations, hypersignality in caudate and putamen areas in brain MRI, generalized high frequency sharp waves in EEG, and protein 14-3-3 identification in cerebrospinal fluid. CONCLUSION: Although CJD is not a common disease, it should be considered in differential diagnoses whenever neuropsychological manifestations, especially progressive decline in cognition, along with symptoms such as visual hallucinations, myoclonus and ataxia are observed in the patient.

A clinic-based screening of mutations in exons 31, 34, 35, 41, and 48 of LRRK2 in Iranian Parkinson's disease patients.

We present results of mutation screening of exons 31, 34, 35, 41, and 48 of LRRK2 in 205 Iranian Parkinson's disease patients. Sixteen percent of the cases were familial. Although age was not a factor in patient recruitment, the Iranian cohort was relatively young (average age at onset of disease: 48.9 years). A notably high male to female ratio (2.96:1) and earlier age at onset (by 2.9 years) in men were observed. A known disease-associated variation, c.C4321T causing R1441C, and IVS31 + 3A > G, a variation that may be associated, were observed. Therefore, disregarding IVS31 + 3A > G, disease status in at least 0.5% of our young cohort and in 3.5% of the familial cases was associated with a mutation in the five exons of LRRK2 screened. Interestingly, the variation causing p.G2019S was not observed.

Prevalence of Dementia Among Older Patients: A Hospital-Based Study in Iran.

BACKGROUND: Dementia constitutes a public health hazard in developing countries. The aim of this study was to evaluate the prevalence of dementia and its associated factors in older hospitalized patients. METHODS: The participants of this cross-sectional study consisted of older patients admitted to medical wards in Rasoul-e Akram hospital in Tehran, Iran. Mini-Mental State Examination, Mini-Cog test, Geriatric Depression Scale, Activities of Daily Living-Instrumental Activities of Daily Living (ADL-IADL) scale, and socioeconomic questionnaires were used. RESULTS: A total of 205 elderly inpatients were included. The mean age was 71.33 ± 7.35 years; 63.4% of the participants had normal cognitive function, while 36.6% had some degree of cognitive impairment. There was a statistically significant relationship between gender, age, number of children, and occupation and the prevalence of dementia. CONCLUSION: Appropriate cognitive screening of older patients upon admission to hospitals could help identify potential adverse events and enhance the quality of care for patients with comorbid dementia.

Deep Brain Stimulation and Drug-Resistant Epilepsy: A Review of the Literature.

Introduction: Deep brain stimulation is a safe and effective neurointerventional technique for the treatment of movement disorders. Electrical stimulation of subcortical structures may exert a control on seizure generators initiating epileptic activities. The aim of this review is to present the targets of the deep brain stimulation for the treatment of drug-resistant epilepsy. Methods: We performed a structured review of the literature from 1980 to 2018 using Medline and PubMed. Articles assessing the impact of deep brain stimulation on seizure frequency in patients with DRE were selected. Meta-analyses, randomized controlled trials, and observational studies were included. Results: To date, deep brain stimulation of various neural targets has been investigated in animal experiments and humans. This article presents the use of stimulation of the anterior and centromedian nucleus of the thalamus, hippocampus, basal ganglia, cerebellum and hypothalamus. Anterior thalamic stimulation has demonstrated efficacy and there is evidence to recommend it as the target of choice. Conclusion: Deep brain stimulation for seizures may be an option in patients with drug-resistant epilepsy. Anterior thalamic nucleus stimulation could be recommended over other targets.

Action Myoclonus and Seizure in Kufor-Rakeb Syndrome.

BACKGROUND: Kufor-Rakeb syndrome (KRS) is a rare autosomal recessive neurologic disease with diverse phenotypic features. Herein we report an Iranian KRS family with seizure and action myoclonus in addition to other typical manifestations of this syndrome. METHOD: All family members underwent careful neurologic examination. Exome sequencing was performed and ATP13A2 variation genotyped in all family members. RESULTS: Cognitive deficits, hypokinesia, rigidity, spasticity, brisk deep tendon reflexes, upward gaze palsy, tremor, and facial-faucial-finger mini-myoclonus were the common manifestations of all affected siblings. Two cases had seizure and the most severely affected sibling demonstrated severe action myoclonus. Exome sequencing identified a homozygous nonsense mutation c.2455C>T;p.Arg819* in ATP13A2 gene. CONCLUSIONS: We reported five KRS affected siblings who manifested myoclonus and seizure. The most severely affected one demonstrated action myoclonus, which has not been reported so far.

Migraine headache in patients with idiopathic intracranial hypertension.

Migraine is a neurological disorder that afflicts many people in the world and can cause severe disability during the attacks. The pathophysiology of migraine is complex and not fully understood. It seems that migraine is common in idiopathic intracranial hypertension (IIH). However, the association between migraine headache and IIH is still unclear. The present study was conducted to assess the prevalence of migraine headache and associated factors in IIH patients. In this cross-sectional study, a total of 68 patients diagnosed with IIH underwent a medical history interview and a neurological examination. The diagnosis of migraine was based on the four diagnostic criteria of the International Classification of Headache Disorders 3rd edition. Forty-five patients (63.2%) met the diagnostic criteria of migraine headache. There was no significant difference between patients with and without migraine headache in respect of their age, gender, body mass. This study revealed high prevalence of migraine headache in IIH patients; appropriate treatment can reduce their headache and prevent unnecessary treatments for IIH.

Stiff person case misdiagnosed as conversion disorder: A case report.

BACKGROUND: Stiff person syndrome (SPS) is a rare neurological disease resulting in stiffness and spasm of muscles. It initially affects the axial muscles and then spread to limb muscles. Emotional stress exacerbated the symptoms and signs of the disease. The pathophysiology of the disease is caused by the decreased level of the glutamic acid decarboxylase (GAD) activity due to an autoantibody against GAD that decreases the level of gamma-aminobutyric acid (GABA). In this paper, we present a case of atypical presentation of SPS with lower limb stiffness misdiagnosed as conversion disorder. CASE PRESENTATION: We report a patient with atypical presentation of SPS with lower limb stiffness and gait disorder misdiagnosed as conversion disorder for a year. Her antithyroid peroxidase antibody (anti-TPO Ab) level was 75 IU (normal value: 0-34 IU). Intravenous immunoglobulin (IVIG) was administered (2gr/kg, 5 days) for the patient that showed significant improvement in the follow-up visit. CONCLUSION: It is essential that in any patient with bizarre gait disorder and suspicious to conversion disorder due to the reversibility of symptoms, SPS and other movement disorder should be considered.

Identification of four novel potentially Parkinson's disease associated LRRK2 variations among Iranian patients.

The results of mutation screening of 24 exons of LRRK2 in 60 Iranian Parkinson's Disease patients are presented. The Iranian cohort represents a novel population and was notably young (average age at onset of disease: 36.0 years). Fifty sequence variations were found, seventeen of which are novel. Variations considered possibly associated with disease were screened in available family members, 145 additional patients and 220 control individuals. It was surmised that four novel sequence variations (IVS49+178A>G, p.R1725Q, p.Q1823K, and p.D2175H) may be associated with PD status, albeit they may be very rare non-disease associated variations. The four variations were all observed in the heterozygous state in early onset cases. If one or more of the variations do indeed contribute to disease status, their penetrance is expected to be low.