Endothelial-Derived Extracellular Vesicles Induce Cerebrovascular Dysfunction in Inflammation.

Blood-brain barrier (BBB) dysfunction is a key hallmark in the pathology of many neuroinflammatory disorders. Extracellular vesicles (EVs) are lipid membrane-enclosed carriers of molecular cargo that are involved in cell-to-cell communication. Circulating endothelial EVs are increased in the plasma of patients with neurological disorders, and immune cell-derived EVs are known to modulate cerebrovascular functions. However, little is known about whether brain endothelial cell (BEC)-derived EVs themselves contribute to BBB dysfunction. Human cerebral microvascular cells (hCMEC/D3) were treated with TNFα and IFNy, and the EVs were isolated and characterised. The effect of EVs on BBB transendothelial resistance (TEER) and leukocyte adhesion in hCMEC/D3 cells was measured by electric substrate cell-substrate impedance sensing and the flow-based T-cell adhesion assay. EV-induced molecular changes in recipient hCMEC/D3 cells were analysed by RT-qPCR and Western blotting. A stimulation of naïve hCMEC/D3 cells with small EVs (sEVs) reduced the TEER and increased the shear-resistant T-cell adhesion. The levels of microRNA-155, VCAM1 and ICAM1 were increased in sEV-treated hCMEC/D3 cells. Blocking the expression of VCAM1, but not of ICAM1, prevented sEV-mediated T-cell adhesion to brain endothelia. These results suggest that sEVs derived from inflamed BECs promote cerebrovascular dysfunction. These findings may provide new insights into the mechanisms involving neuroinflammatory disorders.

The Long Non-Coding RNA H19 Drives the Proliferation of Diffuse Intrinsic Pontine Glioma with H3K27 Mutation.

Diffuse intrinsic pontine glioma (DIPG) is an incurable paediatric malignancy. Identifying the molecular drivers of DIPG progression is of the utmost importance. Long non-coding RNAs (lncRNAs) represent a large family of disease- and tissue-specific transcripts, whose functions have not yet been elucidated in DIPG. Herein, we studied the oncogenic role of the development-associated H19 lncRNA in DIPG. Bioinformatic analyses of clinical datasets were used to measure the expression of H19 lncRNA in paediatric high-grade gliomas (pedHGGs). The expression and sub-cellular location of H19 lncRNA were validated in DIPG cell lines. Locked nucleic acid antisense oligonucleotides were designed to test the function of H19 in DIPG cells. We found that H19 expression was higher in DIPG vs. normal brain tissue and other pedHGGs. H19 knockdown resulted in decreased cell proliferation and survival in DIPG cells. Mechanistically, H19 buffers let-7 microRNAs, resulting in the up-regulation of oncogenic let-7 target (e.g., SULF2 and OSMR). H19 is the first functionally characterized lncRNA in DIPG and a promising therapeutic candidate for treating this incurable cancer.

The evolutionarily conserved long non-coding RNA LINC00261 drives neuroendocrine prostate cancer proliferation and metastasis via distinct nuclear and cytoplasmic mechanisms.

Metastatic neuroendocrine prostate cancer (NEPC) is a highly aggressive disease, whose incidence is rising. Long noncoding RNAs (lncRNAs) represent a large family of disease- and tissue-specific transcripts, most of which are still functionally uncharacterized. Thus, we set out to identify the highly conserved lncRNAs that play a central role in NEPC pathogenesis. To this end, we performed transcriptomic analyses of donor-matched patient-derived xenograft models (PDXs) with immunohistologic features of prostate adenocarcinoma (AR+ /PSA+ ) or NEPC (AR- /SYN+ /CHGA+ ) and through differential expression analyses identified lncRNAs that were upregulated upon neuroendocrine transdifferentiation. These genes were prioritized for functional assessment based on the level of conservation in vertebrates. Here, LINC00261 emerged as the top gene with over 3229-fold upregulation in NEPC. Consistently, LINC00261 expression was significantly upregulated in NEPC specimens in multiple patient cohorts. Knockdown of LINC00261 in PC-3 cells dramatically attenuated its proliferative and metastatic abilities, which are explained by parallel downregulation of CBX2 and FOXA2 through distinct molecular mechanisms. In the cell cytoplasm, LINC00261 binds to and sequesters miR-8485 from targeting the CBX2 mRNA, while inside the nucleus, LINC00261 functions as a transcriptional scaffold to induce SMAD-driven expression of the FOXA2 gene. For the first time, these results demonstrate hyperactivation of the LINC00261-CBX2-FOXA2 axes in NEPC to drive proliferation and metastasis, and that LINC00261 may be utilized as a therapeutic target and a biomarker for this incurable disease.

Eficacia y seguridad del tratamiento quirúrgico en la cefalea en racimos / Efficacy and safety of surgical treatment of cluster headache

ANTECEDENTES Y OBJETIVO: La cefalea en racimos (CR) es la cefalea humana más grave y se cronifica en un 10-20% de los pacientes, pudiendo llegar a ser refractaria a todos los fármacos eficaces en un 10% de ellos. En este escenario se indican procedimientos quirúrgicos: radiofrecuencias del ganglio esfenopalatino ipsilateral al dolor (RF-GEFP), estimulación bilateral de los nervios occipitales (E-NOM) y estimulación cerebral profunda (ECP) del hipotálamo posteroinferior ipsilateral. Se ha analizado específicamente la eficacia y seguridad de cada una de ellas, pero no se ha descrito la evolución de una serie de pacientes siguiendo este itinerario quirúrgico por orden de agresividad. PACIENTES: Pacientes con CR crónica y refractaria según los criterios de la European Headache Federation. Fueron sometidos secuencialmente a RF-GEFP, E-NOM si ineficacia del anterior y ECP si ineficacia del anterior. RESULTADOS: Incluimos prospectivamente a 44 pacientes entre noviembre de 2003 y junio de 2018 con una edad media de 38,3 años siendo el 70% hombres. El seguimiento medio fue de 87,4 meses. Respondieron a 74 procedimientos de RF-GEFP 19 pacientes (33,3%). De los 25 restantes, se implantó un dispositivo de E-NOM en 22 de ellos, mostrando una eficacia del 50%. Finalmente, se sometieron a ECP del hipotálamo posteroinferior ipsilateral 9 pacientes con una eficacia del 88,8%. No se constataron complicaciones graves en ninguno de los 3 procedimientos. CONCLUSIONES: La aplicación secuencial de los 3 procedimientos quirúrgicos logró revertir la grave situación de CR crónica y refractaria a una CR episódica en el 93% de los pacientes con una morbilidad quirúrgica aceptable

BACKGROUND AND OBJECTIVES: Cluster headache (CR) is the most severe human headache and is chronic in 10%-20% of patients, and 10% can become refractory to all effective drugs. In this scenario, surgical procedures are indicated: radiofrequencies of the sphenopalatine ganglion ipsilateral to pain (RF-SPG), bilateral stimulation of the occipital nerves (NOM-S) and deep brain stimulation (DBS) of the ipsilateral posterior hypothalamus. The efficacy and safety of each of these procedures has been specifically analyzed, but the progress of a series of patients following this surgical route in order of aggressiveness has not been described. PATIENTS: Patients with chronic and refractory CR according to the criteria of the European Headache Federation. The patients underwent RF-SPG, NOM-S sequentially if the previous procedure had been ineffective, and DBS if the previous procedure had been ineffective. RESULTS: We prospectively included 44 patients between November 2003 and June 2018 with an average age of 38.3 years; 70% were men. The mean follow-up was 87.4 months. Nineteen patients responded to 74 procedures of RF-SPG (33.3%). Of the remaining 25 patients, a NOM-S device was implanted in 22, showing an efficacy of 50%. Finally, 9 patients underwent ECP of the ipsilateral lower-posterior hypothalamus with an efficacy of 88.8%. No serious complications were found following any of these 3 procedures. CONCLUSIONS: The sequential application of these three surgical procedures succeeded in reversing the serious situation of chronic CR refractory to an episodic CR in 93% of patients with acceptable surgical morbidity

Efficacy and safety of surgical treatment of cluster headache. / Eficacia y seguridad del tratamiento quirúrgico en la cefalea en racimos.

BACKGROUND AND OBJECTIVES: Cluster headache (CR) is the most severe human headache and is chronic in 10%-20% of patients, and 10% can become refractory to all effective drugs. In this scenario, surgical procedures are indicated: radiofrequencies of the sphenopalatine ganglion ipsilateral to pain (RF-SPG), bilateral stimulation of the occipital nerves (NOM-S) and deep brain stimulation (DBS) of the ipsilateral posterior hypothalamus. The efficacy and safety of each of these procedures has been specifically analyzed, but the progress of a series of patients following this surgical route in order of aggressiveness has not been described. PATIENTS: Patients with chronic and refractory CR according to the criteria of the European Headache Federation. The patients underwent RF-SPG, NOM-S sequentially if the previous procedure had been ineffective, and DBS if the previous procedure had been ineffective. RESULTS: We prospectively included 44 patients between November 2003 and June 2018 with an average age of 38.3 years; 70% were men. The mean follow-up was 87.4 months. Nineteen patients responded to 74 procedures of RF-SPG (33.3%). Of the remaining 25 patients, a NOM-S device was implanted in 22, showing an efficacy of 50%. Finally, 9 patients underwent ECP of the ipsilateral lower-posterior hypothalamus with an efficacy of 88.8%. No serious complications were found following any of these 3 procedures. CONCLUSIONS: The sequential application of these three surgical procedures succeeded in reversing the serious situation of chronic CR refractory to an episodic CR in 93% of patients with acceptable surgical morbidity.

PPARγ agonist-loaded PLGA-PEG nanocarriers as a potential treatment for Alzheimer's disease: in vitro and in vivo studies.

OBJECTIVE: The first aim of this study was to develop a nanocarrier that could transport the peroxisome proliferator-activated receptor agonist, pioglitazone (PGZ) across brain endothelium and examine the mechanism of nanoparticle transcytosis. The second aim was to determine whether these nanocarriers could successfully treat a mouse model of Alzheimer's disease (AD). METHODS: PGZ-loaded nanoparticles (PGZ-NPs) were synthesized by the solvent displacement technique, following a factorial design using poly (lactic-co-glycolic acid) polyethylene glycol (PLGA-PEG). The transport of the carriers was assessed in vitro, using a human brain endothelial cell line, cytotoxicity assays, fluorescence-tagged nanocarriers, fluorescence-activated cell sorting, confocal and transmission electron microscopy. The effectiveness of the treatment was assessed in APP/PS1 mice in a behavioral assay and by measuring the cortical deposition of ß-amyloid. RESULTS: Incorporation of PGZ into the carriers promoted a 50x greater uptake into brain endothelium compared with the free drug and the carriers showed a delayed release profile of PGZ in vitro. In the doses used, the nanocarriers were not toxic for the endothelial cells, nor did they alter the permeability of the blood-brain barrier model. Electron microscopy indicated that the nanocarriers were transported from the apical to the basal surface of the endothelium by vesicular transcytosis. An efficacy test carried out in APP/PS1 transgenic mice showed a reduction of memory deficit in mice chronically treated with PGZ-NPs. Deposition of ß-amyloid in the cerebral cortex, measured by immunohistochemistry and image analysis, was correspondingly reduced. CONCLUSION: PLGA-PEG nanocarriers cross brain endothelium by transcytosis and can be loaded with a pharmaceutical agent to effectively treat a mouse model of AD.

Ocular ptosis: differential diagnosis and treatment.

PURPOSE OF REVIEW: The current article provides a brief summary of the clinical approach to congenital and acquired ptosis. An increasing number of publications analyze causes of ptosis or describe diagnostic tests or advances in ptosis genetics. The aim of our work is to summarize these findings and provide an updated algorithm for the diagnosis and treatment of patients with ptosis. This review covers important clinical research and studies relevant for neurologists recently published. RECENT FINDINGS: Ptosis is a common cause of referral to neuromuscular units. Knowledge of the different causes of this symptom has grown substantially in recent years, from diagnostic tests and genetics studies to potential new therapeutic agents, making it essential to keep up to date on the diagnostic and therapeutic relevance of these contributions. SUMMARY: We emphasize that ptosis should be studied as a complex symptom. Efforts should be made to identify accompanying neurologic or ophthalmologic signs in clinical examination that could lead to a diagnosis. A growing number of diagnostics tests are available in the field, especially in genetics. Meanwhile, surgery continues being the most used therapeutic approach for these patients.

Mutation Spectrum in the CACNA1A Gene in 49 Patients with Episodic Ataxia.

Episodic ataxia is an autosomal dominant ion channel disorder characterized by episodes of imbalance and incoordination. The disease is genetically heterogeneous and is classified as episodic ataxia type 2 (EA2) when it is caused by a mutation in the CACNA1A gene, encoding the α1A subunit of the P/Q-type voltage-gated calcium channel Cav2.1. The vast majority of EA2 disease-causing variants are loss-of-function (LoF) point changes leading to decreased channel currents. CACNA1A exonic deletions have also been reported in EA2 using quantitative approaches. We performed a mutational screening of the CACNA1A gene, including the promoter and 3'UTR regions, in 49 unrelated patients diagnosed with episodic ataxia. When pathogenic variants were not found by sequencing, we performed a copy number variant (CNV) analysis to screen for duplications or deletions. Overall, sequencing screening allowed identification of six different point variants (three nonsense and three missense changes) and two coding indels, one of them found in two unrelated patients. Additionally, CNV analysis identified a deletion in a patient spanning exon 35 as a result of a recombination event between flanking intronic Alu sequences. This study allowed identification of potentially pathogenic alterations in our sample, five of them novel, which cover 20% of the patients (10/49). Our data suggest that most of these variants are disease-causing, although functional studies are required.

[Changes introduced into the recent International Classification of Headache Disorders: ICHD-III beta classification]. / Novedades en la reciente Clasificacion Internacional de las Cefaleas: clasificacion ICHD-III beta.

INTRODUCTION: The International Headache Society (IHS) has published the third edition of the International Classification of Headache Disorders (ICHD-III beta), the most commonly used guide to diagnosing headaches in the world. AIMS: To review the recent additions to the guide, to explain the new entities that appear in it and to compare the conditions that have had their criteria further clarified against the criteria in the previous edition. DEVELOPMENT: We have recorded a large number of clarifications in the criteria in practically all the headaches and neuralgias in the classification, but the conditions that have undergone the most significant clarifications are chronic migraine, primary headache associated with sexual activity, short-lasting unilateral neuralgiform headache attacks, new daily persistent headache, medication-overuse headache, syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis. The most notable new entities that have been incorporated are external-compression headache, cold-stimulus headache, nummular headache, headache attributed to aeroplane travel and headache attributed to autonomic dysreflexia. Another point to be highlighted is the case of the new headaches (still not considered entities in their own right) included in the appendix, some of the most noteworthy being epicrania fugax, vestibular migraine and infantile colic. CONCLUSIONS: The IHS recommends no longer using the previous classification and changing over to the new classification (ICHD-III beta) in healthcare, teaching and research, in addition to making this new guide as widely known as possible.

TITLE: Novedades en la reciente Clasificacion Internacional de las Cefaleas: clasificacion ICHD-III beta.Introduccion. La Sociedad Internacional de Cefaleas (IHS) ha publicado la tercera edicion de la Clasificacion Internacional de las Cefaleas (ICHD-III beta), la guia diagnostica de las cefaleas mas utilizada en el mundo. Objetivo. Revisar las recientes aportaciones de la guia, explicando las nuevas entidades que en ella aparecen y comparando las entidades que han matizado sus criterios con sus criterios de la edicion precedente. Desarrollo. Hemos registrado multitud de matices en los criterios de practicamente todas las cefaleas y neuralgias de la clasificacion, pero las entidades que han experimentado mas matizaciones trascendentales son la migraña cronica, la cefalea asociada exclusivamente a la actividad sexual, las cefaleas neuralgiformes unilaterales de breve duracion, la cefalea diaria persistente de novo, la cefalea por abuso de medicacion sintomatica, el sindrome de cefalea y deficits neurologicos transitorios con pleocitosis linfocitaria. Las entidades nuevas mas destacables que se han incorporado son las cefaleas por presion externa, las cefaleas por crioestimulo, la cefalea numular, la cefalea atribuida a vuelos de avion y la cefalea atribuida a disreflexia autonomica. Tambien cabe destacar las nuevas cefaleas, aun no consideradas como entidades, que se incorporan al apendice, entre las que destacan la epicranea fugax, la migraña vestibular y los colicos infantiles. Conclusiones. La IHS recomienda utilizar ya la nueva clasificacion (ICHD-III beta), prescindiendo de la anterior clasificacion, en la asistencia, la docencia y la investigacion, asi como hacer la maxima difusion de esta nueva guia.

Novedades en la reciente Clasificación Internacional de las Cefaleas: clasificación ICHD-III beta / Changes introduced into the recent International Classification of Headache Disorders: ICHD-III beta classification

Introducción. La Sociedad Internacional de Cefaleas (IHS) ha publicado la tercera edición de la Clasificación Internacional de las Cefaleas (ICHD-III beta), la guía diagnóstica de las cefaleas más utilizada en el mundo. Objetivo. Revisar las recientes aportaciones de la guía, explicando las nuevas entidades que en ella aparecen y comparando las entidades que han matizado sus criterios con sus criterios de la edición precedente. Desarrollo. Hemos registrado multitud de matices en los criterios de prácticamente todas las cefaleas y neuralgias de la clasificación, pero las entidades que han experimentado más matizaciones trascendentales son la migraña crónica, la cefalea asociada exclusivamente a la actividad sexual, las cefaleas neuralgiformes unilaterales de breve duración, la cefalea diaria persistente de novo, la cefalea por abuso de medicación sintomática, el síndrome de cefalea y déficits neurológicos transitorios con pleocitosis linfocitaria. Las entidades nuevas más destacables que se han incorporado son las cefaleas por presión externa, las cefaleas por crioestímulo, la cefalea numular, la cefalea atribuida a vuelos de avión y la cefalea atribuida a disreflexia autonómica. También cabe destacar las nuevas cefaleas, aún no consideradas como entidades, que se incorporan al apéndice, entre las que destacan la epicránea fugax, la migraña vestibular y los cólicos infantiles. Conclusiones. La IHS recomienda utilizar ya la nueva clasificación (ICHD-III beta), prescindiendo de la anterior clasificación, en la asistencia, la docencia y la investigación, así como hacer la máxima difusión de esta nueva guía (AU)

Introduction. The International Headache Society (IHS) has published the third edition of the International Classification of Headache Disorders (ICHD-III beta), the most commonly used guide to diagnosing headaches in the world. Aims. To review the recent additions to the guide, to explain the new entities that appear in it and to compare the conditions that have had their criteria further clarified against the criteria in the previous edition. Development. We have recorded a large number of clarifications in the criteria in practically all the headaches and neuralgias in the classification, but the conditions that have undergone the most significant clarifications are chronic migraine, primary headache associated with sexual activity, short-lasting unilateral neuralgiform headache attacks, new daily persistent headache, medication-overuse headache, syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis. The most notable new entities that have been incorporated are external-compression headache, cold-stimulus headache, nummular headache, headache attributed to aeroplane travel and headache attributed to autonomic dysreflexia. Another point to be highlighted is the case of the new headaches (still not considered entities in their own right) included in the appendix, some of the most noteworthy being epicrania fugax, vestibular migraine and infantile colic. Conclusions. The IHS recommends no longer using the previous classification and changing over to the new classification (ICHD-III beta) in healthcare, teaching and research, in addition to making this new guide as widely known as possible (AU)

New subtype of spinocerebellar ataxia with altered vertical eye movements mapping to chromosome 1p32.

IMPORTANCE: To provide clinical and genetic diagnoses for patients' conditions, it is important to identify and characterize the different subtypes of spinocerebellar ataxia (SCA). OBJECTIVE: To clinically and genetically characterize a Spanish kindred with pure SCA presenting with altered vertical eye movements. DESIGN Family study of ambulatory patients. Electro-oculographic and genetics studies were performed in 2 referral university centers. SETTING: Primary care institutional center in Spain. PARTICIPANTS: Thirty-six participants from a large Spanish kindred were clinically examined, and 33 family members were genetically examined. Detailed clinical data were obtained from 9 affected relatives. Two ataxic siblings and 2 asymptomatic family members were examined using an enhanced clinical protocol for a follow-up period of 7 years. MAIN OUTCOMES AND MEASURES: High-density genome-wide single-nucleotide polymorphism arrays, along with microsatellite analysis, and genetic linkage studies were performed. Whole-exome sequencing was used for 2 affected relatives. For most patients, the initial symptoms included falls, dysarthria, or clumsiness followed by a complete cerebellar syndrome. For all 9 affected relatives, we observed altered vertical eye movements, as initial ocular signs for 3 of them and for the 2 asymptomatic family members, all having inherited the risk haplotype. Neuroimaging showed isolated cerebellar atrophy. RESULTS: Initial genome-wide linkage analysis revealed suggestive linkage to chromosome 1p32. Multipoint analysis and haplotype reconstruction further traced this SCA locus to a 0.66-cM interval flanked by D1S200 and D1S2742 (z(max) = 6.539; P < .0001). The causative mutation was unidentified by exome sequencing. CONCLUSIONS AND RELEVANCE: We report a new subtype of SCA presenting in patients as slow progressing ataxia with altered vertical eye movements linked to a 11-megabase interval on 1p32. The Human Genome Nomenclature Committee has assigned this subtype of ataxia the designation SCA37.

Pourfour du Petit Syndrome in a Patient with Thyroid Carcinoma.

The clinical presentation of Pourfour du Petit syndrome (PdPs) is the opposite of Horner syndrome. Although all disorders underlying Horner syndrome may potentially present as PdPs, very few cases of the latter have been described in the literature. We report a patient with PdPs due to carotid compression by a thyroid tumor.

Estimulación del nervio occipital para la cefalea en racimos refractaria al tratamiento farmacológico / Stimulation of the occipital nerve in the treatment of drug-resistant cluster headache

Objetivo. Evaluar la utilidad de la estimulación del nervio occipital en el tratamiento de la cefalea en racimos crónica refractaria al tratamiento farmacológico. Pacientes y métodos. Serie prospectiva de cuatro pacientes, tres varones y una mujer. La edad media es de 42 años. Hay historia de cefalea en racimos de entre 1 y 16 años, con mal control de las crisis mediante tratamiento farmacológico. En todos los casos se han colocado percutáneamente electrodos octopolares en ambas regiones occipitales. Se ha realizado un seguimiento de seis meses. Resultados. A los seis meses se obtuvo una reducción de la frecuencia de las crisis del 56% (rango: 25-95%), una disminución en la intensidad del 48,8% (rango: 20-60%) y una disminución de la duración de un 63,8% (rango: 0-88,8%), sin observarse empeoramiento ni progresión de la enfermedad en ningún caso. La mejoría en la calidad de vida respecto a la prequirúrgica fue de un 15,4% (rango: 6-31,5%) en el cuestionario de salud SF-36. Excepto en un caso, se objetivó una reducción significativa en la cantidad y la dosis de fármacos requeridos respecto al tratamiento prequirúrgico. No se han detectado complicaciones postoperatorias. Todos los pacientes aconsejarían el procedimiento como opción terapéutica. Conclusiones. La estimulación del nervio occipital puede ser una alternativa terapéutica segura y efectiva en el tratamiento de la cefalea en racimos crónica refractaria al tratamiento farmacológico. Sin embargo, son necesarios más estudios para valorar la efectividad de la técnica en un mayor número de pacientes y los resultados a largo plazo (AU)

Aim. To evaluate the occipital nerve stimulation therapy in as a treatment for drug-resistant cluster headache. Patients and methods. Prospective study of four patients, three males and one female. Mean age of 42 years. Patients complained of a cluster headache lasting between one and 16 years, with suboptimal control of the attacks with medication. In all cases octopolar electrodes were placed percutaneously in the occipital region bilaterally. Follow-up of 6 months. Results. At 6 months, there was a 56% (range: 25-95%) reduction in the frequency, a 48.8% (range: 20-60%) decrease in the intensity and a 63.8% (range: 0-88.8%) reduction in the duration of the attacks. Worsening or progression of the illness was not observed in any case. All patients referred a 15.4% (range: 6-31.5%) improvement in their quality of life compared to their previous basal situation in SF-36. In all cases but one there was a significant reduction in the amount and dosage of medication required. Postoperative complications were not observed. All patients would recommend the procedure. Conclusions. Occipital nerve stimulation may be considered a safe and effective therapeutic option in the drug-resistant cluster headache. However, studies with more patients and a longer follow-up are required to evaluate the efficacy of the technique (AU)

[Stimulation of the occipital nerve in the treatment of drug-resistant cluster headache]. / Estimulación del nervio occipital para la cefalea en racimos refractaria al tratamiento farmacológico.

AIM: To evaluate the occipital nerve stimulation therapy in as a treatment for drug-resistant cluster headache. PATIENTS AND METHODS: Prospective study of four patients, three males and one female. Mean age of 42 years. Patients complained of a cluster headache lasting between one and 16 years, with suboptimal control of the attacks with medication. In all cases octopolar electrodes were placed percutaneously in the occipital region bilaterally. Follow-up of 6 months. RESULTS: At 6 months, there was a 56% (range: 25-95%) reduction in the frequency, a 48.8% (range: 20-60%) decrease in the intensity and a 63.8% (range: 0-88.8%) reduction in the duration of the attacks. Worsening or progression of the illness was not observed in any case. All patients referred a 15.4% (range: 6-31.5%) improvement in their quality of life compared to their previous basal situation in SF-36. In all cases but one there was a significant reduction in the amount and dosage of medication required. Postoperative complications were not observed. All patients would recommend the procedure. CONCLUSIONS: Occipital nerve stimulation may be considered a safe and effective therapeutic option in the drug-resistant cluster headache. However, studies with more patients and a longer follow-up are required to evaluate the efficacy of the technique.

Early-onset familial lewy body dementia with extensive tauopathy: a clinical, genetic, and neuropathological study.

We describe a Spanish family in which 3 of 4 siblings had dementia with Lewy bodies, 2 of them starting at age 26 years and the other at 29 years. The father has recently been diagnosed with Lewy body disease, with onset at 77 years. Neuropathological examination of the brain of the index patient disclosed unusual features characterized by diffuse Lewy body disease and generalized neurofibrillary tangle pathology but with no amyloid deposits in any region. Moreover, Lewy body pathology colocalized with neurofibrillary tangles in most affected neurons. Mutation screening that included all coding exons of presenilin 1 (PSEN1), presenilin 2 (PSEN2), alpha-synuclein (SNCA), beta-synuclein (SNCB), microtubule-associated protein tau (MAPT), leucine-rich repeat kinase 2 (LRRK2), glucocerebrosidase (GBA), and exons 16 and 17 of the amyloid precursor protein (APP) genes did not identify any mutation. Genome-wide single nucleotide polymorphism was performed in 4 family members and ruled out any pathogenic duplication or deletion in the entire genome. In summary, we report a unique family with pathologically confirmed early-onset dementia with Lewy bodies with widespread tau and alpha-synuclein deposition. The absence of mutations in genes known to cause Lewy body disease suggests that a novel locus or loci are implicated in this neurodegenerative disease.

Marketed oral triptans in the acute treatment of migraine: a systematic review on efficacy and tolerability.

BACKGROUND: In the current literature, there is neither a reported systematic review comparing the efficacy of triptans at 30 minutes and 1 hour after the migraine treatment, nor data related to efficacy of new marketed triptans. OBJECTIVE: The main objective of this analysis was to compare the efficacy and tolerability of currently marketed oral, non-reencapsulated triptan formulations vs placebo in the treatment of moderate-to-severe migraine attacks. METHODS: A systematic review of double-blind, randomized clinical trials reporting data after a single migraine attack was conducted. Efficacy results are shown using relative risk ratios with 95% confidence intervals. A sensitivity analysis was also conducted. RESULTS: After reviewing 221 publications, 38 studies were included. All marketed triptans provided significant relief and/or absence of pain at 2 hours, and relief at 1 hour when compared with placebo. After 30 minutes, fast-dissolving sumatriptan 50 and 100 mg, sumatriptan 50 mg, and rizatriptan 10 mg showed significant relief when compared to placebo, whereas the fast-dissolving formulation of sumatriptan 100 mg was the only oral triptan that was superior to placebo in meeting the pain-free endpoint. On the other hand, fast-dissolving sumatriptan 50 and 100 mg and eletriptan 40 mg showed a lower rate of recurrence than placebo, whereas rizatriptan 10 mg was the only triptan with a recurrence rate greater than that of placebo. Adverse events associated with treatment with tablet formulations of sumatriptan and zolmitriptan were significantly more frequent than those of the placebo group. The inclusion of trials with reencapsulated triptans in the analysis introduced minor specific changes in these results. CONCLUSION: This analysis updates the comparative data available for the 7 currently marketed oral triptans and clearly demonstrates their efficacy when compared to placebo, even with stricter endpoints, such as efficacy at 30 minutes. No triptan exhibited better tolerability than placebo. Results are diverse, depending on the triptan, which probably is a reflection of heterogeneous pharmacokinetics.

Rizatriptan 10-mg wafer versus usual nontriptan therapy for migraine: analysis of return to function and patient preference.

BACKGROUND: More than half of patients with migraine suffer moderate to severe functional disability during migraine attacks. OBJECTIVE: To compare effects on functional disability at 2 hours after treating a migraine with rizatriptan 10-mg wafer versus usual nontriptan therapy for triptan-naïve patients with migraine. DESIGN: Open-label, prospective, two-attack study conducted at 111 neurology clinics. METHODS: Adult patients with migraine treated two migraine attacks, the first with their usual nontriptan therapy (nonsteroidal anti-inflammatory drugs, 57%; analgesics, 27%; or ergot derivatives, 16%) and the second with rizatriptan 10-mg wafer. Patients recorded pain intensity and functional disability at the start, and functional disability at 2 hours, as well as the time of return to normal function. RESULTS: A total of 1353 patients, 76% of them female, completed the study and were considered evaluable. During first and second migraine attacks, 55% and 63% of patients, respectively, reported severe disability or requiring bed rest. At 2 hours after treatment, the likelihood of experiencing any disability was more than five times greater after usual nontriptan therapy than after rizatriptan (odds ratio, 5.68; 95% confidence interval (CI), 4.66 to 6.94; P < .001). Rizatriptan was twice as likely to return patients to normal function than usual nontriptan therapy after adjusting for confounding factors (adjusted hazard ratio, 2.08; 95% CI, 1.92 to 2.25; P < .001). Assessed over all time points up to 6 hours, the speed of return to normal function was 52% faster after rizatriptan therapy (P < .001). Significantly more patients preferred rizatriptan than usual nontriptan therapy (78.8% vs. 21.2%; P < .001). The most common reasons cited for preference for rizatriptan were faster relief of headache pain and faster return to normal function. CONCLUSIONS: Patients in this study were more likely to experience a return to normal function at 2 hours after receiving rizatriptan than after their usual nontriptan therapy for migraine. The results of this study, using patient-oriented, clinically relevant endpoints such as functional disability and preference, will help to guide practitioners in making recommendations for acute migraine treatment.

Diagnostic potential of acoustic startle reflex, acoustic blink reflex, and electro-oculography in progressive supranuclear palsy: a prospective study.

We carried out a prospective study to analyze the diagnostic potential of acoustic startle reflex (ASR), acoustic blink reflex (ABR) and electro-oculography (EOG) in early stages of atypical parkinsonian syndrome. The study was carried out in a consecutive series of 41 patients clinically diagnosed as atypical parkinsonism (mean time from first symptoms of 38 months and follow-up of 26 months). The three procedures were carried out immediately after the first clinical evaluation. ASR and ABR were elicited by auditory stimuli while the patient was attending to a simple reaction time task. Outcome measures were: ASR (absence/presence, latency), ABR (absence/presence, latency) and EOG (suggestive/not suggestive of progressive supranuclear palsy [PSP]). Final clinical diagnosis was carried out by two neurologists blind to the neurophysiological results. A study of diagnostic sensitivity and odds ratio (OR) calculation for the PSP diagnosis was carried out. Neurophysiological examination showed the following sensitivity/specificity (%) for the diagnosis of PSP: ASR: 100/89; ABR 85/89; EOG 100/72. OR values were: ASR: 0.011; ABR: 0.037; EOG: 0.038. The three tests taken simultaneously showed a sensitivity of 100% and a specificity of 95%. The three neurophysiological tests investigated provided sensitive and specific measures with predictor value in early stages of atypical parkinsonian syndrome.

Anticuerpos anti-GQ1b: utilidad de su determinación en el diagnóstico del síndrome de Miller-Fisher / Anti-GQ1b antibodies: usefulness of its detection for the diagnosis of Miller-Fisher syndrome

FUNDAMENTO: Estudiar la presencia de anticuerpos anti-GQ1b como herramienta para el diagnóstico del síndrome de Miller-Fisher (SMF). PACIENTES Y MÉTODO: Se estudiaron 54 pacientes con sospecha de SMF y 10 pacientes con diagnóstico cierto de síndrome de Guillain-Barré con oftalmoplejía (un caso), encefalitis de Bickerstaff (un caso), oftalmoplejía recidivante (7 casos) y diplopía recidivante (un caso). Los resultados se compararon con 130 pacientes con otras neuropatías disinmunes. Se realizó determinación de anticuerpos anti-GQ1b mediante ensayo enzimático de inmunoabsorción (ELISA) y posterior comprobación por cromatografía en capa fina (CCF), así como serología de Campylobacter jejuni mediante test de fijación de complemento. RESULTADOS: Se confirmó el diagnóstico de SMF en 38 pacientes. En un 97,3 por ciento de ellos se detectaron anticuerpos anti-GQ1b, siendo todos negativos para serología de Campylobacter jejuni. Ningún paciente con sintomatología aguda troncoencefálica resultó positivo. Sólo un 1,8 por ciento de pacientes con otras neuropatías presentaron anticuerpos anti-GQ1b. Un 84,2 por ciento (16/19) de enfermos a los que se les realizó una segunda determinación a las 4-5 semanas negativizaron los anticuerpos, coincidiendo además con una mejoría clínica. CONCLUSIONES: Los anticuerpos anti-GQ1b son indicadores del SMF y sirven para su diagnóstico diferencial, sobre todo con otras enfermedades agudas cerebelosas y de tronco cerebral. Su positividad depende del momento en que se realiza el estudio, por lo que se recomienda su investigación dentro de las primeras 4 semanas de curso clínico. La correlación entre la tríada de ataxia, arreflexia y oftalmoplejía y títulos positivos de anticuerpos anti-GQ1b confirma su especificidad para el diagnóstico del SMF (AU)

Relación entre las alteraciones visoespaciales y los parámetros oculomotores en la enfermedad de Parkinson / Relationship between visuospatial impairment and oculomotor parameters in Parkinson's disease

Se han estudiado las funciones visoespaciales y los parámetros oculomotores en una muestra de 96 pacientes afectados por Enfermedad de Parkinson 8EP). Los déficit visoespaciales han correlacionado con el deterioro a nivel motor y la gravedad de la enfermedad, así como con las anormalidades oculomotoras. Se realizaron correlaciones parciales con la finalidad de determinar si las alteraciones visoespaciales podían considerarse secundarias a los trastornos oculomotores. Las pruebas de Cubos de las Escala WAIS y el Test de Orientación de Líneas mantenían su correlación con la alteración motora y la gravedad de la enfermedad, tras haber controlado las variables de persecución y los movimientos sacádicos. En síntesis, los resultados del presente estudio muestran que los déficits visoespaciales no pueden ser explicados por anormalidades oculomotoras en los pacientes con EP, pudiendo considerarse ambos expresión del defecto estriatal (AU)

Visuospatial functions and oculomotor parameters were studied in a sample of 96 patients with Parkinson’s Disease (PD). Visuospatial deficits correlated with both motor impairment and severity of illness, as well as with oculomotor abnormalities. Partial correlations were performed to determine whether visuospatial impairment was secondary to oculomotor disorders. After controlling for gaze pursuit variables and saccades, Block Design (WAIS) and Line Orientation Test maintained their correlations with motor impairment and severity of illness. In conclusion, the results of the present study show that visuospatial deficits cannot be explained through oculomotor abnormalities in PD patients, pointing to a simultaneous expression of striatum dysfunction (AU)