Clinical Neuroscience

[Ketamine administration in case of severe, therapy resistant depressed patient, case report]

MORVAI Szabolcs1, NAGY Attila István2, BÁLINT-SZÖLLŐSI Adrienn1, MÓRÉ E Csaba3, BERECZ Roland3, FRECSKA Ede3

NOVEMBER 30, 2016

Clinical Neuroscience - 2016;69(11-12)

DOI: https://doi.org/10.18071/isz.69.0421

[Objective - In our case report we present the treatment of a female patient suffering from therapy resistant depression. This procedure is not in practice in Hungary at present, the aim of our work to reproduce the findigs of international studies in domestic circumstances. Matter - Major depression is a common, chronic and severe mental disorder, with 16.2% lifetime prevalence. Many international randomized, placebo controlled trials found administration of ketamine infusion effective in depressed patients. Methods - Since ketamine is an anesthetic agent, its administration was performed in the post-operative monitoring room of our hospital operating-room, supervised by an anesthesiologist. According to formerly published data, a dose of 0.5 mg/kg of body weight was administered intravenously in 40 minutes by perfusor. The drug was administered in a same manner fifteen days later. Subject - The patient was admitted to our inpatient ward with severe depression. During two months of combined antidepressant therapy her condition has not improved significantly. Approval for off label drug indication was granted with urgency by the National Institute of Quality and Organizational Development in Healthcare and Medicines. Results - During the two treatments the Hamilton Depression Rating Scale 21 items rating scale score was reduced to 8 from the baseline 28, the Hamilton Anxiety Rating Scale score was reduced to 6 from 25, Beck Depression Inventory was reduced to 9 from 20. Upon administration of the drug no severe adverse event was detected, the mild dissociative state related to ketamine was ceased in a short period of time. Discussion - With administration of 0.5 mg/kg ketamine the authors managed to achieve rapid improvement in a therapy resistant depressed patient, without permanent side effects. Our future plan is to repeat the use of the drug within a double-blind, placebo controlled trial in order to prove its efficacy in hospital settings. ]

AFFILIATIONS

  1. Kenézy Gyula Kórház Rendelôintézet, Felnôtt Pszichiátriai Osztály, Debrecen
  2. Kátai Gábor Kórház, Pszichiátriai Osztály, Karcag
  3. Debreceni Egyetem Klinikai Központ, Pszichiátriai Klinika, Debrecen

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[Recommendation for treatment options in advanced Parkinson's disease]

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[The treatment of advanced Parkinson’s disease is challenging for both physicians and caregivers. The device-aided therapies need expertise and dedicated hospital centers. In this summary we have concluded the available data and recommendation for the treatment options in advanced Parkinson’s disease and adopt them to the daily care in Hungary. ]

Clinical Neuroscience

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Clinical Neuroscience

How to minimize the risk for headache? A lumbar puncture practice questionnaire study

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Background - To lower the risk for post lumbar puncture (LP) headache the American Academy of Neurology (AAN) recommended using small bore atraumatic needles together with stylet reinsertion in a report from 2005. It is unclear whether these recommendations are followed or not. Objectives - To investigate the diagnostic LP preferences with respect to the AAN guidelines among neurologists by use of a short online questionnaire, and to review previously published literature on the subject. Results - A total of 284 respondents who performed diagnostic LPs completed the questionnaire. Almost half (41%) answered that they always use atraumatic needles. The most common reason (73%) for not using atraumatic needles was that these were not available. Less than half of the respondents who performed LPs had knowledge about the AAN guidelines for diagnostic LPs, and 48-76% agreed with the different recommendations therein. Five previously (1998-2015) published studies investigating LP practice among neurologists were identified. The reported frequency of atraumatic needle use (always/routinely) varied between 2 and 16%. Discussion - Atraumatic needle use was more common in this study compared with previous publications. There is still skepticism regarding some of the AAN recommendations, and needle availability appears to be the most important factor preventing atraumatic needle use. To increase the use of atraumatic needles we may perform additional studies investigating their potential benefits, and arrange training sessions for neurologists to increase their awareness and level of comfort with the atraumatic LP technique.

Clinical Neuroscience

Could red cell distribution width and mean platelet volume be a predictor for lumbar disc hernias?

DAGISTAN Yasar, DAGISTAN Emine, GEZICI Riza Ali, HALICIOGLU Sıdıka, AKAR Semih, ÖZKAN Nezih, AKTAS Gulali

Background - Lumbar disc herniation (LDH) causes major disabilities worldwide. Several studies in the literature had reported the correlation between radiculopathy and inflammatory markers. Mean platelet volume (MPV), red cell distribution width (RDW) and neutrophil to lymphocyte (N/L) ratio are parameters of hemogram which have been found to be associated with inflammatory conditions. Purpose - Since inflammation has an important role in lumbar disc hernias, and RDW, MPV and N/L ratio are also known to be in correlation with inflammation, we have investigated these parameters of the patients with lumbar disc hernias and compared them with the results of the healthy subjects. Methods - Our study group was composed of patients with lumbar disc hernia, whereas the control group was consisted of healthy volunteers whom visited our outpatient clinics for a routine check-up. Patient characteristics and hemogram parameters of the study cohort were obtained from computerized database system of our institution. SPSS software (SPSS 15.0 for Windows, Chicago, IL, USA) was used for the analysis. Results - There was no significant difference between study and control groups in terms of WBC, neutrophil count, lymphocyte count, neu\lym ratio, Hb, Htc, MCV, and PLT levels (all p>0.05). RDW was significantly increased in study group [15.6 (12.3-22.5)] when compared to control group [14.5(11.9-16.3)] (p=0.004). And MPV in the study group [9.25 (6.38-14.5)] was also significantly increased in comparison to the control subjects [8.8 (6-10.1)] (p=0.013). Discussion - In this retrospective study, we found that, RDW and MPV values in hemograms were increased in patients with lumbar disc herniation when compared to the control group. Conclusions - We suggest that, elevated RDW and MPV may help physicians in decision taking to order radiological imagings in patients with symptoms which can be associated with possible LDH diagnosis. However, for the sake of precision, prospective studies with larger populations are needed.

Clinical Neuroscience

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VANYA Melinda, FÜVESI Judit, KOVÁCS A. Zoltán, GORGORAPTIS Nikos, SALEK-HADDADI Afram, KOVÁCS LÁSZLÓ, BÁRTFAI György

Introduction - N-methyl-D-aspartate receptor (NMDA-R) antibody-associated encephalitis has been reported in the international neurological literature to be associated with mature or immature ovarian teratomas (OTs). However, few cases of encephalitis were diagnosed in Hungary. In 2011 Hollody et al. described the first case of anti-NMDA receptor associated encephalitis in Hungary. Objective - Our aim was to present a case of NMDA-R antibody-mediated encephalitis in a woman with OT thereby providing information facilitating diagnosis of OT in women, who present with symptoms of encephalitis. Case - We report the case of a 25 year-old women, who developed NMDA-R -antibody associated autoimmune encephalitis and who displayed confusion, disorientation, a behavioural disturbance with agitation and features of paranoia and at least one reported generalized tonic clonic seizure and orofacial dyskinesia. Magnetic resonance imaging revealed a functional ovarian cyst measuring 3.3 cm, which was removed surgically and demonstrated histologically to be a mature cystic OT. The serum was positive for antibodies to NMDA receptors. Following intravenous immunoglobulin treatment, oophorectomy and a 5-day course of plasma exchange, followed by corticosteroid and azathioprine immunosuppressive therapy, the patient displayed a significant clinical improvement. Conclusion - Cystic teratomas are common benign ovarian lesions in women of reproductive age. Although the association of OTs and NMDA-R antibody-associated encephalitis has been described in the international neurological literature, this relationship needs to be considered from on the interdisciplinary aspect by the health care providers.

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