Clinical Neuroscience

[The treatment of advanced Parkinson’s disease]


NOVEMBER 30, 2018

Clinical Neuroscience - 2018;71(11-12)


[The treatment of Parkinson’s disease depends on the symptoms of the patients and obviously the stage of the disease. Several different approaches can be found in the literature. Based on the published data, in this review we try to summarize the different approaches to the disease stages and theirs’ clinical relevance. Actually, one of the most important issue is the recognition of advanced stage and therefore we reviewed the device-aided therapies. ]



Further articles in this publication

Clinical Neuroscience

Inflammatory biomarkers in benign paroxysmal positional vertigo: A Turkey case-control study


Objective - Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo. Inflammation is a hypothetic etiological factor in BPPV. The aim of this study was to evaluate inflammatory biomarker levels in BPPV patients and compare these with the healthy subjects. Materials and methods - This prospective case-control study was conducted with 114 newly diagnosed BPPV patients and age- and sex- matched 83 healthy subjects. The laboratory investigations included serum hemogram, full biochemistry profiles, vitamin levels, thyroid hormone profiles, high sensitivity C-reactive protein (hsCRP) and erythrocyte sedimentation rate (ESR). Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte to HDL-cholesterol ratio (MHR) values were calculated and compared between the patients and healthy subjects. Results - The mean age was 39.1 ± 12.4 years for patients, and 37.0 ± 11.9 for controls. Vitamin B12, hematocrit (Hct), creatinine, urea, and fT4 values, lymphocyte, total bilirubin, direct bilirubin and indirect bilirubin levels were significantly lower in BPPV patients (p ˂ 0.05), while HDL, SGOT, and ESR values were significantly higher. In the BPPV patients the mean NLR, PLR, and mean platelet volume (MPV) values were significantly higher than in the control subjects. Neutrophil, platelet, monocyte, MHR, and CRP values were similar in both groups (p ˃ 0.05). Conclusion - Our result suggests that NLR, PLR, MPV, ESR, and bilirubin levels should be taken into account as potential biomarkers of BPPV. As they are inexpensive parameters and widely available, they can be used in clinical practice for prediction of BPPV. However, further large-scale studies are required to confirm this relationship.

Clinical Neuroscience

[Neuropsychological rehabilitation following acquired brain injury]

TAMÁS Viktória, KOVÁCS Noémi, TASNÁDI Emese

[Neuropsychological rehabilitation or rehabilitation neuropsychology is a field within applied neuropsychology. It originally diverges from applied clinical and functional neuropsychology, although it could not be entirely differed from them. The unique nature of this area over the complexity is given by its process-controlled and system-approach aspects. In Hungary the number of neurorehabilitation centres and departments requiring neurocognitive rehabilitation has been continually increasing. Nevertheless, the number is still low; accordingly in our country this field is relatively young and isn’t well known. Authors of this review would like to draw attention to the importance of rehabilitation of patients with acquired brain injury and improvement of their quality of life with the theoretical and practical knowledge, as well as the necessity of future alterations and challenges emphasizing the need of a significant change of this narrow domain. ]

Clinical Neuroscience

Psychoform and somatoform dissociative experiences in migraine: relationship with pain perception and migraine related disability

SENGUL Yildizhan, SENGUL Serdar Hakan, TUNC Abdulkadir

Objective - Migraine is a common and often debilitating disorder. Although the existence of a link between migraine and certain psychological features has long been known, data on dissociative experiences in migraine patients is insufficient. The aim of this study was to evaluate the presence of psychoform and somatoform dissociative experiences among migraine patients without aura and to examine their relationship with pain perception and disability. Methods - A total of 110 outpatients diagnosed with migraine based on the International Classification of Headache Disorders-III (ICHD-III) criteria and 70 healthy subjects were enrolled to this study. Sociodemographic data, Somatoform Dissociation Questionnaire (SDQ), Dissociative Experience Scale (DES), Beck Depression Inventory (BDI), and Beck Anxiety Scale (BAS) scores were recorded for each patient. The Migraine Impairment Disability Assessment Scale (MIDAS) and Visual Analog Scale (VAS) scores were also determined. Results - The mean SDQ and DES scores were significantly higher in migraine patients (p<0.001, p<0.01). According to SDQ, somatoform dissociation disorder, dissociative disorder not otherwise specified, and dissociative identity disorder were considered in 29.4%, 18.3%, and 10.1% of the migraine patients, respectively. Also, 20.9% of the patients had possible psychoform dissociation according to DES. A significant positive correlation was found between DES, SDQ scores, and VAS, MIDAS scores. Patients were found to have statistically significantly higher levels of depression and anxiety symptoms compared to healthy controls (p < 0.001). Higher DES and SDQ scores were associated with increased disability and pain level (p<0.01). Conclusion - Our findings seem to confirm the increased occurrence of somatoform and psychoform dissociative experiences in migraine patients. This study was intended as a beginning towards understanding dissociative experiences in migraine.

Clinical Neuroscience

[Effects of neural therapy on quality of live in patients with inoperable lower extremity artery disease ]

MOLNÁR István, DEÁK Botond Zsolt, HEGYI Gabriella, KOVÁCS Zoltán, KAPÓCS Gábor, SZŐKE Henrik

[Objectives - Our aim was to evaluate the effects of percutaneous neurolysis of lumbal sympathetic ganglions on pain and the resulting changes in quality of life with validated objective and subjective methods. To follow the adverse effects and complications of the procedure. Materials and methods - A prospective, non-randomized, interventional, clinical cohort study under real life conditons was conducted. The time of the observation was 6 months. Palliative neural therapy was performed to reduce the ischemic pain of the affected leg of the patients involved in the study. Prior to treatment and after 35 days, Visual Analogue Scale (VAS) was used to measure the intensity of lower limb pain. The related changes in the quality of life were followed by a general 36-Item Short-Form Health Survey (SF-36) questionnaire. We measured the changes of the patients’ skin temperature and ankle/arm index. The post-treatment results were compared to the pre-treatment results. We compared the results of objective and subjective measures. We followed the side effects and complications of the pain therapy. Each of the examined subjects had obliterative (Fontaine II/b stage) arterial disease of the lower limbs, in which no revascularization intervention was feasible and their ischemic pain was of VAS≥7. Results - Data of 124 patients (69 male, 55 female) could be evaluated. The decrease in intensity of limb pain in the post-treatment period was significant (p=0.001). Quality of life also indicated a significant improvement (p=0.004). Changes in skin temperature and ankle/arm index demonstrated significant improvement (p≤0.005): skin temperature increased from 27.6°C to 31.2°C, the ankle/arm index inceased from 0.67 to 0.83 on average. Changes in objective and subjective measures correlated with each other. No worthening of symptoms, serious adverse events or complications were observed. Conclusion - The chemical denervation of the lumbar sympathetic ganglions with percutaneous application is a minimally invasive intervention, useful in outpatient care, which can be well tolerated by the patient without any significant side effect or complication. Its hyperaemic effect and the pain reduction of the leg can improve the quality of life of the patients.]

Clinical Neuroscience

[Comparison of subthalamic nucleus planning coordinates in 1Tesla and 3Tesla MRI for deep brain stimulation targeting ]

JUHÁSZ Annamária, KOVÁCS Norbert, PERLAKI Gábor, BÜKI András, KOMOLY Sámuel, KÖVÉR Ferenc, BALÁS István

[Backgroud - Deep brain stimulation (DBS) involves placing electrodes within specific deep brain nuclei. For movement disorders the most common indications are tremors, Parkinsons disease and dystonias. Surgeons mostly employ MR imaging for preoperative target selection. MR field geometrical distortion may contribute to target-selection error in the MR scan which can contribute to error in electrode placement. Methods - In this paper we compared the STN target planning coordinates in six parkinsonian DBS patients. Each patient underwent target planning in 1T and 3T MRI. We statistically compared and analysed the target-, and the fiducial coordinates in two different magnetic fileds. Results - The target coordinates showed no significant differences (Mann-Whitney test, p > 0.05), however we found significant difference in fiducial coordinates (p < 0.01), in 3T MRI it was more pronounced (mean ± SD: 0.8 ± 0.3 mm) comparing to 1T (mean ± SD: 0.4 ± 0.2 mm). Conclusion - Preliminary results showed no significant differences in planning of target coordinates comparing 1T to 3T magnetic fields.]

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Clinical Neuroscience

Retinal morphological changes during the two years of follow-up in Parkinson’s disease

ATUM Mahmut, DEMIRYÜREK Enes Bekir

The study aims to investigate the relationship between the progression of idiopathic Parkinson’s disease (IPD) and retinal morphology. The study was carried out with 23 patients diagnosed with early-stage IPD (phases 1 and 2 of the Hoehn and Yahr scale) and 30 age-matched healthy controls. All patients were followed up at least two years, with 6-month intervals (initial, 6th month, 12th month, 18th month, and 24th month), and detailed neurological and ophthalmic examinations were performed at each follow-up. Unified Parkinson’s Disease Rating Scale part III (UPDRS Part III) scores, Hoehn and Yahr (H&Y) scores, best-corrected visual acuity (BCVA), intraocular pressure (IOP) measurement, central macular thickness (CMT) and retinal nerve fiber layer (RNFL) thickness were analyzed at each visit. The average age of the IPD and control groups was 43.96 ± 4.88 years, 44.53 ± 0.83 years, respectively. The mean duration of the disease in the IPD group was 7.48 ± 5.10 months at the start of the study (range 0-16). There was no statistically significant difference in BCVA and IOP values between the two groups during the two-year follow-up period (p> 0.05, p> 0.05, respectively). Average and superior quadrant RNFL thicknesses were statistically different between the two groups at 24 months and there was no significant difference between other visits (p=0.025, p=0.034, p> 0.05, respectively). There was no statistically significant difference in CMT between the two groups during the follow-up period (p> 0.05). Average and superior quadrant RNFL thicknesses were significantly thinning with the progression of IPD.

Clinical Neuroscience

[Dopamine agonists in Parkinson’s disease therapy - 15 years of experience of the Neurological Clinics from Tîrgu Mureș. A cross-sectional study ]

SZÁSZ József Attila, CONSTANTIN Viorelia, MIHÁLY István, BIRÓ István, PÉTER Csongor, ORBÁN-KIS Károly, SZATMÁRI Szabolcs

[Background and purpose - There is relatively few data regarding the usage of dopaminagonists for the treatment of Parkinson’s disease; furthermore, there are no publications regarding Central- and Eastern-European countries. The aim of the study was to evaluate the use of dopamine agonists as a therapeutic option amongst Parkinson’s disease patients admitted to the Neurological Clinics of Tîrgu Mures during the last 15 years. Methods - In our study we investigated the data of all Parkinson’s patients treated at our clinics between the 1st of January 2003 and the 31st of December 2017. We analyzed the particularities of dopamine agonists’ usage based on the therapeutic recommendations from the final report of these patients. Regarding time since the diagnosis, we divided the patients in two groups: less than or equal to 5 years and more than 5 years. Results - During the studied period a total of 2379 patients with Parkinson’s disease were treated at the Clinics. From the 1237 patients with disease duration under 5 years 665 received dopamine agonists: 120 as monotherapy, 83 together with monoamine oxidase inhibitors and in 234 cases associated with levodopa. The remaining 228 patients were treated with a triple combination of levodopa, dopamine agonists and monoamine oxidase inhibitors. In patients suffering from Parkinson’s disease for more than 5 years, in 364 cases out of 653 a dopamine agonist was part of the therapy. Conclusion - The usage of dopamine agonists was similar to the data presented in other studies. We consider that clinicians treating the disease should, with the necessary prudence, use the available and recommended dopamine agonist with the utmost courage to their maximum therapeutic potential.]

Clinical Neuroscience

[Earlier and more efficiently: the role of deep brain stimulation for parkinson’s disease preserving the working capabilities]

DELI Gabriella, BALÁS István, KOMOLY Sámuel, DÓCZI Tamás, JANSZKY József, ASCHERMANN Zsuzsanna, NAGY Ferenc, BOSNYÁK Edit, KOVÁCS Norbert

[Background – The recently published “EarlyStim” study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson’s disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients. Methods – We reviewed the data of 39 young (<60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pécs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job (“Job+” group, n=15) and retired patients (without active job, “Job-” group, n=24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation. Results – As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p<0.01, McNemar test). Conclusion – Although our retrospective study has several limitations, our results fit well with the conclusions of “EarlyStim” study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.]

Clinical Neuroscience

Vestibular evoked myogenic potential responses in Parkinson’s disease


Background - Our objectives were to determine the differences in the vestibular evoked myogenic potential (VEMP) responses in patients diagnosed with early staged idiopathic Parkinson’s disease (PD) compared to the normal population and evaluate the vestibular system disorder causing balance-posture disorders. Second aim of this study was to investigate caloric test responses particularly in early staged PD compared to normal popu­lation. Material and methods - Thirty patients (14 females and 16 males; mean age, 60.6 ± 13.1 years) diagnosed with idiopathic PD and 28 healthy subjects (20 males and 8 females; mean age, 59.1 ± 6.4 years) were included. The patient and control groups were subdivided according to their age, gender and the patient group was subdivided according to onset time of the Parkinson symptoms, Hoehn-Yahr staging. The subgroups were compared for VEMP and caloric test responses. Results - There were no significant differences between the study and control groups for right and left VEMP measurements. Patients over 60 years and under 60 years did not show significant differences in terms of right and left mean VEMP measurements. However, P1 amplitude was significantly lower in patients over 60 years old (P = .004). Gender, disease duration, BERG balance scale and Hoehn-Yahr stage had no effect on the VEMP amplitudes. There was no significant correlation with the side of Parkinsonian symptoms to the side of canal paresis (P = .566) and the side on which no VEMP response was obtained in caloric test. Conclusion - VEMP responses were not different between PD and healthy subjects. VEMP P1 amplitude was decreased with age in PD group. Canal paresis and symptoms side were not statistically correlated in caloric test.

Clinical Neuroscience

Association of cardiovascular risk factors and Parkinson’s disease - case-control study in South East Hungary


Aims - Parkinson’s disease (PD) has the second highest incidence among neurodegenerative diseases in the world population. The study aimed to investigate the presence of some cardiovascular risk factors - dyslipidemia, diabetes, and hypertension - in PD patients and to compare their risk with non-PD population in South East Hungary. Methods - A case-control study was conducted at the Department of Neurology, University of Szeged, Hungary. The study included 1299 subjects out of which 620 patients were identified as cases of diagnosed PD and 679 as controls. Logistic regression analyses were conducted to reveal the association of vascular risk factors with PD. Results - In the univariate analysis, diabetes mellitus was positively associated with PD, while dyslipidemia showed negative association to it in the total population, and no significant associations were found between hypertension and PD. The multivariate logistic regression models showed that the odds of diabetes mellitus was higher (OR=2.86), while the odds of dyslipidemia was lower (OR=0.58) among PD patients than in the control group. Hypertension showed a different pattern by gender: the odds of registered hypertension was significantly lower in female PD patients (OR=0.68), whereas the result was not significant in males. Conclusions - This is the first study that provides a comprehensive view of the cardiovascular risk factors in PD patients in Hungary and shows considerable relationship between diabetes mellitus and PD.