Lege Artis Medicinae



NOVEMBER 30, 2004

Lege Artis Medicinae - 2005;15(02 klsz)

[The first drug used as an antipsychotic was chlorpromazine in 1952. The effective drugs after chlorpromazine in the treatment of schizophrenia and acute manic episodes were named as “major tranquillants” then neuroleptic drugs and later as first-generation antipsychotics. The discovery of clozapin has opened a new era in psychiatric therapy which was followed by new antipsychotics with less and less neurological sideeffects. These are called atypical neuroleptics or second generation antipsychotics. The author reviews the path that is characterized by the changes in the naming of these drugs and has led to a situation where clinical recommendations - both in Hungary and internationally - are used to distinguish between the second generation antipsychotics as first or second treatment of choice.]



Further articles in this publication

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BÁNKI M. Csaba

[Schizophrenia is a severe and chronic disorder affecting almost 1% of the population worldwide. Antipsychotic drugs, currently in their secondgeneration (atypical) antipsychotics, represent its first-line treatment. Compliance during long-term maintenance pharmacotherapy is one of the key factors in successful patient management; longacting, injectable antipsychotics may significantly contribute to the improvement of the patients The new form of this drug is the first long-acting, injectable second-generation antipsychotic; administered biweekly it produces stable, reliable clinical efficacy. Low peak plasma concentrations and smaller plasma level fluctuations result in excellent tolerance, less side effects than with per os risperidone and minimal local pain due to its specific technology. There is strong evidence from controlled clinical trials for its prolonged efficacy during long-term administration and for patient satisfaction being usually better than with most other antipsychotics. Switching over to long-acting injectable risperidone often results in further improvement even in previously stable patients. No safety concerns have emerged from published evidence. The long-acting injectable risperidone appears to reduce the rehospitalisation rate, a major factor towards its cost-effectiveness.]

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[INTRODUCTION - In the past 15 years new antipsychotic drugs have come forward with higher efficacy in the treatment of schizophrenia. These new medications are safer and have less side-effects. It is now established that longacting maintenance therapy is favourable than intermittent therapy CASE PRESENTATION - The author introduces the case of a male schizophrenic patient who was hospitalized three times over ten years. He discontinued maintenance therapy because of lack of symptoms first time, then because of severe side-effects and then he stopped seeing his psychiatrist. However after a new acute episode his treatment was changed to longacting injectable risperidone with a success. With maintenance therapy the patient is now symptom-free and went back to work. CONCLUSION - Continuous long-acting injectable therapy proved to be successful in the prevention of symptom recurrence and with its application patient compliance has improved and smaller doses have become sufficient to maintain stedy-state.]

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[As many as 80% of patients with schizophrenia have serious problems with the compliance at some point during their course of their treatment. In most cases, patients are partially compliant, taking only a portion of their prescribed medication. Early warning signs of such partial compliance may confuse some clinicians with non-response to treatment and may result in switching these patients to alternative oral antipsychotic drugs. This review focuses on factors that can contribute to partial compliance such as poor insight, negative attitude or subjective response toward medication, cognitive dysfunction, treatment-related side effects, substance abuse and complicated treatment regimen. Partial compliance is among the most common causes of psychotic relapse and the need for rehospitalisation. The reduced incidence of adverse side effects such as extrapyramidal symptoms with atypical antipsychotic agents has the potential to improve compliance in the maintenance treatment of schizophrenia. Administration of a long-acting injectable antipsychotic provides confirmation of whether patients have taken their medication. Furthermore, it allows physicians to distinguish non-response and non-compliance. Strategies for managing partial compliance include the use of a long-acting injectable atypical antipsychotic, psychoeducation and cognitive-behavioural interventions.]

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Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

Neuroscience highlights: Main cell types underlying memory and spatial navigation

KRABOTH Zoltán, KÁLMÁN Bernadette

Interest in the hippocampal formation and its role in navigation and memory arose in the second part of the 20th century, at least in part due to the curious case of Henry G. Molaison, who underwent brain surgery for intractable epilepsy. The temporal association observed between the removal of his entorhinal cortex along with a significant part of hippocampus and the developing severe memory deficit inspired scientists to focus on these regions. The subsequent discovery of the so-called place cells in the hippocampus launched the description of many other functional cell types and neuronal networks throughout the Papez-circuit that has a key role in memory processes and spatial information coding (speed, head direction, border, grid, object-vector etc). Each of these cell types has its own unique characteristics, and together they form the so-called “Brain GPS”. The aim of this short survey is to highlight for practicing neurologists the types of cells and neuronal networks that represent the anatomical substrates and physiological correlates of pathological entities affecting the limbic system, especially in the temporal lobe. For that purpose, we survey early discoveries along with the most relevant neuroscience observations from the recent literature. By this brief survey, we highlight main cell types in the hippocampal formation, and describe their roles in spatial navigation and memory processes. In recent decades, an array of new and functionally unique neuron types has been recognized in the hippocampal formation, but likely more remain to be discovered. For a better understanding of the heterogeneous presentations of neurological disorders affecting this anatomical region, insights into the constantly evolving neuroscience behind may be helpful. The public health consequences of diseases that affect memory and spatial navigation are high, and grow as the population ages, prompting scientist to focus on further exploring this brain region.

Clinical Neuroscience

Autonomic nervous system may be affected after carpal tunnel syndrome surgery: A possible mechanism for persistence of symptoms after surgery

ONDER Burcu, KELES Yavuz Betul

After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose – The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.

Clinical Neuroscience

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm


The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

Clinical Neuroscience

Acute effect of sphenopalatine ganglion block with lidocaine in a patient with SUNCT


Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/short-lasting unilateral neuralgiform headache with cranial autonomic features (SUNCT/SUNA) is a rare severe headache. At the time of an attack, it can hinder a patient from eating and requires acute intervention. The sphenopalatine ganglion is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. Sphenopalatine ganglion block has long been used in the treatment of headache, particularly when conventional methods have failed. Here, we present a patient who was resistant to intravenous lidocaine, but responded rapidly to sphenopalatine ganglion block during an acute episode of SUNCT/SUNA.