Faculty Bibliography

Cerebellitis is not a recognised manifestation of Lyme disease. We describe a patient with clinical features of subacute cerebellitis, cerebrospinal fluid (CSF) monocytic pleocytosis, positive CSF Borrelia burgdorferi antibodies, negative brain magnetic resonance imaging and a benign course after treatment with ceftriaxone. Possible earlier cases are discussed. Lyme disease should be considered in all cases of subacute cerebellitis

OBJECTIVE: To evaluate the efficacy of embolization for spinal dural arteriovenous fistulae (SDAVF). METHODS: We reviewed 49 cases of SDAVF treated by embolization. An acrylic material was used in all except two cases. Variable stiffness microcatheters were used in 38 cases. RESULTS: "Adequate" initial treatment was performed in 39 cases (80%). After the introduction of variable stiffness microcatheters, the initial success rate of embolization increased to 87% (33 of 38 cases). Eight patients underwent subsequent embolization for recurrence after "adequate" embolization. Causes of recurrence were collateralization in five cases, development of new fistulae in one, and unknown in two. Two additional patients developed subsequent aggravation of the symptoms, probably caused by progressive venous thrombosis, that responded to heparinization. Ten cases were initially "inadequately" embolized. Five of the 10 cases were treated before the introduction of variable stiffness microcatheters. Each of three of the remaining five cases had a common trunk from which the feeder and a spinal cord artery arose. CONCLUSION: Embolization with an acrylic material should be the first choice of treatment for SDAVF, unless a spinal cord artery shares the same pedicle as the feeder of SDAVF. Subsequent aggravation of the symptoms after embolization can occur by various mechanisms. Therefore, periodic and long-term follow-up examinations are important.

Sinemet-controlled release (CR4) consisting of 50 mg carbidopa/200 mg levodopa was compared with Sinemet 25/100 in 24 Parkinson's disease (PD) patients during a 16-week double-blind cross-over study. The mean age of the patients was 66.2 years, their mean duration of PD was 9.3 years. All of the patients had response fluctuations consisting mainly of the 'wearing-off' phenomenon. Some of the patients also experienced the 'on-off' phenomenon. All patients were evaluated using the unified Parkinson disease rating scale. The following significant differences were noted on Sinemet CR4. More patients noted a decrease in dyskinesias and response fluctuations; more patients experienced a decrease in stage when 'on'; more patients were 'on' longer during the day, and more patients were globally improved. The mean number of doses per day were significantly less on Sinemet CR4 (mean 5.0, range 3-8) than on Sinemet 25/100 (mean 6.2, range 4-11 doses/day). The mean dose of levodopa in Sinemet CR4 was 1,186 +/- 458 mg and the mean dose of carbidopa was 797 +/- 115 mg. The mean dose of levodopa in Sinemet 25/100 was 873 +/- 304 mg and the mean dose of carbidopa was 218 +/- 76 mg. This study indicates that Sinemet CR4 is a useful addition for patients with response fluctuations

Deprenyl, a selective inhibitor of monoamine oxidase, type B, which is free of the 'tyramine effect,' may ameliorate symptom fluctuations in advanced Parkinson's disease (PD). We randomized 96 patients with marked symptom fluctuations at three centers to receive either deprenyl 5 mg b.i.d. or placebo in parallel fashion in addition to a previously optimized levodopa/carbidopa (Sinemet) regimen. Disability was recorded hourly at home by patients 3 days weekly during the 2-week baseline and the 6-week treatment period. Disability during the 'on' state was assessed each week by examination. Mean hourly self-assessment of gait improved in 28 of 50 patients (56%) receiving deprenyl (mean degree of improvement 0.25 points on a 0-2 scale) and in 14 of 46 (30.4%) taking placebo (mean 0.15). Mean hourly overall symptom control improved in 29 (58%) taking deprenyl (mean 0.34) and in 12 (26.1%) taking placebo (mean 0.15) (p less than 0.01 for each parameter). No significant improvement occurred in the objective quality of the 'on' state with deprenyl. Mean daily Sinemet dosage decreases were 17% in the deprenyl group and 7% in the placebo group. Adverse effects included nausea, light-headedness, dyskinesias, and hallucinations, all of which abated after the Sinemet dose was reduced. We conclude that deprenyl is of moderate benefit in a majority of patients with symptom fluctuations complicating PD and is generally well tolerated

We have evaluated 5 DA agonists-bromocriptine, lergotrile, lisuride, pergolide, and mesulergine in studies encompassing 278 patients with advanced PD. In most of our patients the DA agonist was added to levodopa. Most of our patients were no longer satisfactorily responding to levodopa. Previous attempts at managing these patients by changing the dose of levodopa (increasing or decreasing it), the treatment schedule, or the ratio of levodopa to carbidopa or by temporarily discontinuing levodopa [drug holiday] were unsuccessful. The majority of our patients had diurnal fluctuations in performance, either 'wearing off' or 'on-off' phenomena. The addition of a DA agonist resulted in a decrease in parkinsonian disability in most patients and a decrease in the severity of the diurnal fluctuations in performance. Improvement in many patients was maintained for at least 2 years. Adverse effects included mental changes, dyskinesias, orthostatic hypotension, and nausea. All of the adverse effects were reversible when the agonist was decreased or discontinued. As a group the agonists behaved similarly but individual patients often responded better to one agonist than another. The main role of agonists is in combination with levodopa in the treatment of patients with early PD who have not yet developed dyskinesias or diurnal fluctuations in performance