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Eine 51-jahrige Patientin stellte sich akut in der interdisziplinaren Notaufnahme wegen vor 1 – 2 Stunden akut aufgetretener lumbaler Schmerzen mit pseudoradikularer Ausstrahlung in beide Beine vor, begleitet von einer vorubergehenden Schwache beider Beine und einer initial klinisch noch nachweisbaren, im Verlauf rasch rucklaufigen Gangunsicherheit. Auserdem berichtete sie uber bereits seit Langerem bestehende muskelkaterartige Schmerzen und Krampfe in beiden Beinen sowie fleckige rotliche Hautveranderungen, die seit Wochen immer wieder an Handinnenflachen und Fussohlen auftreten wurden. Im weiteren Verlauf des stationaren Aufenthalts entwickelte sie auch eine schmerzhafte Schwellung an den Fingergelenken der linken Hand, verbunden mit einer Kraftminderung. Die weiterfuhrende Diagnostik (TTE, TEE) ergab letztlich als Ursache dieses Beschwerdekomplexes ein linksatriales Myxom, das offensichtlich in das Myelon, aber auch in die oberen und unteren Extremitaten embolisiert hatte. Auch Arthralgien und Myalgien liesen sich so gut erklaren, da kardiale Myxome Interleukin-6 produzieren und freisetzen und so Symptome infektioser, autoimmunologischer bzw. maligner Erkrankungen verursachen konnen 11 12 . Die nach erweiterter kardiologischer Diagnostik (Koronarangiografie, Kardio-MRT) durchgefuhrte herzchirurgische Resektion des Tumors sowie die postoperative Phase waren komplikationslos, die Patientin danach anhaltend beschwerdefrei. Kardiale Myxome stellen die haufigsten benignen Tumore des Herzens und treten in 75 % im linken Herzvorhof auf 1 2 3 4 16 . Heute werden sie uberwiegend als Zufallsbefund bei TTE/TEE-Untersuchungen entdeckt, die aufgrund anderer Verdachtsdiagnosen veranlasst worden sind. Pathognomonische klinische Leitsymptome liesen sich bislang nicht herausarbeiten. Typisch sind zum einen kardiale Symptome (haufig gehoren zu den ersten Symptomen z. B. Prasynkopen bzw. Synkopen oder andere Zeichen einer Obstruktion der Mitralklappe), zum anderen systemische Beschwerden (Fieber, Gewichtsverlust, Fatigue) und neurologische Krankheitsbilder, hier besonders embolische Schlaganfalle 1 16 . Diagnostische Methode der Wahl ist die Echokardiografie, auch in der postoperativen Verlaufskontrolle 13 14 , Therapie der Wahl die herzchirurgische Entfernung des Tumors. Die Langzeitprognose gilt als exzellent 1 .

Purpose The aim of the study was to estimate normal ranges and test-retest measures for various parameters characterising dopamine metabolism from a prolonged 18F-dopa positron emission tomography (PET) measurement using a reference tissue model and compare their value for the detection of early Parkinson’s disease (PD).

Although extrapyramidal diseases are commonly thought to solely affect the (extrapyramidal) motor system, non-motor symptoms such as behavioural abnormalities, dysautonomia, sleep disturbances and sensory dysfunctions are also frequently observed. Autonomic dysfunction is an important clinical component of extrapyramidal disease, but it is often not formally assessed, and thus frequently misdiagnosed. Symptoms of autonomic dysfunction can impact more on quality of life than motor symptoms. Appropriate symptom-oriented diagnosis and symptomatic treatment as part of an interdisciplinary approach can greatly benefit the patient. This review elaborates a limited overview on the treatment of cardiovascular, gastrointestinal, urogenital and sudomotor autonomic dysfunction in various extrapyramidal syndromes.

Objectives/Hypothesis: Infection of the upper respiratory tract is one of the most common causes of olfactory loss. One of the possible underlying pathologic pathways is an increase of apoptosis of olfactory receptor neurons. Therefore, treatment with the antibiotic minocycline, which has been shown to act as an antiapoptotic agent, is thought to accelerate improvement of olfactory function. To investigate this idea, 55 patients with postinfectious olfactory dysfunction were tested for their olfactory ability. Study Design: Randomized, prospective, double-blind, placebo-controlled. Methods: Olfactory function was examined by means of a standardized psychophysical method (Sniffin' Sticks) before and 7 months after a 3-week treatment with either minocycline (2 × 50 mg/d) or a placebo. Results: Statistical analyses did not reveal any influence of the treatment on the progress of olfactory function, possibly indicating that pathologic changes other than apoptosis contribute to postinfectious olfactory loss, either on a peripheral level (e.g., scarring/reorganization of the olfactory epithelium) or on a central nervous level. Conclusions: In conclusion, the present results indicate that minocycline in the given dosage has little or no effect on the recovery of human olfactory function following postinfectious olfactory loss. However, spontaneous recovery is found in approximately 20% of the patients over an observation period of 7 months. Laryngoscope, 2011

The cold hand sign (CHS) is a distinct feature of multiple system atrophy (MSA), but its pathophysiology is poorly understood. We, therefore, conducted a study to examine the skin temperature and the skin blood flow at rest and after local heating in 6 age-matched MSA patients with CHS (MSA + CHS), 18 MSA patients without CHS (MSA - CHS) and 13 patients with idiopathic Parkinson's disease (PD). Basal skin temperature and blood flow were significantly lower in MSA + CHS patients than in MSA - CHS or PD patients. Local heating induced a greater response in terms of amplitude in MSA + CHS compared to MSA - CHS and PD. Considering kinetics, skin blood flow increment per 1 degrees C was higher in MSA + CHS than MSA - CHS but was similar when compared to PD patients. Skin blood flow rate (change per second) did not differ among the groups. Our findings suggest that despite impaired basal skin perfusion, the skin vasomotor response to local heating is intact in MSA + CHS but disturbed in MSA - CHS. By measuring skin temperature and blood flow, the presence of CHS can be diagnosed in MSA patients. Further studies are necessary to understand regulation of skin perfusion in patients with extrapyramidal disease.

Autonomic dysfunction has been frequently demonstrated in patients with extrapyramidal diseases by cardiovascular autonomic testing. In addition to classical testing, we applied the more detailed baroreflex and spectral analysis on three traditional cardiovascular tests in this study to get additional information on autonomic outflow. We recorded continuously blood pressure, electrocardiogram, and respiration in 35 patients with multiple system atrophy, 32 patients with progressive supranuclear palsy, 46 patients with idiopathic Parkinson's disease and in 27 corresponding healthy subjects during cardiovascular autonomic testing (metronomic breathing, Valsalva manoeuvre, head-up tilt). Baroreflex and spectral analyses were performed by using trigonometric regressive spectral analysis between and during the manoeuvres. Consistent with previous interpretations, our data showed an increase of sympathetic activity in head-up tilt and Valsalva test in healthy controls. This sympathetic activity was significantly decreased in patients with typical and atypical Parkinson syndromes. Significant modulation of baroreflex activity could be observed especially during metronomic breathing; again it was significantly lower in all patient groups. Baroreflex and spectral parameters could not only differentiate between patients and healthy controls, but also differentiate between clinically symptomatic (with autonomic dysfunction as eg. orthostatic hypotension) and asymptomatic patients. In conclusion, our approach allows the evaluation of autonomic variability during short and nonstationary periods of time and may constitute a useful advance in the assessment of autonomic function in both physiological and pathological conditions.

The aim of the study was to investigate the efficacy of the antibiotic minocycline as a drug treatment in patients with Multiple-System-Atrophy Parkinson-type (MSA-P). Sixty-three patients were randomized to minocycline 200 mg/d (n = 32) or a matching placebo (n = 31). The primary outcome variable was the change in the value of the motor score of the Unified Multiple-System-Atrophy Rating-Scale (UMSARSII) from baseline to 48 weeks. Secondary outcome variables included subscores and individual Parkinsonian symptoms as determined by the UMSARS and the Unified-Parkinson's-Disease Rating-Scale (UPDRS). Health-related quality of life (HrQoL) was assessed using the EQ-5D and SF-12. "Progression rate" was assumed to be reflected in the change in motor function over 48 weeks. At 24 weeks and 48 weeks of follow-up, there was a significant deterioration in motor scores in both groups, but neither the change in UMSARSII nor in UPDRSIII differed significantly between treatment groups, i.e. "progression rate" was considered to be similar in both treatment arms. HrQoL did not differ among the two treatment arms. In a small subgroup of patients (n = 8; minocycline = 3, placebo = 5)[(11)C](R)-PK11195-PET was performed. The three patients in the minocycline group had an attenuated mean increase in microglial activation as compared to the placebo group (P = 0.07) and in two of them individually showed decreased [11C](R)-PK11195 binding actually decreased. These preliminary PET-data suggest that minocycline may interfere with microglial activation. The relevance of this observation requires further investigation. This prospective, 48 week, randomized, double-blind, multinational study failed to show a clinical effect of minocycline on symptom severity as assessed by clinical motor function.

Differential diagnosis of parkinsonian syndromes is a major challenge in movement disorders. Dysautonomia is a common feature but may vary in clinical severity and onset. The study attempted to find a pattern of autonomic abnormalities discriminative for patients with different parkinsonian syndromes. The cross-sectional study included 38 patients with multiple system atrophy (MSA), 32 patients with progressive supranuclear palsy (PSP), 26 patients with idiopathic Parkinson's disease (IPD) and 27 age-matched healthy controls. Autonomic symptoms were evaluated by a standardized questionnaire. The performance of patients and controls was compared on five autonomic function tests: deep breathing, Valsalva manoeuvre, tilt-table testing, sympathetic skin response, pupillography, and 24-h ambulatory blood pressure monitoring (ABPM). Disease severity was significantly lower in IPD than PSP and MSA. Except for pupillography, none of the laboratory autonomic tests distinguished one patient group from the other alone or in combination. The same was observed on the questionnaire. Receiver operating characteristic curve revealed discriminating performance of pupil diameter in darkness and nocturnal blood pressure change. The composite score of urogenital and vasomotor domains significantly distinguished MSA from IPD patients but not from PSP. Our study supports the observation that even mild IPD is frequently indistinguishable from more severe MSA and PSP. Thus, clinical combination of motor and non-motor symptoms does not exclusively point at MSA. Pupillography, ABPM and the questionnaire may assist in delineating the three syndromes when applied in combination.

The triplet consisting of two monophyletic taxa and one paraphyletic taxon as constructive element of the phylogenetic system Evolution has produced very many novelties (apomorphies). Most of them are small and relatively inconstant, these are more or less indicative of the phylogenetic relationships between closely related species. They cannot be the constitutive character of a supraspecific taxon that exists since a long time and comprises many diversified species. Such a taxon of higher rank can only be characterized by an improbable, rare novelty that has developed only once and has been preserved in all descendent species. Two consecutive apomorphies of this persistent type (‘fixed apomorphies’) characterize three supraspecific taxa, the triplet “A”, “B” and “A minus B” (Fig. 1). The group “A minus B” is rejected in Hennig's theory because it is ‘paraphyletic’, but it is not an artefact created by the systematicist. It is an inevitable mathematical consequence of the differentiatison of the group “B” within the group “A”. Being the result of a subtraction, it is necessarily associated with the two monophyletic partners in the triplet, as it is delimited on one side by the synapomorphy of the group “A”, of which it is a part, and on the other side by the autapomorphy of the separate group “B”. Traditional classifications often include paraphyletic groupings that are inconsistent with phylogenetics, e. g. the Reptilia and the Apterygota. The fault in such cases is that these groups are extended beyond the limits of a triplet and cover more than a single interval between consecutive monophyletic taxa. Paraphyletic groups are admitted in the phylogenetic system only for bridging the gaps in our cladistic information. According to HENNIG'S theory, all supraspecific taxa should be arranged two by two as sister-groups originating from one ancestral species and comprising all descendents of that species. The fixed evolutionary novelties which characterize higher supraspecific taxa are, however, rare and scattered. It is highly improbable that they have developed in sister species, therefore the taxa marked by them cannot be sister-groups (except in very rare cases). In HENNIG'S earlier papers, e. g. in his system of Lepidoptera (1953: 46–49), the alleged ‘sister-groups' are, in reality, the groups “B” and “A minus B” of a triplet (see Fig. 2). In his revised concept (1957 and later), two autapomorphic groups which are most closely related in the recent fauna (“B” and “C” in Fig. 3) are called ‘sister-groups’. But these have originated independently from different ancestors in a plesiomorphic complex of extinct species and are more closely related to parts of this complex than to each other. True sister-groups (“Bx” and “Cx” in Fig. 4) would be formed if these related plesiomorphic species were included, but this extension of the ’backward‘ border of the taxon is not justified by synapomorphy (in the terms of logic, it is a ’metabasis‘), and it would make the classification of fossil species impossible, unless these show at least one synapomorphy with either “B” or “C”. In the system of the recent fauna the sister-groups are identical with the autapomorphic groups, because the plesiomorphic species are extinct. The natural system based on synapomorphies and autapomorphies is the triplet-system as outlined in Figure 6. It is not a new type of classification, but its theoretical foundation was missing, and precise instructions were needed for its use in phylogenetics. The information obtained by HENNIG'S method is entirely preserved in this system and can be retrieved from it, and both recent and extinct species can be classified together. The disadvantage of the triplet-system is that it contains twice as many taxa as HENNIG'S classification. This complexity will limit its use in the practice of taxonomy, but it may be simplified by transforming the system into a sequence of paraphyletic taxa terminating in a single monophylum.

The most important features that characterize and differentiate progressive supranuclear palsy (PSP) from other parkinsonian syndromes are postural instability, supranuclear gaze palsy, pseudobulbar palsy, and cognitive disturbances. Although it has been reported that significant autonomic dysfunction is an exclusionary feature for PSP diagnosis, we could demonstrate in this study using semiquantitative clinical interview and cardiovascular testing that both PSP and idiopathic Parkinson's disease (PD) patients can present with significant autonomic dysfunction. The parasympathetic cardiovascular system seems to be involved to a similar extent in PD and PSP patients, whereas sympathetic cardiovascular dysfunction is more frequent and severe in PD patients, but can also be found in PSP patients. Our findings have a profound implication on the diagnosis and treatment of PSP patients.

The most important features that characterize and differentiate progressive supranuclear palsy from other Parkinsonian syndromes are postural instability, supranuclear gaze palsy, pseudobulbar palsy, parkinsonism, and cognitive disturbances. In this article, we demonstrate that progressive supranuclear palsy patients exhibit pathologically decreased pupil diameters after dark adaptation recorded by TV pupillography. A cut off value of 3.99 mm was defined to differentiate progressive supranuclear palsy patients from patients with other extrapyramidal disorders like Parkinson's disease and multiple system atrophy with a specificity of 86.4% and a sensitivity of 70.8%. Other pupil abnormalities could not be described in patients with extrapyramidal syndromes.

Auf Grund neuerer klinischer und histopathologischer Studien wird immer deutlicher, dass es sich nicht nur bei der Multisystematrophie (MSA), sondern auch beim idiopathischen Parkinson-Syndrom (iPS) um eine multisystemische Erkrankung handelt. So konnen bei beiden Erkrankungen zahlreiche nicht-motorische Symptome - von psychiatrischen und sensorischen Storungen uber Schlafstorungen bis hin zu autonomen Dysfunktionen - auftreten. Sowohl MSA- als auch iPS-Patienten konnen im Krankheitsverlauf - z. T. deutlich vor Entwicklung motorischer Symptome - in unterschiedlicher Auspragung Funktionsstorungen des autonomen Nervensystems entwickeln, die sich klinisch v. a. im kardiovaskularen, gastrointestinalen und urogenitalen Bereich manifestieren. Dabei kann durch fruhzeitige Diagnostik und adaquate symptomorientierte Therapie der autonomen Dysfunktion im Rahmen eines interdisziplinaren Konzepts ein erheblicher therapeutischer Nutzen fur den einzelnen Patienten erzielt werden. In dieser Ubersichtsarbeit soll zunachst ein pathophysiologisch orientiertes Konzept zur Genese autonomer Funktionsstorungen bei MSA und iPS diskutiert, danach die einzelnen autonomen Funktionssysteme mit ihrer jeweiligen klinischen Symptomatik, Diagnostik und Therapieoptionen vorgestellt werden. Due to new clinical and histopathological data there is growing recognition that not only the atypical Parkinson syndromes like multiple system atrophy (MSA), but the common Parkinson's disease (PD) itself as well are multisystemic disorders which are characterized by a number of non-motor features ranging from psychiatric abnormalities over sleep disorders to autonomic dysfunction. MSA and PD patients can develop significant autonomic dysfunction at an early stage which gets clinically evident in the cardiovascular, gastrointestinal und urogenital autonomic subsystems - sometimes before the classic motor components become prominent. Early diagnosis and sufficient symptomatic treatment of autonomic dysfunction can greatly benefit the patient as part of an interdisciplinary approach to extrapyramidal diseases. In this review, a pathophysiologically orientated concept is presented to explain the source and presence of autonomic dysfunction in MSA and PD patients. Afterwards, the involved autonomic subsystems are discussed concerning characteristic clinical details, tools for early diagnosis and appropriate symptom-orientated therapy.

We report a 52-year-old patient with Miller Fisher syndrome and discuss Wernicke's encephalopathy as one important differential diagnosis. This article focuses on diagnostic criteria and possible nosological relations between Miller Fisher syndrome, Guillain-Barre syndrome with ophthalmoplegia, Bickerstaff's brainstem encephalitis, and acute ophthalmoparesis without ataxia.

ZusammenfassungDie Depression ist ein häufiges Symptom bei idiopathischen und atypischen Parkinson-Syndromen und beeinflusst neben den Aktivitäten des täglichen Lebens auch wesentlich die Lebensqualität der Betroffenen. Die Studienlage belegt, wie schwierig es ist, die affektiven Symptome zu messen und sie effizient zu behandeln. Für das idiopathische Parkinson-Syndrom liegen Untersuchungen zur Wirksamkeit einer antidepressiven Pharmakotherapie vor, allerdings erfüllen sie gegenwärtig noch nicht die Kriterien der evidenzbasierten Medizin. Für die atypischen Parkinson-Syndrome (Multisystematrophie, progressive supranukleäre Blickparese, Demenz mit Lewy-Körperchen und kortikobasale Degeneration) bestehen bislang erst klinische Fallsammlungen. Die Wahl der antidepressiven Therapie bei idiopathischen und atypischen Parkinson-Syndromen ist daher eine individuelle Entscheidung und beruht auf der Kenntnis der aktuell verfügbaren Literatur, die im Folgenden zusammengefasst wird.

The aim of this investigation was to define characteristic properties of cellular energy metabolism in meningiomas in vitro dependent on the histological subtype. We analysed marker enzymes of representative metabolic pathways localized in the mitochondria (respiratory chain, citric acid cycle, beta-oxidation of fatty acids) and in the cytoplasm (glycolysis, pentose phosphate shunt). The activities of the intramitochondrial enzymes were significantly reduced in the meningiomas compared to normal cortex tissue. Glycolytic enzymes were not significantly different, but the marker enzyme of the pentose phosphate shunt was increased by a factor of 3.5-6 in the tumours. Further analysis of the histological subtypes showed that phosphofructokinase and lactate dehydrogenase were significantly increased in the anaplastic meningiomas compared to the benign subtypes.

Bei der Behandlung des idiopathischen Parkinson-Syndroms stellen die L-Dopa-induzierten motorischen Spatkomplikationen wie Wirkungsfluktuationen (wearing-off, End-of-dose-Akinese) und Dyskinesien ernste Komplikationen dar. Diese prospektive offene Studie zeigt, dass eine Add-on-Therapie mit Entacapon Wearing-off-Phanomene und die End-of-dose-Akinese signifikant verringert. Die Therapie ist gut vertraglich und einfach durchfuhrbar.

Objective: To evaluate the effects of levodopa and the dopamine D2 agonist cabergoline on striatal dopamine turnover estimated as the inverse of the effective dopamine distribution volume ratio (EDVR) measured by 18 F-dopa PET in de novo Parkinson disease (PD). Methods: Single-center, parallel-group, randomized, observer-blinded study of cabergoline (3 mg/day) and levodopa (300 mg/day) over 12 weeks in patients with de novo PD. Primary efficacy measure was the change of the side-to-side averaged putaminal EDVR comparing baseline and end-of-maintenance period. Results: Thirty-five out of 39 randomized patients were assigned to the primary efficacy analysis (cabergoline, n = 17; levodopa, n = 18). At the end of treatment period, mean EDVRs were significantly lower compared to baseline solely in the levodopa group (relative change −1.0 ± 13.0% in cabergoline [ p = 0.525 when compared to baseline], −8.3 ± 11.8% in levodopa group [ p = 0.006]) with a nonsignificant trend between groups (mean relative difference: 7.3% (95% confidence interval −1.2% to 15.8%; p = 0.091). There was significant clinical improvement in both groups at 12 weeks compared to baseline, but no significant differences between groups in clinical and PET secondary outcome measures. Both pharmacologic treatments and PET scanning were well-tolerated and safe. Conclusion: Putaminal dopamine turnover is increased by levodopa treatment in de novo PD. The nonsignificant trend toward a larger influence by levodopa compared to cabergoline is supported by ancillary statistical analyses. This augmentation of early compensatory events by levodopa might contribute not only to its symptomatic effects, but also to its induction of motor complications.

Changes of mitochondrial and cytoplasm tumor metabolism were studied in malignant gliomas and normal cortex probes in vitro. By spectrophotometric methods marker enzymes of different mitochondrial (whole respiratory chain, citrate acid cycle, fatty oxidation) and cytoplasm (glycolysis, pentose phosphate shunt) metabolic energy pathways were analysed. Generally, the activities of intramitochondrial key enzymes were significantly decreased in gliomas when compared with enzyme activities of normal cortex tissue (p < 0.01). Glycolytic enzymes and a representative of the pentose phosphate shunt were unchanged or increased. Ratios of marker enzymes of the glycolytic pathway (lactate dehydrogenase) and glycose-6-P dehydrogenase revealed a significant difference between glioblastomas (p < 0.05) and grade III (p < 0.05) tumors in comparison to normal astrocytic tissue and astrocytomas WHO grade II. Thus, biochemical analyses allow metabolic grading of gliomas in vitro and may be a useful tool for understanding tumor biology.

We report on a 44-year-old man who suffered from severe anterocollis. Repeated computed tomographically controlled injections of botulinum toxin into the right longus colli muscle allowed a precise location of the needle and injection of the toxin, leading to clear improvement of symptoms.

Objective: Multiple system atrophy (MSA) and progressive supranuclear palsy (PSP), known as atypical parkinsonian syndromes (APS), are neurodegenerative disorders with severe disability and decreased life expectancy. Little is known about the health-related quality of life (HrQoL) and its determinants in patients with those disorders. The objective of our cross-sectional study was to evaluate the HrQoL in patients with APS and to identify the determinants of HrQoL. Methods: A total of 101 consecutive patients with MSA (n = 54) and PSP (n = 47) were recruited in four German neurological centers. Disease severity was assessed using the Hoehn and Yahr stages and the Unified MSA Rating Scale. The HrQoL was evaluated using the EuroQol instrument (EQ-5D and EQ-VAS). Independent determinants of HrQoL were identified in multiple regression analyses. Results: The mean EQ-VAS score was 52% lower than that reported for the general population (36.9 ± 18.3 vs. 77.4 ± 19.0). Of the study participants, 63% reported severe problems in at least one dimension of the EQ-5D. Cerebellar dysfunction was associated with a more considerable reduction of HrQoL. Independent determinants of reduced HrQoL were female gender, Conclusions: The HrQoL in MSA and PSP is considerably reduced. While therapeutic options in the treatment of motor symptoms remain restricted, greater attention should be paid to the treatment of depression, which was identified among independent determinants of HrQoL. Independent determinants of HrQoL should be considered when developing healthcare programs aimed at improving the HrQoL in APS.

The valsalva manoeuvre (VM), used as an autonomic function test, can detect sympathetic and/or parasympathetic autonomic dysfunction. This study investigated the value of VM in patients with different Parkinsonian syndromes (PS). We continuously recorded blood pressure, ECG and respiration among 38 patients with multiple system atrophy (MSA), 32 patients with progressive supranuclear palsy (PSP), 26 patients with idiopathic Parkinson's disease (PD) and in 27 healthy subjects matched in age and sex (Con). VM was performed in addition to metronomic breathing and tilt-table testing. VM could not be analysed in 26% of the ES patients. Valsalva ratio (VR), as a parameter of cardiovagal function, was pathologically decreased in all patient groups. Valsalva ratio (VR) was not able to discriminate parasympathetic dysfunction between patients and controls as well as E/I ratio of metronomic breathing. As a parameter of sympathetic dysfunction during VM, the physiological increase of blood pressure was more often missing during phase IV than phase II especially in PD and MSA patients. Correlation with orthostatic hypotension during tilt-table testing was only moderate. Although VM can demonstrate sympathetic and parasympathetic autonomic dysfunction, we cannot recommend VM as a first line autonomic test in PS patients. Metronomic breathing and tilt-table test seem more capable as parasympathetic resp. and sympathetic function tests to identify cardiovascular abnormalities in PS patients.

Previous data on the prevalence of olfactory dysfunction in Parkinson's disease (PD) range from 45% to 90%. The present multicenter study aimed to provide data on the prevalence of smell loss in a large sample of PD patients from three independent populations. Olfactory sensitivity was tested in 400 patients from Australia, Germany, and The Netherlands by means of a psychophysical olfactory test, the "Sniffin' Sticks", which is comprised of 3 subtests of olfactory function. Out of the total number of patients 45.0% presented as functionally anosmic, 51.7% were hyposmic, whereas only 3.3% were normosmic. This indicates that 96.7% of PD patients present with significant olfactory loss when compared to young normosmic subjects. This figure falls to 74.5%, however, when adjusted to age-related norms. Thus, olfactory dysfunction should be considered as a reliable marker of the disease.

Multiple system atrophy (MSA) can clinically be divided into the cerebellar (MSA-C) and the parkinsonian (MSA-P) variant. However, till now, it is unknown whether autonomic dysfunction in these two entities differs regarding severity and profile. We compared the pattern of autonomic dysfunction in 12 patients with MSA-C and 26 with MSA-P in comparison with 27 age- and sex-matched healthy controls using a standard battery of autonomic function tests and a structured anamnesis of the autonomic nervous system. MSA-P patients complained significantly more often about the symptoms of autonomic dysfunctions than MSA-C patients, especially regarding vasomotor, secretomotor, and gastrointestinal subsystems. However, regarding cardiovascular, sudomotor pupil, urogenital, and sleep subsystems, there were no significant quantitative or qualitative differences as analyzed by autonomic anamnesis and testing. Our results suggest that there are only minor differences in the pattern of autonomic dysfunction between the two clinical MSA phenotypes.

Cardiac autonomic abnormalities have been described in Parkinson’s disease and other extrapyramidal syndromes. To investigate baroreflex sensitivity as an important risk marker of cardiovascular mortality in patients with Parkinson’s disease and other extrapyramidal syndromes. We recorded continuously blood pressure, ECG and respiration in 35 patients with multiple system atrophy (MSA), 32 patients with progressive supranuclear palsy (PSP), 46 patients with idiopathic Parkinson’s disease (PD) and in 27 corresponding healthy subjects (Con). Recordings of 2 min at rest were used to calculate baroreflex and spectral analysis of heart rate and systolic blood pressure. Resting baroreflex sensitivity (BRS) was significantly lower in the MSA and the PSP group but not in the PD group in comparison to the Con group. With increasing Hoehn & Yahr stage, BRS significantly decreased in all patient groups. In spectral analysis, all patient groups had a significantly lower relative low frequency (LF)-band power than the healthy controls. Patients with extrapyramidal disorders frequently demonstrate pathologically decreased BRS values and abnormalities of spectral analysis. This may have fundamental impact on the cardiovascular prognosis of patients with extrapyramidal disease.

Olfactory dysfunction is a prominent symptom in Parkinson's disease (PD) and found in about 70-100% of patients. In earlier studies significant loss of olfactory function seemed to be unrelated to disease duration, did not correlate with motor function, and was uninfluenced by antiparkinsonian medication. We suggest that the increase of dopaminergic cells in the olfactory bulb is responsible for the hyposmia in PD patients. Interestingly, this olfactory dysfunction is not found in progressive supranuclear palsy or corticobasal degeneration. In multiple system atrophy, the deficit is mild and indistinguishable from cerebellar syndromes of other aetiologies. Intact olfaction has also been reported recently in Parkin disease (PARK 2) and vascular parkinsonism. Olfactory tests may significantly enhance the diagnostic armamentarium in the differential diagnosis of parkinsonian syndromes and indeterminate tremors. Furthermore, olfactory testing may also prove to be a useful aid in the early or "preclinical" detection of PD, once effective disease-modifying therapies are found. Braak and coworkers have confirmed the widespread, extranigral pathology in PD and suggested that pathology in the anterior olfactory region may be one of the earliest appearances of neurodegeneration in PD.

Purpose of this cross-sectional study was to estimate the occurrence of depressive symptoms, as related to other clinical data, in a sample of Parkinson's disease (PD) patients ( n = 226). Furthermore, we examined the medical care of depressive symptoms in this sample. H&Y stages, cognitive status, sleeping disorders, and dysphagia resulted as significant predictors for depression. Prevalence of depressive symptoms was 35.4%. Only 25.0% of patients suffering from moderate to severe depressive symptoms were prescribed antidepressants. This study supports the view that depression may be underrecognized and undertreated in PD patients. A significant proportion of patients continues to experience depressive symptoms despite antidepressive medication. Recognition and treatment of depression remains a challenge for management of PD. Possible coexisting depressive symptoms should be revealed and assessed by standardized interviews in everyday clinical routine. Large scale randomized controlled trials examining efficacy and safety of antidepressants in PD patients are urgently required.

Major hallmarks in the pathophysiology of Parkinson disease are cellular energy depletion and oxidative stress leading to cellular dysfunction and death. Coenzyme Q(10) (CoQ(10)) is an electron acceptor bridging mitochondrial complexes I and II/III and a potent antioxidant that consistently partially recovers the function of dopaminergic neurons.To determine whether nanoparticular CoQ(10) is safe and displays symptomatic effects in patients with midstage Parkinson disease without motor fluctuations.Multicenter, randomized, double-blind, placebo-controlled, stratified, parallel-group, single-dose trial.Academic and nonacademic movement disorder clinics.One hundred thirty-one patients with Parkinson disease without motor fluctuations and a stable antiparkinsonian treatment. Intervention Random assignment to placebo or nanoparticular CoQ(10) (100 mg 3 times a day) for a treatment period of 3 months. Stratification criterion was levodopa treatment.The subjects underwent evaluation with the Unified Parkinson's Disease Rating Scale (UPDRS) at each visit on a monthly basis. The primary outcome variable was the change of the sum score of the UPDRS parts II and III between the baseline and 3-month visits.One hundred thirty-one subjects were randomized according to the protocol. The mean changes of the sum UPDRS parts II/III score were -3.69 for the placebo group and -3.33 for the CoQ(10) group (P = .82). Statistical analysis according to the stratification did not result in significant changes of the primary outcome variable. No secondary outcome measure showed a significant change between the placebo group and the CoQ(10) group. The frequency and quality of adverse events were similar in both treatment groups.Nanoparticular CoQ(10) at a dosage of 300 mg/d is safe and well tolerated and leads to plasma levels similar to 1200 mg/d of standard formulations. Add-on CoQ(10) does not display symptomatic effects in midstage Parkinson disease.

Olfactory function is diminished in patients with idiopathic Parkinson disease (IPD). Because previous work almost exclusively relied upon cross-sectional studies, the present investigation aimed to address the correlation between olfactory loss and duration of disease within the context of a longitudinal study, accompanying well-diagnosed patients over an average period of 4.4 years. A group of 27 IPD patients was examined (5 women, 22 men; age range 27–64 years; duration of disease: 0 to 19 years). Psychophysical olfactory testing was performed after 3–6 years (mean 4.4 years) using the "Sniffin’ Sticks" test battery which consists of subtests for odor thresholds, odor discrimination, and odor identification. The study yielded the following major results: (1) olfactory function in IPD patients changes in an unpredictable manner, (2) especially when considering results from the second session relatively few IPD patients were completely anosmic; none of the patients, however, were normosmic. One possible explanation for these findings may lie in the hypothesis based on results by Huisman et al. (2004) who reported an increase of dopaminergic neurons in the olfactory bulb in IPD patients. In this scenario, olfactory loss seen early in the disease may be based on an incomplete inhibition of olfactory input at the level of the olfactory bulb.

Depressive symptoms are common in patients with neurodegenerative disorders. Imaging studies suggest that a disruption of frontal-subcortical pathways may underlie depression associated with basal ganglia disease. This pilot study tested the hypothesis that frontal dysfunction contributes to depression associated with multiple system atrophy (MSA) and progressive supranuclear palsy (PSP). Depressed patients with MSA (n = 11), PSP (n = 9), and age-matched controls (n = 25) underwent measures of cerebral glucose metabolism applying positron emission tomography with (18)F-fluorodeoxyglucose. Regional metabolism in the patient groups was compared to the normal subjects using the voxel-based statistical parametric mapping. Depressive symptom severity (Hamilton Depression Rating) and degree of locomotor disability (Hoehn & Yahr) were assessed in the patient groups. The association between prefrontal metabolism and the occurrence of depressive symptoms and the degree of locomotor disability was investigated. When compared to controls, MSA patients revealed significant metabolic decreases in bilateral frontal, parietal, and cerebellar cortex and in the left putamen. In PSP patients, significant hypometabolism was demonstrated in bilateral frontal cortex, right thalamus, and midbrain. Depression severity but not the patients' functional condition was significantly associated with dorsolateral prefrontal glucose metabolism in both patient groups. The findings of this pilot study support the hypothesis that depressive symptoms in MSA and PSP are associated with prefrontal dysfunction. (c) 2006 Movement Disorder Society.

We report a 52-year-old patient with Miller Fisher syndrome and discuss Wernicke's encephalopathy as one important differential diagnosis. This article focuses on diagnostic criteria and possible nosological relations between Miller Fisher syndrome, Guillain-Barré syndrome with ophthalmoplegia, Bickerstaff's brainstem encephalitis, and acute ophthalmoparesis without ataxia.