J Neurol (2001) 248 [SuppI2]: 11/1-11/208 © Steinkopff Verlag 2001

Eleventh Meeting of the European Neurological Society 21-25 April, 2001, Paris, France Symposia and Free Communications

The abstracts have been reviewed by:

J. Berciano, J. Bogousslavsky, P.Boon, G. Comi, A. Czlonkowska, D. A. S. Compston, H.-C. Diener, S. DiDonato, J. G. Hildebrand, R. Hohlfeld, C. Krarup, D. Leys, E. Melamed, I. Milonas, G. Said, A. Steck, P. Scheltens, K. Toyka

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Contents Abstracts oftheSymposia Presidential symposium: New frontiers in neurological research Animal Model Disorders for the Study of Disease Mechanisms and New Treatments ll/3 Genetic Determinators in Spinal Muscular Atrophy II/3 Huntington's Disease: the enigma of triplet repeats in neuronal degeneration II14 Molecular Pathology of prion diseases ll/5 Symposium 2: Pathophysiology and treatment of movement disorders and Parkinsons's disease Parkinson's Disease: Pathophysiology Of L-Dopa Induced Dyskinesias ll/6

Pathophysiology of Motor Fluctuations Il/6 From genes to pathophysiology II16 Symposium 3: Progress in stroke CADASIL: from disease to vessel wall physiology ll/7 Progress in stroke Prevention II17 New Contributions of MRI Techniques in Stroke: MRI Diffusion-Perfusion in Stroke II18 Symposium 4: Neuro-imaging and function Imaging and the management of epilepsy ll/9 Recovery and rehabilitation in stroke ll/9 Conscious and unconscious action Ull 0 Cultural effects on normal and dyslexic reading III 11 Computational morphometry: The new in vivo anatomy ll/11 Symposium 5: Management of immunological disorders of the nervous system Management of Myasthenia Gravis and of other Neuromuscular Junction Disorders ll/I2 Inflammatory myopathies ll/I3 New treatments in multiple sclerosis II1I3 Paraneoplastic neurological syndromes II1I3

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Abstracts for Poster Sessions Poster Session - I Clinical Neurophysiology II!70 Cerebrovascular Disorders ll/72 Extrapyramidal Disorders II178 General Neurology II180 Multiple Sclerosis ll/85 Muscle Disorders ll/90 Peripheral Neuropathy ll/92 Poster Session - 2 Cerebrovascular disorders ll/95 Extrapyramidal disorders ll/99 General neurology III I0I Dementia higher functions disorders Immunology ll/108 Infection ll/109 Motor neuron disease IIIl11 Multiple sclerosis II1112 Peripheral neuropathy III 117

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Poster Session - 3 Cerebrovascular disorders ll/119 Extrapyramidal disorders II1124 Epilepsy ll/126 General neurology IIIl29 Higher functions disorders II/I31 Multiple sclerosis ll/I33 Muscle Disorders ll/I38 Neuro-ophthalmology - Neuro-otology

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Poster Session - 4

Abstracts for Oral Sessions Cerebrovascular disorders - I ll/16 Cerebrovascular disorders - 2 III 17 General Neurology III9 Ataxias II/20 Immunology - I II122 Immunology - 2 ll/23 Multiple Sclerosis I ll/24 Multiple Sclerosis - 2 II126 Motor neuron disease and amyotrophic lateral sclerosis Neuro-ophthalmology ll/29 Peripheral neuropathy - I II130 Peripheral neuropathy - 2 ll/32 Cerebrovascular disorders - 3 II/33 Cerebrovascular disorders - 4 ll/34 Parkinson's disease - I II136 Parkinson's disease - 2 II138 Neurogenetics - I II140 Neurogenetics - 2 II141 Multiple Sclerosis - 3 II143 Multiple Sclerosis - 4 II144 Clinical Neurophysiology - I II146 Clinical Neurophysiology - 2 II147 Peripheral neuropathy - 3 II149 Higher Functions Disorders and Dementia - I II150 Higher Functions Disorders and Dementia - 2 II/52 Higher Functions Disorders and Dementia - 3 II153 Epilepsy - Ill/55 Epilepsy - 2 ll/56 Neurogenetics - 3 ll/57 Neuro-epidemiology ll/59 Multiple Sclerosis - 5 ll/60

Multiple Sclerosis - 6 II/62 Neuro-oncology - I ll/64 Neuro-oncology - 2 ll/65 Muscle disorders ll/67 Infection of the nervous system

Cerebrovascular disorders II1143 Epilepsy II1146 General neurology ll/148 Genetics II1150 Dementia higher function disorders Multiple sclerosis II1154 Neurobiology ll/158 Neuro-oncology II1159 Pain-Headache ll/164 II/28

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Poster Session - 5 Peripheral neuropathy ll/169 Multiple sclerosis IIII 73 Dementia higher function disorders Genetics III 180 General neurology II1183 Epilepsy IIIl87 Extrapyramidal disorders ll/190

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Abstracts arrived after theeditorial deadline Author index

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Monday, Apri123, 2001 Presidential symposium NEW FRONTIERS IN NEUROLOGICAL RESEARCH Chair: K. V. Toyka, Wª

Animal Model Disordersfor the Studyof Disease Mechanismsand New Treatments Klaus V. Toyka, Department of Neurology, University of Wª Animal models are helpful tools to understand how neurologic disorders develop and how treatments may work. Animal models are defined as experimental or natural disorders in mammals which reflect typical disease features. Even in Drosophila melanogaster and C.elegans particular mutations in genes related to the nervous system may provide clues for understanding pathogenic mechanisms applying to human disease. A s a surrogate for the human disorder, the animal models can be studied systematicaUy with traditional pathology and modern laboratory testing, and insights can be gained into disease evolution and progression. By understanding the model system we may develop surrogate markers which can than be used in patients (1). We can also investigate the cause-and-effect relationship of e. g.antigens and antibodies, or of infectious agents in certain disorders of suspected autoimmune nature, or in the unconventional infectious disorders, and we have the opportunity to study the animal counterparts of genetically determined disorders (2). We can explore new molecular treatment strategies in the animal model before evaluating its potential benefit in patient including (a) gene repair or modulation of defective genes; (b) supply, replacement or upregulation of protective compounds, e. g. trophic factors; (c) modulation of aberrant signal transduction; (d) neutralisation of toxic ptoducts, e. g. metal ions or excitotoxins (3). The traditional animal species used are rats and mice, guinea pigs, rabbits and non-human primates, i. e. monkeys. Then there are the natural mutants in various species incl. dogs and mice, which have taught us several lessons in hereditary disorders and in autoimmune diseases like the Guillain-Barre syndrome and myasthenia gravis. More recently, genetically engineered mutants have been made that lack or overexpress a certain gene and subsequently generate defective gene products. An exciting development has been the generation of mutants that carry the gene defect only in a certain tissue such as the CNS, with the defective gene switched on or off by simple treatments such as tetracyclin or related compounds given to the animal (conditional and tissue-specific knock-outs). Beyond the genetic models for an enlarging number of human disorders, there are numerous infectious disease and autoimmune disorder models available. Three human neuromuscular disorders are discussed as examples to emphasize how animal models can help us to understand important disease mechanism, to develop new treatments and to determine their mode of action. (1) myasthenia gravis (MG): this prototypic autoimmune disorder was the first neuroreceptor disorder shown to be antibody-mediated as demonstrated by experimental autoimmune MG in rabbits and other species and by passive transfer of antibodies to acetylcholine receptor from man to mouse [1, 2]. This had immediate impact on using immunosuppressive treatments and therapeutic plasma exchange in human MG. This discovery was followed by that of the immunopathogenesis of the Lambert-Eaton myasthenic syndrome through passive transfer of antibodies to voltagegated calcium channels from patients to mice [2, 3]. (2) The Guillain-Barre syndrome and Miller Fisher syndrome: In the animal model, experimental autoimmune neuritis (EAN), the typical immunopathologic features of GBS are reproduced 4. Principal mechanisms including transmigration of T lymphocytes to the nerve parenchyma, the role of macrophages in local inflammation and recruitment of the host's immune response, the toxic role of oxygen and NO and radicals, termination of inflammation by T cell apoptosis were identified, a n d a large number of new treatments including IVIG, metalloproteinase inhibitors, oxygen radical scavengers were tested successfully in EAN [4]. Moreover, the neuromuscular blocking action of circulating IgG antibodies, possibly directed at ganglioside epitopes, in GBS and MFS could be demonstrated in mouse nerve-muscle preparations [5, 6]. These effects can be neutralised by therapeutic IgG fractions. (3) Charcot-Marie-Tooth disease: The generation of mice with defined mutations, deletions, or duplications in the myelin genes PMP 22, PO, Cx32, and EGR2 (Krox 20) has helped to formally study the basic disease mechanisms in CMT and related disorders [7]. In a recent concept, developed by Martini and colleagues, the role of immune cells in inherited demyelination was analysed bx cross-breeding myelin mutants (PO+/- mice) with mice

lacking mature T lymphocytes (RAG 1-/-; T cell receptor or deficient in macrophage activation (M-CSF deficiency). In the corresponding double mutants, demyelination was substantially reduced giving hope for future immunomodulating treatments in CMT [7-9]. Moreover, a new model of neuromyotonia (Isaac's syndrome) was defined in P0- and PMP22 k.o. mice [ 10]. In conclusion, the new genetic and the more traditional animal models are a promising tool to study pathomechanisms in human disorders and to develop new treatments. References 1. Toyka KV, Drachman DB, Pestronk A, Kao I (1975) Science 190, 397 2. Vincent A, Beeson D, Lang B (2000) Eur J Biochem 267, 6717 3. Lang B, Newsom-Davis J, Prior C, Wray D (1983) J Physio1344, 335 4. Hartung HP, Pollard J, Harvey G, Toyka KV (1995) Muscle Nerve 18,137 and 154 5. Buchwald B, Toyka KV, Zielasek J et al. (1998) Ann Neurol 121, 1257 6. Willison HJ, O'Hanlon GM (1999) J Neuroimmunol 100,3 7. Martini R (2000) J Neurosci es 61,244 8. Schmid CD, Stienekemeier M, Oehen Set al. (2000) J Neurosci 20, 729 9. Carenini S, M~iurer M, Werner A et al. (2001) J Cell Biol in press 10. Martini R, Zielasek J, Toyka KV (1998) Curr Opin Neurol 11,545 11. Zielasek J, Martini R, Suter U, Toyka KV (2000) Muscle nerve 23,696

Genetic Determinatorsin Spinal MuscularAtrophy Michael Sendtner, Institute for Clinical Neurobiology, University of Wª burg, Germany Proximal spinal muscular atrophy (SMA) is an autosomal recessive disorder, characterized by progressive loss of spinal motoneurons. With a worldwide similar incidence of 1/10000 live births (Emery, 1991),it appears a s the most common recessive genetic disorder lethal to infants. In SMA-patients, motoneurons are generated during embryonic development, and most of them succeed in making contact with the skeletal muscle. Then, a degenerative process starts, which leads to predominan@ proximal symmetric muscle weakness due to denervation (Crawford, 1996). In most severe cases, this degenerative process can already be detected during late stages of pregnancy, whereas other forms of the disease exist, which onlybecome apparent during childhood. This has led to the distinction of three subclasses named type I, type II and III SMA, type I SMA being the most severe form with onset during the first 6 months of life a n d a rapid course leading to death within few years. This clinical classification did not only prove useful for prognostic clues,it also appeared quite helpful for molecular analysis. Positional cloning strategies have led to the identification of a region on human chromosome 5 containing the survival motoneuron (SMN)-gene (Lefebvre et al., 1995)and the neuronal apoptosis inhibitory gene (naip) (Roy et al., 1995). This region is duplicated on the long arm of chromosome 5, resuhing in two copies of SMN and NAIP in the human genome. More than 95 % of SMA patients have deletions of the telomeric SMN gene. In contrast, the mouse genome contains only one copy of the SMN gene but six copies of the NAIP gene. We have generated mice in which the SMN gene is deleted by introduction of a lacZ/Neo cassette into exon 2 of the mouse SMN-gene. Mice with homozygous deletion of the SMN gene die during early development in the late morula/early blastocyst stage (Schrank et al., 1997). In contrast, mice with heterozygous smn gene deletion survive, but develop a specific disease of motoneurons, resembling SMA type III (Jablonka et al., 2000a). Mice with deletion of the smn gene have been cross-bred with mice overexpressing the human centromeric SMN 2 gene. These hSMN 2 tg/Smn - / - mice develop to term but die within few days after birth (Monani et al., 2000). Interestingly, the number of motoneurons is not decreased in these mice at birth, demonstrating that the human SMN 2 gene can compensate for deficiency of the mouse smn gene in motoneurons during embryonic development but not after birth. The identification of SMA patients with microdeletions, point mutations, in particular with exon 6 and 7 of SMN 2, supported the view that SMN is the disease gene for SMA. However, no correlation could be made between deletion/mutation of this gene and phenotype severity. The SMN gene product has been found as constituent of protein complexes involved in assembly and regeneration of spliceosomal complexes. Therefore, we have investigated splicing of a candidate mRNA, Ich 1 in these mice. Interestingly, splicing of the Ich 1 tuRNA is not disturbed in smn + mice at the same developmental stages when motoneurons are degenerating. Similarly, no defect in splicing of this mRNA was observed in the hSMN 2 tg/ Smn - / - mice. Thus, motoneuron degeneration does not correlate with a general defect of mRNA splicing. In conclusion, mice overexpressing hSMN 2 on a Smn - / - background resemble type I SMA, and smn +/- mice type III SMA. In both cases, the loss

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of motoneurons develops postnatally. In the SMA type I model, loss of 40 % of motoneurons can be observed during the first postnatal week, and in the type III m o d e l a similar number of motoneurons is lost between six and twelve month of age. Surprisingly, the motor deficit in the SMA type 1 mouse model is much more severe than in the SMA type III modal, indicating that smn does not only regulate motoneuron survival but also functional properties of these neurons (Jablonka et al., 2000b). Future studies have to identify these specific cellular functions of smn in motoneurons. Specific focus will be the role of smn on axon growth and integrity. Such analyses are now feasible by isolation and cell culture of motoneurons from mice resembling type I and type III SMA. Moreover, these mouse models offer new chances for development of therapy. The pathophysiology and the processes leading to motoneuron degeneration can now be studied in detail on the cellular and molecular level, and neurons can be isolated and kept in culture as tools for drug screening. In a second step, such drug candidates can then be tested in vivo for efficacy in compensation for the cellular defects caused by lack of the SMN gene products in spinal muscular atrophy. References 1. Crawford TO (1996) From enigmatic to problematic: the new molecular genetics of childhood spinal muscular atrophy. Neurology 46:335-340 2. Emery AE (1991) Clinical and genetic heterogeneity in spinal muscular atrophy-the multiple allele model. Neuromuscul Disord 1:307-308 3. ]ablonka S, Rossoll W, Schrank B, Sendtner M (2000b) The role of SMN in spinal muscular atrophy. 1 Neuro1247 Suppl 1:I37-I42 4. lablonkaS, SchrankB, KralewskiM, RossollW, Sendtner M (2000a) Reduced survival motor neuron (Smn) gene dose in mice leads to motor neuron degeneration: an animal model for spinal muscular atrophy type III. Hum Mol Genet 9:341-346 5. Lefebvre S, Burglen L, Reboullet S, Clermont O, Burlet P,Viollet L, Benichou B, Cruaud C, Millasseau P, Zeviani M, et al. (1995) ldentification and characterization of a spinal muscular atrophy- determining gene. Cel180:155-165 6. Monani UR, Sendtner M, Coovert DD, Parsons DW, Andreassi C, Le TT, Jablonka S, Schrank B, Rossol W, Prior TW, Morris GE, Burghes AH (2000) The human centromeric survival motor neuron gene (SMN2) rescues embryonic lethality in Smn(-/-) mice and results in a mouse with spinal muscular atrophy. Hum Mol Genet 9:333-339 7. Roy N, Mahadevan MS, McLean M, Shutler G, Yaraghi Z, Farahani R, Baird S, Besner Johnston A, Lefebvre C, Kang X, et al. (1995) The gene for neuronal apoptosis inhibitory protein is partially deleted in individuals with spinal muscular atrophy. Cel180:167-178 8. Schrank B, Gotz R, Gunnersen JM, Ure IM, Toyka KV, Smith AG, Sendtner M (1997) Inactivation of the survival motor neuron gene, a candidate gene for human spinal muscular atrophy, leads to massive cell deatb in early mouse embryos. Proc Natl Acad Sci USA 94:9920-9925

Huntington's Disease:the enigma of triplet repeats in neuronal degeneration Gillian Bates. GKT School of Medicine, King's College, University of London, UK Huntington's disease (HD) is an inherited progressive neurodegenerative disorder caused by a CAG/polyglutamine (polyQ) repeat expansion. Patients display a wide range of symptoms, which include personality changes, motor impairment and cognitive decline. The non-pathogenic repeat range extends from 6 to 35 CAGs and the pathogenic range starts at 36 CAGs. Repeats of 36-39 are incompletely penetrant whereas alleles of 40 and above invariably cause the disease [ 1]. The CAG repeat encodes a stretch of polyglutamine residues in the huntingtin protein, which can therefore tolerate a wide variation in the length of the pol.yQ tract, which at a sharp threshold becomes pathogenic. This threshold effect is most likely the result of a structural change. The kinetics with which N-terminal huntingtin fragments form amyloid-like fibrils in vitro, increases dramatically as the polyQ repeat expands from 32 to 37Q [2]. Currently, nothing is known of the initiating phase transition or early steps in the aggregation pathway but the close correlation with the pathogenic repeat threshold suggests that this process is important in the disease aetiology. The neuropathology of HD is characterised by a selective neurodegeneration primarily but not exclusively affecting the cortex and striatum, a generalised atrophy that occurs across all brain regions and the more recen@ described aggregate pathology. In HD autopsy brains, polyglutamine aggregates have been described in the form of nuclear inclusions, dystrophic neurites and neuropil aggregates. They are thought to contain N-terminal huntingtin, are predominan@ located outside of the nucleus, are more frequent in the cerebral cortex than the stria-

tum and have been described in the cerebral cortex of presymptomatic patients [3,4]. Insights into the early events in the molecular pathogenesis of HD have come from the analysis of mouse models. The most extensively studied are the R6 lines that express exon 1 of the human HD gene under the control of its own promoter [5]. Line R6/2 exhibits an especially accelerated phenotype. PolyQ aggregates can be detected prior to four weeks of age in some brain regions and develop in both the nuclei and neuropil [6, 7]. Nuclear aggregation first appears a s a diffuse nuclear staining followed by the formation of puncta and finally a single nuclear aggregate with the clearing of the nuclear staining. A movement disorder can be detected by tire weeks [8] and selective cell death is a late event occurring after 14 weeks [9]. Tberefore, the R6 phenotype is caused by neuronal dysfunction and not by neurodegeneration. There are now multiple lines of evidence to indicate that transcriptional dysregulation of selective genes may underlie this neuronal dysfunction. Microarray analysis has highlighted deficits in selective neurotransmitter receptor signalling pathways, calcium homeostasis and retinoid signalling [10]. Consistent with this, a down-regulation of G-protein coupled neurotransmitter receptors has recen@ been described in HD post-mortem brains [11]. The mechanism underlying this down regulation is currently unknown. Polyglutamine aggregation does not easily kill neurons. Before 12 weeks of age, the R6/2 mouse brains comain prominent nuclear and extranuclear aggregates throughout all brain regions. Despite this, the first evidence of neuronal cell death is restricted to the striatum, frontal cortex and cerebellar Purkinje cells [9]. The relatively selective neurodegeneration is likely occurring in neurons that are vulnerable to toxic insults generated by a comparatively widespread neuronal dysfunction. In support of this, evidence of damage caused by reactive oxygen species has been restricted to the striat um in the R6 lines [12, 13]. Several independent studies would support the involvement of an excitotoxic process in the R6 transgenic model. Pharmacological and genetics approaches are being used in order to rescue the phenotype in the R6 lines. Oral administration of creatine has been shown to prolong survival and delay all aspects of the phenotype including the formation of polyglutamine aggregation, striatal shrinkage and motor impairment [14]. Similarly the antibiotic, minocycline, has been shown to prolong survival and delay the onset of the motor impairment [15]. Mouse models of neurodegenerative disease promise to allow the early molecular stages in the disease process to be studied and to provide an accurate progressive mouse model in which to test therapeutic approaches. In the case of Huntington's disease, in the space of only four years this promise is being realised. The neuropathological hallmark of polyglutamine disease has been uncovered, major insights into the early stages of the disease process are in hand and compounds that have shown ah efficacy in the transgenic mice are already moving into the early stages of clinical trials. References 1. Myers RH, Marans KS, MacDonald ME (1998) Huntington's disease, in Genetic instabilities and hereditary neurological diseases, R. D. Wells and S. T. Warren, Editors. Academic Press: San Diego, 301-323 2. Scherzinger E, et al. (1999) Self-assembly of polyglutamine-containing huntingtin fragments into amyloid-like fibrils: implications for Huntington's disease pathology. Proc Natl Acad Sci USA. 96(8): 4604-9 3. DiFiglia M, et al. (1997) Aggregation of huntingtin in neuronal intranuclear inclusions and dystrophic neurites in brain. Science 277(5334): 1990-3 4. Gutekunst CA, et al. (1999) Nuclear and neuropil aggregates in Huntington's disease: relationship to neuropathology. J Neurosci 19(7): 2522-34 5. Mangiarini L, et al. (1996) Exon 1 of the HD gene with an expanded CAG repeat is sufficient to cause a progressive neurological phenotype in transgenic mice. Cell 87(3): 493-506 6. Davies SW, et al. (1997) Formation of neuronal intranuclear inclusions underlies the neurological dysfunction in mice transgenic for the HD mutation. Cel190(3): 537-48 7. Li H, et al. (1999) Ultrastructural Iocalization and progressive formation of neuropil aggregates in Huntington's disease transgenic mice. Hum Mol Genet 8(7): 1227-36 8. Carter R], et al. (1999) Characterization of progressive motor deficits in mice transgenic for the human Huntington's disease mutation. J Neurosci 19(8): 3248-57 9. Turmaine M, et al. (2000) Nonapoptotic neurodegeneration in a transgenic mouse model of Huntington's disease. Proc Natl Acad Sci USA. 97( 14): 8093-97 10. Luthi-Carter R, et al.(2000) Decreased expression ofstriatalsignalling genes in a mouse model of Huntington's disease [In Process Citation]. Hum Mol Genet 9(9): 1259-71 11. Glass M, Dragunow M, Faull RL (2000) The pattern of neurodegeneration in Huntington's disease: a comparative study of cannabinoid,

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12. 13. 14. 15.

dopamine, adenosine and GABA(A) receptor alterations in the human basal ganglia in Huntington's disease. Neuroscience 97(3): 505-519 Tabrizi SI, et al. (2000) Mitochondrial dysfunction and free radical damage in the Huntington R6/2 transgenic mouse. Ann Neurol 47(I ): 80-6 Perez-Sereviano F, et al. Striatal oxidative damage parallels the expression of a neurological phenotype in mice transgenic for the mutation of Huntington's disease. Brain Res. 862:234-7 Ferrante RJ, et al. (2000) Neuroprotective effects of creatine in a transgenic mouse model of Huntington's disease [In Process Citation]. l Neurosci 20(12): 4389-97 Chen M,et al. (2000) Minocycline inhibits caspase- 1 and caspase-3 expression and delays mortality in a transgenic mouse model of Huntingron disease. Nat Med 6(7): 797-801

Molecular Pathology of prion diseases Adriano Aguzzi, Institute of Neuropathology, University Hospital, CH-8091 Zurich, Switzerland The nature of prions: According to all available evidence, the agents causing transmissible spongiform encephalopathies, termed prions, are devoid of informational nucleic acids and consist of ah "infectious" protein (termed PrP s') capable of converting a normal host protein called PrP cinto a likeness of themselves [ 1]. The only organ system in which histopathological damage and its clinical sequelae can be demonstrated a s a consequence of infection with prions is the nervous system [2]. This consideration applies to both the human transmissible spongiform encephalopathies, such as Creutzfeldt-lakob disease, Gerstmann-Striiussler-Scheinker Syndrome, Kuru and fatal familial insomnia, and all known prion encephalopathies of animals. The latter comprise scrapie in sheep, bovine spongiform encephalopathy, and chronic wasting diseases of mule, deer and exotic ungulates. However, there is no doubt that prions, herewith operationally defined as the infectious agents causing transmissible spongiform encephalopathies, can colonize organs other than the central and peripheral nervous system, and can be demonstrated in extracerebral compartments [3]. Genetically engineered mouse mutants to study prion pathogenesis To address the question of CNS pathogenesis in prion diseases [4], we grafted neuroectoderm from mice which overexpress PrP cinto the brain of scrapie-resistant PrP-deficient (Prnp ~176mice, and inoculated it with scrapie prions, lnfected grafts developed scrapie and contained high amounts of PrP Se and infectivity, while neighbouring cells remained unaffected [2]. Therefore, availability of endogenous PrP c to the infectious agent, rather Se than deposition of PrP", correlates with scrapie neurotoxicity in vivo. We then addressed the spread of prions from peripheral sites to the CNS, by transplanting neuroectoderm from mice overexpressing PrP c to the brain of Prnp ~176recipients. Scrapie was not detected in grafts after intraocular (i. o.), intraperitoneal (i. p.), or subcutaneous (s. c.) inoculation [5]. Immunity to PrP developed in several animals soon after grafting, but anti-PrP titers did not influence the course of the disease after i. c. inoculation, and no transport of i. o. infectivity was detected in animals tolerant to PrP. Adoptive transfer of PrP-expressing bone marrow cells restored prion replication in the spleen, but did not reconstitute neuroinvasion via i. p. route [5]. We then went on to show that B-lymphocytes are crucial for neuroinvasion [6]. However the requirement for B-lymphocytes is independent of their expre~ion of PrPC: B-cell deficient mice resist i. p. inoculation of prions, and infectibility is restored upon transfer of PrP-positive or negative B-cells [7]. B-cells support maintenance of follicular dendritic cells by presenting lymphotoxin-trimers to them: we therefore asked whether interference with this pathway by administration of soluble lymphotoxin receptors may impair lymphoid replication of prions. This was indeed the case [8]. Not only lymphocytes, but also plasma components may be important for neuroinvasion: PrP s' binds e. g. plasminogen in a conformation-dependent manner [9]. This ma}, indicate a target for post-exposure prophylaxis [10]. Finally, neuroinvasion is dramatically delayed by chemical sympathectomy, while reconstitution of PrP c expression on sensory neural pathways of Prnp ~176mice does not suffice to restore prion migration from footpad to spinal cord [11,12].

Conclusions of clinical and public health relevance As prions can be detected in lymphoreticular tissues, an understanding of the peripheral pathogenesis is of immediate importance in assessing risks of iatrogenic transmission of human BSE via exposure to blood or tissues from preclinical cases, and possibly from contaminated surgical instruments, or even blood and blood products [ 13]. Additionally, such advances might pare the way for the development of sensitive diagnostic tests and the means to block prion neuroinvasion. Given the current state of knowledge, one might wonder why contamination of the blood supply with prions should be an issue at all. After all, very thorough epidemiological surveys over two decades have not evidenced blood transfusions, or administration of blood products, asa risk factor for prion diseases. The problem is, of course, new variant CID. For one thing, we by far do not know as much about the epidemiology and iatrogenic transmissibility of this new disease as we do for sporadic CID (sCJD). What is most unsettling, the distribution of preclinical disease in Great Britain and possibly in other countries is totally obscure, and the little knowledge that is being gathered is far from reassuring. Moreover, there is all reason to believe that nvClD may be much more "lymphoinvasive" than its sporadic counterpart. In particular, nvCJD prions can be easily detected in lymphatic organs such as tonsils and appendix, a fact that was previously demonstrated to be true for scrapie, but not for sCJD prions. While all available evidence points to follicular dendritic cells as the prion reservoir in lymphatic organs, splenic lymphocytes of experimentally inoculated mice can be infected with prions [14]. Although prion infectivity of circulating lyn~phocytes appear to be at least two logs lower than that detected in splenic lymphocytesl4, the possibility that circulating lymphocytes may be in equilibrium with their splenic siblings call for cautionary measures. The nature of the latter is still matter of controversy and debate: leukodepletion has been advocated, but at present there is no certainty about its efficacy, and even whether the presently available technologies for leukoreduction are necessary and/or sufficient for decreasing the threat to blood supply that derives from nvCJD. In addition, ir has to be taken into account that, even if blood prion infectivity were to be originally contained in lymphocytes in vivo, lysis of cells may lead to contamination of non-particulate fractions and, in the absence of appropriate measures of removal, of stable blood products. Given that many of the virus removal steps involved in the production of stable blood products have some positive effects on prion removal, the latter possibility can be regarded as worst-case scenario. The second consideration applies to secondary prophylaxis. Given the very large amount of infectious BSE material that has entered the human food chain, it is possible that many individuals harbor preclinical nvCJD. It is imperative and urgent to develop strategies that will help control spread of the agent and that will hopefully prevent the clinical outbreak of symptoms in these persons. Possible targets for the interference with neuroinvasion are rate-limiting processes that control prion replication within the infected individual. In light of the knowledge discussed above, treatments that target the neuro-immune interface of prion replication and neuroinvasion [ 10] seem a promising area for research aimed at post-exposure prophylaxis. Acknowledgmeots The work described above was performed by the following postdoctoral and pre-doctoral scientists in the Aguzzi lab: Sebastian Brandner, Christiane R6ckl, Manuela Maissen, Petra Parizek, Axel Behrens, Markus Glatzel, Frank Heppner, Marco Prinz, Cynthia Hawkins, Fabio Montrasio, Michael A. Klein, and Isabelle Arrighi. Our work is supported by grants from the European Union (Bundesamt fª Bildung und Wissenschaft), the Swiss National Research Programs NFP38/NFP38+, the Kanton of Zurich, the Migros and Coop foundations, and the companies Abbott and Baxter. References 1. Aguzzi A, Kaeser PS, Montrasio F (2001) Prions: health scare and biological challenge. Nature Reviews Mol Cell Biol in press 2. Brandner S, Isenmann S, Raeber A, Fischer M, Sailer A, Kobayashi Y, Marino S, Weissmann C, Aguzzi A (1996) Normal host prion protein necessary for scrapie-induced neurotoxicity. Nature 379, 339-43 3. Aguzzi A, Bliittler T, Klein MA, R~iber AJ, Hegyi I, Frigg R, Brandner S, Weissmann C (1997) Tracking prions: the neurografting approach. Cell Mol Life Sci 53, 485-95 4. Aguzzi A,Weissmann C (1997) Prion research: the next frontiers. Nature 389,795-798 5. Bliittler T, Brandner S, Raeber Al, Klein MA, Voigtliinder T, Weissmann C, Aguzzi A (1997) PrP-expressing t issue required for transfer of scrapie infectivity from spleen to brain. Nature 389, 69-73 6. Klein MA, Frigg R, Flechsig E, Raeber Al, Kalinke U, Bluethmann H,

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7. 8. 9. 10. 11. 12. 13. 14.

Bootz F, Suter M, Zinkernagel RM, Aguzzi A (1997) A crucial role for B cells in neuroinvasive scrapie. Nature 390, 687-90 Klein MA, Frigg R, Raeber Al, Flechsig E, Hegyi I, Zinkernagel RM, Weissmann C, Aguzzi A (1998) PrP expression in B lymphocytes is not required for prion neuroinvasion. Nat Med 4, 1429-33 Montrasio F, Frigg R, Glatzel M, Klein MA, Mackay P, Aguzzi A, Weissmann C (2000) Impaired prion replication in spleens of mice lacking functional follicular dendritic cells. Science 288,1257-9 Fischer MB, Roeckl C, Parizek P, Schwarz HP, Aguzzi A (2000) Binding of disease-associated prion protein to plasminogen. Nature 408, 479-483 Aguzzi A, Collinge J (1997) Post-exposure prophylaxis after accidental prion inoculation. Lancet 350, 1519-20 Glatzel M, Aguzzi A (2000) PrP(C) expression in the peripheral nervous system is a determinant of prion neuroinvasion. J Gen Virol 81, 2813-2821 Glatzel M, Flechsig E, Navarro B, Klein MA, Paterna JC, Bueler H,Aguzzi A (2000) Adenoviral and adeno-associated viral transfer of genes to the peripheral nervous system. Proc Natl Acad Sci USA 97, 442-7 Aguzzi A (2000) Prion diseases, blood and the immune system: concerns and reality. Haematologica 85, 3-10 Raeber AJ, Sailer A, Hegyi I, Klein MA, T R, Pischer M, Brandner S, Aguzzi A, Weissmann C (1999) Ectopic expression of prion protein (PrP) in T lymphocytes or hepatocytes of PrP knockout mice is insufficient to sustain prion replication. Proc Natl Acad Sci USA 96, 3987-3992

Tuesday,Apri124, 2001 •ymposium 2: PATHOPHYSlOLOGYAND TREATMENTOF MOVEMENT DISORDERSAND PARKINSONS'S DISEASE Chair: Y. Agid, Paris; E. Melamed, Tel Aviv

Parkinson'sDisease:PathophysiologyOf L-Dopa Induced Dyskinesias Yves Agid - F›233 de Neurologie, Centre d'Investigation Clinique INSERM U 289 - H6pital de la Salp~tribre - ParŸ France Levodopa-induced Dyskinesias (LIDs) constitute a remarkable model of movement disorders as they reproduce all known phenotypes of dyskinesias encountered in neurological practice. Elucidation of their pathophysiology would therefore help to understand the anatomo-biochemical bases of aH kinds of dyskinesias. In addition to myoclonus, Akathisia and off-dystonia, LIDs are usually divided into monophasic (occurring at time of maximal clinical improvement) and biphasic (coinciding with the relief and the reappearance of Parkinsonian symptoms) dyskinesias. LIDs are considered to result both from the severity of dopaminergic denervation in the striatum an irrevocable phenomenon - and sensitisation resulting from long term pulsatile administration of levodopa. Keeping in mind that LIDs reproduce the behavior of a normal infant, it can be hypothesized that LIDs result from lesion-induced release of archaic patterns of activity. Recent improvements in the current functional model of the basal ganglia (parallel processing, direct and indirect pathways, hyperactivity of the subthalamic nudeus and substantia nigra pars reticulata, loss of the selectivity of neuronal activity in the pallidum) and new information on functional abnormalities in diseased cells (internalisation of dopamine receptors, appearance of D3-receptors, neuronal plasticity) may gire new insight into the pathophysiology of LIDs.

Pathophysiologyof Motor Fluctuations Eldad Melamed, Department of Neurology, Rabin Medical Center, Beilinson Campus, Tel Aviv University, Tel Aviv, Israel When levodopa therapy is initiated on Parkinson's disease, the response is robust, smooth and stable and patients do not feel the beneficial effect of every single dose. However, after several years of continued administration, the pattern of responsiveness to levodopa changes and the majority of patients develop motor fluctuations, i. e., periods of clinical relief induced by individual doses of the drug. Patients now experience the onset as well as the termination of effect of each dose and their daily motor performance oscillates between phases of parkinsonian crises of varying severity ("off" periods) or relief ("on"periods) usually associated with dyskinesias. Itis now realized that each motor fluctuation temporally consists of two parts which have different pathogenetic mechanisms and require different therapeutic strategies, i. e., beginning and end-of-dose difficulties."Beginning-of-dose problems include phenomena such as "delayed on" (prolonged durations from dose ingestion (to turning on) and "no-on" (dose failure). These are mainly due to peripheral pharmacokinetic mechanisms and particularly to delayed or lack of absorption of orally-taken levodopa. The predominant cause here is a combination of poor levodopa solubility and delayed gastric emptying that leads to prolonged stagnation of the drug in the akinetic stomach. "End-of-dose" problems are manifested by the "wearing off" phenomenon ("end of dose" akinesia) characterized by shrinkage of durations of"on" periods. This may be due to a combination of many operating mechanisms: a) Disease-associated progressive loss of nigrostriatal dopaminergic nerve-terminals with loss of the capacity in the striatum to synthesize and particularly store dopamine from exogenous levodopa. Levels of dopamine in the basal ganglia become dependent of plasma levels of levodopa generated by oral intake of the drug. b) Postsynaptic dopamine receptor down-regulation or even depopulation in the striatum due to the chronic "bombardment" with exogenous levodopa. There cotdd also be a fluctuating blockade of these receptors by aberrant metabolites produced from levodopa or the generated dopamine that actas "false neurotransmitters", c) Rapid metabolism of levodopa in peripheral tissues and also in brain. For instance, catechol-0-methyltransferase (COMT) converts levodopa to the inert metabolite 3-0-methyldopa and thus rapidly terminates its action. Knowledge of the complex mechanisms responsible for the emergence of the various subtypes of motor fluctuations now enables better management of these disabling problems in many of our patients.

From genes to pathophysiology A. Brice (Paris, F) Several genetic epidemiological studies have suggested the existence of predisposing genetic factors in Parkinson's disease, which can be considered to be a multifactorial disorder. However, at least tire monogenic forms have been recognized, which should help to understand the pathological mechanisms. Studies on the alpha-synuclein and Parkin genes have been very fruitfui. The alpha-synuclein gene has been implicated in a small number of families with autosomal dominant Parkinson's disease with Lewy bodies. Subsequently, alpha-synuclein turned out to be a major component of Lewy bodies and Lewy neurites. The familial mutations increase oligomerisation or polymerisation of alpha-synuclein into fibrillar structures, which are found in Lewy bodies. Animal models over expressing normal and mutated alphasynuclein reproduce some features of Parkinson's disease. A wide variety of Parkin mutations are associated with autosomal recessive Parkinson's disease. They account for half of the early onset familial cases a n d a signi¡ proportion of patients without family history but with early onset. In addition to early onset, Parkin cases are characterized by frequent dystonia at onset, excellent and sustained response to levodopa with frequent levodopa induced dyskinesias, and slow progression of the disease. It was recently shown that Parkin, which is expressed ubiquitously in the central nervous system, functions as an E3 ubiquitin ligase. Therefore, Parkin is expected to ubiquitinate specific substrates targeted for degradation by the proteasome. Interestingly, Parkin patients present severe nigrostriatal dopaminergic neuronal loss without Lewy bodies. This particularity might be related to the function of Parkin for which it is now crucial to identify the substrates. It will also be necessary understand the relevance of these observations to idiopathic Parkinson's disease.

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Pathophysiology of myoclonia. J. Obeso, Pamplona: Symposium 3: PROGRESS IN STROKE Chair: M.-G. Bousser, Paris; J. Bogousslavsky, Lausanne CADASIL:from diseaseto vesselwall physiology A. Joutel ( 1,2 ), F.Andreux ( 1) ,V. Hyenne ( 1), A. Fran~ois ( 1), V. Domenga ( 1), P. Favrole ( 1), C. Lescoat (2), M. C› (2), C. Godfrain (3), F. Chapon (4) & E. Tournier-Lasserve (1,2) Affiliations: (1) Equipe Propre INSERM 99-21, Facult› de M› Lariboisir Paris; (2) Laboratoire de Cytog›233 H6pital Lariboisi~re, Paris ; (3) Neuropathologie, Clinique St Luc, Bruxelles ; (4) Neuropathologie, CHRU Caen CADASIL is an increasingly recognized autosomal dominant cause of stroke and dementia in adulthood. Neuropathological lesions include multiple deep infarcts, severe white matter lesions and diffuse alterations of the small cerebral arteries characterized by a prominent loss of vascular smooth muscle cells. We recen@ established that CADASIL is due to mutations in the Notch3 gene. Highly stereotyped mutations have been identified in CADASIL patients; all mutations, without any exception, lead to an odd number of cysteine residues within the EGF-like repeats of the extracellular domain. Notch3 belongs to the highly conserved Notch/Lin 12 receptors family. Extensive studies performed in Drosophila, and mice have established that Notch receptors are involved in a variety of cell-cell signaling interactions essential for development. Function of Notch3 in human adult as well as the precise mechanisms that lead from Notch3 mutations to the CADASIL phenotype ate yet unknown. During early stages of the development, Notch3 is abundan@ and widely expressed. In normal human adult tissues, Notch3 is very weakly expressed and its expression is essentially restricted to the vasculature and the smooth muscle cells (VSMC), Notch3 being detected both in the cerebral and the extracerebral vessels. Notch3 undergoes, like the other Notch receptors, a proteolytic cleavage in the secretory pathway generating an extracellular (210kDa) a n d a transmembrane (97-kDa) fragment, which are the only species found in human adult tissues. The resultant polypeptides associate as an intramolecular heterodimer expressed on the cell surface. In cultured cells mutated proteins undergo proteolytic processing and subcellular distribution equivalent to the wild-type protein. In tissues from CADASIL patients, we found evidence of a dramatic and selective accumulation of the Notch3 ectodomain (210-kDa) at the membrane of vascular smooth muscle cells, accumulation being detected both in the cerebral and the extracerebral vasculature. In the cerebral vessels Notch3 accumulation appears to be equivalent in arteries, veins and capillaries while in the peripheral vessels veins and capillaries ate either spared or much less affected. Altogether these data indicate that (i) vascular smooth muscle cell is the primary target of Notch3 mutations, (ii) the pathogenic process includes an impaired clearance of the Notch3 receptor and (iii) this process affects the systemic vasculature, however the reason why the devastating consequences are restricted to the central nervous system remains enigmatic. Experiments are currently ongoing to determine the consequences of CADASIL mutations on Notch3 signaling and the mechanisms of the impaired clearance of the Notch3 receptor. Preliminary data suggest that the pathogenic process requires a ligand and/or an additional cofactor. Our findings also point out to the unsuspected role of Notch3 in the biology of smooth muscle cells in mature vessels. VSMC ate mature but not terminally differentiated cells which may exhibit some changes in their differentiated state, including changes in their morphology, matrix production and growth responsiveness.We hypothesized that the Notch3 signaling pathway could control these changes, which have been referred to as phenotypic modulation. Experiments are currently ongoing to investigate this hypothesis using human VSMC grown in primary culture expressing a constitutively activated Notch3 receptor.

Progressin strokePrevention Marie-Germaine Bousser, H6pital Lariboisi~re Paris, France Despite advances in acute stroke treatment, the most effective method to reduce the burden of stroke is prevention which should best combine mass st rategies in the general population and high risk strategies in individuals or groups of individuals. Prevention is based for all the varieties of stroke on the modification of risk factors and, for ischemic strokes, on the use of antithrombotic drugs and, in highly selected cases, on carotid surgery. Riskfactors Hypertension remains the most important risk factor for all varieties of stroke, hemorrhagic as well as ischemic. The value of treating all varieties of hypertension has been fully confirmed in all studies if primary prevention. A major advance has been the HOPE study, which showed that ramipril, an ACE inhibitor reduces the risk of death, myocardial infarction, and stroke in a wide range of high risk patients, whether hypertensive or not. As regards secondary prevention, results of the large PROGRESS study devoted to blood pressure lowering afgter a first stroke should be available in May 2001. Although cholesterol and triglycerides have not been convincingly established as independant risk factors for stroke, it is remarkable that clinical trials using statins and gemfibrozil in patients with coronary artery disease demonstrate a 25 % reduction in the risk of stroke,A specific secondary prevention study in stroke patients is starting. The benefits of smoking cessation, of a regular physical activity and, of moderate alcohol consumption have been confirmed, as well as the dose-relationship existing between homocysteine and stroke risk. Secondary prevention trials are ongoing assessing the efficacy of vitamines B6, B12, and folic acid on stroke risk. Hormone replacement therapy, once thought to decrease the vascular risk, has been shown to be ineffective in the secondary prevention of myocardial infarction and stroke. The question remains open as regards primary prevention. Anti-Thrombotic Drugs The optimal use of antithrombotic drugs in stroke prevention depends on the etiopathogenic subtype of ischemic stroke. In the prevention of atherothrombotic stroke, the efficacy of antiplatelet drugs has long been established for aspirin and ticlopidine and has been confirmed for new drugs such as clopidogrel and for combinations such as the combination of high dose dipyridamole with low dose aspirin. By contrast, all trials devoted to oral GP Ilb/Illa inhibitors have been stopped because of increased bleeding and mortality. The association of aspirin with clopidogrel, which is currently undergoing clinical trials, seems promising. The risk of high dose oral anticoagulants (INR _>3) has been illustrated by the SPlRIT study which was prematurely stopped because of an excess of deaths'and of intracerebral hemorrhage. The results of WARSS are pending; they will show the benefit-risk ratio of moderate anticoagulation (INR 2-3) in atherothrombotic stroke.Another study of moderate oral anticoagulation (INR 2-3) (ESPRIT) vs antiplatelet drugs (aspirin - dipyridamole) is currently undergoing. In cardioembolic stroke, the large beneficial effect of oral anticoagulants (relative risk-reduction around 70 %) has been confirmed as well as the Iow risk-reduction with aspirin (20%). A major recent advance has been the identification of risk factors in patients with atrial fibrillation allowing a risk stratification and an adaptation of the anti-thrombotic strategy (aspirin or oral anticoagulants) to the stroke risk. Studies are starting comparing the direct oral thrombin inhibitors, such as melagatran, to the reference drug warfarin in patients with atrial fibrillation. Carotid Surgery Further analysis of the results of NASCET and ECST have helped to identify in patients with symptomatic carotid stenosis, the risk factors for both spontaneous ipsilateral cerebral infarction and surgical morbidity thus allowing risk stratification and better indications for surgery. As regards asymptomatic carotid stenosis, there is still a lot of debate after the results of ACAS since, in this study, the benefit, though statistically significant, was marginal and was present neither in women and nor the prevention of severe stroke. The first results of carotid angioplasty are promising and this new technique is currently beeing compared with surgery in various randomised trials.

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Public Health A number of studies have been devoted to the cost efficacy of preventive approaches. The interventions which would have the greatest impact on preventing stroke in the population are effective blood pressure lowering, antiplatelet drugs, anticoagulation in patients with an embolic source in the heart and efforts to discourage smoking. Unfortunately, numerous studies have shown that there is a large underuse of these interventions, pointing to a major and worrying"evidence to practice" gap. The narrowing of this gap is a crucial challenge for an effective stroke prevention. References Barnett HJM, Eliasziw M, Meldrum HE (1999) Prevention of ischaemic stroke. BMJ 318:1539-1543 Boysen G, Porsdal V (1999) The value of stroke prophylaxis. Eur. 1 Neurol 6 (suppl 2) $25-$29 Devuyst G, Paciaroni M, Bogousslavsky (1999) Secondary stroke prevention. A european perspective. Cerebrovasc Dis 9 (suppl 3): 29-36 Hankey GJ, Warlow CP (1999) Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet 354:1457-1463 Lees KR, Bath PMW, Ross Naylor AR (2000) Secondary prevention of arterial and venous disease. BMI 320:991-994 Goldstein LB, Adams R, Becker K, et al. (2001) Primary prevention of ischemic stroke. A statement for healthcare professionals from the stroke council of the American Heart Association. Stroke 32:280-299

New Contributions of MRI Techniquesin Stroke: MRI Diffusion-Perfusion in Stroke Rª ron Kummer, Dept. of Neuroradiology, University of Technology, D-01307 Dresden, Germany So far, computed tomography (CT) has been considered to be the first diagnostic step in patients with acute focal central neurologic deficit in many hospitals because of its wide availability, relative insensitiveness to motion, and its capability to differentiate cerebral ischemia from hemorrhage and to detect ischemic brain edema early [1]. In the meanwhile, magnetic resonance imaging (MRI) has become the primary clinical imaging tool for CNS diseases because of certain advantages over CT: better tissue contrast, detection of flow phenomena, no beam hardening artefacts blurring basal brain structures, multiplanar imaging, and angiography. Moreover, very fast imaging with advanced gradient echo techniques or echo planar imaging allows now perfusion imaging and detection of changes in brain water diffusion [2, 3]. Improved diagnostic accuracy in stroke should result in improved patient outcome by allowing selection of the most appropriate therapy [4]. In this regard, MRI has not yet shown that ir is superior to CT. Diffusion-weighted MRI (DWI) can show regions of ischemic injury within minutes [5]. The signal increase caused by disturbed diffusion is widely interpreted as ischemic cellular edema. FoUow-up studies have shown that disturbed diffusion as detected by DWI later than 2 hours afler stroke onset means irreversible damage [3]. The final volume of infarction corresponds with the initial volume with disturbed proton diffusion. Others have shown, however, that the volume of disturbed diffusion can be become smaller either spontaneously or after thrombolytic treatment [6, 7]. MRI can quantify proton diffusion by repeated measurements with varying gradient strength. The apparent diffusion coefficient (ADC) drops when cerebral blood flow (CBF) declines below 40 ml per 100 g and minute [8, 9]. This perfusion threshold is clearly above the thresholds of the ischemic penumbra [10] and may explain the high sensitivity, but limited specificity of DWI for irreversible tissue damage. After one week the ADC of the infarcted tissue will increase first to normal then hypernormal values indicating an increase in proton diffusion due to vasogenic edema and later free water in a tissue necrosis [11]. This change in diffusion over time enables to elegantly differentiate between acute and old ischemic lesions. MRI offers 2 possibilities to image brain tissue perfusion: by tracking a bolus of a paramagnetic contrast agent and by tracking labeled spins [12]. The first method is more robust and already introduced into clinical routine [13, 14]. Perfusion MRI provides different parameter maps presenting the mean transit times of contrast, the times to peak of contrast concentration, cerebral blood volumes, and cerebral blood flow. Quantification has to deal with the arterial input function and other conditions that impair the validity of calculation. Moreover, even accurate quantitative measurements of CBF have not proven useful for reliably predicting tissue viability [15-17]. It was suggested to combine DWl with MR perfusion imaging to assess the brain tissue at risk from ischemia [14, 18]. The area of hypoperfusion

(low CBE prolonged mean transit time) oflen exceeds the area of disturbed diffusion. This "missmatch" indicates tissue with low perfusion but (still) normal diffusion. This tissue volume may decrease over time if the tissue volume with disturbed diffusion increases because of low per fusion [ 19]. AIthough it seems feasible to perform DWI and perfusion MRI in the acute stroke patient [20], it is not proven so far that the area of"mismatch" - however it is defined - really represents tissue of risk that can be successfully treated with a benefit for the patient. Conventional spin-echo and DWI and CT have been compared directly in early stroke [21-26]. In most studies, CT was performed earlier than MRI. These studies did not convincingly show superiority of one modality in detecting early signs of hemispheric ischemia or hemorrhage. Both, CT and MRI become increasingly sensitive for ischemic alterations of brain parenchyma during the first hours after stroke[22, 23, 27-30]. The early clinical experience showed that MRI is superior to CT in detecting brain stem lesions and the underlying vascular pathology like dissection, intramural hematoma, or occlusion of cervical and intracranial arteries [31]. References 1. ron Kummer R, Bozzao L, Manelfe C (1995) Early CT diagnosis of hemispheric brain infarction. 1st ed. Heidelberg: Springer 2. Warach S, Gaa J, Siewert B, Wielopolski P, Edelman R (1995) Acute human stroke studied by whole brain echo planar diffusion-weighted magnetic resonance imaging. Ann Neurol 37:231-241 3. L6vblad K, Laubach H, Baird A, Curtin F, Schlaug G, Edelman R, Warach S (1998) Clinical experience with diffusion-weighted MR in patients with acute stroke. AJNR Am J Neuroradiol 19:1061-1066 4. Powers W, Zivin J (1998) Magnetic resonance imaging in acute stroke. Not ready for prime time. Neurology 50:842-843 5. Moseley M, Cohen Y, Mintorovitch J, Chileuitt L, Shimizu H, Kucharczyk J, Wendland M, Weinstein P (1990) Early detection of regional cerebral ischemia in cats: comparison of diffusion- and T2-weighted MRI and spectroscopy. Magn Reson Med 14:330-346 6. Kidwell C, Alger J, Di Salle F, Starkman S,ViUablanca P, Bentson J, Saver J (1999) Diffusion MRI in patients with transient ischemic attacks. Stroke 30:1174-1180 7. Kidwell C, Saver h Mattielloo J, Starkman S, Vinuela F, Duckwiler G, Gobin Y (2000) Thrombolytic reversal of acute human cerebral ischemic injury shown by diffusion/perfusion magnetic resonance imaging. Ann Neuro147:462-469 8. Perez-Trepichio A, Xue M, Ng T, Majors A, Furlan A, Awad I, Jones S (1995) Sensitivity of magnetic resonance diffusion-weighted imaging and regional relationship between the apparent diffusion coefficient and cerebral blood flow in rat focal cerebral ischemia. Stroke 26:667-675 9. Wang Y, Hu W, Perez-Trepichio A, Ng T, Furlan A, Majors A, Jones S (2000) Brain tissue sodium is a ticking clock telling time after arterial occlusion in rat focal cerebral ischemia. Stroke 31:1386-1392 10. Hossmann KA (1994) Viability thresholds and the penumbra of focal ischemia. Ann Neurol 36:557-565 11. Lutsep H, Albers G, de Crespigny A, Kamat G, Marks M, Moseley M (1997) Clinical utility of diffusion-weighted MRI in the assessment of acute stroke. Ann Neuro141:574-580 12. Calamante F, Thomas D, Pell G, Wiersma I, Turner R (1999) Measuring cerebral blood flow using magnetic resonance imaging techniques. J Cereb Blood Flow Metab 19:701-735 13. Maeda M, Yuh W, Ueda T, Maley h Crosby D, Zhu M, Magnotta V (1999) Severe occlusive carotid artery disease: Hemodynamic assessment by MR perfusion imaging in symptomatic patients. AJNR Am J Neuroradiol 20:43-51 14. Sorensen A, Copen W, Ostergaard L, Buonanno F, Gonzalez R, Rordorf G, Rosen B, Schwamm L, Weisskopf R, Koroshetz W (1999) Hyperacute Stroke: Simultaneous measurement of relative cerebral blood volume, relative cerebral blood flow, and mean tissue transit time. Radiology 210:519-527 15. Furlan M, Marchal G, Viader F, Derlon J, Baron J (1996) Spontaneous neurological recovery after stroke and the fate of the ischemic penumbra. Ann Neuro140:216-226 16. Marchal G, Furlan M, Beaudouin V, Rioux P, Hauttement I, Serrati C, de la Sayette V, Le Doze F, Viader F, Derlon J, Baron J (1996) Early spontaneous hyperperfusion after stroke. A marker of favourable tissue outcome? Brain 119:409-419 17. Firlik A, Rubin G,Yonas H, LR W (1998) Relation between cerebral blood flow and neurologic deficit resolution in acute ischemic stroke. Neurology 51:177-182 18. Tong D, Yenari M,Albers G, O'Brien M, Marks M, Moseley M (1998) Correlation of perfusion- and diffusion-weighted MRI with NIHSS score in acute (< 6.5 hour) ischemic stroke. Neurology 50:864-870 19. lansen O, Schellinger P, Fiebach h Hacke W, Sartor K (1999) Early re-

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20.

21. 22. 23. 24.

25.

26. 27. 28. 29. 30.

31.

canalisation in acute ischaemic stroke saves tissue at risk defined by MRI. Lancet 353:2036-2037 Schellinger P, lansen O, Fiebach J, Heiland S, Steiner T, Schwab S, Pohlers O, Ryssel H, Sartor K, Hacke W (2000) Monitoring intravenous recombinant tissue plasminogen activator thrombolysis for acute ischemic stroke with diffusion and p erfusion MRI. St roke 31:1318-1328 Kertesz A, Black S, Nicholson L, Carr T (1987) The sensitivity and specificity of MRI in stroke. Neurology 37:1580-1585 Bryan N, Levy L, Whitlow W, Killian J, Preziosi T, Rosario J (1991 ) Diagnosis of acute cerebral infarction: Comparison of CT and MR Imaging. AJNR Am J Neuroradiol 12:611-620 Mohr J, Biller J, Hilal S, Yuh W, Tatemichi T, Hedges S, Tali E, Nguyen H, Mun I, Adams Jr H, Grisman K, Marler J (1995) Magnetic resonance versus computed tomographic imaging in acute st roke. Stroke 26:807-812 Barber P, Darby D, Desmond P, Gerraty R,Yang Q, Li T, Jolley D, Donnan G, Tress B, Davis S (1999) Identification of Major Ischemic Change: Diffusion-Weighted Imaging Versus Computed Tomography. Stroke 30:2059-2065 Barber P, Demchuk A, Hill M, Pexman W, Hudon M,TomanekA, Beaupre D, Frayne R, Buchan A (2001) A comparison of CT versus MR imaging in acute stroe using ASPECTS: Will the "new" replace the "old" as the preferred imaging modality.~ Stroke 325 (abstract) Lansberg M, Albers G, Beaulieu C, Marks M (2000) Comparison of diffusion-weighted MRI and CT in acute stroke. Neurology 54:1557-1561 Yuh W, Crain M, Loes D, Greene G, Ryals T, Sato Y ( 1991) MR imaging of cerebral ischemia: Findings in the first 24 hours. AJNR Am J Neuroradiol 12:621-629 Tomura N, Uemura K, Inugami A, Fujita H, Higano S, Shishido F (1998) Early CT finding in cerebral infarction. Radiology 168:463-467 Truwit C, Barkovich A, Gean-Marton A, Hibri N, Norman D (1990) Loss of the insular ribbon: Another early CT sign of acute middle cerebral artery infarction. Radiology 176:801-806 ron Kummer R, Meyding-Lamad› U, Forsting M, Rosin L, Rieke K, Hacke W, Sartor K (1994) Sensitivity and prognostic value of early computed tomography in middle cerebral artery trunk occlusion.AJNR Am J Neuroradiol 15:9-15 Katz B, Quencer R, Kaplan J, Hinks R, Post M (1989) MR imaging of intracranial corotid occlusion. AINR Aro J Neuroradiol 10:345-350

Wednesday,Apri125, 2001 Symposium 4: NEURO-IMAGINGAND FUNCTION Chair: R. Frackowiak, London

Imaging and the management of epilepsy John S Duncan MA DM FRCP. Professor of Neurology - UCL Epilepsy Centre. Medical Director - The National Society for Epilepsy MRI protocols have been developed over the last decade to optimise' their sensitivity and specificity and ability to detect both the causes and consequences of epilepsy. The Neuroimaging Commission of the International League against Epilepsy has produced recommendations on optimal protocols. Ideally, all patients developing epilepsy should have high quality brain MRI scans,with the exception of children with clear-cut epilepsy syndromes that have a good prognosis. MRI scanning is particularly important in patients with partial seizures, in those in whom seizures start in the first year of life or in adulthood, and if there is a fLxed deficit on physical or neuropsychological examination. Further important indications for MRI are difficulty obtaining seizure control with anti-epileptic drugs, a loss of seizure control o r a change in the pattern of seizures. MRI can reliably detect hippocampal sclerosis, which is the most common structural abnormality underlying refractory partial seizures. The use of quantitative MRI, with volumetry, morphometry and T2 relaxometry has defined the spectrum of severity of hippocampal sclerosis that is important in both clinical practice and in research studies. MRI also identifies cavernomas, arterio-venous malformations, indolent tumours, granulomas and

areas of acquired cerebral damage and, increasingly, subtle malformations of cortical development. Identification of the cause of seizures is important as this may lead to specific treatment of the underlying cause and, in addition, may lead to the possibility of surgical treatment. Ir a single abnormality is shown on MRI and is identified by subsequent neurophysiological studies as being the likely cause of the epilepsy the chances of surgical resection stopping the seizures completely may be as good as 70 %. MRI technology and the hardware and software of MRI scanners' are developing rapidly and new techniques and improved scanning hardware are identifying abnormalities in a growing proportion of the 15 % of patients with refractory partial seizures in whom conventional MRI does not reveal an underlying structural abnormality. Functional MRI may localise areas of brain involved in particular cerebral functions. This is important when planning neurosurgical resections that are close to eloquent areas such as primary motor cortex. The lateralization of language function has been shown to be useful and reliable, but the reliable localization of areas that are crucial for language function has not yet been achieved. It is possible to record the EEG during functional MRI examinations and this has led to the localisation of areas of brain involved in generation of interictal epileptiform activity. This is an area of intense research endeavour and. it is possible that this will turn out to be a significant advance in pre-surgical evaluation. MR Spectroscopy allows the measurement of metabolites in the brain such as N-acetyl aspartate, choline, creatine and lactate and may be used to characterise areas of neuronal dysfunction, even in the absence of any evident structural abnormality. Recent developmen~s have enabled the measurement, in life and entirely non-invasively using MRI Spectroscopy, of GABA, glutamine and glutamate. It is anticipated that this method will prove to be useful in the future in characterising neurochemical abnormalities associated with epilepsy and in identifying new treatment targets. Interictal single photon emission computed tomography (SPECT) commonly shows an area of reduced cerebral blood flow in relation to an epileptic focus. Localisation using this method, however, is not reliable. An ictal increase in local cerebral blood flow associated with a seizure may be identified with ictal SPECT scans and comparison of interictal and ictal scans gives increased reliability, which is enhanced by the co-registration of ictal and interictal scans, their subtraction and superimposition on structural MRI. The present places of this technique is in the investigation of patients with refractory seizures in whom MRI is unremarkable, shows dual pathology or diffuse abnormality and can be used to help guide the placement of intracranial electrodes. Positron Emission Tomography (PET) using 18F fluorodeoxyglucose (FDG) was the main stay of pre-surgical evaluation though the 1980s, with the finding of hypometabolism in the region of an epileptic focus. For clinical purposes this has largely been superseded by high quality MRI and the current place of 18F-FDG PET is in the investigation of patients with refractory partial seizures in whom the MRI is unremarkable or unclear. PET studies using ligands specific for the central benzodiazepine receptor may also identify areas of focal neuronal loss, or increased binding. The latter appears to be a specific feature of malformations of cortical development. In as many as :/3 of patients with refractory partial seizures and normal high quality MRI, 11C-flumazenil PET shows focal abnormalities but the proportion of patients in whom there is a single abnormality that presents a promising surgical target is less than that. 11C-flumazenil PET is also revealing abnormalities of neurones in the white matter, that were not previously identifiable in vivo. Other receptors are also being investigated, but the clinical role of these is not yet clear. A current very exciting research area is the use of dynamic PET studies to identify specific neurochemical circuits involved in specific tasks or events with anatomical precision. Using such techniques, for example, it was shown that endogenous opioids were released in the speech area during reading induced seizures in patients with reading epilepsy. Further neurochemical advances will depend on the availability of new PET ligands that will probe different neurochemical systems, such as the NMDA receptor.

Recovery and rehabilitation in stroke Cornelius Weiller, UKE, Hamburg Modern brain charting techniques are perfectly suited to re-test classical hypotheses about the human brain in-vivo. It is the obligation of neurologists to use these findings to improve the care of patients. There are two issues important to an understanding of the mechanisms underlying recovery or rehabilitation: 1. Brain functions may be to a lesser part localised in distinct functionally

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specialised brain regions (e. g.; visual perception of motion in V5 or MT) but are mainly represented in extended, connected, overlapping and highly parallel or reciprocal processing networks, the modular parts of which may substitute each other. Function determined by the interaction. 2. Localisation is not unchangeable, even the adult human brain retains a "plastic" potential. Learning represents one prominent cause for an actively produced reorganisation. Learning can be seen a s a refinement of connection between assemblies within the pre-existing network. In the normal brain, associative learning is reflected in repetition suppression of activation and increased effective connectivity as interaction between brain regions. In a object-location memory experiment, 6 subjects had to learn and recall the associations between real objects and locations during fMRI under 4 conditions, Encoding (ENC), Controll (CO1), Retrieval (RET) and Control2 (CO2) (Bª et al. 1998). Object-location memory implies segregated activation of ventral and dorsal visual pathways for processing of categorical or spatial stimulus features. The areas activated besides V 1 were dorsal extrastriate (DE) visual cortex, posterior parietal cortex (PP) and lateral parietal cortex (LP). Ventrally, ir was the posterior inferotemporal cortex (ITp) and the parahippocampal gyrus (ITa). The hypothesis was that learning of object-location results in repetition suppression, as adaptation of regional neural responses over multiple repetitions and in an increase in effective conncetivity, which means an interaction between these both systems. All subjects showed an asymptotic learning curve. There was indeed a decrease in activation during learning, indicating repetition suppression within the ventral and dorsal visual pathway, here exemplified for dorsal extrastriate cortex. Effective conncetivity was assessed by path analysis using structure equation modelling. As an indication of a change in interstream conncetions there was a significant increase in path coefficient between PP and ITp. Thus these data show in addition to repetition suppression an increase in the functional integration as a mechanism in learning. In other words, during learning under physiological conditions, neural responses decrease over reported exposure to identical stimuli, which reflect a progressive optimisation of neural reponses elicited by the task, so progressively fewer neurons are needed to perform it. Can we expect the same in brain lesioned patients? "Plastic" changes representan uniform reaction pattern of the brain and occur under very different conditions in the intact as well as in the lesioned brain a s a result of learning or adaptation, with or without any concomitant change in behavioural performance. Afler lesions they may be found either a s a compelling consequence of the structural defect (this is probably the case with diaschisis) of due to active intervention (hopefully the correlates of rehabilitation). Plastic changes may occur without any obvious teleological reason, i. e.; definetly without any improvement of function. For exampie, in patients with peripheral facial nerve palsy ("Bell's Palsy" of face musculature) the large lateral extension of the hand representation into the neighbouring fallow face area has no other reason than the competitiveness inherent to the brain. Is there a relation between reorganisation after a central lesion and behavioral recovery? We recently performed two studies in which we related the training-induced improvement of lost function to reorganisational changes in the brain. In the first study, the effect of constraint induced (CI) movement therapy on the brain was examined in chronic stroke patients. This therapy is derived from basic research with monkeys given somatosensory deafferentation and is based on a behavioural theory of"learned nonuse" of the affected limb. Cl therapy reverses this learned non-use by constraining the movement of the healthy upper extremity and by intense training of the paretic arre. It has been shown to be effective in a subset of stroke patients. We charted the effects of this training on the motor cortex by using transcranial magnetic stimulation. After two weeks of CI therapy, motor performance had improved substantially in all patients. This improvement was accompanied by an increase of motor output area size and amplitudes of motor evoked potentials, as well asa shift of the centre of gravity of the motor output maps. This indicates preserved neuronal excitability of the unused motor cortex in the damaged hemisphere, which can be brought into action by rehabilitation. We meanwhile were able to trace the time course of these changes more carefully in another 13 patients. Time points were 2 baselines, post training, 4 weeks and 6 months later. MAL improved during the training and remained well afterwards, the patients were able to transfer the training effects to all day life. The area enlargement over the affected hemisphere, expressed as relative values affected to not affected hemisphere, increased dramatically during the training and then later on became normal, while the recovery of function was preserved. Thus, we have assessed a temporary augmentation of exitability, probably due to focal disinhibition, during learning in the affected cortex in contrast to the repetition suppression in the physiological situation. In our current hypothesis stroke is seen a s a disconnection phenomenon. For recovery the brain has to upregulate,best focally, its excitability to make use of the sparse remaining connections. Once, some function has regained, repetitive used and learning

will increase the effective connectivity of this feasible pathway a n d a s a consequence fewer neurons will be needed for the same effect resulting in a concomitant normalisation of activation. These ideas may forro the rationale for the temporary use of amphetamine, SSRI or coffeine in stroke patients. In a second study aimed to assess the relation between reorganisation and recovery of function, we investigated whether language training induces cortical reorganisation in aphasic stroke. We studied 4 patients with Wernicke's aphasia a n d a left perisylvian lesion. Language comprehension, a function that is often abolished in aphasia but tends to recover quickly, was assessed by an exerpt from a short version of the Token Test in 12 consecutire PET scans. Between the scans, the patients underwent intense comprehension training sessions of 8 minutes each. The training-induced improvement of language comprehension during the scanning correlated with rCBF changes in language-related areas in the right hemisphere only (middle, superior temporal gyrus and supramarginal gyrus, respectively). This study strongly supports the notion of the role of the right hemisphere in recovery from aphasia and substantiates the evidence that reorganisation is actually beneficial. - .In our opinion, there is not one single crucial component of recovery, like the premotor cortex or the ipsilateral motor cortex in hemiparesis. Rather, recovery of function seems to imply the"reconnection" or perhaps better the recoordination of a network of areas, each of which may be specialised in one or more aspect of the lost function but requires the coherent and timely support from others to reach a high level of proficiency.

Consciousand unconsciousaction lerome N. Sanes. Department of Neuroscience, Brown Medical School, Providence, Rhode Island, 02912 USA Motor actions driven by sensory stimuli require transformation of neural signals related to perceptions into those suitable for controlling muscle activity, and brain areas distributed through the cerebral cortex and sub-cortical sites parricipates in these processes. In recent years, progress has been made on delineating how human brain areas participate in premotor processing that likely involves interactions between movement, perception, and attention. Recent data indicate dissociations between visual perception and motor performance, such that visual illusions have little effect on movements, suggesting that motor actions can operate independently of stimulus attributes and relevance. We investigated interactions between perception and movement by manipulating the perceptability and location of visual stimuli preceding a go-cue by modifying the time between stimuli onsets.We found that spatial incompatibilities between the precue and target at short stimulus onset asyncbrony (< 40 msec) generated longer reaction times and more misreaching to "unseen" targets even thougb without perceptual awareness.Tbese data suggest that antecedent visual stimuli, even subliminal ones, can influence motor actions. Stimuli with low perceptability, or subliminal stimuli, can exert effects on motor actions by modifying onset times and spatial accuracy. That perception affects movement suggests that attention may interact with motor processing, perhaps similarly to attentional modulation of sensory processing. Thus, we investigated if visual attention could enhance hand movement representations in cerebral cortex and cerebellum with functional magnetic resonance imaging (MRI).Participants performed movement-alone; visual attention-alone o r a combined movement and visual attention task. Functional MR labeling occurred mostly in regions commonly activated during repetitive finger movements in frontal and parietal Iobes and the cerebellum. Visual attention increased the extent of movement related MR label in nearly all these motor regions, especially in the cerebellum, but not primary motor cartex (M 1). The enhancement of activation by visual attention in several non-primary motor cortical areas and the cerebellum provides further evidence that these brain regions contribute to cognitive motor control. The cbanges in the motor cerebellum, in contrast to a current lack of effect in MI, may indicate a dissociation between cerebral and cerebellar contributions to motor performance. Humans respond to different sensory cues, and these movements often entail transforming cue attributes into spatial motor commands. Cues may not have intrinsic spatial properties thereby requiring spatial encoding before"entering" the motor system. To address where this additional encoding may occur, we investigated if spatial motor processing triggered by verbal stimuli activates regions of the parietal lobe known to participate in sensory to motor spatial transformations. We found increased activation in the posterior parietal lobe during movements cued by either spatial or verbal stimuli; no such activation occurred in the prefrontal cortex. These results suggest that verbal information, likely first coded in the temporal lobe, enters

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the motor system in the parietal lobe, thereby being processed at early stages in the visual-to-motor information stream. In snmmary, we have provided evidence that perception, attention, and verbal processing all interact with motor processing and that these interactions occur at multiple sites in the human CNS.

Cultural effects on normal and dyslexic reading Eraldo Paulesu (1), ]. E D›

(2), E Fazio (1), C. D. Frith (3), Uta Frith (3)

1. University of Milano-Bicocca, Scientific Institute H San Raffaele, ltaly; 2. INSERM U455, Hopital Purpan, Toulouse, France; 3. University College London, London, UK Alphabetic writing systems differ in the consistency of their orthographic rules. For instance, in English the mappings between graphemes, phonemes and whole word sound are essentially ambignons, as illustrated by pairs such as pint - mint, cough - bough, clove - love. By contrast, in Italian the mappings from graphemes to phonemes ate unequivocal. Young Italian readers can achieve 92% accuracy on word reading tests after only 6 months of schooling, while learning to read in English takes much longer. In this talk, I will present behavioural and anatomical evidence for a multi-component reading system where different components have precedence depending on culture-specific demands of orthography. In a series of behavioural studies, Italian students showed faster word and nonword reading than English students. In two PET studies Italians showed greater activation in left superior temporal regions which have been associated with processing phonemes. In contrast, and for non-words in particular, English readers showed greater activations in left posterior inferior temporal gyrus and anterior inferior frontal gyrus, areas which have been associated with word retrieval during both reading and naming tasks. We have also studied the impact of different orthographies onto reading proficiency and cognitive impairment in populations of aduJt well compensated dyslexics from UK, France and Italy. We found that Italian dyslexics are facilitated by their shallow orthography and read faster and more accurately than English and French dyslexics. However, all dyslexics were equally impaired relative to their peers on reading and phonological tasks. PET scans showed the same rednced brain activation in left middle and inferior temporal cortex during explicit and implicit reading in all dyslexics. We conclude that there is a universal neuro-cognitive basis for dyslexia and that differences in reading performance among dyslexics of different countries are due to different orthography. We suggest that a phonological processing deficit is the core problem in dyslexia and has the same biological impact in shallow and deep orthographies. A s a consequence of the orthography effects, in languages with shallow orthography, such as Italian, Spanish, dyslexia has a more hidden existence. By contrast, deep orthographies like that of English and French contribute to make clinically relevant otherwise mild cases of dyslexia.

Computational morphometry: The new in vivo anatomy Richard Frackowiak, Institute of Neurology, UCI,. Queen Square, London, UK Major advances in computing and mathematics have led to new opportunities for the study of the structure, function and structure-function relationships non-invasively in the human brain. X-ray computed tomography (CT) was the first non-invasive imaging technique that allowed for direct visualization of the brain parenchyma. It revolutionized the evaluation of patients with neurological and neurosurgical disorders because it could image bone and provided the first opportunity to see the brain directly. It has a small dynamic contrast range so that differentiation of grey and white matter is difficult. However, it is very sensitive for identifying cerebral haemorrhage and also lesions associated with an alteration in the blood-brain barrier, by virtue of leakage of iodinated contrast material into them. Magnetic resonance imaging (MRI) is now the structural imaging modality of choice in imaging neuroscience. Its superior spatial resolution and contrast range,particularly useful in differentiating grey and white matter, ate but two features of MRI that make it superior to CT for structural imaging. The analysis of structural brain images can nowadays be carried out automatically. The procedure uses a standard method from functional brain imaging known as statistical parametric mapping (SPM). There is a first preprocessing stage of anatomical realignment and then normalization into a

standard brain shape in a standard space. This is oflen carried out with a mixture of affine transformations and non-linear warps. Smoothing to improve contrast to noise follows this step. Then images can be averaged and compared using standard statistics within the general linear model that is used to partition variance due to experimental factors, nuisance factors and error. Inferences are drawn from the comparison images using thresholds determined with the theory of Random Gaussian Fields. MRI TI weighted images optimised to give maximal contrast between cranial tissues can be automatically segmented into grey and white matter volumes as well as into a CSF partition. These tissue-specific images can then be compared to normal templates. Using this method ir is possible to determine subtle focal or widely distributed changes in local and global anatomy. There area number of levels at which anatomical investigation can be conducted. The most developed technique is called voxel-based morphometry (VBM) which is optimised to show focal change. Deformation based morphometry (DBM) shows up differences in global shape between brains without giving information on local differences. Tensor based morphometry is a hybrid of these techniques that identifies both positional and magnitude changes locally and globally. At presentit is very difficult to implement because itis computationally very expensive, but this method is the way of the future. The resultant ability to perform clinical-functional-anatomical correlatire studies in life with complete objectivity and unparalleled sensitivity is providing powerful new opportunities for the study of brain pathology and plasticity. Examples from grey and white matter disease will be demonstrated in the lecture as will the use of these techniques to demonstrate anatomical correlates of genetic abnormalities. One of the most exciting and dramatic observations to come from human brain mapping with a wide range of strnctural and functional techniques has been the dynamic plasticity of function in both normal brains and the brains of patients with neuroIogical and neuropsychiatric disorders. Recent activation studies have provided interesting information about the brain's capacity to reorganise after injury and in association with practice and learning. Though presenfly in the realm of basic physiology, the study ofbrain plasticity and its modulation by drugs and other therapies indicates a novel approach to the rehabilitation of brain damaged adults. Brain maps must therefore be viewed as dynamic, changing with development, disease progression, normal learning and in the recovery of function after acute injury. The dynamic plasticity of functional brain maps provides an exciting opportunity to study these processes. For example, justas structural and functional studies must be normalized for spatial variability in the population, disease-based structural and functional maps must be normalized in time to account for dynamic changes that occur with disease progression. Thus, a comparison of patients with Alzheimer's disease of other neurodegenerative disease should be stratified by time of onset, or other variables that take into account the pattern of changing structure (atrophy) as the disease progresses. The same is true after an acute brain injury, such as trauma or cerebral infarction and for plastic changes associated with recovery and reorganization afler irreversible damage. A study of occupation associated change in the conformation and relative size of the human hippocampi in taxi drivers is a case in point. The degree of hippocampal structural ehange is correlated with the length of time taxi-drivers spend in their profession! References Ashburner ], Hutton C, Frackowiak RS], ]ohnsrude I, Price C, Friston K (1998) Identifying global anatomical differences: deformation-based morphometry. Hum Brain Mapp 6,348-57 Ashburner ], Friston K] (2000) Voxel-based morphometry - the methods. Neuroimage 11,805-21 Maguire EA, Gadian DG, ]ohnsrude IS, Good CD, Ashburner ], Frackowiak RS], Frith CD (2000) Navigation-related structural change in the hippocampi of taxi drivers. Proc Natl Acad Sci USA 97, 4398-4403

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Symposium 5: MANAGEMENTOF IMMUNOLOGICALDISORDERSOF THE NERVOUSSYSTEM Chair: D. Miller, London; R. Hohlfeld, Munich

Management of MyastheniaGravisand of other NeuromuscularJunction Disorders lohn Newsom-Davis, Department of Clinical Neurology, University of Oxford Three disorders will be discussed: Myasthenia gravis (MG), the LambertEaton myasthenic syndrome (LEMS) and Neuromyotonia (NMT). Management requires an understanding of their pathogenesis. Each of them can occuras a paraneoplastic disorder oras a spontaneous condition. Each of them is antibody-mediated, ion channels concerned with neuromuscular transmission being targeted either directly or indirectly. The targets are vulnerable because they lack the protection of the blood-nerve barrier and have extracellular domains accessible to circulating antibodies. Myasthenia gravis MG is n o t a single disorder. In 85 % of patients, anti-acetylcholine receptor (AChR) antibodies lead to AChR Ioss; 10-12% of them have a thymoma, early-onset cases (< 45 years) usually have thymic hyperplasia, and late-onset cases have thymic involution. Our recent studies indicate that the effectot mechanisms in most of the remainder who are seronegative for antiAChR are likely to be IgG antibodies to MuSK [ 1]. MuSK is a muscle specific tyrosine kinase that is responsible for orchestrating AChR aggregation, particularly during development. Investigations should include assaying for anti-AChR antibodies, electromyographic confirmation of disordered neuromuscular transmission, and thymus imaging. Ir a thymoma is detected, surgery is usually indicated because of the risk of local infiltration, but its removal should not be expected to improve myasthenic weakness. Most patients will obtain symptomatic benefit from anticholinesterase medication (e. g. pyridostigmine 30-60 mg four or five times daily). In earlyonset anti-AChR antibody positive patients whose generalised weakness is still not adequately controlled but who are fit for surgery, thymectomy is normally recommended, although an evidence-based review has stressed the lack of randomised studies demonstrating its benefits [2]. Thymectomy is not recommended either for those seronegative for ant-AChR antibodies or for those with restricted ocular myasthenia. Immunosuppressive drug therapy should be considered for patients who are unfit for thymectomy, or who have failed to respond to it, or for whom thymectomy is not indicated. Many patients will respond to prednisolone, and this treatment is particularly suitable for ocular MG. But in generalised MG a recent randomised controlled trial showed that prednisolone plus azathioprine (2.5 mg/kg) was more effective and better tolerated than prednisolone alone [3]. When remission has been obtained at full dosage, prednisolone should be tapered to the minimum necessary to maintain control. Ir is not usually possible fully to withdraw this medication without a return of symptoms. Cyclosporin, methotrexate and mycophenolate mofetil are alternative immunosuppressive agents in those intolerant of azathioprine. Only the former has been subjected to a randomised trial. Plasma exchange (plasmapheresis) or IVlg infusion can be used in patients with severe generalised weakness to prepare them for thymectomy or in the postoperative period, to gain short term control of symptoms in myasthenic crisis, a n d a s repeated treatment in those with chronic severe disease if also combined with immunosuppressive medication. A comparison of plasma exchange with IVlg infusion showed that they were of equal effectiveness over the first 15 days [4] although some patients who fail to respond to IVlg can benefit from subsequent plasma exchange. Lambert-Eaton myasthenic syndrome LEMS is paraneoplastic (small cell lung cancer, occasionally lymphoma) in about 60 % of patients. Serum anti-P/Q-type voltage-gated calcium channel (VGCC) antibodies are detectable in over 90 % of both idiopathic and paraneoplastic LEMS. These antibodies down-regulate VGCCs at motor nerve terminals on which acetylcholine release depends [5].

lnvestigations should include electromyography, assay for anti-VGCC antibodies and CT chest scan. Most patients are helped symptomatically by 3,4-diaminopyridine (10-20 mg four times daily) which increases transmitter release 16]. Specific tumour therapy in those with small cell lung cancer often results in improvement or recovery in the neurological disorder [71. Prednisolone may also be beneficial in those still symptomatic. In the non-cancer group, many patients will respond to prednisolone alone or combined either with azathioprine or cyclosporin. A randomised controlled crossover study of IVlg versus placebo infusion in non-cancer LEMS showed that the active preparation induced a significant improvement in strength peaking at 2-4 weeks, and was associated with a significant decline in mean anti-VGCC antibody titre [8]. Improvement would also be expected in paraneoplastic LEMS. Both groups can respond to plasma exchange. Neuromyotonia NMT is paraneoplastic in 10-15 % of patients, the commonest tumour being a thymoma, but occasionally lung tumour is associated [9]. Ir may occur with MG. The disorder is due to hyperexcitability of peripheral nerves, particularly motor nerves. Serum antibodies to voltage-gated potassium channels can be detected by radioimmunoassay in about 50 % of patients [ 10]. They lead to nerve hyperexcitability by down-regulating VGKCs and thus interfering with membrane repolarisation [ 11 ]. Investigations should include electromyography (myokymic or neuromyotonic discharges), CT chest scan and serological tests. Many patients will be helped symptomatically by medications that down-regulate voltage-gated sodium channels (phenytoin, carbamazepine). In resistant cases immunosuppressive therapy (prednisolone alone or with azathioprine) should be tried. Some patients obtain short-term benefit from plasma exchange or IVIg infusion. References 1. Hoch W, McConville 1, Helms S, Newsom-Davis J, Melms A, Vincent A (2001) Autoantibodies to the receptor tyrosine kinase MuSK in patients with myasthenia gravis without acetylcholine receptor antibodies. Nat Med (in press) 2. Gronseth GS, Barohn RI (2000) Practice parameter: thymectomy for autoimmune myasthenia gravis (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 55( 1):7-15 3. Palace 1, Newsom-Davis I, Lecky B (1998) A randomized double-blind trial of prednisolone alone or with azathioprine in myasthenia gravis. Myasthenia Gravis Study Group. Neurology 50(6): 1778-1783 4. Gajdos P, Chevret S, Clair B, Tranchant C, Chastang C (1997) Clinical trial of plasma exchange and high-dose intravenous immunoglobulin in myasthenia gravis. Myasthenia Gravis Clinical Study Group. Ann Neurol 41 (6):789-796 5. Newsom-Davis l, Lang B (1999) The Lambert-Eaton Myasthenic Syndrome. In: Engel AG (ed) Myasthenia Gravis and Myasthenic Disorders. New York;Oxford: Oxford University Press 205-228 6. McEvoy KM (1994) Diagnosis and treatment of Lambert-Eaton myasthenic syndrome. Neurol Clin 12(2):387-399 7. Chalk CH, Murray NM,Newsom-Davis l,O'Neill IH, Spiro SG (1990) Response of the Lambert-Eaton myasthenic syndrome to treatment of associated small-cell lung carcinoma. Neurology 40(10): 1552 - 1556 8. Bain PG, Motomura M, Newsom-Davis 1, Misbah SA, Chapel HM, Lee ML, et al. (1996) Effects of intravenous immunoglobulin on muscle weakness and calcium- channel autoantibodies in the Lambert-Eaton myasthenic syndrome. Neurology 47(3):678-683 9. Newsom-Davis l, Mills KR (1993) Immunological associations of acquired neuromyotonia (Isaacs' syndrome). Report of tire cases and literature review. Brain 116 (Pt 2):453-469 10. Hart IK,Waters C,Vincent A, Newland C, Beeson D, Pongs O, et al. (1997) Autoantibodies detected to expressed K+ channels are implicated in neuromyotonia. Ann Neuro141(2):238-246 11. Newsom-Davis J (1997) Autoimmune neuromyotonia (Isaacs' syndrome): an antibody-mediated potassium channelopathy. Ann N Y Acad Sci 835:111-119

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Inflammatory myopathies R. Hohlfeld, Institute for Clinical Neuroimmunology and Department of Neurology, Klinikum Grosshadern, University of Munich, Marchininistr. 15, D-81366 Munich, Germany The group of"idiopathic" inflammatoy myopathies comprises polymyositis (PM), dermatomyositis (DM), and inclusion body myositis (IBM). For DM and PM, immunosuppression is the main therapeutic principle. In contrast, IBM is essentially resistant to therapy. Regular control of muscle strength and serum CK is essential to assess the effect of treatment. For PM and DM, corticosteroids remain the mainstay of treatment, but often are insufficient to induce complete clinical remission. Azathioprine and methotrexate are considered second-line treatments, but most adult patients with DM or PM require co-treatment with one of these agents in addition to corticosteroids. Aggressive cytotoxic agents like cyclophosphamide may be needed in patients with severe extramuscular manifestions (especially interstitial lung disease) and patients refractory to other treatments. The evidence for efficacy of ivlg is strongest in DM. Whether ivlg is helpful in at least some cases of PM or IBM remains controversial.A few IBM patients showed clinical improvement. However, these effects were minor and difficult to capture with statistical methods.'r162 such a mild improvement in a small number of IBM patients justifies a 2-3 month trial with IVIg is a matter of clinical judgement in individual cases. Although beneficial effects of plasmapheresis in myositis were reported in case reports and open studies, a randomized, placebo-controlled trial failed to demonstrate a significant effect of plasmapheresis or leukapheresis over placebo. For DM and PM, treatment is usually required for years. During longterm treatment with corticosteroids muscle weakness can reoccur a s a sign of steroid myopathy, which may be exacerbated by immobilisation and concurring systemic disease. Steroid myopathy can be difficult to differentiate from a relapse of myositis. In some cases, rebiopsy may be required to distinguish between the conditions. /

New treatments in multiple sclerosis Michel Clanet, CHU Toulouse Purpan, France The therapeutical efficacy of beta interferons has confirmed that immune deviation strategies are relevant in altering progression of MS. However this therapeutical effect is only partial and new target of therapy must be identified. The mechanisms of symptoms and disability in MS are complex: inflammation, demyelination, oligodendrocyte and axonal loss are the main mechanisms. Many types of interventions might be useful: relapse prevention via immune modulation, alteration of progression of disability, neuroprotection and CNS repair and restoration. Strategies for disease modification target the immune system by different ways: modulation of the immunological synapse, modification of the costimulation pathways, modulation of the immune mediators network (cytokines and chemokines) or blocking adhesion molecules. Modulation of the immunological synapse can induce an antigen specific tolerance by different strategies. Numerous variants of vaccination have been proposed: vaccination with whole myelin specific T cells,with T cell receptor peptides, DNA encoding autoantigens or T cell receptor sequences. The binding site of the major histocompatibility complex molecules can be blocked by anti MHC monoclonal antibodies, but it is also possible to administrate the class II MHC soluble o r a soluble complex HLA DR2/peptide derived from the myelin basic protein (MBP) to induce tolerance. Altered peptide ligands have become interesting candidates for antigen selective immunotherapy because they induce anergy in the T cells. Oral tolerance induced by the oral administration of the antigen can induce clonal anergy but a recent phase III study of administration of bovine MBP in MS patients failed to show clinical benefit. Systemic administration of soluble antigens is an efficient way to prevent EAE in animals in an antigen specific manner. Modification of the costimulation pathways: T cells require second signals to be activated after engagement of the trimolecular complex (TCR/ HLA/peptide). It is possible to manipulate the two important pathways for activation: the CD28/CTLA4-B7-1/B7-2 system and the CD40/CD40 ligand. Therapeutical trials aimed to block these stimulatory pathways are in progress in different autoimmune diseases. Modulation of the immune mediators network involves the signalling molecules of the immune cells, cytokines and chemokines. The goals consists in enhancing the antiinflammatory responses and inhibiting the proinflammatory network. This is the basic explanation of the therapeutical effect of beta interferons. Our knowledge of the actual range of clinical impact of these cytokines is increasing with new data coming from the last published

trials. Other cytokines like TGF beta, IL 10, inhibition of IL1, TNF alpha are under investigations. Some strategies aimed to modulate the chemokines, which play an important role in cellular inflammation, have been successful in prevention of EAE and should be relevant in the treatment of MS. Blocking of adhesion molecules: adhesion molecules are cell surface proteins that are involved in leukocyte circulation, homing, and transendothelial migration. Blocking the interaction of adhesion molecules can reduce the recruitment of effector cells and contain the disease process. Some preliminary results obtained by a monoclonal antibody targeting VLA 4 antigen are promising. Inhibitors of metalloproteinases, enzymes involved in the BBB disruption and tissue breakdown, have been successfully used in EAE prevention. Neuroprotective strategies would be able to protect, foster repair and promote the regeneration of axons and oligodendrocytes which are destroyed by the MS pathological process. Different neuroprotective agent are possible candidates such as neurotrophic factors, neuropoietic cytokines, gliotrophic factors, glutamate antagonists, neuroimmunophilins, NO inhibitors... These factors might be delivered as systemically or in the CNS with pumps or with transplanted genetically modified cells. The use of transplantation has emerged a s a viable technique for repair the myelin or the nervous system. These approaches however raise several problems: which transplanting cells must be used, adults or progenitor oligodendrocytes; how to enhance the transplanted cells migration and differentiation; which lesion should be transplanted with such a multifocal disease; how to differentiate the qualitative aspects of elementary lesions by MRI before the transplantation. These questions must be addressed before the initiation of any transplantation in MS patients. Finally it must be emphasized that these different innovative strategies, directly transposed from the experimental models, must be validated through controlled trials performed with a rigorous methodology. Performing clinical trials in MS is becoming more complex because, as the field has advanced, new issues have arisen: heterogeneity of the disease, development of new clinical outcomes and surrogate markers, new designs for replacing placebo controlled trials, combination therapies, use of data registries. These are the main challenging aspects of the future therapeutical research in the next 10 years. An updated bibliography can be found in the chapter: "Future strategies for MS therapies" in a recent book "Multiple Sclerosis: Current status and strategies for the future" edited by the Institute of Medicine and available free on line on the following web site: http://books.nap.edu/ books/0309072859/html.

Paraneoplasticneurologicalsyndromes Francesc Graus, M.D., Service of Neurology, Hospital Clinic. Barcelona, S~?ain Paraneoplastic neurological syndromes (PNS) are a group of disorders of unknown etiology that occur exclusively, or with increased frequency, in the setting of cancer. PNS ma), involve any structure of the central and peripheral nervous system (table 1). PNS represent less than 1% of the neurological complications of cancer but they are important in clinical practice because are associated with specific types of tumors and usually antedate the diagnosis of the cancer that usually is in a localized stage where the chances to cure the tumor are highest [ 1]. Diagnostic approach to patients with suspected PNS The clinical evaluation of patients with suspected PNS is difficult because similar syndromes may occur in absence of cancer and the tumor is not evident at the onset of the neurological disorder in the majority of patients. The diagnosis of some neurological syndromes, sensorimotor neuropathy, myelopathy, neuromyotonia or dermatomyositis, is n o t a n indication for an aggressive search of an underlying neoplasm unless there are clues in clinical or routine laboratory examinations. However, other neurological syndromes must suggest a paraneoplastic etiology as one of the leading diagnosis (table 2). In these cases, several steps must be followed to reach a rapid diagnosis and treatment: 1. When you find clues of PSN, work fast. Until otherwise proven, cancer cells grow during weekends and in many PNS there is a subacute loss of neurons. When symptoms appear, a significant number of neurons probably are already dead and the best hope of the

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treatment is to stabilize the PNS rather than to improve it. Most of PNS have in common the subacute onset, severe neurological deterioration, and, in those involving the CNS, frequent evidence of mild CSF pleocytosis or IgG oligoclonal bands [2]. Therefore, these clues should alert the possibility of PNS when the neurologist is evaluating one of the neurological syndromes described in table 2. A common PNS is paraneoplastic sensory neuropathy. Around 40% of patients present with pure sensory symptoms and the diagnosis is more straightforward. However, patients may also show clear but less relevant symptoms or motor weakness or dysautonomia and the EMG may suggest a sensorimotor neuropathy. In this situation the neurologist ma), consider the patient has a'common' sens0rimotor neuropathy due to damage of the peripheral nerve and consequently dismiss the possibility of a paraneoplastic etiology. The cause of the motor weakness in these patients is unclear and probably not uniform. There are autopsy studies that demonstrate a loss of motorneurons in the anterior horn of the spinal cord [3,4] or involvement of peripheral nerves with inflammatory infiltrates and demyelination [5-7]. The important clue, is that although there is clinical or EMG evidence of motor involvement, the sensory symptoms are more relevant and follow the pattern of pure sensory paraneoplastic neuropathy. Early diagnosis of the underlying tumor is the best chance to cure the neoplasm. In addition, effective treatment of the neoplasm contributes to improve or stabilize the PNS.The positive effect of tumor treatment has been observed in two PNS. Paraneoplastic opsoclonus have a more severe clinical course than idiopathic opsoclonus and usually does not respond to treatment with IVIG or corticosteroids. In a recent study, paraneoplastic opsoclonus progressed to encephalopathy that was the cause of death in five patients whose SCLC was not treated. By contrast, the eight patients whose tumor was treated showed a complete or partial neurological recovery [8]. In 51 patients with paraneoplastic encephalomyelitis (PEM), small cell lung carcinoma (SCLC), and anti-Hu antibodies, PEM improvement (3 patients) or stabilization (33) was observed in 36 patients. Improvement/stabilization of PEM was associated with response of the tumor to antineoplastic treatment. A complete tumor response was achieved in 64% of patients whose PEM stabilized or improved and 20 % of those who h a d a neurological deterioration [9]. Early tumor diagnosis requires a high index of suspicion by the radiologist that does the radiological examination [ 10]. Recently, positron emission tomography showed a better sensitivity that thorax CT to demonstrated the underlying neoplasm [ 11 ]. 2. Make a rational use of antineuronal antibodies to prove the diagnosis. The most helpful test that suggests the paraneoplastic etiology of the syndrome is the detection of well defined antineuronal antibodies (table 3). Most antineuronal antibodies are tighfly associated with particular PNS and tumor types. However, the predictive value depends on the antineuronal antibody and the PNS. Patients with Lambert-Eaton myasthenic syndrome (LEMS) almost always harbor anti-voltage-gated calcium channel (VGCC) antibodies but these antibodies do not identify those LEMS patients with an underlying cancer (around 60 %). In a study of patients with paraneoplastic sensory neuropathy, the specificity of anti-Hu antibodies was 99 % and the sensitivity 82 %. Nine (18 %) patients were anti-Hu negative and their sera did not harbor other specific antineuronal antibodies, SCLC was the leading neoplasm in the anti-Hu positive (79%) and negative (44%) groups [15]. Anti-amphiphysin [16] and anti-CV2 [17] antibodies may be found in antiHu-negative patients with paraneoplastic sensory neuropathy but their sensitivity probably is lower. Around 50 % of patients who present with paraneoplastic cerebellar degeneration (PCD) associated with SCLC have anti-Hu antibodies that predict the development of neurological dysfunction outside the cerebellum [18]. Up to 36% of patients with PCD, SCLC and no anti-Hu antibodies harbor anti-VGCC antibodies. The majority of these patients will have a coincident LEMS but a few present anti-VGCC antibodies without clinical or EMG evidence of LEMS. To look for anti-VGCC antibodies is indicated in patients with subacute cerebellar disease even in absence of LEMS particularly if they are at risk for SCLC (smokers, age > 50years). Anti-Yo antibodies have an almost 100% sensitivity and specificity for PCD associated with breast or ovarian cancer [19]. Only a few cases with anti-Yo antibodies have PNS other than PCD or different cancer types that breast or ovary (table 4). Similarly, the absence of anti-Yo antibodies in PCD patients with breast or ovarian cancer is exceptional [28]. PCD may antedate the diagnosis of Hodgkin's disease and in this setting anti-Tr antibodies are very specific [29]. We have identified anti-Tr antibodies in the serum or CSF of 20 patients (unpublished).All had a cerebellar syndrome and Hodgkin's disease was diagnosed (14 patients) of was in remission in 18 patients. Hammack et al. [30] found positive anti-Purkinje cell antibodies (probably anti-Tr) in only 28% of patients with PCD and Hodgkin's disease but the technique to detect anti-Tr antibodies was subop-

timal so the true sensitivity of anti-Tr antibodies remains uncertain. Other antineuronal antibodies have been described in a few patients with PCD and their predictive value is unknown (tables 3, 5). Limbic encephalitis is mainly associated with SCLC. In this setting, around 50 % of patients have anti-Hu antibodies that similar to PCD predict the involvement of other areas of the nervous system [41]. The second most frequent tumor is testicular carcinoma and the patients present antiMa2(also called anti-Ta) antibodies [42]. Unlike patients with limbic encephalitis and SCLC, patients with anti-Ma2 antibodies have symptoms suggestive of diencephalic and upper brainstem involvement. MRI may show contrast enhancing lesions that may mimic brain metastasis and immunosuppressors are usually effective in improving the neurological dysfunction (]. Dalmau personal communication). Less frequent tumors associated with limbic encephalitis are thymoma, that ma), be associated with anti-CV2 antibodies, and Hodgkin's disease. In adults, the opsoclonus-myoclonus syndrome is associated with SCLC and breast carcinoma [43]. Patients with paraneoplastic opsoclonus are older than those with idiopathic opsoclonus and have a higher frequency of associated encephalopathy that may lead to coma and death. Serum of idiopathic and paraneoplastic OMS patients does not show antineuronal antibodies or VGCC antibodies. A few patients with opsoclonus and SCLC may have anti-CV2, anti-Hu or anti-amphiphysin antibodies. Anti-Ri antibodies were initially described in patient with breast [32]. However, there are patients with opsoclonus and breast cancer that lack anti-Ri antibodies. Conversely, anti-Ri antibodies have been described in patients with breast or SCLC with different neurological syndromes, usually a subacute brainstem disorder without opsoclonus (table 5). 3.When the tumor is found, make sure it is the right tumor. Antineuronal antibodies are good marl~ers of a particular PNS but also of a given type of cancer. Sometimes, the tumor discovered is not the one usually associated with the PNS or the antineuronal antibody. In this situation, the tumor may be the responsible for the PNS or the patient may harbor another tumor that is the real responsible for the PNS. A way to solve this dilemma is to find ifthe tumor expresses the antigen recognized by the antineuronal antibody. Patients with PNS and anti-Hu antibodies usually have SCLC. We found positive Hu immunoreactivity in the extrathoracic tumors of six out of seven patients with PNS and anti-Hu antibodies in whom'autopsy or long foUow-up ruled out a coexisting SCLC. Therefore, a positive Hu immunoreactivity strongly supports that the tumor found is the responsible for PEM and further studies to discover a SCLC would not be necessary in these patients. We observed that the Hu expression may be restricted to a few cells so the possibility of a false negative result may be expected if the analysis is done in srnall biopsies as is the case of prostate cancer. Treatment of the paraneoplastic neurological syndromes The clinical course of PNS is not always uniform. Spontaneous improvement is reported in a few patients with PEM and SCLC, opsoclonus-myoclonus syndrome associated with neuroblastoma, PCD in Hodgkin's disease, acute or chronic sensorimotor neuropathies, and subacute motor neuronopathies. Furthermore, some patients with sensory neuropathy and anti-Hu antibodies may present with a slowly indolent clinical course over years in absence of any treatment [44]. Several immunosuppressor therapies including corticosteroids, plasmapheresis and intravenous high dose immunoglobulins have been used in the treatment of PNS [45]. These therapies are useful in the opsoclonus-myoclonus syndrome associated to neuroblastoma, LEMS, multineuritis with vasculitis, dermatomyositis and in a few patients with limbic encephalitis particularly those with anti-Ma2 antibodies. In most of these disorders, the damage to the nervous system is functional more than structural and the target neurons of the autoimmune attack may regenerate, so a clinical improvement may be expected after treatment. In PNS with neuronal degeneration such as PEM/SSN or PCD, immunosuppressor therapies have been not succesful [46]. However, we favor a trial of immunosuppressor or immunomodulating drugs based on the evidence these PNS probably are immune mediated and occasional case reports that improved with intravenous immunoglobulins or other immunotherapies. Although theoretically, immunosuppression could exacerbate tumor growth, we did not find that these treatments were an adverse prognostic factor for survival [9]. References 1. Dalmau 1, Graus F (1997) Paraneoplastic syndromes of the nervous system. In Black P, Loeffler ]S. eds. Cancer of the nervous system. BlackweU Science 674-700

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2. Posner JB (1989) Paraneoplastic syndromes. Curr Neurol 9:245-278 3. Henson RA, Hoffman HL, Urich H (1965) Encephalomyelitis with carcinoma. Brain 88:449-64 4. Graus F,Elkon KB,Lloberes P, et al. (1987) Neuronal aninuclear antibody (anti-Hu) in paraneoplastic encephalomyelitis simulating acute polyneuritis. Acta Neurol Scand 75:249-52 5. Antoine JC, Mosnier JF, Honnorat J, et al. (1998) Paraneoplastic demyelinating neuropathy, subacute sensory neuropathy, and anti-Hu antibodies: clinicopathological study of an autopsy case. Muscle Nerve 21: 850-7 6. Eggers Ch, Hagel Ch, Pfeiffer G (1998) Anti-Hu-associated paraneoplastic sensory neuropathy with peripheral nerve demyelination and microvasculitis. J Neurol Sci 155:178-81 7. Younger DS, Dalmau J, Inghirami G, Sherman WH, Hays AP (1994) antiHu-associated peripheral nerve and muscle microvasculitis, Neurology 44:181-3 8. Bataller L, Graus F, Saiz A, Vilchez JJ, for the Spanish Opsoclonus-Myoclonus Study Group. Clinical outcome in adult onset idiopathic or paraneoplastic opsoclonus-myoclonus. Brain (in press) 9. Keime-Guibert F, Graus F, Br6et P, et al. (1999) Clinical Outcome of patients with anti-Hu-associated encephalomyelitis after treatment of the tumor. Neurology 53:1719-1723 10. Chartrand-Lefebvre C, Howarth N, Grenier P, Keime F, Orcel B, Beigelman C (1998) Association of small cell lung cancer and anti-Hu paraneoplastic syndrome: radiographic and CT finddings. AJR 170:1513-7 11. Antoine JC, CinottiL, Tilikete C, et al.(2000) [ISF] fluorodeoxyglucose positron emission tomography in the diagnosis of cancer in patients with paraneoplastic neurological syndrome and anti-Hu antibodies. Ann Neuro148:105-8 12. Sillevis Smitt P, Kinoshita A, de Leeuw B, et al. (2000) Paraneoplastic cerebellar ataxia due to autoantibodies against a glutamate receptor. N Engl J Med 342:21-27 13. Silverman IE (1999) Paraneoplastic stifflimb syndrome. J NeurolNeurosurg Psychiatry 67:126-127 14. Butler MH. Hayashi A, Ohkoshi N, et al. (2000) Autoimmunity to gephyrin in stiff-man syndrome. Neuron 26:307-312 15; Molinuevo JL, Gratis F, Serrano C, et al. (1998) Utility of anti-Hu antibodies in the diagnosis of paraneoplastic sensory neuropathy.Ann Neurol 44:976-980 16. Antoine JC, Absi L, Honnorat J, et al. (1999) Antiamphiphysin antibodles are associated with various paraneoplastic neurological syndromes and tumors. Arch Neuro156:172-177 17. Antoine JC, Mosnier JF, Absi L, Honnorat J, Rougemond V, Daniel M (1999) Anti-CV2 antibodies react with antigens of peripheral nerve (ULIP proteins) and are associated with peripheral neuropathy in patients with paraneoplastic neurological disorders Neurology (Abstract) 52 (Supp12):A282 18. Mason WP, Graus F, Lang B, et al. (1997) Small-cell lung cancer, paraneoplastic cerebellar degeneration and the Lambert-Eaton myasthenic syndrome. Brain 120:1279-1300 19. Peterson K, Rosenblum MK, Kotanides H, Posner JB (1992) Paraneoplastic cerebellar degeneration. I. A clinical analysis of 55 anti-Yo antibody-positive patients. Neurology 42:1931-1937 20. Felician O, Renard JL,Vega F,Creange A, Chen QM, Bequet D, et al. (1995) Paraneoplastic cerebellar degeneration with anti-Yo antibody in a man. Neurology 45:1226-1227 21. Krakauer J, Balmaceda C, Gluck JT, Posner JB, Fetell MR, Dalmau J (1996) Anti-Yo-associated paraneoplastic cerebellar degeneration in a man with adenocarcinoma of unknown origin. Neurology 46:1486-1487 22. Smith JL, Finley JC, Lennon VA (1988) Autoantibodies in paraneoplastic cerebellar degeneration bind to cytoplasmic antigens of Purkinje cells in humans, rats, mice and are of multiple immunoglobulin classes. J Neuroimmunol 18:37-48 23. Greenlee JE, Dalmau J, Lyons T, Clawson S, Smith RH, Pirch HR (1999) Association of anti-Yo (type I) antibody with paraneoplastic cerebellar degeneration in the setting of transitional cell carcinoma of the bladder: detection of Yo antigen in tumor tissue and fall in antibody titers following tumor removal. Ann Neuro1445:805-809 24. Meglic B, Graus F, Grad A. Anti-Yo-associated paraneoplastic cereb'ellar degeneration in a m a n with gastric adenocarcinoma. J Neurol Sci (in press). 25. Konanc DA, O'Neill BP, Caselli RJ, Lennon VA (1995) Peripheral neuropathic presentation in 3 patients with seropositivity for type 1 antiPurkinje cell antibodies (PCA-1) and ovarian or related Mullerian carcinoma. Neurology (Abstract) 45(suppl 2):A320 26. Petit T, Janser JC, Achour NR, Borel C, Haegele P (1997) Paraneoplastic temporal lobe epilepsy and anti-Yo autoantibody. Ann Oncol 8:919-920 27. Greenlee JE, Dalmau J, Lyons T, Clawson S, Smith RH, Pirch HR (1999) Association of anti-Yo (type I) antibody with paraneoplastic cerebellar

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degeneration in the setting of transitional cell carcinoma of the bladder: detection of Yo antigen in tumor tissue and fall in antibody titers following tumor removal. Ann Neuro145:805-809 Hammack JE, Kimmel DW, O'Neill BP, Lennon VA (1990) Paraneoplastic cerebellar degeneration: A clinical comparison of patients with and without Purkin)e cell cytoplasmic antibodies. Mayo Clin Proc 65:1423-1431 Graus F, Dalmau ],VaUdeoriola F, et al. (1997) Immunological characterization of a neuronal antibody (anti-Tr) associated with paraneoplastic cerebellar degeneration and Hodgkin's disease. J Neuroimmunol 74:55-61 Hammack JE, Kotanides H, Rosenblum MK, Posner JB (1992) Paraneoplastic cerebellar degeneration. II. Clinical and immunologic findings in 21 patients with Hodgkin's disease. Neurology 42:1938-1943 Honnorat ], Antoine JC, Derrington E, Aguera M, Belin MF (1996) Antibodies to a subpopulation of glial cells anda 66 kDa developmental protein in patients with paraneoplastic neurological syndromes. J Neurol Neurosurg Psychiatry 61:270-278 Luque A, Furneaux HM, Ferziger R, et al. (1991) Anti-Ri: an antibody associated with paraneoplastic opsoclonus and breast cancer.Ann Neurol 29:241-251 Escudero D, Barnadas A, Codina M, Fueyo J, Graus F (1993) Anti-Ri associated paraneoplastic neurologic disorder without opsoclonus in a patient with breast cancer. Neurology 43:1605-1606 Gennaula CP, Eidelman BH (1995) Anti-Ri paraneoplastic syndrome in association with primary lung carcinoma. Neurology (Abstract) 45:1417 Lucchinetti CF, Lennon VA (1996) Neurologic and oncologic correlations in patients seropositive for type 2 antineuronal nuclear autoantibodies. Neurology (Abstract) 46:A219 Folli F, Solimena M, Cofiell R, et al. (1993) Autoantibodies to a 128-kd synaptic protein in three women with the stiff-man syndrome and breast cancer. N Eng J Med 328:546-551 Dropcho EJ (1996) Antiamphiphysin antibodies with small-cell lung carcinoma and paraneoplastic encephalomyelitis.Ann Neuro139:659-667 Saiz A, Dalmau J, Butler MH, et al. (1999) Anti-amphiphysin I antibodles in patients with paraneoplasfic neurologic disorders associated with small cell lung carcinoma. J Neurol Neurosurg Psychiatry 66:214-217 Floyd S, Butler MH, Cremona O, et al. (1998) Expression of amphiphysin I, an autoantigen of paraneoplastic neurological syndromes, in breast cancer. Molecular Med 4:29-39 Vernino S, Lennon VA (2000) New Purkinje cell antibody (PCA-2): Marker of lung cancer-related neurological autoimmunity. Ann Neurol 47:297-305 Gultekin SH, Rosenfeld MR,Voltz R, Eichen J, Posner JB, Dalmau J (2000) Paraneoplastic limbic encephalitis: neurological symptoms, immunological findings and tumor asociation in 50 patients. Brain 123:1481-1494 Voltz, Gultekin SH, Rosenfeld MR, Gerstner E, Eichen J, Posner JB, et al. (1999) A serological marker of paraneoplastic limbic and brainstem encephalitis in patients with testicular carcinoma. N Engl J Med 340:1788-1795 Anderson NE, Budde-Steffen C, Rosenblum MK, et al. (1988) Opsoclonus, myoclonus, ataxia, and encephalopathy in adults with cancer: A distinct paraneoplastic syndrome. Medicine 67:100-109 Graus F, Bonaventura I, Uchuya M, et al. (1994) Indolent anti-Hu-associated paraneoplastic sensory neuropathy. Neurology 44:2258-2261 Das A, Hochberg FH, McNelis S (1999) A review of the therapy of paraneoplastic neurologic syndromes. J neuro-Oncol 41:181-194 Keime-Guibert F, Graus F, Fleury A, et al. (2000) Treatment of paraneoplastic neurological syndromes with antineuronal antibodies (anti-Hu, anti-Yo) with a combination of immunoglobulins, cyclophosphamide, and methylprednisolone. J Neurol Neurosurg Psychiatry 68:479-482

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Oral sessions Monday, Apri123 rd2001 Oral session 1 Cerebrovascular disorders - 1 1 Do MI Stroke Subtypes Get The Same Benefit From Stroke Unit Care.~ B Fuentes, E. DŸ Tejedor, A. Frank, R Barreiro (Madrid, E) Background: The efficacy of Stroke Units (SU) has been demonstrated, though at present, there are only few studies analysing which type of patients get the most benefit from the SU care. Methods: We compared the outcome of four samples of patients before (1994) and after (1995-97) the establishment of a SU in our neurological department. In 1994 all stroke patients were cared for a stroke team. Inclusion criteria and health professionals were the same. We analyzed length of stay, functional outcome at discharge. Results: 2032 stroke in-patients were admitted, 1438 presenting as ischaemic stroke. In territorial infarction we found a reduction in length of stay (up to 38 %; p < 0.05) anda better functional outcome (modified Rankin scale) (p < 0.0001) in favour the SU. In lacunar infarctions, a shorter mean stay (up to 43,4%; p < 0.01) a n d a trend to an improved functional status were seen for the SU, but with no statistical significance. On the other hand patients with the diagnosis of undetermined or unknown origin stroke did not get any benefit in terms of both length of stay or functional outcome. Conclusions: Patients with territorial infarction get the most benefit from the SU care, followed by lacunar infarction patients. There are no benefit of SU care in undetermined or unknown stroke. These data could help us to optimise the SU resources. 2 Echo-enhanced Transcranial Colour Coded Duplexsonography for Anterior Circulation Cerebrovascular Events. A Validation Study. G. Gahn, G. Hahn, A. Kunz, H. Reichmann, R. "con Kummer (Dresden, D) Objective: To assess the diagnostic efficacy of echo-enhanced transcranial colour coded duplexsonography (eTCCD) for non-invasive evaluation of the anterior circulation in patients with cerebrovascular symptoms. Material and methods: Since 1.1.2000 we prospectively evaluated 62 consecutive patients (16 women, 46 men, mean age 56,5 + 14,4) with eTCCD and DSA. We applied an intravenous galactose palmitic acid based echo-enhancing agent. All patients were admitted to our neurology department for acute onset of cerebrovascular symptoms in the anterior circulation. Results: In 61/62 patients (98,4%) eTCCD visualized all basal arteries of the circle of Willis. eTCCD correctly identified abnormal findings in the intracranial circulation in 23/29 patients [sensitivity 79,3 % (95 % C160-92 %), specificity 100 % (95 % CI 89-100 %)]. eTCCD correctly identified collateral flow patterns through the circle of Willis in 28/31 patients with critical symptomatic internal carotid artery obstruction (sensitivity 85 %, 95 %CI 62-97 %, specificity 100 %, 95 %C172-100 %). eTCCD suggested MCA-occlusion in 4 patients, all confirmed by DSA. In 2 patients eTCCD failed to identify occlusion of a M3-segment. eTCCD showed 2 MCA stenoses. In one of these DSA first missed a severe MCA stenosis but confirmed it after angiographic re-evaluation, eTCCD showed 2/3 intracranial internal carotid artery stenoses. In 2/5 patients with atypical intracranial haemorrhage eTCCD correctly suggested an AVM as the source of bleeding. The remaining 3 patients had normal eTCCD and DSA. One patient with subarachnoid hemorrhage had normal eTCCD and DSA. Conclusion: In this ongoing trial eTCCD is a highly specific diagnostic tool for evaluation of the intracranial arteries in patients with anterior circulation cerebrovascular events. 3 Teleconsultation in Hyperacute Stroke - The Reliability of Evaluating of Patients and CT by a Video Conference System. A. Wiborg, R. Huber, W. Aurnhammer, B. Schmitz, M. Krauss, M. W. Riepe, B. Widder (Gª Ulm, D) Introduction: In rural areas it is difficult to provide stroke patients with appropriate care. In order to clarify the possible role of telemedicine to overcome this problem, we tested, in a first step, whether a reliable neurological examination of acute stroke patients could be performed by means of a video-conference system. In a second step, the transmission and interpreta-

tion of computer tomographic (CT) images by the same system were studied concerning reliability and time needed. Compared to the established teleradiology using DICOM-standard, video transmission during the dinical examination could save time. Methods: In a 3 month interval all patients admitted to the stroke units of Ulm or Gª with a suspected diagnosis of stroke were examined by one "bedside" neurologist and, at the same time, by a "remote" neurologist in the other hospital using a video-conference system (N=44) with data transmission at 384 kilobits/s. Each patient was scored with the Scandinavian and the European Stroke Scale (SSS, ESS). In a second step the CT images of 50 patients admitted to the stroke unit in Gª were examined by a neuroradiologically experienced neurologist directly and, simultaneously, a"remote" neurologist using the same video conference system. Results: The interrater-reliability (Kappa-coefficient) concerning the examination of patients admitted within 6 hours after stroke onset (N= 12) was 0.78 for the SSS and 0.79 for the ESS thus displaying a good agreement. Regarding CT interpretation the interrater-agreement was fair to good for all scans studied (Kappa=0.59). So-called "early signs" in CT scans performed within 6 hours (N---33) were identified with good reliability (Kappa=0.73). The extent of an infarct in'the middle cerebral artery territorium could be evaluated with moderate agreement (Kappa=0.58). All Kappa-values were comparable to those already published for direct examination. CT interpretation took an average time of 88 s (range 20-156 s). Conclusion: By using a vŸ conference system (= "tele-consultation") it seems possible to examine patients with hyperacute stroke with the same reliability as it is possible directly on the scene. In the same session ir is furthermore possible to interpret CT scans with satisfactory interrater-agreement, although data transmission using DICOM standard still remains the "gold standard". Thus tele-consultation could be a reliable tool for improving stroke care in rural areas. 4 Systemic and cerebral complications of heparin early prescribed after acute stroke. S. E.M Jeangette, S. Blecic, J. Hildebrand, J. Bier (Brussels, B) The aim of this study was to assess the safety of AC prescribed early after acute stroke onset. Methods. From 1991 to 1999, 2721 patients (pts) have been admitted to the Stroke Unit. 1581were treated with heparin within the 15 hours following stroke onset, to reach in the 12 following hours an APPT value between 2 and 2.5 the original value. Other pts were either untreated or treated with aspirin. Extensive Stroke work up was performed and AC was discontinued as early as ac cardiac embolism or artery dissection have been excluded. Pts under AC were further distributed into 3 groups, according their age, Group 1: pts < 50 year-old (N=206), Group 2 pts between 51 and 70year-old (N=650), and group 3, p t s > 71 year-old (N=724). Control APPT and blood analysis were daily performed. Control brain CT scan was performed 14 days after stroke onset and earlier in case of deterioration. Results Average AC duration was 6.5 + 3.8 days [range 1 to 11 days]. Hemorrhagic transformation occurred in 33/1581 (2.1%) pts treated with heparin and in 23/1140 (2 %) treated with aspirin (NS). No statistical difference was nbserved between the 3 groups. Serious systemic hemorrhage occurred in 58/1140 (5.1%) pts treated with aspirin and in 164/1581 (10.4 %) pts treated with heparin (p=0.001), 9 pts (3.2 %) were found in Group 1, 23 in Group 2 (3.5%) and 132 in group 3 (18.2%), (p < 0.001). Only2 pts died from brain hemorrhage, all belonging to the group 3. Of 35 I~ts dead from systemic hemorrhage (peritoneal hemorrhage), 33 were found in group 3. In all instances APPT control was over 2.5 Conclusions. In our study, secondary brain haemorrhages were rare and not statistically different from what was observed in pts under aspirin. However, systemic haemorrhages were significantly more frequent in pts treated with heparin, and particularly encountered in elderly pts, constituting in these pts a risk of death. 5 Early medical complications in ischemic stroke patients: Quality measure for stroke care? I. Henriques, L. Rebocho, C. Barata, T. Tribolet-Abreu (Evora, P) Introduction: Medical complications after ischemic stroke are sometimes predicable and avoidable by simple measures. It is now accepted that organized stroke hospital care can improve patient outcome. To monitor hospital stroke care in our department we studied the prevalence of pulmonary and urinary tract infection. Material and methods: We studied pulmonary and urinary tract infection in 169 consecutive ischemic stroke patients. All patients were studied acc0rding to a protocol that includes at least one CT-scan of MRI, transtho-

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racic echocardiogram and triplex-scan. We considered all infections that were diagnosed during hospital stay and excluded all infections previous to ischemic stroke. We classified patient according to Rankin scale at discharge and considered two groups: one included Rankin 1 and 2 and the other Rankin 3, 4 and 5. We used the Chi-square test as statistical tool. Results: From 169 consecutive patients with ischemic stroke, 18 (10.7%) had either pulmonary or urinary tract infection. There were 3 patients with pulmonary infection (2 male, 1 female), and 15 (12 male, 3 female) with urinary tract infection. Infection was related to Rankin scale above 2 at discharge (p=0.0012). Conclusion: In our patients pulmonary and urinary tract infections were associated with a worse Rankin at hospital discharge. Implementing measures to avoid expected infection complications after stroke might improve outcome. Measuring the rates of medical complications in stroke services may contribute to improve quality in stroke care. 6 Etiologic investigation of young stroke patients: What was the influence of a protocol based approach? T. Tribolet-Abreu, L. Rebocho, C. Baratta, I. Enriques (Evora, P) Background and Purpose: Since 1996, in our Department, all stroke patients aged 45 years or less are studied by a protocol that includes extensive etiology research. The aim of our study was to determine if the number of patients with "undetermined etiology" (by TOAST criteria) was less since the protocol was used. Methods: From 1990 to 1999, of the 4369 patients discharged from our Hospital with the diagnosis of stroke, 37 (0.85 %) were 45 years or less. Of this young stroke patients, 25 (67.6%) had a cerebral iufarction. After 1996, 8 of this patients were studied using a protocol (protocol patients), that included at least one CT scan or MRI, transthoracic echocardiogram, triplex scan, coagulation, serologic infectious and autoimmune tests. We retrospectively compared protocol with non-protocol patients regarding number of "undetermined etiology" strokes. We used the performance of triplex scan as'a marker for analysing the degree of etiologic investigation. We analysed the data with a T-test to compare means anda test of hypothesis on two proportions to compare proportions. Results: A total of 25 young ischemic stroke patients (14 men, 11 women) 2 to 45 years old (mean age, 35 years) were studied. The differences in sex distribution and mean age between protocol and non-protocol patients were non significant (male 50%vs59%, p=0.68; mean age 39.3vs33.1 years, p=0.12). Triplex scans were performed in 100% of protocol patients and 52.9 % of non-protocol patients (p=0.03). According to the TOAST criteria, 25 % of protocol patients and 29.4 % of non-protocol patients were classified as "undetermined etiology" (p=0.8). Conclusi0ns: Although more investigation was performed in our protocol studied patients, no difference was found in the prevalence of"undetermined etiology", by TOAST criteria. Other type of etiology classification might be needed in young ischemic stroke patients.

Oral Session 2

Cerebrovascular disorders - 2 7 Mood disorders after stroke: a 3-year follow-up study. A. Verdelho, H. H› F. Lebert, F. Pasquier, D. Leys (Lille, F) Background: Depressive symptoms are frequent after stroke and they negatively influence stroke outcome. Dementia is also frequent in stroke patients. However, little is known about predictors and evolution over time of mood disturbances and about the relationship between mood disturbances and dementia. The aim of this study was to determine the prevalence and determinants of depressive symptoms occurring after stroke, their course, and their relationship with cognitive decline. Methods: We prospectively evaluated the presence and severity of depressive symptoms using the MADR scale in 202 consecutive stroke patients, followed-up over a 3-year period.We

considered patients with a MADRS score > 6 as having depressive symptoms. Dementia was diagnosed accordiug to standardized criteria. Results: Depressive symptoms were present in respectively 43%, 36%, 24 % and 18 % of the survivors after 6,12, 24 and 36 months. Using bivariate analysis, we found depressive symptoms at month-6 to be more frequent in patients with a more severe neurological deficit at admission (p=0.02), right superfcial lesion (p=0.01), more severe functional (p=0.04) and neurological deficit (p=0.007) at month-6, and in patients demented at month-6 (p=0.006). Using multivariate analysis,we found severity of the neurological deficit at admission to be the only independent predictor of depressive symptoms (p=0.009), and depressive symptoms to be more frequent in patients with previous depression (p=0.04), right superficial lesions (p=0.03) and dementia (p=0.005). Bivariate analysis found depressive symptoms at year-3 to be more frequent in youuger patients (p=0.01), in patients with more severe deficit at admission (p < 0.001) and more severe leukoaraiosis (p=0.01). Multivariate analysis revealed that only age (p=0.01) and right superficial lesions (p=0.001) were independently related with depressive symptoms at year-3. We did not find any influence of pre-stroke dementia. Conclusion: The prevalence of depressive symptoms remains high during one year after stroke onset, then decreases. Pre-stroke dementia is uot a predictor of mood disturbances. Post-stroke dementia is related with depressive symptoms at short but notat long term follow-up. Right superficial lesions ate related with depressive symptoms at short and loug term followup. 8

Extracranial and/or Intracranial Vascular Atherosclerotic Disease: An Evaluation of 1,000 Patients with Angiography. A. P. Narata, W. O. Arruda (Curitiba, BR) Objective: to analyse the predictive value of extracranial atherosclerotic vascular lesions (EVL) in relatiou to the presence or not of intracranial atherosclerotic vascular lesions (IVL). Methods: 1,000 neurological patients were submitted to digital subtraction angiography (DSA). ?dl reports were reviewed and only one DSA per patient was recorded for analysis. 559 women and 441 meu with ages from 2 to 99 years (mean age 49 years) were evaluated as follows: extra- and iutracranial lesion of the anterior and/or posterior circulation, their side and stenosis grade: grade 1 (< 40%); grade 2 (41-69%); grade 3 (> 70%) (NASCET). Occlusion due to trauma or cardioembolic disease was exdude& Results: 343 (34.3 %)out of all exams were normal. The most frequent abnormal finding was intracranial aueurysm (271 cases; 41.2 % of abnormal DSA).197 (30 %) patients showed some degree of stenosis or occlusion; 159 cases had extracranial carotid lesion, 82 cases had vertebral lesion, and 8 cases had basilar artery lesion.12 cases had only intracranial anterior circulation lesion, without extracranial lesion. In 32 cases we found both extraand intracranial lesion or occlusion; 24 out of this 32 patients had more than one EVL (36 critical lesions out of a total 67 lesions). Conclusion: EVL (308 lesions) were more common than IVL (64 lesions). 32 patients (16.2 % out of 197 patients with some vascular lesion) had both EVL+IVL. About hall had grade 3 lesions (53.7 %) and more than one EVL was common (75%). Isolated IVL were relatively uncommon (6%). Therelote, almost one quarter of lesions (22.2 %) had ah intracranial component, what highlights the importance of a throughout vascular evaluation (e. g. DSA, perhaps MRI angiography). The relative limitation of using only extracranial ultrasound methods to evaluate the severity of atherosclerotic vascular disease and the therapeutic approach should not be overemphasised. 9 Cerebrovascular CO2 -Reactivity After DALI-, HELP- and MDF-Apheresis. G. Gahn, A. Kunz, G. Hahn, S. Hallmeyer-Elgner, U. Julius, H. Reichmann (Dresden, D) Objective: Hypercholesterolemia impairs endothelium-dependent vasoreactivity. Lowering of LDL cholesterol is capable of improving endothelial dysfunction. Direct adsorption of lipoproteins (DALI) selectively removes LDL cholesterol and lipoprotein(a) [Lp(a)] from the blood.Alternative techniques are less selective heparin-mediated extra corporal LDL precipitation (HELP) aud membrane differential filtration (MDF). We tested the change in cerebrovascular reserve capacity (CVR) in patients undergoing successive treatment with DALI, HELP and MDF. Methods: Six Patients (2 female, 4 male, mean age: 61,7 -+ 6,3 years) with familia1 hypercholesterolemia consecutively underwent DALI, HELP and MDF aphaeresis, 2 treatments each, in weekly intervals. We assessed CVR of both middle cerebral arteries (MCA) before and after each treatment and

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measured serum levels of total, LDL and HDL cholesterols, Lp(a) and fibrinogen. Using transcranial Doppler (TCD) we assessed CVR by measuring %change in mean MCA blood flow velocities during breath-holding. We plotted scatter gratas describing the percentage change in MFV of the MCA versus the length of the individual breath-holding periods. From the scatter grams we derived regression lines describing CVR (CVR-slope). Results: CVR: CVR-slopes before aphaeresis with DALI, HELP and MDF were 1.70 _+ 0.35, 1.72 + 0.35 and 1.59 -+ 0.47, respectively. After DALI aphaeresis CVR-slopes increased to 1.96 + 0.30 which is significantly different from baseline at a p-value < 0.01. CVR-slopes after HELP and MDF aphaeresis were 1.79 -+ 0.38 and 1.52 + 0.37, respectively, and did not show a significant change compared to baseline. Serum tests: DALI reduced serum leve|s of LDL by 76 + 9 %, HELP by 56 + 7 % and MDF by 61 + 14 %. Compared to HELP and MDF, the LDL reduction with DALI was significantly higher (p < 0.01). Lp(a) serum levels were reduced by 79 + 16 % with DALI, by 61 _+23 % with HELP (p < 0.05 vs. DALI) and by 55 + 11% with MDF (p < 0.01 vs. DALI). In contrast, fibrinogen serum levels were significantly (p < 0.01) more lowered with HELP and MDF (reduction by 58 -+ 4% and by 51 _+8%, respectively) than with DALI (reduction by 13 -+ 7%). HDL serum levels before and after aphaeresis were nearly unchanged with DALI and HELP whereas they were reduced by 18 -+ 5 % after MDF. Conclusion: Lipidapheresis with DALI improves the CO2-reactivity whereas HELP or MDF do not. Reduction of LDL cholesterol and Lp(a) serum levels may improve endothelium-dependent vasoreactivity in the brain. 10 Recurrence after first cerebral infarction according to stroke etiology: Results from a community-based stroke registry in Germany. P. Heuschmann, B. Neundoerfer, E Kolominsky-Rabas (Erlangen, D) Background: Stroke, and in particular recurrent stroke are preventable diseases. For developing effective public health strategies in stroke prevention long-term data from representative studies are necessary. The aim of the present study was to investigate long-term recurrence of different etiological stroke subtypes within a population-based setting. Methods and results: The Erlangen Stroke Project (ESPro) is a population-based stroke registry in Germany, monitoring risk factors, etiology and outcome of stroke in a study population of 100330 inhabitants. Between 1994 and 1998, 583 patients after first ischemic stroke were registered in the ESPro, from these 531 (91%) were classified according to the TOAST criteria. Patients were followed up for a two year period. Kaplan-Meier method was used to estimate rates of recurrence free survival after first ischemic stroke, COX regression was performed for multiple analyses. The overall risk of recurrence after ischemic stroke was 3 % (95 % confidence interval (CI) 2-5) at 3 month, 11% (95 % CI 8-14) at 12 months and 15 % (11-18) at 24 months. Long-term recurrence up to 2 years by ischemic stroke subtypes varied from 10 % (95 % CI 2-18) in large-artery atherosclerosis, 22 % (95 % CI 14-30 %) in cardioembolism, 11% (95 % C150-17 %) in small-artery occlusion and 14 % (95 % CI 8-20) in undetermined etiology. Stroke subtype failed to be identified a s a significant predictor of long-term recurrence after adjustment for age and sex. Conclusion: Our unselected, population-based study demonstrated substantial differences of recurrence rates in ischemic stroke subtypes. Late-recurrence of cardioembolic stroke was nearly two-fold higher comparing to other subtypes. These data highlight the importance of an etiological stroke classification for designing custom-made secondary prevention programmes. 11 MR diffusion histogram analysis from CSF suppressed and non-suppressed images in CADASIL. M. Dichgans, B. Pª D. Auer (Munich, D) Objective: To determine the diffusion characteristics of whole brain parenchyma (WBP), T2-hyperintense lesions and normal appearing brain tissue (NABT) outside free CSF in 13 CADASIL patients and an equal numher of age-matched controls. Methods: Histograms of the trace of the apparent diffusion coefficient (ADC-t) were obtained from CSF-suppressed and non-suppressed data using a tetrahedral acquisition scheme. A semiautomatic threshold-hased region growing algorithm was used for segmentation of T2-hyperintense lesions on CSF suppressed b0 images. Segmentation masks derived from this sequence were additionally applied to the images of the standard sequence. Histograms of ADC-t maps were calculated for WBP, lesions and NABT (WBP-lesions). Results: Average ADC-t and peak positions for WB and NABT obtained

from CSF suppressed b0 images were significantly lower and peak heights significantly higher than those obtained from non-suppressed images. Histogram-derived measures for lesions did not differ significantly between the two acquisition protocols. The average ADC-t and peak positions for WBP, lesions and NABT obtained from CSF suppressed b0 images were significantly higher and peak heights were significantly lower in the CADASIL group compared to the controls.Average ADC-t (CSF-suppressed b0 images) ofWBP (partial correlation coefficient [PCC] = 0.95, p < 0.001) and NABT (PCC = 0.84, p < 0.001) strongly correlated with total lesion volume. Total lesion volume further correlated with the peak positions for lesions (PCC = 0.70, p = 0.01). Conclusion: This study shows variable degrees of tissue destruction outside free CSF within T2-visible lesions and in brain tissue outside of T2-visible lesions in CADASIL. Our data suggest that higher lesion volumes are associated with more severe tissue destruction within T2-visible lesions and in normal appearing brain tissue. The observed differences for histogram derived measures between suppressed and non-suppressed images suggest partial volume effects of free CSF on non-suppressed b0 images. The generation of diffusion histograms of whole brain parenchyma is a fast and fully automated procedure. The'use of CSF suppressed acquisition modes allows intrinsic segmentation of whole brain parenchyma. The method may thus be suited to monitor the evolution of CADASIL operator-independently. 12 Differences in number and location of microembolic ischemic lesions after percutaneous transluminal angioplasty and operative thrombendarteriectomy. H. Poppert, T. Wilhelm, M. Resch, W. Theiss, R. Brandl, K. Winbeck, B. Conrad, D. Sander (Munich, D) At least 20 % ischemic strokes are caused by stenoses or occlusions of the extracranial carotid arteries. In addition to pharmacological treatment two different invasive procedures are possible: thrombendarteriectomy (TEA) and percutaneous transluminal angioplasty (PTA). Compared with TEA PTA of the internal carotid artery (ICA) is associated with an increased rate of microembolic signals (MES) detectable by intraprocedural transcranial doppler-ultrasonography (TCD). Nevertheless there are no data available at the moment that provea positive correlation with the periprocedural rate of ischemic events. Diffusion weighted resonance imaging (DWI) is a-new high-sensitive method to detect even smallest ischemic lesions. We studied patients who underwent PTA or TEA before and after the procedure by DWI. In patients with detected lesions a Tl-weighted cranial MRI was performed ten days later. Furthermore all patients who underwent PTA were monitored by TCD of the middle cerebral artery during the procedure. 29 patients treated by TEA and seven patients treated by PTA were investigated until now. Acute DWI-abnormalities after the procedure were found in four patients (57 %) who underwent PTA with ah average of 5.0 lesions per patient, compared with six (21%) of 29 patients in the TEA-group with an average of 2.6 lesions per patient. Whereas all lesions found in the TEA-group were observed in the ICA territory ipsilateral to the treated artery, in the PTA-group two of the four conspicuous patients showed lesions in the ipsilateral as well as the contralateral posterior circulation area. In only one case we found a focal-neurologic deficit in the neurological examination after PTA. We did not find a significant positive correlation concerning the number of MES detected during the procedure and the MRIfindings. 13 Hospital admission after stroke: reasons for delay. I. Henriques, T. TriboletAbreu, C. Barata, L. Rebocho (Evora, P) Background and purpose: Delay in hospital admission after stroke may exdude patients from new acute stroke therapies. We studied factors that might have contributed to delay in order to suggest correction measures to diminish delay. Methods: We registered the delay in arriving at hospital in a sample of 199 consecutive first ever stroke patients (169 ischemic, 30 hemorrhagic) with median age 61 years (32-86). We considered time from the first symptoms and five groups of delay: before 3h, before 6h,before 24h, after 24h and unknown. Unknown delay was considered in all patients that woke with the deficit. All patients were studied according to a protocol that includes level of conscience and walk status at admission. Ischemic stroke patients were classified according to TOAST criteria for etiology.We analysed the data with a statistical package that includes logistic regression analysis. Results: From 169 patients with first ever ischemic stroke,41 (24.3 %) arrived before 3h and another 38 (22.5%) before 6h. Patients with cerebral hemorrhage arrived earlier (43.3% before 3h and 13.3% before 6h). In ischemic stroke patients,lacunar infarction etiology (p= 0.0132; O. R. 2.3 and

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+ 95 % Confidence Interval 1.8-4.3) was related to 3h admission. Changes in the level of conscience or walking deficits did not influence early admission. Conclusion: Ischemic stroke patients arrive late after first symptoms (24.3 % before 3 hours). Delay in hospital admission was not influenced by changes in the level of conscience of walking deficits. Public information about stroke is biased towards deficits in strength whicb might be a reason for patients with motor lacunar infarctions arriving eartier. Correction measures are needed to change time of admission after stroke in our Hospital.

Oral session 3

GeneralNeurology 14

A unique family with adult onset Krabbe disease and normal neuroimaging. N. P. S. Bajaj, A. D. Waldman, R. W. Orrell, K. P. Bhatia (London, UK) Krabbe disease (KD)(globoid leukodystrophy) is an autosomal recessive disorder caused by a deficiency in the activity of galactocerebrosidase (GALC). Deficiency of GALC leads to accumulation of galctosylceramide within the white matter of the peripheral and central nervous systems leading to demyelination. The disease may be sub-divided into ah infantile form with onset within 6 months of birth, a juvenile form presenting between 2 to 10 years, a n d a r• adult form with onset greater than 10 years old. The infantile form is the most severe presenting with spasticity, ataxia and seizures and subsequent psychomotor decline resulting in quadriparesis and death within years of onset. Juvenile and adult forms of the disease have a milder phenotype and slower rate of progression. Despite the heterogeneity in clinical presentation of KD, long-standing cases with normal neuroimaging (including proton magnetic spectroscopy[MRS]) have never been reported. We present the clinical findings of a family with adult onset KD and normal neuroimaging after more than 20 years of disease in the index case. The index case was a m a n of 33 with a 22 year history of deteriorating gait resulting in spastic paraparesis. His brother did not present until the age of 32, again with spastic paraparesis. Their father presented with falls at the age of 54. Examination of the index case revealed a spastic paraparesis with loss of vibration sense and pin prick distally and joint position sense in the toes. His brother similarly h a d a spastic paraparesis with asymmetrical loss of temperature sensation in the lower limb. Their father h a d a normal neurological examination apart from brisk lower limb reflexes. Both siblings had GALC levels within the homozygous range for KD; the father was within the heterozygous range. Brain and spinal MRI for the index case was normal (a non-specific thalamic lesion was seen in the MRI brain ofhis sibling). Brain MRS ofboth siblings was normal. Somatosensory evoked potentials from the legs showed a delay in central conduction in the index case; nerve conduction studies were normal. This family illustrates the heterogeneity in adult onset KD (both in phenotype of homozygote versus heterozygote and in varying age of presentation in the homozygotes). In addition, this is the first report to our knowledge of normal neuro-imaging in adult onset KD, and highlights the need to consider this diagnosis in idiopathic adult spastic paraparesis. 15 Cerebral venous thrombosis: clinical outcome in 57 consecutive patients admitted between 1995 and 1998. G. Breteau, O. Godefroy, F. Mounier-Vehier, M. Girot, ].P Pruvo, D. Leys (Lille, F) Background: cerebral venous thrombosis (CVT) was been considered as rare and associated with a poor outcome before the era of magnetic resonance imaging (MRI). Aim of the study: to evaluate the clinical outcome in 57 consecutive patients with CVT admitted over a 4-year period (1995-1998). Patients and method: the study population consisted of 46 women (80.7%) and 11 men (19.3%),with a median age of 39 years (range: 16-77).

Clinical findings were: isolated intra-cranial hypertension in 18 patients (31.6 %), progressive focal neurological deficit with fever in 11 (19.3 %) and without fever in 8 (14 %), acute headache suggesting sub-arachnoid hemorrhage in 6 (10.5%), stroke in 11 (19.3%) and isolated transient focal neurological deficits in 3 (5.3 %). Headache was present at onset in all patients but 3 (94.7 %). The diagnosis of CVT was performed on MRI in all patients, except in 2 with contra-indications a n d a positive CT-scan. Twelve patients (21.1%) had no clear cause nor risk factor for CVT. Brain imaging revealed ah infarct in 9 patients (15.8 %), hemorrhage (or hemorrhagic infarct) in 19 (33.3 %) and was normal in 29 (50.9 %). The median delay between the q symptom and diagnosis was 5 days (range: I to 33). Patients received heparin at the acute stage, then oral anticoagulation. The outcome was assessed with the modified Rankin scale (mRS). Results: the median follow up was 36 months (range: 12-60). At the end of the follow-up period, 45 patients (78.9%) were independent, 10 (17.5%) were dependent and 7 (12.3%) were dead. Of 50 survivors, 7 (14%) had epilepsy, 6 ( 12 %) had motor deficits and 5 (10 %) had visual field defects. Of 48 survivors who were able to communicate, 29 (60.4%) had residual headache, 15 (31.3 %) had neuropsychological complaints and 8 (16.7 %) had depression. No recurrent CVT occurred. The 3 subsequent pregnancies remained uneventful. No life-threatening complications of anticoagulant occurred. The logistic regression analysis found focal neurological deficits and cancer as independent predictors of dependence or death, and headache as isolated symptom at the moment of diagnosis as independent predictor of survival and independence (p < 0.01). Conclusion: CVT remains a serious disorder, and most survivors are symptomatic. 16 Three year outcome for patients with the chief symptom of dizziness.A longitudinal study of differences of handicap and emotional distress in patients with organic and non-organic (somatoform) dizziness. A. EckhardtHenn, B. Kappis, C. Thomalske, S. O. Hoffmann, H. C. Hopf (Mainz, D) Objective: Hardly any systematic studies have been carried out on larger patient collectives investigating patients with organic and patients with nonorganic dizziness states in terms of psychosocial factors influencing the course of the illness. Methods: 202 consecutive patients with significant dizziness at a neurological outpatient dinic had been evaluated in an interdisciplinary study using blind neuro-otological testing, a neuro-otological and general medical examination, blind psychiatric examination, including semi-structured interviews (according to DSM-IV) and psychometric tests (SCL-90-R, GBB, SBA-S, IIP-C). Results: In 28 % of the patients (N=50) dizziness was of organic origin (O-group); in 55.3 % (N=99) of psychogenic origin (PSY-group), and in 16.8 % (N=30) vestibular dysfunction triggered the development of psychogenic dizziness states (Intermediate/INT group). The most frequent psychiatric disorders (PSY- and INT-groups) were anxiety and phobic disorders (43 %; N=56). The patients with psychiatric disorders (P8Y- and INT-groups) had much more extensive workups for dizziness, intense emotional distress, more interpersonal problems, greater handicaps in their occupational activities, more frequent absences from work and high somatization scores. Three years later these patients were evaluated again; the results of the first study were supported: although in both groups approximately the same percentage of patients still suffered from dizziness,the patients with non-organic (i. e. somatoform) dizziness showed significant greater handicap in their daily activities because of the dizziness, higher emotional distress and had more medical workups for dizziness. Conclusion: Psychiatric disorders should be included in the differential diagnosis in patients with a long duration of dizziness and great handicaps in their occupational activities. These patients should be treated with a specific psychotherapy to prevent chronicity of their illness and the following consequences (handicap, emotional distress, high medical costs). 17 Diagnostic value of triplexsonography in the diagnosis of interna/carotid artery dissection in a migraineur with painful Horner's syndrome. M. Mayr, M. Czarnecki, S. Haaser, D. Proeckl, M. Jeschow, R. Knapp, K. Berek (Kufstein, AT) lntroduction: Spontaneous internal carotid artery dissection (ICAD) is an uncommon, but not rare cause of headache and acute neurological deficit. We describe a female migraineur having h a d a change of headache-character accompanied by an incomplete Horner's syndrome. ICAD was diagnosed by means of extracranial triplexsonography in combination with a transcranial dopplersonography (TCD) a n d a magnetic resonance angiography (MRA). Case report: A 55 year old woman with a long lasting history of migraine

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was admitted because of a change of character of"her headache", still unilateral, but located more occipital and below the angle of the mandibule. She also complained about a pulssynchronous noise in the ipsilateral ear. On neurological examination we found an incomplete Horner's syndrome with ptosis and miosis. Extracranial triplexsonography performed immediately after clinical investigation revealed a high-resistance flow pattern signal along the internal carotid artery (ICA) without significant atherosclerotic changes of the vessel wall. TCD detected a cross-flow to the affected side. MRA showed a subtotal occlusion in the upper cervical part of the ICA with ah intramural hematoma. Our patient was treated with heparin intravenously for 14 days followed by an oral anticoagulation therapy for three months. Background: Pain is the most common symptom of an ICAD, as figured out by Biousse it was seen in 74 % of all patients, headache was ipsilateral in 79 %, cervical and facial pain was always homolateral. A painful Horner's syndrome was diagnosed in 31% of all cases,but in 16 % it was the only manifestation. In absence of ischemic signs, it is by far the most frequent presentation of ah extracranial ICAD. The combination of triplexsonography and MRA offers a very useful non-invasive modality for early diagnosis and serial follow-up examinations. The overall sensitivity of sonography asa combination of TCD and extracranial triplexsonography has been shown by Sturzegger to reach 95 % for detection of a clinically suspected carotid artery stenosis. Because of the limitations of sonography MRA techniques are necessary to illustrate the artery in its entire lenght and to detect the intramural hematoma. Conclusion: Our case iUustrates the value of triplexsonography of the extracranial carotid artery in a migraineur with ICAD, which must be considered as possible reason of painful Horner's syndrome until proven otherwise. 18 Creutzfeldt-Jakob, Pick, Lewy & Co. B. Mollenhauer, D. Varges, I. Zerr, C. Jacobi, L. Cepek, S. Hengst, M. Otto, S. Poser (Goettingen, D) Since 1993 until may 1999, 846 patients, who were suspected to have Creutzfeldt-Jakob disease (CJD) have been noted and seen by the nationwide German Surveillance Unit for CJD. After visiting them in their treating hospitals we classify them according to the current clinical classification criteria for CJD (established by the WHO 1998 and the BIOMED 2-study 1998). Among these 846 patients we classified 201 as"probable CJD" and 66 as"possible CJD". In 310 cases we obtained neuropathological verification. 269 patients we had to classify as "other disease" because of insufficient clinical symptoms and atypical technical investigations. In recent studies we investigated the spectrum of differential diagnoses among these "other cases" originally notified as CJD. Alzheimer's disease foUowed by vascular dementia and inflammatory CNS-diseases were the most frequent final diagnoses. The airo of this actual study was to examinate neurodegenerative diseases in more detail (about 50% of al1 "other diseases"): Alzheimer's disease, dementia with Lewy bodies, multiple sytem atrophy, corticobasal degeneration, frontotemporal dementia. 155 patients could be classified according to the current classification criteria ot~ these diseases: 58 patients had Alzheimer's diseases, 9 patients had dementia with Lewy bodies, 3 hada multiple system atrophy, 3 had corticobasal degeneration and 6 patients h a d a frontal degeneration. 28 of these patients died and we got neuropathological verification of these diseases.We compared clinical symptomatology, as well as the results of the technical investigations such as EEG, MRI and CSFanalysis between these other diseases and CID patients in order to find discriminating features. 19 Recurrent nonhemorrhagic mass lesion due to cerebral amyloid angiopathy. B.Vandersmissen, I. Salmon, J. Hildebrand (Brussels, B)

Introduction: cerebral amyloid angiopathy (CAA) is characterized by acellular thickening of the waLls of small and medium-sized arteries, and less often veins, due to amyloid deposition. CAA is often asymptomatic. Mass effect is mosfly due to intracerebral hemorrhage (ICH) and exceptionally due to amyloidoma. CAA may be associated with primary angiitis of the central nervous system (PACNS), which is characterized by granulomatous or lymphocytic perivascular infiltrates and systemic inflammatory signs. Recently rare cases of CAA presenting a s a pseudotumoral lesion, with or without signs of PACNS have been described. We now report on a patient, who presented an ICH and then two consecutive, non hemorrhagic, expansive cerebral lesions due to CAA. Case report: a 59-year old man of Turkish origin, was admitted because of progressive cognitive decline. His history started at the age of 46,when he h a d a left parieto-occipital ICH, attributed to hypertension. At discharge

only a mild dysphasia was present, but no visual field defect. Two years later, he developed a right hemianopsia. Brain MRI revealed a left parieto-occipital mass lesion, not enhanced by Gadolinium. Biopsy showed only amyloid deposition in the arterial wall. His medical condition remained stable during the following 11 years. Few months prior to this admission, his family noted a progressive memory decline and orientation difficulties. Neurologic examination showed a global cognitive dysfunction with a MMSE score of 16/30. His gait was slow and unsteady. Brain MRI revealed a diffuse expansive proces in the right hemisphere, with an important mass effect and no Gadolinium enhancement. To rule out a tumor, a new biopsy was performed and showed isolated cerebral amyloid angiopathy. Discussion: rare cases of nonhemorrhagic expansive cerebral lesions, associated with CAA have been published. In most histopathological examination showed amyloidoma or PACNS. Exceptionally, as in our patient, isolated CAA was found. This case is unique because of its recurrent character. To our knowledge, this is the first report of two consecutive nonhemorrhagic mass lesions, caused by CAA. We suggest that CAA should be considered in the differential diagnosis of non-enhancing cerebral mass lesions, especially if a history of ICH is present.

Oral session 4 Ataxias 20 Clinical and genetic study of autosomal recessive cerebellar ataxia with retained tendon reflexes in Tunisia. G. Eleuch-Fayeche, R. Amouri, S. Belal, C. Ben Hamida, I. Turki,. Ben Hamida, M. Ben Hamida, F. Hentati (Tunis, TN)

The objective of this study is to report a phenotype genotype study of patients with autosomal recessive cerebellar ataxia with retained tendon reflexes (ARCARR). Background: Recent molecular genetic analysis of early onset cerebellar ataxia with retained tendon reflexes (EOCA) patients showed the genetic heterogeneity of this syndrome. Some patients shared friedriech's ataxia (FA) mutation (friedriech's ataxia with retained tendon reflexes or FARR) and in others the gene locus is linked to autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) locus. Methods: Starting from 20 patients selected on clinical criteria of EOCA a field study was carried out and allowed the analysis of 78 patients belonging to 20 families. All the patients were clinically evaluated according to the International Cooperative Ataxia Rating Scale.A genetic linkage study using markers spanning known autosomal recessive ataxias loci [FA locus, ARSACS locus, ataxia with isolated vitamin E deficiency (AVED) locus and infantile onset spino-cerebellar ataxia (IOSCA) locus)] was performed. Results: 25 % of patients ate linked to ARSACS locus. This group is characterized by early age of onset, brisk knee jerks, absent ankle reflexes mixed peripheral neuropathy and severe disturbances of sensory evoked potentials (SEP). 5 % of patients are linked FA locus. These patients showed similar peripheral neuropathy than FA whereas SEP atea less involved. Genetic linkage with autosomal recessive cerebellar ataxias loci is excluded in 70% of patients. In this last group, clinical, neurophysiological and nerve biopsy data allows to isolate three phenotypic subgroups; one with similar to ARSACS phenotype, the second with variable jerk's pattern between members of the same family and the third group with brisk tendon reflexes in all limbs. Conclusion: EOCA is clinically and genetically heterogeneous. At least two three loci involved to be identified. 21 Cerebellar ataxia with autoantibodies to glutamic acid decarboxylase. Treatment with intravenous immunoglobulin. I. E. Markakis, E. Alexiou, M. Xifaras, A. Tsakiris, S. Tsalavoutas, N. Matikas (Athens, GR) Background: Autoantibodies to glutamic acid decarboxylase (anti-GAD) are a common finding in insulin-dependent diabetes mellitus (IDDM) and stiffman syndrome. Recently they have been reported in a few cases of other neurological disorders like subacute cerebellar ataxia, therapy-resistant epilepsy and palatal myoclonus.

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Case history: A 70-year old woman was admitted in our department with an 18-month history of progressive gait disturbance, vomiting and dysarthria. On neurological examination there was a severe ataxia of stance and gait, dysmetria, dysdiadochokinesis, marked dysarthria a n d a multidirectional gaze-evoked nystagmus. Brain MRI revealed a mild diffuse cerebellar atrophy. On cerobrospinal fluid (CSF) analysis, a moderate elevation of IgG and IgG index was found with detection of oligoclonal bands. Testing for antibodies against onconeural antigens (Yo, Hu, Ri) was negative. High levels of anti-GAD antibodies were detected in CSF and serum by a radioimmunoassay method, with evidence of intrathecal synthesis. In addition, anti-pancreatic islet antibodies (IA-2), anti-thyroglobulin (HTG) and anti-thyroid peroxidase (TPO) were present in patient's serum. Blood glucose levels were normal and there was no family history of IDDM or ataxia. There was no evidence of viral infection or neuroborreliosis. Underlying malignancy, systemic disease and vitamin B12 or E deficiency were excluded. Because of the reported beneficial effect of intravenous immunoglobulin in stiff-man syndrome, the patient was given three 5-day courses of IgG, 0.4 g/kg/day, at monthly intervals. Severity of ataxia was assessed according to the International Cooperative Ataxia Rating Scale (ICAR). Four weeks after her final treatment session a considerable improvement was observed. Nystagmus and vomiting were absent and the ICAR score was reduced by 9 points compared to her initial assessment. Conclusions: The search for anti-GAD antibodies in patients with cerebellar ataxia of uknown aetiology offers an important therapeutic option in an otherwise untreatable disorder. 22 Cerebellar Ataxia with anti-Glutamic Acid Decarboxylase Antibodies and Polyglandular Autoimmune Syndrome - A Case Report. S. Rueegg, M. Buehlmann, M. Stahl, A. I. Steck (Basel, CH) Background: Subacute or chronic progressive cerebel]ar ataxia associated with anti-glutamic acid decarboxylase antibodies (anti-GAD-Ab) of nonparaneoplastic origin is a newly recognised clinical syndrome. Often, these ~atients have coexistent type I insulin-dependent diabetes mellitus (IDDM) and/or other autoimmune endocrine disorders (polyglandular autoimmune syndrome (PGA)). Methods: We reporta case of cerebellar ataxia with anti-GAD-Ab and PGA. Case report: A 62 year-old woman complained of progressive gait unsteadiness and blurred vision. Clinical examination revealed vertical gazeevoked nystagmus, gait and stand ataxia and brisk reflexes in the legs. CSF examination was normal. Infra-red oculography revealed saccadic smooth pursuit. Motor-evoked and somatosensory-evoked potentials were normal. Cranial MRI showed slight cerebellar atrophy. A search for occult cancer was negative. Routine laboratory results were normal as were testing for rheumatologic and infectious diseases, for TSH, erythrocyte-bound folic acid, vitamin E, anti-intrinsic factor-, anti-TSH receptor-, anti-gliadin- and paraneoplastic antibodies. The anti-GAD65- and anti-GAD67-Ab-levels were markedly elevated. Additionally, increased levels of anti-parietal cell antibodies and cobalamin deficiency indicated latent pernicious anemia. Positive anti-thyroid peroxidase- and anti-thyroglobuline antibodies showed silent autoimmune thyroiditis. We considered that the cerebellar ataxia was due to an autoimmune process associated with anti-GAD-Ab and treated the patient with intravenous immunglobulins (0.4 g per kg body weight daily for 5 days), but no improvement occurred. Conclusion: In cases of subacute or chronic progressive cerebellar ataxia of unknown origin, a search for anti-GAD-Ab is warranted, especially when other autoimmune disorders such as IDDM, autoimmune thyroiditis or pernicious anemia are present. Our case demonstrates that cerebellar ataxia can precede theclinical onset of other autoimmune manifestations by months or years. The exact pathogenetic mechanisms of anti-GAD-Ab-induced cerebellar ataxia are still unknown. Immunomodulation with intravenous immunglobulins has been reported to ameliorate the course of the disease but they did not show any improvement in our case. 23 A Clinical Study Of Idiopathic Late Onset CerebeUar Ataxia. V. Villanueva, M. Garc› L. Bataller, ]. ]. Vflchez (Valencia, E) Introduction: Idiopathic late onset cerebella ataxias (ILOCA) is group of progressive not fully defined cerebellar disorder in which genetic or acquired known causes are excluded. This picture requires a thorough work up. Objective: To analyse the clinical profile, follow up and outcome of an ILOCA series. Patients and Methods: ILOCA was considered any isolated patient with

an unexplained progressive cerebellar ataxia beginning after the age of 25 years and undertaking a minimum of six month follow-up. Laboratory investigations included: an adapted ataxia rating scale, cerebral and spinal MRI, central and peripheral nerve conduction, genetic screening for inutations of SCA and Friedreich ataxia genes, thyroid hormones, a panel of antitissue antibodies and serum vitamin levels. CSF quantification of 14-'3-3 and antineuronal antibodies were availab]e in almost all patients. Muscle biopsy and specific biochemical studies (i. e. mitochondrial) were performed in selected cases. Results. Initially 37 patients fulfilled the criteria for ILOCA. In the course of the study 4 cases were dropped out after discovering affected close relatives. Six definitive diagnoses were achieved: 1 paraneoplastic, 1 Creutzfeldt]akob disease, and 4 cases harbouring the Friedreich ataxia mutation. From the 27 cases of"real" [LOCA, 17 patients evolved with a pure cerebellar syndrome and 10 of them, called the "plus" group, manifested additional features (ophthalmoparesis, pyramidal, parkinsonism or autonomic). Three cases of the latter group reached the criteria of multiple system atrophy. Conclusions: Afler exhaustive investigations and prolonged follow up of ILOCA definitive diagnose is not achieved in 70% of cases. These patients representa heterogeneous group because there are at least two different clinical profiles.

24 Idebenone in Friedreich's Ataxia: preliminary results of a double-blind dinical trial after six months of treatment. C. Mario.tti, L. Marano, D. Torta, A. Solari, C. Fiorentini, S. Di Donato (Milano, I) Friedreich ataxia is the most common inherited ataxia with an estimated prevalence of 1 in 50,000. The disease is characterized by progressive gait and limb ataxia, dysarthria, sensory loss, pyramidal weakness of the lower limbs. In 90 % of the cases, a hypertrophic cardiomyopathy is present. The disease is due to mutations in the gene coding f o r a mitochondrial protein, named frataxin. It has been recently reported that treatment with Idebenone,a shortchain quinone analogue, was associated with a substantial decrease in myocardial hypertrophy in three patients. (Rustin, et al., 1999) We are carrying out a randomized, double-blind placebo-controlled on the efficacy of idebenone in Friedreich patients with hypertrophic cardiomyopathy. Echocardiography and neurological examination (Ataxia Rating scale) were scheduled at the initiation of the treatment and after 6 and 12 months.A total of 29 patients have been randomized to either idebenone (5 mg/kg/die) or placebo. There were 6 females and 23 males,the mean age of participants was 26.5 years (SD= 8.2; range 14-47); the mean disease duration was 14.3 years (SD=7.54; range 2-32 years). One patient died 5 months after the enrolment, because of diabetic ketoacidosis. Data on 22 patients with 6-month foUow-up showed a median decrease of the septal thickness, assessed by echocardiography, of 0.61mm in the group assigned to idebenone, versus a median increase of 0.41 m m in the placebo group (Wilcoxon's sign rank test, p=0.04). No significant differences were found for the left ventricular posterior wall thickness, and for the scores on neurological ataxia rating scale. Our preliminary results are in agreement with previous findings, and indicate a possible positive effect of idebenone treatment on hypertrophic cardiomyopathy in Friedreich patients 25 Extrapyramidal Motor Symptoms in Spinocerebellar Ataxia Type 2. S. Boesch, J. Mª P. Hollosi, S. Ung, •. Wissel, W. Poewe (Innsbruck, AT) Background: Spinocerebellar ataxia type 2 (SCA2) is neuropathologically not only characterized by olivopontocerebellar atrophy but also by neuronal ce11loss in the basal ganglia. Objective: To study the prevalence and the clinical characteristics of extrapyramidal motor symptoms (EPMS) in three multigenerational SCA2 families. Methods: 18 genetically confirmed SCA2 patients were screened for EPMS. In case of EPMS Unified Parkinson's Disease Rating Scale (UPDRS) and/or Tsui scale (semiquantitative rating scale for cervical dystonia) were performed. Patients with cervical dystonia underwent EMG-polygraphy with bilateral surface electrode recordings of sternocleidomastoid and trapezius muscles and needle electrode recordings of splenius capitis musdes bilaterally. 'Results: Applying UPDRS we obtained uni/bilateral action tremor in 5/18 SCA2 patients. Bradykinesia defined by an impairment of alternating hand movements was present in 9/18 (50 %). Rest tremor and rigidity were absent. Interestingly, 11/18 patients (61%) presented with cervical dystonia. Six out them agreed to EMG-polygrapby which distributed a disturbance of reciprocal inhibition of neck muscles in all of them and confirmed cervical dystonia. Their mean age at onset of disease was 35 years (range 26-55), disease

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duration ranged from 5-15 years(mean 11.4), and their triplet repeats were on average 39.8 (range 38-43). Conclusion: Involvement of the basal ganglia in SCA2 is reflected by various EPMS. Still, within the range of triplet repeat expansions in our SCA2 population dystonic features appear to be more frequent than parkinsonian symptoms. 26

Clinical and genetic analysis of a new atypical autosomal dominant spinocerebellar ataxia. D. Devos, S. Schraen-Maschke, I. Vuillaume, K, Dujardin, P. Nazze, C. Willoteaux, A. Dest› B. Sablonni~re (Lille, F) Objective: To reporta new forro of spinocerebellar ataxia (SCA) clinically and genetically. Background: The autosomal dominant cerebellar ataxia (ADCAs) are a clinically heterogeneous group of disorders characterized by ataxia, dysarthria and intention tremor involving some degree of cerebellar dysfunction a n d a varying degree of signs from other components of the nervous system. The mutations for SCA1, 2, 3, 6, 7, 8, and 12 have been identified and caused by an expansion of a CAG o r a CTG repeat in the coding region of these genes. Four other SCA loci on chromosomes 16, 11, 22, 15 and 19 have been identified and named SCA4, SCA5, SCA 10, SCA 11 and SCA 13. The growing heterogeneity of autosomal dominant forros of these diseases explains that the genetic aetiologies of at least 20% of ADCAs have yet to be elucidated. Methods: We ascertained and clinically characterized a four-generation pedigree segregating an autosomal dominant phenotype for SCA. We performed direct mutation analysis, RED analysis and linkage analysis for all known SCA loci. Results: Direct mutational analysis excludes SCA1, 2, 3, 6, 7, 8 and 12; and genetic linkage analysis excludes SCA4, 5, 10 and 11 giving lod scores less than - 2 throughout the candidate regions. Clinical analysis of individuals in this family shows that all affected members have gait ataxia and akinesia with associated clinical features of dysarthria, hyporeflexia, mild dementia and essentially normal eye movements. Cranial magnetic resonance imaging shows atrophy of the cerebellum without involvement of the brainstem. Analysis of the age at onset in four parent-child pairs reveals that the onset of the disease was significantly earlier in the offspring with anticipation ranging from 12 to 19 years. Conclusion: This family represents a new and genetically distinct form of SCA characterized by a cerebellar ataxia having distinctive associated clinical features of prominent extrapyramidal signs.

Oral session 5

Immunology - 1 27 Antibodies against vohage-gated potassium channels in Morvan's syn-

drome and neuromyotonia. E. Tª252 S. Longe, R. Liguori, E Montagna, A. Vincent (Oxford, UK; Bologna, I) Background: Morvan's syndrome is a rare disease characterised by neuromyotonia, autonomic and central nervous system (CNS) involvement. A1though existence of antibodies against voltage-gated potassium channels has been recently established, their causative role in the CNS symptoms of Morvan's syndrome has not been investigated. Materials and Methods: Serum samples of 3 patients with Morvan's syndrome (M1 had sleep disturbance; M2 and M3 had thymomas), 7 patients with neuromyotonia (3 with thymomas), and 3 healthy controls, were used for immunohistochemistry (IHC) and radioimmunoassay (RIA) studies. IHC was performed on frozen sections of adult rat brain and of neonatal mouse heads (postnatal days (P) 1, 5, 10, 15) by using sera at 1:200 dilution on fixed tissues. The levels of orexin and neuropeptide Y, which are involved in sleep pathways, were examined in Ml's cerebrospinal fluid (CSF) using a competitive RIA. To try to demonstrate functional effects of the antibodies, 1 rol of plasma from M 1 a n d a healthy control were injected into two groups (A, B) of five female mice for four days. The mice were tested for light/dark preference, exploratory behaviour and activity on an accelerating rotor rod

before and after the injections. Statistical comparisons for significant differences between different groups were carried out by ANOVA method. Results: Ml's serum antibodies bound to the cytoplasm of most CNS neurones. In addition, they bound more strongly to the rostral portions of the parafascicular nuclei (PFN) and fasciculus retroflexus (FR) of the medial thalamus in both adult and developing brain sections. These structures are involved in sleep. Interestingly, antibodies from M2 and M3, did not show binding to these regions. All the Morvan and neuromyotonia sera showed weak to strong binding to different layers of hippocampus, which is known to express VGKCs. Ml's orexin and neuropeptide Y levels were within normal limits. There were no significant differences between Morvan's and healthy control's plasma-in)ected mice in behavioural tests. Discussion: Antibodies against VGKCs seem to playa causative role in clinical symptoms of Morvan's syndrome and especially in sleep disorder related with this disease. The antibodies may target particular pathways in the nervous system that are involved in sleep regulation. However, some of the reactivity that we detected, appeared to reflect the presence of a thymoma, complicating the interpretation of the results. 28

Differentially expressed cytokines and immunoregulatory genes indicate an active regulatory role of h u m a n cerebral endothelial cells (HCEC) at the blood brain barrier (BBB). B. Kallmann, S. Wagner, V. Hummel, K. Toyka, P. Rieckmann (Wª D) Background: Cerebral endothelial cells as main cellular constituents of the blood brain barrier (BBB) are not only involved in maintaining metabolic homeostasis of the CNS, but are also known to control cellular trafficking at sites of inflammation, trauma, infection and ischemia. Increasing evidence supports an active role of cerebral endothelial cells under normal and pathological conditions of the CNS. Objective: The aim of this study was to search for characteristic gene expression in human cerebral endothelial cells (HCEC) in comparison to endothelial cells of other origin. Methods: By using cDNA array techniques to screen for large panels of differentially expressed genes (in total 375 using Human Cytokine Expression Array from R&D Systems) we compared primary cultures of HCEC with h u m a n umbilical vein endothelial cells (HUVEC) unstimulated and after TNF-alpha treatment. Differences at the tuRNA level were flirther confirmed at the protein level by ELISA, in situ immunohistochemistry and immunocytochemistry. Restdts: Distinct gene expression profiles in both groups of endothelial cells could be observed, severa1 genes were newly described in association with HCEC. 31 genes were identified to be exclusively or predominan•y expressed in HCEC rice versa 17 genes in HUVEC. Differences found at the tuRNA leve1 were further confirmed for protein expression in cell cultures, brain tissue and umbilical cord. Several genes were found to be characteristic for HCEC including members of the family of angiogenic faetors, cytokines, chemokines, binding proteins, proteases and of the TGF-beta and TNF-superfamily and their receptors. Conclusion: Our study detected distinct gene expression pattern of HCEC compared to HUVEC. These markers for cerebral endothelial cells support the important role of HCEC in angiogenesis, growth regulation and immunomodulation at the BBB. 29 Effects of Interferon beta on dendritic ceUs. E. V. Wiesemann, D. S6nmez, E Heidenreich, A. Windhagen (Hannover, D) Interferon beta (IFN-b) is one of the type I interferons, a group of pleiotropic cytokines produced in response to viral infections. Type I interferons are used therapeuticaUy in chronic viral hepatitis, some forros of cancer and more recently in multiple sclerosis, an autoimmune disease of central nervous system myelin. However, a s a potential side effect type I interferons can also induce autoimmune disease. Since dendritic cells play an important role in the regulation of the immune response we studied the effects of IFN-b on the phenotype and function of these cells at different stages of maturation. Dendritic cells were generated by culturing monocytes from peripheral blood with IL-4 and GM-CSF and maturation was induced with TNF-alpha. When IFN-b was added to the monocyte-culture the development of DCs was inhibited, However, when added at later stages when immature DCs had already developed IFN-b caused a concentration-dependent upregulation of surface expression of the costimulatory molecules CD80, CD86 and HLA-DR on immature and maturing DCs, but had no effect on mature DCs. Staining for the high-affinity IFN-receptor (CD 118) revealed that mature DCs do not express the receptor unlike the other cell populations. Function of DCs was assessed by their ability to stimulate autologous T-cells to proliferate

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(AMLR) and secrete IL-13, IL-5 and IFN-gamma. Corresponding to the increased expression of costimulatory molecules on DCs an increase in AMLR was detected when IFN-b was added to DCs during maturation. In contrast, when immature DCs were incubated with autologous T-cells in the presence of IFN-b the AMLR was strongly inhibited, indicating that IFN-b has a direct antiproliferative effect on T-cells that dominates over the effect on DCs in our in vitro system. In summary, IFN-b has an immunostimulatory effect on maturing dendritic cells by increasing the expression of costimulatory and HLA molecules and therefore their capacity to present antigen. Effects of IFN-b in vivo will be dependent on the stage of maturation of DCs, local concentration of IFN-b and on influences on other cell types participating in the immune response. 30 The human Ma proteins: A family of four novel neuronal proteins. M. Schª D. ]enne, R. Voltz (Munich, Martinsried, D) Background and Goals: 2/3 of patients with paraneoplastic neurological syndromes harbour antibodies in their serum which recognize proteins expressed both in the nervous system and the associated tumors (onconeuronal proteins). Recently, we described two novel antibody reactivities, antiMa (Dalmau et al., Brain, 1999) and anti-Ta (Voltz et al., NEJM, 1999), and cloned the corresponding antigens, the Ma proteins. Here, we report on the four members of this novel protein family, some of theii molecular characteristics and expression pattern. Methods: DNA sequences were obtained by double strand sequencing. Sequences were screened for homologous entries in Genbank up to 01/01, and the entries analysed for homologies and amino acid composition. Exon/intron structure was analysed by PCR using the respective primers spanning the entire coding regions. Expression pattern of Ma-5 was analysed by Northern blot. Results: Resequencing the original vector pBSMA1 (Dalmau et al., 1999) we obtained ah corrected human Mal Sequence (hMalc; Genbank AF320308) with a different amino acid composition and multiple frameshifts with the consequence of a new stop codon a n d a predicted protein of 353 instead of 330 amino acids. Homology analysis in Genbank of this hMalc sequence revealed three more members of this Ma protein family: Ma2, Ma5 (al1 onconeuronal proteins recognized by the serum of patients with paraneoplastic neurological disorders) and MAP-1 (a Bax-associated pro-apoptotic protein; Tan et al.,in press),with strongest homology (greater than 50 %) between Mal and MAP- 1. Investigating the exon/intron structure we found that all are intronless genes and confirmed this by PCR on human chromosomes. Previously it was shown that Mal tuRNA expression is strongest in brain and testis, while Ma2 tuRNA is primarily found in brain and MAP- 1 in heart and brain. We complemented these data by finding Ma5 tuRNA expression in brain (major transcript 4,4 kb) and testis (major signal of 5,5 kb). This indicates different splice variants of Ma5 in different tissues. Conclusion: We present the corrected hMal sequence. Analysis of homologous sequences indicate a new protein family consisting of Mal, Ma2, Ma5 and MAP- 1. We also demonstrated that Ma 1, Ma2, Ma5 and MAP- 1 ate intronless genes and show expression of differentially spliced Ma5 transcripts mainly in brain and testis. These data wi11help to further understand the function of the Ma protein family. 31 Recovery from progressive, multifocal leukoencephalopathy (PML) is associated with virus specific production of interferon-gamma. E Weber, P. Young, H. Petry, C. Goldmann, W. Lfike, T. Weber (G6ttingen, Mª Hamburg, D) Background: Progressive multifocal leukoencephalopathy (PML) is ah almost fatal, demyelinating disease caused by ]C virus (JCV) in patients with severe immunosuppression. In most cases PML is fatal, but some long-term survivors ate describe& Studies about the cellular and humoral immune response in patients with PML ate rare. This is mainly due to the limited availability of viral antigen based on the difficulties to propagate JCV in cell culture. Objective: To investigate the proliferation and cytokine production of peripheral blood mononuclear cells (PBMC) and of the antibody response in a long term survivor and a rapidly deteriorating PML-patient. Methods: To obtain sufficient amounts of ]CV-related antigen, we expressed the major structural protein VP 1 of ]CV as virus-like particles (VP IVLP) in a baculovirus system. PBMC were isolated by ficoll gradient centrifugation and stimulated with VP1-VLP, tetanus toxoid (TT) and phytohaemagglutinin (PILA). Proliferation was determined by 3H-thymidine incorporation. IFN-gamma and IL-10 were measured in the culture su-

~~~~~%~~ ~~~~~~ ~ ~~~~~~~ ~~~~ ~ ~ ~ ~ ~ ,

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pernatant by enzyme linked immunoabsorbent assay (ELISA). In addition antibodies against VP1 were determined by ELISA. Results: The long term survivor showed a proliferative response a n d a strong production of interferon-gamma after stimulation with VP 1-VLP or PHA, which was severely suppressed in the rapidly deteriorating patient. In contrast the IFN-gamma response against TT was similar in both patients. Production of IL-10 was low after stimulation with all three antigens and showed no striking difference between the two patients. In addition the titters of antibodies specific for VP1-VLP were similar. Conclusion: PML with a fatal course coincides with an irnpairment of the cellular immune response, which is demonstrated by a suppressed proliferation a n d a failure of IFN-gamma production in presence of viral antigen. Proliferation and production of IFN-gamma in presence of a viral surface antigen, however, may be associated with convalescence. 32 Anti MOG antibody detection in sera from Multiple sclerosis, drug-resistant epilepsy and other neurological disease patients. R. Mantegazza, P. Cristaldini, C. Antozzi, C. Milauese, L. La Mantia, N. Mascoli, F. Cornelio, R. Spreafico, P. Bernasconi (Milan, I) Multiple sclerosis (MS) is an immune-mediated disease characterized by an infiltration of inflammatory cells within the CNS and demyelination. Several myelin proteins can be encephalitogenic, i.e. myelin basic protein (MBP), proteolipid protein (PLP) and myelin oligodendrocyte glycoprotein (MOG), the latter being expressed only in the CNS on the external layer of myelin sheaths and hence accessible to antibody attack. To test the immunoreactivity of MS sera against MOG, we produced the extracellular domain of MOG fused with the GST protein in E. coli. The recombinant MOG, produced and purified from the supernatant and from inclusion bodies, was cleaved from GST and used as antigen in ah ELISA assay. We tested 148 sera from MS patients, subgrouped in 106 relapsing-remitting, 17 progressive primary forros and 25 secondary progressive. Sera from 44 drug-resistant epileptic patients and from 46 patients affected by other neurological diseases (OND) were also included in the study. Sera from 227 healthy donors were tested as controls. Preliminary results showed that anti MOG antibodies were detected in 41% MS sera, with a predominance of the progressive form. Among epileptic patients, 27% of them were positive for anti MOG antibodies, while in 30 % OND patients anti MOG antibodies were detected. The presence of anti MOG antibodies indicates that a humoral response may playa role in lesion formation in MS. The presence of antibodies in epileptic patients might be related to the neuronal damage due to seizures. We ate currently extended the group of OND patients.

Oral session6

Immunology - 2 33

X-linked adrenoleukodystrophy: no association of serum anti-MOG antibody responses with polymorphisms in the 3'flanking region of the MOG gene. S. Schmidt, G.M. Marrosu, C.G. Haase, W. K6hler, T. Klockgether (Bonn, D; Cagliari, I; Essen, Wermsdorf, D) Background: The mechanisms of demyelination in cerebral forms of Xlinked adrenoleukodystrophy (X-ALD) are not fully understood.Although a cytotoxic T cell reaction strongly contributes to myelin degradation, there is indirect evidence that humoral immune responses might also be involved. We have previously shown that autoantibodies to myelin oligodendrocyte glycoprotein (MOG) are present in serum of various phenotypes of X-ALD in a frequency comparable to that of patients with Multiple Sclerosis (MS). Ob)ective: To test the hypothesis that aUelic variations consisting of (TAAA)n repeats in the 3'flanking region of the MOG gene might be associated with anti-MOG autoantibody responses. Methods: Allelic variations of MOG gene were analyzed by allele-specific PCR in 42 patients with X-ALD. Anti-MOG antibodies in serum were determined by ELISA and Western Blot, and serum levels of IL-4, IL-10, IL-6 and its soluble receptor components sgp 130 and sIL6R by commercially available ELISA. Results: The allelic

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distribution of MOG gene variations in the 42 X-ALD patients was not distinct from that of healthy Caucasian controls (Malfroy et al., Hum Genet 1995; 96: 737-738). Moreover, the allelic variations of MOG gene were neither associated with anti-MOG autoantibodies nor with clinical phenotypes of X-ALD. Finally, no association with serum levels of IL-4, IL-10, IL-6, spg130 and sIL6R were found. Conclusions: Allelic variations in the 3'flanking region of the MOG gene are not associated with humoral immune responses against MOG or clinical phenotypes in patients with X-ALD. 35 Differential expression of BDNF in human cerebral and umbilical endothelial cells. A. Bayas, V. Hummel, B. A. Kallmann, K. V. Toyka, P. Rieckmann (Wuerzburg, D) Background: In multiple sclerosis lesions a potentially neuroprotective role of brain derived neurotrophic factor (BDNF),produced byimmune cells, has been discussed. Recent data suggest, that apart from other cell types endothelial cells of different origin are also capable of producing BDNF. Concerning possible neuroprotective properties we raised the question, ir human cerebral endothelial cells (HCECs) differ from endothelial cells outside the central nervous system (human umbilical endothelial cells, HUVECs) regarding their extent of BDNF expression under unstimulated and inflammatory conditions. Materials and methods: HCECs and HUVECs were cultured for 24 and 72h untreated and treated with TNF-alpha. BDNF mRNA was detected by a human cytokine cDNA expression array (R&D Systems) after 24h, BDNF protein levels were measured by ELISA. Results: cDNA array analysis: BDNF cDNA levels in HCECs were detected already under unstimulated conditions and further increased after TNF-alpha stimulation. In HUVECs BDNF cDNA levels were below the detection limit under unstimulated as well as stimulated conditions. Protein expression: There was a significantly higher basal BDNF protein expression in HCECs than in HUVECs after 24 and 72h (24h: HCECs 124 -+ 46 pg/ml, HUVECs 22 -+ 5 pg/ml; 72h: HCECs: 276 +- 109 pg/ml, HUVECs 44 -+ 4 pg/ml; mean +_ SEM). TNF-alpha treatment resulted in a significant increase of BDNF protein expression in HCECs after 72h (2fold induction), whereas in HUVECs a significant decrease (by 63 _+5 %) could be observed. Conclusions: Our results demonstrate, that HUVECs and HCECs differ regarding the extent of BDNF production with a higher production in HCECs. Furthermore we could show, that endothelial cells of cerebral but not umbilical origin respond to TNF-alpha treatment by increased BDNF production. This increase in BDNF expression by HCECs after TNF-alpha treatment might contribute to tissue repair in the central nervous system during inflammation. 36 Clonal CD8+ T cell expansion in the cerebrospinal fluid from MS patients. M. ]acobsen, S. Cepok, E. Quak, M. Happel, R. Gaber, A. Ziegler, B. Omer, R. Holzbach, S. Schock, W.-H. Oertel, N. Sommer, B. Hemmer (Marburg, D) Multiple sclerosis is a chronic inflammatory demyelinating disease of the central nervous system. Although the etiology of MS is sti11 unknown, ir is widely believed that T cells playa central tole in the disease pathogenesis. To identify and characterize disease relevant T cells in MS, we analyzed the TceU receptor V beta chain repertoire of CD4+ and CD8+ T cells freshly isolated from the cerebrospinal fluid and peripheral blood by flow cytometry. We found significant differences in the expression of individual TCRBV chains between CSF and blood primarily on CD8+ T cells and to a much lesser extent on CD4+ T cells. Expanded CD8+ T cells mainly showed a memory phenotype. The over-expression of specific TCRBV chains was found to be stable over months. In two patients studied, TCRBV skewing of CD8+ CSF T cells was found to be caused by ah expansion of T cells with highly similar of identically rearranged TCR-beta and TCR-alpha chain sequences. Our findings demonstrate a selective dona1 accumulation of memory CD8+ T cells in the CSF ofMS patients strougly suggesting a role of those cells in the disease pathogenesis. 37 Expression of chemokine receptors in oligodendroglial cells. M. Stangel, D. Nguyen (Berlin, D) Chemokines ate small proteins that actas chemoattractants and activators in leukocytes during physiological and inflammatory processes. In the CNS chemokine receptors have been shown to be expressed on neurons, astrocytes and microglia, but their function in the CNS is poorly understood.

GRO-alpha is considered to influence proliferation of cultured oligodendrocyte progenitor cells (OPC), but neither the mechanism is known, nor is there evidence for the expression of chemokine receptors on OPC. We have used RT-PCR specific for various chemokine receptors in the oligodendrocyte precursor cell line CG-4. mRNA for the chemokine receptors CXCR1, CXCR2, CCRI and CCR4 was found, but not for CCR2, CCR3, and CCRS. In addition, both CG-4 cells and primarily cultured rat OPC were immunoreactive for CXCR2, the potential receptor for GRO-alpha. These findings demonstrate that the chemokine/chemokine receptor system is probably also involved in the regulation of oligodendroglial cells during developmental processes and may even have implications for repair mechanisms in demyelinating diseases like multiple sclerosis. 38 Axonal expression of adhesion molecules and remyelination in multiple sclerosis. P. Charles (1), B. Stankoff (1, 2), M. S. Aigrot (1), D. Seilhean (3), R. Reynolds (4), B. Zalc (1), C. Lubetzki (1, 2) 1. INSERM U-495, 2. F› de Neurologie I, 3. Laboratoire de Neuropathologie, H6pital de la Salp~tri~re, ParŸ 4. MS Brain Bank, Imperial College, Charing Cross Hopital, London Many factors have been shown to promote central nervous system myelination, but few have been shown to be inhibitory.We have recently showed that expression of the polysialylated forro of Neural Cell Adhesion Molecule (PSA-NCAM) at the surface of axons, could negatively regulate myelin formation. In an in vitro co-cultures system of neurons and oligodendrocytes we have shown that PSA-NCAM axonal expression is down regulated as myelination proceeds and ir PSA-NCAM expression is prematurely de~ creased by either antibodies or enzymatic removal of PSA moieties, myelination is increased 4- to 5-fold. Those results were confirmed in vivo in the optic nerve. To determine whether in some demyelinated diseases such as multiple sclerosis (MS), failure of remyelination could be related to reexpression of negative signals such as PSA-NCAM, we analysed PSA-NCAM axonal expression on 22 post mortem multiple sclerosis frozen brains by immunohis~ tochemistry. In the vast ma)ority of cases investigated we show that some axons in the plaques re-express PSA-NCAM. Our results strongly suggest that re-expression of PSA-NCAM at the axonal surface could be involved in the failure of remyelination in MS, despite relative sparing of oligodendro~ cytes.

Oral session7

Multiple Sclerosis 1 39 Acute Disseminated Encephalomyelitis and Multiple Sclerosis: A Magneti-

zation Transfer and Diffusion Tensor Imaging Study. M. Inglese, E Salvi, G. Iannucci, G. Mancardi, G. ComŸ M. Filippi (Milano, Bologna, Genoa, l) Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease which is usually monophasic and occurs aftera viral illness of vaccination. At onset, patients with ADEM ma), have a pattern of magnetic resonance imaging (MRI) abnormalities indistinguishable from of multiple sclerosis (MS). However, MS is not limited to macroscopic lesions visible on conventional MRI scans, but ir also involves the normal appearing brain tissue (NABT).We performed magnetization transfer imaging (MTI) and diffusion tensor imaging (DTI) to evaluate whether abnormalities in NABT can be detected in the brain and spinal cord of patients with ADEM. We studied 8 patients with ADEM (median disease duration=2.5 yrs, range=l-9 yrs), 10 patients with MS (median disease duration=4.0 yrs, range=l-7 yrs; median EDSS=2.0, range=l.0-6.0) and 10 age- and sexmatched healthy volunteers. Dual echo, 2D gradient echo (GE) with and without an MT saturation pulse, pulsed-gradient spin-echo echo-planar (EPI) pulse sequence and post-contrast Tl-weighted scans of the brain were acquired. Fast short tau inversion recovery (fast-STIR) and 2D gradient echo

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(GE) with and without an MT saturation pulse were acquired for imaging the spinal cord. We measured: brain T2 and T1 lesion volume (LV), MTR histogram-derived metrics of the brain NABT and cervical cord and mean diffusivity (MD) histogram-derived metrics of the brain NABT. Volumes of brain T2 and TI lesions were not significantly different between ADEM and MS patients. No significant differences were found between patients with ADEM and controls for any of the MTR and MD histogram-derived quantities. A significantly lower average brain NABT-MTR histogram (peak position p < 0.001) a n d a significantly higher average MD (p---0.03) were found in MS compared to ADEM. MS patients h a d a significantly lower average cervical cord MTR and histogram peak position (p=0.05 and p=0.008, respectively). This study shows that, in patients with ADEM, the pathology is confined to macroscopic lesions. Assessing NABT change in patients with ADEM might be useful in the diagnostic work-out and for increasing our understanding of the pathophysiology of different CNS demyelinating conditions. 40 Is benign multiple sclerosis a true entity? Lessons from 30 years follow-up in a French multiple sclerosis population. M. Coustans, E. Le Page, F. Le Duff, ]. Yaouanq, E. Sartori, ]. Chaperon, G. Edan (Rennes, F) We attempt to determine the characteristics of multiple sclerosis (MS) patients with a benign course defined as EDSS _<3 at 20 years (y) of disease duration and to evaluate their disability lO y later (at 30 y followup). There is few longitudinal data that would help to predict the disease course of MS identified as benign ata given time. the heterogeneous criteria used to definite benign MS (BMS) may account for the varying prevalence (5 to 40%) found in the literature. We found of interest to evaluate the progression of the disease after 20 y of follow-np. A total of 292 clinically definite MS patients whose disease onset was at least 20 y before inclusion (point date: 06/01/00) were extracted from our database using EDMUS (European database for multiple sclerosis). Seventythree (25 %) of them were classified as BMS at 20 y of disease duration, and 219 (75%) as having a moderate or severe disease (Non-BMS). The two groups were compared for demographic, clinical data, course of the disease and number of relapses during the first y of the disease. Comparisons were made using the chi2 square test and non-parametric methods when appropriate. We further examined 33 BMS patients at 20 y whose disease duration was 30 y at inclusion. At 20 y disease duration, we found that BMS were more often women (sex-ratio F:M = 3 vs 1.6, p < 0.046) and started their disease at a younger age (median age at onset: 23 vs 26.5 y, p < 0.001) than non BMS. All patients with BMS as only 77 % of Non-BMS h a d a remitting course at onset. No difference was found between the two groups in term of presenting signs, first year number of relapses or interval between the two first relapses. Among the 73 initial BMS patients, 33 reached 30-y follow-up. Interestingly 54% of these patients had developed a secoudary progressive disease during ten additional y follow-up. Twenty five percent of our MS population followed 20 y had a benign course. Three factors were of good prognostic value at MS onset: gender (female), early age and remitting course. However, with a longer-term followup, 54% of this apparently BMS h a d a progressive worsening of their disability, indicating that BMS is still a questionable entity. 41 Acute disseminated encephalomyelitis (ADEM): Clinical, CSF and MRI findings, and differentiation from Multiple Sclerosis (MS). S. Schwarz, A. Mohr, M. Knauth, B. Wildemann, B. Storch-Hagenlocher (Heidelberg, D) Objectives: Airo of our study was to describe the cliuical, CSF, aud radiological findings, and long-term follow-up in a cohort of patients with ADEM, and to determine possible prognostic factors for progression to MS. Methods: 40 adults (28 women, mean age 33.5a) diagnosed with ADEM were analyzed. At onset of disease, clinical symptoms, cranial MRI and CSF findings, and the response to a standardized treatment were documented. The final diagnosis of ADEM or clinically definite MS was established upon follow-up examiuation after 8-137 months. The patients with ADEM and MS were compared to detect differences between the two groups. Results: 15 patients had a preceding infection (n=14) or immunization (n=l). The most frequent clinical signs were motor deficit (80%), followed by sensory deficits, brainstem signs, and ataxia. CSF findings were highly variable; normal results were present in 20 %. Oligoclonal bands were positire in 65 %. 95 % of all patients improved during the acute phase of the disease. Upon follow-up, 14 patients had developed clinically definite MS. Of the

26 patients with the final diagnosis ofADEM,two patients had died, nine had minor, three moderate deficits,and 12 patients had no remaining symptoms. Patients with the final diagnosis of ADEM were older, more often hada preceding infection, clinical signs of brainstem involvement, a higher CSF albumin fraction, and infratentorial lesions. Conclusions: A substantial proportion of patients initially diagnosed with ADEM develop clinically definite MS upon long-term follow-up. We were notable to detect useful diagnostic criteria for the differentiation of a first episode of MS from monophasic ADEM. The term ADEM may still be employed a s a description of a clinical syndrome, but should not be used as a distinct entity until reliable diagnostic criteria have been developed. 42 Risk of developing multiple sderosis. Evidence from a French AfroCaribbean migrant population of Martinique (French West Indies). P Cabre, S Olindo, D Smadja (Fort de France, Martinique, F) Background: A number of migration studies have suggested that the risk of developing multiple sclerosis (MS) is largely determined before the age of 15 years. Martinique (French West Indies) is a particularly suitable atea in which to study the effects of migration on the risk of developing MS,because a large proportion (40 % + 3.4 %) of French Afro-Caribbeans (FAC) have immigrated for economical reasons in Metropolitan France (MF) and began to return in the early 1980s, as the economy improved on the island. FAC ate descendants of interracial mating that occurred between French Caucasians and black Africans in the 17th and the 18th centur~es. Methods: All FAC MS patients being 15-64 years of age, deriving from a population-based study, and prevalent on December 31,1999 were collected. Prevalence rates were calculated according to age at migration. We also evaluated demographic characteristics and blood group distribution in migrant and non migrant FAC healthy controls who were 15-64 years of age (N=800). Results: Sixty-seven patients (48 females, 19 males, ratio 2.72:1) were identified with definite of probable disease by the Poser criteria. The prevalence of MS in the FAC population 15-64 years old of Martinique was of 28.8/100,000 (95% CI 21.9 to 35.7). MS was about 2 times more frequent among migrant FAC (prevalence, 42.4/100,000, 95% CI 29.1 to 55.7) than among FAC born and raised in Martinique (prevalence, 19.8/100,000, 95% CI 12.5 to 27.1). FAC who had migrated before the age of 15 hada much more higher prevalence of MS (prevalence, 106.2/100,000, 95% CI 66.4 to 156) to that observed in FAC who had migrated after the age of 15 (prevalence, 28.9/100,000, 95 % CI 16.7 to 41.1). Demographic characteristics (age and sex distribution) were similar between non migrant and migrant FAC controls. Likewise, non migrant and migrant FAC, whatever the age at migration, did not show significant differences in the ABO and Rh blood distribution. This su.ggests that Caucasian admixture was similar between non migrant and mlgrant FAC. Conclusion: Our study evidences that environmental factors especially acting before 15 years of age might be the underlying cause for the higher susceptibility to develop MS among FAC who had lived in Metropolitan France, a well-known high risk area for the disease. 43 Demographic and clinical characteristics associated with health-related quality of life (HRQoL) in Israeli multiple sclerosis (MS) patients. S. Dishon, A. Tamir, I. Kirstein, H. Rawashdeh, A. Miller (Halla, IL) Background: The Israeli population of MS patients is unique in its heterogeneity, being part of the general heterogeneity of the country's population and specifically due to the considerable number of immigrants from highrisk zones, such as the former Soviet Union in the years 1990-2000. Despite growing interest in HRQoL of chronic disease patients, no study has been reported in recent years, on its characteristics in the IsraelŸMS patient population. Objective: To evaluate the impact of demographic and clinical characteristics on HRQoL of IsraelŸ MS patients. Patients & Methods: The recognized questionnaires, "MS Quality of Life-54" (MSQoL-54) and "Fatigue Severity Scale" (FSS), in their translated forms, were distributed to MS patients followed at the outpatient clinic of our MS centre. Demographic and clinical data, including EDSS, were extracted from the clinical records. For the questionnaires' evaluation a score range of 0-100 (higher number indicates better score) was utilised. Results: One hundred fifty eight patients, 117 female (74%),41 male (26%) aged 16.5-65 years (mean:41 + 11),completed the self-administered questionnaires during the year 2000. Among the Israeli born were 80 ]ewish and 10 Arab patients. Among the remaining participants were 32 immigrants from the former Soviet Union who arrived before 1990 ("old-timers") and 36 who arrived between 1990-2000 ("new-comers"). The overall mean score of the MSQoL-54 was 58.47 -+ 28.33 and of the FSS was 30.15 + 28.33. QoL scores in all domains, except for"cog-

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nitive functions" were inversely correlated with EDSS. No significant difference was found between females and males on almost any domain, except for females' significant lower scores in questions related to "emotional problems" (P < 0.04). Scores were significantly higher among the patients participating in the working-population, compared to those of non-working patients, even after controlling for EDSS. The "new-comers" reported significantly lower (worse) QoL scores on almost all domains, compared to both Israeli-born and"old-timers", even after controlling for EDSS. Conclusions: Our findings support the notion that cultural background, demographic characteristics and clinical status do affect HRQoL and FSS in MS patients. Additionally, this study emphasizes the fact that MS patients of distinct cultures differ in the significance they attribute to various abilities and states of being, as expressed in the HRQoL and FSS. 44 Association of HLA-DR 15 with female gender and younger age at diagnosis in multiple sderosis. A. E. Hensiek, S. J. Sawcer, J. Deans, A. Mander, E. Akesson, R. Roxburgh, E Coraddu, D. A. S. Compston (Cambridge, UK) An association of multiple sclerosis with class II alleles of the major histocompatibility complex (MHC), in particular the DRB1*1501-DQBl*0602 haplotype, is well established, but its role in determining specific features of this clinically heterogeneous disease is unknown, as few studies with large patient sample sizes have yet been performed. We have performed HLA typing for the DR15 phenotype on 729 individuals with multiple sclerosis, All patients underwent clinical assessment and a detailed evaluation of their patient records was undertaken. The presence of DR15 was associated with a younger age at diagnosis and female gender, but there was no associafon with disease course (relapsing-remitting/secondary-progressive versus primary progressive type), disease outcome, specific clinical features (opticospinal versus disseminated forro), diagnostic certainty (clinically/laboratory supported definite versus clinically probable multiple sclerosis) and the presence/absence of oligoclonal bands in the CSF or characteristic abnormalities on MR imaging of the central nervous system. Even though DR15 carriers are more likely to be female and prone to an earlier disease onset, our resnlts indicate that there is no association with other specific clinical outcomes or investigation results examined here.

Oral session 8

Multiple Sclerosis - 2 45 Brain NMR spectroscopic imaging in grey and white matter of patients following clinical isolated syndrome - a 13 years follow up study. P. Kapeller, P. Brex, M. McLean, D. Chard, C. Griffin, A. J. Thompson, D. H, Miller (London, UK) Background: To investigate differences in brain spectroscopy for grey and white matter in patients 13 years after a clinically isolated syndrome (CIS). Subject and methods: 42 patients (27 females and 15 males; mean age 44 yrs) 13 years after CIS suggestive for multiple sclerosis (MS) and 21 controls (6 females, 15 males; mean age 35 yrs) were studied. Patients were divided in into 3 groups: MS patients with EDSS < 3 or >-3 a n d a group who stayed clinically isolated. Quantitative 1HMRSI (TE: 30ms, TR: 3000ms) was performed to determine concentrations for myo-inositol (Ins), choline containing compounds (Cho), creatine/phosphocreatine (Cr), and N-acetyl-aspartate (t-NAA). LCModel was used as quantification method. T1 and T2 weighted MRI with and without Gadolinium and 1.5mm 3D fast spoiled gradient recall were performed for voxel positioning and segmentation (SPM96) to determine the percentage of grey and white matter and cerebro-spinal fluid (CSF). To avoid CSF partial volume effects we omitted voxels containing more tban 20% CSE Results: MS patients EDSS < 3 vs controls - white matter: t-NAA decreased from controls (8.73 mmol/l) to MS normal appearing white matter (NAWM) (8.44 mmol/1) to MS lesions (7.94 mmol/1; p: 0.021). Ins increased from controls (3.58 mmol/1) to NAWM (3.93 mmol/1; p: 0.035) to MS lesions (4.75mmol/1; p: 0.001). MS lesions showed elevated Cho (1.47mmol/1; p:

0.01) and Cr (5.04mmol/l; p: 0.057) in comparison to controls (Cho: 1.25 mmol/1; Cr: 4.59 mmol/1). MS patients EDSS < 3 vs controls - grey matter: Although t-NAA was reduced in MS cortical grey matter (CGM) compared to controls this difference was not statistically significant (7.98 mmol/1 vs 8.42 mmol/1; p: 0.071). MS patients EDSS _>3 vs controls - white matter: We found a decrease in t-NAA with the lowest value in MS lesions (controls: 8.73 mmol/1; NAWM: 8.32 mmol/1; lesions: 7.71 mmol/l; p: 0.005). In comparison to controls MS lesions showed elevated Cho (1.25mmol/1 vs 1.49 mmol/1; p: 0.056). MS patients EDSS _>3 vs controls - grey matter- No differences were found between control grey matter and MS CGM. Clinically isolated syndromes: No differences could be found between controls and CIS patients for white or grey matter. Conclusions: CIS NAWM and grey matter do not differ in their spectroscopy patterns from normal controls white and grey matter. Next to the known reduction of t-NAA in the MS brain our study points on the importance of Ins in MS. 46 Progressive ventricular e¡ in patients with Clinically Isolated Syndromes is associated with the development of Multiple Sclerosis. C. M. Dalton, P. A. Brex, R. Gordan, N.C Fox, K. A. Miszkiel, W. R. Crum, J. I. O'Riordan, G.T Plant, A. J. Thompson, D. H. Miller (London, UK) Objective: To assess whether ventricular enlargement occurs over one year in patients with Clinically Isolated Syndromes (CIS) suggestive of Multiple Sclerosis (MS) and if this relates to clinical outcome. Background: In patients with CIS, the extent of MRI lesion load influences the probability and time to development of MS. Cerebral atrophy is recognized in established MS,but how early it develops and whether in early disease it is related to MRI lesion load is uncertain. Methods: The MIDAS ventricular measurement technique was applied in a cohort of 55 patients with CIS, recruited consecutively and imaged within 3 months of the onset of symptoms and again after i year. Results: Significant ventricular enlargement was seen in 18 patients who developed clinical MS over the follow up period (p=0.006). There was no significant ventricular enlargement in the 37 patients wbo developed no further symptoms. There were only moderate correlations between baseline lesion load and subsequent ventricular enlargement (T2 lesions r=0.30, T1 hypointense lesions r=0.44; and Gd enhancing lesions r=0,29) Conclusion: Progressive ventricular enlargement is occurs at the earliest clinical stage ofMS and is associated with early relapse in patients with CIS. The data suggest that while lesions and atrophy are both associated with early relapses leading to a diagnosis of clinical MS, they develop by at least partly independent mechanisms. The findings suggest pathogenic heterogeneity in MS with multiple mechanisms already in operation even in the earliest clinical stage of the disease. 47 Volumetric analysis of magnetic resonance imaging related changes in assessment of progressive cerebral atrophy in multiple sderosis. E Vajda, H. Butzkeuven, M. Cook (Victoria, AUS) Introduction: Measurement of cerebral atrophy represents one of the critical techniques for objective evaluation of changes in MS. Combined with clinical measures of disease severity, monoclonal antibodies, and electrophysiological parameters, MRI changes have lead to more accurate diagnosis of the disorder, relapses and progression. MRI is the most accurate method of determining progression in the absence of clinical relapse. Techniques are now appearing to better defne the distribution and degree of cerebral atrophy, some based on linear measures of cerebral dimensions, others voxel based methods, estimating volume from axial T2 and PDW images, usually acquired as part of a routine MS MRI protocol. Method: 140 patients with a definite clinical diagnosis of MS were studied, confirmed with MR imaging, measuring three linear dimensions (intercaudate width, 3rd ventricular width, and cerebral diameter) in axial images both in patients and 100 normal controls. Control subjects had also a cerebral volumetric study to allow correlation of the linear dimensions with the true cerebral volume, calculated by a 3D-morphometric procedure. The measures in patients were correlated with disease duration, but not with T 1 or T2 lesion load, nor with clinical severity. Results: of the linear dimensions measured, intercaudate distance had the best correlation with whole brain volume estimates based on the 3D morphometric process. Transfrontal width and 3rd ventricular width correlated poorly. In these patients, volume estimates correlated best with disease duration, but not with severity or T1 or T2 lesion load. Conclusion: Estimates of cerebral volume based on linear measures of cerebral structures need to be correlated with volumetric methods of rol-

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ume estimation, recognising that some are poor surrogates for total cerebral volume. Intercaudate measures have the closest relationship to true cerebral volume measures. The disparity between volume estimates and other measures of disease load suggests caution when interpreting the results of various therapies, as more than one process may be implicated in the generation of volume changes. Supported by Schering Australia. 48 Effect of Glatiramer Acetate on Brain Volume in Patients with Relapsing-Remitting Multiple Sclerosis. M. Rovaris, G. Comi, M. A. Rocca, ]. S. Wolinsky, M. Filippi,. The European/Canadian GA Study Group,. The European/Canadian GA Study Group (Milan, I; Houston, USA) The assessment of brain volume change by serial magnetic resonance imaging (MRI) scans provides an objective marker of one aspect of the evolution of mukiple sclerosis (MS). Measures of brain volume are correlated with the level or change of disability and might, therefore, serve as outcome measures for MS treatment trials. Glatiramer acetate (GA) has a beneficial effect on clinical and several MRI measures of MS activity and burden. This study investigated the impact of short-term GA treatment on the development of brain atrophy in patients with relapsing-remitting (RR) RRMS. The study consisted of a nine-month, double-blind, placebo-controlled phase, where patients were randomized to receive either 20mg GA or placebo by daily subcutaneous injections, followed by a nine-month, openlabe[ phase, where all patients received active treat ment. Dual echo, pre- and post-contrast (0.1 mmol/kg gadolinium-DTPA) Tl-weighted MRI scans of the brain were obtained every month during the first phase and every three months during the second phase of the study. Using a semi-automated segmentation technique, brain volume was measured from a slab of seven contiguous periventricular slices on pre-contrast Tl-weighted scans obtained at baseline, end of the double-blind phase and end of the study. One hundred and thirteen patients randomized to GA and 114 randqmized to placebo treatment were studied. No significant differences bet~een placebo- and GA-treated patients were found for baseline brain volume and rate of brain volume change during the study. The mean reductioos of brain volume during the two study phases were 0.7% and 0.6 % in patients originally treated with placebo, 0.8 % and 0.4 % in patients originally treated with GA. Over the whole study period, brain volume decreased by 1.4% and 1.2% in placebo and treated patients, respectively (p=0.001 and 0.0001 vs baseline, respectively). During the double-blind phase, significant correlations between the numbers of contrast-enhancing or new T2 hyperintense lesions and the changes of brain volume (r=-0.30 and -0.26, p=0.001 and 0.005, respectively) were only found in placebo patients. Brain volume was significantly correlated with patient disability only on a cross-sectional basis. In RRMS patients, the progression of brain atrophy is only in part explained by the ongoing MRI-measurable disease activity. GA does not significantly influence the changes of brain volume within nine months of in_ stituting treatment. 49 Are soluble tumor necrosis factor-receptor 1 (sTNF-RI) and sTNF-R2 suitable markers to identify subgroups of patients who are likely to respond better than others to treatment with interferon beta-lb in multiple sclerosis? C. Laske, E Oschmann, ]. Tofighi, B. S. Kª H. Diehl, T. Bregenzer, J. Kraus, N. Chatzimanolis, R. Bauer, H. Traupe, M. Kaps (Giessen, Berlin, D) Objectives: To investigate the influence of interferon (IFN) beta-lb on the serum levelg of sTNF-R1 and sTNF-R2 in patients with multiple sclerosis (MS) in correlation with clinical and MRI activity. Materials and Methods: Serum samples were obtained every 3 months from 24 patients treated with 8 x 106 U of IFN beta- lb every other day (treatment group) and from 21 patients without any immunomodulatory therapy (control group) over a 15-month observation period. The cytokine-receptor levels were measured by ELISA. Cranial MRI was performed every six months to determine the burden of disease. ResuIts: In the treatment group we found an obvious increase of sTNFR1 and sTNF-R2 (p < 0.001) during the observation period of 15 months. In contrast, in the control group sTNF-R1 showed a significant decrease (p < 0.001) during the same time. In the treatment group, the MRI-responders had significant larger mean AUC (area under the concentration-time curve) values of sTNF-R1 (p = 0.04) and sTNF-R2 (p = 0.01) when compared to the MRI-nonresponders during the 15-month observation period. The main differentiating step between MRI-responders and MRI-nonresponders occurred as early as during the first three months of treatment, where median values of sTNF-R1 and sTNF-R2 of MRI-responders crossed the line of

sTNF-Rs of MRI-nonresponders towards higher values, reaching statistical significance for sTNF-R1 (p = 0.04) and for sTNF-R2 (p = 0.02). As regards an increase of sTNF-R1/2 of more than 20 % during the first three months of treatment, we observed a sensitivity of 33 %/58 %, a specificity of 90 %/60 % a n d a positive predictive value of 80%/64% for MRI-response during the 15-month observation period. A decrease of sTNF-RI/2 of more than 20 % during the first three months of treatment h a d a sensitivity of 40 %/20 %, a specificity of 100 %/100 % anda positive predictive value of 100 %/100 % for further MRI-nonresponse. Conclusions: The present data suggest that IFN beta-lb induces the expression and/or shedding of TNF-R1 and TNF-R2 in patients with RR-MS. Although this inductive effect is qualitatively independent of dinical and MRI activity, there are quantitative differences which may contribute to identify subgroups of patients who are likely to respond better than others to treatment with IFN beta-lb. This could help to establish a cost-effective prescription pattern for this expensive, partially effective treatment, which is of importante for the future management of patients with MS. 50 Evidence for grey matter involvement in primary progressive MS: a magnetisation transfer imaging study. D.H Miller, S. Leary, ]. Dehmeshki, D. Chard, H.C Watt, N. Silver, P. Tofts, A.| Thompson (London, UK) Background: 15 % of patients have a primary progressive (PP) course of MS with slow development of disability without relapscs. Such patients often exhibit relatively small brain MRI lesion loads with few enhancing lesions. The mechanisms of disability are poorly understood. In the present study, magnetisation transfer ratio (MTR) analysis was performed on segmented lesions, normal appearing white matter (NAWM) and normal appearing grey matter (NAGM), to investigate abnormalities in each, and to assess their relationship with disability. Methods: 30 patients with PPMS and 30 age matched healthy controls were studied using SE based MTR imaging of the brain. The brain was segmented into NAWM and NAGM using SPM 99 and lesions were segmented using a local thresholding technique. From normalised histograms, the following parameters were measured: average NAWM MTR, average NAGM MTR, average lesion MTR, and T2 lesion loa& Disability was assessed on the Kurtzke EDSS. Results: Compared to the controls, patients h a d a significantly reduced average NAWM MTR (p=0.001 ), and NAGM MTR (p=0.004). Univariate correlations of the four MR parameters with EDSS was significant only for NAGM MTR (r= -0.41, p=0.02). Multivariate analysis confirmed the association only between NAGM MTR and EDSS. Conclusion: both NAWM and NAGM are abnormal in PPMS. The NAGM changes appear to be functionally significant and should be further investigated. 51 MRI predictive value in clinical trials - Initial 6 month values as predictors of subsequent relapse activity. D. Paty, D. Li, G. S. Francis flor the PRISMS Study Group) (Vancouver, CDN; Norwell, USA) Objective: To determine whether MRI variables in the first 6 months of a clinical trial predict subsequent relapse rate in RRMS. Introduction: MRI scans are used extensively as secondary outcome measures in clinical trials a n d a s primary measures in Phase 2 trials in MS. The value of MRI outcomes has been questioned in terms of predictive value for clinical behaviour. Methods: PRISMS-2 patients (n = 560) had biannual T2 weighted scans for 2 years while a subgroup (n = 280) had monthly gadolinium scans up to month 9. MRI variables measured included active T2 lesions, active T1 lesions and active combined unique (CU) lesions, a measure taking into account both new T1 and T2 activity but taking care to avoid double counting [1]. Results: There were 66 placebo patients providing data on high frequency scanning and 182 providing data on low frequency scanning. The correlation between CU lesion activity at 6 months and relapses at 12 months was r = 0.197 (p = 0.11) and r = 0.236 at 24 months (p = 0.06) while for CU activity at 9 months, r = 0.183 (p = 0.14) and r = 0.221 (p = 0.08) for relapses at 12 and 24 months. T2 lesion activity (monthly scans) at 6 months correlated with relapses at 12 (r = 0s p = 0.03) and 24 months (r = 0.316; p = 0.01) while using 9 month T2 activity, r = 0.244 (p = 0.05) and r = 0.298 (p = 0.02) for relapses at 12 and 24 months. Finally, T2 activity based on a single scan at 6 months showed correlation with relapses at 12 (r = 0.230; p = 0.002) and 24 months (r = 0.268; p < 0.001). Conclusions: Monthly T2 lesion activity correlates better with subsequent relapses than CU activity. Both have modest correlation with subse-

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quent relapses. Single non-enhanced scanning provides comparable correlation to monthly T2 measures and is superior to monthly CU measures. These data confirm that MRI measures over a short time interval are predictive of subsequent clinical activity in untreated patients validating the use of MRI in clinical trials. Frequent scanning provides minimally stronger correlation than infrequent scanning but requires fewer patients. Reference 1. PRISMS study group (1998) Randomized double-blind placebo-controlled study of interferon-la in relapsing/remitting multiple sclerosis. Lancet 352:1498-1504

Oral session 9

Motor neuron disease and amyotrophic lateral sclerosis

only, reminding the patients of their progressive loss of function. We therefore asked the patients themselves to assess two widely used QoL questionnaires,the Sickness Impact Profile (SIP),and the Short Form 36 (SF36) against anewinstrument which assesses QoLviapatient-eliciteddomains,the Schedule for Evaluation of Individual QoL - Direct Weighting (SEIQoL-DW). Patients and methods: 42 ALS patients were examined at least 3 times at 2-month intervals. The SIP was filled out by all patients. The SF36 and the SEIQoL-DW were assigned at random. After each examination the patients were asked to assess, using visual analogue scales, their subjectively perceived validity and emotional distress of the scales applied. Results: The validity of the SEIQoL-DW, when compared to the SIP, was rated higher (p < 0.001) and the resulting emotional distress was judged to be lower (p < 0.005). There was no significant difference in validity or emotional distress between the SIP and the SF 36. The validity of the SEIQoL-DW was rated higher than that of the SF-36 (p < 0.001). The most frequently mentioned QoL domain in the SEIQoL-DW was the family (100 %), followed by health (51%) and profession (49 %). Conclusion: The SEIQoL-DW, was perceived by the patients as reflecting their QoL more precisely a n d a s being less emotionally distressing than the SIP and the SF 36. Since the latter scales are widely used in ALS drug trials and QoL studies, these resuhs should prompt further discussion and investigation on the most appropriate way to assess QoL in ALS patients. 54

Comparison of Community Service utilisation by Patients with Motor Neu52 Decreased f-Actin polymerization in immortalized motoneurons containing neuropil aggregates of androgen receptor with elongated polyglutamine tract. F. Piccioni, U. Fascio, L. Martini, A. Poletti (Milano, I) Spinobulbar muscular atrophy (SBMA) or Kennedy's disease, an X-linked recessive pathology, is characterized by death of motoneurons in the anterior horn of the spinal cord and in the bulbar region. The motoneuronal loss has been linked to an expansion of (CAG)n repeat present in the androgen receptor (AR) gene. The expansion is translated into an elongated polyglutamine (polyGln) tract in the N-terminal transactivation domain of AR, possibly responsible for the acquired neurotoxicity of the mutated protein. Formation of intracellular aggregates containing the mutated proteins have been reported; however, their pathogenetic role is still debated. Different types of inclusions have been reported: a) nuclear, b) cytoplasmic or c) neuropil aggregates. To analyse the role of aggregates in SBMA, we have produced cellular models using immortalised motoneurons (NSC34) transfected with wild type or mutated forms of AR. The cells expressing the AR with elongated polyGln tract have a reduced growth/survival rate in basal condition, but show aggregation of the mutated AR protein (mainly cytoplasmic) only after AR activation by testosterone. Interestingly, testosterone treatment increased survival indicating that cytoplasmic aggregate formation and cell survival are not correlated. On the contrary, neuropil aggregates might become toxic by altering axonal/dendritic functions. This is supported by our recent experiments performed cotransfecting NSC34 with chimeric construct of green fluorescent protein and the SBMA AR (GFP-AR.Q48) or wtAR (GFP-AR.Q0) a n d a blue fluorescent protein containing a mitochondrial localization signal (mtBFP). We have found that, in motoneuronal cells transfected with the mutated AR the distribution of mitochondria is altered in neuronal processes, forming 'jams' at one side of the aggregate. Confocal microscopy performed on these cells counterstained with TRITC-phalloidin to detect filamentous actin (f-actin) has shown that motoneuronal cells bearing neuropil aggregates have a marked reduction in the f-actin polymerised fraction (globular actin analysed in western blot analysis was not changed), a n d a significant change in cell morphology due to reduced adhesion to the substrate. These data suggest that the aggregates physically alter neurite transport and may deprive neuronal processes of factors/components important for axonal/dendritic functions. Telethon (Italy) Grant n. 1283 is gratefully acknowledged.

rone Disease and Multiple Sclerosis. O. Hardiman, B. Corr, P. Gibbons, BJ Traynor (Dublin, Boston, IRL) Adults with motor neurone disease (MND) and multiple sclerosis (MS) have unique and ongoing requirements that are best serviced within the community. In Ireland, services for these patients may be dif¡ to access, and are often not freely available to patients that are most in need of them. Specific data on the reasons for the delay or failure in the provision of services are not readily available. The aim of this study was to compare and contrast access to and utilization of services for patients with acquired neurological disabilities with respect to disease category and geographic region. Methods: The study was based on a telephone questionnaire that was administered to patients with ALS or MS in the 8 health board regions of the Republic of Ireland, between October 1998 and Apri12000.'Patients between 25 and 65 years of age, and with moderate or severe disability were selected randomly from databases held by the relevant voluntary organisations. Those residing in nursing homes were excluded. Patients were initially contacted by letter informing them of the study. The telephone questionnaire was administered by clinical specialist nurses in MS and MND respectively. Results: 53 MND patients (approximately 25 % of the MND population) and 188 MS patients ((approximately 5 % of the MS population) participated in the study. The mean score on the Barthel Index was 12.5 for ALS patients, and 15.1 for MS patients. There was significant regional variation with respect to access to community services for both conditions. Within each geographical region, severely disabled MND patients were more successful at accessing the community services, and were less likely to have paid for service/equipment than were severely disabled MS patients. MND patients were also more likely to have free medical care than MS patients. Conclusions: Significant geographic differences exist with respect to accessing community service, suggesting the absence of a coherent policy in the management of these conditions. Despite more limited statutory entitlements, patient with MND are more likely to access and utilise community based services that ate similarly disabled MS patients. The reasons for this may relate to the activities of the voluntary organization working on behalf of MND patients. 55

Cytokine levels in plasma of patients with Amyotrophic Lateral Sclerosis (ALS). P. Bongioanni, M. Tarar~, M. Metelli, M. Carboncini, B. Rossi, P. Pietrini (Pisa, I)

53 Three different approaches to quality of life assessment: A randomised trial in patients with amyotrophic lateral sclerosis (ALS). C. Neudert, M. Wasner, G. D. Borasio (Greifswald, Munich, D) Ob)ective: The evaluation of Quality of Life (QoL) plays an increasingly important role in clinical research and drug trials in ALS. However, most of the scales employed so far are based on ah external value system and may therefore not reflect the patients subjective perception of QoL accurately. In addition, several ALS patients complain about the psychological distress inflicted by QoL questionnaires, which are most often focused on functional status

Among various pathogenetic hypotheses for Amyotrophic Lateral Sclerosis (ALS), that linked to immunological abnormalities keeps to stimulate some interest. Cytokines are a family of peptides with modulatory effects on immunity and trophism, even in the central nervous system: in neurodegeneration, the cytokine network may be altered, leading to both deranged immunomodulation and impaired neurotrophism. In the present work, we assayed cytokines (Interleukin(IL)- 1-beta, IL-2, IL-6 and Tumor Necrosis Factor (TNF) with their soluble receptors sIL-2R, sIL-6R, sTNFRI and sTNFRII) in plasma from ALS patients, compared to sex- and age-matched healthy controls. In the same groups, Apo1/CD95 (an

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apoptotic marker), Superoxide Dismutase, Glutathione Reductase and Glutathione Peroxidase activities were assayed as well. We found that patients with definite or probable ALS, differently from those with possible or suspected ALS (according to the El Escorial criteria) had significantly (p < 0.05) higher plasmatic levels of IL-l-beta, IL-2, and TNFRs, but significantly (p < 0.025) lower Apol/CD95 levels than controls. A significant difference only in the Glutathione Peroxidase activity was observed between patients with definite ALS and healthy controls These data might indicate a Th-response with activation of apoptotic events in ALS, and contribute to discriminate among different patients' subgroups. 56 Impaired Oxidative Metabolism In Exercising Mnscle From Als Patients. G. Siciliano, E. Pastorini, L. Pasquali, M1 Manca, M. Mancuso, S. Tovani, L. Murri (Pisa, I) Amyotrophic lateral sclerosis (ALS) is a disorder characterised by a degeneration of the anterior horn cells of the spinal cord and cortical motor neurons. Although aetiopathogenesis of the neuronal death in ALS remains unclear, the hypothesis that mitochondria are involved in the degeneration process of motor neurons is gaining increasing evidence. Aim of our study was to indirectly investigate in vivo oxidative metabolism of exercising muscle in a case history of patients affected by ALS. To this purpose 11 patients, 8 male and 3 female, mean age + SD: 52.4 + 11.1 yr., performed a bicycle incremental test for the assessment of lactate production. At rest, there was increased lactate concentration in patients: 2.77+ 0.79 vs. 1.45+ 0.29mmol/L in normal controls (normal range: 0.67-2.47 mmol/L). Analysis of lactate curve during exercise showed a lactate production increased compared to controls. Furthermore, anaerobic lactate threshold was detected at 40-50% of the predicted normal power output, anticipated with respect to normal and functional-matched non ALS chronically denervated controls (60-70%), suggesting that mitochondrial dysfunction can occur in exercise skeletal muscle form ALS patients.

Oral session 10 Neuro-ophthalmology 57

Impaired vestibulo-ocular reflex in spinocerebeUar ataxia. K. Bª Nauth, M. Fetter, K. Beykirch, I. Dichgans (Tª D)

M.

The spinocerebellar ataxias (SCA) area heterogeneous group of dominantly inherited neurological disorders characterised by progressive ataxia that results from degeneration of the cerebellum and its afferent and efferent connections. In most families, there is clinical and neuropathological evidence for additional involvement of brainstem, basa1 ganglia, spinal cord and peripheral nervous system. The most frequent genotypes, SCA1, SCA2 and SCA3, have been cloned, and the mutations have been shown to be unstable CAG trinucleotide repeat expansions present within coding regions of the respective genes. Most of the structures concerned with eye movements are involved in the degenerative process in SCA. in particular, we were interested in alterations of the vestŸ reflex (VOR). The VOR serves to stabilise gaze during head movements by producing eye movements that compensate for head rotations. In normals, the gain of the vestibulo-ocular reflex is approximately 100 % in the light and around 70-80 % in the dark. The major components of the vestŸ reflex arc ate the hair cell receptors located in the semicircular canals of the labyrinth, the first vestibular neurones that forro the vestibular nerve, the vestibular nucM in the brainstem and the oculomotor nuclei. In cerebellar disease, the VOR gain is usnally increased. This effect is explained by an inhibitory influence of the cerebellar flocculus on the vestibulo-ocular reflex. In SCA1, SCA2, and SCA3, the VOR gain was shown to be markedly impaired despite prominent cerebellar involvement. These observations are likely to be contingent upon disruption of the vestibular arc. They do not allow determination of whether a concomitant lesion may lŸ in the vestibular afferents or in the vestibular nuclei. Degenerative changes in the vestibular nuclei have been reported in SCA1, SCA2 and SCA3 while labyrinthine receptors and vestibular nerves have not been studied neuropathologically in SCA.

58 Diagnosis of progressive supranuclear palsy with magnetic resonance imaging: a controlled study. Y. Rolland, M. Verin, F. Lallement, V. Claeyssen, G. Edan (Rennes, F) We investigated the accuracy of routine magnetic resonance imaging (MRI) in the positive and differential diagnosis of progressive supranuclear palsy (PSP). MRI semiology of PSP remains actually not well known mainly because of 1) the few number of previous controlled studies and 2) the use in these studies of heterogeneous no standardized MRI acquisition procedures. Twelve patients with clinical defined PSP and 12 patients with Parkinson's disease (PD) were included. AII the patients were randomly selected and underwent the same standardized 1.5 Tesla MRI examination, including sagittal and axial T 1; axial proton density and axial and coronal T2 weighted sequences (slice thickness 3mm). Two independent reporting were performed by two of the investigators (Y. R. and M. V.), both blinded for clinical status. The inter-observer variability was evaluated by a kappa test. There was a good concordance between the two observers (kappa value: 0.8). All MRI of PSP patients were found abnormal. Several items were only observed in the PSP patients: atrophy of the mesencephalon and enlargement of the aqueduct of Sylvius in 11 of 12; peri-aqueductal hypersignal in T2 weighted axial sequences, bilateral hypersignal of the medial part of the globus pallidus and bilateral hypersignals of the upper part of the mesencephalon in axial and coronal T2 weighted sequences in 10 of 12. Our results confirrn the particular interest of routine 1.5 Tesla MRI examination for both the positive and the differential diagnosis of PSP.

59 Long-term Changes Of Visual Cortex Excitability In Subjects Being Blind Due To Pre-chiasmatic Lesions. S. A. Brandt, ]. Gothe, S. R6richt, B.-U. Meyer (Berlin, Magdeburg, D) Repetitive transcranial magnetic stimulation (TMS) was used to study visual cortex activation in blind subjects (n =35) visually deprived by long-standing pre-chiasmatic lesions. Phosphenes were directly elicited by cortex stimulation to bypass the retino-geniculate pathways. We assumed that susceptibility to phosphene induction can be used as a rough measure of functional intactness of the visual cortex in humans. We were specifically interested in the influence of residual visual function on cortical excitability changes and therefore studied blind subjects with and without residual visual function. Occurrence of phosphenes were analysed with regard to their threshold and distribution of stimulns effective sites over visual cortex. Methods: Ten poor sighted subjects (visual acuity < th0), 15 blind subjects with residual vision (acuity < lh0), 10 blind subjects without any residual vision and 10 healthy controls were examine& Stimulation mapping, with short trains of 15 Hz-stimuli was performed on a lx 1 cm surface grid with 130 stimulation points overlying occipital cortex. TMS thresholds for eliciting phosphenes were compared with individual motor thresholds in the blind and the sighted subjects. Results: TMS elicited phosphenes in al1 poor eye sighted subjects. The number of effective stimulation sites and their spatial distribution was similar to that in normal subjects (36.8 -+ 29.2 versus 39.5 _+21.2). 60 % of blind subjects with residual vision perceived phosphenes in response to TMS, but phosphenes occurred at less stimulation points than in normal sub}ects (29.7 -+ 26.6 versus 39.5 _+21.2). Only two of the blind subiects without residual vision reported phosphenes. Phosphene and motor thresholds did not significantly differ between normal and blind subjects. Conclusion: Blind subjects show an altered response to direct activation of the visual cortex by TMS. The ability of eliciting phosphenes was reduced in subjects with high degree long-term visual deafferentation and especially in those subjects without previous visual experience. The assumption that early visual deprivation leads to a suppression of the development of the visual cortex is supported by the finding that only blind subjects with prior visual experience were able to perceive phosphenes. TMS of the visual cortex might be a useful tool to pre-operatively test for residual functions of the visual cortex in blind subjects prior to cor tex stimulation with visual prosthesis.

60 Three-dimensional nystagmus components in mesencephalic lesions. C. Helmchen, H. Rambold, U. Kempermann, U. Bª (Luebeck, Mª D) According to experimental animal data at least 2 mesencephalic structures are involved in the premotor control of vertical and torsional eye movements: the rostral interstitial nucleus of the MLF (riMLF) and the interstitial nucleus of Cajal (iC). However, results from clinical single case studies differ

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from experimental data. Specifically, the topodiagnostic value and specificity of nystagmus in patients with mesencephalic lesions is controversial and anecdotal yet. Since both riMLF and iC reduce vertical oculomotor range it has been proposed - based on single case reports - that torsional nystagmus may be useful to distinguish riMLF from iC lesions. Therefore we studied 13 patients with vascular MRT- identified mesencephalic lesions and clinical evidence of vertical-torsional gaze holding disorders. Focus was put on the three-dimensional nystagmus components (x, y, z) that were recorded with the three-dimensional (3D) search coil technique. Al1 patients showed conjugate vertical and/or torsional nystagmus (TN) on gaze straight ahead. All patients with contralesional TN showed anatomical (MRT) and/or clinical evidence for riMLF involvement. Ipsilesional TN was found in patients with midbrain lesions (infarctions) involving iC or MLF or midbrain haemorrhage. In conclusion, this is the first study on the topodiagnostic specificity of torsional and vertical nystagmus in a large group of patients with midbrain lesions. Whereas vertical gaze-evoked nystagmus may be absent due to vertical saccade palsy or slowing, unilateral lesions often elicit torsional spontaneous nystagmus. In accordance with animal data, TN in riMLF lesions was contralesional, in contrast to ipsilesional nystagmus in iC lesions. Additional torsional and/or vertical gaze-evoked nystagmus with decreased time constants indicates additional involvement of iC as shown on anatomical MR-slices. Supported by German-Israel Foundation (GIF) and Deutsche Forschungsgemeinschaft (DFG).

patients (n=31) consecutively entered into the study with suspected MSA or SCA was analysed with oculography in a ten year- follow up investigation. Patients and Methods: Saccadic and smooth pursuit eye movements were investigated in 31 patients with suspected MSA or SCA. Saccades (20 deg.) and sinusoidal Smooth Pursuit Eye Movement (SPEM) (0.33 Hz) were measured with an infrared oculographic system. The percentage of patients having eye movement disturbances at first admittance was analysed and these patients were followed up after 10 years and examined for the development of MSA and SCA. The control groups consisted of healthy controls and of patients with other neurological diseases (non-MSA/non-SCA). Statistics were done with chi2-test. Results: The whole group of 31 patients showed a significantly higher rate of pathological eye movements than the group of healthy controls. The final diagnosis was MSA in 14 of the 31 patients, SCA in 6 patients, and other disorders in 11 patients. The following abnormalities in eye movements were found: 1. saccadic pathologies: MSA in 50%, SCA in 33%, non-MSA/nonSCA in 27 % of patients,2. SPEM pathology: MSA in 79 %, SCA in 100 %, nonMSA/non-SCA in 57 % of patients, 3. both parameters combined: MSA in 86 %, SCA in 100 %, non-MSA/non-SCA in 57 % of patients. With these measurements, it was possible to separate the sample into two groups: MSA/SCA and non-MSA/normals, the difference was significant (p < 0.001). Conclusion: Oculography may help to identify patients with MSA and SCA at an early stage of their disease.

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Comparison of balance training performed with Cawthorne-Cooksey exercises or continuous displacements of a supporting platform in patients affected by instability of vestibular origin. A. Nardone, S. Coma, M. Galante, A. Prestinari, M. Schieppati (Veruno (Novara),Vercelli, Paria, I) We compared effectiveness of vestibular rehabilitation performed through Cawthorne-Cooksey exercises (E, n=15), and instrumental (I) training consisting in standing on a periodically (0.2 or 0.6 Hz) anterior-posterior translating platform with eyes open (EO) of dosed (EC). Patients suffered from complete or incomplete unilateral vestibular lesion due to ischaemic, in_ flammatory or unknown cause. The following evaluations were performed prior to and at end of treatment: body sway area, recorded during stance with EO of EC, and self-evaluation of body sway, assessed by subjective score; capability to maintaiu balance while standing on the moving platforro, stereometrically detected through LEDs fixed on hip and head; Tinetti clinical evaluation of balance and gait; self-questionnaire about instability (Dizziness Handicap Inventory, DHI). ANOVA showed that both trainings produced an improvement of balance under both static and dynamic conditions. I and E groups showed a decrease in sway atea, which was significantly larger in I. All patients reported a subjective feeling of increased steadiness under all conditions. Improvement in counteracting the platform displacements was present in both groups: in the most demanding task (0.6 Hz, EC) 44% and 77% of patients in both groups performed successfully,respectively before and after training. Displacement ofhip and head was decreased to the same extent in both groups. ClŸ evaluation of balance and gait, and score of DHI improved significantly after treatment. In ten patients, sway atea recorded about one month before and at start of training showed no significant changes, whilst it decreased markedly at end of treatment. Follow-up performed three months after end of training showed persistence of &crease in sway area. Results show that both types of training are effective for treating vestibular balance disorders indepeudently of their cause and severity. The larger decrease in sway area after I suggests that this type of training is more effective than E in improving those mechanisms important for balance during quiet stance. The decrease of sway after but not before training suggests that positive effects are not connected to spontaneous recovery. Improvement affects both control of body stability during movements of the platform and, more importantly, performance of activities of daily living. Finally, instrumental rehabilitation may allow easier treatment of patients than conventional exercises. 62

Diagnostic Value of Eye Movement Disturbances in Patients with suspected Multiple System Atrophy (MSA) of Spinocerebellar Atrophy (SCA) - a TenYear- Follow up. U. Gschwandtner, ]. ]akscha, A. J. Steck, P. Fuhr (Basel, CH) Objectives: Abnormality of eye movements as documented by oculography often precedes other movement disorders in MSA and SCA. A sample of

Oral session 11

Peripheral neuropathy - 1 63

MR imaging of the brachial plexus in polyneuropathy associated with monoclonal gammopathy. M. Eurelings, N. C. Notermans, H. Franssen, H. W. van Es, L. M. P. Ramos, J. H. J. Wokke, L. H. Van den Berg (Utrecht, NL) On magnetic resonance (MR) imaging of the brachial plexus increased signal intensity and swelling of the brachial plexus has been found in CIDP. To study whether these proximal abnormalities are also present in polyneuropathy associated with monoclonal gammopathy characterized by predominantly dista1 symptoms and signs we studied the MR imaging of the brachial plexus of 39 patients: 30 patients with polyneuropathy associated with monoclonal gammopathy (11 IgM with anti-MAG antibodies, 10 IgM without anti-MAG antibodies and 9 IgG) and 9 patients with CIDP as disease controls. We correlated the MR imaging findings with clinical and electrophysiologic features. Of the 24 patients with demyelinating polyneuropathy associated with monoclonal gammopathy, not only 4 patients with proximal symptoms and signs but also 19 patients with only dista1 symptoms and signs had increased signa1 intensity of the brachial plexus on the T2weighted images. Of the 9 patients with CIDP, 6 patients had abnormalities of the brachial plexus. None of the six patients with axonal polyneuropathy associated with monoclonal gammopathy had such abnormalities (p <

0.0001). In conclusion, MR imaging of the brachial plexus shows that polyneuropathy associated with monoclonal gammopathy predominated by distal symptoms and signs also has abnormalities of proximal nerves and nerve segments and is a more generalized disease than presumed. 64

Idiopathic sensory chronic inflammatory demyelinating polyneuropathy: report of six cases. O. 1. M. Nascimento, M. R. G. De Freitas, T.M. Escada, M. D. Hahn (Rio de ]aneiro, BR) Patients,who present sensory symptom and signs in the distal limbs and fuifil laboratory criteria for chronic inflammatory demyelinating polyneuropathy (CIDP), and improve with corticosteroid (CS) or intravenous immunoglobulin (IVIG) treatments are included in the pure sensory CIDP modality. Objective: Evaluate the clinical and laboratory characteristics and nosologic position of the pure sensory CIDP. Methods: Six patients with distal sensory symptoms in the four limbs,

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and progressive course, were clinically, electrophysiologically and histopathologically studied. Nerve conduction (NC) studies fulfilled the previously proposed criteria for demyelinating neuropathy. Laboratory tests included electrophoresis of protein (EPP) and dosage of immunoglobulins (Ig). CSF examination and sural nerve biopsy were performed in all patients. Results: Patients were male with a mean age of 50 years (39-59). Numbness in the extremities was the most frequent symptom. Neurologic examination disclosed tendon hypo/areflexia, pinprick, thermal and tactile hypoesthesia in a stocking-glove distribution, and decreased vibration sense in the feet. Motor symptoms and reduction of strength were not observed. NC studies disclosed reduction of motor and sensory conduction velocities witb increased distal latencies, and conduction block in motor nerves. NC alterations pointed to a more distal compromise of peripheral nerves. Increased protein level in CSF examination was seen in 5 cases. The EPP and serum Ig levels were in normal ranges. Three patients improved with IVIG and 3 with CS: 2 treated with prednisone; one patient initially non responsive to IVIG improved with methylprednisolone pulsetherapy. Two patients presented relapsing course during the mean follow-up time (2 years). Conclusion: Sensory CIDP involves not only sensory nerves but also subclinically the motor ones. This group appears to differ from classic CIDP, motor and sensory, distal and proximal. The term "distal acquired demyelinating symmetric (DADS) neuropathy",recently applied by Katz et al. (2000) for those idiopathic cases of predominant sensory polyneuropathy (DADS-I) or with gammopathy IgM/Anti-MAG (DADS-M), could be modified for"distal acquired demyelinating sensory (predominant) [DADS] neuropathy". By tbis way, changing the word "symmetric" for "sensory", there was also the possibility to apply tbis term for probable cases with asymmetric clinical presentation. 65 Diabetic polyneuropathy and chronic inflammatory demyelinating polyneuropathy (CIDP) in diabetic patients: a prospective study. S. Jann, M. Bramerio, C. Defanti (Milano, I) Diabetic polyneuropathy is a frequent complication of diabetes mellitus. It is commonly an axonal neuropathy but recently bave been described few patients with a demyelinating polyneuropathy indistinguishable from CIDP. In order to evaluate the aetiology, the evolution, prognosis and response to treatment of tbese two different polyneuropatbies we studied 20 patients with diabetic polyneuropathy (group 1) and 10 diabetic patients with a CIDP-like polyneuropathy (group 2). Twelve males and 8 females, mean age 69.5 years,were enrolled in group 1 and 8 males and 2 females, mean age 60.7 years, in group 2. Diabetes mellitus was type 1 in 6 cases and type 2 in 14 cases in group 1 patients and type 1 in 4 cases and type 2 in 6 cases in group 2 patients. The mean duration of diabetes before presentation was 12.7 years in group 1 patients and 5.6 years in group 2 patients. The management of diabetes was mucb more difficult in group 1 patients witb frequent, sustained hyperglycemia than in group 2 patients. Most patients in group 1 complained other complications of diabetes such as retinopathy, nephropathy and so on, while only one patient in group 2 h a d a retinopathy. The main problem in group 1 patients was neuropathic pain wbile limb weakness was the main problem in group 2 patients. Diabetic polyneuropathy in group 1 patients, as expected, was distal, symmetric, predominantly sensory and axonal. In group 2 patients the demyelinating polyneuropathy showed clearly predominant motor symptoms in all cases anda more proximal involvement in 4 out of 10 patients. A significant improvement of carbohydrate metabolism was slightly effective in group 1 patients and no effective at all in group 2 patients. Diabetic patients with CIDP-like polyneuropathy were treated with intravenous immunoglobulins (0.4 g/kg/daily tbr 5 consecutive days) with significant improvement of the limb weakness. In concLusion CI DP in diabetics seems to be an immunomediated disorder without correlations witb sustained hyperglycemia. It must be recognized because it is responsive to immunosuppressive treatment. 66 Anti-Campylobacter Jejuni Lipopolysaccharide Reactivity In Multifocal Motor Neuropathy. F. Terenghi, S. Allaria, M. Carpo, G. Scarlato, E. NobileOrazio (Milan, I) Multifocal motor neuropathy (MMN) has been frequently associated with anti-ganglioside antibodies but the cause of this immune response is not known.A possible association with an antecedent Campylobacter jejuni (CI) infection has been reported in 3 patients developing MMN and anti-GMl antibodies after CJ enteritis while reactivity with the lipopolysaccharides (LPS) of C1 have been reported in some patients with chronic motor neuropathies and high anti-ganglioside antibodies. To determine whether CJ may be involved in the pathogenesis of MMN we examined 22 patients with

MMN, including 6 with anti-ganglioside reactivity (2 GM1, 2 GDIa, 1 GM1 +GD1 a, 1 GM 1+GM2), for the presence of anti-Cl antibodies by ELISA and immunoblot, and correlated their presence with that of anti-ganglioside antibodies. As controls we examined 17 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 23 with amyotrophic lateral sclerosis (ALS), 43 with other neurological diseases (OND) and 23 normal subjects (NS). By ELISA we found high titters (1/640) of anti-CJ antibodies in 8 patients (36%) with MMN (4 lgM, 2 lgA, 1 IgM+lgA, 1 IgM+IgG+IgA), 2 each with CIDP (12%; 1 IgA and 1 IgM) and ALS (9%; 1 IgM and 1 IgG),one with OND (2 %; IgG) and in none NS (MMN vs. neurological controls p < 0.0005; MMN vs. NS p < 0.005). By immunoblot, 5 patients with MMN (23%), only one of whom positive by ELISA, had an intense reactivity (1/3,200 up to 1/100,000; 3 lgG, 1 IgA, 1 IgG+IgA) with a 14 kD band corresponding to the LPS of CJ. A similarly intense reactivity was only observed in two patients with ALS (9%; 1 IgG and 1 IgM), one with CIDP (6%; IgG), one NS (4%), while no reactivity was found in OND (MMN vs. neurological controls p < 0.01). Overall anti-CJ antibodies were detected by least one method in 12 MMN patients (55%),3 CIDP (18%),4 SLA (17%), 10ND (2%) and 1 NS (4%) (MMN vs. neurological controls p < 0.0005; MMN vs. NS p < 0.0005). Anti-ganglioside antibodies were similarly frequent in patients with (33 %) or without (20%) anti-CJ reactivity. The bigh frequency of anti-Cl antibodies in MMN patients supports the hypothesis of an association between MMN and CJ even if it is unclear whether this reflects a concurrent or previous CJ infection involved in the pathogenesis of MMN. If this is the case, the lack of association with anti-ganglioside antibodies suggests that this antibodies might not be the only anti-neuronal antiRens induced by CJ. 67 Resident endoneurial macrophages in peripheral nerve pathology as revealed by green fluorescent protein transgenic bone marrow chimeric mice. M. Mueller, C. Leonhard, E. B. Ringelstein, M. Okabe, W. F. Hickey, R. Kiefer (Mª D; Osaka, J; Lebanon, N. H., USA) Macrophages exert important functions during autoimmune and degeneratire neuropathies. While hematogenous macrophages are required for effective myelin removal following nerve injury, the regulatory role of resident endoneurial macrophages has long been underrecognized due to a lack of discriminating markers. Using a radiation bone marrow chimeric rat model, we recently identified resident endoneurial macrophages that became activated, proliferated and phagocyted myelin very rapidly following a crush lesion, suggesting an early regulatory role for these cells. We now created a novel mouse model for easy recognition of resident endoneurial macrophages. Bone marrow from green fluorescent protein (GFP) transgenic mice was transplanted into irradiated C57B16 wildtype mice and allowed to mature for three months. In such animals all blood leukocytes showed a green fluorescence. In normal peripberal nerve, approximately one half of all resident endoneurial macrophages exhibited green fluorescence, indicating 50 % physiological turnover frorn the blood. The other one half of resident endoneurial macrophages did not express GFP, indicating their persistence locally within the nerve f o r a longer period. Following a sciatic nerve crusb lesion, GFP-negative, resident endoneurial macrophages became rapidly activated as revealed by their altered morphology. These cells retracted their processes and rounded up. Both GFP-positive and GFP-negative endoneurial macrophages gradually increased in number, but a strong influx of GFP-positive hematogenous macrophages was not observed before day four. Although the number of GFP-positive infiltrating macrophages further increased with time, GFP-negative, long-term resident endoneurial macrophages with a highly activated morphology were strikingly frequent throughout all time points examined. There was also a notable presence of GFP-negative resident endoneurial macrophages expressing major histocompatibility class 11. Our results indicate that resident endoneurial macrophages become very rapidly activated upon a nerve lesion in mice. Preliminary estimations suggest that their quantitative contribution to the total macrophage pool during Wallerian degeneration may be much higher than previously thought. They may thus playa crucial role during the pathogenesis of peripheral neuropathies, and radiation bone marrow chimeras using GFP-transgenic mice area powerful tool to furtber delineate their role in peripheral neuropathy.

68 Course of neuropathy with benign lgM monoclonal gammopathy. D. Adams, C. Th› P. Labauge, C. Papeix, G. Said (Le Kremlin-Bic~tre,Villejuif, F) Background: The long term incidence of hematological malignancy in patients with neuropathy associated with lgM monoclonal gammopathy of undetermined significance (MGUS) remains controversia1.

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Aim: We reviewed the clinical, haemato-immunological and pathological data of 31 patients with symptomatic neuropathy and MGUS followed in our institutions by a combined neurological and haematological team.At the time of diagnosis, aU patients with neuropathy and monoclonal gammopathy have been referred to the Gustave Roussy Insitute for malignant disorders where a complete workout was performed. Method and patients: We reviewed the files of patients with neuropathy and IgM MGUS referred to our department over the past 15 years in order to assess the course of the neuropathy and of the monoclonal gammopathy. At referral, the median age was 65 years (range from 29 to 79) and the median duration of the neuropathy was 2 years (range from 0.5 to 17). Twelve patients h a d a purely sensory neuropathy (group 1), 8 a mild sensory-motor neuropathy (group 2) and 11 a severe sensory-motor neuropathy (group 3). Eighteen patients (58%) h a d a distal symmetrical polyneuropathy and 13 (42%) a multifocal neuropathy. The neuropathy was demyelinating in 20 (65%), axonal in 6 (19%) and mixed, axonal and demyelinating in 5 (16%). 10/24 patients had anti-MAG antibodies. Results: The mean follow-up was 5 years (ranging from 1 to 13). Nineteen patients (61%) received a treatment for a disabling or progressive neuropathy. Seventeen (17) patients received alkylating chemotherapy, and 2 iv Ig for a median duration of 16 months (range from 3 to 72 months).Among the 11 patients with a severe sensory-motor neuropathy (group 3), 4 patients improved significantly after therapy and 5 stabilized. One patient worsened, leading to secondary diagnosis of amyloidosis. Among patients of groups 1 and 2, 5 improved and 4 remained stable. For the 12 untreated patients, neuropathy remained unchanged in 8, secondary worsened in 4 requiring therapy in 3. Severe hand tremor occurred in 5 patients. Seven patients (23 %) developed a malignant lymphoplasmacytic proliferation including systemic non-Hodgkin lymphoma in 5 (16%), Waldenstr6m's disease in 2. Two patients (6,5 %) developed a cancer including one who had previously received chemotherapy. Among the patients with lymphoma, the mean interval from referral for a polyneuropathy to diagnosis of lymphoma was 60 months (ranging from 4 to 108). Four of them h a d a stable sensory and demyelinating neuropathy and one a severe sensory-motor neuropathy at the time of diagnosis of lymphoma. One patient had previously received chemotherapy. Two patients improved after treatment and 3 died. Conclusion: This study shows a high incidence of hematological malignancies in patients with neuropathy and IgM MGUS and stresses the need for long term neurological and oncological follow-np of these patients. Analysis of potential predictive factors are under way.

Oral session 12 Peripheralneuropathy-2 69 Types ]V and V hereditary sensory and autonomic neuropathy are a|lelic. H. Houlden, R. H. M. King, A. Hashemi-Nejad, N. W. Wood, C. J. Mathias, M. Reilly, P. K. Thomas (London, UK) Type IV hereditary sensory and autonomic neuropathy (HSAN IV) or congenital insensitivity to pain with anhidrosis (CIPA) has been shown to be due to mutations in the gene for the high affinity nerve growth factor receptor TrkA (NTRK 1). Pathologically it is characterized by a normal density of unmyelinated nerve fibres a n d a virtual absence of unmyelinated axons in the peripheral nerves. HSAN V, on the other hand, shows a selective deficiency of small myelinated fibres and only a mild reduction in unmyelinated axon density. We describe a boy born to consanguinous parents with episodes of pyrexia from early life related to anhidrosis, accompanied by selective loss of pain and temperature sensibility resulting in neuropathic joint degeneration. Nerve biopsy showed the features of HSAN V. Molecular genetic studies revealed that the patient was homozygous for a novel missense mutation in the NTRK 1 gene, his parents being heterozygous. HSAN IV and V may therefore not be separate disorders but different phenotypic manifestations of mutations in the same gene.

70 Rapid Induced Myelination and Demyelination in a Conditional Mouse Model of Charcot-Marie-Tooth Disease Type lA. J. Perea, A. M. Robertson, T. Tolmachova, J. Muddle, R. H.M. King, P.K. Thomas, C. M. P. H. Huxley (Evry Cedex, F; London, UK) Charcot-Marie-Tooth disease type lA (CMT1A) usually results from a 1.5 Mb duplication on chromosome 17p11.2, This region contains the peripheral myelin protein 22 (PMP22) gene the over-expression of which results in a progressive demyelinating neuropathy. Potential therapeutic approaches to treating the over-expression of PMP22 could be aimed at reduction of PMP22 expression either by drugs or by antisense gene therapy. For such approaches to be feasible, it will be necessary for the myelin to be able to correct once the initial demyelination has occurred. It would also be advantageous if the myelin were stable once corrected when therapy is withdrawn. We have generated a transgenic mouse model with conditional over-expression of PMP22 specifically in Schwann cells. Over-expression of PMP22 throughout life causes a demyelinating phenotype while myelination is nearly normal when it is switched off. Correction begins within a week of switch off of over-expression of PMP22 indicating that the Schwann cells are poised to commence remyelination almost as soon as PMP22 overexpression is prevented. Active demyelination after up-regulation of the gene was observed within I week indicating that Schwann cells with mature myelin are sensitive to increased amounts of PMP22 such that they rapidly demyelinate. 71 Correlation and differential features of Charcot-Marie-Tooth disease associated with the 17p11.2 duplication (CMT1A). D. Pareyson, F. Taroni, M. Milani, V. Scaioli, C. Ciano, M. Morbin, M. Marchetti, G. Lauria, A. Sghirlanzoni (Milan, I). A duplication of the chromosomal region 17p 11.2 including the gene coding for the peripheral myelin protein-22 (PMP22) is the most common genetic abnormality underlying Charcot-Marie-Tooth disease (CMT). We analysed clinical and electrophysiologic features of our series of CMT1A patients harbouring the duplication, and compared them with those of non-duplicated CMT1 and CMT2 cases. There were 92 patients from 53 families, representing 42% ofall CMT index cases (n = 125) and 64% of CMT1 probands (n = 83). In CMT1A patients,mean age at onset was 9.7 yrs (SD 11.4), significantly lower than in non-duplicated CMT1 cases (12.6 yrs, SD 9.7, p < 0.01) and CMT2 cases (21.5 yrs, SD 17, p < 0.001). Clinical severity was significantly milder than in non-duplicated CMT 1 cases, and was similar to that of CMT2 patients. Pes cavus, upper limb involvement, deep tendon reflexes abnormalities, and sensory loss were more frequent than in CMT2. Electrophysiologic examination revealed that motor and sensory conduction velocity (MCV, SCV) were always below 32 m/s in upper limb nerves, and were significantly lower than in non-duplicated CMT1 patients.Amplitudes of upper limb compound muscle action potentials (CMAPs) and of upper and lower limb sensory action potentials (SAPs) were significantly lower than in CMT2, paralleling clinical differences. Clinical severity correlated with decrease of CMAP amplitude and with disease duration. On the other hand, MCV slowing was correlated neither with severity nor with duration of the disease. There was a direct correlation between age at onset and upper limb MCV values. Conclusions: CMT1A is an early onset but slowly progressive disorder, overall milder than other CMT 1. Axonal loss rather than demyelination per se underlies disease progression. Partly supported by a grant from the Italian Ministry of Health. 72 Phenotypic expression of a Pro87Leu mutation in the connexin 32 gene in a family with Charcot-Marie-Tooth nenropathy. T. Kuntzer, M. Dunand-Ditisheim, J. M. Vallat, D. F. Schorderet, J. Bogousslavsky (Lausanne, CH; Limoges, F) We report on detailed clinical and electrophysiological data in 19 CMT patients from the same family. Linkage analysis confirmed the know Cx32 gene locus on chromosome X a n d a novel P87L mutation was observed in all patients. Median age at onset and type of initial complaints were not significantly different between sexes. On examination, all patients had variable muscle weakness in the distal lower limb muscles, and, in most of them, a reduced strength in the small hand muscles. The following dinical data affected predominantly male patients; (i) severity of sensory loss, (ii) presence of vertebral or foot deformation and (iii) correlation between physical impairment and duration of the disease. Nerve conduction velocity studies (NCVs) were evaluated in 56 nerves.

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The median value of NCVs and of compound motor action potential (CMAPs) amplitude were not statistically different between sexes, but a non homogeneous slowing in NCVs could be shown among individual patients. The values of the different parameters varied widely from normal to severely reduced, but a strong correlation could be shown between low CMAPs amplitude and duration of the disease in male patients only. It is concluded that in tbis family, phenotypic variation does not correlate with conduction velocity that is non homogeneously reduced but correlates with (i) CMAPs amplitude, a marker of axonal degeneration and (ii) with the duration of the disease in male patients only. 73 Initial semeiology in children with Charcot-Marie-Tooth disease I a (CMTlA) duplication. ]. Berciano, A. Garcia, O. Combarros (Santander, E) Background: Longitudinal studies in children with CMT-1A are scanty and therefore evolution of semeiology has not been sufficiently documented. Objective: 1"o describe initial signs and symptoms in CMT-1A. Patients and methods: Twelve secondary cases with CMT-1A were prospectively and serially evaluated, lnitial ages of clinico-electrophysiological examination ranged between 1 month and 4 years (mean: 2 years) and final ages between 6 and 23 years (mean: 13). Nerve conduction maturation was systematically abnormal. Resuhs: First signs of the disease were detected at initial or upon serial exams in all 12 patients at ages ranging between 1 and 10 years (median: 4). The most frequent signs were as follows: lower limb areflexia in 12, difficulty in heel walking in 6, nerve enlargement in 4, atrophy of extensor digitorum brevis muscle in 4, shortening of tendo aquilis in 3, pes planus in 1, peroneal weakness in 1, and stocking hypoesthesia in 1. Only three patients showed difficuhy in running or walking, or shoes not fitting. In five patients aged from 1 month to 2 years (median: 11 months) initial exam revealed no signs of the disease. Furthermore and before the appearance of such signs, seven serial exams in these tire children, then aged between 6 months and 5 years (median: 3 years), continued being normal. , Conclusions: Initial signs of CMT1A duplication usually appear in infancy though they may be quite subtle and require serial exams for detection. Lower limb areflexia is the only early constant sign. Most patients with incipient signs are asymptomatic. 74 Diagnostic strategy for familial and sporadic cases of hereditary neuropathy with liability to pressure palsies associated with chromosome 17pi 1.2 deletion. O. Combarros, A. GarcŸ ]. Infante, ]. Berciano, J. M. Polo, F. Palau (Santander, E) Background: Although hereditary neuropathy with liability to pressure palsies (HNPP) is usually presented as an autosomal dominant trait, sporadic cases carrying a de novo deletion have been described. Assessment of familial and sporadic cases has not been specifically considered in recent guidelines for the diagnosis of HNPE Objective: "lb formulate the most valuable approach for the identification of both sporadic cases and affected, but asymptomatic, relatives in HNPP families. Methods: We recruited 14 consecutive index cases showing the 17pl 1.2 deletion. Clinical, electrophysiologic and molecular studies were performed in a total of 45 at-risk family members. Resuhs: Sporadic cases due to de novo deletion accounted for 21% of the investigated HNPP families (3 out of 14). A total of 17 affected cases were symptomatic, whereas electrophysiologic and genetic testing allowed us to detect 15 asymptomatic patients. The electrophysiologic hallmark in both symptomatic and asymptomatic deletion carriers was the presence of a nonuniform sensorimotor demyelinating polyneuropathy with conduction abnormalities preferentially located at common entrapment sites and distal nerve segments. A perfect correlation was found between the molecular and electrophysiologic analyses. Conclusion: A reliable screening method to detect clinically unaffected carriers of the deletion in families with HNPP was the evaluation of motor conduction in at least two nerves across common entrapment sites, especially the ulnar nerve at the elbow, a n d a search for sensory conduction in the sural nerve. In sporadic cases due to a de novo deletion, electrophysiologic studies were suggestive but not sufficient for the diagnosis, and molecular analysis represented the most sensitive diagnostic tool.

Tuesday, AprŸ

2001

Oral session 13

Cerebrovascular disorders - 3 75 Behavioral changes and poststroke depression. A. Carota, E Staub, T. Karapanayiotides, A. Berney, ]. Bogousslavsky (Lausanne, CH) Objectives: To evaluate the incidence of poststroke depression (PSD) and its relationship with early behavioral changes. Methods: At the admission and at one year follow-up, we assessed 64 patients with first-ever unique stroke (mean age: 56 :l= 16) with neurological, neuropsychological and psychiatric evaluation. Functional handicap was scored with Barthel index and Rankin scale. In the acute phase, patients were daily evaluated with an observational scale, independent from language abilities, specifically designed for behavioral appraisal (EBIF). The EBIF indudes 38 items grouped in 7 categories: sadness, passivity, aggressiveness, indifference, disinhibition, denial, and adaptation. In patients without major comprehension deŸ237 (89 %, n=57), Hamilton Depression Rating Scale (HDRS) was per formed and psychiat ric diagnosis was established according to DSM-IV criteria. Lesions were evaluated with MRI and CT scan. Results: In the acute phase, the frequency of de pression (HDRS > 8) was 17% (n=ll) while at one year follow-up it was 38% (n=24), mostly (96%, n=23) being de novo cases. At any time afler stroke, we did not find significant correlation between PSD diagnosis and lesion side and site, neuropsychological deficits and observed behaviours, even crying or overt sadness. Nevertheless, in the chronic, but not in the acute phase of stroke, functional disability correlated with PSD (p=0.03, Mann-Whitney U-Test). Logistic regression showed that a different profile for HDRS sub-items was associated with time after stroke. Conclusion: In acute stroke, emotional behaviours are dissociated from PSD diagnosed with standardized scales. They do not predict the risk to develop late PSD. In the acute phase, we did not find a correlation with any specific lesion location and PSD seemed independent from disease awareness and deficit severity. On the other hand, in the chronic phase, depression correlated with functional disability, limitation in daily activities and anxiety, suggesting a component of psychological reaction to stroke consequences. 76 [ 1 IC]-Flumazenil Positron Emission Tomography in hemispheric stroke. I. Bonnaud, L. Spelle, G. Rancurel, ]. Z. Salama, ]. Moret, Y. Samson (Bobigny, ParŸ F) Introduction: PET with [llC]-Flumazenil (CFLU PET) allows to evaluate cortical neurona] integrity by imaging benzodiazepine receptor (BZR) density, and functional cortical changes, by measuring cerebral blood flow (rCBF)variations. Using this method, we studied functional and structural cortical changes in the subacute stage of hemispheric infarction, and four months later. Methods: Five patients (mean age: 60 y.o.) presenting with subcortical ischemic stroke located in the deep middle cerebral artery (MCA) territory were evaluated, 5 to 18 days afler the onset of symptoms, using clinical scores (NIHSS and Barthel scores), cerebral MRI and CFLU PET. For each individual patient, the PET images were compared with those of ten normal subjects, using SPM software. The same imaging protocol was repeated four months later, and data were compared with clinical improvement. Results: At the subacute stage, rCBF decrease and BZR density abnormalities were found co-localized in similar cortical regions, as found on MRI, but none of them correlated with final clinical scores of degree of functional recovery. At the chronic stage, the area of BZR loss had further increased in 4 patients and decreased in one. The extent of BZR loss correlated with final clinical scores (p < 0.05), whereas the variation of the extend of hypoperfusion (mean: -126.8, range: -206 to +69) correlated with clinical recovery (mean 28.8% changes in NIHSS) (p < 0.05). Conclusion: This suggests that delayed functional (CBF) and structural (BZR density) changes may occur in stroke patients between the subacute ( 1-2 week) and the chronic (3 months) stages. Furthermore, these changes ma}' be related to recovery and residual deficit.

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77 3D-reconstruction of intracranial collateral pathways using contrast enhanced transcranial color-coded sonography. C. K16tzsch, G. Lammers, T. Wessels, A. Bozzato (Aachen, D) The aim of this study was the morphological assessment (normal diameter, hypoplasia, duplication, aplasia) of intracranial collateral pathways using three-dimensional transcranial color-coded duplexsonography (3D-TCCS) and digital subtraction angiography (DSA). 41 patients with large-vessel-disease and 30 patients after subarachnoidal hemorrhage (mean age 52 -+ 15 years) were involved. The 3D-system consisted of an electromagnetic localizer for the ultrasound probe and a computer workstation for offline analysis of the data.After application of the ultrasound contrast enhancer Levovist (R), power-mode based images were stored and post processed along with the spatial information to create vascular 3D-reconstructions. Morphological details of the main collateral arteries (anterior + posterior communicating artery AcomA/PcomA; precommunicating segments of the anterior + posterior cerebral artery AICA/PICA) were investigated. Compared with DSA, 3D-TCCS was able to demonstrate 608 of 639 (95 %) of the relevant arterial segments. The comparison ofboth techniques resulted in a weighted kappa value of 0.63 for the AcomA (p < 0.001) and 0.56 for the AICA (p < 0.001). In the posterior circulation kappa values of 0.45 (p < 0.001) for the PICA and 0.56 (p < 0.001) for the PcomA respectively were found. Agreement for the detection of a fetal origin of the PCA resulted in a kappa value of 0.7 (p < 0.001). In patients with patent temporal bone windows we observed a good agreement between 3D-TCCS and DSA. The main advantage is that the 3Dsystem enables the investigator to reconstruct any arbitrary view angle. Combined with hemodynamic data from conventional Doppler sonography 3D-TCCS might increase the diagnostic impact of transcranial Doppler ultrasound. 78 Second harmonic imaging - an ultrasound technique to assess human brain perfusion. J. Harrer, C. K16tzsch (Aachen, D) Second harmonic imaging (SHI) is a novel ultrasound technique that allows the evaluation ofbrain tissue perfusion. The purpose of this study was to assess cerebral perfusion in two different transtemporal insonation planes. In 25 patients (aged 50 + 19 years) without cerebrovascular diseases SHI examinations were performed in a transversal and a coronal diencephalic insonation. After i.v. administration of 2.5 g (400 mg/ml) of a galactosebased echo contrast agent, 62 time-triggered images (1 frame/2.5sec) were recorded and analysed off line. Time-intensity curves including peak intensity (PI) [dB] and positive gradient (PG) [dB/sec] were calculated to quantify ultrasound intensity in 4 different regions of interest (ROI) in both planes of section: thalamus (ROIa), territory of the middle cerebral artery (ROIb), interna/capsule (ROIc) and lentiform nucleus (ROId). PI ratios for ROIb/a and ROIc/a were calculated. Characteristic time-intensity curves with high Pis and steep PGs were recorded in ROIc and d. No significant differences were found between the 4 ROIs in the transversal versus the coronal insonation plane. PI was significantly higher in ROIa than in ROIb (6.99 vs. 4.64 dB, p < 0.05), there was no significant difference in PI between ROIa, ROIc and ROId. PG was significantly higher in ROIa than in ROIc (0.12 vs.0.23 dB/sec, p < 0.05), PG was comparable in ROIa, ROIb and ROId. PI ratios showed significantly smaller values for ROIb/a than for ROIc/a (0.78 vs. 1.52, p < 0.05). Analysis of time-intensity curves of transversal and coronal insonation planes show comparable values of Pis and PGs. The analysis of new ROIs that are only depictable via the coronal plane of section, e. g. the temporo-basal and the parietal region near the skull and the calculation of the PG might be useful especially in focal abnormalities of cerebral perfusion. 79 Brain CT-Scan In Acute Ischemic Stroke Patients: Silent Infarcts And Relation To 6-Month Outcome. E Corea, R. Luccioli, E. Ciorba, L. Parnetti, V. Gallai (Perugia, I) Background/Objective: Silent cerebral infarcts (SI) are common findings in stroke patients, but their clinical significance remains uncertain. The aim of this study was to evaluate the relevance of SI on 6-month vital outcome, in a consecutive population of acute stroke patients. Methods: The study population consisted of 191 patients (95 males) with a median age of 75 years (range: 36-99), consecutively admitted for an ischemic or hemorrhagic acute stroke in the period between Sept. '98 and Mar. '99. Presence of SI was assessed on CT-scan performed at admission.

Results: Of 191 patients, 11 (5.7%) died during in-hospital staying, 74 (38%) had SI on CT-scan. Presence of SI with size higher than 10mm (11.5 %) was associated with increased in-hospital death (p=0.02). The 6month mortality rate, in the ischemic subgroup, was 12 %. Patients who died during the 6-month follow-up period were more likely to have a known previous vascular disease history (p=0.015), a more severe deficit at admission (p=0.02) and TACI subtype of stroke. Presence of SI was associated with a small vessel disease as presumed cause of stroke (p=0.025) a n d a more severe cerebral atrophy score (p=0.01). Conclusion: Presence of SI did not influence the 6-month mortality, but was associated with stroke of lacunar subtype. The size of the lesion was associated to an increased rate of in-hospital death, which may be due to different etiopathogenetical mechanisms underlying the vascular brain damage. 80 Migraine and the risk of cervical artery dissection.A prospective case-control study. C. Tzourio, L. Benslamia, B. Guillon, S. Aidi, K. Berthet, M. Bousser (ParŸ F) Background: Several recent studies have established migraine asa risk factor for ischemic stroke. However, it is not known whether this association concerns all types of ischemic stroke of is limited to some subtypes. We therefore decided to study migraine in a case-control study on cervical artery dissection. Methods: Patients with cervical artery dissection were prospectively and consecutively recruited in two centres during a 18 month period. They were compared to controls hospitalised in the same centres during the same period for an ischemic stroke not due to cervical artery dissection. Controls were included if they were roughly comparable to cases on sex and age in order to have a group matching on these variables. Diagnosis of migraine previous to the stroke was made with a structured questionnaire during a face to face interview with a neurologist. The algorithm used for the diagnosis was based on the International Headache Society criteria. Results: 48 patients with cervical artery dissection were compared to 53 controls of same mean age (44.6 (7.5) vs. 45.2 (9.1), P=0.72) and sex distribution (46 % of women vs. 43 %, P=0.81). Migraine was diagnosed in 48.9 % (23/47) of the cases and 21.2 % (11/52) of the controls (P = 0.004). In a logistic model adjusting for age, sex,body mass index, level of education, and centre, the only factor associated with CAD was migraine with an odds ratio of 3.6 (95% Confidence Interval=l.5-8.6). The odds ratio was higher in patients with multiple dissections: OR = 6.7 (95 % CI 1.9-24.1) than in patients with a dissection of a single artery: OR = 2.9 (95 % CI 1.1-7.6). Conclusion: In this study, we observed a specific and strong association between migraine and cervical artery dissection compared to other subtypes of ischemic stroke, which seems to indicate that an underlying arterial wall disease could be a predisposing condition for migraine.

Oral session 14

Cerebrovascular disorders - 4 81 VCAM-1 and ICAM-1 in the CSF indicate poor outcome in patients with intracerebral hemorrhage. 1. Kraus, J. G. Heckmann, S. Leis, P. Oschmann, B. Neundoerfer (Giessen, Erlangen-Nuremberg, D) Objective: To evaluate, whether cerebrospinal fluid (CSF) and serum levels of adhesion molecules (AM) could be used as prognostic markers for the clinical outcome of patients with intracerebral hemorrhage (ICH). Background: The AM ICAM- 1 and VCAM-1 are proinflammatory parameters for the activation of the immune system. In ischemic stroke correlation between serum levels ofAM and clŸ outcome was found. It has been suggested that an inflammatory reaction is responsible for reperfusion damage leading to brain oedema and tissue destruction after acute ischemia. Methods: 10 patients with acute ICH with ventricular tamponade were included into this study. All of them were treated at the neurological intensive c a r e unit after neurosurgical application of a ventricular drainage to

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treat acute hydrocephalus. Paired serum and CSF samples from the ventricular drainage were obtained five times every other day. Concentration levels of soluble ICAM-1 and VCAM-1 (slCAM-1, sVCAM-I) were determined by ELISA. In corresponding clinical examination the Scandinavian stroke scale scores were determined. Results: 4 of the 10 patients died within 8 weeks after the acute ICH. In their CSF we measured initial concentration levels for slCAM-1 of above 18.3 ng/ml and of sVCAM-1 of above 44.5 ng/rnl, respectively'. However, in the group ofsix patients who survived the acute ICH for more than 8 weeks the initial slCAM-1 CSF concentration levels of slCAM-I were below 13.7 ng/ml and of sVCAM- 1 below 35.4 ng/ml In addition, the AM concentration levels were independent from the amount of erythrocytes in the CSF sampies. Conclusion: Our data show a strong correlation between clinical outcome and the concentration levels of AM in the CSF of patients with acute ICH and ventricular drainage. It can speculated, whether brain tissue destruction is primarily leading to the release of AM due to necrotic destruction. Another possibility would be that ICH initiates an inflammatory process leading to secondary brain damage. According to this hypothesis it could be interesting to test antiinflammatory treatment in patients with ICH a n d a highly elevated amount of AM in their ventricular CSF samples. 82 Reduced progression of early atherosclerosis following antibiotic treatment afler ischemic stroke and chlamydia pneumoniae seropositivity. D. Sa nder, K. Winbeck, I. Klingelh6fer, T. Etgen, B. Conrad (M ª Chem nitz, D) Chlamydia pneumoniae (Cp) infection has been associated with atherosclerosis and has been proposed asa possible additional cardiovascular risk factor. Some studies indicate a possible beneficial effect of antibiotic therapy on future cardiovascular events in Cp seropositivity. We evaluated the effect of roxithromycin therapy (150 mg twice daily for 30 days) on the progression of the intima to media-thickness (IMT) of the common carotid artery using duplex ultrasonography in a prospective study with a follow-up of at least 2 years in 272 consecutive patients with ischemic stroke aged over 55 years in whom the first IMT measurement and the Cp testing (IgG and IgA) was performed at least 3 years before the beginning of roxithromycin therapy. Cp IgG antibodies (> 1:64) were initially found in 123 (42 %) patients and IgA antibodies (> 1:8) in 119 (40.8%) patients. In the 3 years before the onset of antibiotic therapy, patients with serological detection of Cp showed a significant enhanced progression of the IMT even after adjustment for other cardiovascular risk factors (0.12 mm/year [95 % confidence interval 0.10; 0.15] vs.0.06mm/year [0.03; 0.09]; p < 0.001). The 61 Cp positive patients given roxithromycin showed a significantly decreased IMT progression after 2 years compared to the Cp positive patients without therapy (0.07 mm/year vs. 0.11 mm/year, p < 0.01). However, no significant difference in the occurrence of future cardio-vascular events was found between both groups during the follow-up period. No change of IMT was observed in Cp negative patients given roxithromycin (n=75), compared to those without therapy (0.05 vs. 0.06 mm/year). Our findings suggest a possible positive impact of antibiotic therapy on early atherosclerosis progression in Cp seropositive patients with cerebrovascular disease. 83 Diffusion-weighted MRI reliably identifies brainstem and thalamic infarctions. W. Kª I. Weise, H. Krapf, E Schmidt, S. Friese, M. B~ihr (Tª D) Background and Purpose: Diffusion-weighted MRI (DW-MRI) has demonstrated its high sensitivity to acute supratentorial ischemic lesions. In this study we examined the sensitivity of DW-MRI for acute brainstem and isolated thalamic infarctions. Methods: We performed diffusion- and T2-weighted MRI in 45 patients with clinical symptoms of infratentorial infarction. The time between the onset of symptoms and the first MRI was 2 hours to 7 days with a mean of 2 days. MRI repeats were performed in 4 cases. Lesion detectability and size were evaluated for different brainstem and thalamic localizations in appreciation of the clinical symptoms. Results: A brainstem or thalamic infarction could be identified in all patients by comparison of DW-MRI, T2-weighted images and clinical symptoms. Pons infarctions were the largest, followed by midbrain and thalamic lesions. Medulla oblongata in farctions were small in comparison. Pons, midbrain and thalamic infarctions were reliably identified beginning 12 hours after the onset of symptoms. In contrast, detectability of medulla oblongata

infarctions varied within the first 24 hours and their overall visibilily was worse than that of other brainstem infarctions. Two medulla oblongata and one pontine infarctions examined within the first 5 hours afler the onset of symptoms were not identified initially but could be demonstrated by followup. Conclusion: Acute pontine, midbrain and thalamic infarctions can reliably be visualized by a combination of DW-MRI and T2-weighted images beginning 12 hours after ischemia. However, sensitivity seems to be lower during the first hours and for medulla oblongata infarctions. 84 Risk factors to subclinical carotid atherosclerosis in healthy pilots - predictors of intima-media-thickness in a 10-years follow-up. F. Weber (Fª D) Ultrasound measurement of carotid artery intima-media thickness (IMT) is generally considered a s a valid index of atherosclerosis. Several risk factors for IMT, such as age, blood pressure, total cholesterol, HDL cholesterol, body mass index, male gender, diabetes and smoking, have been identified both in cross sectional and in longitudinal studies. The special aim of this study was to determine carotid IMT in a low risk population of healthy individuals. Data were obtained from a cohort of 445 healthy German military pilots in their fifth or sixth decade of life, all in active military flying service, observational period was 10 years. Determinants of IMT by multiple linear regression were age (Coefficient = 0.022; p < 0.00~1), number of cigarettes smoked daily at the beginning of the study (Co. = 0.010,p = 0.0003) and systolic blood pressure (Co. = 0.008, p < 0.0001). In this study, lipids, body mass index and parameters of physical activity had no significant influence on carotid IMT. Besides the well known effects of age and smoking, the influence of the systolic blood pressure is remarkable, because all participants of this study were normotensive individuals. So even "high normal" blood pressure may increase the risk of carotid atherosclerosis 85 The natural history of familial cerebral cavernomas malformations: Follow-up of 33 asymptomatic patients with clinical examination and cerebral MRI including spin-echo and gradient-echo sequences. P. Labauge, L. Brunereau, S. Laberge, l.P Houtteville (Nimes, Tours, ParŸ Caen, F) Objectives: To determine the spontaneous evolution of familial cerebral cavernous malformations (CCM) in a population of 33 symptom-free patients. Background: CCM is one of the most common vascular malformations of the central nervous system. Familial CCM are increasingly diagnosed but little is known about their spontaneous evolution especially in asymptomatic patients. Design/methods: During a previous national survey, we have analyzed clinical and magnetic resonance (MR) imaging features of 173 patients from 57 unrelated French families, including 73 asymptomatic subjects. Cerebral MRI systematically included spin-echo (SE) and gradient-echo sequences (GRE). Occurrence of clinical symptoms and MRI changes of CCM, i. e. hemorrhage, change in signal intensity, change in size, new lesions appearance were recorded by means of comparison of first and last MR examinations. Results: A total number of 234 CCM (mean 7.1 lesions, range 1-86), were followed during a mean period of 2.1 years (range: 0.5-4.5). Of the 33 patients who were initially symptom-free, 2 became symptomatii: one patient presented brainstem hemorrhage and one partial seizures. Serial MRI examinations demonstrated evolution of lesions in 15 patients (46%): i) bleeding occurred in 3 lesions (1.3%) in 3 patients (9.1%). These events only concerned type 2 CCM. ii) 30 new lesions appeared in 10 patients (30.3%); iii) change in signal intensity was observed in 1 lesion (0.4%) in 1 patient (3%), and increase in size was observed in 4 lesions (1.7%) in 3 patients (9.1%). Conclusions: Spontaneous clinical and MRI evolution ofCCM appears to be less aggressive in asymptomatic patients than in symptomatic patients. We conclude therefore that interval between two clinical and MR examinations can be increased in the follow-up of symptom-free patients. 86 Prevalence Of Peripheral Arterial Disease In lschemic Stroke Patients In A Stroke Unit. C. Lucas, N. Vaz, M. Mackowiak, D. Deplanque, H. H› D. Leys (Lille, F) Double localization of atherosclerosis could modify medical management and is a factor of bad prognosis ir endarterectomy is necessary. To our

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knowledge, there is no prospective study of prevalence of peripheral arterial disease (PAD) in ischemic stroke. Aim: The aim of the study was to evaluate the prevalence of PAD in consecutive ischemic stroke and TIA patients in a stroke unit Methods: This study was conducted prospectively during 4 months. One hnndred and forty eight patients, mean-age 67.2, were included. One hundred and eight patients had ischemic stroke (79.7 %)and 30 (20.3 %) h a d a TIA. We systematically clinically searched PAD signs, symptomatic or not, in these patients. Results: Thirty fore patients (23 %) had PAD signs. Eight patients ignored to have PAD. PAD was 2 times more frequent in patients with ischemic stroke presumed to be of atherosclerosis origin than in lacunar patients. Carotid stenosis > 70% was found in 17 patients (11.7%). Discussion: This study shows that a quarter of patients with ischemic stroke in a stroke unit has PAD signs based on clinical data. PAD is probably underestimated in such patients. 87 Etiopathogenic of cerebral ischemia in 202 young adults. C. Bolcu Emir, J. Agaoglu, S. Bek, M. Gnr, O. Tanik (Istanbul, TR) Introduction: People younger than 45 with ischemic stroke account for about 5-15 % of all strokes. Etiology of ischemic strokes in young adults include a variety of disorders that are less frequently seen in older adults. Risk factors and etiology were retrospectively investigated in 202 patients aged 9-45, referred to our neurology unit with cerebral transient ischemic attacks or infarction during the period 1999-2000. Method: 202 cases were divided into two groups according to their ages, as 9-30 and 30-45 years of age gronps. Al1 patients underwent neurological, medical-cardiological evaluation, routine blood and urinary examinations, electrocardiography, echocardiography, cerebral computerized tomography scanning (CT) and/or magnetic resonance imaging (MRI) and carotid doppler ultrasonography evaluation. Cerebral angiograpby, transesophageal echocardiography, haematological and immunological tests and cerebrospinal fluid examination were performed in required cases. Migraine, hypertension, diabetes mellitus, hyperlipidemia, smoking, pregnancy and oral contraceptive intake were considered as possible risk factors. Results:153 cases (70 %) were in the 30-45 years of age group and 39 subjects (30%) were in the 9-30 years of age group. Under 30 years of age, female predominance for stroke was observed, whereas after 30 years of age male predominance was apparent. Hypertension,hyperlipidemia and smoking were the most common risk factors and hypertension was significantly high in patients with ischemic stroke in their family. Atherosclerosis was the leading etiology occurring in 30-45 years of age group (35 %) and vasculopathy was markedly high in 9-30 years of age (23 %).In addition, cardiac embolization was determined in 20 % of all cases. A cardiac embolic disorder was considered the probable cause of ischemia in 40 cases and among these cases, cardiac valve disease (58%), atrial fibrillation (16%), ischemic heart disease (27%) and cardiomyopathy (2%) were determined by the investigation methads. Further possible etiologies were hyperviscosity (4 %), puerperium (4%), homocysteinemia (3%) and other uncommon conditions. Conclusion: The wide spectrum of etiologies and risk faetors in young adult ischemic strokes were evaluated together. The most striking finding of our study was the high frequency of cardiac valve disease in young adult ischemic strokes in our country when compared with the previous reports in the literature.

ical features. Previous studies with Single Photon Emission Computerized Tomography (SPECT) describe an original pattern with asymmetric hypoperfusion in pre and retro-rolandic regions, but those studies are few. Objective: To compare the regional cerebral blood flow measurements studied by SPECT with 99m-Technetium HMPAO in CBD and Parkinson's disease (PD), using a statistical analysis. Methods: Fifteen patients with probable CBD (ten women; mean age: 66.1 years; mean disease duration: 4 years) and 15 patients with PD (nine women; mean age: 65.5 years; mean disease duration: 5.6 years) underwent brain SPECT imaging after intraveinous injection of 740 MBq of 99m-Technetium HMPAO. We studied by a stepwise discriminative analysis the relative fixation of 26 regions of interest drawn on two transverse slices (orbitomeatal plane + 5 centimetres and + 8 centimetres). Results: There was a decrease of HMPAO uptake in both medial frontal regions in the CBD group when compared to the PD group (P < 0.05) with a Wilcoxon test. In order to classify automatically the patients, a predictive score was established by a factorial discriminant analysis from cortical indexes. Conclusions: A medial frontal'hypoperfusion on upper slices allowed to separate the CBD group fŸ the PD group. We estimate that this semi-automatic classification can be a precious tool to comfort clinical differential diagnosis between CBD and PD. 89 Guadeloupean Parkinsonism: dinical and epidemiological update, D. Caparros-Lefebvre, A. Lees, A. Lannuzel, E. Tolosa (Pointe a Pitre, F; London, UK; Barcelona, E) Background: In 1996, we reported an unexpected high frequency of atypical parkinsonism in the French West Indies. More than 75 % respond poorly to L-Dopa and have postural instability, frontal lobe dementia and delayed pseudo-bulbar palsy. The remaining 20 % present with classical Parkinson's disease (PD). Such distribution is opposite to the one encountered in Europe and USA. We continued the study and have included 185 patients up to now. Methods and Patients: Patients referred for parkinsonism to our department have been included except those with previous stroke, neuroleptic treatment, history of encephalitis or severe head trauma. The clinical and neuropsychological study aimed at the accurate classification of patients according to stringent criteria for PD, progressive supranuClear palsy (PSP), multiple system atrophy (MSA), Lewy bodies disease (LBD), fronto-temporal dementia (FTD). Patients who did not respond to these criteria were considered as having unclassifiable parkinsonism (UP). We recorded also the occupation, places of living and compared them to the exposition of pesticides in drinking water. Results: 185 patients have been included. 54 (29 %) had PSP,75 (40 %) had UP,41 (22 %) had PD, 13 (7 %) had amyotrophic lateral sclerosis with parkinsonism and 2 had MSA. To be a farmer was strongly associated with PSP and ALS. This association was independent from age, sex, and place of living. The sex ratio was significantly in favour of males in PSP and ALS. We observed small clusters of PSP or ALS in 3 different towns. There was no obvious relation with the exposition to altered drinking water, containing pesticides (dieldrin, cyclohexane, chlordecone), as assessed by the public health department. Conclusion: This update (in addition with the neuropathologic report) confirms a specific cluster of PSP and parkinsonism-dementia in the French West Indies. PSP and ALS occurred mainly in farmers.

90 Wilson's Disease: Initial Manifestation and Clinical Presentation in 30 Patients. A. P. Narata, H. G. Teive (Curitiba - Parana, BR)

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Parkinson's disease - 1 88 Corticobasal degeneration and Parkinson's disease assessed by HMPAO SPECT. A. Kreisler, P. Charpentier, P. Lecouffe, L. Defebvre, M. Steinling, A. Dest› (Lille, F) Introduction: Corticobasal degeneration (CBD) is a rare parkinsonian syndrome. This diagnosis is difficult despite the existence of some typical clin-

Objective: evaluate the initial manifestation of Wilson's Disease (WD) and correlate witb the normal clinical course. Methods: 30 patients with WD were evaluated with detailed neurologic and medical history and examinations. A protocol was performed with special attention to clinical presentation (neurologic or not). Others established criteria as serum coeruloplasmin and copper levels, family history, onset age, race, sex were studied. Results: 14 women and 16 men were evaluated,with age of onset of symptoms: up to 15 years old=6 patients; 16-20=11 patients; 21-30=6 patients; 31-40--5 patients; more than 41=2 patients. Only 2 patients were not white. Half of the patients had family history confirmed, 19 had hepatic form (with 5 patients without others manifestations). 25 patients had neurologic presentation ( 11 patients without hepatic form). The hepatic presentation more frequent was splenomegalia and tremor was the most observed in neurologic examination. Kayser-Fleisher ring were found in almost all patients with tremor. Mean coeruloplasmin was 8.05 (from 1 to 27). The initial man-

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ifestation more frequently seen was the neurologic ones (movements disorders - tremor and dystonia), followed by hepatic ones (visceromegalias). We also noticed rheumatic disorders, haemolytic anaemia. 2 patients had dysgraphia as the only complaint. Conclusion: in our series the most common neurologic manifestation were tremor and dystonia. It is very important to emphasizes that in 2 cases the only complaint was difficulty to write. So, this study has intention to review diagnosis criteria and clinical manifestation that, sometimes, not suggesta typical WD. 91 Gait analysis in de novo Parkinson's disease: identification of reliable parameters for a correct diagnosis and influence of acnte L-dopa administration. M. Guidi, C. Catalano, G. Campoleoni, O. Scarpino, E Pace, G. Ghetti (Ancona, I) The diagnosis of Parkinson's disease (PD) still remains mainly clinical and easy to perform when the signs and symptoms of motor impairment are evident. Signs like postural instability and the compromise of walking ability and maintaining balance are common in the end-stage of PD and initially disregarded. In the early stages of illness a pharmacological test may assist in the diagnosis. The aims of this study were: (1) to define the characteristics of PD at an early stage by a 3-D gait analysis; (2) to investigate the relationship between gait pattern and motor impairment; (3) to identify measures which, in con)unction with a pharmacological test, may be reliable for ah early diagnosis of idiopathic PD. The gait analysis obtained by an optoelectronic ELI.TE system was evaluated in 7 untreated patients suspected to have a PD at an early stage before and after acute oral administration of 200 mg L-dopa and 50 mg benserazide. The patients had very mild symptomatology and were assessed with the modified Hoehn and Yahr scale and UPDRS. The age ranged between 60 and 75 years. We observed some cinematic parameters like pelvic tilt, pelvic rotation and hip rotation which varied from normal subjects, but were not influenced by pharmacological administration, whereas dynamic parameters especially the peak of ankle power, the second peak of vertical force and the mean walking velocity increased significantly. Furthermore, in our results the patient gait pattern was always correlated to clinical aspect. Our conclusion is that the 3-D gait analysis investigation in conjunction to a pharmacological test is a reliable diagnostic instrument for an early diagnosis of PD. 92 Camptocormia Associated With Parkinson's Disease. E Roudot, C, Lacroix, G. Said (Le Kremlin Bicetre, F) Parkinsonian patients in standing position are bending slightly forward. In some cases, this posture dramatically increases, reaching a trunk flexion till ninety degrees called camptocormia (Hall, 1919). Charcot, in 1886 already drew attention to this highly invalidating posture. We tried to disclose whether camptocormia is due to parkinsonian rigidity of the trunk fexor muscles, to dystonia of paraspinal muscles or to weakness of the trunk extensor. Patients: Six patients, 4 men, 2 women are included. Neither the type of the Parkinson's disease nor the age at onset determine camptocormia: in five of six cases, tremor was the first clinical symptom, in only one case rigidity. The mean age of onset of camptocormia varied from 43 to 78 years. In two patients, camptocormia anticipated by several years (4 to 10) the first clinical parkinsonian symptoms; in the other cases, ir manifested itself 3 to 15 years after the onset of parkinsonism. The abnormal posture appears in standing position: the trunk suddenly flexes forwards. The spine can be maintained in a normal posture in standing or seating position with a back support; when lying down, the flexed attitude easily disappeared. As soon as the back support is removed, the trunk suddenly bends forward. The patient is able to correct the flexion himself by extending the arms with the hands placed on the thighs, moving them progressively upwards. On CT-scan of lumbar muscles, the muscle fascicles appeared irregular in size with adipose overload, contrary to the morphology of the iliacus muscles. In four cases biopsies of paraspinal lumbar muscles showed irregular muscle fibres, dissociated by intense dissecting fibrosis; the inflammatory signs were light. In one case, a great number of fibres are ragged-red, a mitochondrial abnormal overload was visible after oxidative coloration. Thus clinical, CT-scan examinations and muscle biopsies demonstrated that the trunk flexion is due to a weakness of the extensor muscles and not to the hypertonia of the flexors. What kind of relation exists between the myositis with fibrosis and the Parkinson's disease? Immunological factors were proposed in the genesis of Parkinson's disease, are these myositis due to similar processes?

93 The Role of Magnetic Resonance Imaging with Gradient Echo Sequences in the Differential Diagnosis of Patients with Parkinson's Disease and Multiple System Atrophy. E. Kraft, C. Trenkwalder, D. P. Auer (Ulm, Munich, D) Introduction: MRI may be a useful procedure in the differential diagnosis between idiopathic Parkinson's disease (PD) and multiple system atrophy (MSA). So lar no study has used T2* weighted gradient echo sequences to compare PD with MSA. The goal of our study was, to assess the frequency and extent of paramagnetic susceptibility changes in the putamina in both diseases using a T2* weighted gradient echo (GE) sequence in comparison with a T2 weighted fast spin echo (FSE) sequence. Patients: 38 patients with PD according to the criteria of the UK Brain Bank and 16 patients with MSA fulfilling the criteria of the consensus guidelines for the diagnosis of MSA were studied. Methods: Images were recorded with a 1,5 Tesla MRI scanner using a T2 weighted sequence FSE in transverse plane, as well a s a T2* weighted GE sequence in the same orientation. Signal intensity of the putamen was evaluated by two raters, who were blinded to the diagnosis of the patients. The signal of the putamen was assessed in both sequences in comparison to the signal intensity of the pallidum and thalamus. Results: Interrater reliability was good for the evaluation on FSE (> 0.53) and even better for GE sequences (> 0.68). Both raters found a significant difference between MSA and PD for relative putaminal hypointensities in the T2* weighted sequences (p < 0.01). In contrast no significant difference was found when the relative hypointensities were c,ompared between PD and MSA with T2 weighted sequences. Conclusion: Our findings suggest that T2* GE sequences but not FSE ate sensitive enough to detect the pathological putaminal iron accumulation occurring in patients with MSA. These results indicate that inclusion of T2* GE sequences into the scanning protocol for patients with parkinsonism will improve the diagnostic value of MRI. 94 Value of Apomorphine Challenge in the Early Differential Diagnosis of Parkinson's Disease. P.H. Kraus, P. Klotz, M. Langkafel, H. Przuntek (Bochum, DE) During the last years apomorphine challenge became a method for assuring clinical diagnosis of idiopathic Parkinson's disease. Using an instrumental method we tested the hypothesis that patients suffering from a lack of dopamine should improve in motor performance after application of apomorphine and should less improve after placebo. We examined 48 Parkinsonian patients who were slightly or moderateIy disabled. Administering a double blind placebo controlled AB-design we tested our patients during two consecutive days with the motor performance test after Schoppe. This is a multidimensional test of hand dexterity proofed to differentiate acute severity of hand disability in PD patients. Before admission to the challenge all patients were diagnosed by an independent neurologist conversant with Parkinson's disease. Signs and symptoms were for all patients clear associated. Two baseline values were measured for both treatment conditions. After baseline apomorphine or placebo was injected. Repeated measurements followed 5, 15, 30, 45, 60, and finally 90 minutes later. Thirty-four patients were under specific antiparkinsonian treatment with l-dopa and dopamine agonists - these patients had their last dose at least 12 hours before baseline test. 14 patients were untreated until testing. The effect of apomorphine to the baseline condition was significant (p < 0.05). But comparing the effect of apomorphine to placebo no difference was realised. Apomorphine tests provides no contribution to differential diagnosis even when using motor performance tests for those patients suffering only slight or moderate symptoms. These patients are also hardly accessible by rating scales because of reduced resolving power by the only small changes in symptomatology. Overviewing literature about apomorphine challenges which were predominantly concerned with distinct Parkinsonian syndrome it is to state that a placebo controlled design is required. The placebo effect is in many patients to large for estimating a challenge as positive when an improvement was found for only one dose in a design of consecutive tests of different doses of apomorphine.

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Oral session 16 Parkinson'sdisease 2 -

95 Long term efficacy of chronic subthalamic nucleus stimulation for Parkinson's disease. L. M. A. Romito, M. Iacoangeli, M. E Contarino, E. Moro, M. Scerrati, A. Albanese (Roma, I) Objective: To show the long term results of the chronic bilateral stimulation of the subthalamic area in patients with severe forros of Parkinson's disease (PD). Background: PD is characterized by hyperactivity of the subthalamic nucleus (STN); functional inactivation of the 8TN may improve all the signs of the disease and reduce the requirement for dopaminergic therapy. Methods: Quadripolar leads were implanted bilaterally under stereotactic conditions in the STN of 25 patients with advanced PD (mean age: 56.6 years; mean disease duration: 14.3 years). Following implant, antiparkinsonian medication was reduced to the mŸ possible and stimulation gradually increased. Patients were evaluated in the prar off and on conditions using the unified PD rating scale (UPDRS) and the Schwab & England scale. The average follow-up was 16.6 + 13.5 months. Results: Parkinsonian features were greatly improved in all patients, the greatest change being seen in rigidity, tremor and then by bradykinesia. Compared with the pre-surgery condition, at the last visit, off-drug UPDR8 motor scores improved by 48.4% (p=0.000108), UPDRS activities of daily living (ADL) scores improved by 70.1% (p=0.00020), and the Schwab & England scale improved by 256.9 % (p=0.000107). The levodopa-equivalent daily dose (LEDD) was reduced by 55.5 %.Night sleep improved in all patients and in 20 patients insomnia resolved. Stimulation amplitude was 2.89 + 0.36 V and the total energy delivered per patient averaged 1.5 + 0.5 W x 10-6.8ideeffects were mild and tolerable. In all cases, a trade-off between the optimal voltage and the severity of side-effects made it possible to control parkinsonian signs effectively. The most marked side-effects directly related to 8TN stimulation consisted of ballic or choreic dyskinesias of the neck and of the limbs elicited by contralateral STN stimulation above a given threshold voltage that varied depending on the individual. Conclusions: PD signs can be controlled by bilateral high frequency STN stimulation; the procedure is well tolerated. Off-period disappeared in all patients and on-state dyskinesias were greatly reduced, due to the reduction of anti-PD medication combined with a direct effect of the stimulation. Bilateral STN stimulation greatly compensated for drug reduction: 7 patients succeeded in stopping every antiparkinsonian drug. Long term follow-up indicates a stability of the results, 96 Is cortical activation the clue of Parkinson's disease improvement obtained by pallidal stimulation? D. Devos, L. Defebvre, P. Derambure, J. L. Bourriez, F. Cassim, S. Blond, J. D. Guieu, A. Dest› (Lille, F) Background: In Parkinson's disease (PD), the motor preparation impairment is revealed by movement-related cortical potential (MRCP) amplitude reduction and by a delay in the appearance of event-related desynchronization (ERD) over the contralateral primary sensorimotor cortex (cPSM). The cortical deactivation impairment is reflected by MRCP-post motor potential amplitude decrease. Chronic GPI stimulation can be proposed in parkinsonians with severe motor fluctuations to control dyskinesias and the parkinsonian triad. Aim of the Study: To compare the cortical activation patterns induced by bilateral chronic internal globus pallidus (GPi) high frequency stimulation (HFS) and by L-Dopa on ERD and MRCP. Methods: Six PD patients performed self-paced wrist flexion movements with the most akinetic hand in 3 conditions: without HFS and L-Dopa (Off Stim), with HFS and without LDopa (On Stim) with HFS and L-Dopa (Best On). ERD based on EEG activity average was analysed from 13 source derivations. Results: The diminution of UPDRS III was 47.8 % (60 % of rigidity and 40 % of akinesia) in On Stim with a 49 % supplementary UPDRS III reduction in Best On. The m u rhythm ERD latency on central contralateral derivation was significantly increased in Best On compared to the 2 others conditions. The m u rhythm ERD surface was significantly decreased on the fronto-central ipsilateral derivation in On Stim and Best On compared to Off Stim. The post motor potential was significantly higher in Best On compared to the 2 other conditions. Conclusion: The cortical pattern in advanced PD was characterized by an important cPSM hypoactivation which could be compensated by an ear-

lier activation of ipsilateral premotor dorsolateral frontal cortex. Akinesia represented by a low cortical activation could be indirectly and mildly improved by GPi HFS, since this compensatory mechanism disappeared. The absence of cortical activation increase and the better improvement of rigidity suggest that GPi HFS could act through pathways different from thalamocortical ones such as the descending reticulospinal pathways. Association of GPi HF8 and L-Dopa partially restored cortical activation and deactivation processes in PD, 97 Impact of bilateral sub-thalamic or globus pallidus internalis high frequency chronic deep brain stimulation on quality of life in Parkinson's disease. S. Drapier, E Lallement, I. Rivier, S. Raoul, P. Damier, G. Edan, Y. Lajat, M. Verin (Rennes, Chantepie, Nantes, F) We investigated by patient's self-assessment the influence of bilateral subthalamic (STN) or globus pallidus internalis (GPI) high frequency chronic deep brain stimulation (DBS) on quality of life (QoL) in Parkinson's disease (PD). Evaluation of PD patient's QoL after surgery remains actually neglected in the literature. However patient's point of view of the benefits may differ from the clinician's aims. The results of ten patients for levodopa doses, motor score of the Unified Parkinson's Disease Rating Scale (UPDRS part III) and Parkinson's Disease Questionnaire 39 (PDQ39) were compared after 6 and 12 months of STN (n = 6) or GPI (n = 4) DBS. Preoperative general and neurological characteristics of patients in the two groups were identical except for levodopa doses, lower in the GPI group. The mean reduction of levodopa dose for STN group was 31% at 6 months and 22 % at 12 months. For GPI group, levodopa dose remains unchanged after surgery. The mean improvement of UPDRS part III preoperative in OFF dopa condition compared with UPDRS part III postoperative in OFF dopa ON stimulation condition at 6 months was 60 % for STN group versus 44 % for GPI group, and at 12 months 73% for STN group versus 36% for GPI group. In PDQ39, the mean postoperative STN group improvement was 35 % versus 27% for GPI group at 6 months and 37% versus 38% at 12 months. There was no difference in term of global QoL. All the subscores were improved in STN group and items like emotional weU being, cognition, bbdily discomfort and communication were better for STN group than GPI group. The improvement of mobility, activity of daily living and social support was similar in the two groups. The improvement of stigma was better in GPI group. However communication was aggravated postoperatively for GPI group in relation with hypophonia for 2 patients and stuttering for 1. From clinician's point of view, STN is a better target than GPI regarding the reduction of postoperative levodopa doses and the UPDRS part III improvement. From patient's point of view, global quality of life is improved equally by STN and GPI DBS but communication is impaired by GPI DBS. For both patient's and clinician's point of view, STN is the best target for DBS. 98 Effect on mood of chronic subthalamic nucleus stimulation for Parkinson's disease: a series of 18 consecutive patients. A. Berney, I. Ghika, A. Perrin, L. Medinger, J. G. Villemure, P. Guex, 1. Bogousslavsky,F. J. G. Vingerhoets (Lausanne, CH) Background and method: Subthalamic Nucleus stimulation (STNS) improves motor signs of Parkinson's Disease (PD). Cognitive modifications after STNS have been studied, but very little is known about neuropsychiatric effect of STNS. A single study showed a slight amelioration of self reported mood measure (BDI) 3 to 6 months after STNS. Case reports described acute depressive symptomatology or bipolar mood swings under stimulation. We evaluated a consecutive series of 18 PD patients before and 3 months after STNS. Each patient was evaluated by a psychiatrist and a neuropsychologist using mood scales as part of a standardized evaluation (MADRS, Hamilton-D, Hamilton-anx). These investigators were blind to the level of stimulation, the neurological motor improvement and the medication status. Resuhs: Mean scores of MADRS and HDRS of the whole group were slightly improved at 3 months under STNS. In 13 patients (group 1) no change (9 patients), or resolution of minor depressive symptomatology (4 patients) occurred. In 5 patients (group 2) the mood state worsened, with minor or fuUy symptomatic depressive symptomatology despite motor improvement; 2 of them were suicidal and needed antidepressant treatment. Group 1 and 2 differed significantly at 3 months for mean scores of MADRS (p < 0.001) and HDRS (p < 0.005). These scores were not significantly differentat baseline. Motor improvements and reductions of antiparkinsonian

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medication under STNS were similar in group 1 and 2. Testing of executive function showed similar evolution of performances in the two groups independently of the mood state.Acute postoperative confusional state was more frequent in group 2 (4/5 patients) than in group 1 (2/13 patients). Conclusions: STNS seems to have no or minimal effect on mood in a majority of cases. Nevertheless, one third of patients experienced worsening of tbeir mood state in the 3 months following intervention, despite motor improvement. Two patients became suicidal in the acute postoperative phase, stressing the importance of neuropsychiatric assessment as part of the evaluation for deep brain stimulation. These changes in mood could be secondary to a direct effect of STNS, but ate probably multifactorial. Changes of antiparkinsonian medications may playa role, although there was such significant effect in our series. Acute postoperative confusional state may predict development of a depressive mood state. (Supports: Swiss National Science & Vaud-Gen6ve Foundations)

99 Update on 10-year follow-up data of the Parkinson's Disease Research Group of United Kingdom randomised trial of levodopa, lcvodopa in combination with selegiline or bromocriptine in patients with early, mild Parkinson's disease. R. Katzenschlager, J. Head, u Ben-Shlomo, A.J. Lees (London,Bristol, UK) - On behalf of the Parkinson's Disease Research Group of the United Kingdom Background: The long-term effectiveness of three different initial drug regimes in patients with early, mild Parkinson's disease has been evaluated by the Parkinson's Disease Research Group of the United Kingdom (PDRGUK). In t 995, the selegiline arre of the trial was terminated following an interim analysis. The other two arms continued and 10-year follow-up results are now reporte& Methods: This was an open, randomised trial of patients with early Parkinson's disease who had never received dopaminergic treatment. 782 patients with early Parkinson's disease were recruited between 1985 and 1990 and were randomised to one of three interventions: Levodopa and dec• inhibitor (arm 1); levodopa and decarboxylase inhibitor in combination with selegiline (arm 2); or bromocriptine (arm 3). The main endpoints were mortality, disability and adverse events. Intention-to-treat analysis was used. Findings: There was no significant difference in mortality between the bromocriptine and the levodopa arm (hazard ratio 1.07 [95 % CI 0.95,1.21], p=0.27). Patients initially randomised to bromocriptine had slightly worse disability scores throughout follow-up. This difference was statistically significant during the first years. Patients in the bromocriptine arre returned to pre-treatment levels of disability one year earlier than those in the levodopa arm. Patients randomised to bromocriptine hada significantly lower incidence of dyskinesias than those randomised to levodopa (rate ratio 0.73 [95 % CI 0.57, 0.93], p=0.0056). However, this difference was not significant when only moderate to severe dyskinesias were considered. Patients randomised to bromocriptine also had slightly lower rates of dystonias and onoff fluctuations, but moderate and severe forms were equally frequent in both arms. Interpretation: Our results show that starting treatment with the dopamine agonist, bromocriptine does not reduce mortality in Parkinson's disease but may lead to a slightly lower incidence of motor complications. This is achieved at the expense of significantly worse disability scores throughout the first years of therapy. We conclude that there is no universal answer to the question how to best treat early Parkinson's disease and that initial treatment should be chosen on an individual basis, balancing the risk of possible long-term side effects against optimal improvement of motor disability.

100 Subthalamic Deep Brain Stimulation in Parkinson's Disease: Methodology for preoperative targeting of the STN and postoperative MRI position of the electrodes in 13 patients. C. Pollo, J. G. Villemure, J. Ghika, P. Maeder, R. Meuli, F. J. G. Vingerhoets (Lausanne, CH) Objective: To describe a MRI based methodology for targeting the STN and defining the postoperative electrode position for Deep brain stimulation (DBS) in Parkinson's disease (PD). Method: We studied 13 consecutive PD patients who underwent STNDBS. Preoperative target coordinates were determined on an IR T2 MRI coronal section perpendicular to AC-PC plane 3 mm posterior to midcommissural point (MCP) and 12 mm lateral to midline in the inferior aspect of subthalamic region.A CRW stereotactic frame was used for the surgical procedure. For each patient a postoperative 3D IR T2 MRI was performed in order to determine the precise location of the stimulated contact. These loca-

tions were determined on the artifacts produced by the electrodes corrected with parameters obtained from a phantom study (trigonometric rules). Each contact was projected on sagittal slices of the Schaltenbrandt and Wahren atlas. Results: All patients had monopolar stimulation; 5 patients had monopolar stimulation on 2 adjacent contacts. Seven patients stopped antiparkinsonian medication and 6 patients reduced their medication by an average of 65 %. Activily of daily living improved (baseline: 16 + 5; last follow-up: 11 + 5; p < 0.05). UPDRS III "on"was unchanged; UPDRS III "off"was reduced by 54% (50 -+ 14; 27 -+ 12; p < 0.001). Fluctuations and dyskinesia disappeared in 9 patients and reduced tu mild in 4. Twenty six electrodes and 35 contacts were studied. The mean coordinates of the stimulated contacts were (in mm): AP=-2.6 + 1.1, Lat=11.0 -+ 1.6, Vert=-2.3 -+ 2.2 related to the MCP. 23 contacts projected in the STN, 5 contacts in the zona incerta, 1 contact in the substantial nigra (SN) and 6 contacts in the Voa/Vop of the thalamus. Conclusions: Our MRI procedure, based on stereotactic and trigonometric concepts, aUows to target the STN and to check the postoperative location of the patient's electrodes. This methodology allows us to study for each patient the postoperative MRI location of the stimulated contacts.We found that despite excellent clinical responses in this group of patients, one third of the active contacts were outside the STN projection of the Schaltenbrandt and Wahren atlas, mainly above and behind it. This may suggest that the STN effective target may not be strictly confined to the localization suggested by the Schaltenbrandt and Warren atlas. (Supports: Grants # 32-51090.97 and 3153006.97 of the Swiss National Science Foundation; Vaud-Gen6ve Foundation) 101 Chronic pallidal stimulation and Parkinson's disease: results of a multicentric study. P. Krystkowiak (Lille Cedex, F) Chronic high frequency internal globus pallidus (GPi) stimulation can be proposed for the treatment of Parkinson's disease (PD) with severe levodopa induced dyskinesias (LID). The beneficial effects which can be observed on the different features of parkinsonism (aMnesia, tremor, rigidity and other symptoms like gait disorders) are more variable. The airo of this multicentric study was to evaluate the benefit induced by GPi stimulation on LID and to specify its effects on the parkinsonian syndrome. Eighteen patients were included by 5 centres (Bordeaux, Creteil, Grenoble, Lille, ParŸ Nine patients underwent the bilateral implantation of a quadripolar electrode (Medtronic, Minneapolis) in the posteroventral part of the GPi in a single session (group 1). Nine patients underwent a unilateral procedure (group 2). Among this last group, 5 patients were bilaterally implanted 6 months later. All the patients were studied in 4 conditions of stimulation and levodopa medication, by using the UPDRS (Unified Parkinson's Disease Rating Scale) anda dyskinesia scale: On stimulation - Off drug, On stimulation - On drug, Off stimulation - Off drug, Off stimulation - On drug. We studied the group 1 before then 3, 6 and 12 months after surgery. The group 2 was studied before then 3 months after surgery, with 2 conditions more: ipsi and contralateral effects. Finally, we compared the results of the 2 groups 3 months after surgery. Stimulation alone (without levodopa) induces a benefit on all the parkinsonian symptoms and dramatically decreases the LID,with moderate adverse events. Furthermore, the study of the Off stimulation condition underlines a possible"restoring"effect of GPi stimulation. Bilateral stimulation is more efficient than unilateral stimulation. Finally, when the stimulation is unilateral, a benefit is found not only on the contralateral side but also on the ipsilateral side. * This study is presented by the author on behalf of the pallidal stimulation French study group in Parkinson's disease.

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Oral session 17 Neurogenetics - 1 102

Parkinson's Disease is not associated with the combined aSynudein/Apolipoprotein E susceptibility genotype. N. Khan, E. Graham, P. Dixon, C. Morris,A. Mander, D. Clayton, N. Quinn,A. Lees, S. Daniel, N. Wood, R. de Silva (London, Newcastle, Cambridge, UK) Introduction: A recent study idenfified a significant allelic association of PD with SNCA polymorphism (NACP-Rep), closely linked DNA markers, D4S1647 and D4S1628 and the APOE-e4 allele, in up to 163 clinical PD cases in a German population. A combined APOE-e4/NACP-Rep genotype increased susceptibility to PD by 12-fuld Methods: We genotyped the same NACP-Rep polymorphism, identical chromosome 4q markers and APOE in a much larger, mostly histopathologically-proven PD population (305 cases) a n d a larger number of closely matched control samples (330 cases). We extended our study to include additional markers D4S2460 and D4S423 that lie closer to and flank SNCA such that the order of markers used in this study is cen-D4S2460-NACP Rep/IN4D4S423-D4S2380-D4S 1578-D4S 1628-D4S 1647-tel (www.ncbi.nlm.nih.gov, Stanford Radiation Hybrid Map, ftp://cedar.genetics.soton.ac.uk). The data indicates that D4S1647 and D4S1628 lie up to 8Mb distal to SNCA. Our PD samples also included a cohort of familial cases (FPD) a n d a larger number of younger onset cases (YPD).We also investigated a novel polymorphism of the intron 4 region of SNCA (IN4). Results: We failed to observe an increased susceptibility to disease due to the NACP-Rep aUele 2, D4S1628(158bp), D4S1647(140bp) and APOE-e4 nor the combined NACP-Rep allele 2/APOE-e4 genotype.We also failed to detect an association with additional markers D4S2460 and D4S423 that lie closer to and fiank SNCA. Conclusion: Our results cast doubt on the importance of the combined a-synuclein/apulipoprotein E genotype as a risk factor in sporadic PD. 103 Novel missense mutation of ANT 1 gene in autosomal dominant progressive external ophthalmoplegia. L. Napoli, A. Bordoni, G. P. ComŸ M. Zeviani, A. Terentiou, M. Sciacco, V. Tiranti, A. Prelle, M. Moggio, A. Papadimitriou, G. Scarlato (Milano, I; Larissa, Athens, GR) Autosomal dominant progressive external ophthalmoplegia (AdPEO) is a genetically heterogeneous mitochondrial disorder characterized by adultonset of extraocular muscles involvement and mild descending myopathy, variably associated with signs of peripheral neuropathy, sensorineural hypoacousia, major depression and endocrine dysfunction. The main common features shared by different affected families are represented by muscle tissue changes, namely, partial COX deficiency, scattered Ragged Red fibers and multiple deletions of mtDNA. AdPEO links to different identified loci (chromosomes 4q35, 10q24), with some families Unlinked to any of them. The ch 4q35 gene is the adenine nucleotide translocator-1 (ANT1): only one familial missense mutation has been so far identified in four Italian families (alanine-to-proline substitution at codon l14,A114P).An additional missense mutation V289M was found in a sporadic case of PEO. We now report on a second ANT 1 familial mutation. This was discovered in a Greek pedigree showing the autosomal dominant transmission of a PEO disorder. The proband was a 35-year-old female, with progressive external ophthalmoplegia and ptosis since the age of 17 years. Her 70-years-old mother has the same clinical findings since the age of 28 years. Five other family members were also affected. The proband's muscle showed all the adPEO pathological hallmarks. Sequence analysis of the entire ANT1 coding sequence revealed a heterozygous change at nt 293, changing a Leucine to Proline at the aminoacid residue 98. This aminoacid substitution is likely to modify the ANT1 protein secondary structure. Pedigree analysis demonstrated the segregation of the mutation with the disease phenotype. This study confirms the ANT1 role in mtDNA maintenance and expands the repertoire of the ANT1 mutant alleles. ANT1 mutations may account for AdPEO in families with different ethnic background. The L98P mutation seems to result in a mitochondrial disorder with earlier onset respect to the A114P mutation, suggesting a genetic basis for phenotypic heterogeneity in this disorder.

104 Presymptomatic testing in the context of pregnancy: the experience with Huntington disease (HD) and Autosomal Dominant Cerebellar Ataxia (ADCA). G. Lesca, C. Goizet, P. Sarda, P. ]onveaux, N. Philip, M.-C. Malinge, J. Yaouanq, O. Cohen, A Brice, A. Durr (Lyon, Bordeaux, Montpellier, Vandeeuvre Les Nancy, Marseille, Angers, Rennes, Grenoble, ParŸ F) Presymptomatic testing (PT) and prenatal diagnosis (PND) for Huntington disease have been available since 1986. Since cloning of the Huntingtin gene in 1993, direct analysis is available and provides accurate PT and PND. Recent advances in the field of molecular genetics has provided suitable tools for direct testing in an increasing number of hereditary neurodegenerative disorders such as several forros of autosomal dominant cerebellar ataxias, raising specific ethical and psychological issues. Family planning is one of the reasons for requesting PT. Our goal was to determine the attitudes towards PND and the outcome of pregnant couples requesting PT. We performed a retrospective study of data in 839 PT requests for HD (n=789) and ADCA (n=50) from ten PT centers in France, between 1994 and 2000. Forty-four of the requests (4.8 %), 38 in HD and £ in ADCA, occurred in the context of pregnancy, making this situation uncommon but not rare. The pregnant testees were significanfly younger than the others (30 • 6 versus 34 + i I years) in the HD group and half did not already have children. Since the couples were not prepared to face the choice of PT, the first decision was taken in the uncomfortable context of emergency. Fifty-seven percent (25/44) requested PT because of the current pregnancy while for the others, the request was independent of the pregnancy. Thirty-Ÿ couples (73 %) continued the pregnancy and half of them requested PT after delivery. Early termination without PT PND was performed in 3 cases (10 %). Only 9 couples requested rapid PT followed by PND in 4 cases with an unfavourable resultThese data indicate that the at-risk status is unlikely to be a major determining factor influencing the reproductive decision making, since three quarters continued the pregnancy without having PT. PT, in the context of pregnancy, is a challenging situation, which limits the time for reflection to facilitate a mature and autonomous decision. These at-risk couples need more attention from the medical team to make the most appropriate choice despite tight time constrain. 105 Mutation Of Acetylcholine Receptor Epsilon Subunit Gene In A Gypsy Family With Congenital Myasthenic Syndrome. L. Bataller, M.] Chumillas, ]. J. Vilchez, ]. A. Urtizberea, K. Christodoulou (Valencia, E; ParŸ F; Nicosia, CY) Introduction: Congenital myasthenic syndromes (CMS) are heterogeneous disorders with a genetically determined defect leading to a failure in synaptic neuromuscular transmission. Several mutations in genes codifying the acetylcholine nicotinic receptor have been reported in CMS with "postsynaptic" defect. A common mutation (epsilon1267delG) has been reported in Gypsy European families with CMS. Patients and methods: A Gypsy Spanish family affected by a CMS was clinically and electrophysiologically evaluated, epsilon-1267delG mutation was studied by polymerase chain reaction (PCR) and restriction enzyme analysis. Results: Three patients (male 17, female 20 and female 7 year-old) from a extended Gypsy family had ptosis, ophthalmoparesis, weakness of btdbar muscles and generalized weakness that had evolved during their first years of life. Some degree of clinical fluctuation was present but there were no progressive worsening as children grew up. All three cases h a d a positive response to anticholinesterasic drugs and 3-4 diaminopyridine. Electrophysiologic test with repetitive stimulation at 3 Hz showed a pathologic decremented response. The family h a d a high grade of consanguinity and disease was inherited with a recessive autosomal trait. Genetic studies showed homozygotic epsilon1267delG mutation in acetylcoline receptor esubunit gene. Conclusions: (1) epsilon1267delG mutation is associated with autosomal recessive inherited CMS in Gypsy European families. (2) This common mutation suggests that they derive from a common ancestor (founder). 106 A Presenilin-1 mutation (Leu392Pro) in a familial AD kindred with psychiatric symptoms at onset. A. Tedde, P. Forleo, B. Nacmias, C. Piccini, L. Bracco, S. Piacentini, S. Sorbi (Florence, I) Missense mutations in the Presenilin genes are implicated in the majority of early-onset familial Alzheimer's disease (EOFAD) cases. Common phenotypic features of presenilin-1 (PS-1) linked families include onset of mem-

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ory disturbances before age 50 years, shorter disease duration and the presence of myoclonus and generalized seizures. We have performed a clinical and genetic screening in order to search for additional missense PS-1 mutations in families with EOFAD. We identified a new Italian family with a missense mutation in the exon 11 leading to a Leu to Pro substitution at codon 392. Different mutations in the same codon 392, consisting of a substitution of a Leucine (CTG) to a Valine (GTG), have been previously associated with FAD in two different families, one of French origin and one of Italian origin. The proband, a 38 years-old man presented a history of mild memory deficits, characterized by the onset of manic symptoms, including reduction of sleep, overactivity, irritability and weight loss, His Mini-Mental State Examination (MMSE) score was 15/30, with the majority of points lost on time orientation, calculation and three-word recall. At the last follow-up, 6 years after the onset, he was no longer testable or self-sufficient; his speech was repetitive and poor. He presented episodes of aggressive behavior towards his relatives and alteration of the sleep-wake cycle. In February 1999, his sister, a 43 years-old woman, came to our attention because of the presence of memory deficits and behavioral changes characterized by lack of drive, loss of interest and depression over the previous 6 months. Since the age of 36 years she had five episodes of severe and sustained physical activity, with a sense of euphoria and intermittent irritability, followed by a period of remission or episodes of unreasonable guilt about her past acts, anxiety, and reported slowing of thought. Neuropsychological evaluation evidenced a severe overall mental decline (MMSE score 8/30). In this family the onset was characterized by an early age of onset (38.3 _+ 4.0 years, mean -+ SD) with bipolar affective symptoms a n d a mild memory deficit at onset. The clinical phenotype appeared different respect families with different mutations in the same codon within the same hydrophilic loop of exon 11. This is a functionally important domain, which binds to a number of interacting proteins including b-catenin and neuronal plakophilin related armadillo protein/delta-catenin. 107 Heredity of menstrual migraine. N. Lev, S. Lev, E. Melamed, A. Kuritzky (Ramat-Gan, IL) Background: A link between migraine headaches and the menstrual cycle had long been recognized. The primary trigger for migraine associated with the menstrual cycle is not known but appears to be hormonal changes, especially withdrawal of oestrogen. Menstrual migraine had never been looked upon as a group with specific genetic characteristics, and it's mode of inheritance had not been investigated. The objective of this study was to evaluate the hereditary patterns in women with and without menstrual associated migraine. Methods: Records of female migrainous patients from a tertiary headache clinic were reviewed and data related to their family history and peri-menstrual migraine occurrence was collected. Pure menstrual migraine was defined as migraine headaches occurring regularly between days -2 to +3 of the menstrual cycle and at no other time. Women having ah increased number of migraine attacks around the time of menstruation in addition to attacks at other times of the month were defined as having menstrual associated migraine. The study population included 208 women with menstrual associated migraine (of whom 12 women with pure menstrual migraine and 196 women with menstrual associated migraine), and 153 women without menstrual associated migraine. Results: Familial occurrence of migraine headaches was found to be more prevalent in family members of women with menstrual associated migraine - 84.1% of these patients had relatives suffering from migraine headaches versus 65.4 % of the patients without menstrual associated migraine (p < 0.0001). Maternal inheritance of migraine headaches was found in 54.8 % of menstrual associated migraine patients versus 22.9 % of the patients without menstrual associated migraine (p < 0.0001). Paternal inheritance of migraine headaches was found in 13.5 % of patients with menstrual associated migraine while it was found in 34.6 % of patients without menstrual associated migraine (p < 0.0001). In the pure menstrual migraine group maternal inheritance was found in 58 %, while paternal inheritance was found only in 8 % - a pattern similar to the group of patients with menstrual associated migraine. Conclusions: This study provides for the first time evidence that menstrual migraine has a unique hereditary pattern with a maternal genetic component. This implies that menstrual migraine is a genetic subgroup. Research of the genetic basis of this subgroup may help unravel the pathophysiology of migraine.

Oral session 18 Neurogenetics - 2 108 Clinical, electrophysiological and genetic study in a European family with cortical tremor and epilepsy.Absence of linkage to the BAFME/FAME locus on 8q24. P. Labauge, L. Ouldamer, M. Simonetta-Moreau, E Attane, C. Tannier, M. Clanet, G.Castelnovo, A. Brice,A.Ducros,Y.Agid, E. LeGuern (Nimes, ParŸ Toulouse, Carcassonne, F) Objective: To study clinical, electrophysiological and genetic findings in a European family with cortical tremor (CT). Background: CT is defined by a postural and action 10 to 13 Hz tremor, mimicking an essential tremor. Observation of myoclonic pattern of the tremor, involvement of the legs, irregular EMG patterns, and association of seizures strongly suggest the diagnosis of CT. Suspected clinical diagnosis of CT is electrophysiologically confirmed by the observation of giant SEPs, enhancement of C-reflex and premyoclonus spike detected by means of the jerk-locked averaging EEG method. Only four CT families have been previously reported, including three from Japan. These findings were also observed in patients with Benign Adult Familial Myoclonic Epilepsy (BAFME) and Familial Adult Myoclonus and Epilepsy (FAME). The genes responsible for BAFME and FAME were mapped in the same'genetic interval in 8q22.3q24.1. Design/Methods: We report a four generation European family characterized by a familial cortical tremor (including 18 relatives). Clinical analysis was performed in 15 living subjects and electrophysiological study in 5 pafients. Linkage analysis were performed with fluorescent microsatellites encompassing the BAFME/FAME locus, the locus for Myoclonus Dystonia (MD) (7q21) and for MD associated with mutation in D2 Dopamine Receptor (DRD2) on chromosome 11. Pairwise and multipoint lod scores were calculated using the MLINK and LINKMAP programs of the FASTLINK package version 3.0. Results: Ten living and 3 deceased relatives (7 women and 6 men) had the clinical characteristics of CT. Mean age of onset of the 10 living patients was 41 years (range 30 to 60 yo). Eight of the 13 affected subjects had generalized tonic-clonic seizures. Electrophysiological study confirmed CT diagnosis in the 5 studied patients. The patterns of inheritance were consistent with an autosomal dominant inheritance. The two loci responsible for MD were excluded, bipoint and multipoint analysis also excluded the BAFME/FAME locus on 8q23.3-q24.1. Conclusions: Familial cortical tremor is a rare disease and was mainly described in the Japanese population. Observation of a European family suggests its worldwide distribution. Common clinical and electrophysiological findings with BAFME and FAME suggest that these three diseases ate strongly related. Absence of linkage of CT to BAFME/FAME locus established the genetic heterogeneity of this group of pathologies. 109 A CNTF null mutation a s a potential modifier to disease onset in familial ALS with a mutation in the SOD-1 gene and transgenic SOD-I mutant mice. R. Giess, B. Holtmann, M. Braga, K. Toyka, M. Sendtner (Wuerzburg, D; Milano, I)

Objective: To identify modifier genes which explain the broad clinical variations in one familial amyotrophic lateral sclerosis (FALS) pedigree carrying the same mutation within the SOD-1 (Copper/Zinc Superoxide Dismutase 1) gene. Background: Mutations in the SOD-1 gene are found in 20% of FALS cases. Single gene mutations are also reported in sporadic forms of ALS within the ciliary neurotrophic factor (CNTF) gene which is considered as a modifier gene in motoneuron disease. Methods: We have screened the family of a 25-year-old male who died from FALS after a rapid disease course of eleven months for mutations in the SOD- 1 and CNTF genes. In order to investigate whether CNTF acts asa modifier gene also in an animal model of motoneuron disease, we have crossbred CNTF deficient mice with human SOD-1 G93A (hSOD-1G93A) transgenic mice to generate animals carrying double gene defects. Results: Sequencing of the SOD-1 gene of the 25-year-old male FALS patient revealed a heterozygous thymidine to guanine exchange at position 1513 within exon 5 coding for a Valine to Glycine substitution at position 148 of the mature protein. The same mutation was found in his yet unaffected 33-year-old sister and 53-year-old mother. Screening for candidate modifier genes responsible for the early onset and rapid disease progression in the 25-

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year-old patient revealed an additional homozygous deletion of the CNTF gene, which was not found in other family members. In mice carrying double gene defects (hSOD-1G93A/CNTF deficient) motoneuron disease developed significantly earlier than in hSOD-1G93A/CNTF wild type mice. Conclusion: CNTF is a modifier gene in transgenic SOD-1 mutant mice and possibly in some FALS patients with SOD-1 mutations leading to early onset and accelerated disease progression. 110 Familial study in idiopathic dystonia: high frequency of secondary cases unaware of their symptoms in non DYT1 famUies. S. Tezenas du Montcel, A. Camuzat, M. Vidailhet, P. Jedynak, A. Dª M. Cohen, S. Sangla, G. Ponsot, P. Landrieu, C. Bonaiti, E Clerget-Darpoux, A. Brice (ParŸ Le Kremlin Bicetre, Villejuif, F) Background: Idiopathic torsion dystonia is a clinically and genetically heterogeneous movement disorder.A GAG deletion at position 946 of the DYT1 gene was the first mutation found, in early-onset dystonia, with an autosomal dominant transmission and reduced penetrance. However, several other loci have been mapped and there is evidence for greater genetic heterogeneity. Objective: To investigate inheritance of dystonias in non DYT 1 dystonia. Methods: A large genetic survey was initiated with the recruitment of patients in neurological centers or in botulinum toxin consultations. After written informed consent, information was obtained by a standardized questionnaire administered face to face by a unique medical interviewer. Investigation of the family history was performed by interview on the first and second generation and by examination of al1 the consenting first-degree relatives. Each subject, index or related case, was videotaped during the assessment using a standardized protocol. All videotapes were reviewed by two senior neurologists and in case of discrepancy by a third one. Blood samples were obtained from each subject. Results: There were only 4 DYT 1 families with a generalized dystonia beginning in the upper limb (3) or the trunk (1). The inheritance of dystonia was investigated in 156 families, excluded from the DYT1 mutation. The mean age at onset of index cases was 44.1 _+ 16.8 (range from 6 months to 78 years). One hundred and one cases were focal (26 blepharospasm, 54 torticollis, 16 writer's cramp, 2 dysphonia and 3 oromandibular dystonia), 21 segmental,27 multifocal and 7 generalized (onset with torticollis (3),lower limb (2) or upper limb (2)). Because of refusal, familia1 investigation was possible only in 58 % of the families.A family history of dystonia was found in 15.5 % of the cases a n d a family history of tremor in 4.7 %. Affected relatives always presented a similar o r a less severe distribution of dystonia as the index cases. Sixty-five percent of the secondary cases were not aware of any dystonia. Conclusions: Family history of dystonia is relatively frequent supporting the hypothesis of the involvement of genes other than DYT1 in dystonia. This study emphasizes the importance of investigating all first-degree relatires when performing a genetic study in dystonia. 111 Genetic And Clinical Analysis'Of Sca8 Repeat Expansion. E. Cellini, P. Forleo, B. Nacmias, A. Tedde, S. Bagnoli, M. Ciantelli, S. Piacentini, S. Sorbi (Florence, I) Spinocerebellar ataxia type 8 is the first dominant form of ataxia caused by a CTG trinucleotide repeat expansion in the untranslated region of the disease gene. This disorder, clinically characterized by pure cerebellar ataxia with slow disease progression, evidences maternal anticipation in contrast to the majority of dominant SCAs showing paternal anticipation. Normal alleles have a repeat size varying from 16-91 cornbined CTG/CTA repeats, whereas SCA8 patients carry expanded alleles with 107-127 pure CTGs. However, possible pathogenic combined repeats of 92 to 250 (CTA)/(CTG) repeats were reported in ataxic patients since the original report. In addition, recent collaborative studies, using large panels of patients and controls reported non-specific SCA8 pathogenic expansions in healthy subjects, and in patients with different neurological and psychiatric disorders, suggesting that CTG expansions linked to SCA8 may represent rare polymorphisms. In order to better define the molecular features of these expansions we have genotyped for SCA8 120 ataxic patients, including 47 family members from 30 kindreds with proven dominant cerebeUar ataxia, 13 family members belonging to 4 families with autosomal recessive hereditary ataxia and 60 subjects with ILOCA (Idiopathic late onset cerebellar ataxia), 115 healthy controls, 46 healthy centenarians, 64 schizophrenic patients and 61 patients with a familial history of bipolar affective disorders. SCA8 repeat expansions in the pathogenic range were identified in 8 sub-

jects (of which 5 patients affected by ataxia and 3 apparently unaffected relatives) belonging to 4 families with no evidence of autosomal dominant pattern of inheritance. In particular one of these ataxic patient presented Vitamin E deficiency with unknown gene defect and another sporadic patient was affected by suspected gluten ataxia. Repeats in the normal range were observed in the remaining population. These results extend the phenotypic range of expanded alleles, suggesting that pathogenic expansions in the SCA8 locus may cause ataxia. It could be also speculated a possible epistatic effect of this gene on susceptibility to malabsorption disturbances leading to ataxia. 112 Presenilin I mutation in a patient with spastic paraparesis. M.-L. Jacquemont, D. Campion, V. Hahn-Barma, C. M. E. Tallaksen, T. Frebourg, A. Durr, A. Brice (ParŸ Rouen, F) Background: Recently, families with autosomal dominant Alzheimer's disease and spastic paraparesis were reported. They were caused by three missense mutations oran exon 9 deletion in the presenilin 1 (PSEN 1) gene. We present such a familial case with a different PSEN 1 mutation whose disease began with spastic paraparesis and whose dementia was not typical of Alzheimer's disease. Methods: The patient was admitted for spastic gait. He was clinically evaluated and underwent detailed neuropsychological testing and paraclinical investigations. Sequence analysis of the entire coding region of the PSEN 1 gene was performed in the proband. No DNA was available from affected relatives. Results: A) Clinical findings: At age 54, the patient had progressive spastic paraparesis due to pyramidal syndrome in all limbs. Walking required a walker at age 61.No sensory loss or cerebellar signs were found. Memoryloss was not prominent at first examination. At age 60, after six years of evolution, detailed neuropsychological examination was performed revealing atypical features for Alzheimer's disease. There was no impairment of executive functions, no aphasia, no gestual apraxia and no retrograde memory loss. MMS score (14/30) was relatively preserved considering disease duration. Brain MRI showed mild cortical atrophy. Other investigations were negative. Family history was poor but compatible with autosomal dominant transmission: three relatives in three generations deceased demented, ohe of which with gait difficulties. B) Molecular analysis: Sequence analysis revealed a frequent mutation in the PSEN1 gene for typical Alzheimer's disease (Pro264Leu), not reported yet in association with spastic paraparesis. Conclusion: This case suggests that the association of dementia and spastic paraparesis is not restricted to specific PSEN 1 mutations but can also represent variable phenotypic expression of more common mutations, usually causing typical AD. 113 Relative frequency of SCAs and clinical comparison in autosomal dominant cerebellar ataxias. A. Durr, A. Camuzat, H. Fujigasaki, G. Stevanin, A. Brice (ParŸ F) Background: Autosomal dominant cerebellar ataxias are clinically and genetically heterogeneous with at least 14 distinct loci. Translated CAG repeat expansions encoding polyglutamine are involved in six genes: SCA (spinocerebellar ataxia) 1, SCA2, SCA3/MJD (Machado-Joseph disease), SCA6 (calcium channel subunit al), SCA7 and SCAI5 (Tata-binding protein). In addition, untranslated CAG repeats have been recently identified at the SCA8 and SCA12 loci and a pentanucleotide repeat expansion is responsible for SCA10. Five other loci have been determined in single or few families (SCA 4, 5, 11, 13, 14). Ataxia can also be caused by CAG repeat expansion at the DRPLA (dentatorubropallidoluysian atrophy) locus. Our goal was to determine the frequency of these loci in cerebellar ataxias. Methods: 409 families with dominant ataxia and 168 isolated cases were tested. Direct analysis of the mutation was performed for SCA 1,2, 3, 6, 7,12, 15 and DRPLA. Linkage analysis was performed in 8 informative families for the SCA 4, 5, 13 and 14 loci. Results: 54% of the French families (n=260) were caused by the following mutations: SCA1 n-=31 (12%), SCA2 n=17 (7%), SCA3 n=69 (27%), SCA6 n=5 (2%) and SCA7 n = l l (4%). Among the 149 families from other origins the frequencies were different: SCA1 (100%) in Polish families (n=4), SCA2 (90 %) in West Indies (n= 10), SCA3 (60 %) in Portuguese, Spanish and Brazilian families (n=35) and 50% in Black-Africans (n=8), SCA7 (37 %) in North African Families (n=30). CAG repeat expansions were found in an Indian family in the SCA12 gene and in the SCA15 gene in a Belgian family. Among the 8 families excluded from all loci but informative for linkage analysis, one each were linked to SCA5 and SCA13, and two were possibly linked to SCA4.

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Among the isolated cases only 5 % were due to SCA2 (n=3), SCA3 (n=4) and DRPLA (n= 1) mutations. A detailed clinical comparison will be presented at the meeting. Conclusion: Close to 50% of the families with dominant ataxia from France are not accounted for by the known loci. The frequency of CAG repeat expansions at known loci depends on the geographical origin, probably resulting from regional founder effects. In isolated cases the detection of CAG repeat expansions in those genes remains very rare and screening should be considered only when family history is censored.

agnosed as MS and seven normal controls (NC) were studied. Expression pattern and distribution of ADAM-10 and ADAM-17 were investigated immunohistochemically using an avidin-biotin detection system. Immunoreactivity for ADAM-17 was observed in acute and chronic active MS plaques, localized to small, round cells, primarily observed in perivascular cuffs. On serial sections these cells, morphologically consistent with lymphocytes, were similar in appearance and distribution to cells detected with the T-cell marker anti-CD3. ADAM-10 immunoreactivity could be demonstrated in all MS and NC sections studied. On serial sections ADAM-10+ cells were similar in appearance and distribution to those staining positive for GFAP, indicative of astrocytes. Based on the present observations we conclude that ADAM-10 appears to be constitutively expressed in the CNS by astrocytes, wbereas ADAM-17 was found to be upregulated in acute and chronic active MS plaques only, pointing to a potentially critical involvement of ADAM-17 in the pathogenesis of MS.

Oral session 19

Multiple Sclerosis - 3 114

Interferon-beta and high-dose steroid therapy in multiple sclerosis:effects on mRNA expression of matrix metanoproteinases. S. Marckmann, P. Treder, P. B. Musholt, R. Lichtinghagen, F. Heidenreich (Hannover, D) Matrix metalloproteinases (MMPs) ate a group of at least 20 zinc-dependent enzymes which degrade extracellular proteins. They contribute to migration of activated peripheral lymphocytes through the blood-brain barrier (BBB) and to tissue destruction in multiple sclerosis (MS). MMP activity is regulated by tissue inhibitors of metalloproteinases (TIMPs). This balance is disturbed in MS, resulting in higher activity of MMPs, particularly MMP-9. Itis hypothesised that interferon-beta (INF-b) downregulates MMP-9 activity, thereby inhibiting the migration of activated cells into the central nervous system (CNS). One of the effects of corticosteroids in MS is the stabilization of a disrupted BBB so that effects of steroids on MMP activity can be expected. Utilizing a longitudinal study design, we examined the effects of INF-b and high-dose steroid medication on mRNA expression of MMPs and TIMPs in peripheral blood mononuclear cells (PBMC). mRNA expression of MMP-2, -7, -9, and TIMP-1 in PBMC was determined using quantitative competitive RT-PCR; serum levels of MMP-9 and TIMP-1 were measured with a standard ELISA. Samples were taken from 19 patients before and 4 weeks after initiation of INF-b therapy; from 26 patients before, during, and/or after high-dose steroid medication; and from 15 healthy individuals. INF-b significantly reduced the mRNA expression of MMP-9 in PBMC (p=0.01). Untreated MS patients demonstrated a raised MMP-g/TIMP-1 ratio when compared with healthy controls (p=0.02). This ratio normalised during treatment. On the other hand, INF-b augmented serum levels of both MMP-9 and TIMP-1 (p=0003). mRNA expression of MMP-9 and TIMP-1 increased during steroid treatment of MS patients with a relapse (p=0.03). After treatment, MMP-9 expression fell below the initial level while TI19IP-1 expression persisted. In all patients examined, the expression of MMP-7 was not altered, and MMP-2 expression was not detectable in PBMC. INF-b decreases MMP-9 expression in PBMC and restores the balance between MMP-9 and TIMP-1. PBMC seem to be an important, but not the only, source of MMP-9 and TIMP-1 in MS. This supports the hypothesis that 1) peripherally activated lymphocytes enter the CNS in MS aided by secretion of MMP-9, and 2) that these cells are targeted by INF-b. The decrease of MMP-9 and increase of TIMP-1 expression after tr'eatment with steroids reflects the stabilization of the BBB. However, this effect is only seen several weeks after therapy. 115 The Expression Pattern of Tumour Necrosis Factor-alpha-Converting Enzyme in Multiple Sclerosis Lesions. B. C. Kieseier, T. Seifert, W. W. Tourtellotte, W. W. Tourtellotte, II.-E Hartung (Graz, AT; Los Angeles) Tumour necrosis factor-alpha (TNF-alpha) is a major proinflammatory cytokine implicated in the pathogenesis of multiple sclerosis (MS). Soluble TNF-alpha is released from its membrane-bound precursor by shedding through a proteinase, identified as TNF-alpha-converting enzyme (TACE; ADAM- 17), a member of the ADAM (A Disintegrin And Metalloproteinase) domain family of proteins. ADAM- 17 shares close sequence similarities and potential structural features with ADAM-10. The latter has been implicated in myelin degradation. To investigate the expression pattern of TACE in multiple sclerosis lesions post mortem CNS tissue samples from seven cases di-

116 Allergy to self myelin peptides in experimental autoimmune encephalomyelitis. R. Pedotti, D. Mitchell, J. Wedemeyer, M. Karpuj, D. Chabas, E. Hattab, M. Tsai, S.] Galli, L. Steinman (Stanford, USA) Experimental autoimmune encephalomyelitis (EAE) is the prototypic animal model of T cell autoimmunity, and it shares many clinical and pathological features with the human disease multiple sclerosis (MS). While EAE is classically a prototypic Thl mediated autoimmune disease, EAE can also be induced with Th2 T cells, in the absence of any Th 1 T cell response. Anaphylaxis, the most severe manifestation of allergy-a Th2 immune response, is associated with exposure to a foreign antigen, often derived from a medication, insect venom or food. Here we report that after self-tolerance is broken and EAE is established, anaphylaxis may be triggered by a self-antigen, in this case an epitope of myelin proteolipidic protein (PLP).Anaphylaxis occurred in mice with EAE after the first challenge with the myelin peptide PLPp 139-151, at the time of the recovery or of the first relapse, and not during the acute phase of EAE. Anaphylaxis was associated with a drop in body temperature and airway hyper responsiveness. The significant correlation between high titers of IgG1 anti-PLPp139-151 antibodies and allergic signs at the moment of the challenge, suggested that in these mice anaphylaxis was mediated by IgG 1 antibodies. Treatment of mice with EAE with cyproheptadine, an anti-histamine/serotonin drug, could significantly reduce mean disease score at day 13, reduce mean disease severity and delay mean day of disease onset, raising the possibility that allergic mechanisms may promote the development and severity of EAE. In conclusion, our findings suggest that autoimmune responses to self peptides may include also allergic responses to self. Allergic responses to myelin peptides could play an important role in the development of EAE and could therefore representa new target in the treatment of EAE and of the human disease MS. 117 A Superantigen Animal Model for Multiple Sderosis (MS): Cooperation of Intracerebral Snperantigen with Activated Peripheral T CeUs to Form Lenkoencephalitis. M. Kornhuber, C. Ganz, R. Lang, T. Brill, W. Schmahl (Halle/Saale, Mª D) Superantigens (SAg) bound to MHC II (HLA) potently activate T cells via T cell receptor Vbeta. SAg from bacteria or viruses may playa role in autoimmune diseases like multiple sclerosis (MS). Staphylococcal enterotoxin (SE) SAg were used to study local effects after injection into the Lewis rat brain in vivo. The response was followed by histology (hematoxylin-eosin-stain). SEA, SEE but not SEB or saline induced a variable perivascular inflammation oflow or moderate intensity (n = 38). 5.5 -+ 6.1 (mean _+SD) reactive blood vessels (RBV) were detected per tissue section scattered around the injection site. Adoptive transfer of naive ConA-activated syngeneic splenocytes strongly enhanced this perivascular response that lasted roughly 2 weeks. With 107 cells the number of RBV rose significantly to 18.5 _+ 11.4 (n = 32; p < 0.05; two-sided U-test). Adoptive intravenous transfer of ConA-blasts without SE resulted in bihemispheric perivascular round cell infihrates mainly around the ventricles and in the corpus callosum for 2 up to 4 days depending on the cell dose. These findings demonstrate that the local expression of SAg in the brain together with increased numbers of activated peripheral T cells can cause leukoencephalitis like in MS. The pattern of splenocyte entry to the brain is very similar to the distribution of MS plaques. The SAg model does neither require breakdown of immune tolerance nor myelin autoantigens. It explains why relapses are precipitated by nonspecific immune stimuli. Furthermore, the dualism of the superantigen a n d a virus is compatible with different types of MS course as part of the

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same disease. Finally, HLA-association in MS and the finding of cerebrospinal fluid oligoclonal IgG are well in accord with HLA-specific presentation of SAg.

Oral session 20

118 Role of antibodies in Multiple Sclerosis: Analysis of clonally expanded B cell populations in MS brain tissue by CDR3 spektratyping and laser microdissection assisted single cell PCR. N. Goebels, M. Hofbauer, H. Zander, A. Skerra, I. Newcombe, L. Cuzner, R. Hohlfeld (Mª D; London, UK)

Multiple Sclerosis - 4

Background: Recently the importance of antibody-mediated immune mechanisms in the pathogenesis of multiple sclerosis (MS) has been emphasized. Oligoclonal immunoglobulin bands represent the most common and constant immunological feature in multiple sclerosis. However, their antigen specificity and pathogenetic relevance ate still unknown. Methods: To analyse the clonal composition of B cells in MS brain tissue we performed CDR3 spectratype analysis on cDNA of 6 cryopreserved brain tissue specimens of MS patients. CDR3 spectratyping relies on the natural length polymorphism of the third hypervariable region of the rearranged immunoglobulin heavy chain gene. Whereas polyclonal B cell populations result in a Gauss distributed spectratype pattern, expanded B cell ciones can be identified as "peaks". Results: CDR3 spectratyping of MS brain tissue cDNA identified multiple expanded B cell clones on a polyclonal background in all MS tissue specimens studied. To analyse the heavy and light chain usage of expanded Band plasma cells we are currently employing single cell PCR of laser microdissected cells from MS brain tissue cryosections. In preliminary experiments we expressed heavy and light chain immunoglobulin genes of an established hybridoma specific for myelin oligodendrocyte glycoprotein (MOG) in a bacterial expression system. We could demonstrate by FACS analysis and immunohistochemistry that the antigen specificity of the original hybridoma was maintained by the recombinant Fab fragment. Using secondary antibodies we additionally demonstrated antigen specific, complement mediated lysis of MOG transfected myeloma cells. Conclusion: The combination of CDR3 spect ratyping and single cell PCR allows the identification and molecular characterisation of expanded B cell populations in MS brain tissue. Recombinant expression of heavy and light chain genes of individual expanded B cell ciones may provide the basis to analyse specificity and pathogenic potential of these cells and their role in MS. Supported by Deutsche Forschungsgemeinschaft (GO 514/4-1), MaxPlanck-Society, University of Munich.

120 Expression of CCR5 mutation in patients with multiple sclerosis. M. Bakhanashvili, R. Kantor, G. Ishuev, 1. Zeitun, E. Novipsky, S. Miron, A. Achiron (Ramat-Gann, IL) The perivascular accumulation of mononuclear cells in brain white matter is critical in the development of active lesions in multiple sclerosis (MS). Chemokines are chemotactic proteins that contribute to monocytes and T lymphocytes infiltration into the tissues by increasing cell adhesiveness and by promoting migration through endothelium and the extracellular matrix. We examined in MS patients the presence of the b-chemokine receptor, CCR5, and its truncated allele, the CCR5 delta32, which encodes a non-functional receptor. Previous studies showed that humans carrying this mutation have no overt immunodeficiency, but this allele influences host susceptibility and prognosis in HIV infection. CCR5 delta32 was also shown to be associated with a lower risk of recurrent clinical disease activity in MS patients. The purpose of the present study was to analyze the frequency of the CCR5 deha32 mutation in MS patients and to see whether a correlation exists between the mutation and disease prognosis. We examined DNA of 340 MS patients, age range 20-62 years, female to male ratio was 2:1,85% h a d a relapsing- remitting course, with disease duration between 1-26 years. The detection of heterozygote (CCR5 and CCR5 delta32) and homozygote carriers (only CCR5 delta32) was done using RT-PCR. Out of 340 examined, 31 patients (9%, 20 females) were heterozygotes and 6 patients (0.2%, 4 females) were homozygotes. Al1 CCR5 homozygote carriers were of Ashkenazi origin (western/northern Europe) and h a d a mild disease, as measured by low progression index. These results suggest that the truncated allele of the chemokine receptor, CCR5 deha32, can be one of the factors that indicates a good prognosis of MS. 121

Serum autoantibodies against heat-shock proteins in multiple sclerosis: a comparison with other inflammatory neurological disorders. O. Lily,A. Vincent, I. Palace (Oxford, UK)

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Fibroblast growth factor-li gene therapy reverts the clinical course and the pathological signs of chronic experimental autoimmune encephalomyelitis. F. Ruffini, R. Furlan, E. Brambilla, P. Marconi, G. Comi, G. Martino (Milan, Ferrara, 1) The development of therapies aimed to promote remyelination is a major issue in chronic inflammatory demyelinating disorders, such as multiple sclerosis (MS), where the permanent neurological impairment is due to the axonal loss resulting from recurrent episodes of immune-mediated demyelination. Here, we show that the intrathecal injection of an herpes simplex virus (HSV) type-1 replication-defective multigene vector, engineered with the human fibroblast growth factor (FGF)-II gene (TH:bFGF rector), was able to significantly revert the clinico-pathological signs of chronic experimental autoimmune encephalomyelitis (EAE), the animal model of MS, in C57/BL6 mice. The treatment with the TH:bFGF vector was initiated within one week after the clinical onset of EAE and was effective throughout the whole follow-up period (i. e. 60 days). The disease-ameliorating effect in FGF-II-treated mice was associated to: (i) central nervous system (CNS) production of FGF-II from vector in fected cells which were exclusively located around the CSF space (ependimal and choroidal cells); (ii) significant decrease (p < 0.05) of the number of myelinotoxic cells (T cells and macrophages) both in the CNS parenchyma and in the leptomeningeal space; and, (iii) significant increase (p < 0.05) of the number of oligodendrocyte precursors and of myelin-forming oligodendrocytes in areas of demyelination and axonal loss. Our results indicate that CNS gene therapy using HSV-l-derived rector coding for neurotrophic factors (i. e. FGF-II) is a safe and non toxic approach that could representa potential useful "alternative" tool for the treatment of immune-mediated demyelinating diseases.

lntroduction: Multiple sclerosis (MS) is thought to be an organ-specific autoimmune disease but the autoantigens are as yet unknown. Failure to demonstrate autoantibodies using standard immunofluorescence techniques has led to speculation that the relevant antigens may not always be present in normal tissue, but may be inducible by stressful physiological conditions such as inflammation. This hypothesis has been strengthened by the demonstration that many patients with MS produce autoantibodies against the heat-shock protein alpha-B crystallin. Objectives: To look for autoantibody binding to inducible cytoplasmic antigens in live human glial cuhures and compare results using serum from MS patients and controls. Methods: Serum samples were collected from the following groups: healthy controls, active relapsing-remitting MS (RRMS), secondary progressive MS (SPMS) and other inflammatory central nervous system diseases (OIND, n=10 for all groups). Human astrocytoma cells (CCF-STTG1) and human oligodendroglioma cells (HOG) were fixed and permeabilised before being incubated with serum (diluted 1 in 10 in phosphate buffered saline) for one hour at room temperature. Antibody binding was developed using fluorescein-conjugated secondary antibodies (to lgG and IgM) and quantified by flow cytometry. One flask of each cell type was heat-shocked at 43c for 20 minutes, 24 hours prior to the experiment. Resuhs: There was no significant difference in median cell fluorescence (a measure of autoantibody binding) between the different groups without heat-shock in either cell line. Heat-shock produced no effect in the astrocytoma line. However in the oligodendroglioma cell line, heat-shock treatment produced a marked increase in antibody binding using serum from both RRMS (p=0.005) and SPMS patients (p=0.006). This effect was not significant in healthy controls (p=0.112) of OIND patients (p=0.112). Only the heat-shocked oligodendroglioma line showed a significant difference in autoantibody binding between healthy controls and MS patients (p=0.007) with 50 % of MS patients exceeding the mean plus 2 standard deviations for controls. Conclusions: Many multiple sclerosis patients had serum autoantibodies that bound oligodendrocyte antigens but only after the cells were

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stressed by heat-shock. As this binding was only seen in cells of oligodendrocyte lineage, it could be relevant to the mechanism of oligodendrocyte loss and demyelination seen in this disease.

124 Patterns of cerebrospinal fluid pathology correlate with disease progression in multiple sclerosis. S. Cepok, M. Jacobsen, S. Schock, B. Omer, S. Jaekel, I. Boeddeker, W. H. Oertel, N. Sommer, B. Hemmer (Marburg, D)

122 Immunogiobulin G Fc-receptor (FcyR) in the serum of MS patients. G. Conti, E. Scarpini, P. L. Baron, R. Clerici, M. De Riz, G. Scarlato, C. A. Vedeler (Milan, I; Bergen, N)

Multiple sclerosis (MS) is a chronic i~flammatory and demyelinating disease of the central nervous system (CNS) with a yet unknown etiology. Temporal profile, intensity, and treatment responses are highly variable in MS suggesting pathogenetic heterogeneity. This hypothesis has been supported by histopathological studies disclosing at least four different subtypes of acute demyelinating lesions. Although stratification of MS patients into these categories would be extremely helpful for clinical studies, this approach is impractical, as it requires brain biopsy. Instead, we investigated cerebrospinal fluid (CSF) cytology from 60 MS patients by flow cytometry. We identified different patterns of CSF cytology, which were independent of immunological parameters in the peripheral blood. In those studies the most variable CSF parameter was the B cell to monocyte ratio, which remained stable during different phases of disease and correlated with disease progression but not with disability or disease duration. Further characterisation of the B cell and T cell responses demonstrated a specific enrichment of memory B cell and T cells in the CSF of MS patients compared to peripheral blood. Our study demonstrates (a) that immune parameters in the CSF of MS patients are independent from the distribution in the peripheral blood and (b) the existence of different CSF cytology patterns in MS. The resuhs suggest that the CSF reflects the heterogeneity in disease pathogenesis and may be valuable for stratification of MS patients for clinical studies. Further prospective studies have to clarify the implications of distin~t CSF cytologies for the prognosis and therapeutic interventions in MS.

The Immunoglobulin G Fc-receptor (FcyR) IIA and IIIB polymorphisms appear to be related to Multiple Sclerosis (MS) clinical disability. Moreover, the evidence that microglia express FcyR that is increased in MS lesions suggests that this molecule may be of functional importance in antibodydependent cell-mediated cytotoxicity, phagocytosis, and local immunoregulation.. In this study has been evaluated ir soluble FcyR III serum levels is a possible biological marker for MS diagnosis and follow-up. Soluble FcyR 11I has been analyzed by a sandwich-ELlSA method in the serum of 12 MS patients (6 RR-MS, 6 CP-MS) and 6 healthy controls. More over, the serum levels of FcyR III collected every 3 months for 1 year from the 6 CP-MS patients have been compared to the Expanded Disability Status Score (EDSS). Our resuhs indicate that soluble FCyR III plasma levels have a great variability among RR-MS patients and controls. However, in CP-MS patients FCyR III serum levels were higher and modifications have been found related to EDSS modifications. These data seem to indicate that, although soluble FCyR III has a high variability among RR-MS patients and controls, this molecule might be a biological marker for the diagnosis and the clinical follow-up of CP-MS. 123 P-selectin glycoprotein ligand-I(PSGL-1) has a critical role in preferentiai recruitment of Thl versus Th2 lymphocytes in brain microcirculation. L. Piccio, B. Rossi, E. Scarpini, G. Scarlato, C. Laudanna, D. D'Ambrosio, R. Grenningloh, C. Giagulli, G. Constantin (Verona, Milano, 1) Background: Migration of CD4+T helper cell into the brain is a critical event in multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE). Lymphocyte extravasation involves: tethering and rolling, chemoattractant-triggered activation, firm arrest and diapedesis. Selectin-dependent tethering and rolling is the earliest event in the recruitment of lymphocytes to sites of inflammation. Recent studies showed the expression of functional PSGL-1, a ligand for E and P selectin, m o s @ on Thl and in a lesser extent on Th2 cells. Objective: The goal of this study was to determine the mechanisms of Thl and Th2 lymphocyte recruitment in brain microcirculation during early stages of inflammation. Methods: Cerebral vessels in mice were visualized by using intravital microscopy. A catheter was inserted into the right carotid artery for the injection of fluorescently labelled T cells. In order to exclude from our analysis non cerebral vessels, right external carotid and pterygopalatin arteries were ligated. Observation were made through the skull by using a long focal distance objective, epifluorescence microscopy and an highly sensitive videocamera. In vivo activation of endothelium was obtained by treating mice with LPS or TNFalpha, 5-6h before the experiment. PLP 139-151 T cell lines, Th 1 and Th2 lines were used. E and P selectin expression in brain vessels was investigated afler in vivo activation of endothelium by LPS and during preclinical and clinical phases of passive and active EAE by using intravital microscopy after injection in mice of fluorescently labelled antibodies. Results: Encephalitogenic T cells and Th 1 cells efficiently tethered, rolled and firmly arrested in brain venules. In contrast, few Th2 lymphocytes rolled and firmly adhered to brain endothelium. Antibodies anti-E and P selectin, blocked tethering and rolling of lymphocytes in brain venules. Moreover, antibodies anti-PSGL-1, but not anti L selectin, completely prevented the interactions of T cells in brain venules. Brain vessels express both E and P selectin after in vivo stimulation with LPS or TNE Importantly, E and P selectin are also expressed on vessels during preclinical phases of both active and passive EAE and the distribution is patchy. Conclusions: Our findings reveal new insights for the pathogenesis of MS/EA E and provide evidence that PSGL-1/endothelial selectins may represent key molecules in the preferential recruitment of Thl lymphocytes during early inflammation.

125 Distinct modulation of MMPs and TIMPs in monocytes by inflammatory and anti-inflammatory cytokines: Relevance to multiple sclerosis. M. Avram, S. Shapiro, N. Lahat, A. Miller (Haifa, 1L) Background & Objectives: Accumulating evidence implicates matrix metalloproteinases (MMPs) in the pathogenesis of immune-mediated diseases, such as multiple sclerosis (MS). Though cytokines seem to be key modulators of MMPs, little is known regarding the distinct modulation of these enzymes by pro-inflammatory versus anti-inflammatory cytokines in monocytes. We therefore studied the effects of the inflammatory cytokines involved in MS pathology, TNF-alpha, IL-18 (IFN-gamma-inducing factor) and IL- 12, as well as the anti-inflammatory cytokine IL-4, related to disease remission, on the expression of MMPs and TIMPs. Materials & Methods: Human monocytic cells (U937) were exposed to TNF-alpha (0.1-20 ng/ml) or IL-18 (10-200 ng/ml), in the presence or absence of IL-12 (1-10 ng/ml), or IL-4 (0.1-10 ng/ml). The tuRNA levels of MMP-2, -9, MT1-MMP, TIMP-1 and -2 were assessed by northern blot, while protein levels were assessed by zymography (MMP-2, MMP-9) or FACS (MT1-MMP). Results: MMP-9 tuRNA expression was dose-dependently increased by TNF-alpha, while not significantly affected by IL-18 or IL-12. In contrast, MMP-2 mRNA and protein expression were only slightly increased by TNFalpha, while significan@ increased by IL-18 and synergistic elevated at the tuRNA level by combined IL-18 and IL-12. TNF-alpha, as well as combined IL-18 and IL-12 led to a significant elevation of MT1-MMP tuRNA. TNF-alpha induced an elevation of MT1-MMP protein, while IL-18 and IL-12, separately as well as combined, also up-regulated this protein. Neither TNF-alpha nor IL-18/IL-12 had a significant effect on TIMP-1 or TIMP-2 mRNA levels. IL-4 dose-dependently suppressed both constitutive and TNF-alphainduced MMP-9 expression, while leading to a significant elevation of TIMP-I tuRNA only when combined with TNF-alpha. Conclusions: This study suggests diverse effects mediated by the inflammatory and anti-inflammatory cytokines on the regulation of MMPs/TIMPs in immune cells, illuminates a potential role for IL-18 and IL-12 in inflammatory autoimmune processes and suggests implementation of IL-12 or 1I:18 inhibitors as future therapeutic strategies for MS. 126 Effect of treatment with interferon-beta on proliferation and cytokine production of mononuclear cells in patients with primary progressive multiple sclerosis. F. Weber, A. Kolb, A. Bitsch, T. Bogumil, A. Dressel, D. Bahner, E. Elitok, H. Tumani, S. Poser, B. Kitze (G6ttingen, D) Background: According to current concepts MS is an autoimmune disease, in which auto reactive T cells playa pivotal role. Several studies indicate, that the production of proinflammatory cytokines like tumour-necrosis-factoralpha (TNF-alpha) and interferon-gamma (IFN-gamma) is elevated in re-

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lapse, whereas interleukin-10 is increased in remission. Interferon-beta (IFN-beta) is an established therapy for patients with relapsing-remitting multiple sclerosis (RRMS). However, data about its effects in patients with primary progressive MS (PPMS), which is different in imrnunological aspects, are limited. Objective: The aim of this study was to investigate the proliferation and cytokine production of peripheral blood mononuclear cells (PBMC) from patients with PPMS under treatment with IFN-beta. Methods: 18 patients with PPMS were treated with 8 M IU IFN-betalb (Betaferon) subcutaneously every second day. Blood was collected before therapy and at months 1, 3 and 6 during treatment. PBMC were isolated by Ficoll gradient centrifugation and stimulated with concanavalin A (CunA) and an immobilized antibody against CD3 (OKT3). Froliferation was determined by 3H-thymidine incorporation. TNF-alpha, IFN-gamma and IL-10 were measured in the culture supernatant by enzyme linked immunosorbent assay (ELISA). Results: PBMC collected from patients during treatment with IFN-beta showed a significantly reduced proliferative response after stimulation with immobilized OKT3 antibody in vitro. The proliferation of ConA-activated PBMC was decreased, but did not reach statistical significance. After stimulation with ConA the IFN-gamma and TNF-alpha production of PBMC increased up to month 3 and declined to pre-treatment values at month 6, but the rise was not statistically significant. Stimulation with OKT3 antibody, however, significantly increased TNF-alpha production of PBMC at month 3 of IFN-beta therapy. Production of IFN-gamma was increased, too, but was not significant. Production of IL-10 was significantly increased at month 3 after stimulation of PBMC with ConA and declined thereafter. After activation with OKT3 antibody, however, IL-10 production of PBMC decreased steadily and reached statistical significance at month 6. Conclusion: The effects of IFN-beta demonstrated here in patients with PPMS differ from those reported in RRMS and therefore give additional evidence for differences in the immunological status between patients with RRMS and PPMS.

Oral session 21 Clinical Neurophysiology- 1 127 Study on the latency difference between compound muscle and sensory nerve action potentials. O. Hasegawa, G. Gondo, S. Matsumoto (Yokohama, Fukuoka, J) In motor nerve conduction studies compound muscle action potentials (CMAPs) appears later than sensory nerve action potentials (SNAPs). This time lag originates from the conduction delay at the distal motor axon, neuromuscular transmission time and muscle action potential induction time. To investigate the latency difference between CMAPs and SNAPs we studied 46 healthy individuals, 46 patients with diabetes mellitus and 33 patients with carpal tunnel syndrome, using the lumbrical and interossei recording method. In this method the recording electrode was placed on the 2 nd lumbrical muscle and the reference electrode on the proximal palmar aspect of the index finger.A supramaximal stimulation was given to the median or ulnar nerve trunk at 9-cm proximal to the recording electrode. CMAP from the 2ndlumbrical muscle (L) and SNAP from the digital nerve (N) were recorded after median nerve stimulation, and CMAP from the 2nd interossei muscles (I) was recorded after ulnar nerve stimulation. The residual latency, which is arbitrary signified as the latency difference (L-N) in this study, was 1.38 + 0.15 (mean + SD) msec in healthy individuals.About 1 msec out of the residual latency was regarded as the time for neuromuscular transmission and the time to evoke muscle activities. Thus, the conduction delay at the dista/ motor axon was calculated as 0.4 msec in healthy individuals. The residual latency was constant in 29 diabetic patients without conduction delay across the carpal tunnel. Their sensory nerve conduction velocities (calculated from N latency) were always more than 40 m/sec. On the other hand, in diabetic patients with conduction delay across the carpa/tunnel the residual latency gradually increased in reverse proportion to the sensory nerve conduction velocities. Their sensory nerve conduction velocities were mostly less than 40 m/sec. The similar relationsbip was observed in patients with carpal tunnel syndrome without diabetes mellitus. We conclude that in pa-

tients with obvious conduction delay across the carpal tunnel degeneration of distal motor nerves increases the residual latency. This delay corresponds to the latency difference between compound muscle and sensory nerve action potentials. Patients witb diabetes mellitus without conduction delay across the carpal tunnel, their conduction velocities were always maintained more than 40 m/sec, h a d a constant residual latency. 128 Movement-Related Desynchronization/Synchronization of the EEG in patients with Multiple Sclerosis and frontal lobe deficits. L. Leocani, V. Martinelli, M. Filippi, G. Santuccio, M. Rovaris, F. Possa, G. Magnani, G. ComŸ(Milan, I) Involvement of frontal lobe executive functions is a relatively frequent finding in Multiple Sclerosis (MS). Frontal lobes a/so play an important role in the control of voluntary movements, particularly in motor planning and execution. Event-Related Desynchronization (ERD) of the sensorimotor EEG rhythms indicates cortical activation during movement preparation and execution,while event-related synchronization (ERS) of the same rhythms, occurring after movement termination, is considered a correlate of cortical idling or inhibition. We evaluated the pattern of cortical activation during voluntary movements in MS patients with frontal lobe involvement by means of ERD/ERS analysis of self-paced finger movements. Ten MS patients with and 11 without neuropsychological frontal lobe deficits, with similar disability and disease duration were studied. Data were compared to 11 age-matched normal subjects. Patients a/so underwent quantitative assessment of brain magnetic resonance imaging (MRI) lesion load. ERD onset to movement preparation was delayed in frontal patients compared both to normal subjects (p=0.01) and to non frontal patients (p=0.003). Postmovement ERS was not significantly different in the two MS groups, and it was reduced in both of them when compared to normal subjects (p < 0.02). Frontal MS patients had higher MRI lesion burdens than control MS patients, overall and in the frontal lobes. Delayed ERD onset during movement preparation in frontal patients is consistent with the role of frontal lobes in motor programming, and with the MRI findings. Reduced post-movement ERS, which reflects inefficient cortical inhibitory mechanisms, is not specific of frontal lobe involvement, but rather to MS pathology. 129 Pre-perceptual pain sensory responses (NI component) in type 1 diabetes mellitus (DM): a laser evoked potentials (LEPs) study. P. Rossi, M. Serrao, S. Morano, U. Di Mario, G. Pozzessere (Rome, I) Background: LEPs ma), be a useful and sensitive diagnostic tool for assessing the function of small-myelinated fibers (A-delta) in diabetic neuropathy (DN). This statement is based on recent studies measuring the N2/P2 vertex potentials. This component is strongly influenced by attention processes and may reflect cognitive processing of nociceptive inputs. It represents a drawback of LEP studies. Recently, it has been demonstrated that a smaller N1 component is not influenced by attention shifts and is thought to be more specific for the sensory-discriminative aspects of pain. Aim of the study: To evaluate the integrity of the ascending pathways for pain sensitivity, in the early stage of type 1 DM, by measuring simultaneously the N1 component and the conventional N2/P2 vertex potentials of LEPs. Subjects: 20 healthy volunteers and 20 age- and sex-matched type 1 diabetic patients, without either clinical neuropathy or electrophysiological evidence of large-fiber damage. Methods: The cortical responses were obtained following hand (LEPH) and foot (LEPF) stimulation. The N1 component was measured using a simple fronto-temporal derivation. NI and P2 mean peak latencies and NI-P2 transit time (TT) were studied in every subject. Results: A biphasic N2/P2 potential was clearly identified in every subj ecy. The N 1 component was recorded in 19/20 of controls, 18/20 of patients. No significant difference was found for LEPH. N1 and P2 latencies were significantly prolonged after foot stimulation (Controls; NI= 201 + 18 msec, P2= 398 + 26 msec, Patients; NI= 236 + 27 msec, P2= 435 + 24 msec, p < 0.05). No difference was found for the N I-P2 TT.Abnormal LEPF values were found in 25 % of diabetic patients. Discussion: LEFs reveal an early, subclinical and selective damage of pain sensation in diabetic patients. N1 and P2 potentials are delayed in parallel giving an indirect evidence that LEP abnormalities are not secondary to a cognitive dysfunction and mostly reflect a small-fiber dysfunction.

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130 Exercise related shortening of central conduction time of tibial nerve SSEP as a sign of subcortical facilitation within the somatosensory pathway. W. Hey, J. Koehler (Mainz, D) Objectives: Slight muscle innervation leads to facilitation mechanisms of motor evoked potentials. The purpose of our study was to evaluate the somatosensory system with respect to facilitation mechanisms. Therefore tibial nerve somatosensory evoked potentials (SSEP) were recorded before and after exercise. Methods: Tibial nerve SSEP were recorded (512 averaged stimuli, stimnlus frequency 5Hz, bandpass 20-3200Hz, analysis time 90ms) from 13 healthy subjects (age 28-54, mean 33.7, 6 female, 7 male) before and after exercise. For exercise the subjects walked 4• steps (2 times up- and downwards) in 5-10 minutes to achieve an intense sensory input of the lower extremities. Skin temperature was measured during SSEP recordings. The cortical P40 and N50 potential was recorded at Cz, the lumbar N21 potential at LI. Reference was placed at Fz resp. contralateral iliac crest. The central conduction time (CCT) was calculated (early CCT: P40 latency - N21 latency; late CCT: NS0 latency - N21 latency) For statistical evaluation the paired T-test and linear correlation (Pearson) was used. Resutts: The early and late CCT decreased afler exercise (mean 15.4 ms before vs. 14.9 ms after exercise resp. 24.0 ras vs. 23.3 ms; p < 0.01, early CCT: T=3.47,1ate CCT:T=3.15; paired T-test). The N50-P40 latency differences before and afler exercise were similar (p > 0,4,T=0.86). No correlation of skin temperature differences before and afler exercise (mean 0.15~ and CCT could be found (p > 0.05, Pearson linear correlation). Conclusions: Exercise related shortening of the central conduction time after tibial nerve stimulation point to central influences of the afferent volleys after exercise. This could be explained by facilitation within the central somatosensory pathway. Because of no additional effects of latency of the secondary generated cortical potentials we think facilitation takes place in subcortical structures like thalamus or thalamocortical radiations. 131 Intracortical excitability in developmental stuttering. M. Sommer, S. Wischer, E Tergau, W. Paulus (Goettingen, D) Developmental stuttering, a motor disorder of obscure origin, has clinical similarities with task-specific dystonias. In these dystonias a reduced intracortical inhibition is present in the cortical representa tion of clinically involved and clinically uninvolved muscles. We, therefore, studied the intracortical inhibition and facilitation in 11 patients with developmental stuttering (mean age, 38 years) and compared the results with 11 controls (mean age, 39 years). We used a figure-of-eight coil of transcranial magnetic stimulation over the optimal representation of the abductor digiti minimi of the handed side and determined the motor thresholds conventionally; for intracortical excitability we used a conditioning-test paired-pulse paradigm with a conditioning pulse of 90% active motor threshold followed by a suprathreshold pulse after 1,2, 3, 4, 5, 6, 7, 8,10,15, 20 or 30 ms. A group comparison showed normal motor thresholds a n d a normal intracortical inhibition (pool of intervals 1-4 ms, Anova, p=0.8) and facilitation (pool of intervals 8-20 ms, Anova, p=0.6) in the patients. Individual analysis showed two patients with a markedly reduced intracortical inhibition and facilitation. We conclude that the motor threshold and the intracortical inhibition are normal in the hand muscle representation of many patients with developmental stuttering. We ate currently expanding the patient group to see whether there is truly a subgroup of patients with abnormal intracortical excitability. 132 Intracortical Inhibitory Mechanism in Normal Human Sleep. P. Grosse, R. Khatami, E Salih, A. Kª Bu. Meyer (Berlin, D) Background: We present the first systematic study using the technique of transcranial magnetic stimulation (TMS) to explore basic neurophysiological mechanism of normal human sleep. In particular we were interested in the varying degree of inhibition in the regulation of the motor cortex in different sleep stages and in the extent of intracortical inhibitory mechanisms activity during sleep. Methods: We examined 22 healthy volunteers recording excitability curves (relationship between MEP amplitude and stimulus intensity) with the single pulse technique and intracortical inhibition (ICI) and facilitation (ICF) using the conventional paired TMS paradigm in different sleep stages. For excitability curves a round shaped coil placed over the vertex was used while for ICI/ICF a figure-of-eight-coil was placed over the optimal spot eliciting maximal EMG response. Surface EMG was recorded from the first in-

terosseous muscle. Sleep stages were determined polygraphically including surface EEG, submental EMG and EOG. To increase the intensity of NREM4 sleep and improve sleep performance in the sleep laboratory volunteers underwent partial sleep deprivation the night prior to the experiment. The experiment was repeated during wakefulness. Results. Excitability curves could be obtained in six volunteers in sleep stages NREM2, NREM4 and REM. Resting motor threshold levels increased for all stimulus intensities in all sleep stages (NREM2 > REM > NREM4) in comparison to wakefulness. Amplitude decreased within a proportional range to stimulus intensity in each sleep stages compared to wakefulness. The reduction of amplitude was maximal in NREM2 and REM reaching from 10 % to 25 % of amplitudes of wakefulness while in NREM4 amplitude were only halved. Whereas in NREM4 the amplitude ratio between sleep and wakefulness was approximately constant for all stimulus intensities, in NREM2 and REM the ratio decreased with stimulus intensity. In two individuals paired pulse technique applied in NREM4 ICI was increased compared to wakefulness while ICF did not change. In contrast in NREM2 ICI and ICF were identical to the wakefulness in the one subject examined. Conclusion: Decrease of cortical excitability as measured by diminished amplitudes was maximal in NREM2 and REM with almost identical excitability curves. In contrast, the decrease of cortical excitability in NREM4 was far less without reaching the level of wakefulness. These results cannot be explained by decreasing muscle tone during sleep or spinal inhibitory mechanism alone, because of the similar range of excitability in NREM2 and REM. Furthermore enhanced intracortical inhibition demonstrated by increased ICI while ICF was unchanged will explain our data best. However, different mechanism of inhibition will regulate di'fferent sleep stages as ICI was increased in NREM4, whereas in NREM2 there was no difference to wakefulness.

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Clinical Neurophysiology - 2 133 Excitatory and inhibitory effects of deep brain stimulation of the motor pathway through the electrodes implanted in the subthalamic nucleus of patients with Parkinson's disease. J. Valls-So]› J. Molinuevo, F. Valldeoriola, J. Rumih (Barcelona, E) Chronic high frequency bilateral subthalamic nucleus (STN) stimulation is currently used for treatment of patients with advanced Parkinson's disease. The implanted electrodes ate able to stimulate not only the STN neurons and circuits but also other excitable structures in the vicinity of the STN. We examined the excitatory and inhibitory effects induced in the motor pathway by controlled unilateral single electrical stimuli. We examined 14 patients with Parkinson's disease 3 to 5 days after stereotactic implantation of electrodes for STN stimulation (DBS 3389m, Medtronic), just before programmable pulse generators (Itrel II, Medtronic) were implanted in the subclavicular region.A home-made adaptor was used to connect the four external electrode leads to the electrical stimulator of an EMG apparatus (MystroSPlus). We applied low intensity single stimuli ranging from 50 to 300 V without any significant patient discomfort. At rest, single pulse stimulation induced strictly contralateral responses in thenar muscles at a mean latency of 20.1 ms, and bilateral responses in facial and cervical muscles, at mean latencies ranging from 5.3 for masseter and sternocleidomastoid muscles to 9.1 ms for facial nerve innervated muscles.When the most caudal, medial and posterior lead was used a s a cathode, the responses of cranial nerves were facilitated, and those of the thenar muscles depressed, with respect to when the cathode was the most rostral, lateral and anterior lead. During voluntary contraction, stimuli of an intensity of 120 % above resting motor threshold induced a silent period in all muscles recorded from. In most subjects, the silent period of contralateral thenar muscles was divided into two phases. The characteristics of the silent period varied according to the stimulus intensity and the strength of the muscle contraction, being present even at intensities below motor threshold. Silent periods were also induced in the ipsilateral thenar muscles. They were bilateral in cranial and cervical muscles. The implantation of electrodes for deep brain stimulation brings new

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possibilities for neurophysiological study of the motor pathway, through direct activation of the motor fibres in the internal capsulae, without patient discomfort or adverse effects. Interindividual differences regarding the pattern of excitatory or inhibitory responses could inform on the variability of electrode placement, and be correlated with therapeutic effects. 134 Cerebellar ataxia results from abnormal feedforward control. V. Sanguineti, G. Brichetto, M. Farinelli, G. L, Mancardi, P. G. Morasso, L. Baratto, C. Solaro (Genova, Arenzano (GE), I) Objective: To provide an interpretation of cerebellar ataxia in terms of abnormal control. Background: In the motor system, at least two different control modalities are present: (i) a feedforward component, in which a detailed description of the desired movement is transformed into the corresponding motor commands; (ii) a feedback modality, responsible for corrections based on in_ formation on the ongoing movement. It is not clear whether the disorder in cerebellar subjects involves feedforward, feedback control or both. Methods: We tested 9 subjects of ages 33-66 (mean 52.4), 1 male and 8 female, one with Friedreich Ataxia, one with cerebellar stroke and seven with idiopathic cerebellar ataxia (IDCA), and 10 young controls of ages 23-35 (mean 29.3). Subjects performed planar arm reaching movements under visual control and with a fast-and-accurate directive. Tra)ectories of shoulder, elbow and fingertip were recorded by means of reflective markers. Both right and left arre were separately tested. Results: Examination of the early portion (0 120 ras) of the movement, in which feedback control is inactive, showed that all subjects display aiming errors. The latter vary systematically with movement direction, and are significantly larger in cerebellar patients. Estimates of muscle torques showed that they cannot be explained by insufficient force in either shoulder or elbow muscles. We then focused on the later portion of the trajectories, when feedback control also comes into play. In all control subjects and in all but two cerebellar patients (subjects with stroke and FA),we found that the maximum lateral deviation is relatively independent of the aiming error. For each subject,we also estimated movement smoothness (measured by the jerk integral) before and after the peak in hand speed. In cerebellar subjects, we found a much larger pre-peak jerk, whereas there were no significant differences in pre-peak and post-peak magnitudes (again with the exception of the same two cerebellar patients). Conclusions: The larger aiming errors and pre-peak jerks point to an impaired feedforward control. In contrast, invariance of lateral deviation with respect to the aiming error, and similarity of pre- and post-peak )erk suggest an intact capability to perform on-line corrections; therefore, feedback control (with two exceptions) seems relatively unaffected. The two exceptions are likely due to an additional proprioceptive impairment. 135 Brain stem auditory evoked potentials in Wallenberg's syndrome. ]. Agaoglu, C. Bolcu Emir, S. Ozyedek, E. Akinturk, O. Tanik (Istanbul, TR)

Introduction: Clinical utility of brain stem auditory evoked potentials (BAEPs)stems from the close relationship between evoked potential waveforros and specific anatomic structures. The spasticity allows localization of conduction defects in the brain stem to within a centimetre; and BAEPs provide a sensitive tool for assessment ofbrain stem auditory tracts and nearby structures. Patients with lateral medullary infarcts (Wallenberg's syndrome) are known to have normal BAEPs, as would be expected, since the structures involved are below the leve1 of entry of auditory tracts; but BAEPs may be abnormal in some patients with Wallenberg's syndrome, probabty because in some patients the posterior inferior cerebellar artery (PICA) supplies structures more rostrally in the brain stem, that is pontomedullary junction and low pons. Method: The relationship between the BAEPs and neuroimaging findings was retrospectively investigated in 30 patients (21 male, 9 female) aged 38-80 years, referred to our neurology clinic with Wallenberg's syndrome during the period 1999-2000.All the patients underwent neurological evaluation, routine laboratory tests and magnetic resonance imaging (MRI) and/or cerebral computerized tomography scanning (CT) examinations. Results: BAEPs were abnormal in 65 % of all cases. MRI findings revealed posterior circulation involvement in all cases and PICA territory was involved in the maj ority of cases with Wallenberg's syndrome. 65 % of all cases with ischemia in PICA region on MRI had normal BAEPs. In cases with pathological BAEPs, the most common findings were the unilateral III-V interpeak latency prolongation a n d a delay in the appearance of wave V. Also we found a correlation between increasing BAEPs abnormalities and increasing severity of residual defects.

Conclusion: In patients with brain stem infarcts, MRI may be the preferred initial test but the BAEP is less expensive a n d a non-invasive investigation method. In addition BAEPs evaluation can be performed at bed side and can be used more frequent for follow up; with the combination of structural imaging techniques, BAEPs provide a sensitive tool for localization of brain stem lesions. 136 No acute effects of gabapentin on excitability parameters of peripheral nerves in vitro. S. Quasthoff, J. Grosskreutz, P. Liebmann, H. Hartung (Graz, AT) Gabapentin has been introduced as an add-on therapy for epilepsy (Levy et al. 1995). It has recently received attention for the treatment of various neurological conditions other than epilepsy, including neuropathic pain. The precise mechanism of action of gabapentin is unknown; it has been suggested that it may modify excitability of CNS and PNS neurons. Furthermore, Mariani et al. (2000) reported that gabapentin was able to suppress hyperpathic neuropathy in patient treated with the chemotherapeutic agent oxaliplatin, a substance inducing repetitive action potential firing (Adelsberger, 2000). The aim of the present study was to investigate the acute effects of gabapentin on nerve excitability parameters in vitro before and after oxaliplatin application. Seven sensory nerves were investigated on a cellular level using rat sural nerves. The amplitude and duration of compound action potentials of A-fibres (96 _+ 13%; 100 • 4%; n = 7) and C-tibres were not affected (102 _+ 19 %; 98 • 6 %; n = 7) by gabapentin (100 ~tM, 1 mM, 3 mM). In electrotonus experiments the drug did not mimic the effects caused by blockers of voltage-gated potassium channels or of voltagegated sodium channels. In the presence of gabapentin (3 mM) oxaliplatin still induced an increase in action potential amplitude (243 + 76%; n = 7) and repetitive firing. In contrast the effect of oxaliplatin could be antagonised by the sodium channel blocker carbamazepine (1 mM, n = 7). This observation, together with the absence of any effect on oxaliplatin induced hyperexcitability, suggests that gabapentin has no acute effect on peripheral sensory nerves in vitro. This observation is in line with previous studies where gabapentin did not block sustained repetitive firing (SRF) of action potentials in mouse spinal cord neurons after acute administration. Therefore, the mechanism by which gabapentin is effective in neuropathic disease rernains unclear. 137 Vestibular cortex identified with caloric stimulation in fMRI. M. ron Brevern, R. Weuzet, O. Fasoid, M. Kuhberg, A. Villringer, T. Lempert (Berlin, D) Introduction: Spatial orientation and perception of movement require processing of vestibular information at the cortical level, but comparatively little is known about the cortical representation of the vestibular system. There is no primary vestibular cortex which obtains projections exclusively from vestibular afferents, instead several multimodal sensory areas integrating vestibular, visual and somatosensory signals have been identified. For this study, we implemented caloric stimulation in fMRI by means of irrigation with cold nitrogen gas to stimulate each vestibular organ separately. Thereby, we intended to further characterize cortical vestibular areas and to test for hemispheric dominance of vestibular information processing. Methods: Imaging was performed on a 1.ST Siemens Vision echo-planar system with a standard head coil. Echo-planar-images were acquired in 16 slices in transversal orientation (TR 2s, TE 60s, flip angle 90o, Fov 256'256mm, imaging matrix 64'64, slice thickness 5mm, gap 0.Smrn). For surface reconstruction and inflation high resolution 3D-flash datasets were acquired which served as a detailed individual anatomical reference. Normal subjects (n-5) were examined during vestibular stimulation of the right and left ear canal with cold nitrogen. Before the MR-experiment an individual threshold for motion perception and nystagmus was tested outside the scanner. In each subject one minute of caloric irrigation induced nystagmus for at least 90 seconds after the end of irrigation and only this period was included for statistical analysis. The baseline condition was defined as the 60 seconds before caloric stimulation. Each subject underwent 6-10 stimulation cycles for each ear canal in complete darkness with eyes closed. One cycle lasted 10 minutes and included two caloric irrigations. Statistical rnaps were calculated with a general linear model and overlaid on the individual reconstructed surface. Results: Distinct foci of activated cortex were found in the insular cortex and parietal, temporal, occipital and frontal cortical areas. These comprise the posterior and anterior insula, frontal operculum, posterior superior temporal sulcus and gyrus, dorsolateral parietal cortex, inferior temporal sulcus, lateral occipital gyrus, pre- and postcentral gyri, precentral sulcus, dor-

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solateral prefrontal cortex and posterior part of the cingular sulcus. Regardless of the stimulated side there was strong right hemispheric dominance in all subjects with respect to the number of areas as well as their size. Conclusion: Caloric stimulation with cold nitrogen is a novel method that is suitable for vestibular stimulation in the MRI-scanner, whereas water has been shown to produce susceptibility artefacts. We found multiple cortical areas involved in vestibular signal processing which are in accordance with previous findings from animal experiments, intraoperative cortical stimulation and functional imaging in humans using caloric stimulation in PET and galvanic stimulation in fMRI. Furthermore, this study demonstrates a strong right hemispheric dominance of vestibular cortex areas, regardless of the stimulated side. 138 Pathophysiology of fatigue-induced proximal tremor associated with posterior fossa malformations. M. Manto, J. Jacquy, J. Moor (Bruxelles, Charleroi, B; Boston, USA) An intermittent leg tremor in patients presenting a posterior fossa arachnoid cyst compressing the cerebellum in the midline has been exceptionally reporte& It has been hypothesized that a brainstem compression was the underlying mechanism. We report two patients presenting a posterior fossa malformation and exhibiting a upper limb tremor triggered by fatigue. Tremor was restricted to proximal muscles. Patient 1 is a 29-year-old woman presenting a marked hypoplasia of right cerebellar hemisphere. Neurological examination showed a slight irregularity of the movement during finger-to-nose test on the right side. Patient 2 is 39-year-old woman presenting a hypoplasia of the cerebellum predominating on the midline and associated with a large retrocerebellar cyst. She exhibited dysmetria of saccades, slight bilateral dysmetria during finger-tonose test and heel-to-knee test, slight ataxic gait. EMG activities of the anterior deltoid, biceps, triceps, flexor carpi radialis and extensor carpi radialis were analysed before and after exertion. No rythmic activities were identified before effort. In patient 1, fatigue induced co-contracting bursts at a ffequency of 3.2 Hz (FFT) in the anterior deltoid, the biceps and the triceps on the right side. In patient 2, fatigue induced a 3.9 Hz tremor in the anterior deltoid on both sides, predominating on the right side. Cross spectral analysis showed a high coherence between left and right anterior deltoid.The frequency of the tremor in our cases was suggestive of a lesion of cerebellar pathways. It has been shown that motor cortex in cerebellar patients is more susceptible to rhythmic oscillations. Gain of long-latency stretch reflexes is increased in cerebellar patients during postural tasks and it is known that physical exercise precipitates or enhances oscillations in neuronal networks. Our results show that fatigue should be considered a s a precipitating factor of low-frequency proximal tremor in cerebellar patients. Appearance of tremor after exercise in patient 1 argues against the hypothesis of a brainstem compression. Coherence analysis in patient 2 strongly suggests a common generator for the two upper limbs.

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Periphera| neuropathy - 3 139

Bone marrow transfer reverts the beneficial effect of immunodeficiency in P0 + - mice. M. M~iurer, C. Schmid, F. Bootz, J. Zielasek, K. V. Toyka, S. Oehen, R. Martini (Wª D; San Diego, USA; Zª CH) Inherited demyelinating neuropathies are chronically disabling human disorders caused by various genetic defects in the respective myelin genes. We have shown that in P0 +- mice - a mouse model for CMT1B - that an additional null mutation in the recombination activating gene (RAG-1-) leads to a substantially milder disorder, indicating a disease modifying tole of Tlymphocytes. In the present study, we addressed the tole of lymphocytes in this mouse model by reconstituting bone marrow of P0 +-/RAG- mice with bone marrow from wild type mice. We compared the pathology and nerve conduction in PO +-/RAG- mice with that in double mutants after receiving bone marrow transplant.We found that the milder demyelination seen in the lymphocyte-deficient P0 +-/RAG- mutants was reverted to a more severe

pathology by re-establishing a competent immune system by bone marrow transfer. These data support the concept that the immune system contributes substantially to the pathologic process in the mouse model and my open new perspectives to ameliorate human hereditary neuropathies by exploiting immunosuppressive treatments. 14O Hereditary Sensory And Autonomic Neuropathy Type I With Chromosome 9q22.1-22.3 Locus - An Autopsy Study. S. D Lhatoo, B, Perunovic, S. Love, G. Nicholson, E Scaravili, M. ] CampbeU (Bristol, UK; Sydney,AUS; London, UK) Hereditary sensory neuropathy (HSN I) is an autosomal dominant neuropathywhich predominantly affects the lower limbs. Genetic linkage has established a locus on chromosome 9q22.1-q22.3. There may be considerable clinical heterogeneity within this group of neuropathies and also within kindreds. Substance P abnormalities have been described in the spinal cords of mutant rats with mutilated feet, which have a phenotype similar to HSN I. We present autopsy findings in 3 affected patients (1 female and 2 male) from 2 large kindreds with HSN I linked to the HSN I locus on chromosome 9q22.l-q22.3. Autopsy studies were conducted on 3 affected patients who died at the ages of 93, 59 and 51 years. The cord, dorsal root ganglia (DRG) and lower limb peripheral nerves were examined in all 3 cases. Upper limb peripheral nerves and autonomic ganglia were studied in 1 patient. Immuno-staining of the spinal cord with antibody to substance P was also carried out. The cord showed moderate loss of myelinated fibres in the dorsal columns. There was marked loss of myelin from th~ posterior roots. In one patient, multiple levels of spinal cord were immuno-stained with antibody to substance P. Granular immuno-staining was found confined to the laminae I and II of the dorsal columns, where nociceptive axons terminate. DRG showed severe loss of ganglion cells with reduction in density of intra-ganglionic myelinated fibres. Median, radial, ulnar, femoral and sural nerves were examined. Sural nerve and cutaneous branch of the radial nerve were severely depleted of nerve fibres. There was almost total loss of unmyelinated and small myelinated fibres. Overall myelinated fibre density was < 20/mm 2. Mixed peripheral nerves showed moderate decrease in density of myelinated fibres, Examination of the mesenteric ganglion and vagus nerve were unremarkable. This is the first autopsy series in patients proven to have chromosome 9q22.1-q22.3 linked neuropathy. These patients showed predominant affliction of the DRG and marked peripheral loss of unmyelinated fibres with some loss of myelinated fibres in sensorimotor nerves. Limited examination did not show autonomic involvement. Unlike in the "mutilated foot" mutant rat model, there was no decrease in substance P immuno-staining in the spinal cord suggesting that deficiencies of this peptide may not be pathogenetically implicated in HSN I. 141 Late Onset Homocystinuria And Methylmalonic Aciduria. E. Roze, D. Gervais, H. Ogier de Baulny, E Bolgert (ParŸ F) Combined homocystinuria and methylmalonic aciduria (HC-MMA) is a rare disorder of genetic origin characterised by inability to convert vitamin B12 (vB12) into its metabolites adenosylcobalamin and methylcobalamin. Most patients presents in the first year of life with systemic and neurological abnormalities although disease onset in adolescence has been reported. We report the case of a 16-year-old girl who presented with a three months history of dissociative symptoms and delusions of persecution with visual and auditory hallucinations. A month prior to admission, she had also developed an unsteady gait and urinary incontinence. Her 24-year-old sister had suffered from an unexplained subacute combined degeneration of the spinal cord two years ago. On admission, examination revealed areflexic paraparesis with a right extensor plantar response and impaired position and vibration sense of the lower limbs. The results of neurophysiological studies and sural nerve biopsy were consistent with a predominantly axonal neuropathy. Routine laboratory examination and tests for common causes of peripheral neuropathy including serum vB12 and CSF were normal. EEG showed diffuse slow waves and an MRI brain study showed only mild cortical atrophy. Over the following six months, the motor deficit progressed to involve the upper limbs and the respiratory and bulbar musculature. On examination, she displayed persistent psychotic features, and h a d a complete tetraplegia with spasticity of the upper limbs and flaccidity of the lower limbs. She was fully dependent on mechanical ventilatory support. A metabolic work-up disclosed high urinary methylmalonic acid (3890 mmol/mol creatinine, normal < 50) and serum homocystine (205 micromol/L, normal < 15), hypomethioninemia (7 micromol/L, normal > 20) but normal serum transcobalamin II. The clinical picture and the metabolic tests were consistent with a diagnosis of HC-MMA. After six weeks of treatment, psychotic features disappeared and she was weaned off ventilation. She regained up-

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per limbs mobility and enough axial motor strength to allow her to sit. Screening of her sister revealed that she had the same disorder. This report provides evidence of new variants of HC-MMA and emphasises the possibility of later onset disease. Screening for HC-MMA should be considered in the investigation of adolescents and young adults with undiagnosed neurological disease, particularly when the clinical picture is suggestive of vB12 deficiency. 142 Selective loss of cholinergic sympathetic fibers innervating sweat glands in four patients with Ross-Syndrome. C. Sommer, T. Lindenlaub, K. Toyka, M. Naumann (Wª D) Background: Ross syndrome is a rare disorder characterized by tonic pupils, areflexia and segmental hypohydrosis. The patients' presenting complaint is mostly of an area of profuse hyperhydrosis. The etiology of the syndrome is unknown, a selective autonomic neuropathy has been assumed a n d a relation to more widespread autonomic disease has been suggested. We have previously shown selective loss of sudomotor fibers in a patient with Ross syndrome. Here we present clinical and morphological data from four further patients. Methods: Clinical examination, electrophysiological studies, quantitatire sensory testing (QST) and autonomic tests were performed. Skin biopsies were taken from ah anhydrosis a n d a hyperhydrotic atea in all patients. H&E staining and immuno-fluorescence for the panaxonal marker PGP 9.5 and for acetylcholinesterase (AChE) as a marker of cholinergic fibers was performed on 14 ~m frozen sections. Immunoreactive nerve fibers were morphometrically (PGP 9.5) of semiquantitatively (AChE) assessed. Results: Minor nerve conduction abnormalities were present in 3 patients. QST gave normal results. Heart rate variability was normal, the sympathetic skin response was absent in 3 patients. In routine morphology of the skin biopsies there was no pathological change in the skin and sweat glands. Using PGP 9.5 immunohistochemistry,morphometry revealed normal epidermal innervation density in hyperhydrotic (17,7 +_ 1,3 fibers per mm epidermal length; 6226 +_ 1215 m m 2 per mm) and anhydrosis ( 17,6 -+ 1,4 fibers per m m epidermal length; 6762 -+ 1488 m m 2 per mm) areas. Innervation of the sweat glands was reduced in all patients with significant differences in innervation density between hyperhydrotic (99 -+ 25mm2 per 1000mm2 sweat gland atea) and anhydrosis (43 _+ 5,5mm 2 per 1000mm2 sweat gland area) areas. AChE-immunoreactive nerve fibers surrounding the sweat glands were only seen in the hyperhydrotic areas,but absent in the hyperhydrotic specimens. Three of the 4 patients were successfully treated with intracutaneous injection of botulinum toxin A in the area of hyperhydrotic, one patient did not wish treatment. Conclusions: We provide morphological evidence of selective loss of cholinergic sudomotor fibers in 4 patients with Ross syndrome. An autoimmane of neurodegenerative etiology are possible. Intracutaneous injection of botulinum toxin Ais an efficient symptomatic treatment.

ties, cases of GBS with atypical features ate not fundamentally different to clinically classic GBS, where similar neuropathology may be seen. 144 Is Campylobacter Jejuni Gastroenteritis A Risk Factor For GuiUain-Barr› Syndrome In Italy? A Case-Control Study By Western Blot In Northern Italy. M. Carpo, S. Allaria, A. Bersano, E Terenghi, A. Citterio, G. Scarlato, E. NobileOrazio (Milan, Paria, I) Campylobacter Jejuni (CJ) infection is one of the most frequent cause ofbacterial diarrhoea in developed countries a n d a large number of evidences supports the hypothesis that CJ could induce Guillain-Barr› Syndrome (GBS). The diagnosis of CJ infection is usually based on isolation of CJ from stool cultures and elevation of serum antibodies against CJ. Anti-CJ antibodies are reported in a variable proportion of GBS patients ranging from 14 % up to 67 % probably because of the different ELISA methods used to determine this reactivity. In order to establish if CJ enteritis could be a risk factor for GBS also for Italian patients,we measured anti-CJ antibodies byWestern blot and Covalink ELISA in the sera of 47 GBS patients, 45 neurological controls (NC) and 44 non neurological controls (NNC) included in a casecontrol study performed in Western Lombardia and in whom stool cultures were not available. By Western blot analysis we found a very strong IgG reactivity (> 1/100,000) against the lipolysaccharide (LPS) fraction of CJ in 7 (15 %) GBS patients, 5 of whom (71%) had diarrhoea in the two months preceding the onset of GBS. In the 3 positive patients re-examined after 3 or more weeks, antibody levels were found reduced supporting the hypothesis of recent CJ infection disease. None of the neurological and non-neurological controls, including 6 with an antecedent diarrhoea, had similarly high anti-CJ antibodylevels (p < 0.005). Measurement of anti-CJ antibodies in patients' sera by Covalink ELISA was much less sensitive as it revealed their presence in only 2 GBS patients (4%), both with antecedent diarrhoea, and in 1 NC (2 %) (p: n. s.). In conclusion CJ gastroenteritis appeared to be a risk factor for the development of GBS also in Northern Italy even if this association could only be demonstrated by Western blot analysis.

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Higher Functions Disorders and Dementia - 1 145

143 Atypical Guillain-Barr› syndrome: Clinical features and pathology. H. Rauschka, K. Jellinger, M. Schmidbauer (Vienna, AT)

Donepezil: A Meta-Analysis of Individual Patient Data from Randomised Controlled Trials in the Treatment of Patients with Mild to Moderate Alzheimer's Disease. G. Wilcock, A. Whitehead, J. Grimley Evans, J. Birks, C. Perdomo, R. Pratt (Bristol, Reading, Oxford, UK; Teaneck, USA)

Background: Patients with suspected Guillain-Barr› syndrome (GBS) but additionally atypical clinical features of laboratory results representa profound diagnostic problem to the practising neurologist. Objective: To describe clinical course and pathologic features of atypical GBS-cases and to investigate their relationship to the classical GBS. Methods: In our neuropathologic archive we identified 9 cases with the intra vitam diagnosis of GBS with atypical features. We reconstructed preceding events, clinical history and laboratory result by going through all available hospital records. Furthermore we studied neuropathologic featutes using routine staining procedures and immunohistochemistry for antigens of astroglial cells, microglial cells and hematopoetic cells. Additionally we investigated the presence of neurotropic viruses by performing immunohistochemistry for various viral antigens. Results: Presenting signs and symptoms according to Asbury (1978) were evident in all cases. Duration of illness from first sign to death ranged from 8 to 52 days. Symptoms indicative of infectious illness preceded in 3/9 cases. The following atypical features occurred in the course of illness: sharp sensory level: 6/9, mental deterioration: 3/9, unusual heavy involvement of urinary function: 2/9, neck stiffness: 1/9, CSF-results: ceU-count higher than 50/microliter in 2/9, presence of polymorphonuclear leukocytes in 2/9 cases. Neuropathology: In addition to polyradiculoneuritic pathology one case showed mild meningoencephalitic inflammation and another case showed sparse meningeal inflammation. Conclusion: Despite clinical heterogeneity and pathologic particulari-

Objective: To evaluate the efficacy and tolerability of donepezil (5 and 10 mg/day) relative to placebo in Alzheimer's disease (AD) patients' cognitire and global funr in a systematic review of individual patient data from randomised controlled trials. Design/Methods: All Phase II and III double-blind, randomised, placebo-controlled studies of up to 24 weeks in duration and completed as of 20 December 1999 were induded in the analysis. Fixed and random effects meta-analyses were performed. Results: Ten trials were included in the analysis involving 2376 patients randomised to placebo (n=893), donepezil 5 (n=821) or 10 mg/day (n=662). 84%, 84% and 76% of patients in the placebo, 5 and 10 mg/day donepezil groups, respectively, completed the study period. At 12 weeks, cognitive performance measured by the ADAS-cog was better in patients receiving donepezil 5 mg/day than in patients receiving placebo by 2.1 points (95 % C. I. 1.6-2.6; p < 0.001). At 24 weeks, the improvement over placebo was 2.0 points (95% C.I. 1.3-2.7; p < 0.001). For patients receiving donepezil 10mg/day, the 12- and 24-week improvements were 2.5 points (95% C.I. 2.0-3.1; p < 0.001) and 3.1 points (95 % C. I. 2.4-3.9; p < 0.001), respectively, relative to placebo. Differences between the 5 and 10mg/day donepezil doses were statistically significant at 24 weeks (p=0.005). The odds ratio (OR) for improvement (scores 1, 2 of 3) on the global impression of change scale (CIBIC-plus) for patients receiving donepezil 5mg/day relative to placebo at 12 and 24 weeks were 1.8 (95% C.I. 1.5-2.1; p < 0.001) and 1.9 (95% C. I. 1.5-2.4; p < 0.001), respectively. Corresponding ORs for donepezil

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10mg/day versus placebo were 1.9 (95% C.I. 1.5-2.4; p < 0.001) and 2.1 (95% C.I. 1.6-2.7). Donepezil was well tolerated. The adverse events that did occur were cholinergic in nature and generally of mild severity and brief duration. Conclusions: Donepezil has shown consistent statistical and clinically meaningful benefits in cognition and global function relative to placebo across all studies. While both doses were clinically effective, donepezil 10 mg/day provides greater cognitive benefit than donepezil 5 mg/day. 146

The Tolerability, Ease of Use and Efficacy of Donepezil and Rivastigmine in Alzheimer's Disease Patients: A 12-Week, Multinational, Comparative Study. C. Hock, D. Wilkinson, P. Passmore, R. Smith, F. Potocnik, R. Bullock, C. Maud, S. Hopker (Zurich, CH; Southampton, Belfast, Bradford, UK; Tygerberg, ZA; Swindon, UK; Mayville, ZA)

ized in the study. In participants with a high level of education, there was no significant association between WMHs and cognition. To investigate further this triangular relationship between WMHs, education and cognition, we focused on MMSE. We found that, in people whose cognition was preserved (MMSE=30), those who had severe WMHs h a d a significant higher education level (mean=13.3(2.8)) than those who had no or minor WMHs (mean=li.8(3.4) p < 0.05). In participants with cognitive impairment, those with severe lesions h a d a lower education level than those with no or minor lesions. Conclusions: In this population-based study of elderly individuals, we found that education modulates the consequences of WMHs on cognition. Participants with a high level of education were protected against the cognitive deterioration re[ated to vascular insuhs. 148

Cognitive deficits in spinocerebellar ataxia type 6 (SCA6). C. Globas, K. Purpose: To explore the tolerability, ease of use and cognitive effects of donepezil and rivastigmine in Ahheimer's disease (AD) patients. Methods: 111 AD patients were randomised to receive open label rivastigmine (up to 6 mg twice daily) or donepezil (up to 10 mg once daily) for 12 weeks, according to recommended dosing in approved product labelling. Dose increases or reductions were permitted. Physicians and caregivers rated ease of use and satisfaction with assigned treatment for each patient at Weeks 4 and 12 by completing Likert-type questionnaires. Cognition was assessed using the ADAS-cog by trained independent ratters who were blind to assigned study medication. Results: Demographic characteristics were similar in donepezil- (n=56) and rivastigmine-treated patients (n=55). More donepezil- (89.3 %) compared with rivastigmine-treated patients (69.1%) completed the study (p=0.009) and 10.7% and 21.8 % of patients, respectively, discontinued due to adverse events (AEs). Nausea and vomiting, the two most common AEs, were experienced by fewer donepezil- (10.7 % and 7.1%) compared with rivastigmine-treated patients (41.8% and 23.6%), respectively. The rates of these AEs for both groups were consistent with the respective product labdling. 98.2% of donepezil-treated and 60% of rivastigmine-treated patients, reached the maximum effective daily dose. 87.5% donepezil- compared with 47.3 % of rivastigmine-treated patients, respectively, remained at the maximum daily dose until the final visit. Both groups showed comparable improvements from baseline on ADAS-cog assessments (blinded rating) at Weeks 4 and 12 (Week 12: donepezil, 0.90 + 0.56; rivastigmine, 1.05 + 0.67). Both physicians and caregivers reported significantly higher satisfaction with donepezil use compared with rivastigmine at Weeks 4 (p < 0.0001) and 12 (p < 0.05). Conclusions: In this trial using dosing regimens from approved respective product labelling, donepezil was better tolerated with fewer rivastigmine-treated patients able to reach and be maintained at the maximum dose, although both agents improved cognition to a similar extent. Consistent with this, physicians and caregivers reported significantly higher overall satisfaction and ease of use with donepezil compared with rivastigmine. 147

Cerebral White Matter Hyperintensities, Education, and cognition. C. Dufouil, A. Alperovitch, C. Tzourio (Paris Cedex, F) Background: Many studies have found a relationship between Alzheimer's Disease (AD) and lower education. An explanation for this finding is that, in patients exposed to the causal factors of AD, education might protect against the clinical manifestations of dementia or delayed its onset. Cerebral White Matter Hyperintensities (WMHs) have been associated with cognitive impairment in demented and nondemented elderly subjects. The aim of this work is to determine whether education level modulates the effects of cerebral WMHs on cognition. Material: The EVA-MRI study is an ongoing longitudinal study on vascular ageing and cognitive decline including 845 persons aged 60 to 69 years old at entry. At each examination, cognitive functions were assessed by standard tests including Mini-Mental State Examination (MMSE), Trail Making Test Part B (TMTB), Wechsler Adult Intelligence Scale-Revised (WAIS-R), Finger Tapping Test (FTT) and Word Fluency Test (WFT).At four-year follow-up, a cerebral magnetic resonance imaging examination has been performed in order to detect WMHs. Results: Subjects mean age was 69.0 years old (SD = 2.9) and 58.1 percent of the sample were women. Severe WMHs were present in 17 percent of the participants. In the whole sample,we found that subjects with severe WMHs had significantly lower cognitive performances for tests involving attention tasks (TMT B, WAIS R, FTT). We observed that, in participants with a low level of education, those with severe WMHs had significant lower cognitive performances than those with mild WMHs, for all the cognitive tests real-

Bª

C. Zª

]. Dichgans (Tª

University of Lª

D)

Spinocerebellar ataxia type 6 (SCA6) is an autosomal dominantly inherited cerebellar ataxia. The underlying mutation is an unstable CAG repeat on chromosome 19p in a gene encoding the voltage dependant alA subunit of the calcium channel CACNA1A that is important for the development and function of cerebellar Purkinje ceUs. Neurodegenerative abnormalities have been shown to be restricted to cerebellar Purkinje and granular cells. Therefore, SCA6 constitutes a model disease to study the cerebellar role in cognition. In order to study the cognitive impairment in SCA6, eleven individuals and eleven age - and IQ - matched controls were submitted to a neuropsychological test battery that comprised tests for IQ, attention, executive function, verbal and visuospatial memory. None of the SCA6 individuals had general intellectual impairment. Mild deficits could be demonstrated on a test sensitive to front-executive dysfunction. There is evidence from anatomical investigations and functional imaging studies that prefrontal association areas are linked to the cerebellum via a cerebrocerebellar circuitry. The cognitive deficits present in SCA6 may therefore be contingent upon disruption of this cerebrocerebellar circuitry. 149

Rivastigmine (Exelon| treatment improves cognitive fnnction of patients with Parkinson's disease and dementia. A. Korczyn, H. Shabtai, B. Benbunan, T. Gurevitch, M. Anca, S. Sidis, N. Giladi (Tel Aviv, IL) Introduction: Approximately one-third of patients with Parkinson's disease (PD) develop dementia during the more advanced stages of their illness. Dementia in PD may be caused by a variety of underlying pathological processes and neurochemical deficits, including loss of cholinergic function. Currently available agents used to treat parkinsonian symptoms are unable to provide cognitive benefit for this group of patients. A number of recent reports have shown that the cholinesterase inhibitor rivastigmine shows significant clinical benefits in patients with diffuse Lewy Body disease, and anecdotal reports have noted benefit with cholinesterase therapy for PD. In this preliminary study we examined the effect of rivastigmine on cognitive and motor functions in 26 clinically characterised PD patients with dementia. Methods: Patients were given 3 mg rivastigmine daily, increased to a maximum tolerated dose or 12mg daily. Assessments using the Unified Parkinson Disease Rating Scale (UPDRS), the Ahheimer Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and the Clinical Global Impression of Change scale (CGIC) (recorded from caregiver, patient and physician) were made at baseline, week 12, 26 and after 8 weeks of washout. Patients also underwent medical and laboratory safety analysis. Only week 12 results are presently available for analysis. Findings: At week 12, rivastigmine treatment (mean dose of 8 mg/day) resulted in significant improvement over baseline for total scores in the UPDRS (65.1 vs. 61.2, respectively; p < 0.03). Significant improvements were noted on the mentation, behaviour and mood section and the activities of daily living section of the scale. Significant improvements over baseline were also noted on the ADAS-Cog (27.1 vs. 19.7, respectively; p < 0.002; 27% reduction in total score vs. baseline) and on the CGIC patient, caregiver and neurologist scores (p < 0.001; p < 0.025 and p < 0.002, respectively n=18). Improvement on the CGIC was scored by the groups as marked in 28 %, 34 % and 56%, respectively, moderate in 56%, 56% and 28%, or mild in 5%, 5% and 3 %. Safety and tolerability of rivastigmine were judged as acceptable in this group of patients with six discontinuations. Conclusion: These preliminary findings suggest that rivastigmine can significantly improve cognitive function in PD patients with dementia. Future double-blind studies are needed to verify these results in a larger population.

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150 Cholinesterase activities in Cerebro Spinal Fluid and plasma of mild AD patients following 12 months of rivastigmine treatment. T. Darreh-Shori, A. Svensson, E. Hellstr6m-Lindahl, Z. Guan, A. Nordberg (Stockholm, S)

Objective: To study the effect of one-year treatment with rivastigmine on acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) activities in CSF and mixed cholinesterase activity in plasma of mild Alzheimer's disease (AD) patients. Methods: Eleven mild AD patients (MMSE scores 25 +- 1; all values mean -+ SEM) aged 59 to 80 years (70.4 -+ 1.8) received rivastigmine for 12 months. Seven patients were titrated to a maximal dose of 11.8 _+0.2 mg/day, four patients tolerated only 3.3 -+ 0.4 mg/day. Mean dose for all patients was 8.6 _+ 1.3 mg/day after 12 months. Cholinesterase activities were measured colorimetrically. Results: AChE inhibition in CSF for all patients was 35 _+ 7% after 12 months of treatment. BuChE inhibition was 41 +_ 8%. High-dose patients showed 45 -- 7% inhibition of AChE and 58 -+ 5% for BuChE at 12 months. Large increases in inhibition of CSF AChE and BuChE (55 % and 61%, respectively) were observed between 3 and 12 months, although the mean dose of rivastigmine only increased from 9.6 to 11.8 mg/day during this period. These data contrast with earlier findings from this group demonstrating the absence of a time related, persistent CSF cholinesterase inhibition with longterm tacrine treatment. Plasma cholinesterase activity was inhibited by 17 +_ 7, 24 _+ 7, 22 _+ 6 and 22 -+ 7% at 3, 6, 9 and 12 months respectively. Plasma cholinesterase inhibition was therefore consistent and strongly correlated with inhibition of AChE and BuChE in CSF. Conclusion: Rivastigmine treatment for 12 months causes persistent inhibition of CSF BuChE and AChE which appears to be dose-related and dependant on the duration of treatment. Plasma cholinesterase inhibition appears to be independent of duration of treatment but may serve as a useful indicator for predicting AChE and BuChE inhibition in CSF.

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Higher Functions Disorders and Dementia - 2 151

The Diagnostic Value Of Objective EEG Criteria In Creutzfeldt-]akob Disease (CJD) In 150 Verified CJD Cases Versus 55 Excluded Cases Of Similar Clinical Appearance. B.J. Steinhoff, M. Glatting, W. Schulz-Schaeffer, H. A. Kretzschmar, I. Zerr, S. Poser (Kehl-Kork, G6ttingen, Munich, D) Objective EEG criteria previously proposed and published by our group were prospectively applied in all cases reported to us as possible CID as part of the German CJD surveillance study. EEG analysis of the records was performed without any additional information about complementary dinical and laboratory data. In this study, we reanalysed sensitivity and specificity exclusively in cases undergoing autopsy confirming of exduding CID. One hundred and fifty cases with definite CJD versus 55 cases with definitely different dementias were included. Objective EEG criteria were positive in 64 % (n = 96) of the CID cases and falsely positive in 11% (n = 6) of other dementias clinically suggestive for CJD. Thus, the sensitivity and specificity were 64 % and 89 %, respectively. In the falsely positive cases,Alzheimer's disease (n = 5) and vascular dementia (n = 1) were represented. These data finally prove that our objective and easy to apply EEG criteria provide ah excellent diagnostic value in CID and make EEG a suitable diagnostic marker for multicenter CJD surveillance studies among other complementary diagnostic criteria and tests. Reference: Steinhoff B], R~icker S, Herrendorf G, Poser S, Grosche S, Zerr I, Kretzschmar HA, Weber Th (1996) Accuracy and reliability ofperiodic sharp wave complexes (PSWC) in Creutzfeldt-Jakob disease. Arch Neurol 53:162-166

152 Procedural Learning in Patients with moderate Alzheimer's disease: a prospective Study of Wahz-Lessons. A. R6sler, E. Seifritz, K. Kr~iuchi, D. Spoerl, I. Brokuslaus, S. Proserpi, A. Gendre, F. Mª M. Hofmann (Frankfurt/Main, D; Basel, CH; Freiburg, D) Background: Procedural learning in experimental tasks such as mirror tracing and rotary pursuit have been found to be preserved in patients with mild Alzheimer's disease (AD). However, more "real life" or rehabilitative learning situations in the dinical setting have not been examine& Methods: The authors administered 30 ruin single-waltz lessons daily during a period of 10 days to study procedural learning in 5 patients with moderate Alzheimer's disease (mean MMSE 14.8) and an age- and gender matched control group of 5 patients with major depression (mean Geriatric Depression Scale: 4.2). Lessons were given by a certified dance-therapist according to a standardized protocol. Al1 lessons were videotaped on day 1, 5, and 10 by an independent film-team who was blind to the patients' diagnosis. VŸ sequences were cut into 30-s dips by the film-team to highlight each individual patient in each of these 3 training sessions. The resuhing 30 clips were randomized and inspected by a second dance therapist who was blinded regarding diagnosis and order of session. Acquisition of rhythmical skills, expression, smoothness of movements, creativity, usage of space and a mean overall performance score were rated on a 14cm visual analogue scale anchored with minimum and maximum range of each feature. The numbers of newly learned dance-steps were counted according to a predefined checkqist. Results: Repeated measures analysis of variance showed a significant improvement in the overall dancing score in AD patients (p=0.014). Subscores of rhythmical skills and usage of space improved significantly in AD patients (p=0.013 and p = 0.049, respectively), expression and creativity scores w~re close to significance (p=0.05; p=0.06), whereas the number of new steps learned did not show a significant increase (p=0.17). Patients with major depression did not show any significant learning effects in all of these criter~a. Conclusion: Patients with moderate AD, but not patients with major depression, showed a significant procedural learning effect during dance lessons. Preserved procedural skill learning in patients with moderate AD can be used in daily clinical and rehabilitative settings. 153 ChE inhibitors in dementia. How does it works? A. Thomas, C. Paci, G. D'Andreamatteo, D. Iacono, M. Onofrj (Pescara, I)

We studied the correlation between neuropsychological and nenro electrophysiological measures of fluctuating cognition (FC) as primaryindex on efficacy of cholinesterase (CHE) inhibitors in dementing patients. We evaluated 20 patients affected by mild to moderate dementia with fluctuating cognition. All patients underwent Mini Mental State examination (MMSE) (10-26), Unified Parkinson's Disease Rating Scale (UPDRS), Columbia University Scale for Psychopathology in Alzheimer's Disease (CUSPAD). Fluctuating confusion was tested by the Clinical Assessment of Confusion and by one day fluctuation assessment scale. Neurophysiological measures indnded QEEG, event related P3, blink reflex (BR) and choice reaction time.All patients underwent these assessments during a double blind cross over Rivastigmine (Riv)/Donepezil (DPZ) or placebo administration. The 20 patients were randomly assigned to the Riv/Dpz (5/5) group and to the placebo (10) group for a follow-up of two months. Dosage of therapy was 5 to 10 mg for Dpz and 3 to 12 mg for Riv. After two months all patients on ChE inhibitor treatment cross over to placebo and all patients on placebo received treatment. All neurophysiological measurements were assessed at baseline after two months and after 4 months. All patients during treatment with ChE inhibitors had significant P300 latency reductions (9.5+3.4msec/Dpz, 12.8+3.5msec/Riv; p < 0.01); BR-R2 latency decreased by 5.2 msec during ChE inhibitors therapy. Electrophysiological measures of fluctuations expressed in variance of band frequency on EEG shows a reductions of slow frequencies and of spectral map variance. Choice reaction time decreased during ChE inhibitors treatment and the decrement was paraUed by reduction of cognitive fluctuation single day evaluation. The finding suggests that ChE inibitors act by reorganizing electrocortical arousal and cholinergic polysynaptic pathways probably located in part of the reticular activating system, and therefore that cholinesterase inhibitors might act by improving the "attentional matrix" in these patients, rather than specific cognitive functions.

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154 Failure of the Dual Task to detect executive fnnction deficits in patients with frontal lesions. G. Vezzadini, A. Venneri, A. Venneri,A.Venneri, A.Venneri, G. Messa, F. Dieci, S. Copelli, P. Caffarra (Parma, I; Aberdeen) The term "executive functions"is used to refer to a range of processes which are involved in activities such as "planning", "problem solving', "cognitive estimation',"initiation" of activity and "prospective memory". Historically these processes have always been linked to the frontal lobes and damage to them has resulted in the range of symptoms known as the"frontal lobe syndrome". Executive functions seem to be required to perform two simultaneous tasks involving visuospatial and verbal information. This capacity might indicate the ability to distribute the memory capacity resources and was studied using a dual-task paradigm in the framework of Baddeley and Hitch's working memory (WM) model. This model comprises an attentional control system, the central executive, which coordinates the operation of two slave system, the phonological loop, which is assumed to be a mechanism for the retention of speech-based material, and the visuospatial scratchpad, which constructs and preserves visual images. Dual task performance is intended to be an indicator of the patient's ability to deploy the available resources of memory capacity. Della Sala and colleagues devised a paper-and-pencil version of the dual-task test by combining the box-crossing (BC) and the digit-span (DS) tasks to contribute to the assessment of patients with Alzheimer's disease or with frontal lesions. The dual-task test consists of the execution of the single DS and BC tasks and subsequently the combined execution of DS and BC in the dual-task condition. The performance in dual task is estimated by an index of the ability to coordinate concurrent DS and BC tasks.We administered the dual task test to 21 patients with focal frontal lobe lesions and dysexecutive symptoms and 21 sex, age and education matched healthy controls as part of a more extensive neuropsychological battery and we were unable to find any statistically significant difference between the two groups (p= 0.15) using mu values. These findings do not support previous evidence that the dual task is a p£ instrument for testing executive functions. We suggest that larger population studies need to be carried out before assuming that the dual task technique is a valid measure to detect frontal lobe dysfunction. 155 Alzheimer's disease in a genetically isolated population: the GRIP study. G. Roks, K. Sleegers, P. Heutink, J.C. Van Swieten, P. J. L.M. Snijders, C. Van Broeckhoven, B.A. Oostra, C.M. Van Duijn (Rotterdam & Tilburg, NL; Antwerp, B) Genetic factors play an important role in Alzheimer's disease (AD). Mutations in the amyloid precursor protein gene (APP) and the presenilin genes (PSENI/PSEN2) cause autosomal dominant early-onset AD. The most important genetic determinant for AD in the general population is the apolipoprotein E gene (APOE) which explains about 17 % of the occurrence of AD in the general population. Several genome wide studies identified regions of interest of which the chromosome 10 and 12 regions are the most promising. There is increasing interest in identifying genes in genetically isolated populations such as the Finnish and Icelandic populations. In this study we evaluated the feasibility of studying the genetics of AD in a Dutch recently isolated population of 20,000 inhabitants. This population was founded 300 years ago by 150 subjects and is characterized by minimal immigration. We ascertained 74 probable AD patients with a mean onset age of 73 years. The patient population comprised 65 % females. Family history in first degree relatives was positive in 58 %.We studied genealogy up to 15 generations, wtrich revealed that at least 63 patients (79 %) were related within 14 generations. We found no causal mutations in APP, PSEN1, and PSEN2. The APOE e4 allele frequency was 38 % which is comparable with Caucasian AD patients (37 %). Our study shows that AD in this isolated population is not fully explained by the known AD genes, and given the high percentage of patients with a positive family history other AD genes are to be expected. At presenta genomic screen is performed on a cluster of closely related patients. Our results on the chromosome 10 and 12 regions will be presented. 156 Clinical characteristics of genetic prion diseases in Germany. Inga Zerr, O. Windl, W. Schulz-Schaeffer, Chr. Jakobi, B. Mollenhauer, H.A. Kretzschmar, S. Poser (G6ttingen, D) In 1993, a Creutzfeldt-Jakob disease (CJD) surveillance study was established in G6ttingen, Germany. Suspected CJD cases were notified by participating hospitals and were examined by a neurologists. Clinical data and technical

examinations as well as neuropathological and genetic data were centralized in the surveillance unit. In the recent 6 years, a mutation in the prion protein gene was found in 46 out of 655 definite and probable CID cases. Codon 178 mutation combined with methionine at codon 129 (D178N-129M), which leads to the fatal familial insomnia (FFI),was the most frequent mutation in Germany (n=13). Nine patients had codon 200 mutation (E200K), which is the most frequent genetic prion disease worldwide. There were 6 patients with codon 210 mutation and insert mutations and 5 with codon 102 mutation (Gerstmann-Str~iussler-Scheinker syndrome, GSS). Patients with mutation were in general younger than patients with sporadic CJD, however, the age at disease onset varied between subgroups. Patients with FFI were the youngest (median 55),whereas patients with E200K and V210I mutation had age at disease onset which was close to sporadic CID (61 vs.64 vs.66, respectively). The mean disease duration was 9 months in genetic cases and 7 in sporadic CJD. The electroencephalogram showed typical periodic complexes only in rare cases with E200K mutation (2/9) and V210I (5/6). 14-3-3 proteins in the cerebrospinal fluid, a marker of neuronal damage, which is also included in the clinical criteria of sporadic CJD, were detectable in almost all patients with genetic prion diseases. The only exception were patients with FFI, all of them have been 14-3-3 negative in the CSF. Only one patient with GSS was 14-3-3 positive. The inclusion of 14-3-3 proteins in the clinical CJD criteria will probably lead to the identification of more genetic prion diseases. However, some particular mutations may be missed.

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Higher Functions Disorders and Dementia - 3 157

Narrowing of the "Zoom Lens" of Focal Attention in Alzheimer's Disease: Evidence from Visual Search. A. R6sler, A.K. Hays, M. Mapstone, M.-M. Mesulam, D.R. Gitelman, S. Weintraub (Frankfurt/Main, D; Chicago, IL, Rochester, NY, USA) Objective: To investigate whether visual search deficits in Alzheimer's disease (AD) are in part due to adoption of a serial search strategy as reflected in eye fLxation patterns. Background: Patients with AD make more eye fixations while searching for visual targets than age-matched cognitively intact subjects (R6sler et al., 2000). One possible explanation for this change in the architecture of visual search in AD is that the narrowing of the zone of focal attention that occurs in AD necessitates shifts of gaze to attend to the entire global workspace. Methods: Eye fixation number and duration were compared in two regions of interest (ROIs) (central fLxation and peripheral target locations) in 9 patients with mild AD, 9 cognitively intact age-matched control subjects, and 9 young controls, while they searched for a target object in a radial arra), that varied from i to 6 stimuli. Results: Target detection time was longer in AD subjects than in both young and older control groups (p=0.0016,p=0.0182, p=0.0 036 for array size 1, 4 and 6, respectively). The old and young controls did not differ in target detection time for any array size. There were no differences among groups in the mean duration of eye fixations in the central ROI, a location that normally serves a s a "center of gravity" from which the search sequence is planned (Findlay, 1982; He and Kowler, 1989). In contrast, AD patients made significantly more and longer fLxations in the peripheral target locations than both control groups. Conclusions: AD interferes with visual search by reducing the capacity for global allocation of attention and necessitating shifts of gaze to explore the global workspace. 158 Plantar stimulation can affect unilateral spatial neglect. C. Richard, J. Honor› M. Rousseaux (Lille, Villeneuve d'Ascq, F) The rightward orientation bias on neglect patients has been shown to be decreased by postural changes, suggesting that afferences coding the posture relative to gravity might influence the body-centred spatial reference frame. Among the afferences involved in this coding,the contribution of plantar signals remained unknown. In this study, we assessed the effects of plantar stim-

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ulations on the subjective straight ahead (SSA) of neglect patients. Five neglect patients presenting with a vascular lesion in the right hemisphere and 3 normal subjects matched with age were tested. Neglect assessment included cancellation andbisection tasks.Two patients showed a strong rightward shift of the SSA (+19.3 o) in a preliminary testing. They were compared to the 3 other neglect patients without deviation (SSA = +5.3 o) and to 3 control subjects (SSA = +1.4~ Electrical (100 Hz, intensity clearly supra-liminar without being unpleasant) and vibratory (100 Hz, 0.5 mm) stimulations were applied to the median part of the plantar sole. Pointing straight ahead of the navel was achieved in the dark, using the right hand; a ring-shaped horizontal board recorded its polar coordinates. Five sessions were performed: no stimulation, electrical or vibratory stimulation of the left or right sole.Without stimulation, the SSA kept constant in the three groups of subj ects. Plantar stimulations only affected the SSA of the two neglect patients with a strong baseline deviation. Electrical stimulation significantly reduced this error (p < O.045),by the same amount wbether applied to the left or right sole. By contrast, the effect of vibration depended on the side (p < 0.029),with a dramatic improvement when the left sole was vibrated and no significant influence of right vibration. In conclusion, plantar stimulation influenced the SSA only in neglect patients presenting with a strong baseline shift. The different effects of the two kinds of stimulation suggest two mechanisms: a non specific activation induced by electrical stimulation anda specific effect ofvibration,possibly due to the recruitment of receptors coding the gravitational posture. Tbis last effect supports the idea of a tight relationship between body orientation relative to gravity and spatial representations. 159 A reevaluation of subjective straight-ahead and line bisection in neglect patients, C. Richard, ]. Honor› M. Rousseaux (LiUe,Villeneuve d'Ascq, F) Neglect patients with a right cerebral lesion show a rightward orientational bias. It has been suggested that the lesion disturbs the dynamic building of the egocentric reference guiding actions within the personal and extra-personal spaces. This impairment is usually assessed by asking patients to indicate their subjective straight-ahead (SSA), for instance by a manual pointing movement in the dark. Indeed, a rightward shift of the SSA was reported in several studies. However, negative findings were receutly published. Some authors failed to demonstrate rightward SSA shift in neglect patients, or correlation with performance in standard visuo-spatial tests. The aim of this study was to revaluate the SSA and correlations with the other measures of spatial neglect, and especially to compare the rightward bias observed in SSA pointing with that observed either in bisection obtained in the same experimental conditions, or in bisection obtained in clinical setting. Three groups were evaluated: right brain-damaged patients with neglect (n=8) or without neglect (8), and control subjects free of any neurological problem (8). Clinical neglect assessment took place one week before the experiment and included bells cancellation, line bisection (Schenkenberg) and scene drawing (Ogden) tests. In the experimental session, the SSA was assessed by manual pointing with reference to a precise median body part, then bodyceutred lines (2.5, 5,10, 20 cm) were bisected. In the experimental condition, a dissociation between normal SSA and rightward bisection error was found in 2 neglect patients. Nevertheless, the neglect group showed significant (p < 0.05) rightward bias in both tasks (SSA and bisection). Moreover, in neglect patients only, the SSA position strongly correlated with the line bisection error for longer lines ( 10 and 20 cm). However, the SSA did not correlate with performance in clŸ neglect assessment, including the line bisection task (Schenkenberg). This study showed that - taken a s a group, patients with spatial neglect present with significant SSA shift, and - when performed in the same and controlled conditions, SSA and bisection deviations are well correlated. Methodological problems probably explain discrepancies observed in previous studies. SSA deviation must be considered as an important feature of spatial neglect. 160 What kind of informed consent in Alzheimer's disease.~ Italian physicians answer. E. Pucci, G. Borsetti, E. Cartechiui, G. Giuliani, E. Pucci, K. Rossetti, A. Solari (Macerata, Ancona, Siena, Milano, I) Background: Loss of decision-making capacity is an inescapable point of arrival for patients affected by Alzheimer's disease (AD). However, decisionmaking capacity deteriorates progressively and it fluctuates according to the decision and the context. In the absence of a verified loss of competency, physicians should consider the person affected by AD as capable of providing a valid consent. Thus, to be legally binding, the AD patient's consent must be voluntary, informed, and competent. Objective: To establish if physicians know the fundamental characteristics of the consent, when they are asked about patients affected by AD.

Participants: Three groups of Italian physicians: I) 139 general practitioners (GPs), attending a training course organised by the local public health authority; II) 20 specialists in disciplines to whom AD may be referred (neurology, psychiatry and geriatrics) selected through personal contacts; III) 20 specialists in other disciplines selected through personal contacts. Methods: Participants should answer the foUowing question: "To be legally binding, an Alzheimer's disease patient's informed consent must be: a) voluntary, competent, and witnessed by a physician; b) voluntary and informed; c) voluntary, informed, and competent; d) voluntary, informed, and witnessed by a physician". This question was drawn from the "UAB Alzheimer's disease knowledge test for health professionals" (Barrett et al. (1997) Alzh Dis Assoc Disord, 11:99-106). The following currictflum data were also requested: age, gender, position, year of degree, speciality and other titles. Results: A correct response was provided by 8.4 % (15/179) of participating physicians only; 32.4 % of the GPs attending the training course refused to answer. Condusions: Competence is difficult to assess in AD, but this is another story! Here it should be stressed .that most physicians interviewed do not know the basic principles of consent. Educational programs targeting valid informed consent seem to be mandatory both for practising physicians and medical students. Conversely people, in particular frail people such as AD patients, could be denied the right to participate appropriately in the decisions concerning their health. 161 Variant Alzheimer's disease with spastic paraparesis and white matter abnormalities on MRI. S. O'Riordan, P. McMonagle, J. ]anssen, M. Farrell, J. Collinge, M. Rossor, M. Hutchinson (Dublin, IRL; London) Background: Mutations of presenilin 1 (PS-1) on chromosome 14 are the major cause of early-onset familial Alzheimer's disease (FAD), accounting for 18-70 % of cases. A variant of Alzheimer's disease with spastic paraparesis and unusual plaques on neuropathology has been reported due to deletion of exon 9 of PS- 1. Phenotypic heterogeneity in FAD is otherwise limited to variations in age of onset and perhaps the presence or absence of seizures, myodonus and aphasia. Case History: A 48 year old man from a large family with FAD linl/ed to PS- 1 presented initially with a 10 year history of progressive difficulty walking and now walks with a frame. He also complained of urinary urgency and frequency and his wife had noticed increasing forgetfulness in the preceding year. He had no other neurological symptoms. On examination he hada spastic paraparesis with bilateral extensor plantar responses. Cognitive testing using the Cambridge cognitive examination gave a score of 711107, indicating mild dementia. Remaining neurological and other systems examination was normal. Cranial MRI showed extensive white matter abnormalities but visual evoked potentials were normal and CSF examination did not reveal oligoclonal bands. Other investigations including haematology, fasting lipids, vitamin B12, ECG, CXR and imaging of carotid and vertebral arteries were normal. Molecular genetic analysis of the PS-1 gene on chromosome 14 revealed a glutamic acid to glycine substitution at position 280 in exon 8 of PS-1. Presence of the mutation was confirmed using allele specific oligonucleotides. An older sibling had white matter changes on MRI and prominent myoclonus but no paraparesis.Another sibling hada spastic paraparesis and an internuclear ophthalmoplegia responsive to steroids but MRI was not available. Both died of dementia before age 50. Conclusion: We describe a variant of FAD with a novel combination of clinical and radiological findings due to an E280G mutation in exon 8 of PS-1, further expanding the phenotypic spectrum at this gene. 162 Donepezil Reduces the Time Caregivers Spend Providing Care: Results of a One-Year, Double-Blind, Randomised Trial in Patients with Mild to Moderate Alzheimer's Disease. A. Wimo, B. Winblad, A. Haglund, L. Jacobson, R. Miceli, R. Zhang, P. Subbiah, V. Mastey (Umea, Huddinge, Taby, Sweden, S; New York, USA) Purpose: To investigate the effects of treatment with donepezil on the amount of time spent by caregivers caring for patients with mild to moderate Alzheimer's disease (AD) over the course of 1 year. Methods: Patients with possible or probable, mild to moderate AD from five Northern European countries were randomised to receive either donepezil (n=142) or placebo (n=144). Assessments included the Progressive Deterioration Scale (PDS), the Instrumental Activities of Daily Living (IADL) scale and the Physical Self-Maintenance Scale (PSMS). The amount of time caregivers spent assisting patients was also collected using the Resource Utilization in Dementia (RUD) questionnaire.

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Results: Patient baseline demographic characteristics were similar with mean baseline MMSE scores of 19.4 -+ 4.4 and 19.3 _+ 4.5 for patients randomised to donepezil and placebo, respectively. Donepezil-treated patients gained significant functional benefits relative to placebo, as assessed by the PDS at Week 52 (p=0.042) and analyses of the percentage of patients in decline for individual items of the IADL scale at Week 52 (p=0.025) and the PSMS at Weeks 24 (p=0.011) and 36 (p=0.032). Caregivers in the donepezil group spent an average of 9.9 hours per day providing care compared with 11.0 hours per da)' for caregivers in the placebo group over 52 weeks. Furthermore, caregivers in the donepezil group spent less time relative to the placebo group assisting patients with both basic (2.4 versus 3.7 hours/day) and instrumental ADLs (7.7 versus 8.3 hours/day), respectively. More caregivers of placebo-treated patients compared with donepezil-treated patients reported spending at least 16 hours per day caring for patients at Weeks 24 (3% versus 0%; p < 0.05), 36 (5% versus 0%; p < 0.05) and 52 (6% versus 2 %; p=O. 1), respectively. Conclusions: These resuhs suggest that the functional benefits of donepezil treatment reduce the amount of time a caregiver spends assisting the patient. Therefore, treatment with donepezil may reduce caregiver burden.

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Epilepsy - 1 163

Seizure-Associated Headache in Epilepsy. T. Leniger, K. lsbruch, S. von den Driesch, H. C. Diener, A. Hufnagel (Essen, D) Purpose. Headache is often ignored a s a symptom of epileptic seizures. The purpose of this study is to analyze frequency, classification, and charcteristics of seizure-associated headache (SH) according to the criteria of the lnternational Headache Society. Methods: Over 15 months 341 patients with epilepsy, consecutively evaluated at our outpatient clinic for SH, completed a standardized questionnaire. Results: 115 of the 341 (34%) epileptic patients experienced SH with a pain intensity of 6.1 + 1.6 (SD) on the VAS and a duration of 12.8 -+ 15.7 (SD) hours. Seizures were always accompanied by headache in 69 of these 115 (60 %) patients. SH occurred in 4 of 115 (3 %) patients only preictally, in 31 of 115 (27 %) patients periictally, and in 80 of 115 (70%) patients only postictally. In the majority of the 115 patients (55.7%) SH could be classified as migraine headache while in 36.5 % as tension-type headache. The type of SH was not correlated with sex, an epilepsy syndrome o r a seizure type. Migraine-like SH was significantly associated with a history of migraine (p < 0.001 ). In 20 of the 26 (76.9%) patients experiencing migraine-like SH with a history of migraine, the phenomenology of migraine-like SH and migraine attacks was identical. Conclusions: SH is a frequent, long lasting and severe symptom of epileptic seizures causing major impairment of daily living. A history of migraine significantly increases the risk for developing migraine-like SH. 164

Effects of vagal nerve stimulation in severe refractory epilepsy. M. Casazza, G. Avanzini, G. Broggi, P. Ferroli, F. Villani (Milano, 1) From 1995 to 2000 seventeen vagal nerve stimulators (VNS) were implanted in patients with refractory epilepsy and at least six polymorphous seizures per month. In every patient seizures were recorded by video-EEG before implantation. Patients with progressive brain disorders were excluded. In 9 patients epilepsy was cryptogenic, in 8 patients it was secondary to perinatal injury, neuronal migration disorders, of associated with cavernoma, oligoastrocytoma, aneurysm and derived hydrocephalus. Five patients had previously been operated on for lesionectomy or epilepsy surgery without significant improvement on seizure frequency. In the other patients surgery was exdude& No severe complications of side effects were observed. Only one patient did not tolerate the VNS, that was removed 2 months after implantation. Follow-up ranges from 6 months to 5 years. In 4 patients seizures were reduced more than 50%, in 6 patients the reduction was between 20 and

50 %. Eight patients h a d a significant decrease in falling seizures not always associated with a reduction in minor and total seizures. The most responsive seizures seem to be those originating from temporal lobe, the worst results have been observed in seizures with frontocentral onset. At present in 11 patients VNS is still on, in 5 patients it was removed, one patient died for reasons not directly connected with VNS. In the first year of stimulation, antiepileptic drugs (AEDs) were not modified. After tbis period, in patients with good results from VNS AEDs were tapered. 165 Peri-insular functional hemispherectomy: rationale and surgical technique. G. Broggi, P. Ferroli, M. Casazza, L. D'lncerti, I.G. Villemure (Milano, 1; Lausanne, CH) Cerebral hemispherectomy is, since 1950, the most effective technique for the treatment of seizures in hemiplegic patients affected by drug-resistant epilepsy originating from the lesioned hemisphere. Due to the high incidence of late complications (hemosiderosis in 1/3 cases with a clinical follow-up of 4-25 years) this method was withdrawn in the sixties on behalf of surgical methods of disconnection with limited ablation of cerebral tissue and related fewer complications. The latest kind of "functional hemispberectomy" is the peri-insular hemispherectomy introduced by Villemure in 1995. This method brings to the sectioning of all the fibers coming from the cortex of the lesioned hemisphere by completely isolating the epileptogenic cortex and by preserving the healthy hemisphere from the effects of a diffusion of the seizure through the systems of inierhemispheric connection. The name originates from the key role of the exposition of insula as a startpoint for all tractotomies. The incision along the circular sulcus allows the access to the lateral ventricle from the frontal horn to the trigon and to the temporal horn by totally destroying the whole fiber system of the internal capsula. Parasagittal callosotomy through the median wall of the lateral ventricle, the posterior transection of the hippocampus from the temporal horn, the radical amygdalectomy, the section of fibers fr0m the frontobasal to the giro rectus of the cortex, of the insular fibers and of the other connection of the anterior commissural system complete the hemispheric disconnection. Leaving in situ the deafferented hemisphere there ate less "ex vacuo" complications on short and long term while the efficacy of this procedure is similar to that of complete hemispherectomy. The surgical smaller exposition makes surgery shorter and with fewer blood loss during surgery. The rationale, technical aspects and advantages of this procedure will be discussed on the basis of the first 5 patients operated on at the Istituto Nazionale Neurologico "C. Besta" of Milano. 166

GABA, glutamate and glutamine levels in plasma of epUeptic patients. C. Ferrarese, G. Galimberti, C. Agazzi, G. Sala, C. Zucca, M. E. Raggi, E. Beghi, G. Bogliun, L. Frattola (Monza (MI), Bosisio Parini (LC), I) Background and goal: GABA (gamma aminobutyric acid) is the major in_ hibitory neurotransmitter in the central nervous system and plays a tole in the pathophysiology of epilepsy. Levels of GABA are lower in brain samples from patients with complex partial seizures than in controls; patients with well-controlled seizures had higher brain GABA levels than in patients with recent seizures. Moreover, various studies have shown an increase of cerebrospinal fluid and plasma GABA concentration in vigabatrin responsive patients. To further investigate possible GABA modifications linked to the disease of to the pharmacological treatment, we have now analyse GABA leyels in plasma of epileptic patients, together with glutamate and glutamine levels, given their metabolic relationship with GABA. Patients and methods: 55 epileptic patients (31 generalized and 24 partial epilepsies) were selected. Al1 patients were on conventional antiepileptic medication (carbamazepine, valproate, vigabatrin, phenobarbital, phenytoin, ethosuximide, lamotrigine, topiramate). Most of them were in monotherapy and some were treated with two or more drugs. Three of these patients were considered drug-resistant. Twenty seven normal volunteers served as age-related controls. Analysis of GABA, glutamine and glutamate levels in plasma were performed by high performance liquid chromatography. Results: GABA level in plasma from patients was about three fold higher respect to controls (p < 0.0005). No differences were found between generalized and partial epilepsies and among patients with various epileptic syndromes; drug therapy did not influence plasma GABA level. A significant increase in glutamine levels (49%, p < 0.05) was also observed in patients compared to controls, while glutamate levels were similar in patients and controls. GABA levels were inversely correlated to glutamate and glutamine plasma levels both in epileptic patients and in controls. Conclusions: increased peripheral GABA levels in drug-treated epileptic

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patients may not be merely related to inhibition of GABA-transaminase, since various drugs display similar effects. Moreover, glutamine is also increased, indieating increased GABA turn-over; thus, increased aminoacid levels in blood suggest upregulation of GABAergic system in drug-treated epileptic patients.

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167 Can presurgical fMRI testing of language on a 1 Tesla clinical MR scanner in patients with temporal lobe epilepsy replace the Wada-test.~ P Boon, K. Deblaere, P. Vandemaele, K. Vonck, G. Vingerhoets, L. Defreyne, E. Achten (Gent, B) Introduction: The presurgical evaluation of patients with refractory temporal lobe epilepsy (TLE) requires localization of language and memory processing, The gold standard for such localization is the Wada-test. This study tests the feasibility and reliability of performing presurgical language lateralization with fMRI at 1T as compared with the Wada-test. Patients and Methods: We prospectively examined 12 patients with TLE. All patients underwent a Wada-procedure with consecutive injection of 2 mg/kg sodium amobarbital in the right and left-sided internal carotid artery, fMRI was performed on a 1T MR system. A silence gap of 2 seconds with asparse sequence allowed auditive cues. A block design with 2 conditions was use& The duration of each test epoch was optimal at 10 scans (60 sec). In condition 1 the patients were given a word through the headphones, instructed to create new words starting off with the last letter of the previous word (covert word chain task) and avoid repetitions. In condition 2 the patients were instructed to start counting (covert) at their own pace. Image post-processing and statistical analysis was performed using SPM99. The contrast of condition 1 versus condition 2 was studied. Language lateralization was visually and quantitatively analysed. Results: Two patients failed the Wada procedure due to lack of cooperation. In one of these, fMRI data were corrupted with too many motion artifacts. In 9 of the 10 remaining patients there was significant activation in language related areas (p < 0.05, corrected); all but one were right-handed. In the only ambidexter patient activation was less significant (p < 0.05 uncorrected) presumably a/so because of dental prosthesis susceptibility artifacts. In 9/10 patients, including one left-hander, resuhs of the Wada-test and fMRI were congruent in showing unequivocal left-sided language dominance. One right-handed patient showed bilateral activation on fMRI, slightly more in the right hemisphere. This patient failed to have language disturbances on both right and left-sided injection during the Wada procedure. Discussion: The word chain task is an easy to perform language task despite the long duration of the test epoch, due to the low field MR system that was used. Our study suggests that reliable language lateralization with fMRI at 1T, as compared to Wada results, is feasible when the paradigm is adapted to the possibilities of the clinical MR unit.

168 Favourable Outcome Of Epileptic Blindness In Children. E. Shahar, D. Savitzki, I. Andraus (Halla, IL) Blindness is a rare ictal phenomenon of epileptic seizures.We report on thirteen children with epileptic amaurosis investigated as regard to ictal and electroencephalographic manifestations, along with the response to therapy and substantial outcome. They experienced single or recurrent episodes of acute visual obscuration, lasting for 1-30 minutes, mainly letal and some pre-ictal with no post-ictal events were recorded. Ten patients had accompanying generalized seizures, with could be induced by photic stimulation in three children. CT of brain performed in tire children were unremarkable. Eight had generalized epileptiform discharges on EEG, including a photosensitive response in three of them. Three children had the constellation of letal amaurosis, occipital paroxysms and postictal migrainous manifestations compatible with the syndrome of occipital lobe epilepsy. These patients as well the rest of the children with generalized epileptic perturbations became seizure free within a period of 3-26 months and the episodes of letal blindness abated. Most patients in this group were treated with valproic acid. Three children had either focal motor phenomena and/or unilateral EEG disturbances,with a normal head CT. The drug of choice in this group was carbamazepine and all became asymptomatic. Conclusions: Our data suggest a relatively benign nature a n d a favorable outcome in most children with letal blindness, along with control of accompanied seizures and preservation of cognitive functions. Epileptic blindness in our experience is almost always associated with other overt epileptic phenomena.

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A prospective study of epilepsy surgery in the United Kingdom. S.D. Lhatoo, J. Solomon, A. MacAvoy, N. Kitchen, S.D. Shorvon (Bristol, London, UK) Introduction: The field of epilepsy surgery has seen some remarkable advances in the last two decades. Of the 30,000 (50/100,000 incidence) persons who develop epilepsy annually, 6000 (20 %) will develop intractable seizures and up to 1000 (3.33 %) may eventuaUy require surgery. Although the number of operations for epilepsy worldwide has increased dramatically, the extent to which this reflects in epilepsy management in the United Kingdom (UK) is not precisely known. Methods: All consultant adult and pediatric neurosurgeons in the UK who had performed any epilepsy surgery in the past one year were identified by means of a postal questionnaire. Epilepsy surgery was identified as surgery undertaken primarily to control epilepsy. Each identified surgeon was then asked to undertake a prospective, record of the number and types of operations carried out for 6 months by means of a monthly questionnaire. Results: 30 neurosurgeons were identified. 154 (86%) out of 180 questionnaires were returned. 252 operations (504 annually or 17 per surgeon per year) were carried out. 178 (70%) were curative and 75 (30%) were palliative. Temporal lobe resections for hippocampal sclerosis (35 %) and other lesions (20 %) accounted for 78 % of all curative procedures.Vagal nerve stimulator implants accounted for 27 % of all surgeries and 92 % of the palliative procedures. Conclusions: Based on a prevalence of 5/1000 persons with epilepsy, there are approximately 4500 patients in the UK who require epilepsy surgery. The annual incident population with newly diagnosed epilepsy adds another 1000 patients to this "surgical poo]" every year. Our figures suggest that with 354 curative procedures per year, there are substantial numbers of patients who may still benefit from surgery who have not been operated on. Lack of awareness of the efficacy of surgery amongst non-specialists as well as patients probably accounts for this treatment gap in some part. The need for more specialist epilepsy centres as well as trained epilepsy surgeons is emphasized by this study.

170 The ILAE syndromic dassification applied to an adult neurology dinic population. A. Awada, T. Obeid ( Riyad, KSA) From January 1994 to December 1996, 304 epileptic patients aged 15 years or more were prospectively studied. Based on the epilepsy age of onset, seizure type, clinical examination, EEG and neuroradiological data, we attempted to apply the ILAE syndromic classification to these patients. A hundred and sixty patients (54.6 %) had localization related epilepsies with clear focal EEG changes in 91 of them. Sixty patients (19.7%) had generalized epilepsies documented by generalized epileptic discharges on EEG in 54 of them. However in 78 cases (25.6 %) the epileptic syndrome was difficult to classify. Interesting findings were the prominence of Juvenile myoclonic epilepsy in the idiopathic generalized epilepsy group (20 cases out of 38) and the almost equal number of cryptogenic (n=80) and symptomatic (n=86) localization-related epilepsies. Despite the difficulties in classifying a quarter of the patients, and all the on-going debate about the ILAE classification,we belleve that this classification is still the most valid one in common neurological clinical setting. 171 Results of the Anterior Temporal Lobectomy/Amygdalohippocampectomy in a Series of 54 Patients with Medically Intractable Complex Partial Seizures. P. Sioutos, M. E. Weinand (Tucson, Arizona, USA) Clinical Material And Methods: This study includes 54 patients (34 males, 20 females) with medically intractable complex partial seizures of medial temporal lobe origin, treated with an anterior temporal lobectomy/amygdaloippocampectomy (ATL/AH) at the University of Arizona. The patients' ages at operation ranged from 14 to 56 years (mean: 32 years). The preoperative work-up included: brain MRI (n=54),Video/EEG (n=54), Neuropsych exam (n=54),Amytal test (n=54), SPECT: interictal (n=27) / intraictal (n=6) / / interictal - intraictal (n=6), PET (n=16), Subdural Strips (n=23), Subdural Strips with simultaneous measurement of the Cortical Cerebral Blood Flow

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with the Thermal Diffusion Flowmetry method (n=15), Subdural Grids (n=2). The brain MRI findings were: normal (n=13), hippocampal atrophy (n=21), high T2 hippocampal signal (n=7), temporal lobe pachygyria (n=2), lateral temporal cortex calcifications (n= 1), temporal horn dilatation (n=3), hippocampal cavernous angioma (n=2), hemispheric atrophy (n=3), high insular signal (n= 1), hippocampal necrosis (n= 1). The Video/EEG failed to localize the epileptic focus in 21 cases (40 %). Five patients were reoperated for further hippocampal resection. The followup ranges from 5 weeks to 3.5 years (mean: 11.8 months). Results: There was no death in this series. Thirteen patients (24 %) developed minor complications postoperatively: transient incomplete III nerve palsy (being the most frequent complication: n=7), superior quadranopsia, transient hemiparesis, meningitis and a moderate verbal memory defect. One patient (1.8%) developed a serious complication: permanent hemiparesis and expressive aphasia. Within the follow-up period 36 patients were seizure free (66.6 %), 14 patients had significant improvement of the seizure frequency (26%), 2 patients had simple improvement (3.7%), and 2 patients (3.7%) did not have any change in the seizure frequency. Among patients with MRI diagnosed MTS, 19 were seizure free (67.8%) and 8 had signific• improvement (28.5 %). Among patients with normal MRI, 10 were seizure free (77 %), and 2 had significant improvement (15.3%). Conclusions: The results of thŸ study are in concordance with the literature as concerns the seizure control following an ATL/AH. There was no significant difference in the seizure control rates between patients with MRI diagnosed MTS and those with normal brain MRI. 172 Psychiatric morbidity following epilepsy surgery. G. Michielsen, E. Thiery, 1. Caemaert, T. Vandekerckhove, ]. De Reuck, P. Boon (Gent, B) Rationale: Psychopathology following epilepsy surgery is a well-known, but underestimated phenomenon. The importance of neuropsychological inv£ in epilepsy surgery centres is often neglected. Methods: Eighty-two patients underwent surgery for refractory epilepsy between 1992 and 2000. During follow-up, the frequency and nature of psychiatric symptoms were assessed. Results are retrospectively correlated to pre- and postsurgical variables. Results: Out of 82 operated patients, 18 (22%) developed psychiatric symptoms (11 females, 7 males). All 18 had undergone a partial temporal lobectomy, 15 of whom ate seizure-free. Mood disorders were present in 14 and anxiety disorders in 4. In the former group, depression was accompanied by manic episodes in 1 patient and by anxiety in 3. Overall, somatoform symptoms and social phobia were seen in 4 and 2 patients, respectively. Disrupted family dynamics arose in 5 patients. Average IQ amounted 114. Four patients were unemployed. Presurgical neuropsychological assessment showed psycho-neuroticism and/or poor social adaptation in 82%. Overt psychosis was presurgically present in 3 patients and depression in 1. There was no correlation between the presence of psychopathology and the side of operation. Symptoms arose on average 3 months after surgery (range 0-9). Eleven patients needed psychological counselling, 2 of whom were admitted to hospital. Arttidepressants alone were started in 6 patients, anxiolytics in 1 and a combination of both in 4. Medication was on short term in 6. Conclusions: Psychiatric sequelae are common after epilepsy surgery. Psychological counselling, pre- and postsurgically, plays a major role in the improvement of life quality. This study was supported by Grants BOZF-01104495, BOZF-01 105 399 and 011D0996 from Ghent University and by Grant 1.5236.99 from the fund for Scientific Research - Flanders (E W.O). 173 Vagal Nerve Stimulator for the Treatment of Epilepsy. E Sioutos, S. Gianakodimos, K. Karageorgiou, M. E. Weinand (Athens, GR; Tucson, USA) Objective: We report the combined experience of the University of Arizona Medical Center and of the Athens General Hospital with the Vagal Nerve Stimulator (VNS) for the treatment of medically intractable seizures. Clinical material and methods: This study includes 23 patients (12 males, 11 females) who underwent left Vagal Nerve Stimulator implantation for treatment of medically intractable seizures. The patients' age at operation ranged from 13 to 62 years (mean: 36.3 years). The seizure types were as follows: complex partial seizures secondary generalized (n= 16), primary generalized tonic-clonic (n=5), primary generalized not otherwise specified (n=l), drop attacks/ absence (n=l). Seizure frequency was at least 10 seizures per mnnth. One patient has a large, inoperable, hemispheric arachnoid cyst and another patient has a past medical history of encephalitis. A

male patient had underwent a corpus callosotomy in the past without a change in the seizure frequency. All patients underwent left Vagal Nerve Stimulator implantation using standard technique. The follow-up ranges from 1 to 25 months (mean: 13 months). Resuhs: All patients tolerated the procedure well. Postoperatively two patients h a d a transient difflculty in swallowing liquids and one patient had a transient hoarseness of moderate degree. The postoperative seizure frequency reduction was: more than 75 % reduction in 8 patients (35 %), 50 to 75 % reduction in 4 patients (17 %), 25 to 50 % reduction in 3 patients (13 %), and less than 25 % reduction in 8 patients (35 %). Conclusions: In our experience the implantation of the Vagal Nerve Stimulator is a safe and effective method of treatment for select patient populations (patients not candidates for brain surgery). Based on the results of this study the VNS provides at least 50 % reduction of the seizure frequency in more than half of the patients.A significant improvement (more than 75 % reduction in the seizure frequency) has been documented in over 1/3 of the patients in this study. 174 Status epilepticus in stroke: characteristics of stroke type. D. Kaya, N. Afsar, S. Aktan, C. Aykut-Bingol (Istanbul, TR) Background and objective: Status epilepticus (SE) is a common medical emergency which has a significant morbidity and mortality. It has been recently reported that SE associated with structural cerebral lesions h a d a bad prognosis. The aims of this study were to investilgate the association of SE with stroke, and to assess the time delay for its occurrence following stroke onset. Methods: Sixteen poststroke SE patients (with 18 episodes), out of 76 admitted to the Marmara University Neurology Department between May 1998-April 2000 were documented. There were 12 women and 4 men with a mean age of 73 -+ 10 years (range 50-83). SE was defined as an epileptic seizure lasting > 30 min or intermittent seizures without recovery of consciousness between seizures lasting > 30 min. Patients were subgrouped as having SE at stroke onset, early-onset (occurring within 2 weeks of the stroke), and late-onset (occurring more than 2 weeks after stroke) SE. Results: Poststroke seizures constituted 21% of all SE patients (n = 76). Three patients developed SE at stroke onset, 6 had early, and 7 had late-onset SE. Furthermore 2 patients, had recurrent SE. Five out of 16 poststroke SE patients had intracerebral hemorrhage, 10 had ischemia (5 MCA, 4 PCA, 1 brainstem), and one patient had subarachnoid hemorrhage followed by an MCA infarct. Four of the patients with hemorrhage had early-onset SE and no history of epilepsy, whereas 4 of the late-onset SE patients did have epilepsy history. Conclusion: Stroke was an important etiological factor for SE in our series, in accordance with recent reports. Moreover, ischemia outnumbered hemorrhage regarding poststroke SE etiology emphasizing the necessity for a high degree of suspicion for SE in acute stroke patients.

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Neurogenetics - 3 175 A molecular genetic study of hypokalemic periodic paralysis in the UK - a new skeletal musde sodium channel gene (SCN4A) mutation. N. Davies, L. Eunson, M. Samuels, R. Wise, M. Hanna (London, UK) Objectives: To determine the clinical features and molecular genetic basis of hypokalemic periodic paralyses in the UK. Background: The periodic paralyses are autosomal dominant skeletal muscle channelopathies, characterised by altered muscle membrane excitability. Historically, these conditions have been divided into hyperkalemic (hyperPP) of hypokalemic (hypoPP) variants depending on the serum K+ during an attack. It has been established that most cases of hypoPP are due to mutations within the skeletal muscle voltage-gated calcium channel gene (CACNA1S) and cases of hyperPP are caused by mutations within the skele-

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tal muscle voltage-gated sodium channel gene (SCN4A). However, mutations within SCN4A have recently been implicated in a few cases of hypoPP. Methods: Genetic analysis was performed on 52 families with hypoPP. In each patient, using a combination of RFLP analysis and DNA sequencing we screened for the two most common mutations in hyperPP (T704M, M1592V) and hypoPP (R528H, R1239H). We also screened the mutation negative hypoPP patients for mutations within SCN4A. Results: We identified 11 families with mutations in CACNAIS causing hypoPP. In 41 individuals with definite hypoPP, only I had a mutation within SCN4A. This was a previously unreported heterozygous point mutation C2014A in exon 12. This mutation is predicted to result in ah amino acid substitution (R672S) in a highly conserved region of the voltage sensor ($4) in transmembrane domain II. Conclusions: we have identified the genetic defect underlying hypoPP in 30 % of individuals tested. We reporta new mutation in SCN4A causing hypoPP but observe that SCN4A mutations are ah uncommon cause of the disorder in the UK population. 176

Relevance of splicing determinants in the dystrophin gene for physiological and pathogenetic splicing mechanisms. M. Sironi, U. Pozzoli, R. Cagliani,

rents with persistent activation on hyperpolarization. Mean instantaneous current amplitudes at - 125 mV were 7.3 _+1.4 nA and 6.5 + 1.2 nA for WT and WT-Q552R respectively. Peak current amplitude for Q552R was 7.9 -+0.9 nA. The voltage dependence of relative open probability (Popen) was also dramatically altered. Whereas WT could be described by a single Boltzmann function (V1/2 = -66.5 + 3.1, slope factor 27.6 + 2.7), Q552R CIC-1 channels produced a curve of ah inverted bell shape, incompatible with a Boltzmann distribution.In contrast to the dramatic changes seen with Q552R, analysis of the WT-Q552R heteromer produced currents similar to WT. The voltage activation curve could also be described by a single Boltzmann function (Vl/2 = -55.9 _+9.7, slope factor 5 I. 1 + 10.1) and, when compared with WT, caused a depolarising shift of about 10 mV at half maximal Popen. This is the first successful expression and characterisation of the Myotonia levior mutation since its identification in 1995. We show that the mutant is indeed functional when expressed in a mammalian cell line and argues for the re-evaluation of other mutations (particularly those thought to be nonfunctional) using this expression system. The voltage activation curve for the WT-Q552R heteromer is not simply intermediate between it's component subunits and Popen cannot be predicted from a knowledge of the individual activation curves. Furthermore, the slight degree of rightward shift observed with WT-Q552R may account for the mild symptoms in this condition.

G. P. Comi, A. Bardoni, N. Bresolin (Bosisio Parini (LC), Milan, I) The molecular mechanisms that direct splice site selection and assure that an orderly array of exons is maintained in mature mRNA have not been fully clarified. The extraordinary nature of the dystrophin gene with respect to its size and number of exons points to several potential hurdles in the processing of transcripts. In this study dystrophin statistical and thermodynamic splicing parameters were evaluated with the aim of providing further insight in splicing physiology. We show that concomitant use of CV scores and DG~ values for UlsnRNA annealing better discriminates between real donors sites and donor-like sequences. Evidence is also shown that, on average, out-of-frame dystrophin exons have significantly stronger CVs and more favorable DG~ This feature might representan evolutionary buffer to reduce the probability of misplicing involving out-of-frame exons that would determine production of frame-shifted mRNAs ultimately leading to protein truncation. Splicing defects are estimated to account for about 15 % of disease-causing mutations in humans; dystrophin splicing mutations have been reported to determine either Duchenne or Becker Muscular Dystrophy but no comprehensive genotypic/phenotypic correlation has ever been investigated.We provide analysis of splicing affecting single-base pair substitution in the dystrophin gene with respect to their effect on splicing parameters and their functional and clinical consequence. We found 5' splice site mutation occurrence to be statistically related to mutability quotients; we also show that, for the dystrophin gene, evaluation of DG~ values is a more effective tool than CV scote alone to describe 5' splice site mutation consequences. Moreover, since splicing mutations have the potential to be leaky, predictive information can be sought as to whether residual normal tuRNA molecules are going to be produced; we demonstrate tbat 5' mutated splice sites retaining partial activity present very small DG~ relative decrements and much higher CV decrements. Our analysis also indicates a nearly 100% correlation between clinical phenotype and the reading frame rule determined at the RNA level. We consider elucidation of the relative importance of splicing determinants might help to clarify the molecular mechanisms that direct correct splicing in complex genes and might be useful in the validation of predictive models. 177

Myotonia Levior-expression and analysis of the disease-causing mutation. A. Ryan, C. Fahlke, R. Ruede1 (Ulm, Aachen, D) Autosomal dominant myotonia congenita (Thomsen disease) is due to mutations in the voltage-gated skeletal muscle chloride channel hC1C- 1. Analysis of dominant mutations has provided valuable insight into the structure of this channel. Myotonia levior is a variant of Thomsen disease with a milder clŸ phenotype. Previons analysis of the causal mutation (Q552R) in the Xenopus expression system revealed it to be non-functional. We sought to re-examine and characterise this mutation using a mammalian expression system. Using pRcCMV-hC1C-1/Q552R a n d a construct containing pRcCMVhC1C-1/WT-Q552R, we transienfly expressed the mutation in tsA cells. Currents were recorded 24-36 hours after transfection by the whole-cell configuration of the patch-clamp technique. WT hC1C-1 currents are characterised by a rapid but incomplete deactivation upon hyperpolarization. In contrast, the Q552R mntant displayed cur-

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Levodopa is not always well tolerated in Dopa-responsive dystonia with CGH1 mutations. S. Tezenas du Montcel, L. Ould Amer, A. Dª M.-A. Barthez-Carpentier, P. Calvas, P. Castelnau, P. Edery, P. Landrieu, E ClergetDarpoux, A. Brice (ParŸ Tours, Toulouse, Lyon, Le Kremlin-Bic~tre, F) Background: Dopa-responsive dystonia (DRD) is an autosomal dominant inherited form of dystonia with rednced penetrance caused by mutations of the gene encoding GTP cyclohydrolase I (GCH 1). Most patients present childhood-onset dystonia characterized by a dramatic and sustained response to relatively low doses of levodopa. Methods: We studied 15 index cases with a phenotype compatible with levodopa-responsive dystonia, meaning at least 50% improvement under levodopa. There was positive family history in 4 cases. Blood samples were obtained from each subject after written informed consent. The six coding exons, the 5'-untranslated region and the exon-intron boundaries of the GCH 1 gene were sequenced in all index cases. If a mutation was found in the index case it was tested in other sampled family members. For new mutations, 50 controls were tested to ensure that it was n o t a polymorphism. Results: Four heterozygous independent mutations were identified in the CGH1 gene including one small deletion (693delG) and 3 missense (Glu65Stop, Phel04Leu, Gln180Pro). Two mutations (693delG and Phel04Leu) were new. In the four families with a mutation, there were 7 patients (4 men and 3 women) and 4 asymptomatic carriers (3 men and 1 woman). All patients had typical dystonia (generalized with childhood onset). In one case with the Glu65Stop mutation levodopa was not well tolerated but a dopamine agonist (bromocriptine) was efficient. However, fluctuations were occurring once or twice a month. A patient with the Phel04Leu mutation initially did not tolerate well levodopa but after 9 months treatment could be pursued at the dose of 100 mg/day with major improvement. No mutation was detected in the 11 isolated cases. Among the non-mutated cases, 5 h a d a typical DRD phenotype and 6 an atypical phenotype: 1 with levodopa-responsive tremor, 4 with adult onset and no generalization of the dystonia and 1 with very early onset (4 months). Conclusions: We have detected 4 different CGH 1 mutations, jncluding 2 novel, in 4 familial cases with DRD. Although marked response to levodopa characterizes DRD, in 2 instances the treatment was not well tolerated leading to the prescription of dopamine agonists with excellent result, in one patient. No CGH1 mutations were identified in the 11 isolated cases with DRD, suggesting the existence of undetected mutations affecting this gene or the involvement of at least another gene. 179

The French experience in presymptomatic genetic testing in Huntington's disease and Autosomal Dominant Cerebellar Ataxias. C. Goizet, G. Lesca, P. Calvas, J. Yaouanq, M.-C. Malinge, N. Philip, P. Sarda, P. ]onveaux, O. Cohen, D. Lacombe, E. Ollagnon, H. Plauchu, F. Tison, J. Feingold, A. Brice, A. Durr (Bordeaux, Lyon, Toulouse, Rennes, Angers, Marseille, Montpellier, Vandoeuvre Les Nancy, Grenoble, Paris, F) Background: Presymptomatic genetic testing consist of determining the genetic status of still asymptomatic at-risk individuals. It is offered internationally since 1986 in Huntington's disease. Autosomal dominant cerebellar ataxias (spinocerebellar ataxias) are neurodegenerative disorders similar to

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HD in term of late onset, progressive evolution, severity and genetic mechanisms, for which presymptomatic testing became recen@ possible. Methods: We present the experience for presymptomatic testing in HD and in SCAs in 10 plurisciplinary centres belonging to the French Presymptomatic Testing Group, in order to compare at-risk populations for both disorders up to March 2000. The presymptomatic test protocol included an information session and comprised at least two separate interviews before the decision to take the test or not. A post-test follow-up was proposed to all participants. Resuhs: 839 at risk individuals who requested presymptomatic testing were included in this survey (789 for HD,50 for SCAs). The vast majority (93 % and 96 % in H D and SCAs,) were at 50 % risk. Doubts about subtle neurological signs were noted in 75 individuals ( 10 %, n=759). 57 % of requesters were accompanied (n=709), most commonly by the partner. The most frequent motivations were to relieve uncertainty and family planning. Only 55 % hada result: 434 in HD (55 %) and 31 in SCAs (62 %). Presence of an accompanist was significantly correlated with obtaining a result (p < 0.01). Among the 39 requesters at risk for HD for whom subtle signs were noticed, 13 obtained a normal result. During the follow-up of 336 participants (72 %, n=465), 55 individuals (16%, n=336) reported at least one serious adverse event, more frequently in SCAs (32%, n=17) than in HD (15 %, n=317). Catastrophic events (defined as psychiatric hospitalisation, suicide attempt, or successful suicide) have been reported in 7 persons (2%, n=336). 40 pregnancies occurred after receiving an abnormal result leading to twenty-one prenatal diagnosis (52 %, n=40). Conclusion: Although the major motive for presymptomatic testing is relieving uncertainty in HD and planning a family in SCAs, the proportion of withdrawal before the result is similar. Mild neurological abnormalities noticed by the team ate not always associated with a carrier status. The frequency of adverse events is similar for the two types of disorders. These results reinforce our opinion that presymptomatic testing in SCAs justify the same protocol as for HD. 180

Ciinical and genetic study of 269 families with hereditary spastic paraparesis. Cree Tallaksen, A. Durr, C.-S. Davoine, J. Hazan, B. Fontaine, A. Brice (Paris, Evry, F) Hereditary spastic paraparesis, HSP is characterized by great clinical and genetic heterogeneity. In addition to the pure forms, numerous complex phenotypes have been described often in single families. To date, 16 loci, SPG1 to 15 and ARSACS,have been mapped. The genes for SPG 1: L1-CAM, SPG2: PLP, SPG4: spastin, SPGT: paraplegin and ARSACS: sacs in have been identified. However, the frequency of each phenotype according to the mode of inheritance remains unknown. Material and methods: The clinical data of 269 HSP families referred between 1991 and 2000, have been systematically evaluated using a standardised examination forro and recorded in a database. The purpose was to evaluate the frequency of various forros of HSP according to the mode of inheritance and to the associated signs. Results: Transmission was dominant -D in 194:72 %, recessive -AR in 75: 28 %. 149 of the D families presented with pure HSP,44 with a complex form, while 52 of the AR families hada complex form. Age of onset < 10 years was observed in 50 families, between 10 and 30 in 65, and after 30 in 107. The most frequent associated signs in the complex forms were cerebellar ataxia in 46 families ( 14/41 in D-HSP, 32/49 in AR-HSP), and neuropathy in 19 (10 in D-HSP, 9 in AR-HSP). Cognitive disturbances were found in 5 kindreds with D-HSP, while mental retardation was reported in 17 AR-HSE Extrapyramidal symptoms were found in 14 families, 6 D-HSP and 8 AR-HSP,and moderate to severe amyotrophy in 11 families, 6 D-HSP and 5 AR-HSE Retinitis pigmentosa or optic atrophy were reported in 6 AR-HSP only. Among the D-HSP, SPG4 was identified in 29 families and excluded in 61. Linkage analyses also identified 2 SPG 12 and 1 SPG3 families. Among AR-HSP families, one was identified as SPG7. Among complex forms, 1 had SPG1, 1 GM1 gangliosidosis and 2 adrenoleukodystrophy. Conclusions: Pure HSP is most frequent in dominant families whereas most recessive forms are complex. Age at onset is mostly in adulthood in D families, whereas ir is younger in AR-HSP often associated with complex forms. Ataxia is the most frequent sign in complex forms both in D and ARHSP whereas mental retardation and ophthalmological anomalies are mostly found in AR-HSP. Except for SPG4 which accounts fora significant proportion of pure D-HSP, other loci seem to be rare and the molecular basis of most families remains unknown.

Oral session 30 Neuro-epidemiology 181

The epidemiology of hereditary spastic paraparesis in Ireland. P. McMonagle, S. Webb, P, Byrne, N. Parfrey, M. M. Hutchinson (Dublin, Cork, IRL) Introduction: Hereditary spastic paraparesis (HSP) is clinically and genetically heterogeneous. It is classified based on the mode of inheritance as autosomal dominant (AD), recessive (AR) of X-linked and as'pure' or'complicated' depending on the presence or absence of additional features. 'Pure' ADHSP is most common and the SPAST gene on chromosome 2p is the major disease gene for this forro of HSP. Aims: To determine the prevalence and features of'pure' ADHSP in the island of lreland. Methods: Ireland covers a small atea anda relatively homogeneous population allowing unique opportunities for epidemiological studies. Index cases were identified from a 5-year survey of all adult and paediatric neurologists, clinical geneticists, GPs and HIPE data in lreland, north and south. Families were examined by two neurologists and classified as 'affected' or 'unaffected' according to specific criteria. Blood was taken for genetic analysis and cognitive assessments performed in all patients over age 20. The prevalence date was set at June 1st,2000 and the pol~ulation of lreland on that date from the last census was 5.2m. Results: We identified 33 families with 'pure' and 'complicated' HSP over 5 years. There were 82 individuals with 'pure' ADHSP anda further 12 obligate carriers from 20 families. Linkage to SPAST was confirmed in 5 pedigrees, excluded in 3 and genetic status was not known in 12. AII 5 SPAST pedigrees showed evidence of late-onset cognitive impairment. In total 69 tases with 'pure' ADHSP were alive and resident in Ireland at the prevalence date. 29 % of these were asymptomatic but with signs of paraparesis. Conclusion: We estimate the prevalence of ADHSP in Ireland to be 1.33 per 100,000 population. The high proportion of asymptomatic cases and obligate carriers means that this condition is likely to be underdiagnosed. The frequency of cognitive impairment in our SPAST patients suggests the current classification system is ambiguous. 182

Lifelong occupational exposition and amyotrophic lateral sclerosis (ALS): resuhs of a case-control study. A. Terreni, E. Herrero-Hernandez, G. Discalzi, F. Plano, P. Ghiglione, C. Carmellino, A. Rossi, R. Mutani, A. Chi6 (Torino, I) Background and objective: ALS is a progressive neurodegenerative disease whose pathogenesis is still unknown. A possible toxic pathogenesis has been advocated. This study evaluates the lifelong occupational exposures in a consecutive group of ALS patients, seen at the ALS Clinic, Department of Neuroscience, Turin. Materials and Methods: 102 patients (55 men and 47 women) affected by definite or probable ALS seen between October 1998 and ]une 2000 were enrolled in the study. Each patient was paired by gender, age ( _+2 yrs) and area of residence to a control. Controls were selected among patients admitted to a Trauma Center for traumatic fractures (domestic or road accidents) of surgical pathologies. Neurologic, psychiatric, metabolic, and neoplastic disease were exclusion criteria for contruls. A questionnaire-guided interview was performed by an occupational heahh physician to each case/control, anda complete occupational history was collected. Results: A high odds ratio (OR) was found for agriculture (32 cases vs. 21 controls, OR 1.76, 95 % c. i. 0.88-3.54), textile industry ( 13/7, OR 1.98, 95 % c. i. 0.63-6.21 ) and mechanical industry (47/25, OR 2,63, 95 % c. i. 1.42-4.88). Welding activity seems to be a risk factor since in this study ir has be found in 28 cases and 3 controls (OR 12.4, 95 % c. i. 4.32-36.03). Discussion: These data focus the attention to an excess of risk in mechanical and possibly textile and agricultural activities, in particular among welders. This suggests a possible toxic effect of metals, solvents or pesticides. Some of this substances have already been implicated in the pathogenesis of ALS in previous case-control studies, small series, and animal models.

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183 Mortality rates for amyotrophic lateral sclerosis and Parkinson's disease in Italy, 1957-1994: are the trends observed during '80s changing? M. Vercellino, N. Di Vito, P. Ghiglione, A. Calvo, F. Piano, A. Rossi, R. Mutani, A. Chi6 (Torino, I) During '70s and '80s a steady increase of mortality rates for amyotrophic lateral sclerosis (ALS) and Parkinson's disease (PD) has been detected in various European countries, including Italy, and in the United States. This worldwide increase has been variously explained by an interdisease competition (Gompertzian effect), the result of population aging, a real increase of the risk of developing these disorders, ora better reporting of eases in death certificates.We have analyzed the mortality for ALS and PD in Italy ten years after an analogous study in order to verify whether the increasing trend was still present and its current characteristics. Data about number of deaths were obtained from Italian Statistical Bureau. Only death over 20 years of age were considered. Rates were age-adjusted to the 1991 Italian census population. Concerning ALS, increase of mortality rates continued during the last decade, reaching a peak in 1994 both formen (1.42/100, 000 inhabitants) and for women (1.21) (a twofold increase for men a n d a threefold increase for women with respect to 1957 rates). The men to women rate ratio decreased progressively from 1.64:1 in 1957 to 1.17:1 in 1994. The increase was particularly evident in patients older than 60. PD showed a different trend: after reaching a peak in 1985-86, the rate remained steady with a slight decrease in the middle '90. In both sexes, age-specific mortality rates showed a decrease in age-groups under 65, remained stable in 70-74 and 75-79 agegroups and showed a marked increase in older age groups. In conclusion, the persistence of an increasing trend in ALS mortality is consistent with a real increase of the risk of developing the disorder. The steadiness of PD mortality rates after 1985 raises doubts on Gompertzian effect and is consistent with the end of the "delayed death effect" (i. e., 5 to 10 years increase of life expectancy in PD after the introduction of levodopa with a shift of 10 years of age of death). 184 The use of standardized incidence and prevalence rates in epidemiological studies of Multiple Sderosis is advisable. R. Zivadinov, M. Zorzon, L. Iona, L. Monti-Bragadin, A. Bosco,A. ]urievic, C. Taus, G. Cazzato (Trieste, I; Riieka, HR; Ancona, I) Background: Standardization is needed to compare incidence and prevalence rates found in different areas of the world and in populations with different age- and sex- structure but this method is not extensively applied in epidemiological studies on Multiple Sclerosis (MS). Objective: To demonstrate that crude incidence and prevalence rates do not provide sufficient information in epidemiological studies on MS and to establish which variable (s) is related to standarized rates. Methods: A survey of population-based incidence and prevalence studles on MS from 1980 through 1998, found using the terms MS, epidemiology, prevalence, incidence and standardization in the bibliographic databases MEDLINE and EMBASE, has been performed. We included the studies which reported the diagnostic criteria, the number of cases and the population studied, the date of the study, the latitude, and the crude incidence and prevalence rates. According to the inclusion criteria, 68 prevalence and 21 incidence studies out of 127 investigated papers have been considered. The incidence and prevalence rates and the 95 % confidence intervals (CI) age-adjusted to the World and the European standard populations have been calculated. To test the relationship between the crude and age-adjusted incidence and prevalence rates, the Spearman rank correlation analysis has been employed. To verify if the crude and age-adjusted rates could be predicted by some epidemiological variable the multiple regression analysis has been used. Results: We found a weak relationship between the crude and the age-adjusted incidence and prevalence rates. The multiple regression analysis showed that the age-adjusted incidence and prevalence rates were strongly predicted by latitude (R= 0.85 to 0.95, p < 0.0001 for World standard population and R= 0.94 to 0.99, p= < 0.0001 for European standard poptflation), whereas crude rates were not (R= 0.44 to 0.56, p= NS). This indicates that crude incidence and prevalence rates are not useful in comparing studies from different geographic areas. Conclusions: The crude incidence and prevalence rates in epidemiological studies on MS should be adjusted to a common standard population to permita comparison among studies performed in different countries.

185 Guillain-Barr› syndrome (GBS) and cancer: results of a population-based study. M.C. Vigliani, A. Chi6, M. Magistrello, P. Polo, R. Mutani, GBS Register (Turin, I) Background: Guillain-Barr› syndrome (GBS) has been linked to underlying systemic diseases and to malignancies such as Hodgkin's disease, nonHodgkin's lymphoma and small cell lung carcinoma. Indeed the existence of a paraneoplastic GBS is still under discussion. One possibility to approach this issue consists in determining by epidemiological studies whether a statistically significant association between cancer and GBS exists. Objective: To assess whether a higher incidence of cancer can be observed in an epidemiological-based population of GBS patients. Methods: The data have been obtained through the Piemonte and Valle d'Aosta Register for GBS in the years between 1990 and 1998. These two Italian regions have a total population of 4.4 miUions inhabitants. The GBS diagnosis was made following the NINCDS criteria.All patients have been contacted by telephone to ascertain the onset of a cancer in the six months following GBS. The number and features of all cases of malignancies observed in our population have been studied. The number of the expected cases in the general population was calculated using the incidence rates for malignant neoplasms in Piedmont (ICD codes 140-208) in the period 1985-87. Results: In 9 years the Register has observed 435 cases of GBS in our regions. Nine of them developed a cancer in the six months before or after GBS. In seven patients the observation of the tumour (2 non-SCLC lung cancer, 1 kidney cancer, 1 non-Hodgkin lymphoma, 1 cancer of oesophagus, 1 cerebral tumour, 1 case with multiple metastases of unknown origin) was coincidental with the diagnosis of GBS. Two patients (both with bladder cancer) had GBS in the first (2-6) months following the tumour diagnosis. The expected number of malignant tumours in our population was 3.7 cases; therefore the relative risk was 2.43 (95 % CI, 1.11-4.62, p < 0.05). Conclusions: A statistically significant association between GBS and cancer has been found in our population with a remarkable number of cases (7 patients) who developed the GBS and the tumour at the same time. These results suggest a possible relationship between GBS and cancer that deserves further investigations.

186 Epidemiology Of Myotonic Dystrophy In Italy: Re-Appraisal After Genetic Diagnosis. M1.Manca, M. Gennarelli, R. Sposito, MI. Mostacciuolo, A. Rocchi, G. Siciliano (Pisa, Brescia, Padova, I) Before the discovery of the myotonic dystrophy (DM) gene, the DM epidemiological rates could not be accurately estimated. The aim of this study was to calculate the prevalence rate of DM in Padova (North-East Italy) and in four provinces of North-West Tuscany (Central Italy) a n d a s of Iune 30th 1999, using molecular genetic testing. A minimum prevalence of 9.31 • 100,000 inhabitants was found, consistent with epidemiological rates in the world, and more than two times as high as two previous studies conducted in the same areas during the premolecular era. This study, the first in Italy since the discovery of the DM gene, underlines the importance of direct genetic diagnosis of DM especially in detecting mildly affected patients, a fundamental step in correctly estimating the risk of disease transmission in affected families.

Oral session 31

Multiple Sclerosis- 5 187

TNFa-R-I-mRNA in multiple sderosis: influence of corticosteroids and interferon-beta-lb. L. M. Ossege, E. Sindern, T. Patzold, ]. P. Malin (Bochum, D) Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system. Several lines of evidence suggest a dysregulation of the expression of cytokines and their receptors in this process. E. g. it has been demonstrated that Tumor-necrosis-factor-alpha (TNFa), a proinflam-

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matory mediator, is involved. This cytokine mediates its cytotoxic and apoptotic effects by the receptor-type-I (TNPa-R-I). On the other hand several studies showed that soluble TNPa-R-I protein antagonize and inhibit effects of TNFa. Data concerning the TNFa-R-I-mRNA expression are lacking. The mRNA-expression of TNFa-R-I was investigated in CSF cells (CSFC) and blood mononuclear cells (PBMC) of 50 MS-patients (36 patients during acute relapse and 14 patients during remission) by non-radioactive in situ hybridization. In addition, mRNA-expression was examined in PBMC of 10 patients with acute relapse during treatment with prednisolone i.v. for 5 days and in other 10 patients in remission during treatment with interferonbeta-lb (IFNb-lb) s. c. for I year. There was no difference concerning the TNFa-R-I-mRNA-expression in CSFC and PBMC between the patients during acute relapse and the control group (patients without inflammatory neurological diseases). Patients during remission demonstrated an increased expression of TNFa-R-I-mRNA in CSFC and PBMC comparefl to controls (p < 0.01, Mann-Whitney-U-test) and patients with acute relapse (p < 0.001, Mann-Whitney-U-test). The TNFa-R-I-mRNA-expression was higher in CSFC than in PBMC (p < 0.001, Wilcoxon-Rank-Sum-test). During treatment with prednisolone an increased expression ofTNFa-R-I was detectable 3-5 and 8-10days after starting the therapy (p < 0.01, Wilcoxon-Rank-Sum-test) with a maximum at days 3-5. Treatment with IPNb-lb lead to a temporary increase of TNFa-RI-mRNA in PBMC of MS-patients 1, 5 and 15 days after beginning of injections (p < 0.02, Wilcoxon-Rank-Sum-test). Ah effect lasting for a longer period (3, 6, 9,12 months) could not be observed. In summary, these data hint at an association of the TNFa-R-I-mRNA expression with the stable phase of MS. This could possibly indicate apoptosis induced repair processes mediated by TNFa-R-I. The effects of corticosteroids and IFNb-lb on the mRNA-expression of TNFa-R-I are different indicating distinct immunoregulatory mechanisms of these drugs.

188 Effect of Interferon beta 1-b (Betaferon | Treatment on Immunological Parameters in Patients with Secondary Progressive Multiple Sclerosis. P. Ri› N. Kruse, L. Nagelkerken, C. S. Stuerzebecher, H. P. Hartung, R. Hohlfeld, L. Cuzner, C. Polman, E Dahlke, K. Toyka (Wuerzburg, D; Amsterdam, NL; Berlin, D; Graz, AT; Munich, D; London, UK) Background: Subcutaneous IFNb-lb (Betaferon | is a potent immunomodulatory treatment for active secondary progressive multiple sclerosis (SPMS) as recently demonstrated in a large European.multi center study. Long term in vivo effects of IFNb-lb on the irnmune system have not been demonstrated in multiple sclerosis. Objective" Analysis of cytokine and adhesion molecule expression in the blood of MS patients participating in the frequent MRI subgroup of the European Betaferon | SPMS trial. Methods: Serial blood samples were obtained from 38 patients at regular intervals for up to 36 months during the European multi center SPMS clinical trial. Serum and peripheral blood mononuclear cells were stored at -80~ Soluble adhesion molecules (sVCAM- 1, sICAM- 1), soluble TNF-Receptor I (RI) and TNF-RII as well as IL-10 were analysed using commercially available ELISAs in the serum of patients. Cytokine mRNA (TNF-a, IFN-g, IL- 10, TGF-b) from blood cells was quantified by real time RT PCR using the ABI PRISM 7700 sequence detection system. Results: During treatment with Betaferon| IL-10 mRNA expression increased in blood mononuclear cells as early as one month after initiation of treatment whereas no significant changes were observed in placebo treated patients. For the other cytokines we did not observe significant differences in mRNA expression between treatment groups. Early (month 1) and sustained increased levels of sVCAM-1 and sTNF-RII for up to 36 months were detected in patients treated with subcutaneous IFNb-lb but were not observed during placebo treatment. Further analysis of data and correlation of immunological changes to MRI and clinical outcome parameters as well as response to treatment will be presented. Interpretation: sTNF-RII and sVCAM-1 levels in the serum of SPMS patients are reliable and stable biological markers of subcutaneous IFNb-1 therapy and could be promising candidates for long term monitoring of treatment. The clinical relevance of these markers will be discussed upon final data analysis at the meeting. This study was supported by Schering AG.

189 Monthly high dose methylprednisolone pulse therapy in patients with multiple sclerosis: An MRI controlled study with single cross over design. T. Kª E. Schumann, F. Then Bergh, M. Gottschalk, D. Auer, F. Holsboer, C. Trenkwalder (Mª D) In this study we investigated the effect of monthly high dose methylprednisolone pulse therapy on disease activity in MS patients. Primary outcome measures was the number of active lesions in monthly Gd-enhanced cerebral MRI scans. Corticosteroids are ah accepted and effective treatment for acute relapses in MS patients and lead to a rapid reduction of Gd-enhancement in acute demyelinating lesions. However, the effect of pulsatile corticosteroids treatment on Gd-enhanced active lesions in monthly cerebral MRI scans has not been investigated. 10 MS patiems have been investigated using a single cross-over design. The first 6 months, patients were observed clinically and by Gd-enhanced cerebral MRI scans. Patients with active disease (3 new lesions in 6 monthly scans) were then included for therapy (6 months, once monthly 500 mg methylprednisolone i.v. and oral taper with 40 mg, 20 mg, 10 mg one day each). Disease activity was compared between the observation- and treatment periods in every individual patient. At the beginning and at the end of therapy, in all patients a neuroendocrinological testing a n d a bone-density measurement was performed. Treatment with monthly high dose methylprednisolone led to a significant 49,7 % reduction in the number of active lesions in Gd-enhanced MRI comparing the mean number of active lesions before and during therapy (mean of active lesions before therapy 4.9, mean under therapy 2.5; p < 0.Q5). The effects were heterogeneous in the individual patients. 6 patients exhibited a clear reduction (mean: 62%) of active lesions, whereas 3 patients showed only a slight decrease (mean: 28 %) of the disease activity in the MRI. One patient showed a slight increase (21%) in new Gd-enhancing lesions. None of the patients deteriorated clinically during the therapy. Treatment with monthly high dose methylprednisolone was well tolerated by all of the patients. The most frequent side effects were a flush-like feeling immediately during or after infusion of 500 mg methylprednisolone and sleep disturbance the same night. Bone mineral density was unchanged at the end of therapy. Monthly pulsatile high-dose methylprednisolone therapy is effective in the reduction of active lesions in Gd-enhanced cerebral MRI scans. Further studies with an extended study population are necessary to confirm this observation.

190 Magnetic resonance imaging results of a randomised double-blind placebo-controlled treatment trial of hydrolytic enzymes in relapsing multiple sclerosis, la. Freitag, L. Kappos, U. Baumhackl, M. Daumer, A. Guseo, J. Mertin, G. Stauder, E.W. Radue (Basel, CH; St. P61ten, AT; Munich, D; Szekesfehervar, H; Bad Windsheim, Geretsried, D) Objective: To evaluate the effect of orally administered hydrolytic enzymes (HE) on magnetic resonance imaging (MRI) measures of disease activity in patients with relapsing multiple sclerosis (MS). Background: Uncontrolled evidence suggested positive clinical effects of orally administered HE in patients with MS. Oral administration of HE prevented the development of experimental allergic encephalomyelitis (EAE). Patients and Methods: 306 patients with relapsing MS were recruited from 22 European centers into a randomised double-blind placebo-controlled treatment trial of orally administered hydrolytic enzymes (90mg Bromelain, 48 mg Trypsin and 100 mg Rutosid • 3H20). Study duration was two years. Brain MRI scans were performed at Baseline, Month 12 and 24. Number of gadolinium (Gd) -enhancing lesions in T1 weighted (T lw) scans, lesion load in T2 weighted (T2w) sequences and the number of new lesions on T2w scans after 12 and 24 months of treatment was determined without knowledge of the clinical data in the MS-MRI Evaluation Centre Basel. Results: Baseline scans of 261 patients could be evaluated. At baseline placebo and active treatment group were well matched for demographic, clinical and MRI variables. Relative median T2w lesion load change over the two years period was 0.99 for each of the two groups. Over the study period oftwo years the cumulative number ofnew lesions on T2w scans was similar for both study groups (mean 10.0 vs. 11.2, n.s.). The percentage of enhancing scans was at Baseline/Month 12/Month 24 for placebo 43%/40%/43% and for HE 47%/49%/37% (n.s.). Baseline EDSS correlated significantly with T2w lesion load (SRCC=0.24). Baseline number of Gd-enhancing lesions was correlated with the attack rate of the following year (SRCC=0.26). Conclusion: No treatment effect between placebo and HE groups could be seen for all MRI parameters. In comparison with most other trials both clinical results and the evolution of MRI measures indicate a more benign disease course in both, placebo and active treatment group. The power of the study may not have been sufficient to detect a therapeutic effect in this pop-

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ulation. The validity of the MRI evaluation is confirmed by correlations between different MRI and clinical parameters. The study was supported by MUCOS Pharma Ltd. Geretsried, Germany.

curnulative dose less than 140 mg/m / (maximum cumulative dose recommended by the FDA), MITOX seemed safe and well tolerated.

191 A Cochrane review of recombinant interferons trials in relapsing remitting multiple sclerosis. G. Rice, B. Incorvaia, L. Munari, G. Ebers, C. Polman, R. D'Amico, G. Filippini (London, Ontario, CDN; Milan, I; Oxford, Amsterdam) Background: Recombinant interferons have been shown to suppress both clinical and MRI measures of disease activity in patients with relapsing-remitting multiple sclerosis (RRMS). Objectives: We performed a Cochrane review of all the randomised, placebo-controlled trials of recombinant interferons in RRMS. We searched for randomised, double-blind, placebo-controlled trials of RRMS patients who were treated with recombinant interferon given by the subcutaneous or the intramuscular route. Search strategy: We identified 208 articles (Medline 124, EMBASE 23, CENTRAL 14, Handsearching 45, unpublished 0, drug manufacturers 0). After detailed reading, seven trials met all the pre-defined criteria and these trials contributed to this review. Data collection & analysis: The quality of these seven trials was highly variable, with substantial shortfalls in allocation concealment, number of patients withdrawn of lost to follow-up and the execution of intention to treat analysis. Baseline characteristics were largely comparable between treatment and placebo groups. Because of prominent treatment-associated side effects, easily identified by patients, these trials should be considered single blind. Main results: The meta-analysis identified a significant effect on the proportion of patients experiencing at least one attack at one year (5 trials, odds ratio = 0.44 [95% CI = 0.32,0.61] p < 0.00001) and at two years (2 trials, OR= 0.47 [0.33, 0.67], p=0.00003). Only two trials contributed data on the effect on confirmed disability at 2 years (OR 0.62 [0.44, 0.89], p=0.009). Disability outcomes were sensitive to the assignment of dropouts and the definitions of treatment failure in the individual trials. It was difficult to perform a quantitative meta-analysis on MRI data because of changing MRI parameters and inconsistent reporting of MRI data across trials. Adverse events were always more frequent in interferon-treated groups. For example, the syndrome of influenza was more common in interferon treated patients (OR=2.31 [1.81, 2.96], p < 0.00001) as was lymphopenia (OR 2.45 [1.61, 3.71], p=0.00003). Conclusions: The effects of recombinant interferons in RRMS at 2 years on attacks and disability should be considered encouraging. It was not possible to conducta meta-analysis beyond two years. Longer trials,better identification of patient dropouts and more uniform reporting of outcome data in the published trials might have allowed for a more compelling conclusion.

192 Safety profile of mitoxantrone in a cohort of 293 multiple sclerosis patients. G. Edan, E. le Page, G. Taurin, O. De Marco, V. Kerdoncuff, E Le Duff, J. Chaperon, M. Coustans (Rennes, F) Background: MITOX, originally developed as an antineoplastic drug, has been recently approved by the FDA for the treatment of MS. Our long experience with MITOX in MS allowed us to evaluate prospectively the safety profile of this agent. Design/methods: Since 1992, 293 MS patients (112 Relapsing Remitting MS, 112 Secondary Progressive MS, 69 Primary Progressive MS), 109 males and 184 females, have been treated with MITOX in our MS Clinic. In these 3 groups (RR, SP, PP), median age at MITOX onset treatment was respectively 30, 38 and 42.5 years; median MS duration before MITO)( onset was respectively 3.8, 10.7, 6.0 years; median follow-up duration after MITO)( onset treatment was respectively 3.2,1.9,1.7 years with a follow-up duration more than 2 years for respectively 73,43 and 27 patients. MITO)(was administered either monthly for 6 courses in 68 % of the cohort followed by MITOX given every 3 months in 20 % of them, or every 3 months in 32 % of the cohort. The median and the mean cumulative dose of MITOX were respectively 120 and 106mg (approximately 72mg/m2). 48 patients received more than 120mg. 148 consecutive patients completed echocardiograms at 0, 6, 24 or 60 months. Patients underwent clinical and hematological evaluation before every MITOX course and every 6 months after MITOX withdrawal. Results: To date, there have been no instances of clinically significant toxicity: there was no evidence of clinical heart failure; however, in 2 patients there was a drop of LVEF < 50 %, detected respectively after 6 and 10 courses which led to stopping the medication. No severe infection and no case of acute leukemia or other malignancy have been encountered. Conclusions: In our experience of MS patients, treated with MITO)( at a

Oral session 32 M u l t i p l e Sclerosis - 6 193 A multicenter trial comparing clinical and MRI efficacy of interferon beta-la and beta-lb in multiple sclerosis. L. Durelli, B. Ferrero, A. Oggero, E. Verdun, A. Ghezzi, E. Montanari, M. Zaffaroni,.. and the INCOMIN Trial Study Group (Torino, Gallarate, Fidenza, Italy, I)

IFN beta is registered for MS treatment at doses ranging from 6 MIU oncea-week to 8 MIU on alternate days. Recent trials demonstrated a dose-response correlation for clinical or MRI effects both for IFN beta-la and for IFN beta-lb, buta direct comparison of the two IFNs at the registered doses is lacking. We prospectively followed up for 1 year 186 relapsing-remitting MS patients of 15 MS centers treated with IFN beta-la, 30 mcg intramuscularly once a week, or IFN-beta-lb, 8 million international units subcutaneously on alternate days. Clinical outcome measures (evaluated in open-label fashion every 6 months) were mean annualized exacerbation tate (ER), percent decrease from baseline of individual ER (delta ER), and number of patients with exacerbations. MRI outcome measures (evaluated in siugleblind fashion after 1-year treatment) were number of patients with active lesions (new T2 lesions, enhancing T1 lesions, or both). After first 6-month treatment period, patients on IFN beta-la had an ER of 0.4, an delta ER of 70 %, and 20 % patients had exacerbations; those on IFN beta-lb had an ER of 0.6, a delta ER of 60 %, and 30 % patients had exacerbations. After second 6-month treatment period, patients on IFN beta-la had an ER of 0.5; a delta ER of 50%, and 26% patients had exacerbations; those On IFN beta-lb had an ER of 0.3, a delta ER of 80%, and 14% patients had exacerbations. MRI outcome measures were, for IFN beta-la group, 33 % patients with new T2 lesions, 22 % with enhancing lesions, and 36 % with overall MRI activity; for IFN beta-lb group, 16 % patients with new T2 lesions, 9 % with enhancing lesions, and 20 % patients with overall MRI activity. ER was reduced from baseline by both drugs without significant difference. Other clinical outcome measures significantly improved during second 6-month period for IFN beta-lb group, becoming significantly better that those of IFN beta-la group. MRI outcome measures were significantly better for IFN beta-lb group. Despite some limitations of the study design, blind MRI evaluation confirmed the unblind clinical results indicating that, over the long term, IFN beta-lb reduced signs of disease activity more effectively than IFN beta-la. A longer follow-up is needed to see whether the different relative efficacy of the two IFN beta preparations will persist over more prolonged therapy. 194 A Retrospective Study in 300 Relapsing-Remitting

Multiple Sderosis (RRMS) patients receiving immunomodulating therapy (IMT). C. Caon, M.

Zvartau-Hind, M. Din, O. Khan (Detroit/Michigan, USA) Objective: To assess patient experiences and response to IMT and determine differences between academic and community neurologists treating RRMS. Background: Currently, three IMT are approved for use in RRMS in the U. S. Few studies have addressed patient experiences with IMT and factors influencing treatment choices. Moreover, there may be differences in prescribing IMT for RRMS between academic and community neurologists. Methods: 300 consecutive RRMS patients receiving IMT (100 each on interferon beta- 1a 6 MU IM once weekly or IMTA, interferon beta- lb or IMTB, and glatiramer acetate or IMTC) were interviewed and charts were evaluated in a retrospective fashion. Eligibility criteria included clinically definite RRMS, treatment naive prior to current IMT, and uninterrupted treatment with current IMT for at least 2 years. Annual relapse tate (prior to IMT) and while receiving IMT for 2 years were obtained from charts. Questions regarding various factors influencing patients' inclination towards a particular IMT at the time of initiating therapy were asked including internet based information, IMT video starter kits supplied by respective pharmaceutical companies, injection frequency, and how well IMT efficacy and safety data

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was explained at the time of initiating therapy. Finally, patients were asked ir they were overall satisfied with their 2 year experience with the particular IMT. Results: Mean age was 33.3 years (n=300). 186 of 300 were women. Mean disease duration was 5.58 years (n=300). Baseline mean annual relapse rate (n=300) was 1.25 and was reduced to 0.62 after two years of therapy (p=0.0001). Individual baseline mean annual relapse rate for IMTA, 1MTB, and IMTC was 1.05, 1.32, and 1.40, respectively, and after 2 years of therapy was significantly reduced (p=O.O001) by 0.39, 0.68, and 0.78 for IMTA, IMTB, and IMTC, respectively. 180 of 300 were started on IMT therapy by community neurologists of which 72 received IMTA.62 %,68 %, and 87 % of patients receiving IMTA, IMTB, and IMTC, respectively, expressed satisfaction with their IMT (62 % vs 87 %, p=O.O01; 68 % vs 87 %, p=0.001). Conclusions: AII three IMT significantly reduced the relapse rate. The highest relative reduction in the relapse rate was seen with IMTB and IMTC. Community neurologists favoured the use of IMTA although the highest percentage of patients expressing satisfaction received IMTC. Additional data regarding various factors influencing selection of 1MT will be presented. 195 Clinical Course After Switching lmmunomodulating Therapy (IMT) in Relapsing-Remitting Multiple Sclerosis (RRMS) Patients. O. Khan, C. Caon, M. Zvartau-Hind, M. Din, R. Lisak (Detroit/Michigan, USA) Objective: To determine the clinical course in RRMS patients who switch immunomodulating therapy (IMT). Background: Three forms of IMT are available in the U. S. for treating RRMS and over 120,000 MS patients in the U. S. are receiving treatment with one of the three IMT. Usual reasons for switching IMT are lack of efficacy or unacceptable toxicity but it is not clear if patients benefit from switching therapy after failing one. Methods: 85 consecutive previously treatment na'fve RRMS patients who received interferon beta-la (IFNB-la or Avonex) at 6 MU IM weekly for at le• 18 months were retrospectively evaluated. Baseline relapse rate for 2 years prior to initiating therapy with IFN B-la was obtained from charts. AII 85 patients were then switched to glatiramer acetate or GA (20 mg) SC daily and prospectively followed for 18 to 24 months. Patients were switched because of persistently active clinical disease as determined by the treating neurologist or persistent unacceptable toxicity. Results: Mean age and disease duration were 33.7 years and 5.7 years, respectively. Annual relapse rate was 1.41 at the time of initiating therapy with IFNb-la. Mean duration of therapy and mean annualized relapse rate on IFNB- 1a was 19.7 months and 1.23, respectively ( 1.41 vs 1.23, p < 0.05). After switching to GA, mean annualized relapse rate on GA (mean duration of therapy: 19.6 months) was 0.53 ( 1.23 vs 0.53, p=O.0001 ). Mean EDSS was 3.49 at the time of initiating therapy with GA and 3.26 at the last visit (p=0.0007). 23 of 85 switched to GA because of persistent toxicity to I FNB-I a and 62 because of lack of efficacy. Subgroup analysis showed that mean annualized relapse rate in patients receiving IFNB-Ia who switched because of toxicity was 0.61 compared to 1.47 for those who switched because of lack of efficacy. There was no significant difference in the relapse rate reduction between IFNB-Ia (0.61) and GA (0.55) for the subgroup of patients who switched treatment because of toxicity. However, for the subgroup of patients who switched because of lack of efficacy, the difference in the reduction in the relapse rate between IFNB-la (1.47) and GA (0.52) therapies was highly significant (p=0.0001). Conclusions: These open-label observations suggest that RRMS patients with clinically active disease despite therapy with weekly IM IFNB-la may benefit from switching to GA. These results also suggest that treatment with GA maybe an appropriate first choice IMT in RRMS.

196 Mechanisms of action of glatiramer acetate in multiple sclerosis: Comparison of patients treated with glatiramer acetate and interferon-beta 1. S. Ragheb, R.P Lisak, I.Y Garbern, ].A Kamholz, O.A Khan, A.C Tselis (Detroit,

USA) Glatiramer acetate (GA) has been shown to be effective therapy for relapsing remitting multiple sclerosis (RRMS). GA was first shown to be effective in prevennon and treatment of experimental autoimmune encephalomyelitis (EA E), a model for MS. The exact mechanism(s) of its effect in MS and EAE is uncertain; several possibilties, based on studies in MS and EAE, have been proposed. We studied GA induced lymphocyte proliferation (LyP) in patients treated with GA for varying periods of time and compared this to untreated patients (UMS) and to patients treated with interferon-beta 1 (IFN-bl). We studied LyP to the recall antigen tetanus toxoid (TT) and to

ant-CD3, as indicators of immune reactivity. Peripheral blood mononuclear cells (PBMC) were obtained from normals (NS), UMS, patients treated with GA for up to 24 months (mos), and patients treated with 1FN-bl.LyP was assayed by incorporation of tritiated thymidine and quantitated asa Stimulation Index (SI), defined as cpm in the presence of stimulant/cpm of unstimulated cells. A significant response was SI > 3.PBMC of 17/22 NS proliferated to GA (mean=8.8; median=5.2) as did 38/43 UMS (mean=15.4, median= 10.7). PBMC of all NS proliferated to anti-CD3 and 15/17 to TT. PBMC of all UMS proliferated to anti-CD3 and TT. In GA treated patients, 417 had LyP at 1-4 mos (mean=lS.8); 3/5 at 5-8 mos (mean=4.4); 4/6 at 9-12 mos (mean=8.2); 4/6 at 17-20 mos (mean=3.2) and 1/6 at 21-24 mos (mean=l.6). In IFN-bl treated patients, 2/3 had LyP at 1-4 mos (mean=28.9); 617 at 5-8 mos (mean=8.5); 8/11 at 9-12 mos (mean=6.0); 5/5 at 13-16 mos (mean=15.4); 3/4 at 17-20 mos (mean=15.5) and 2/3 at 21-24 mos (mean=33.8). LyP to TT and anti-CD3 was essentially positive in all subjects. For comparison, PBMC of 5/17 patients treated with GA for > 60 mos (mean=2.4; median=2.0) and 13/17 patients treated for > 60 months with IFN-bl (mean= 18.5; median= 12.0) proliferated to GA.Treatment of patients with MS with GA resuhs in decreased LyP to GA by PBMC. LyP is markedly decreased by 21-24 mos and is virtually absent in most patients treated longterm; patients treated with IFN-bl do not show this effect. Studies are underway to determine the mechanisms involved in the alteration of the LyP at different time points. It is possible the early effect is caused by a shift of the LyP from TH 1 to Th2 cells whereas the virtual abolishment of LyP with prolonged therapy could represent either clonal anergy or deletion.

197 Results of the European Interferon beta-la (Avonex) Dose-Comparison Study. M. Clanet, L. Kappos, E. W. Radue, H. P. Hartung, R. Hohlfeld, P. Rieckmann, M. Sandberg-Wollheim, M. E Kooijmans, P. Slasor, N. A. Simonian (Toulouse, F; Basel, CH; Graz, AT; Munich, Wurzburg, D; Lund, S; Cambridge, MA, USA) Objective: This dose-comparison study was undertaken to determine whether a higher dose of Interferon Beta-1 a (IFNB-1 a) is more efficacious in Relapsing Multiple Sclerosis (RMS) than the currently approved dose of 30 mcg. Background: Avonex a t a dose of 30 mcg intramuscularly (IM) once weekly (QW) slows physical and cognitive disability progression, reduces relapses, reduces conversion to clinically definite MS, and decreases lesions on MRI scans. Studies of IFNBs at different dosing regimens have suggested a ceiling effect. But until now, studies designed solely to answer this question have not been performed. Design/methods: The Avonex Dose-Comparison Study was a multinational, randomized, double-blind trial, carried out at 38 sites in 10 European countries. Patients were randomized to receive 30 or 60 mcg Avonex IM QW, and the study duration was a minimum of 3 years. Key entry criteria included clinical diagnosis ora laboratory supported diagnosis of MS, relapsing course with 2 relapses in the past three years, and baseline Expanded Disability Status Scale (EDSS) score of 2.0-5.5. The primary study endpoint was the rate of neurologic disability progression as defined by a 1.0 point increase in EDSS or reaching an EDSS of 6.0, sustained for 6 months. Additional clinical endpoints included rate of reaching an EDSS score of greater than or equal to 4.0 or greater than or equal to 6.0, the amount of change in EDSS scores from baseline, IV steroid use and the 9 Hole Peg Test (9 HPT). MRI scans were performed on annual or frequent basis in cohorts of patients. Results: 802 patients were enrolled in the study and 678 (85%) patients completed 3 years of follow-up. Thirty mcg and 60 mcg were equally effective, and there was no statistically significant difference or trend in efficacy between 30 mcg and 60 mcg on any of the clinical outcome measures. Furthermore, there was no evidence that the higher dose was more effective in certain subgroups of patients based on EDSS scores at baseline, or on gadolinium (Gd) activity on their MRI at baseline. The incidence of neutralizing antibodies (NABs) was less than 6% in both groups. Conclusions: This is the first study of IFNB in MS designed solely to address the issue whether a higher dose is more effective. These results demonstrate that IFNB-la 60 mcg is no more effective than 30 mcg IM QW. These results support a ceiling effect in dosing with IFNB. Study supported by: Biogen, lnc.

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198 The European Study on Enzyme Therapy in Multiple Sclerosis (ESEMS). U. Baumhackl, J.Mertin, L.Kappos,E. W.Radue, P. Freitag,A.Guseo, M.Daumer, G. Stauder (St. Poelten, AT; Bad Windsheim, D; Basel, CH; Sz›233225 H; Munich, Geretsried, D) Background and goals: Oral hydrolytic enzymes (HE) act especially by modulating the immune system. Prevention of murine experimental allergic encephalomyelitis is possible. We undertook a double-blind, placebo-contro]led multicenter study in relapsing Multiple Sclerosis (MS) to investigate efficacy, safety and tolerability of HE (1 tablet contained 90 mg Bromelain, 48 mg Trypsin and 100 mg Rutoside • 3H20). Methods: 306 patients from 22 centers in 11 countries, age between 15 and 50 years, with clinically definite or laboratory definite MS of at least 1 year duration, a relapsing course and Kurtzke expanded disability status scale (EDSS) scores between 1,5-5,5 were randomly assigned either HE or placebo, 6 tablets per day for 2 years. Neurological examinations were carried out after 1 and 3 months and thereafter at quarterly intervals. Main objective: to test differences in the EDSS absolute change at study end. Other efficacy criteria were the relapse rate per year, time to relapse and time to deterioration. Secondary endpoints: MRI-results (will be presented elsewhere). Results: Of the 306 patients who had been randomised, 289 entered the intent-to-treat analysis. 216 had a relapsing - remitting (RR), 73 a relapsing - progressive (RP) course. 21 patients (11 in the HE group, 10 in the placebo group) discontinued the study prematurely. RR-patients: 18,6 % showed ah improvement under HE,21,6 % ah increase of the EDSS. The placebo-treated patients improved in 18,8% and deteriorated in 25,4%. The results of the patients with RP course of the disease were similar. The annual attack rate during the study was 0,50 for patients under HE therapy and 0,49.for placebo. Conclusion: No treatment effect between groups eould be demonstrated. However, many patients seemed to have a surprising benefit from participating in this large study. The true size of this effect could, however only be estimated by a comparison with high-quality natural history data. Due to the minimal side effect of the study medication, this trial can be considered as truly double blind. The study was supported by MUCOS Pharma Ltd. Geretsried, Germany. 199 The effect of Autologous haematopoietic stem cell transplantation on serial gadolinium-enhanced MRI in severe cases of multiple sderosis. G. Mancardi, R. Saccardi, A. Murialdo, M. inglese, E Gualandi, L. Massacesi, M. Marrosu, G. Meucci, A. Lugaresi, A. Marmont, M. Filippi (Genova, Florence, Cagliari, Pisa, Chieti, Milano, I) Introduction: Autologous haematopoietic stem cell transplantation (AHSCT) is now evaluated a s a possible alternative treatment in severe multiple sclerosis (MS) cases. Information on the effect of AHSCT on laboratory markers of disease activity such as Magnetic Resonance Imaging (MRI) ate however lacking. Objective: to obtain data on the activity of AHSCT on serial triple dose (TD) Gadolinium (Gd)-enhanced MRI and information on clinical course, feasibility and safety in a population of severe and active MS cases. Methods: in 10 secondary progressive MS patients showing both a EDSS ranged 5-6.5 and documented clinical signs of rapid deterioration over the last year, refractory to conventional treatments, peripheral blood progenitor cells were mobilized with Cyclophosphamide 4 g/m 2 foUowed by G-CSF 10 9g/Kg. The graft was in vivo T depleted with rabbit ATG (5 mg/kg at +1 and +2), following the ablative regimen (BEAM). These cases were submitted to serial monthly TD Gd-enhanced MRI f o r a pretreatment period of three months compared with serial monthly TD Gd-enhanced MRI for the subsequent 6 months period. Then TD Gd-enhanced MR is carried out every three months until month 24. Results: The follow up after AHSCT is now 15 months (range 4-30). We observed in all cases transplanted a complete disappearance of MRI Gd + enhancing lesions in the months following the conditioning regimen. A marked decrease of the number of Gd + lesions was already apparent after the mobilization treatment. The clinical condition remained unchanged or slightly improved. Conclusion: The present data suggest that AHSCT abrogates MRI disease activity in severe secondary progressive MS cases and this effect is sustained with time. The final impact of the procedure on the disease course remains to be established.

Oral session 33

Neuro-oncology - 1 200

Combined Systemic and Intraventricular Chemotherapy in Primary CNS Lymphoma. H. Pels, A. Glasmacher, H. Schulz, A. Zellner, F. Kroschinsky, G. Schackert, M. Vogt-Schaden, A. Ho, J.A. Kraus, T. Klockgether, A. Engert, I. G. H. Schmidt-Wolf, U. Schlegel (Bonn, Cologne, Regensburg, Dresden, Heidelberg, D) Objectives: To evaluate response rate, response duration and toxicity after systemic and intraventricular chemotherapy in primary central nervous system lymphoma (PCNSL). Patients and Methods: Since 1995, 40 consecutive patients with PCNSL (mean age 58 years, range 27 to 72 years) were enrolled in a study evaluating chemotherapy without radiotherapy. A high dose methotrexate (HD-MTX) (cycles 1, 2, 4, 5) and cytarabine (ara-C) (cycles 3, 6) based systemic therapy (including dexamethasone, vinca-alkaloids, ifosfamide and cyclophosphamide) was combined with intraventricular MTX, prednisolone and araC (via an Ommaya reservoir). Results: Complete response (CR) was achieved in 24 (60 %) and partial response (PR) in 4 (10%) patients. Seven patients (17.5%) showed progressive disease (PD) and tire (12.5 %) died from treatment related complications. Observation time is zero to 59 months (median 13.5, mean 13.3 months). Kaplan Meier estimate for median time to treatment failure (TTF) is 33 months, for median survival 55 months. Systemic toxicity was mainly hematological. Ommaya reservoir infection occurred in six patients and transient MTX induced encephalopathy in three. Permanent cognitive dysfunction due to treatment was seen in one patient only after 12 cycles (six at relapse). Conclusions: Primary chemotherapy based on HD-MTX and ara~C is highly efficient in PCNSL. Treatment related systemic toxicity is considerable, particularly in older patients. However, permanent treatment associated neurotoxicity is infrequent. 201 Initial diagnosis of primary central nervous system lymphomas: MRI features in an European population. U. Bª U. Herrlinger, T. Krings, R. Thiex, M. Weller, W. Kª (Tª Aachen, D)

Pre-treatment MRI examinations of 40 immunologically competent patients with primary central nervous system lymphoma (PCNSL) were evaluated (24 female, 16 male, median age 63 years). Seventy lesions were found (mean size 19.9mm). The number of lesions ranged from one (n=25) to six (n=l). The most frequent locations were the cerebral hemispheres (n=22), the corpus callosum and the basal ganglia (n=11). Cerebellar manifestations were found in 10 patients. Contrast enhancement was observed in all lesions. A1though 39 patients had lesions adjacent to the CSF space, leptomeningeal spread was only present in tire patients. Necrosis was seen in two lesions only. Oedema was rated as extensive in 24 patients, moderate in 11 patients and absent in five patients. In conclusion, contrast-enhancing intracerebral lesions in contact with the subarachnoid space and without necrosis are characteristic of PCNSL. 202 Survival Of Patients In Cancer Registry Of The Institute "C. Besta". G. Filippini, B. Incorvaia, M. Farinotti (Milan, I)

Central nervous system (CNS) tumors account for only a small percentage of all cancers but the effects of these tumors can be devastating and variation in the diagnosis, treatment, and care of CNS tumors may have a dramatic influence on the prognosis of these patients. The Cancer Registry of the Neurological Institute "C. Besta" was established in 1997 to provide hospital-based follow-up data on all primary tumors,benign and malignant. While not population-based, this data set is the only large Italian source for survival data on malignant and benign CNS tumors. The Registry identifies all newly diagnosed cases, conducts follow-up on all primary brain tumors and contains complete information regarding treatment of these tumors. It provides an extensive description of tumors at diagnosis and includes recurrence and other information on outcomes. Histology is coded using the ICDO classification. At June 2000, the Registry included 1308 incident cases: 52 % malignant tumors, 43 % benign and 5 % atypicaL

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Survival probability for a malignant CNS tumor was 64% at 1 year and 43% at 2 years and the median survival time was 18 months (95% C.I. 15-20). Age, histological type and type of surgery resulted the most significant prognostic factors for aduh patients. Survival at 1 year deereased significantly with increasing age (87% and 28% for patients aged 15-44 and > 65 years respectively) with a mortality risk eight times higher for older compared to younger patients. Median survival for anaplastic astrocy'tomas and glioblastomas was 15 (95 % C. I. 11- 19) and 14 months (95 % C. I. 12-16) respectively. Survival probability of patients with a meningioma was 95 % at 1 year and 92 % at 2 years. Cerebral biopsy or partial surgery resulted associated with a lower sur viral compared to radical surgery in patients with a malignant tumor with a risk of 0.65 for total surgery compared with partial surgery, i.e. a decreased risk of 35%. These results suggest that survival of patients with a malignant CNS tumor is increasing. The basic question that remains to be answered is: how much of the improved average survival is due to better treatment, to more effective treatment because of earlier diagnosis, or iust to earlier diagnosis?

203 Ependymomas respond to chemotherapy with temozolomide. R Ruda, A Costanza, M Nobile, R Mutani, R Soffietti (Torino, I) Xenograft models document temozolomide activity against ependymoma. There are no published data in the clinical setting. In a series ofpatients with recurrent/progressive primary brain tumors consecutively treated with temozolomide as salvage chemotherapy since 1998, we identified 5 patients with ependymomas. There were 3 females and 2 males, with a median age of 30 years (range 27-51). Histology at original surgery was grade [II ependymoma in 3 patients and infratentorial (IV ventricle) in 2 patients (one with leptomeningeal spread). AII patients had received prior radiation therapy and 3 of them first line chemotherapy. Al1 tumors were contrast-enhancing on MRI and the median Karnofsky Score before chemotherapy was 60 (range 50-90). Treatment consisted of oral temozolomide 150 200mg/m 2 daily on day 1-5 in cycles of 28 days. A 50% decrease of contrast enhancing area was defined as partial response. Resuhs: A median of 7 cycles of temozolomide were administered (range 3-13). We observed: 3 partial responses (decrease of tumor area of 50%, 80 % and 90 % respectively) in two patients with grade III and one with grade II tumor; 1 minor response (decrease of tumor area of 40%) in one patient with grade III tumor; 1 stable disease in one patient with grade 1I tumor. Partial responses were observed after 3 cycles in 1 patient and after 6 and 9 cycles respectively in the other two. Three out of 4 symptomatic patients improved in their neurological symptoms and signs (headache, seizures, ataxia). Two patients unresponsive to previous chemotherapy (PCV, cyclophosphamide+VPl6) and one unresponsive to radiotherapy responded to temozolomide. One patient relapsed after a partial response lasting 3 months, whereas the remaining are free of progression at 4, 6, 12 and 13 months. As for toxicity 2 patients had grade 111 myelotoxicity. Conclusions: Ependymomas seem to respond to temozolomide chemotherapy, even if unresponsive to previous radiotherapy and chemotherapy.

204 Outcome and quality of iife after medulloblastoma treatment in developmental age: a 5 years follow up. E. Castelli, G. Poggi, M. Massimino, S. Bernasconi, M.-R. Liscio, S. Tadeo, V. Badioni, E Fossati (Bosisio Parini, Milan, l) Background: Medulloblastoma accounts for 4-8% of primaty brain tumours of neuroectodermal origin, being 20-30% of brain tumours in developmental age.At present, 50-60 % of patients survive for up to 5 years, and 35-45 % for up to 10 years, due to the combined use of cbemo- and radiotherapy treatments. Survivors areat risk for complex and multiple disabilities and psychoIogical disorders. Ob)ectives: to study outcome in patients survived to medulloblastoma diagnosed in developmental age, in order to evaluate their global functioning, cognitive and psychological sequelae and quality of life, looking for possible correlation among clinical variables and rehabilitative suggestions. Materials ad methods: from a larger group we selected 27 patients (16 male and 11 female) treated for medulloblastoma who received a complete multidisciplinary evaluation including cognitive, psychological and quality of life assessment. Each patient's neurological history (pre- and peri-operative) was scored using the Neurological Severity Score (NSS). Dailyliving autonomy was assessed using FIM and WeeFIM rating score (WFrs). Quality of life was evaluated using Bloom classification and EuroQoL Scale. All data were submitted to statistical analysis. Results: Mean age at diagnosis was 8.5 SD 4.5 years. Mean time between

diagnosis and our follow up was 5.3 SD 4.1 years. After neurosurgery, all but one underwent chemotherapy and radiotherapy. Mean NSS was 4.7 SD 2.3 (range 1- 11). At follow up neurological eva,luation 44 % of patients had pyramidal deficits while 81% had ataxia. 9,5 % of patients hada visual acuity < 4/20. Mean Full IQ was 86.9 SD 23.7, with a higher impairment of Perfi)rmance IQ (83.3) than of Verbal IQ (90.8). 30 % of patients had mental retardation (FIQ < 70). We detected in 24 % of cases a language disorder, in 33 % a memory impairment, in 6 1% an executive function deficit and in about hall patients a learning disabilities. Behavioural alterations were present in 61% of patients. The mean WFrs score was 77.5 (range 17-100). A good quality of life was reported by 71% of patients. A statistical significant direct correlation was found between NSS and quality of life scores (p < 0.001). Conclusions: Outcome after medulloblastoma treatment appears quite good for daily living autonomy but it is worse in cognitive and psychological fields. Rehabilitation can play ah important role in reaching a quicker and better recovery.

205 Applications of 1.5T MRI to gene therapy of malignant gliomas in animals models. M. G. Bruzzone, C. Regna-Gladin, I. Milanesi, L. Caposio, M. Cora, P. Tunici, L. Farina, M. Savoiardo, G. Finocchiaro (Milan, I) Rat brains, harbouring experimental malignant gliomas (C6 glioblastomas, and 9L gliosarcomas), t ransduced with the genes for 2 cytokines, interleukin 4 and interleukin 12 (IL-4 and li.- 12), that may have antitumour effect, were studied by MRI and histology. Seventy-four anirfials underwent MRI, 59 treated by IL-4, 8 by IL-12, and 7 controls (animals implanted with untransduced tumours). Our airo is to describe the MRI findings observed in the follow-up of these experiments. A 1.5 T equipment, normally employed in clinical practice and, therefore, easily accessible, allowed to monitor the effects of the therapy. The features of the tumour, i. e. signal changes, mass effect and pattern of post-contrast enhancement, have been defined. The MRI aspects of inflammation, trace of injection of tumour cells, scar process could be differentiated. In all cases, a strong correlation between the M R images and the clinical and pathological pattern was found. The best resuhs of treatment were obtained in 9L cancer. Seventy percent of the animals with 9L cancer, treated with high dose IL-4, rejected the tumour. The images show that the tumour, which kills the control animals within one month, shrinks to the point of disappearing in the animals treated with IL-4 or IL-12. In long-term survivors challenged with a new dose of neoplastic cells, rejection of the tumour was demonstrated. This can be considered asa proof of immunological memory induced by therapy. We could demonstrate that 1.5 T MRI allows diagnostic images of the tumour and its evolution after the therapy. By being able to choose,on the basis of MRI findings, the best timing for histological and immunohistochemical exams, which are necessary to show the immunological response of the host against cancer, we could reduce the number of sacrificed animals in the experiments.

Oral session 34 Neuro-oncology-2 2O6 Application of the ELISPOT Assay to Examine Cytotoxic T Lymphocyte Responses to cdr2-[ and cdr2-2 in Three Patients with Anti-Yo Antibodies and Cerebellar Degeneration. 1. J. Sutton, l. C. Steele, C. O. Savage, ]. B. Winer, L. S. Young (Birmingham, UK) Background: Anti-Yo antibodies react with a 62kDa Purkinje cell antigen (Yo antigen) and are found in the serum of a sub-group of patients with Paraneoplastic Cerebellar Degeneration (PCD). Post mortem studies on patients with PCD and anti-Yo antibodies reveal Purkinje cell loss. However, anti-Yo antibodies do not appear 1o be involved in the pathogenesis of PCD. Two nine amino acid sequences (cdr2-1, KLVPDSLYV and cdr2-2, SLLEEMLFT) derived from the Yo antigen contain the appropriate anchor residues for binding stability with HLA-A*0201 and using diiect and recall 51Cr release assays Albert et al. [1] have identified cytotoxic T lymphocyte (CTL) responses to cdr2-1 and cdr2-2 in three patients with anti-Yo antibodies and PCD.

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Objective: To delermine whether the cdr2-1 and cdr2-2 specific CTL responses could be delected using an lnterferon-gamma Elispot assay. Methods: An lnlerferon-gamma Elispot assay was used to examine peripheral blood mononuclear cells (PBMCs) from three HLA-A*0201 positive/anti-Yo antibody positive patients with PCD for reactivitywith peptides cdr2-1 and cdr2-2. As most HLA-A*0201 positive individuals show reactivity to the HLA-A*0201 restricted peptide GLCTLVAML(GLC) (derived from Epstein Barr Virus antigen BMLF-1), this peptide was used asa positive control. Resnhs: No responses to cdr2-1 or cdr2-2 were identified in three HLAA'~0201/anti-Yo antibody positive patients with PCD or three healthy HLAA*0201 controls. All patients and controls responded to GLC (Patients; 117, 394,420 spots/1OA6 PBMCs. Controls; 149,372,500 spots/10^6 PBMCs). Conclusion: lnterferon-gamma Elispot assay is a more sensitive investigation than both direct and recall 51Cr release assays for the detection of CTL responses [2], however, ir was not possible to detect responses to cdr2I and cdr2-2 in three HLA-A*0201+ patients with anti-Yo antibodies and PCD. CTL reactivity with peptide epitopes other than cdr2-1 and cdr2-2 may be important in the pathogenesis of PCD and further epitope screening studies need to be undertaken. References 1. Albert ML, et al. (1998) Nat Med 4:1321-4 2. Hickling IK (1998) Exp Rey Mol Medwww.ermm.cbcu.cam.ac.uk

207 ModelIing paraneoplastic disease: Onconeuronal antigen specific T celis mediate encephalomyelitis in the rat. H. Pellkofer, A. Schubart, M. Pagan},, H. Lassmann, R. Hohlfeld, R. Voltz, C. Linington (Martinsried, D; Vienna, AT; Munich, D) Background and goals: Antibodies directed against onconeuronal proteins provide a specific diagnostic marker for paraneoplastic neurological syndromes, and suggest that these autoantigens are targeted during disease pathogenesis. However, so far attempts to generate autoimmune models of these syndromes were unsuccessful. Here we show that the adoptive transfer ofT cells specific for the autologous onconeuronal antigen Mal cause encephalomyelitis in the Dark Agouti (DA) rat. Methods: Rat Ma 1 (rMa 1) was cloned by RT-PCR initially using primers specific for the human Mal sequence and was completed by 5' and 3' genome walking, rMal was cloned into the expression vector pQE60, and recombinant protein purified by metal chelate chromatography. Female DA rats were imrnunized with recombinant rMal and rMal -specific T cell lines generated from the draining lymph nodes ten days p. i. Freshly activated T cell blasts were transferred into naive female DA rats which were sacrificed 8 days later. Results: Rat Mal is 93% homologous to the human Mal (corrected sequence) at amino acid level. Proliferation assays demonstrated that the CD4 positive T line cells were highly specific for rMal using a second recombinant antigen to control for reactivity with contaminating bacterial proteins. After T cell transfer the recipients did not show any clinical signs of disease, although the), developed an intense perivascular inflammatory response in the brain stem and spinal cord. The distribution of lesions, in particular the involvement of the brain stem reproduces that seen in patients with paraneoplastic CNS disease associated with an anti-Mal antibody response. Conclusion: The induction of an inflammatory response in the CNS following the adoptive transfer of rMal-specific T cells provides the first animal model for paraneoplastic neurological disorders of the central nervous system, and strongly supports the hypotbesis that these disorders in man have an autoimmune component.

208 lntracavitary VEGF, BFGF, IL-8 and IL-12 levels in primary and recurrent malignant gliomas. M. Eoli, S. Frigerio, A. Silvani, M. Ge[ati, E. Corsini, G. Broggi, A. Boiardi (Milan, 1) Malignant gliomas are strictly dependent on angioneogenesis for growth and invasiveness. Neoangiogenesis is a multistep process, controlled by bnth proand anti-angiogenic factors; VEGR bFGF and IL-8 promote endothelial cells proliferation, while 1L-12 is an inhibitory factor. 1"o assess intracavitary concentrations ofVEGF, bFGF,IL-8 and IL- 12 in patients with recurrent anaplastic astrocytoma (rec. AA), glioblastoma (GBM) and recurrent glioblastoma (rec. GBM) and to correlate the findings with clinical parameters. Intracavitary fluids were collected 21 days after surgery via an Ommaya reservoir left in the operation site in view of subsequent loco regional chemotherapy in 5 patients with rec. AA, 8 patients with GBM and 16 with rec. GBM. In a small cohort of patients (7), we quantitated also plasma levels of the investigated

factors. Dosages were performed with commercially available ELISA kits (R&D System). In rec. GBM patients, post-surgery progression free survival was correlated to intracavitary concentrations of VEGF, IL-8 and IL-12. A marked interindividual variability was observed; although plasma levels of bFGF, VEGF and IL-8 were higher in patients than in healthy controls (p < 0.004 by Mann-Whitney U test for bFGF), no clear cut correlation emerged between intracavitary and plasma concentrat ions. On the whole,a higher propor tion of patients with elevated int racavitary VEGF,I L- 12 and IL-8 was seen in patients with GBM and rec. GBM as compared with rec. AA. In the 13 rec. GBM patients with a post-surgery progression-free survival longer than 3 months,higher baseline intracavitaryVEGF and I L-8 were related to a shorter PFS,whereas the opposite was true for IL- 12.The findings further confirm the relevance of VEGF in tumour evolution in our cohort of malignant glial tumours. Little is known about intracavitary IL-8 and IL-12 in these patients; our results suggest that alsc~these cytokines are released in the context of the tumour and may have a biological meaning in the regulation of the angiogenic switch,possibly providingbiological markers ofoutcome.A serial study is ongoing to test this last hypothesis.

209 Elevated CSF leveis of soluble vascular adhesion molecule (sVCAM-I) in primary central nervous system lymphomas. S. Frigerio, M. Eoli, A. Silvani, M. Gelati, E. Corsini, B. Zappacosta, A. Boiardi, A. Salmaggi (Milan, I) Adhesion molecules playa crucial role in the immune system and their soluble counterparts have been suggested to represent a mechanism for malignant cells to escape immune surveillance and to promote tumour dissemination by inhibiting the action of the receptor-ligand pairs. Primary central nervous system lymphoma (PCNSL) is a non Hodgkin's lymphoma limited to the central nervous system, which lacks a regular lymphatic system: adhesion molecuIes could playa role in promoting t ransformation of B cel~s in a monoclonal neoplastic slate. A previous study showed that expression pattern of adhesion molecules by tumour cells did not differ between primary CNS lymphoma and cytologically similar systemic lymphomas. Furthermore in systemic non Hodgkin's lymphoma, serum sVCAM-1 and slCAM-1 levels are frequently elevated and associated with poor prognosis. To our knowledge no data are available about soluble adhesion molecules in PCNSL. We investigated sVCAM-1, slCAM-land slCAM-3 in the serum and CSF of 14 PCNLS, in 12 patients with other neurological diseases and (serum only) in 12 healthy controls. Al variance with systemic non Hodgkin's lymphomas we did not find an increase of slCAM- 1 in serum: in CSF the molecule was detectable only in 2 cases. No difference was found also in slCAM3 levels in serum or CSF between patients and controls.A significant increase ofCSF VCAM-1 was observed in PCNSL patients (22 -i--5,1 versus 14 + 1,9,p < 0.01 ). However in PCNSL sVCAM-I levels did not seem to correlate with clinical outcome or disease stage.

210 Allelic Iosses on chromosome lp and 10q as predictor factors of survival in mixed oligoastrocytoma. B. Merciai, M. Eoli, B. Pollo, A. Silvani, E. Salsano, A. Boiardi, G. Broggi, A. Fuhrman, G. Finocchiaro (Milan, 1) Oligoastrocytomas are heterogeneous tumours with uncertain clinical management and prognosis. Loss of genetic material on chromosome lp is a genetic hallmark of o•igodendrogliomas associated with chemotherapeutic response and prolonged overall survival. Conversely the loss of heterozygosity (LOH) on chromosome 10q is a relative frequent event in anaplastic astrocytomas frequently involved in the progression to secondary gliob[astoma. To investigate the diagnostic and prognostic implications of these alterations in mixed gliomas, we studied LOH by amplification of at least one microsatellite of chromosome lp or 10q on lymphocyte and tumour DNA from 24 oligoastrocytoma ( 16 anaplastic, 8 low grade, AnOA and OA respectively) and 6 oligodendrogliomas (4 anaplastic, 2 low grade, AnO and O). Heterozygosity with markers on lp was Iost in 5/16 AnOA and 414 AnO and maintained 11/16 AnO 818 OA and 2/20. lnformative data with 10q markers were obtained in 17/30 cases. Interestingly LOH on 10q was only detec•ed in 5 AnOA, always in the absence of LOH on lp. In oligoastrocytoma patients time to tumour progression (TTP) did not differ significantly between those patients with LOH on lp and those without. While LOH on 10 q was associated with a poor prognosis in 4/5 patients tumour recurrence, despite radiotherapy occurred within two years The data suggest that LOH of lp and 10q are mutually exclusive events that arise during the malignant progression of oligoastrocytoma and oligodendrogliomas.

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211 Paraneoplastic neuroiogical syndromes associated with non-organ specific auto antibodies - a report of 4 cases. F. Blaes, J. Kraus, N. Sieweke, M. Klotz, P. Oschmann, M. Kaps (Giessen, Homburg, D)

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Paraneoplastic neurological syndromes (PNS) ate remote effects of cancer. Clinically, every part of the central or peripheral nervous system can be involved. Since autoantibodies directed against neuronal and tumour cells have been described in these patients, an autoimmune etiology is discussed in these syndromes. Antineuronal antibodies ate detectable in more than 2/3 of these patients and low-titter non-organ specific autoantibodies have been found frequently in antineuronal antibody-positive PNS patients. Here we report four patients with PNS and high-titter antinuclear of antimitochondrial antibodies without detectable antineuronal antibodies. One patient had limbic encephalitis (LE) and small cell lung cancer (SCLC) and three patients had sensomotoric neuropathy (NP), associated with breast cancer (2 patients) or SCLC (1 patient). The LE-patient had high-titter antimitochondrial antibodies (AMA) in the serum and CSF. Calculating antibody-specificity index, an intrathecal synthesis of the AMA could be demonstrated. The three NP-patients had high-titter antinuclear antibody in the serum and CSF, but no intrathecal synthesis was detectable. Western Blot analysis showed that all antigens were expressed in the tumour and brain tissue, but also in Hep-2 and HEK-cells, which have been used as non-neuronal control cell lines. No specific antineuronal antibodies were detectable in any of these patients. The LE-patient had an almost complete remission after steroid therapy, whereas two of the NP-patients showed a partial remission after plasmapheresis. Only one NP-patient with breast cancer did not respond to any therapy. Our results indicate that PNS can be accompanied exclusively by hightitter non-organ specific antibody. These patients seem to have a better response to immunotherapies.

Muscle disorders

212 Recurrent intramedullary fibrillary astrocytomas : pathological and treatnŸ considerations, functional outcome in a serles of 33 cases. F. Parker,

Ph. David, N. Aghakhani, M. Hurth, C. Lacroix, M.C. Petit, D. Adams, M. Tadi› (Service de Neurochirurgie, H6pital Bic› Universit› Paris-Sud, France). Primary intramedullary gliomas are rare tumors with ah approximate annual incidence of 1 per 500,000 inhabitants. From 1972 to 1995, we have treated 65 fibrillary nonpilocytic intramedullary astrocytomas (lA) and selected for this study 33 patients with complete pre and postoperative MRI studies and minimum follow-up of 4 years (average: 5 years). Surgical resection as complete as possible was performed by an experimented neurosurgeon in all cases. Anatomical results: Group without recurrence (group 1): based on clinical and MRI follow-up, 22 patients (67% of cases) had no reeurrence. The histological distribution (WHO) in this group was: 15 grade I of II, 7 grade III. Initial tieatment was based on a complete resection in 19 cases, partial in 3 cases and radiotherapy in 4 cases. Group with recurrence (group 2): recurrence or progression occurred in 11 patients (33 % of cases) diagnosed as having agrade II (6 cases), grade III (4 cases), of grade IV (1 case) IA. In this group initial treatment combined complete resection in 5 tases, partial resection in 6 cases and radiotherapy in 1 case. At time of recurrence reoperation was performed in 7 patients, radiotherapy in 6 patients. Functional results: On a modified McCormick scale (1) for functional evaluation, 6 months after the first surgery, 51% of patients remained stable, 43 % improved, 6 % deteriorated. At 5 years, 52 % remained stable, 30 % improved, and 18% deteriorated. 2 patients (group 2) were operated 3 times and presenta complete neurological deficit. Prognos'tic factors: Tumor subtype (fibrillary) and histological grade (low/high) are the most important prognosis factors. Low grade and aggressive surgical removal appear to be associated with improved survival and better local control whereas age, sex, tumor size and location have no significant prognosis value. Treatment guidelines: Radical removal of lA can be performed without exacerbating neurological deficit. Post-operative radiotherapy is indicated after first surgery in high grade lesions. In case of progression of recurrence, reoperation should be done ir possible, followed by radiotherapy whatever the grade and the quality of the resection. Reference McCormick PC, Torres R, Post KD, Stein BM (1990) intramedullary ependymoma of the spinal cord. J Neurosurg 72:523-532

213 Does CTG expansion size predict cardiac events and electrocardiographic progression in myotonic dystrophy? J. Nixon, N. R. A. Clarke, A. D. Kelion, D. Hilton-Jones, J. C. Forrar (Bristol, Oxford, UK) Background: Myotonic dystrophy is an autosomal dominantly inherited multisystem disorder. The underlying genetic mutation is a cytosinethymine-guanine (CTG) triplet repeat expansion in the myotonic dystrophy gene. Although most patients present with neurological features, cardiac complications are well recognised including arrhythmias and sudden cardiac death. Prediction of cardiac events is difficult. Cross sectional studies have identified a relationship between CTG expansion size and abnormalities on the electrocardiogram (ECG). To our knowledge ours is the first longitudinal study of the relationship between CTG expansion size and progression of cardiac disease Objective: To assess whether the size of the gene expansion can predict progression of cardiac conduction defects, and to identify at risk groups for cardiac events. Methods: A longitudinal study of 77 patients a t a regional muscle clinic stratified by CTG expansion size (E0 to E4), involving blind reporting of ECGs and analysis of hospital and general practitioner records for cardiac events. Mean follow-up was 4.8 and 6.2 years for ECG analysis and cardiac events respectively. Results: First degree atrioventricular block (prolonged PR interval) was present in 23% at baseline and 34% at follow-up with no significant difference between expansion classes. There was a statistically significant positire correlation between increasing expansion size, and firstly prevalence of a prolonged QRS interval (p=0.02), and secondly rate of progression of QRS interval (p=0.04). There were seven new cardiac events during follow-up. These included two cardiac deaths, giving a cardiac mortality tate of 0.4 % per patient year. Six out of seven cardiac events occurred in patients with expansions E2 of higher. No cardiac events occurred in patients with normal ECGs (0/49) (p < 0.0001). Patients having cardiac events hada higher rate of increase of the PR interval (9.9 msec/year vs. 1.6 msec/year, p=0.008). Conclusions: We have shown that in myotonic dystrophy a normal ECG is associated with a low risk of cardiac events in the medium term. Larger myotonic dystrophy gene mutations predict a higher tate of QRS broadening anda trend towards a higher incidence of cardiac events. An annual ECG combined with evaluation of cardiac symptoms is recommended in all patients with myotonic dystrophy.

214 Autosomal Dominant Limb-Girdle Muscular Dystrophy: Description Of A Phenotype. I. Mahjneh, G. Marconi, K. Bushby, L. V. B. Anderson, A. Paetau, O. Carpen, H. Kalimo, B. Udd, H. Somer (Oulu, Kajaani, FIN; Florence, I; Newcastle upon Tyne, UK; Helsinki, Turku, Vaasa, FIN) Limb-girdle muscular dystrophy with autosomal dominant inheritance (LGMD 1) are still poorly characterised, although during the last decade in some families linkages to chromosomes 1,3, 5, 6 and 7 have been shown and three different proteins (Lamin A/C, caveolin 3, and myotilin) have been implicated in these diseases. We here reporta follow-up study of two families, one ltalian and the another Finnish with 8 patients of both sexes affected by limb-girdle muscular dystrophy. The phenotype seen in these patients is characterised by: (1) Autosomal dominant inheritance. (2) Onset in the 3-5 th decades. (3) First symptoms were difficulties in running and climbing stairs. (4) The pattern of muscle involvement was characterised by early involvement of soleus, gastrocnemius, flexor hallucis longus, biceps femoris, semimembranosus, thigh adductors and gluteus maximum. (5) Later on, mild involvement of the upper limb-girdle muscles, i. e. supraspinatus, deltoid, biceps and clavicular head of pectoralis. (6) Sparing of the anterior leg muscles and the small muscles of the feet were spared as well as the dista1 upper limb muscles. (7) Slow and benign clinical course. (8) Slightly increased s-CK levels. (9) Myopathic EMG. (10) Muscle biopsy: Necrosis and regeneration with some rimmed vacuoles and normal immunostaining for known dystrophy-associated proteins. (11) Clinically different and has negative immunohistochemical and/or molecular genetic results for LGMD1A, LGMDIB, LGMDIC, LGMD2B and various other dystrophies. In conclusion, we describe the uniform phenotype of a still undefined

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form of autosomal dominant limb-girdle muscular dystrophy, which affects patients from two families of different ethnic backgrounds. 215 Chemokines in inflammatory myopathies. ]. De Bleecker, B. De Paepe, J. M. Schroeder (Gent, B; Aachen, D). Objective: Immunolocalize chemokines in inflammatory myopathies. Background: Chemokines representa family of small molecular weight cytokines that recruit and activate inflammatory cells in response to inflammation. In polymyositis (PM) and sporadic inclusion body myositis (sIBM) cytotoxic memory T cells surround and invade nonnecrotic invaded muscle flbers. Dermatomyositis (DM) is a complement-mediated endotheliopathy with perimysial accumulation of memory helper T cells and B cells. Methods: Frozen sections from PM (n=5),sIBM (n=5) and DM (n=5) patients, and of normal controls (n=5) were immunoreacted using alkaline phosphatase and double or triple multi-step immunofluorescence techniques. Protein extracts from selected specimens were prepared for Western blotting. Non-cross-reactive antibodies recognizing Thymus and Activation Related Chemokine (TARC), Interleukin-8 (IL-8) and Monocyte Chemoattractant Protein-1 (MCP-I) were used. Positive controls consisted of Hodgkin lymphoma for TARC, lung for IL-8 and thymus for MCP- 1 expression. Results: In autoaggressive inflltrates in nonnecrotic muscle fibers in PM and sIBM, strong MCP-1 expression occurred on the actively invading subset of T cells and on a subset of CD68+ macrophages. Capillaries and arterioles in the vicinity of endomysial inflammatory foci were strongly immunoreactive for MCP- 1, with no or faint expression in unaffected parts of the tissue. In DM, perifascicular capillaries and perifascicular or perimysial arterioles and vendes strongly expressed MCP-1. In some control specimens, a subset of capillaries also expressed MCP-1, possibly reflecting a role of this chemokine in normal immune surveillance. IL-8 occurred on the luminal surface of few endothelial cells of arterioles in normal and inflammatory muscle alike. A strong signal occurred in respiratory epithelium. No TARC staining was found in normal or inflammatory muscle specimens. Reed-Sternberg cells in Hokgkin lymphoma were strongly positive. The absence of TARC in inflammatory myopathies and its presence in lymphoma was conflrmed by Western blotting. Conclusions: We provide evidence that MCP- 1, but not TARC or IL-8, is involved in the cytotoxic immune effector response in PM and sIBM, and possibly in the humoral immune response in DM. This differential expression of chemokines warrants a detailed further study of chemokines and their receptors to identify possible targets for selective immune therapy. 216 Muscle MRI findings in proximal myotonic myopathy (PROMM). C. Schneider, D. Brechtelsbauer, K. Reiners, K. V. Toyka (Wuerzburg, D) Objective: To evaluate muscle magnetic resonance imaging (MRI) findings in patients with proximal myotonic myopathy (PROMM). Background: PROMM is characterised by a variable degree of proximal muscle weakness. Hip flexor and quadricpes muscles are preferentially involved. In some patients weakness is fluctuating. Muscle histopathology is characterised by a mixed pattern of myopathic and neurogenic changes. Fatty degeneration and fibrosis seem to be uncommon in the early stages of the disease, but may occur in severely affected patients. Methods: MRI (SE-, TI- and T2-sequences) of the leg muscles was performed in 10 patients (8 men and 2 women). Five of these patients including the two women had moderate to severe weakness of proximal leg muscles. In the other tire patiems proximal leg muscle weakness was mild of transient. Results: Tl-weighted sequences proved to be the most sensitive sequences to detect fatty degeneration and muscle atrophy on MRI. In the tire patients with mild or transient proximal leg muscle weakness no abnormalities were seen on MRI. In two severely affected patients with hip flexor weakness MRC grade 22-3 the most prominent changes, i. e. muscle atrophy and signs of fatty degeneration, were seen in the muscles of the quadriceps group but spared the rectus femoris muscle. Ischiocrural muscles, particularly the semimembranosus and the semitendinosus muscles were less severely affected than the muscles of the quadriceps group. The adductor magnus and the soleus muscles showed MRI abnormalities in one patient only. In three patients with moderate proximal leg muscle weakness MRC grade 4 the muscles of the quadriceps group except the rectus femoris muscle, but not the hamstrings or distal leg muscles were affected. Muscle MRI abnormalities were slightly asymmetric in al1 the patients with moderate of severe muscle weakness. Conclusion: Pathological muscle MRI findings correlate with the degree of muscle weakness. In patients with mild or transient muscle weakness

muscle MRI was normal. In patients with moderate or severe proximal leg muscle weakness, the muscles of the quadriceps group were affected earlier and more severely than the ischiocrural muscles, but the rectus femoris muscle was usually spared. This has also been described in patients with myotonic dystrophy type 1 (DM1) and MRI abnormalities of proximal leg muscles. In contrast to DM1, MRI abnormalities of distal leg muscles seem to be rare in PROMM. 217 Clinical and muscle biopsy findings in delT-521 mutation in sarcoglycanopathy patients. M. Kefi, R. Amouri, C. Ben Hamida, A. Driss, M. Zouari, S. Belal, M. Ben Hamida, F. Hentati (Tunis, TN) Objective: to report the clinical data, and immunohistochemical results of 108 patients with LGMD 2C staining the same mutation. Background: gamma-sarcoglycanopathy is frequent in Tunisia. A single homozygous mutation a 521-T deletion (del 521-T) is prevalent in Tunisian kindreds and commonly present with a severe clinical course. However, there can be considerable inter and/or intrafamilial variability. The aim of this study is to analyse phenotype and immuno-gamma sarcoglycan expression in patients sharing the same mutation. Methods: 108 patients belonging to 22 families were selected according to the following criteria: progressive limb girdle muscular weakness and wasting, high CK rate, myopathic pattern in EMG, dystrophic features on muscle biopsy, normal dystrophin, linkage to 13 q12 markers, carrying the del 521-T mutation. Patients were then classified in severe, moderate and mild forro according to clinical criteriai Immunohistochemical studies with sarcoglycan subunits antibodies were carried out on 31 biopsies. •esults: HalŸof patients h a d a severe form, while 25 % h a d a mild form. a-SG was reduced in 51% and absent in 45 % of patients, b and g-SG were absent in almost all patients, g-SG were absent in almost all cases, d-SG is absent in 64,5% and reduced in 26%. Conclusion: Patients sharing the same point g-sarcoglycan mutation showed clinical and immuno-histochemistry variability. The muscle biopsy sarcoglycan expression is not correlated to the clinical severity. This work was supported by MDA. 218 Oculopharyngeal muscular dystrophy: Relationship between genotype and phenotype in patients from Spanish families with different short GCG expansions: (GCG)9, (GCG) 10 and (GCG) 11 in PABP2 gene. A. Pou-Serradell, J. Roquer, J. Pascual, E.H. Hammouda, Ja. Urtizberea, P. Richard, B. Brais (Barcelona, E; Evry, Paris, F; Montr› (Qu› CDN) Autosomal dominant oculopharyngeal muscular dystrophy (OPMD) is caused by short (GCG)8-13 triplet-repeat expansions in the polyadenylation binding protein 2 (PABP2) gene, which is localized in chromosome 14ql 1. The severity of the dominant OPMD is variable. Our objective is to assess the relationship between genotype and phenotype in OPMD. Clinicopathological and molecular studies have been performed in six Spanish families with OPMD. The muscular biopsy study under electron microscopy shows intranuclear inclusions (INI) in all the examined patients (one patient per family). The genetic findings confirms the cause of the disease in all the affected members and in 3 clinically asymptomatic members of one recently (XI-2000) examined family: two families (6 and 1 studied members respectively) present the (GCG)9 expansion, two families (1 studied member each one) present the (GCG)10 expansion and two families (I and 7 studied members respectively) present the (GCG)11 expansion. On these 17 patients with a short GCG expansion causing OPMD, clinical tests for OPMD a n d a follow-up study of their clinical course have been carefully assessed: in patients with the (GCG)9 expansion appeared major abnormalities in extrinsic ocular mobility and more precocious presentation of limb girdle (lumbopelvic preferentially) weakness leading to a great disability under the seventies in some patients and leading sometimes to death. In patients with (GCG)10 and (GCG) 11 expansions, eye movements are long time preserved and the limb girdle muscles weakness did not appear before the seventh decade. No correlation seems to exist between age of onset of the ptosis of dysphagia and the different (GCG)n expansions and the surgical treatment of ptosis, performed in 8 patients, showed good results independently of the (GCG)n mutation. Although further clinical and genetic studies are necessary to establish a strict genotype/phenotype correlation in OPMD, we concluded that the (GCG)9 expansion implicate more severe phenotypes than those related to the (GCG) I 0 of (GCG) 11 expansions. Therefore, genetic testing could benefit prognosis in asymptomatic individuals.

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219 Voltage sensor sodium channel mutations cause hypokalemic periodic paralysis. A. Kuzmenkin, V. Muncan, K. ]urkat-Rott, H. Lerche, E LehmannHorn, N. Mitrovic (Ulm, D) Hypokalemic periodic paralysis (HypoPP) is a dominantly inherited muscle disorder characterized by episodes of flaccid weakness. Conclusive for the disease is low ext racellular potassium during paralytic attacks. Several years ago genetic studies revealed mutations in the voltage-dependent calcium channel gene in families with HypoPE The electrophysiological studies on these mutants in different expression systems could not explain the pathophysiology of the disease. Recently, three point mutations, namely Arg672His/Gly and Arg669His in the voltage sensor of the muscle sodium channelgene were reportedin families with HypoPEWeexpressed all the mutants in a human cell line and studied it electrophysiologically. Patch-clamp recordings on mutant channels showed an enhanced fast inactivation and reduced sodium current density even at potentials at which inactivation was removed. Fot two of the mutants the slow inactivation was also enhanced. In accordance with these resuhs a slowing and smaller size of action potentials were found on excised skeletal muscle fibres from a patient with HypoPP. Decreased current and small action potentials suggest a low channel protein density. The aherations are decisive for the pathogenesis of episodic muscle weakness by reducing the number of excitable sodium channels particularly at sustained membrane depolarisation. Until know only the'gain of function' sodium channel mutants were reported causing related neurological syndromes like hyperkalemic periodic paralysis, paramyotonia congenita and potassium-aggravated myotonia. The mutations causing HypoPP are the first 'loss of function' sodium channel mutants.

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Infection of the nervoussystem 220 Antibiotic guidelines and antibiotic use in adult bacterial meningitis in the Netherlands. D. van de Beek, J. de Gans, L.Visser, L. Spanjaard, M. Vermeulen, J. Dankert (Amsterdam, NL) Guidelines recommending restricted use of antibiotics are effective in reducing antibiotic resistance and health care costs. Recommendations for empiric antibiotic treatment of patients with bacterial meningitis should be evidence-based, depending on the suspected bacterial species, clinical setting and antibiotic susceptibility. Objectives: Evaluation of antibiotic guidelines and antibiotic use in adult bacterial meningitis in the Netherlands. Methods: Data on antibiotic guidelines were collected by means of a questionnaire distributed to neurologists ('92) and medical microbiologist ('92 and '96) in the Netherlands. In addition, national guidelines and guidelines used in academic hospitals were evaluated. Data on antibiotic use were also collected prospectively. AII patients (> 16 yrs) of whom a cerebrospinal fluid isolate (CSF) was received by the Netherlands Reference Laboratory for Bacterial Meningitis (NRLBM) from Oct '98 to Dec '99, were included. The NRLBM receives app. 85 % of all CSF isolates in the Netherlands. Antibiotic susceptibility of meningococci and pneumococci was tested by the NRLBM. Resuhs: Antibiotic guidelines: in 1992, 57% of the neurologists used monotherapy with penicillin of amoxicillin and 16% third generation cephalosporins. In 1996, almost 40 % of medical microbiologists would advise physicians to use cephalosporins. Antibiotic guidelines used in the eight academic hospitals were diverse, cephalosporins were widely recommended. National consensus-based guidelines were introduced in 1998. Antibiotic use: of 264 patients data on treatment and risk factors were received (72 % ofall CSF isolates received by the NRLBM). Amoxicillin and penicillin, as well as cephalosporins, were frequently used. Neither age nor presence of risk factors of the patient was of influence on the use of cephalosporins. Antibiotic susceptibility: of the 264 CSF isolates, 0.8% of meningococci and 1.8 % of pneumococci showed intermediate penicillin-resistance. National guidelines: national guidelines were appropriate for evidence-based antibiotic treatment, one-third of the patients was treated according to national guidelines.

Conclusions: Local guidelines do not follow the national recommendations. During '98-'99, one third of all patients with bacterial meningitis was treated according to national recommendations. The consensus-based national guidelines are appropriate for evidence-based antibiotic treatment of aduh patients in Dutch hospitals. 221 Discrepancy between cranial CT scan and raised intracranial pressure (ICP) in pneumococcal meningitis: arguments for early ICP monitoring. E Winkler, S. Kastenbauer, T. A. Yousry, H. W. Pfister (Munich, D) Elevated intracranial pressure (ICP) due to cerebral oedema or hydrocephalus is a well-known complication of acute bacterial meningitis. Therefore, a computed tomography (CT) scan of the brain is recommended before lumbar puncture whenever focal neurological deficits ora depressed level of consciousness suggest raised ICE In clinical practice, it is widely believed that a normal CT scan excludes the possibility of a significantly raised ICE We report on three adult patients with adequately treated pneumococcal meningitis who developed a prolonged or sudden comatose state and severely raised ICP despite normal or only moderately ahered repeated CT scans. Clinical signs of cerebral herniation in two patients and prolonged coma in one prompted the measurement of ICP with a ventriculostomy catheter, which showed dramatically increased values of 44 to 90 mmHg. Continuous ICP monitoring in the ICU helped to guide treatment for increased ICP (mannitol, hyperventilation, hypothermia, sedation, and analgesia). Two patients who showed at the most moderate brain oedema on the CI" scans but had excessively increased ICP at the same time died of cerebral herniation despite maximal treatment for elevated ICP; massive inflammatory brain oedema with concomitant cerebritis was seen on autopsy. One patient with clinical signs of cerebral herniation despite only minimal hydrocephalus on the concurrent CT scan recovered after intensive therapy for increased ICE Possible explanations for the unexpected absence of signs of severely raised ICP and coning in the CT scans include (1) specific pathomorphological features of meningeal diseases such as meningeal hardening preventing narrowing of the subarachnoid space, and (2) the simuhaneous occurrence of brain oedema with decreased CSF absorption which could abolish radiological hints. We conclude from our cases and from a review of the literature that a CT scan is not sufficient to exclude the possibility of raised ICP in a patient with bacterial meningitis. We recommend eaily ICP monitoring of patients with bacterial meningitis who show signs of raised intracranial pressure despite a normal or minimally altered CT scan, especially for those who are persistent comatose despite adequate conservative treatment. Sedation preventing a complete neurological assessment would be an additional indication for early ICP monitoring. 222 Cochlear inflammation is delayed compared with cerebral inflammation during experimental pneumococcal meningitis: an extended therapeutic window for meningitis-associated hearing loss. S. Kastenbauer, U. Koedel, H.-W. Pfister (Mª D) Background: Severe and permanent hearing loss affects up to 30% of survivors of pneumococcal meningitis. In several studies, adjunctive therapy with corticosteroids reduced the incidence of hearing loss but not that of other neurological deficits following bacterial meningitis. 'ro date, no study has been performed to explain this discrepancy. Methods: Aduh male C57/BL6 mice were injected intracisternally with 1.5 • 105 colony-forming units Streptococcus pneumoniae. We studied control animals (24 hs after intracisternal injection of PBS, n=4), animals 24 hs after infection (n=6), and animals 48 hs after infection (treated with 100mg/kg intraperitoneal ceftriaxone 18 hs afler induction of meningitis, n=6). We determined the CSF leukocyte count, cochlear leukocyte infiltration score (from 0 = absent to 4 = severe), blood-brain and blood-labyrinthbarrier disruption (as evidenced by fluorescence microscopic quantification of Evans blue extravasation), and brain and cochlear concentrations of proinflammatory cytokines (IL-1 beta and IL-6) and chemokines (KCchemokine) by ELISA. Unless otherwise stated, data are given as mean + 61617;SD. Results: The CSF leukocyte counts were maximal 24 hs after infection (cells/p.l: 24 hs 9010 + 1237; 48 hs 6983 + 3839; controls 225 +- 126), while the cochlear leukocyte infiltration was sparse at 24 hs and increased strongly unti148 hs (median [range]: 24 hs 0 [0-1 ]; 48 hs 3 [2-4]; cont rols 0 [0] ). Evans blue extravasation was strongly increased 24 hs after infection in the brain (OD/mm2:24 hs 19.5 + 4.6; 48 hs 21.2 + 7.9; controls 6.3 + 3.3),but not in the cochlea (OD/mm2:24 hs 14.7 + 2.6; 48 hs 35.1 _+20.0; controls 13.7 + 2.9). IL-1 beta, IL-6, and KC-chemokine all peaked 24 hs after infection in brain

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and cochlea. However, 48 hs after infection these mediators had returned to baseline in the brain, but were still elevated in the cochlea (e. g., IL-6 (pg/mg protein): brain 24 hs 82.3 + 51.4; 48 hs 5.6 + 1.7; controls 6.1 + 2.9; cochlea 24 hs 1802.9 _+562.7; 48 hs 590.8 + 291.2; controls 31.8 _+ 13.2). Conclusion: Cochlear inflammation during bacterial meningitis is delayed and protracted compared with the cerebral inflammation, indicating an extended therapeutic window for meningitis-associated hearing loss. 223 "Silent Killer" On Intensive Care Units: Reactivation Of Herpes Simplex Virus In Long Term Intubation. U. Meyding-Lamad› W. Lamad› F. Wigger, C. Oberlinner, C. Herfarth, W. Hacke (Heidelberg, D) Aim: this study analyses incidence and outcome of pulmonary manifestation of HSV-infections in long-term incubated patients. Background: pulmonary infections are known to be a common cause of death in long-term incubated. Despite highly effective antibiotic and antimycotic therapy mortality remains high and ranks between 20 % and 50 %. The role of viral etiology is sti11obscure. Patients and methods: Bronchoalveolar lavage fluid was collected serially from 81 intensive care patients and was investigated for the presence of HSV-1 genome and viral load with a dilutional polymerase chain reaction assay. Results: 1. In 55 % of patients there was an increase of viral load in the bronchoalveolar lavage (BAL) fluid samples. In short-term intubated patients (less than 12 hours) no HSV-DNA was detectable. 2. Patients with detectable HSV-infection mortality rate was 2.1 fold increased compared to patients without HSV-genome being detectable in the BAL. 3. Cell culture studies to study the presence of HSV proved to be very unreliable Discussion and conclusion: This study reveals that detection of HSVDNA in the BAL fluid samples is associated with a 2.1 fold increase of mortality. HSV-infection is associated with a long-term intubation - in short term intubated patients no HSV-DNA was detectable. This study provides some clues why diagnosis often is missed. Therefore viral pulmonary infections may well be an underestimated cause of death in long-term intubated patients.

testing (e. g. contraction times). Little is as yet known about their predictive value under different forms of antiretroviral therapy. Patients and Methods: On June 30 th, 2000, a total of 1675 HIV-1 seropositive patients had been consecutively recruited and followed-up in three months intervals in our Neuro-AIDS clinic, the over-all observation period covering 3284.6 patient-years. Patients also underwent electrophysiological motor testing including contraction times (CT). Bilateral prolongation of CT to more than the mean + 3 standard deviations from HIV-1 seronegative controls defined HIV-1 associated MMD. Patients were attributed to four different treatment groups: untreated, zidovudine only, treatment with two nucleoside analogues or highly active antiretroviral therapy (HAART) including HIV- 1 protease inhibitors or non-nucleoside analogues. The predictire value of MMD for the clinical manifestation of HIV-1 associated dementia was calculated using the Cox Proportional Hazards Model, adjusted for age, sex, CD 4+ cell count at therapy onset, number of visits during the follow. The model was stratified for the different therapy regimens. Start points were the date of first HIV-1 seropositive testing or the first clinical visit in our clinic, end point was a 10 year follow-up without the clinical manifestation of HIV-1 associated dementia of the manifestation of dementia. Results: The relative risk for the manifestation of dementia rose from 2008 in untreated patients to 8621 in patients under HAART. Conclusions: HIV-1 associated MMD are highly predictive for HIV-1 associated dementia in patients under HAART and defne a subgroup of patients who may not respond to HAART with regard to HIVo 1 associated CNS disease.

Poster session - 1

Clinical Neurophysiology 224 Human Immunodeficiency Virus type 1 (HIV-I) associated brain disease characterization of phases by psychomotor slowing and HIV- 1 viral load. G. Arendt, H. J. von Giesen, O. Adams, H. Ebel, H. K611er (Dª D) Background: HIV-1 associated minor motor deficits (MMD) predict HIV-1 associated dementia, the acquired immune deficiency syndrome (AIDS) and death. MMD can be quantified by electro-physiological motor testing (e. g. contraction times). Little is as yet known about the pathophysiological and virological correlates of this early form of HIV-1-associated brain disease. Goals: We wanted to examine the relationship between HIV-1 virological markers in the cerebro-spinal fluid (CSF) and plasma and the time course of HIV- 1-associated CNS disease. Patients and Methods: HIV-1 viral load and results of electrophysiological motor testing were analyzed in 57 asymptomatic HIV-1 seropositive patients (the control group), 23 patients with electrophysiologically defined incipient MMD, 23 patients with sustained MMD, and 28 patients with HIV- 1-associated dementia. Results: Patients with incipient MMD had significanfly higher plasma viral loads.than asymptomatic patients. Highest plasma levels were found at the time at which MMD was first detected. However, viral loads in patients with sustained MMD did not differ significantly from those in asymptomatic controls.Viral loads in both plasma and CSF were also high in demented patients and in this group there was evidence of intrathecal production of virus. Conclusions: Our findings suggest that HIV-l-associated CNS disease takes a multiphase course with an initial invasion of HIV-1 into the brain, followed by progressive functional deficits finally leading to manifest dementia. Our findings favour the use of antiretroviral therapy as early as possible so as to reduce the initial invasion of HIV-1 into the brain. 225 Human Immunodeficiency Virus type 1 (HIV-1) associated minor motor deficits - predictive value for dementia under different forms of antiretroviral therapy. H. J. ron Giesen, H. K611er,H. Hefter, G. Arendt (Dª D) Background: HIV-1 associated minor motor deficits (MMD) predict HIV-1 associated dementia. MMD can be quantified by electrophysiological motor

P226

Automatic Sleep Stage Analysis with Quisi Version 1.0 versus Manual Analysis of a Polysomnography - A comparison between two methods to perform a sleep prof'de. T. Rotermund, W. Neuk/iter, J. J6rg (Wuppertal, D) For a proof objective classification of the sleep profile in most cases a timeconsuming polysomnography is used. Like a long-term ECG a self-applicable ambulatory ahernative would be useful. 40 patients admitted with various sleep disorders had been recorded with polysomnography according to the standard of the German Sleep Research Society (DGSM) and with the Quisi-Recorder Version 1.0 (Fa. A1phapharm GmbH, Freiburg). Quisi is a one-channel recorder for sleep EEG with a fully automated analysis of the sleep stage. 3 electrodes placed on the forehead close to Fpl, Fz and Fp2 are used. The sleep stage classification of a doctor with a long time experience using the polysomnography according to the rules of Rechtschaffen and Kales was compared with the Quisi-scoring. A comparison of the parameters TST, SOT, SPT, SEI, AWA, SWS latency and REM latency was made as well a s a comparion of the sleep stage classified for each 30s sleep EEG epoch. The results of the sleep parameters and the comparison of sleep stage classification for each epoch showed a good agreement. Quisi often over-estimates REM and SWS. In 2 cases the profiles performed by Quisi are very deviate from the PSG caused by a over-estimation of SWS and REM. In our 40 cases the method showed a good sensitivity of 100 % but was not very specific (50%). The Quisi-Recorder is the first self-applicable ambulatory sleep stage screening method which allows a sufficient and more objective assessment of sleep disorders in the pre- and post-sleep laboratory treatment. P227 Shift From Hypermetria To Hypometria In Multiple System Atrophy: Loss Of Directional Preference In Proximal Muscles. M. Manto, J. Jacquy, B. Legros, P. Bosse (Bruxelles, Charleroi, B) Dysmetria is a classical sign which designates the hypermetria and hypometria when the patient attempts to reach rapidly an aimed target. Dysmetria is typically observed in patients presenting a cerebellar disease. Dysmetria of distal movements is associated with an imbalance between the

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timing and/or the intensity of agonist and antagonist EMG activities. There is only one description in human of a shift from hypermetria to hypometria for fast goal-directed single-joint movements during an aberrant recovery following a cerebellar infarction. This shift has not been analysed so far for proximal movements. We reporta 63-year-old man presenting a multiple system atrophy (MSA). Initially, he exhibited a marked cerebellar syndrome associated with dysautonomia. Brain CT and MRI demonstrated a marked cerebellar atrophy with moderate brainstem atrophy. We analysed the tuning of EMG activities in proximal muscles during reaches in the sagittal plana (12 directions; aimed targets: 25 cm from a central position). Initially, movements were hypermetric. The mean movement amplitude ranged from 28.2 to 33.3 cm. In healthy subjects (n = 7; mean age: 65; range: 39 to 77), the mean movement amplitude ranged from 24.6 + 0.3 to 25.5 -+ 0.4 cm. The proximal hypermetria was associated with a defect in the phasic spatial tuning of the EMG activities. A counter-clockwise displacement of the privileged direction of the maximal peak EMG activity (M peak EMG) was found. The patient developed progressively severa extra-pyramidal signs. Proximal hypermetria turned into hypometria. Thirty-five months later, mean movement amplitude ranged from 15.1 to 18.5 cm. A loss of directional preference of the EMG activities in proximal muscles was found. We suggest that dysmetria was the consequence of the defect of neural adaptation to the anisotropy of inertial resistance. MSA is the second human modal of a shift from hypermetria to hypometria. P228 Acute Cerebellar Ataxia with Axial Myoclonus during Pregnancy (ACAAMP). M. Manto, M. Gille (Bruxelles, B) We report 2 patients presenting a syndrome combining acute cerebellar ataxia and axial myoclonus occurring during pregnancy (ACAAMP syndrome). Such syndrome has not been described previously. Patient 1 is a 29year-old women with no previous medical history. At the 33rd week of first pregnancy, she presented an acute unsteadiness associated with vomiting. General physical examination was normal. Neurological examination show› ocular dysmetria, ocular ¡ dysmetria during finger-to-nose test on the left side, ataxic gait and axial myoclonus. Sensory examination was normal and plantar reflexes were fexor. Blood studies were unremarkable, except for a moderate impairment of liver function tests. Brain MRI, SEP, BAEP,EEG, lumbar puncture and liver echography were normal. An extensiva search for an auto-immune disease, an infection and an occult malignancy was negativa. Newborn was normal. Four months later, recovery was complete. Patient 2 is a 34-year-old woman with a previous history of gastritis 4 years before.At week 31 of first pregnancy, she presented abruptly dizziness and limbs clumsiness. General physical examination was negativa. Neurological examination showed a gaze-evoked nystagmus, saccadic dysmetria, ocular flutter, limbs dysmetria predominating on the right side, ataxic gait and axial myoclonus. Blood studies were normal. Brain MRI and MRA, SEP, BAEP, EEG, lumbar puncture, duplex sonography of neck vessels and transesophageal echocardiography were normal. No infection and no occult malignancy could be found. Newborn was normal. Neurological examination was normal 6 months later. We thus report 2 patients with a strikingly similar neurological syndrome combining acute cerebellar ataxia and axial myoclonus occurring during the last trimester of first pregnancy. Prognosis was excellent and newborns were unaffected. The pathophysiology of ACAAMP might be similar to the pathophysiology of other movement disorders developing during pregnancy, such as chorea gravidarum. P229 High-Frequency Synchronous Bursts Firing Associated with Asynchronous Midbrain" Tremor. E. Vengud, J. ]acquy, B. Vanderkelen, M. Manto (Charleroi, Bruxelles, B) The association of a high-frequency tremor with a midbrain tremor has nevar been described in human. We describe a 17-year-old patient who developed a tremor following a hemorrhage in brainstem due to an arteriovenous malformation. Brain MRI disclosed lesions in the mesencephalon and a marked enlargement of the fourth ventricle. In addition to an asynchronous midbrain tremor in upper limbs (frequency of 4.5-6 Hz), she exhibited short periods of 15-16 Hz synchronous tremor when upper limbs were maintained outstretched. These high-frequency bursts were absent in lower limbs. The synchronous firing was relieved by hyperflexion of the wrists. We believe that the high-frequency discharges were due to the disruption of cerebellar pathways. Indeed, a high-frequency tremor has been reported in patients presenting a symptomatic postural tremor associated with disruption of cerebellar afferences and/or efferences. Experimental studies in cats haya demonstrated repetitive discharges of nucleus interpositus neurons due to impulse reverberation. Explosiva discharges in cerebello-precerebel-

lar reverberating circuits return to a resting state after several hundred msec. It has been proposed that the return to the resting state is due to desynchronization of impulses, depression in the synaptic transmission or summation of aflerhyperpolarization.We suggest that in our patient the disappearance of the high-frequency tremor following the hyperflexion of the wrist might be due to a resetting of the peripheral receptors (muscle spindles) activity, in agreement with the hypothesis that the stretch reflexes associated with postural tasks are impaired in patients exhibiting cerebellar ataxia. We suggest to use the term HFFMT (high-frequency firing with midbrain tremor) to describe this naw form of human tremor. P230 Association of obstructive sleep apnea with serum cortisol and plasma catecholamines. H. ron Lindeiner, S. Noachtar, M. Pihusch, R. Pihusch, W. Mraz, M. Wick, R. de la Chaux, A. Dreher, I. Eisensehr (Munich, D) Introduction: High serum cortisol and catecholamines may be associated with arterial hyper tension. Patients with obstructiva sleep apnea (OSA) were suggested to be at high risk for arterial hypertension. Methods: We measured levels of serum cortisol (COR), plasma epinephrine (E), and norepinephrine (NE) at 9 pm, 6 am (altar waking up), and 9 aro (after getting into the upright position) in 17 patients with polysomnography-confirmed severa OSA (apnea-/hypopnea-index at least 30 per hour total sleep time) before treatment, after short-term (one or two nights) with nasal continuous positiva airway pressure (nCPAP). and after at least 3 months nCPAP treatment, and in 7 age- and sex-matched patients without OSA (controls). Results: COR was similar in untreated patients with OSA and controls. In OSA patients COR, NE and E levels were significantly (p < 0.05, WilcoxonTest) reduced at 9 aro altar short-term nCPAP treatment compared to the time before treatment. Furthermore, E levels were significantly (p < 0.05, Wilcoxon-Test) reduced at 6 am after short-term nCPAP treatment compared to the corresponding time before treatment. There was no significant long-term effect of nCPAP therapy on COR, NE, and E compared to untreated OSA. Conclusion: We conclude from our preliminary results that (1) moderate to severa OSA does not influence serum COR or plasma catecholamine levels, and (2) OSA associated hypertension is not primarily based on elevated serum COR or plasma catecholamines. P231 Muitimodal evoked potentials in malabsorbtion syndrome. B. Paradowski, E. Waszczuk, M. Bilinska, L. Paradowski (Wroclaw, PL) Introduction: The first monographic study of neurological symptoms in malabsorbtion syndrome (MS) was conducted by Patlis and Levis in 1974. The neurological symptoms in course of malabsorbtion ara diversa. However, a few characteristic neurological syndromes, like neuropathies, funiculus posterior degeneration, muscular dysfunction can be distinguished. Material and methods: The multimodal evoked potentials (visual, somatosensory and auditory brainstem) in 23 patients with malabsorption syndrome of different origin were investigated. The diagnosis of the disease was confirmed on the basis of histological examination and result of D-xylosis test. The control group consisted of 30 healthy persons. Results: Examination of visual evoked potentials revealed significant prolongation of latency of P 100 component in examined group in comparison to controls (left 114.4 _+5.6 ms, right 115.0 + 6.3 ms in MS; left 102.3 -+ 7.0 ras, right 102.7 _+6.6 ms in control group). Latency of N13 (left 15.0 _+ 1.7 ms, right 15.3 + 1. I ms in MS) and N20 (left 23.0 + 2.3 ms, right 23.4 -+ 2.5 ms in MS) of somatosensory evoked potentials in patients with malabsorption syndrome were also significantly prolonged when compared to controls, otherwise transit time to cortex (TTC) was merelyprolonged (8.09 + 1.93 ms in MS; 7.22 _+1.56 ms in control group). Auditory brainstem potentials were also abnormal in MS. Changes involved prolongation of latency of I (1.81 + 0.2 ms), III (4.31 _+0.21 ms) and V (6.43 + 0.28 ms) responses and prolongation of inter peak latencies of I-III, III-V, I-V as well. The amplitudes of the examined evoked potentials between patients and controls did not differ significantly. Conclusions: On the basis of obtained results in was pointed out that different specific afferent systems ara affected in patients with malabsorbtion syndrome what seems to be connected with vitamin's deficiency, especially B12 and E. Authors conclude that multimodal evoked potentials examinations ara useful in the diagnosis and monitoring of the disease, specially in subclinical casas.

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P232 Repetitive transcraniai magnetic stimulation: A new treatment for cerebral spasticity. N. El-Nahas, A. E1-Etribi, H. Aref (Cairo, ET) Background: Repetitive transcranial magnetic stimulation (rTMS) is a sale and non-invasive method that has recently been reported a s a promising therapeutic method for depression and Parkinson's disease. Also a brief report was given on its efficacy in treatment of spasticity in cases of multiple sclerosis when applied to the midline at the mid-dorsal region. Airo of the work: to test the efficacy of cortical rTMS on spasticity due to cerebral lesions. Patients and methods: 12 patients with cerebral spasticity were studied (4 with multiple sclerosis, 3 with amyotrophic lateral sclerosis, 2 with ischemic stroke, 2 with rigidity and I with postencephalitic sequelae). All patients had not received any forms of antispastic measures. A structured dinical sheet was done including the initial and serial assessments. Spasticity was assessed using the modified Ashworth score, initiaIly, after each rTMS session and after finishing the treatment course. Also the patient's self score of daily activities was reported. TMS was applied over the motor cortex of the affected limb and repetitive stimulation done at 10hz at 80 % of the motor threshold for 2 seconds every 20 seconds, for 10 runs. This was repeated for four daily sessions then two to four every other day sessions. Resuhs: AII patients showed improvement on the modified Ashworth score and self rating of daily activities with variable degrees, lmprovement showed a relation to the underlying disease rather than the degree of spasticity which will be discusses in more details. Conclusion: rTMS is an effective, safe and easy therapeutic option for treatment of spasticity. Ir has a lasting effect and can be repeated if needed. P233 Neurophysiological investigations - sympathetic skin response (SSR) - in patients with sleep apnoea syndrome. B. L. Labuz-Roszak, K. P. Pierzchala, M. O. Ograbek (Zabrze, PL) Background: The untreated sleep apnoea syndrome (SAS) is associated with cardiovascular complications (arterial hypertension, coronary heart disease, cardiac arrhythmia) and increased morbidity and mortality. Disorders of the autonomic nervous system function aro probably responsible for cardiac arrhythmia. Most researchers evaluated autonomic function using cardiovascular tests. The aim of our study was to assess whether neurophysiological method - sympathetic skin response (SSR) - could be useful in testing function of the autonomic nervous system in patients with SAS. Material and methods: The examined group consisted of 26 patients with SAS recognised by polysomnography (mean apnoea index: 42 _+ 31, mean age: 52 :!: 9 years). The control group consisted of 27 healthy volunteers (mean age: 50.5 +- 3 years). AII the persons underwent physical and neurological examination. People with any symptoms of central or peripheral nervous system disorders were excluded. SSR was recorded simultaneously from the right palm and right foot with active electrode in a palmar and plantar position and inactive electrode at the dorm of the hand and foot, respectively. Latencies and amplitudes of SSR were measured. Recordings were carried out using an electromyograph (Counterpoint). Statistical analysis was performed using student's t-test. Results: In 10 patients with SAS (38.5%) we could not obtain SSR (neither in the upper nor lower limb). In the remaining patients the SSR amplitudes in the upper limb were significantly Iower (250.6 :!: 131 q than in the control group (582.8 _+76.7 btV) (p < 0.001). The SSR amplit udes in the lower limb were also decreased (128.1 -+ 77 i.tV), but not significantly, in comparison to control group ( 156.9 -+ 28.3 pV). We did not observe changes in latencies between the groups. Conclusions: Results of our study provide evidence for autonomic disorders (impairment of sympathetic fibres) in patients with SAS. Sympathetic skin response (SSR) is a simple, fast and reproducible neurophysiological method useful in testing function of the autonomic nervous system in patients with SAS. P234 Cerebral Glucose Metabolism and Early EEG/aEEG in Term Newborn Infants with Hypoxic lschemic Encephalopathy. K. Thorngren-Jerneck, L. Hellstr6m-Westas, T. Ohlsson, A. Sandell, S.-E. Strand, E. Ryding, I. Ros› (Lund, S). Aim: Correlate early EEG or amplitude integrated EEG (aEEG) with cerebral glucose metabolism measured by positron emission tomography (PET) in the subacute period after perinatal asphyxia in term newborn infants with hypoxic ischemic encephalopathy (HIE). Method: PET with 18-FDG (2-(18F) fluoro-2-deoxy-D-glucose) was

used to measure cerebral metabolic rate of glucose (CMRgl) in 19 term infants with HIE after birth asphyxia at postnatal age, median (rango) 11 (4-24) days, gestational age, median (range) 41 (37-44) weeks. One hour before scanning 2-3.7 MBq/kg (54-100 microCi/kg) 18-FDG was injected. All infants had standard EEG and/or aEEG within first 48 hours of life. EEG/aEEG patterns were classified into 4 categories: continuous normal voltage(CNV), normal voltage but slightly periodic (Cper), burst suppression/ continuous extremely low voltage (BS/LV),and inactivo (IN) at 0-6, 6-12, 12-24, 24-48, 48-72 and > 72 hours postnatal age. Presence or absence of sleep-wake cycling and seizure activity was also noted. Results: CMRgl correlated significantly with outcome at 12 months (p=0.013). Infants who developed cerebral palsy had mean (range) CMRghl8 (10-31) micromol/min/100 g. EEG/aEEG background at first 6 hours (p=0.033), at 6-12 hours (p=0.008) a n d a t 12-24 hours (p=0.01) postnatal age, correlated with CMRgl. Occurrence of sleep-wake cycling at 0-6 (p=0.021), 6-12 (p=0.028) and 12-24 (p=0.046) hours postnatal age correlated with CMRgl. Presence of delayed seizure activity ( 12-24 hours), correlated with CMRgl (p=0.016). Conclusion: Background pattern of early EEG/aEEG, occurrence of early sleep-wake cycling and delayed seizure activity correlates well with CMRgl and outcome in term infants with HIE after birth asphyxia. P235 Electronystagmography Findings In Patients With Vertigo In Suspected Central Nervous System Lesions. U. Can, Z. Arlyer, M. Kylynq, • S. Benli, B. Akkuzu, L. N. Ozlª (Ankara, TR) We investigated if electronystagmography (ENG) findings supports a central lesion together with the history and neurological examination in patients complaining of either vertigo or disequilibrium when magnetic resonance imaging (MRI) of the brain does not show a lesion. Thirty-three patients with the complaint of vertigo or disequilibrium were undergone a complete neurological exam, ENG test battery including saccades, gaze, sinusoidal tracking, optokinetic nystagmus, positional test, Dix-Hallpike manoeuvre, calories anda brain MRI. The clinical diagnosis of patients were 55 % transient ischemic attack or stroke, 30 % multiple sclerosis, 9 % tumor, 3 % migraine and 3 % paraneoplastic cerebellar syndrome. Twenty of the patients had MRI lesions compatible with their complaints (group 1). Altho¨ history and neurological examination supported a central lesion, 13 of the patients did not have a lesion in their brain MRI compatible with their complaints (group II). The most prominent ENG abnormalities in group I and II were 60% and 57 % in saccades, 80 % and 79 % in sinusoidal tracking, %65 and 71% in optokinetic nystagmus and 65 % and 57 % in calories respectively. Overal190 % of patients in group 1 and 100 % of group 2 had at least one (mean was 3.7 and 3.6 in groups 1 and 2 respectively) abnormality in the ENG test battery. AII patients complained of either vertigo or disequilibrium. The common presenting features of the patients in group I and II were 95 % and 92 % vertigo, 80% and 77% disequilibrium, hemiparesis 35% and 8%, sensory disturbances 35% and 5%,headache 15% and 25%,double vision 30% and 15 %, speech disturbances 30 % and 15 % respectively. Some of the patients complaining of vertigo with neurological findings suggesting a central lesion had supporting ENG findings although they didn't have a lesion compatible with their complaints in the MRI. ENG may not sbow the location of the lesion but may support the clinical diagnosis when MRI is negative.

CerebrovascularDisorders P236

Short form (SF36) in evaluation of quality of life after stroke. S. Miljkovic, M. Arbutina, M. Zikic, V. D)ajic, Z. Vnjkovic, N. Petrovic, Z. Vukojevic, T. Zikic (Banjaluka, BJH; Novi Sad, YU) According to modern opinions in medicine results of any health measures are valued in the view of quality of life (QOL). The assessment of QOL after stroke has been given the appropriate significance only in a last few decades. For this purpose, general and specific questionnaires are used. The general questionnaire SF36 is used asa supplement in the global assessmenl of QOL, a n d a s a part ofit QOL after stroke The objective is to test on a samp]e the possibility of clinical application of SF36 as an instrument in assessment of QOL after stroke and consequently determine its validity, safety and efficacy in this case. The questionnaire was conveyed during December, 1999 and January, 2000. It comprised a randomized and stratified sample of 100 patients who

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hada stroke in the period 1997-1998, and who were controlled one month and six months after the stroke. SF36 was used as a questionnaire for the assessment of QOL. The questions in the questionnaire referred to three periods (one month before stroke, one month after stroke and six months after stroke). The data was statistically analyzed using chi-square test, t-test, tpaired test, and ANOVA test. The condition was compared in pairs and for two periods, before and after stroke (before and one month after the stroke, before and six months after the stroke, and one and six months after the stroke). The distribution of the responses is statistically significant in all of the periods (p < 0.001). After the stroke in period II there was a dramatic worsening of the condition, and in period 111there was an improvement, ahhough there was still a difference between the reached level and the condition before the stroke (statistically significant). The mean values for total physical and mental score were aRalyzed as well. Before the stroke, the mean value for the total physical score was 51.34, one month after the stroke it was 32.33, and six months after the stroke ir was 37.52; The ratio for the total mental score was 53.30:26.30:33.13. Ir can be seen that both physical and mental total scores decrease dramatically and even six months later they do not reach the values before a stroke. Furthermore, a better physical condition before a stroke predicts a better general condition after a stroke. The paper shows that SF36 can be used successfully in the assessment of QOL after stroke as an instrument for the global evaluation of QOL, i. e. for comparison with the general healthy population. P237 Significance Of Glasgow Coma Score And Neurological Examination Of Stroke Scale For The Forecast Of The Outcome Of l n t r a c e r e b r a l B l e e d i n g . V. Djajic, S. Miljkovic, M. Arbutina, M. Zikic, M. Kovacevic, Z. Vujkovic, D. Racic (Banjaluka, B]H; Novi Sad, Beograd, YU) In the modern medicine there is a big need to have certain descriptive patient characteristics described in numerical values. Those numerical values that we get can be compared to the values of other patients, and with further statistical process certain similarities and differences between them can be seen. There are many scales for scoring the patients with intracerebral bleeding. With their help we can numerically grade certain functions of the patient, and by adding individual values we get an insight into the general state of the patient. In our work we have scored 100 patients with intracerebral bleeding by Glasgow Coma Score (GCS) and Neurological Examination Stroke Scale (NESS). Scoring was carried out during the acceptance of the patients into the hospital. On the basis of GCS we were scoring eye opening, motor functions and speech functions. With the help of NESS we scored the following: level of consciences, pupil reaction, bulb movement, field of sight, motor functions, sensibility, speech functions and plantar response. After four weeks we looked at the outcome oran illness (functional disability and lethality) for each individual patient. At the same time we compared starting values of GCS and NESS with the illness outcome. We noticed that the average values of GCS with completely capable patients 13, minimally incapable 11, partly incapable 9.5, completely incapable 8 and dead patients were 6. Average values of NESS were as follows: - completely capable patients 3 - minimally incapable patients 9 - partly incapable patients 12 - completely incapable patients 16 and - dead patients 22 High level of the illness outcome dependence to GCS and N ESS has been statistically proven (p < 0.001). It has also been proven that there is a high degree of correlation between the scores mentioned above (p < 0.001). We have also looked at the influence of the size and localisation of hematomas to the illness outcome and have noticed that small hematomas located in the small brain and the hemisphere of the big brain had the better forecast than the big hecatombs located in basal ganglia and brain root. P238 circumstances. S. Miljkovic, M. Arbutina, M. Zikic, V. Djajic, Z. Vujkovic, N. Per rovic, T. Zikic (Banjaluka, BJH; Novi Sad, YU)

Stroke and war

Purpose: In the region of Banjaluka we evaluated the incidence, prevalence, lethality, type, course and outcome of stroke with risk factors and variations in sex, age and population of patients. Methods: Our study included 4572 patients treated at neurology clinic in Banjaluka from 1988 to 1998 which is divided in three periods: before war ( 1988-1991 ), war period ( 1992-1995) and after war period ( 1996-1998). We have also created REGISTER for stroke. Results: There was an increase of prevalence and incidence during and

after the war, while lethality decreased in the war. The most frequent was the ischaemic type (82%), followed by intracerebral hemorrhage (14%) and SAH (4 %). The most frequent risk factors were hypertension, coronary diseases, diabetes and cigarette smoking, while the most frequent during the war was st ress (96,8 %), which remain high afler the war (31,6 %).We showed the increase in participation of male patients aged 41- 50 years. (11%) during the war, which remained high after the war (7 %, and 41,6 %). Conclusion: Tendency of increase of the number of patients, high participation of younger patients and importance of stress as risk factor during the war is continuing after the war. P239 Quality of life in post-traumatic s u b a r a c h n o i d brava (Cluj-Napoca, RO)

hemorrhage.

L. Perju-Dum-

In the attempts of recuperation following cranio-cerebral trauma the improvement of quality of life is an important desiderata. The study was made on 20 patients aged 17-62 years with the diagnosis of post-traumatic subarachnoid haemorrhage, in whom the neurologic examination and the CT scanning (CT) revealed no focal cerebral injuries. Ah original questionnaire inspired from Sickness lmpact Profile (SIP) and Short Form Health Survey (SF-36) containing the main quality of life indicators was used, this being filled in by the patients at intervals of 1,3 and 6 months after the traumatic event. Simuhaneously, at the same intervals the neurologic examination, CT and electroencephalogj'aphs were repeated. The data obtained revealed a rapid improvement of the indicators concerning the physical symptoms as well of the physical role and social functionality. The indicators of psychological distress and of the cognitive functions were improved only at the end of the study period. On the other hand, no improvement was obtained in the indicators of the life meaning and of the spiritual aspect. The follow-up of the just mentioned indicators, revealed the fact that, in post-traumatic subarachnoid haemorrhage despite the important physical and cognitive recovery, an important deficit of the spiritual aspect can be preserved. P240 White matter lesions a r e r e l a t e d t o b l o o d pressure variabilit y. E. Gomez-Angelats, A. de la Sierra, C. Siarra, ]. Mercader, A. Coca (Barcelona, E) Background: Hypertension is a well-known risk factor for cerebro-vascular impairment and stroke, and over 40% of hypertensive population experience silent structural white matter lesions (WML). Recent studies also suggest that blood pressure (BP) variability may also playa role in cerebrovascular disease. Objective: to demonstrate that BP variability is also a risk factor for the development of cerebral WML. Patients and methods: We studied 43 untreated essential hypertensive patients (23 men) aged 50 to 60 years (mean age 54 -+ 3 years) without demonstrated target organ lesions. Cerebral magnetic resonance was performed and WML were quantified with the Rotterdam scale. BP variability was assessed continuously with a 24 non-invasive BP monitoring system (Portapres-NO, The Netherlands), which allows to determine BP absolute values and variability heart-beat to beat. 24 hour arterial BP monitoring (ABPM) was also performed with a Holter device (Spacelabs 90207, Redmon, WA), which records BP every 15 minutes. Statistical analysis was carried out by means of the software SPSS-PC Windows 3.1 version. Results: Sixteen patients (37%) had silent white matter lesions. No demographic differences were detected between the WML group and the rest of the patients. Analysis of the ABPM values showed that the WML group displayed greater mean systolic and diastolic BP values than patients with no WML (p=0.013 and p=0.021 respectively) and greater long term variability for systolic BP (p= 0.022). In contrast, portapres analysis only showed that the WML group presented higher mean systolic blood pressure values (p=0.016). Conclusion: Essential hypertension patients with silent cerebral WML suffer greater absolute blood pressure values and greater long term systolic BP variability. These results suggest that absolute BP values and BP variability ate good predictors of silent cerebral damage. P241 F u n c t i o n a l e f f i c i e n c y o f botulinum toxin A on the upper limb of hemiplegic s t r o k e patients. M. Rousseaux, O. Kozlowski, J. Froger (Lille, F)

Botulinum toxin A reduces spasticity in the injected muscles, ttowever, little is known about the potential efficiency in functional tests and daily living. This study aimed investigating this possible benefit an his predictive factors.

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Twenty patients (mean age: 54.4 years; M: 14; right hemiplegia: 12) were included at least 6 months after unilateral hemispheric stroke. Botulinum toxin A (Botox) was injected on the arm adductors (8 cases), forearm flexors (17), pronators, wrist and fingers flexors (20), with a total dose of 300 U. Examinations (days 1, 15; months 2, 5) comprised of: ( 1) elementary deficits: spasticity (modified Ashworth scale) - motor command - maximum thumb-index abduction - passive range of motion (2) functional tests: Nine-hole Peg Test (NPT) - Rivermead Motor Assessment (RMA) of the arm (3) daily living assessment: - Functional Independence Measure (FIM) - distal grasps, grips and pinches used at home (9 items). Patient received physical therapy, and antispastic medicalions were not modified. The alpha risk was p=0.05. We observed - significant reduction in spasticity in the elbow flexors, pronators, wrist and fingers flexors, with a maximum at day 15 (mean: 0.90 to 1 point), with important variations in effect - significant increase in muscle strength of wrist and fingers extensors - significant increase in the active thumb-index abduction - significant increase in the passive wrist extension. There was no effect on the NPT requiring distal manipulation, but the RMA showed significant improvement, which especially concerned the tennis ball manipulation subtest. Injection did not modified the M IE However, significant improvement in using the upper limb was observed, particularly for grasping large objects, grasping and transport of high or thin objects, and holding a bag. Furthermore, patients and relatires reported facilitation in dressing and proximal and distal care of the upper limb, and better position of the upper limb. Adverse reactions mostly consisted in transient pain during injection. The improvement in the RMA was better explained by the initial motor command on distal prehension, and the evolution in domestic activities by the initial severity of spasticity on pronators and wrist flexors (negative correlations). Conclusion. This represent the first comprehensive study of the effects of botulinum toxin A on functional activities of the upper limb, and of her predictive factors. P242 Mild hypothermia as therapeutic option for cerebral ischemia due to vasospasm after subarachnoid hemorrhage. P. Guenther, ]. Berrouschot, A. Wagner, D. Schneider (Leipzig, D) Introduction: lschemic deficits due to vasospasm increase the morbidity and mortality of patients with subarachnoid hemorrhage. Current therapeutic options include hypertensive hypervolemic hemodilution (Triple-H) therapy, angioplasty and intra-arterial papaverine administration. However, in practice these options oflen show limited success. Case report: We report a 32-year-old female who was admitted with subarachnoid hemorrhage (Hunt & Hess Grade I). An aneurysm at the bifurcation of the left medial cerebral artery was coiled a day later. Nimodipine was given IV. The patient hada normal neurological examination but transcranial Doppler indicated vasospasm of the left middle cerebral artery (MCA). Six days afler admission she developed aphasia and hemiparesis of the right hand side. Arteriograpby revealed significant vasospasm of the left carotid, anterior and middle cerebral artery. Since navigation of the microcatheter luto the left ACA and MCA could not be performed angioplasty and papaverine administ ration were iimited in success. Despite of hypertensive hypervolemic hemodilution (Triple-H) therapy CT scan showed cerebral oedema with midline shift due to ischemia and SPECT indicated hypoperfusion of the entire left hemisphere. The patient required intubation and ventilation as well as vent ricular drainage due to increased intracranial pressure. Mild hypothermia was initiated and maintained over a period of two weeks. Hypothermia was established by using a special catheter (Cool LineTM Alsius Corporation). Vasospasm was monitored by transcranial Doppler. According to CT-, MRI- and SPECT findings hypothermia was gradually withdrawn and Triple-H therapy was reduced. The patient survived and recovered although aphasia and hemiparesis of the right hand side maintained. Conclusion: Yet, there are only a few therapeutic options to reduce neurological deficits secondary to vasospasm afier subarachnoid hemorrhage. Mild hypothermia could be an interesting tool to reduce ischemia by decreasing cerebral metabolism and intracranial pressure. P243 Value of anticardiolipin and antinuclear antibodies testing in stroke patients. A Zacharof, C Flevaris, C. Petrogiannopoulos, G. Karachalios, P. Paziouros, G. Chartzoulakis, G. Drakogiorgos (Halandri-Athens, GR) Purpose of the study: The airas of this prospective study were to determine the frequency of anticardiolipin and antinuclear antibodies in an unselected ischemic and hemorrhagic stroke population and to evaluate the clinical significance of these two autoantibodies. Methods: Over a 5-year period, we collected plasma from 825 consecu-

tive patients with ischemic or hemorrhagic stroke hospitalised to our Department. Blood was drawn from each subject into a citrated glass tube. Plasma was obtained immediately by centrifugation and concentrations of IgM and IgG anticardiolipin antibodies were measured at room temperature in normal (not heat-treated) plasma by standardized enzyme-linked immunosorbent assay. Resuhs: A total of 825 patients (44.8%) 28 to 103 years in age (mean age, 76 years) were studied. Anticardiolipin antibodies were present in lO of 825 ( 1.2 %) patients. Two patients were IgG positive and eight patients were IgM positive. Of 825 patients, 73 (8.9 %) were positive for antinuclear antibodies. Anti-DNA antibodies were not demonstrable in any of these patients. Conclusions: The frequency of anticardiolipin antibodies in our stroke population is possibly lower than usually reported. The routine screening of anticardiolipin and antinuclear antibodies in a stroke population is of questionable value. P244

Moderate hypothermia in patients with elevated intracranial pressure. ]. Berrouschot, P. D. Schellinger, C. Graffagnino, S. A. Mayer, S. Schwab (Leipzig, Heidelberg, D; Durham, NC, New York, NY, USA) Background: Moderate hypothermia decreases ischemic damage in experimental stroke models. Wether this therapy is beneficial for stroke patients is unresolved. Uncontrolled intracranial hypertension and subsequent herniation is the main cause of death following massive hemispheric infarction. This study was performed to determine whether moderate hypothermia can reduce intracranial hypertension after severe ischemic stroke. Methods: The clinical course, ICP and CPP of 50 patients treated with moderate hypothermia was prospectively evaluated. Intraparenchymatous ICP probes were inserted ipsilaterally to the site of primary brain injury. Hypothermia was induced within 22 _+ 13 hours after stroke onset, and achieved by externa1 cooling with cooling blankets, cold infusions and cold washing. Patients were kept at 32-33~ body-core temperature for 48 to 72 hours and were passively rewarmed over a mean of 26 hours. Outcome at 4 weeks and at 3 months was aualyzed using the NIH Stroke Scale and Rankin scale. Resuhs: Thirty-one patients survived the hemispheric stroke (52 %). E1evated ICP values were significantly reduced from 24.5 + 10 mmHg to 15.2 -+ 7 mmHg under hypothermia. However in sixteen (32 %) of patients the benefit was only temporary, with a rebound increase in ICP and fatal herniation occurring afier rewarming. Three patients died due to severe coagulopathy or cardiac failure. The most frequent severe complication of hypothermia therapy was sepsis or pneumonia, which occurred in 27 of the 50 patients (54 %). Neurological outcome according to the NIH Stroke store 4 weeks after stroke was 28 (range 13 to 32) and Rankin scale three months afier stroke was 2.9 (range 2 to 5). Conclusion: Moderate hypothermia can reduce elevated ICP values in patients with cytotoxic oedema and mass effect after MCA stroke. However, in 32 % of patients the benefit was temporary, with a rebound increase in ICP and fatal herniation occurring after rewarming. By reducing elevated ICP, hypothermia may improve clinical outcome in these patients, even though it is associated with a variety of severe side effects. P245

Acute stroke in very old people: incidence, clinical, neuroimaging and outcome features in Martinique (French West lndies). S. Olindo, R. Deschamps, P. Cabre, C. Chatot Henry, D. Smadja (Fort de France, F) Background: Stroke incidence increases with increasing age and has an impact on daily living in many areas. With increasing life expectancy the population in the very old age group is expected to raise rapidly. This is the first stroke study focusing on very old patients in a black Caribbean population (Martinique, French West Indies). Methods: All Martinican patients suffering from their first-ever stroke during 1 calendar year between )une 1,1998 and may 31,1999 were collected. Epidemiological, clinical and neuroimaging data during the first month after the acute stroke were compared in very old patients (> 85 years) and patients below 85 years, lncidence and neuroimaging data, Barthel Index (BI) in the first week and outcome variables during the first month (mortality and Rankin score) were compared. Results: Five hundred and eighty patients were included, among them 100 patients were aged 85 years or older and 480 patients were below 85 years (respectively, sex ratio women/men: 2.84 and 0.85, mean age :!: SD: 89.8 -+ 3.8 years and 67.4 -+ 13.1 years). The incidence of first-ever stroke in the Martinique population was of 16.4/10,000/year (Europe and World standardized incidence were respectively of 15.1 and 10). The crude incidence rate was of 182/10,000/year patients aged 85 years or older.Very old patients had greater

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disability following stroke than patients below 85 years (mean BI score: 46.1 vs 70.8, p < 0.0001). There were no significant differences in pathological types of stroke and subtypes of iscbemic stroke between the 2 groups. The 30-day case fatality rate was about twice in very elderly patients (31% vs 18%, p=0.0009) and disability (Rankin) in survivors was higber (79% vs 48%, p < 0.0001).Very old patients showed a significantly lower prnpnrtion of diabetes (19 % vs 32 %,p=0.012) and smoking (0 % vs 8.5 %, p=0.004),and a higher proportinn of lower limbs arteritis (23.5% vs 11.5%, p=0.002). Prevalence of hypertension was identical in the 2 groups (70.5 % vs 70.2 %). Conclusion: This study showed a high incidence of stroke in Martinique, the most developed island in the wbole Caribbean basin. Very old patients with acute stroke bad the same pathological type of stroke, a higher clinical severity anda poorer outcome in the first month compared with stroke patients younger than 85 years. P246 Post-partum cerebral angiopathy: efficacy of nimodipine. S. Olindo, C. Chatot Henry, R. Deschamps, P. Cabre, D. Smadja (Fort de France, F) Backgrnund: Post-partum cerebral angiopathy is a rare disorder angiographically characterized by narrowing nf the medium-sized cerebral arterles. The overall prognosis is benign, but stroke may develnp. We present such a case for which efficacy of nimodipine has been demoustrated. Case report: A 23 year old woman, beginning her 5th day post-partum, cnmplained of acute headache. At day 6, she experienced several left hemisphere seizures and at day 21, she hada sudden aphasia, due to a left hemispheric ischemic stroke, together with increased headache. MRI revealed multiple small areas of high signal and cerebral angiography as well as angio-MRI demonstrated several narrowing among the branches of both anterior and middle cerebral arteries. Therefnre, intravenous nimodipine (1 mg/hour) was started, leading tn complete relief of headacbe over a day. Angio-MRl showed dramatic improvement after 7 days, and normalizatinn was obtained after two months. Nimodipine could be indicated in cases of post-partum cerebral angiopatby. The rapid efficacy of nimodipine in our case confirms a cerebral vasoconstriction as the pathophysiological process of the disorder. P247 Moyamoya disease presenting as Parkinsonism and dementia. N. Sieweke, E. Stolz, F. Blaes, H. Traupe, M. Kaps (Giessen, D) Moyamnya disease is a rare cerebrovascular disnrder which is associated with a wide variety of clinical conditions. Besides the idiopathic forros, in_ fectious and immunological disorders are known to cause the disorder. However, no satisfactnry hypothesis has yet emerged to explain the predilection of the Japanese for this disease. Diagnosis is usually established by means of conventional angiography demonstrating ncclusion of the circle of Willis and collateral formation. Often first clinical manifestations are stroke or hemorrhage. Treatment involves medical treatment (e. g. antiplatelet agents) as well as treatment of an underlying infectious disorder, and surgical revascularization. We report on a case of a 46 years old female patient who first presented with neurnlogical symptoms in her late twenties, cnmplaining about clumsiness of both hands leading to impairment in performing daily work. Additionally, at this time the patient already appeared mentally slowed down. Dementia of unknown etinlogy was diagnosed. On admission, the patient presented with mild dementia and subtle signs of rigidity of the upper extremities including a cogwheel phenomenon. Furthermore, tremor anda broad-based gait were apparent. A CT-scan showed marked atrophy of the brain hemispheres, the vermis and the brainstem. MRI was concurrent with the CT-scan, stroke or hemnrrhage had so lar nnt occurred. Color-cnded and conventional angiography revealed tight stenoses of both the internal carotid arteries located at the cranial base and an extensive collateral network. The diagnosis Moyamoya disease was confirmed. Parkinsnnism and dementia are rare symptoms of Moyamoya disease and may mislead to the diagnosis of a "Parkinson plus"-syndrome. Furthermore, this case is exceptional as no focal ischemic lesions were found on MRI, rather a marked brain atrophy. P248 Vascular Hemichorea And Hemiballism. S. Santos, L.F. Pascual, J.A. Mauri, J. Lopez Del Val, C. I¡ T. Casadevall, C. Tejero, F. Morales (Zaragoza, E) Background: Hemichorea and bemiballism are uncommon symptoms of acute stroke. They seem to be related to contralateral involvement of the

basal ganglia. Our objective is to analyse our series of patients and to detect with magnetic resonance or CT-scan the site of lesion. Patients and methods: We made a retrospective study of the cases with hemichorea or hemiballism due to acute stroke that were admitted in the last tire years. We recorded age, sex, vascular risk factors, mechanism and type of stroke and prognosis. Resuhs: A total of nine patients (six men and tbree women) with an average age of 68.67 years were analysed (seven hemichorea and tbree bemiballism; eight ischemic stroke and one intracerebral hemorrhage). Extrapyramidal symptoms disappeared in a few days in tire cases without treatment. In other cases it was necessary to add haloperidol. In six cases lesions were found in the basal ganglia. The sites were: caudate nucleus in four cases; thalamus in two cases and putamen in one case. All lesions were cont ralateral to the side nf the body affected. In one case the ischemic infarct was preceded by several transient iscbemic attacks (transient hemichorea). Conclusions: Vascular hemichorea and hemiballism are due to smallsized lesions (hemorrhagic or ischemic stroke) with multiple and different locations in the basal ganglia. In all cases patients have a good prognosis with total nr partial remission of symptoms. P249 The apoptosis of neuron and endothelial cell and the expression of Bci-2, Bax and P53 proteins after focal cerebral ischemic and reperfusion in rats. G. Yunliang (Qingdao, VRC). P. R. nf China Objective: This article is to study the differences and changes between neuronal and endothelial apoptosis and their relatinnships to the expression of Bcl-2, Bax and P53 proteins after reperfusion of focal cerebral ischemia in rats. Methods: The animal model of middle cerebral artery occlusion and reperfusion were established. Coronal sections of brain were analyzed using an in situ terminal deoxynucleotdyl transferase-midiated biotinylated denxyuridine triphosphate nike end labelling (TUNEL) and immunohistochemical staining methnds to observe apoptosis and expression of Bcl-2, Bax and P53 after reper fusion (2, 6,12, 24 hnurs and 2, 3, 7,14, 21 days) nf focal cerebral ischemia. Resuhs: ( 1) In the ischemic penumbra, apoptotic neurons were increased at 2h after reperfusion, peaked at 12-24h, then decreased successfully for 7--14 days. The time of apoptotic endothelial cells is same as, but 12h later than that of apoptotic neurons. (2) In the iscbemic penumbra, the expression of Bcl-2 protein began at 2b after reperfusion, peaked at 12-24h, and decreased for 7-14 days. The Bax protein expressed from 6h after reperfusinn, peaked at 24-48h, and lasted fnr 14 days. The expression nf P53 protein increased at 6h after reperfusion, peaked at 24-48h, and decreased for 7 days. (3) The expression principles of Bcl-2, Bax and P53 protein in endothelial cells change similar to, but 12-24h later than that in neurons. (4) The timephase of Bcl-2 expression is similar to, but the Bax and P53 are 12-24h later than that of apoptosis. The ratio of Bcl-2/Bax is reversible to the apoptnsis. (5) The ratios of Bcl-2/Bax and Bcl-2/P53 peaked at 12h after reperfusion, than decreased successfully, and negatively to the apoptotic extents. (6) There area little of apoptotic cells and weak expression of Bcl-2, Bax and P53 proteins in ischemic core. Conclusion: Apoptosis is a pattern of neuron and endnthelial cell death after cerebral ischemia/reperfusion. The neuron is more sensitive to ischemic injure than endothelial cell so that the apoptosis nf neuron is early than endothelial cell. The expression of Bcl-2, Bax and P53 playa regulatory role in the apoptntic process. Bcl-2 enhances, Bax and P53 inbibit apoptosis. The ratins of Bcl-2/Bax and Bcl-2/P53 are negatively to the apoptotic extent. P250 The expressions of growth associated porten-43 and synaptophysin after focal cerebral ischemic in rats and their relationship with nerve growth factor. Feng Yanqing, Guo Zongjun, Guo Yunliang (lnstitute of Cerebrovascular Diseases, Qingdao University Medical College, Qingdao 266003, P.R.of China) Objective: This paper is tn study the expression of growth associated protein-43 (GAP-43) and synaptophysin (p38) after middle cerebral artery occlusion and reperfusion in rats, and the influence of nerve growth factor (NGF) on these two cytokines. Methods: 72 adult female rats were divided randomly into 4 groups: sham-operated group, Natural recovering group, artificial cerebrospinal fluid (ACSF) group, and NGF group. The rats received left middle cerebral artery occlusion nf 2 hours. The sections of the brains which were subjected 6 hours and 1, 3, 7, 14, 21days of reperfusion, and were processed by immunochemistry with antibodies against GAP-43 and p38. Results: In the sham-operated group, GAP-43 and p38 immunoreactivity

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were present in cortical and hippocampal neurons. GA P-43 immunoreactivity was increased at 6 hours reperfusion, and attained the peak at the 7 th day in the boundary zone to the ischemic core, and decreased in the later days, ir remain above at 21 ~t day. p38 immunoreactivity was increased at yd da)', attained its peak at 7th da},, and returned almost to the sham-controlled level at 21 ~t da),. The expressions of GA P-43 and p38 were slightly increased after NGF treatment,but the difference were not remarkably. Conclusion: Ir is suggested that there might be neuroplasticity of regeneration and repair in central nervous system after cerebral ischemic stroke. The regulative effect of exogenous NGF on GAP-43 and p38 need to further study. P251 The mechanism of basic fibroblast growth factor enhancing functional recovery after focal cerebral ischemia and reperfusion in rats. Wang Yanan, Xu Zhenfeng, Guo Yunliang (lnstitute of Cerebrovascular Diseases, Qingdao University Medical College, Qingdao 266003, P. R. of China) Objective: The present study is to observe the effect intracisternal basic fibroblast growth factor (bFGF) on the functional outcome and measure the expression of select proteins including microtubule-associated protein-2 (MAP-2) and growth associated protein-43 (GAP-43) which are associated with neurite plasticity after focal cerebral ischemia and reperfusion in the rats. Methods: Wistar Rats were subjected to 120minutes of middle cerebral artery occlusion (MCAO) and different days of reperfusion. Brains from MCAO rats without any treatment, with swimming training, with intraeisternallybFGF treating,with placebo treating intracisternally, as well as those with control sham-operate and normal were processed by immunohistochemistry with monoclonal antibodies against MAP-2 and GAP-43. Animals were exarnined every other day using three different behavioral test to assess sensorimotor function. Results: There was improvement in the score of behavioral test in both swimming training and bFGF treating groups compared with their control respectively. Immunostaining shows increase in MAP-2 and GAP-43 immunoreactivity in ischemic boundary zone in both treated groups with a statistic significance, p < 0.05. Conclusion: Both swimming and bFGF can improve behavioral outcome of MCAO rats. The function enhancement may be partially due to the upregulation of MAP-2 and GAP-43 whid'r are concomitant with neurite outgrowth. P252 Lyme Neuroborreliosis-associated intracerebral hemorrhage. R. Scheid, D. Y.ron Cramon (Leipzig, D) Introduction: Borrelia burgdorferi is the infectious agent responsible for a variety of neurological disorders. Cerebral vessel involvement is a rarely reported complication. We reportan uncommon case of otherwise unexplained intracerebral hemorrhage in association with clinically and laboratorly proven Lyme Neuroborreliosis (LNB). Case Report: A 56 year old woman with no history of chronic medical disorders experienced subacute strong headache in May 1998. Neurological examination, lumbar puncture and CCT were unremarkable. Five days later CCT showed a right sided intracerebral hemorrhage. Cerebral angiography was unremarkable. A right sided peripheral facial palsy, a lefl sided N. abducens palsy and a left upper quadrant homonyme anopia were diagnosed. On admission to the University Day Care Clinic of Cognitive Neurology, Leipzig/Germany, the patient complained of diffuse slowing of cognitive functions. She reported arthralgias a n d a feeling of thinning of her skin. NMR showed a lesion of the right gyrus temporalis inferior and parietooccipital cortex. A tick-bite is remembered 1993. We found high titers of B burgdorferi antibodies in serum and CSF. Ig-G EL1SA and Western Blot were positive both in serum and CSF. B burgdorferi antibody index (Al) was 2.3. Discussion: There is increasing evidence concerning B burgdorferi associated cerebral vasculopathy. Several reports connect LNB to ischemic stroke. In 1997 Chehrenama et al. reported the first case of subarachnoid hernorrhage in a patient with LNB (1). Oksi and colleagues presented three patients with B burgdorferi infection and intracranial aneurysms (2). We hypothesize, that the hemorrhage in our patient is causally related with B burgdorferi infection. Arguments, which support our hypothesis are: the clinical course of the patient's disease, the localisation of the hemorrhage, and the fact that the residual condition of the patient is not satisfactorily explained by the visible brain lesion only. To our knowledge, this is the first case of an intracerebral hemorrhage and over all the fifth description of a hemorrhagic complication in the context of LNB.

References 1. Chehrenama M, Zagardo MT, Koski CL (1997) Subarachnoid hemorrhage in a patient with Lyme disease. Neurology 48:520-523 2. Oksi J, Kalimo H, Marttila RI et al. (1998) Intracranial aneurysms in three patients with disseminated Lyme borreliosis: cause or chance association.~ I Neurol Neurosurg Psychiatry 64:636-642 P253 CO2 reactivity prior to and after cerebrospinal fluid tap test in patients with normal pressure bydrocephalus. S. ron Stuckrad-Barre, T. Pfefferkorn, M. Staender, K. Herrmann, C. Goetze, G. Hamann, M. Strupp (Frankfurt, Mª D) Background: Recent studies gave evidence that reduced autoregulation and vasomotor reserve (VMR) might play an important role in the pathogenesis of normal pressure hydrocephalus (NPH). Thus, patients with NPH showed no significant reduction in cerebral blood flow velocity (BFV) but impairment of VMR pre-shunting with an increase of VMR post-shunting related to symptomatic clinical improvement 3 months after surgery. Using transcranial Doppler sonography (TCD) we examined CO~ reactivity directly pre and post removal of 30-50 mls of cerebrospinal fluid (CSF) at lumbar puncture (serial CSF tap test) and its correlation with clinical results in 11 patients with NPH. Methods: CO2 reactivity was determined in 11 patients with clinical signs suggestive of NPH undergoing CSF tap test. Cognitive impairment was assessed by Mini-Mental-State-Examination, gait assessment by ambulatory speed and number of steps. Cranial CT showed dilated ventricles with various degrees of periventricular lucency in all patients. Middle cerebral artery mean BFV was detected by TCD. CO2 reactivity was calculated as the percentage change of mean BFV during hypercapnia, induced by inhalation of carbogene (5% CO2 and 95% O2), to normocapnia. Results: Before tap test mean VMR of 11 patients was 29.1 -+ 11.1% compared to 35.1 -+ 12.6% post-tap test VMR. Correlation between changes of pre- and post-tap VMR with clinical outcomes showed a significant higher VMR in patients with gait improvement (r=0.68,p < 0.05). Conclusion: These preliminary results demonstrate that posbtap improvement of VMR tends to relate to symptomatic irnprovement of gait in a small number of patients with suspected NPH. Thus, measurement of BFV includingVMR by means ofTCD pre- and post CSF tap test might be useful for both confirming the diagnosis and predicting the dinical benefit preand post-tap test in patients with NPH. P254 Diffusion weighted MR1 in patients with transient global amnesia during a Valsalva manoeuvre. K. Winbeck, H. Hengge, H. von Einsiedel, T. Etgen, T. Wilhelm, B. Conrad, D. Sander (Munich, D) Introduction: The etiology of a transient global amnesia (TGA) is still uncertain so far. Lewis (Lancet, 1998) hypothesised that a TGA is caused by venous congestion resulting in venous infarction. We recently described an increased frequency of a retrograde flow pattern of the internal jugular vein in patients with TGA during a moderate as well as short lasting maximal Valsalva manoeuvre compared to healthy controls (Sander et al., Lancet, 2000). Methods and subjects: To analyze the changes of diffusion weighted imaging (DWI) before, during and 5 minutes aftera Valsalva manoeuvre we examined 19 patients (7 male, mean age 62 years [95 % confidence interval: 58, 65 ] with proven pure TGA. Two of the patients (1%) h a d a history of ischemic heart disease and one patient reported a history of mild diabetes. 5 (26 %) reported a history of hypertension, 4 (21%) were currently smoking and 4 (21%) were former smoker. Six patients (32%) reported a history of migraine. 14 (74 %) of the patients reported Valsalva-like activities at the beginning of their TGA. In three of these patients DWI MRI was performed within 24 h after symptom onset. In addition we examined the flow pattern of both jugular veins in all patients using duplex ultrasonography. Results: None of the 19 patients developed a transient global amnesia during the Valsalva procedure. A retrograde flow component either during a moderate or during a maximal Valsalva procedure was found in 14 (74%) patients. The DW images and the calculated apparent diffusion coefficient maps showed no signal intensity changes.Additionally we could not find any differences on MRI in relation to the appearance of a retrograde flow component during Valsalva. Conclusion: We did not find any signal abnormalities in all patients with TGA during a Valsalva procedure using DWI. The lack of any DWI changes even in the patients with acute TGA supports earlier findings (Gass et al., Stroke, 1998).

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P255 Man In The Barrel Syndrome Due To Ischemic lnfarct Of The Cervical Spinal Cord. V. Zouvelou, D. Kravaritis, E. Koutra (Athens, GR) "Man in the barrel" syndrome (MIB) refers to brachial diplegia with intact motor functioning of the legs and brainstem reflexes. MIB often follows global cerebral hypoperfusion, especially after cardiopulmonary arrest. Neuroanatomically, the typical lesion is located bilaterally at border zone between the anterior and middle cerebral artery territories.We reporta patient with an atypical presentation of MIB. A 62-year old woman, without any previous relevant medical history, was admitted because of acute and painless brachial diplegia, soon after abrupt getting up in the morning and urination. On examination, we found severe and predominantly proximal weakness of both arras with lost deep tendon reflexes and dissociated disturbance of sensation. Examination of the lower limbs, cranial nerves, bladder and bowel functions were normal. Computed tomography (CT) of the brain was normal, but magnetic resonance imaging (MRI) of the cervical spinal cord (four days after admission) revealed infarct in the territory of anterior spinal artery (ASA) expanding from C3 to C6 and protrusion of C5-C6 intervertebral dise with mild impression of the dural sack. Electrophysiology at that time was normal. Two months later, almost normal muscle strength of the arms with brisk deep tendon reflexes and bilateral Hoffman sign was observed, while electrophysiology revealed denervation from the rigbt deltoid and the left interosseous muscles. Four montbs after admission, the spinal MRI demonstrated the infarct at a chronic stage. Despite the complete investigation, the cause of spinal stroke was not identified. Discussion: The reported case represents an incomplete ASA syndrome. In association with the protrusion of cervical intervertebral dise, we hypothesize secondary compression or perhaps irritation of the branches of the ASA (sulcocommissural artery). In M1B syndrome, an infratentorial lesion site including the cervical spinal cord should be considered. MRI and electrophysiology are valuable tools to further confirm both location and extension of the spinal lesion. P256 F• V Leiden And Arteriailschemic Stroke In Young Adults. Aspects Of Diagnostic Screening. V. Zouvelou, D. Kravaritis, ~ Stifougias, E. Koutra (Athens, GR) Coagulation disorders are among the probable causes of stroke, especially in young adults. Activated protein-C resistance (APC-resistance) is the most frequent cause of inherited thrombopbilia (autosomal dominant trait). APC-resistance is associated with a point mutation in the factor V gene (factor V Leiden) tbat causes a hypercoagulable state by slowing the inactivation of Va by APC. We report the cases of two young women who suffered an ischemic stroke. The full investigation revealed only the presence of APC-resistance due to factor V Leiden (heterozygous condition). Ir was confirmed at first with a functional assay based on APTT test and then with DNA analysis (Polymerase Chain Reaction). Patients' family members were also screened. Case 1: A 20-year old woman presented with total aphasia and right hemiplegia of abrupt onset. Her personal history was free, but her father died from heart attack at the age of 45. Brain MRI revealed iscbemic infarct in the distribution of left middle cerebral artery. Case 2: A 29-year old woman presented witb first episode of simple partial motor seizure of the left arm with secondary generalisation, one day after therapeutic abortion. The clinical examination showed left hemiplegia and left facial weakness. CT and MRI of the brain showed ischemic infarct of the right fronto-parietal region. A miscarriage was reported in the past. The two patients were set on heparin and oral anticoagulation tberapy. Discussion: The usual manifestation of inherited thrombophilia is vein thrombosis (deep or superficial). Arterial thrombosis is reported to be a rare manifestation of APC-resistance. The prevalence of APC-resistance among the general European population ranges from 1-7 %; in Greece it is estimated about 5 %. Coexistence of other acquired or genetic risk factors with APC-resistance strongly increases the risk of thrombosis. Because of the apparently higb prevalence of this defect, we set on thinking whether diagnostic screening should be considered in asymptomatic individuals with or without personal or family history of thrombosis, before or during their exposure to thrombotic risk factors (pregnancy, oral contraception, major surgery or prolonged immobilisation). In addition, we strongly suggest the screening of family members not only to confirm the inherited nature of the defect but also to identify asymptomatic individuals who may benefit from antithrombotic propbylaxis during exposure to circumstantial risk factors.

P257 Clinical features and outcome of the very small non territorial cerebellar infarcts. I. Izquierdo, I. Roquer, V. Puente, M. Gomis, E. Munteis, A. RodriguezCampello, T. Tarancon, C. Oliveras, A. Pou (Barcelona, E) Objectives: The aim of this study is to describe the risk factors, clinical features and the outcome of patients with very small non territorial cerebellar infarcts (VSNTCI) that appeared with acute cerebellar symptoms. Patients and methods: Among 1140 patients included consecutively in our stroke database we identified 47 cases with a cerebellar infarct. OŸthat group, we studied those patients with cerebellar symptomatology and MRI studies that showed VSNTCI as unique cerebellar lesion. Results: 1) We found 5 patients with VSNTCI (10,6%), four males, with ah age average of 72.0 _+9.6 years. 2) Risk factors: Two patients had hypertension, three had embolic cardiopathy, one had dyslipemia, and one had diabetes as the most important risk facIors. 3) In 3 cases MRI angiography was performed and showed in one case a partial occlusion of the homolateral vertebral artery. In the other cases, we didn't found any vascular pathology. 4) All of them also showed supratentorial MRI lesions. 5) The clinical features were: ataxia in all cases, dysarthria in tbree cases and vertigo in two cases as the most common clinical features. 6) After tbree months the Rankin score was between 1-2 in all of them. Conclusions: 1) The 10,6% of the patients with symptomatic cerebellar ischemic stroke and brain-MRl study showed VSNTC1 as unique responsible acute lesion. 2) As in the territorial cerebellar infarcts the prevalence was higher in males. 3) Al1 patients had ataxia as a clinical feature, followed by dysarthria and vertigo.4) lnterestingly all of our pdtients also showed supratentorial lacunar infarcts in brain-MRl studies. 4) The prognosis of VSNTCI is, in general, very good. P258 Could Brain Hemorrhage Be A neurological expression of Sneddon Syndrome.~ M.V.MejŸ E. DŸ Tejedor, M. Alonso, A. Frank, M. Lara, P. Barreiro (Madrid, E) lntroduction: Sneddon Syndrome (SS) is characterised by cutaneus "livedo reticularis" (LR) and ischemic stroke. However cerebral hemorrhage (CH) has been described asa casual finding. Our hypothesis is that CH could be another form of presentation in this syndrome. Material and method: Between 1984 and q 2000 we have selected patients with this SS clinic and radiological criteria: persistent cutaneous LR and, stroke episodes confirmed by cranial CT or IMR. Cerebral angiogram should show small or medium siz~ arteries stenosis or occlusions, with or witbout absence of artery distal territories and band angiogram arterial obstruction or stenosis. Results: Eleven patients fulfil SS criteria (9 women and 2 men), average age was 47 years old (37-58). Stroke was the first manifestation in 8 patients. 3 suffered parenchymatous or subarachnoid hemorrhage, 2 of them had recurrence and also showed ischemic signs in neuroimaging; 3 patients had higb blood pressure, only 1 of them had CH. None of them had coagulation disorder. Conclusion: CHis a not uncommon SS form of presentation (27 % in our series). For this reason, this cause should be considered in any patients with CH and livedo reticularis, sinee its real frequency is probably underestimated. The mechanism tbat origin CH remains not yet clarified. P259 Vertigo as the only manifestation of vertebral artery dissection. A case report. D. Alexiou, T. Arida, J. Delithanasis, B. Traiforos (Kabala, Thessaloniki, GR) Background: Vertebral artery dissection (VAD) is an increasingly recognized cause of posterior circulation ischemia in young and middle aged adults. The commonest clinical presentation is with headache followed after hours or days with ischemic symptoms of the vertebrobasilar system. Occasionally patients may have minimal or no symptoms at all. Case Description: A 45-year-old man was admitted with severe acute vertigo accompanied by nausea, unsteadiness and left sided mild cervicalgia. Neck pain was started 12 hours before the symptoms while he was painting the ceiling. Neurologic examination revealed no focal signs. Laboratory tests, ECG and brain CT sean were normal. Complete resolution of bis symptoms occurred during the same day and he was discharged as a case of peripheral vertigo. One day later he returned, complaining for severe occipital headache and no otber symptoms. Neurologic examination remained normal. Brain MR imaging showed a cerebellar infarct corresponding to the left inferior cerebellar artery (PICA) distribution. Extensive laboratory studies, ECG and transthoracic echocardiography were unremarkable. Color coded

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duplex imaging findings were indicative of left vertebral artery (LVA) dissection in V 1-V2 segments: a double lumen with high resistance flow profile was observed. MR angiography was performed 3 days later: LVA was found occluded in its entire length to the level of LPICA. Sonographic re-examination revealed absence of flow signal in LVA.The patient was discharged on dicumarole treatment. Six months later he continues to complain of mild occipital headache. No recanalization have been revealed in follow-up sonographic studies. Conclusion: Vertigo in close association with headache in young and middle-aged patients may raise the suspicion of vertebral artery dissection. Early diagnosis is essential since ischemic symptoms may develop days after the initial event.

among the most common complications of advancing disease in this population (64 %). Motor fluctuations and dyskinesias affected approximately 30 and 20% of the overall sample, and changes in mental state such as dementŸ depression and hallucinations each affected approximately one fifth of patients. Symptoms of autonomic nervous system dysfunction occurred in the great majority of patients, but were not associated with greater disease severity, disease duration or overall disability. Conclusion: In contrast to clinic-based samples, the most frequently occurring complications of PD in this community-based sample were axial features such as postural instability with falls. These factors should be more taken into account in the allocation of health care resources and the treatment of symptoms of patients with PD in the community.

Extrapyramidal Disorders

P263 3-OMD and Homocysteine Plasma Levels in parkinsonian Patients. T. Mª S. Peters, D. Woitalla, W. Kuhn (Bochum, D)

P260 Multiple system atrophy in familial idiopathic brain calcification. S.D. Lhatoo, B. Perunovic, S. Love, H. Houldeu, M.J. Campbell (Bristol, London, UK)

Familial idiopathic brain calcification (FIBC) is a rare disorder characterised by autosomal dominant trausmission, aduh onset cerebellar and/or extrapyramidal features and idiopathic calcification of the brain. Multiple system atrophy (MSA), which has a similar clinical picture, is invariably a sporadie condition. The two couditions are not known to occur together. We present a family with F1BC where pathological studies shnwed that the proband had both FIBC and MSA, a hitherto undescribed association. The presence of both conditions simultaneously in the same patient is interesting, raising the possibility that these conditions muy-be pathogenetically related,giveu their predilection for involving the sume parts of the central nervous system. P261 Gait rehabilitation and quality of life in Parkinson's disease. ]. L. Molinuevo, M. T. Maneiro, C. Avi¡ A. Masabeu (Palam£ E) Background: Defective scaling of stride length is the main anomaly underlying gait disturbance in Parkinson's disease (PD), and results in an abnormal stride length-cadence relation anda decreased velocity. Ob)ective: To analyze the effect of rehabilitation on PD gait and their influente on health-related quality of life (QoL). Patients and methods: Twelve patients with PD (eight women; mean age, 70.1 years; mean duration of disease,6.2 years) without motor complications performed a gait rehabilitation program. They were instructed every-other day during one month to performed their age-, sex-, and height-matched step length. A control group performed a "placebo" rehabilitation program. Patients were then crossed over both programs. Clinical assessment was blinded and carried out one week before and one week after each rehabilitation program. A set of rating scales (Hoehn & Yahr, Unified Parkinson's Disease Rating Scale (UPDRS), Schwab and England, Northwestern University Disability Scale of Walking (NU DS), and the sit-stand-walk test were applied, and gait parameters analysed. QoL was measured by means of the PDQ 39. Results: After gait rehabilitation, step length siguificantly increased by 25 % which resulted in significant improvement in the UPDRS part I1, III, NUDS, and in the sit -stand-walk test. Although, the global effect on QoL was not different, the mobility dimensions of the PDQ-39 showed a significant improvement (p < 0.01). These improvement were not detected after the "placebo" rehabilitation program. Conclusions: Gait rehabilitation significantly increased stride length, which resuhed in a significaut improvement in gait and gait related QoL in patients with PD. P262 How common are complications of Parkinson's disease.~ A. Schrag, Y. BenShlomo, N. Quinn (London, Bristol, UK) Background: Parkinson's disease (PD) can be associated with a wide range of complications of advancing disease and treatment. However, it is unclear how often these occur in the overall population of patients with PD. Objective: To assess the prevalence of disease and treatment complications and their clinical correlates in a community-based sample of 124 patients with PD. Results: Average current age was 72 (SD 10.9) and mean disease duration 6 (SD 4.3) years. Falls with postural instability and other axial features were

The controversy on the putative neurotoxicity of levodopa (LD) mainly focus on onset of motor fluctuations and various hypotheses on neurodegeneration.Augmented levels of substantial impairment of endothelial function and atherosclerosis inducing homocysteine (H) appeared in LD treated compared to previously untreated parkinsoniau patients (PP) and healthy controls (Mª et al., Lancet 1999; 354:126/7). Main metabolising pathways of LD are decarboxylation and O-methylation with conversion of LD to its long living derivative 3-O-methyldopa (3-OMD) by catechol-O-methyltransferase (COMT). COMT requires Mg 2+ as cofactor and S-adenosylmethionine (SAM) as methyl donor. Thus O-methylatinn of LD to 3-OMD is associated with an increased conversion of SAM to H by COMT. Objective: To demonstrate a relationship of LD, 3-OMD and H in treated PE Subjecls and methods: We measured H, LD and 3-OMD in 40 LD/DDI treated PP (age: mean (M): 61.4 SD: 6.4, range: 48-73 years) analogous to our previous design. Results: Correlation between plasma H (M: 13 SD: 4.4, range: 3.7-17.1 umol/1), 3-OMD (M: 2486 SD: 1122, range: 654-4196 ng/ml), LD (M: 72 SD: 39, range: 13-168 ng/ml), severity of PD - evaluated by the UPDRS (M: 52.3 SD: 25.4, range: 6-98) - and age was performed with un alpha-adjustment to 0.01. H correlated with 3-OMD (r = 0.52, p = 0.0006) and UPDRS score (r = 0.54, p = 0.0003), but not with LD (r = 0.22, p = 0.17) and age (r = 0.13, p = 0.4). We compared H in two groups (I, II: n = 20), subdivided according to their 3-OMD level (I < 2500 ng/ml 3-OMD: H: M: 10.8 SI): 3.0 range 3.7-18.4 umol/1; II > 2500 ng/ml 3-OMD: H: M: 14.9 SD: 4.6 range 6.8-24.6 umol/l. H significantly differed between both groups (I vs 11: p = II.002). Discussion: Short half-life of LD hypothetically causes the missing relation between H and LD. LD dosages usually rise due to increasing severity of PD but not age. The association between H and UPDRS score in contrast to age support this view. The relationship between H and 3-OMD provides further evidence for the impact of LD/DDI metabolism on H. This hypothetically influenced changes in vascularisation density in the parkinsonian substantia nigra (Faucheux et al., Lancet 1999; 353:981/2). COMT inhibitors reduce O-methylation. Folic acid supports metabolism of H to methionine. Both hypothetically decrease LD/DDI induced increase of H and thus prevent occurrence of increased vascular disease in PD. P264

Tapping and Peg Insertion after Levodopa lntake in treated and de-novo parkinsonian Patients. T. Mª Wuppertal, D)

S. Benz, S. Peters, H. Przuntek (Bochum,

Background: Investigators use apparative procedures for objective assessment of parkinsonian motor impairment and antiparkinsonian drug response. Previous studies on treated (tr) parkinsonian patients (PP) did not consider acute and long-term effects of dopaminergic drugs. Objectives: To determine the impact of long-term dopaminergic therapy within a staadardized levodopa challenge test design in combination with two repeatedly performed instrumental tasks [tapping ('1")and peg insertion (PIS); Mª et al., Can 1 Neurol Sci 2000; 27(4):311-315)] in 14 non fluctuating tr PP, taken off medication for 12 hours and 16 untreated (ut) PP. Subjects and methods: Due to half-life of levodopa, we performed T and PIS before, 30, 60, 90 minutes after levodopa intake in combination with simultaneous scoring of PP with UPDRS part III. Raters were blinded to resuhs of the apparative tasks. Resuhs: There were significant differences of T (tr PP: p = 0.009, ut PP: p = 0.001 ) and PIS (tr PP: p = 2.47E-05, ut PP: p = 0.0002) in comparison with matched controls. T significantly decreased after intake of levodopa in ut PP (F(dF 3, dF 45) = 4.70, p = 0.006). Tr PP showed no significant change of T after levodopa intake (F(dF 3,dF 39) = 0.56, p = 0.64). PIS significantly short-

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ened after intake of levodopa in utreated PP (F(dF 3, dF 45) = 5.94, p = 0.0016) and in tr PP (F(dF 3, dF 39) = 3.19, p = 0.034). UPDRS scored motor symptoms of both arms significantly improved in ut PP (F(dF 3, dF 45) = 14.19, p = 1.21E-06) and tr PP (F(dF 3, dF 39) = 11.39, p = 1.68E-05). Conclusion: Decrease of T, which needs low cognitive efforts, in untreated PP hypothetically results from postsynaptically induced upregulated presynaptic inhibitory feedback regulation, sedative effects of levodopa and/or dopaminergic overstimulation. In contrast motor impairment and resuhs of PIS with a need for more and higher cognitive load are sensitive to dopaminergic stimulation in PP. Future studies on the efficacy of antiparkinsonian drugs, using apparative tools for objective assessment, should consider long-term impact of antiparkinsonian drug therapy and necessary cognitive efforts for performance of applied instrumental tasks. P265 Direct MRI localisation of the Subthalamic Nucleus: a multiple, sequential image-fusion technique. M. Egidi, P. Rampini, M. Locatelli, M. Farabola, A. Priori, A. Pesenti, E Tamma, E. Caputo (Milano, I) Localisation of the subthalamic nucleus (STN) asa target site for stereotaxic procedures is usually accomplished through ventriculography or through stereotaxic magnetic resonance imagiog (MRI). The former method is invasive and indirect: the STN is not visualised, rather its position is calculated in relation to other visible anatomical landmarks. The latter method requites frequent checks of the MR environment to correct for real images distortion, which "caries according to the moment, the scanner, the patient, and the frame. A third way can be found in the use of image-fusion techniques that correct for image distortion by matching the MR image to a CT one. A problem arises, however, because only thin T2 images allow for clear viewing of the STN, anda standard MR scanner can produce only a limited number of slices, not enough to make image fusion reliable. We established a frameless MRI study protocol applicab[e to two-dimensional ]'2 imaging generated by standard 1.5-tesla MR machines, which allows to visualise the STN and to correct for real distortion by means of a multiple, sequential image-fusion tecbnique based on stereotaxic CT performed immediately before the operation. This study protocol has so lar beeo used to localise ten STNs as part of deep brain stimulation procedures for treating advanced Parkinson's disease. In all these cases, the STN was adequately viewed. Stereotaxic localisation of the STN proved accurate. Postoperative MR scanning demonstrated a precise correspondence of the final position of the electmcatheter to the chosen target within the subthalamic area viewed preoperatively in the MR images. Moreover intraoperative microrecording was consistent with nuclear activity at the target site in about half the tracks and intraoperative microstimulation was good in all of cases. In conclusion, this multiple and sequential image-fusion technique makes it possible to use frameiess T2 images of the subthalamic atea from standard MR with the geometric accuracy of a stereotaxic CT. STN localisation based on direct visualization improves STN targeting by taking into account the actual anatomy of the particular patient. This could reduce the need for multiple localising tracks. Furthermore, the image quality is such that even a specific portion of the STN may be targeted. This feature holds promise as a potential additional instrument for studying the functional topography of the STN. P266 Integrity of the Blood-Cerebrospinal Fluid Barrier and humoral cerebral immune response in early Parkinson's Disease. P. Haussermann, W. Kuhn, H. Przuntek, T. Muller (Mª D) Background: Dysfunction of the blood-cerebrospinal fluid barrier (BCB) has been implicated in the pathogenesis of Parkinson's disease (PD) and other neurodegenerative disorders. Methods: We assayed serum and cerebrospina] fluid (CSF) from 30 parkinsonian patients and 30 controls for concentrations of albumin and IgG. The CSF/serum ratio for albumin (AQ), lgG (GQ), IgG-index as well as determination of oligoclonal bands were used to evaluate BCB function and to quantify humoral immune response within the central nervous system (ENS). Resuhs: Levels of AQ, GQ and IgG-index did not significantly differ in both groups. We found no dysfunction of the blood-CSF barrier or signs of local synthesis of lgG in the central nervous system of parkinsonian pa.tients. Discussion: In conclusion, the present findings do not support the hypothesis of a compromised BCB function for high-molecular-weight proteins with subsequently increased leakage of serum proteins or immunologically/inflammatory mediated injury of the CNS as pathogenetic mechanism

in PD. An intact BCB function does not rule out the possibility, however, that substances from the serum penetrate the BCB and interact with neuronal function in the brain. Furthermore, the BCB function is not correlated to the severity or duration of disease. In further studies, BCB function should be focused in longitudinal studies and in more advanced stages of PD. P267 The influence of indomethacin on the level of striatum dopamine in the 1methyl-4-phenyl-l,2,3,6-tetrahydropyridine (MPTP) model of Parkinson's disease. M. Babiuch, S. Pilip, I. ]oniec, I. Kurkowska-)astrzebska, A. Przybylkowski, A. Czlonkowski, A. Czlonkowska (Warsaw, PL) lntroduction: The ro]e of inflammatory processes in the occurrence and development of neurodegenerative diseases like Alzheimer's or Parkinson's disease is undesirable. In experimental mouse model of Parkinson's disease MPTP treatment provokes inflammatory reaction in a forro of microglial and astroglial cells activation and lymphocytic infiltration, and leads to the nigrostriatal system degeneration and dopamine depletion. Nonsteroid medications inhibiting the inflammatory processes may contribute to the diminished neurodegeneration as it is suggested in Alzheimer's disease. The aim of the study: The goal of this research was evaluation of the influence of indometbacin on the level of striatum dopamine in MPTP mouse model of Parkinson's disease. Methods: MPTP and indomethacin were given intraperitoneally: MPTP once in the dose of 40 mg/kg; indomethacin in the doses of 1 and 2.5 mg/kg applied 24 hours before MPTP administration and every 48h to the end of experiment. The control group consisted of mouse which were given 0.9 % NaCl. The level of striatum dopamine was measured with the use of highperformance liquid chromatography method (HPLC) on the 2nd and 7th day after MPTP treatment. Results: Decreased striatum dopamine level on the 2nd and 7th days after MPTP administration was observe& The indometbacin alone didn't influence the dopamine level compared to the control group. The combined administration of MPTP and indomethacin in the dose of I mg/kg resulted in a smaller depletion of dopamine level (by 35 % as compared to the MPTP 1 group) on the 2nd and 7th days of experiment. The combined adm'nistration of MPTP and indomethacin in the dose of 2.5 mg/kg was not associated with similar protective effect. Conclusions: 1 mg/kg dose of indomethacin prevents the &crease of striatum dopamine in MPTP model of Parkinson's disease. This effect may be associated with diminished inflammatory reaction after indomethacin treatment. The lack of desired neuroprotective effect of 2.5 mg/kg dose ofindomethacin may be a result of too aggressive inhibition of COX-2 and increased apoptosis of neurons. P268 N-Methyl-Norsalsolinol passes through the blood-brain barrier after intraperitoneal injection. A. Thª A. Benecke, S. Qadri, A. Moser (Lª D) The TIQ derivatives N-methyl-norsalsolinol (2-methyl-6,7-dihydroxy1,2,3,4-tetrahydroisoqninoline and salsolinol were identified as putative endogenously synthesised neurotoxins in parkinsonian lumbar cerebrospinal fluid by high performance liquid chromatography (HPLC) with electrochemical detection (ECD). Since in previous studies a prominent bloodbrain barrier was suggested to exist for salsolinol, it was concluded that salsolinol present in the CNS is not of peripheral origia and TIQs measured in the cerebrospinal fluid have to be formed in the CNS. In vivo microdialysis in conscious, freely-moving rats, were applied to measure extracellular cerebral levels of N-methyl-norsalsolinol in the rat striatum after intraperitoneal injection. Stereotaxic surgical procedures were used to implant guide cannulae aimed at the rat striatum of male Wistar rats. At least 2 days later, artificial cerebrospinal fluid (aCSF) was perfused with 2 lal/min. Aftera 2 hr stabilization period, three 20 min samples were collected and N-methyl-norsalsolinol was injected vŸ an intraperitoneal caonula. The detection of N-methyl-norsalsolinol in aCSF during the subsequent 100 min period was determined using HPLC/ECD analysis. In the first three samples only dopamine and DOPAC could be detected in aCSE After intraperitoneal injection of N-methyl-norsalsolinol, chromatograms of the perfusate always showed peak areas with retention times identical to those of the reference compound (N-methyl-norsalsolinol). In order to confirm the identity of the peak, control aCSF was mixed with various concentrations of N-methyl-norsalsolinol standard. The chromatogram of this mixture showed a sharp and isolated peak area with retention time identical to the one of the original sample. These findings indicate that N-methyLnorsalsolinol well passes through the blood-brain barrier and can be detected in the rat striatum using microdialysis.

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P269 Familial and enviromental risk factors in Parkinson's disease: A case-control study in North-East ltaly. M. Zorzon, L. Capus, A. M. Pellegrino, G. Cazzato, R. Zivadinov (Trieste, I) Background and objective: The etiology of Parkinson's disease remains unknown, although both genetic susceptibility and environmental factors ate considered putative contributors to its origin. We performed a case-control study to investigate the association of familial and environmental risk factots with Parkinson's disease. Methods: We studied 136 patients with neurologist confirmed Parkinson's disease and 272 age- and sex-matched contro[s, affected by neurological diseases not related to Parkinson's disease. The risk of developing idiopathic Park[nson's disease associated with the following familial and environmental factors: positive family history pf Parkinson's disease, positire family history of essential tremor, age of mother at subject's birth, rural birth, rural living, well water use, farming as an occupatiun, exposure to pesticides, head tremor, exposure to general anesthesia and to ionising radiations, food restriction, concentration camp imprisonment and smoking has been assessed by using univariate and muhivariate statistical techniques. Resuhs: In the conditional multiple logistic regression analysis, positive family history of PD (OR 41.7, 95 % CI 12.2-142.5, p < 0.0001 ), positive family history of essential tremor (OR 10.8, 95 % C1 2.6-43.7, p < 0.0001 ), age of mother at subject's birth (OR 2.6, 95% CI 1.4-3.7, p= 0.0013), exposure to general anesthesia (OR 2.2, 95 % CI 1.3-3.8, p= 0.0024), farming as an occupation (OR 7.7, 95 % CI 1.4-44.1, p= 0.0212) and well water use (OR 2.0, 95 % CI 1.1-3.6, p= 0.0308) exhibited a significant positive association with PD, whereas smoking showed a trend toward an inverse relationship with PD (OR 0.7,95% CI 0.4-1.1,p < 0.06). Condusions: We conclude that both genetic and environmental factors may contribute to PD etiology. P270 Dexamethasone treatment diminishes degeneration of MPTP intoxicated dopaminergic neurons. T.L. Litwin, I.K. Kurkowska-Jastrz~bska, I.J. Ioniec, A.P. Przybykowski, A.C. Czonkowski, Ac. Czonkowska (Warsaw, PL)

Dexamethasone is a well-known anti-inflammatory agent with possible neuroprotective properties. Its influence on neurons survival in 1-methyl-4phenyl-l,2,3,6-tetrahydropiridine (MPTP) model had been already suggested. MPTP intoxication in mouse causes damage of dopaminergic neurons in the substantia nigra (SN). The level of dopamine in striatum is reduced and the number of dopaminergic cells in the SN is diminished. Degeneration is followed quickly by ah inflammatory reaction consisting of g[ial activation and lymphocytic infiltration. This inflammatory reaction ma}, contribute to neurons damage. In this study we investigated a dexamethasone effect on neurons survival after MPTP treatment. Animals were injected with dexamethasone (0,1 mg/kg, 1 mg/kg, 10 mg/kg) before MPTP intoxication and one day after intoxication (1 mg/kg) and treated every day to the end of study. The dopamine's content in striatum was checked by HPLC, 7days following the treatment and the inflammatory changes in the SN and striatum were estimated by immunohistological methods (3 and 7 days following intoxication). Dexamethasone (1 mg/kg) revealed a protective effect to neurons damaged by M PTP. Dopamine level in striat um was about 2 times higher in mice receiving dexamethasone (DXM) compared to mice receiving MPTP alone however the protective effect was only partial. The number of dopaminergic cells in the SN was also about 20% bigger in DXM mice than in MPTP mice. The inflammatory reaction was diminished in DXM mice, especially lymphocytic infihration and microglial reaction. Our study sbowed protective effect of dexamethasone on dopaminergic neurons injured by MPTP intoxication. Dexamethasone treatment inhibited inflammatory reaction and protected against neuronal damage suggesting that glial and lymphocyte activation may contribute to the patho[ogical process after MPTP treatment. P271 High-dose ropinirole in advanced Parkinson's disease. C. Pacchetti, E Mancini, R. Zangaglia, S. Cristina, G. Nappi (Paria, I) Background: Levodopa (LD) is still the most effective drug for the symptomatic treatment of Parkinson's Disease (PD), but it is commonly associated with motor fluctuations and dyskinesias. Dopamine agonists ate often adjunct to LD in attempt to reduce its dosage and side effects. Likewise, this strategy may be difficult to maintain because it can be less effective. Methods: In this open-label study we investigated the effects of high doses of adjunctive ropinirole in 25 patients with advanced PD. During the 10 days of hospitalisation phase the mean dai]y dose of ropinirole was in-

creased from 15.9mg to 36.2mg in a median of four separate doses. The mean daily LD dose decreased from 760 mg to 483 mg. Results: at the outpatients follow ups (after 3 and 6 months),this change in therapy produced significant reductions in dyskinesias during "on" periods and improvements in duration and intensity of"olŸ periods. Ropinirole was given at higher doses that recommended maximum dose (24 mg/day). Nevertheless, no patients reported treatmen•-emergent side effects and any pre-existing dopaminergic side effect remained unchanged by this treatment stralegy. Conclusion: this little used therapeutic approach may be useful for patients with advanced PD who ate experimenting LD associated side effects. P272 A comparative (99mTc)-HM-PAO SPECT study in Parkinson's disease paS. Ochudo, J. Siuda, E. tients with and without dementia. B. Jasi¡ Pi› G. Opala (Katowice, PL) The aim of our paper was the comparison of the regional cerebral perfusion quantified by single photon emission computed tomography (SPECT) in 30 PD patients (13 females, 17 males) with idiopathic Parkinson's disease (PD) with and without dementia. Within our group of PD patients the features of dementia were established in 10 (33.3 %) patients. Dementia was recognized according to ICD- 10 and DSM-1II-R criteria. Cognitive functions were executed by means of the Mini Mental State Examination (MMSE) and neuropsychological assessment (i. e.Wechsler adult intelligence scale). The Unified Parkinson's Disease Rating Scale (UPDRS) was used to quantify the severity of PD. SPECT was performed with Siemens Diacom gamma camera after intravenous application of technetium 99m hexamethylpropylene amine oxime (99mTc-HMPAO). HMPAO uptake was measured in the basal ganglia and the superior frontal, inferior frontal, parietal, temporal and occipital cortices. The perfusion values were expressed as cortical or basal ganglia/cerebellum activity ratios. In the subgroup of PD patients with dementia (DPD group) significant hypoperfusion affecting the inferior frontal cortices was observed Mean cerebral cortical uptake ratios were reduced (but not significantly) in DPD group. The tracer uptake ratios in the basal ganglia in the whole group of PD patients were reduce&

General Neurology P273 Two unusual complications of Klippel-Trenaunay syndrome: cerebral venous thrombosis and carpal t unnei syndrome. A. Awada, M. Al •umah, H. Al Ayafi (Riyad, KSA) Most neurological complications of the Klippel-Trenaunay syndrome ate due to the presence of cerebral or spinal arteriovenous malformations and their consequences. We report 2 cases of unusual complications of this syndrome. In the first case, where the anomalies were restricted to the left upper extremity, the occurrence of hand numbness led to the discovery of a carpal tunnel syndrome, probably due to the lymphatic abnormal proliferation within the carpal tunnel, in the second case the disease was much more widespread and affecting, between others, the cephalic extremity. The patient presented with intractable lefi motor seizures thal appeared to be due to an occlusion of the right transverse and sigmoid sinuses. Treatment with beparin and anticonvulsants led to rapid recovery. P274 H reflex threshold in Parkinson's disease patients for different stimulus duration. M. Kushnir, C. Klein, ]. M. Rabey (Zerifin, IL) The data gathered in previous H reflex studies in PD patients are ambiguous. In most investigations long stimulus durations (0.5-1 msec) were used, and no significant difference in H reflex behavior in PD patients and normal subjects was found. The purpose of the present study was to investigate the H reflex threshold in correlation to M response threshold in PD patients at different stimulus duration (0.1 msec to 1.0 msec). Electrical stimuli, with duration starting at 0.1 msec and gradually increased to 1.0 msec was used for eliciting the H reflex in 14 normal subjects and 19 patients with Parkinson's disease (PD). In 71.1% of normal subjects in comparison with 13.2% of PD patients the H reflex to M response threshold ratio (H/M TR) was less than 1 and the H reflex was obtained before the M response for all duration stimuli. For a]l stimuli duration's a significant difference between the H/M TR in the group of normal subjects and in the

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group of PD patients was found (T test 0.002-0.007). The duration effect was found to be highly significant - H/M TR for short stimulus duration was greater than for long stimulus duration's (p < 0.001). The optimal stimulus duration for evaluation H reflex behavior in PD patient was 0.2 msec. These very significant differences in behavior of the H reflex in PD patients could be used as another parameter in the assessment of extrapyramidal rigidity in PD patients. P275 Delirium as a burn encephaiopathy appearance. S. Khroulev, A. Belova, M. Rasteryaeva, A. Struchkov (Nizhny Novgozod, RUS) Introduction: Delirium as a burn encephalopathy appearance makes treatment results essentially worse. Aim of the investigation: to study the delirium morbidity, risk factors and course of the disease in burned patients. Materials and methods: We have analyzed data of 60 consecutive patients with severe burns treated in the intensive care unit of the Regional Burn Center at Nizhny Novgorod Research Institute of Traumatology and Orthopedics in 1999. There were 42 men aud 18 women aged from 16 to 84 (mean 43 + 3 years). The burn area varied from 10% to 98% of body surface and modified Frunk index varied from 16 to 280. 18 characteristics (age, sex, stage of the burn disease, index of the burn severity, type of the burning agent, premorbid brain injuries, alcohol addiction history, intoxication leukoindex which is calculated according to leukocytic formula, alanine aminotranspherase, aspartate aminotransferase, cholesterol, uric acid, creatinine, glucose) were selected as potential important factors in the delirium development. Statistical analysis was performed using Accurate Fisher Method. Results: 1. Delirium was observed in 16,6 % of cases (10 patients) of severely burned patients. 2. The delirium risk factors included alcohol addiction history (p < 0.05), modified Frunk index above 45 (p < 0.01), growing blood serum alanine aminotranspherase above 85 units/liter (the norm is from 5 to 49). 3. Sepsis and pneumonia were observed significantly more often in patients witb delirium development; 4. The delirium patients showed reliable increase (p < 0.01 ) of mortality risk. 5. As high delirium mortality risk markers we used the following signs: aspartate aminotranspherase above 100 units/liter (the norm is from 5 to 34), and intoxication leukoindex above 1.5 (the norm is within 1.5) (p < 0.05). Conclusion: It is necessary to identify the risk factors timely for prevention and early treatment of this hard burn encephalopathy appearance. Serum alanine aminotranspherase is the best prognostic marker for the risk of delirium development. Serum aspartate aminotransferase and intoxication leukoindex are markers of delirium mortality risk. P276 Acquired immunodeficiency syndrome presenting a s a numb chin syndrome. J. L. Molinuevo, A. Gomez, M. GiI, A. Masabeu (Palam£ E) Background: The numb chin syndrome is a mental neuropathy which usually translates the presence of an underlying malignancy. Objective: To reporta patient who presented with a numb chin s•ndrome as the initial manifestation of the acquired immunodeficiency syndrome (AIDS). Case report: A 41 year-old homosexual man consulted for one-week chin numbness. His past medical history was relevant for human immunodeficiency virus (HIV) infection biologically detected in 1993. When HIV was initially detected, bis viral load and CD4 cell count were 1942 copies and 408 cells respectively, and he started treatment with zidovudine. In 1997, he initiated highly active antiretroviral therapy, decreasing the viral load below 200 copies and increasing the CD4 count up to 781. He never had any HIV related infection or disease. One week before admission he experienced chin and lower lip numbness, which was later complicated with invalidating headache and vomiting. Neurological examination revealed bilateral papilloedema, hypoesthesia in the chin and lower lip a n d a right Horner's syndrome. General examination showed a left axilar enlarged lymph node. Contrast cranial MRI was normal. CSF revealed 200 lymphocytes/mm3, glucose 28 mg/dL and protein 160 mg/dL. CSF cytology, lymph node biopsy and bone marrow biopsy revealed the presence of Burkitt's lymphoma cellularity.A diagnosis of Burkitt's lymphoma and A1DS (HIV infection stage CI ) was performed. Conclusion: In this patient, mental neuropathy could be due to infiltration of the inferior alveolar nerves by lymphoma cells secondary to either bone marrow invasion or leptomeningeal seeding. This case report supports the relation of numb chin syndrome with maliguant disease and reinforces its value a s a red flag syndrome.

P277 Atypical onset of neurosarcoidosis: 2 cases. D. Ferriby, 1.de S~ze, T. Stojkovic, I. Hurtevent, P.Vermersch (France, F) Introduction: Neurological involvement during sarcoidosis ate observed in 5 to 15 % of the cases. We report 2 tases of neurosarcoidosis whose clinical onset is exceptional. Case Reports: 1. A 54-year-old woman developed a progressive sensorimotor deficit of the 4 limbs associated with a bilateral uveitis. The clinical, electrophysiological and CSF data were in favour of a chronic polyradiculoneuritis. 2. A 60-year-old woman presented with mnesic and cognitive disorders of progressive installation over several weeks. The neuropsychological evaluation showed a Korsakoff syndrome. In these 2 cases, the diagnosis of neurosarcoidosis was made according to the clinical, biological, radiological and histological data. The clinical course under corticosteroid and immunosuppressive treatment was favourable in the first case, allowing only a clinical stabilization in the second. Discussion: The variability of neurosarcoidosis clinical onset makes the diagnosis of neurosarcoidosis difficult, especially in isolated neurological symptom. In some cases, the clinical course of systemic involvement evidence can be the only way to confirm the diagnosis. Conclusion: These case reports confirm the clinical heterogeneity of neurosarcoidosis and the necessity to evoke this diagnosis in case of any atypical neurological pathology or without evident aetiology. P278 Sensory system interactions during simultaneous caloric vestibular and visual motion stimulation (a PET study). A. Deutschlaender, S. Bense, T. Stephan, S. Spiegel, M. Schwaiger, T. Brandt, M. Dieterich (Munich, D) In earlier PET and fMRI studies using vestibular stimulation we found bilateral activations of the posterior insula and retroinsular regions and simultaneous deactivations of the striate visual cortex bilaterally (Wenzel et al. 96). The aim of this study was to investigate the interaction between the two sensory systems during simultaneous stimulation. Twelve right-handed healthy volunteers were examined using O-15 water-bolus PEZ There were four stimulation conditions: A) purely vestibular stimulation: caloric irrigation of the right ear, water at 44~ eyes closed; B) simultaneously vestibular and visual stimulation: caloric irrigation (see A) while looking at the dot pattern used in C) but stationary; C) small-field vi* sual stimulation with a counterclockwise rotating disk covered with a random dot pattern (no self-motion perception); D) rest condition: no vestibular stimulation, eyes closed. Statistical analysis was performed using SPM99 (p < 0.001). During purely vestibular stimulation (A vs. D) bilateral activation of the posterior insula (PIVC) and the adjacent superior temporal gyrus (BA22) and superior parietal lobule (BA 40) was observe& Further activations were found in the anterior-median and dorsolateral thalamus as well as in the posterior aud anterior cingulate gyri. Simultaneously rCBF decreases occurred in the striate visual cortex bilaterally (BA 17 to 19). During purely visual motion stimulation (C vs. D) highly significant bilateral activations of the visual cortex were found, including the motion-sensitive area MT/V5 (BA 19/37) as well as deactivations in the posterior/retroinsular areas and the middle temporal gyrus (BA21); the latter may represent the visual temporal sylvian area (VTS). During purely visual stimulation there was significantly more activation of the visual cortex and MT/V5 than during the mixed condition (C vs. B). During purely vestibular stimulation there was significantly more activation of the vestibular cortex bilaterally and the anterior cingulate gyrus than during the mixed condition (A vs. B). Thus, the visual-vestibular interaction depends on the predominant stimulus and is reciprocally inhibitory, i. e., stimulation of one system leads to a deactivation of the other system. During combined visual and vestibular input both sensory systems are activated, but significantly less than during pure stimulation conditions. This may be a basic mechanism for spatial orientation and self-motion perception. P279 Lumbar Puncture: Does size matteH N. Tubridy, S. Wilson (London, UK) To compare the incidence of clinical complications and technical problems using 22G atraumatic needles and 22G conventional (bevel) needles for dL agnostic lumbar puncture in a neurological setting we conducted a randomised, double-blind, study. The setting was the neurology ward and iuvestigation unir in a tertiary referral centre for neurological problems. Fifty-six patients who had an elective diagnostic lumbar puncture were randomised. A standardised protocol for lumbar puncture with 22 gauge atraumatic/'pencil-point' or conventional/'bevel-tipped' spinal needles was

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employed. The primary outcome was the frequency of post lumbar headache at 48-72 hours. Secondary end-points included ease of use of each needle type, user preference, incidence of other complications and failure rate of the procedure. There was a low incidence of post lumbar puncture headache in both groups. At 72 hours there were 7 headaches reflecting a rate of 13 % with the 22G Quincke (bevel), 11% with the 22G Whitacre (atraumatic), and 20% with the 20G bevel needle. The difference between the 22G needle types was not statistically significant. Technical problems with the atraumatic needles led to a greater procedure failure rate and the doctors preference was overwhelmingly in favour of the conventional needles. Smaller gauge needles reduce the incidence of post lumbar puncture headaches. Atraumatic needles are associated with a lower incidence of headache but a higher incidence of technical difficulties and are thus unlikely to gain favour among neurologists who perform the procedure less often than anaesthetists.

P280 Magnetoencephalography (MEG) recordings in active and passive hand movements using the current density analysis. ] t. Woldag, G. Waldmann, M. Schubert, U. Oertel, B. Maess, A. Friederici, H. Hummelsheim (Bennewitz, Leipzig, D) Motor tasks lead to a neuronal activation mainly in the pericentral region. Magnetoencephalography (MEG) allows non-invasive and repeated measurement of cortical neuromagnetic tields in humans. MEG recordings have proved to be powerful in localising generators of event-related brain activity with a high temporal resolution. The motor evoked field I (MEF 1) is the largest and most robust signal and it is thought to be generated by proprioceptive inputs to area 3a (Brodmann). The aim of the present study was to elaborate the methodological basis of MEG recordings in a movement paradigm and to characterize movement related neuromagnetic fields during active and passive hand movements in healthy subjects. Neuromagnetic data were recorded from 6 healthy right handed subiects (3 women, 3 men, aged 23-32 years, mean 27.0) using a whole-head neuromaguetometer. The experiments were carried out with the full understanding and written consent of each subject. The study design has been approved by the local ethical committee. In the tirst task subjects had to execute rapid extensions and flexions at the wrist with their right hand. Interval and direction of each movement corresponded to the direction presented by an arrow on a screen in front of the subject. In the second task data were recorded during passive extension and flexion at the wrist. Thirdly, a pure sensory stimulus was given by means of a circumscribed cutaneous air pressure, applied to the middle phalanx of the right index finger. Location analysis using the current density analysis showed no differences between MEF I in active and passive movements. The maximum activation was found in the contralateral pericentral region. In contrast, the sensory evoked field was clearly located in the coutralateral postcentral regiou. Additionally, a shorter latency of MEF I (with respect to movement onset) was measured in flexion movements as compared to extension movements in both, passive and active movements. Our results confirms the assumption that MEF Iis generated by cortical activation from muscle spindle afferents. The marked MEF 1 latency differences between flexion and extension have to be considered in further MEG recordings with movement paradigms. The current density analysis appears to be appropriate for investigating movement related fields also in stroke patients and could allow new insights in neuronal plasticity induced by therapeutic interventions during neurorehabilitation.

P281 Sympathetic sudomotor skin responses induced by laser stimuli. A. Cerrera, M. Veciana, V. Obach, ]. Valls-Sol› (Barcelona, E) Background: The sympathetic skin response (SSR) is a slow resolving action potential attributable to the depolarisation of epidermal eccrine sweat glands. The SSR is usually obtained with electrical stimuli (ES) applied to the median nerve at the wrist or to the posterior tibial nerve at the ankle. It can also be obtained with stimuli of other sensory modalities. However, whether the SSR can also be induced by selective activation of slow conducting pain afferents with laser stimuli (LS) has not been examined yet. Objective: To study whether the SSR could be elicited by LS. To compare the latency, peak amplitude, duration and excitability recovery curve of the SSR induced by LS with those induced by ES. Methods: In 10 healthy volunteers we recorded the SSR with surface electrodes attached to the palm and dorsum of the right hand. The SSR was elicited by ES applied over the right median nerve at an intensity above motor threshold for thenar muscles. LS were detivered by means of a CO2 laser

stimulator prototype. This apparatus tires a laser beato of 2mm diameter, with a maximum intensity of 15W, and up to 100ras duration. The SSR excitability recovery curve was obtained by applying pairs of ES or LS stimuli, separated by interstimuli intervals (lSl) of 1,2, 4, 6, 8 and 10 seconds. Resuhs: In all subjects a SSR could be elicited by LS of intensities above pain perception threshold. With ah intensity of 13W, ah stimulating surface of 2mm and a duration of 40ras, the SSRs hada mean onset latency of 2.28s (SD=0.51), a mean peak amplitude of 1560microV (SD=480), a n d a mean duration of 3.47s (SD=0.46). With pairs of stimuli, the response to the second stimulus was absent up to the ISI of 6s, and recovered partially reaching a percentage of 65 % with respect to the response to the first stimulus at the ISI of 10s. Onset latency and interval of initial recovery were significanfly longer for I.S than for ES. However, the SSR amplitude and duration were not different. Discussion: LS are able to induce consistently SSRs in normal subjects. Our results suggest that the integrative centers responsible for the SSR are activated later, and take longer to recover, with LS than with ES. Testing the LS induced SSR may be used for neurophysiological evaluation of pain induced activation of central nervous system efferent sympathetic sudomotor pathways.

P282 Estimation of the conduction velocity of sympathetic sudomotor C fibers (SSFCV) in healthy subjects and neuropathic patients. M. Serrao, L. Parisi, A. Martini, M. Bartolo, D. Corigliano, P. Rossi (Rome, I) The aim of this study was to establish a simple method for estimating the CV of post-ganglionic sympathetic C fibers (SSFCV) in the upper and lower limbs by simultaneously measuring SSR in two distant sites. Fifty healthy volunteers and twenty neuropathic patients were studied. SSRs were recorded with standard surface electrodes applied to both proximal (axilla and crural line) and distal sites for eacb limb (hand and foot). The CV of the efferent branch of SSR was calculated by dividing the difference in the latencies of the response from two recording sites by the distance between the sites (axillary-hand for upper limb; crural line-foot for lower limb). Day-to-day reproducibility and intra-individual variability of the SSFCV were calculated. Heahhy subjects: For the upper limbs, the SSFCV in the axilla-hand'tract was 2.0 + 0.3 m/sec (range from 1.6 to 2.4 m/sec). For the lower limb, the SSFCV in the crural line-foot tract was 1.4 + 0.4 m/sec (range from 1.2 to 1.6 m/sec). Mean intra-individual variability of the SSFCV for the upper and lower limbs was 0.11 and 0.09, respectively. The coefticient of variation of the SSFCV for the upper and lower limbs was 5.1% and 5.4 %, respectively. Neuropathic patients: The SSR was absent in 40% of neuropathic patients in distal sites (axonal neuropathies). In the remaining patients (demyelinating neuropathies) a significant reduction of SSFCV was found in both upper (1.54 -+ 0.7 m/sec) and lower limbs (0.84 - 0.4 m/set). Our data show that this simple and non-invasive method can reliably be used to measure the CV of the SSF, in proper temperature conditions, and may be useful when investigating the physiological functions of peripheral nerves in patients with peripheral neuropathies.

P283 Paraplegia as the sole manifestation of painless aortic dissection on the ground of probable brucellosis. N.-M. Alexandri, A. Tavernarakis, C. Potagas, G. lsakidou, E. Molari, E. Koutra (Athens, GR) We describe the case of a 51-year-old man, stockbreeder with no history of arterial hypertension or any other systemic disease, who presented paraplegia, with sensory loss level of T12 and sphincter dystunction, as the sole manifestation of acute dissection of the descending aorta. Magnetic Resonance lmaging of the thoracic and lumbar spinal column showed an extensive ischemic lesion of the spinal cord in T8 to TI2 level.'lhe diagnosis of the dissection was established by digital angiography of the aorta, where all left intercostal arteries were absent, and transesophageal echocardiography, which confirmed the existence of a DeBekay type III aortic dissection. Low fever and profuse sweating were mentioned some days before the establishment of paraplegia and Brucella FA titers in serum were positive. Afteran extensive review of the literature we found very few cases with painless aortic dissection revealed by an isolated paraplegia. We also discuss the possible relation of brucellosis with this dissection.

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P284 Tau protein in cerebrospinal fluid: a blood-CSF barrier related evaluation in patients with various neurological diseases. S. Sª H. Tumani (Ulm, D) Background: Tau protein (tau) is primarily localised in neurons, and after brain parenchymal damage its release into cerebrospinal fluid (CSF) is increased. The particular influences of blood-CSF barrier function and of disease topography on CSF tau levels have not been studied yet. Methods: CSF tau concentrations were determined by enzyme-immunoassay in patients with various neurological diseases (Guillain-Barr› syndrome, n=5; neuroborreliosis, n= 10; spinal canal stenosis, n=6; bacterial meningitis, n=7; viral encephalitis, n=7; multiple sclerosis, n= 17, cerebral ischemia, n=3; int racerebral haemorrhage, n=6). Results: 1. There was no correlation between CSF tau and blood-CSF barrier dysfunction in all patient groups. 2. Significant elevation of tau levels occurred in patients with viral meningoencephalitis (range, 327-15 653 ng/L; median, 1061 ng/L) and in cerebral hemorrhage (range, 952-5918 ng/L; 2906 ng/L). 3. In contrast, tau levels remained normal in patients with spinal canal stenosis (median = 149 ng/L), neuroborreliosis (median = 99 ng/L) and bacterial meningitis (median, 95 ng/L) if encephalitic complications did not occur. 4. In patients with Guillain-Barr› syndrome tau levels were lowest (median, 59 ng/L). 5.Increased tau levels in active multiple sclerosis (median, 188 ng/L) compared to clinically nonactive states (median, 109 ng/L) indicate axonal pathology in active disease. Conclusion: CSF tau level is not dependent upon blood-CSF barrier dysfunction and elevated levels indicate brain parenchymal damage independent of underlying aetiology. Elevated CSF tau levels in bacterial meningitis is a marker for brain parenchymal complications. Elevated tau levels in patients with clinically active multiple sclerosis confirm the important role of neurodegenerative mechanisms in early disease stages.

P285 Analysis of spatial tuning of EMG activities during reaches in the vertical pl• evidence for distinct strategies in proximal and distal muscles. C. Steinbrecher, M. Manto, V. De Pasqua, J. Schoenen, I. Jacquy, A. Maertens (Li~ge, Bruxelles, Charleroi, B) The strategies underlying the control of EMG activities during reaches in the vertical plane towards different targets ate poorly defined. Unravelling of these strategies might have critical implications to establish new strategies of neuro-rehabilitation. We analysed the spatial tuning of EMG activities during fast pointing movements towards 12 targets located in the vertical plane ( 144 movements; 0 to 330 degrees) in 4 right-handed healthy subjects (mean age: 24; range: 23 to 26; sex: 1 female). We studied movements during the centrifugal phase. Kinematic profiles and EMG activities of the anterior deltoid (AD),posterior deltoid (PD),biceps (Bi),triceps (TI: Lateral, T2: Medial) and brachioradialis (BR) were recorded with the ELITE system (BTS, Italy). We analysed the behaviour of each muscle during the acceleration and the deceleration phase of the movement.We determined for each muscle the directional preference. A high correlation between peak of EMG activities and EMG activities during the acceleration phase was found for the AD (linear regression; R2 = 0.95), the PD (R 2 = 0.99), T2 (R2 = 0.87). For these musdes, a high correlation was also observed between peak of EMG activities and the deceleration phase (values of R2: AD: 0.94, PD: 0.9, T2:0.81 ). For Bi, T1 and especially for BR,a correlation was found between the peak EMG and the acceleration phase (values of R2: 0.70, 0.63 and 0.92, respectively) but no correlation could be determined between the peak EMG and the deceleration phase (values of R2:0.31,0.34 and 0.01, respectively). The directions with maximal intensities of EMG activities were 0 deg for AD, 150 deg for PD, 120 deg for Bi, 270 deg for T1,300 deg for T2, 120 deg for BR. This is the first demonstration that distinct strategies are used to control muscles acting primarily on the shoulder or the elbow in healthy subjects during performance of vertical movements. We provide here a quantitative approach to estimate the neural control of reaches in the vertical plane.

blindness. The examination was carried out when he developed an episode of vertigo, tinnitus and sudden unilateral hearing loss in the presence of light constitutional symptoms (fever, fatigue,weight loss).At clinical examinations no symptoms or signs of CNS/PNS or the other organ systems dysfunction were recorded.Generallaboratoryinvestigationsincludedhematologicaland serological studies, as well as radiological, sonographic and functional multisystem examinations. Abnormal finding consisted of 90 mm/hr of an ESR. Electromyography (EMG), brain stem auditory evoked potentials (BAEPs), sensory evoked potentials (SSEPs), electroencephalography (EEG), lumbar puncture (LP),computed tomography (CT) and magnetic resonance imaging (MRI) were studied to assess the subclinical central or peripheral nervous system involvement. BAEPs recorded lefl side peripheral conduction velocities defect. Continuous bilateral low-voltage fronto-temporal theta activity was found by EEG. CSF IgG index was elevated. MRI showed the presence of disseminated multifocal cerebral white matter lesions. Results of the other neurological examinations were normal. High-glucocorticoid treatment dosage resolved constitutional symptoms and improved acute ocular inflammation, but ir failed to bring improvement to the left sensorineural hearing impairment. With tapered dose of 10 mg prednisolone every other day the symptoms have not recurred for the last fourteen months. Cogan syndrome should be considered in young patients with recurrent eye inflammations and sudden hearing loss, especially when accompanied by clinical signs/symptoms or subclinical findings for CNS/PNS and/or the other organ systems involvement. Early immunotherapy ma), control the natural course of this inflammatory disease. P287 Ciclosporin Neurotoxicity In A Renal Transplant Patient. U. Can, • S. Benli, M. K~l~'nr A. Y~lmaz, Y. Kaya, M. A6~'ldere, T. Zileli (Ankara, TR) The use of cyclosporine has been associated with several side effects, including neurotoxicity. The mechanism of toxicity is not well known. The neurologic presentation is varied and the neurologic manifestations ate reversible in most instances. It has been described more common in bone marrow and liver transplant patients than renal transplant patients. The neuroimaging studies are helpful in making a diagnosis if they show characteristic findings of hyperintense lesions affecting posterior cerebral regions on T2 weighted magnetic resonance images (MRI). These lesions ate probably due to breakdown of blood-brain barrier resulting in leakage of fluid in interstitial space. Neurotoxicity has been demonstrated in vitro for sirolimus, a novel macrolide immunosuppressant, which is given in combination with cyclosporine. Combination with sirolimus resulted in synergism, which, in part, is explained by a greater distribution of cyclosporine into the brain tissue in the presence of sirolimus. We reporta 20 year-old woman with cyclosporine neurotoxicity after renal transplantation from cadaver. She was on cyclosporine 500mg/d, sirolimus 2 mg/d and prednisolone 20 mg/d immunosuppressant regimen and ciclosporin levels were in therapeutic range until admission. Forty-five days after the transplantation she was admitted with the complaints of severe headache, convulsions, malaise, nausea and epistaxis. Her blood urea nitrogen and creatinine levels were slightly elevated but serum electrolytes and blood pressure were in normal limits. Her electroencephalogram showed generalized slowing, cyclosporine level was 686 ng/ml (therapeutic range 100-400 ng/ml) and magnetic resonance imaging showed bilateral hyperintense lesions affecting occipital and posterior parietal cerebral regions on T2 weighted magnetic resonance imaging. Her clinical and MRI findings disappeared after withdrawal of the drug. Addition of sirolimus to cyclosporine may have made her more prone to cyclosporine neurotoxicity. Although there are rare reports of cyclosporine neurotoxicity even with serum levels in therapeutic range, patients treated with both cyclosporine and sirolimus, drug levels should be monitored more closely to recognize neurotoxicity earlier.

P286 Cogan Syndrome. S. Vlaski-Jekic, G. Kiteva (Skopje, MAK)

P288 Using passive tasks in fMRI studies of patients with neuropathy or multiple sclerosis. H. Reddy, A. Floyer, M. Donaghy, S. Narayanan, D. L. Arnold, P. M. Matthews (Oxford, UK; Montreal, CDN)

Cogan syndrome is an uncommon multisystem inflammatory vascular disease characterized by recurrent episodes of ocular inflammation and vestibulo-auditory dysfunction leading to total hearing loss in about 40 % of patients. Other organ systems are involved in up to 50 %, mostly in the form of cardio-vascular disease. We report a case of Cogan syndrome in a 16 year-old boy. The boy suffered recurrent episodes of bilateral ocular inflammation within a period ofseveral years, which affected different ocular structures and resulted in left side

When studying profoundly weak patients using fMRI, there is the problem of making the task comparable in effort to that for controls. We wished to contrast cortical activation during hand movements in patients with neurological disease and in normal controls using a paradigm that is behaviourally matched between the two groups. Previous work has suggested that a passive movement task could be appropriate. Using FMRI, we first characterised patterns of brain activation during active and passive index finger movements in healthy controls (n=lO). The mean number of significantly

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activated voxels in the primary motor cortex was not significantly different for the passive than for the active task. There was a small posterior shift in the centre of activation of the contralateral motor cortex (CMC) (mean, 8mm, p < 0.02) and of the ipsilateral sensorimotor cortex (IMC) (mean, 11 mm, p < 0.05). No activation with passive movement was found in the patients with sevete distal sensory neuropathy (n=2), suggesting that activation with passive movements is dependent on sensory feedback and not due to mental imagery alone. In contrast, patients with severe pure motor neuropathies (MN, n=2) showed substantial increases in the volumes of activation compared to controls. The relative increases in numbers of pixels activated above threshoLd in different regions of interest for both the active (MN/controls: CMC, 2.1; IMC,8.1; SMA, 5.2) and passive (CMC, 2.6; IMC, 8.0; SMA, 5.1 ) tasks were similar. These results confirm expansion of cortical representation for finger movement in patients with motor neuropathy and demonstrate central reorganisation as a consequence of the motor nerve loss. An expanded representation for finger movement in the primary motor cortex with peripheral weakness suggests that the primary motor cortex may encode motor unir activation rather directly. We also applied this passive movement task to study multiple sclerosis patients with differing levels of disability and differing extents of axonal in_ jury as measured by magnetic resonance spectrnscopy (MRS). As has been found previously, there was greater ipsilateral activation with greater disability and axonal damage. The passive task showed similar activation patterns and correlations as the active task. It may thus provide a useful method of assessing significantly disabled patients, using fMRI. P289 Hypokalemic periodic paralysis in North Greece - Report of 6 cases and review of the literature. N. Ramopoulos, P. Pet rikis, E Drakopoulou, K. Michailidis (Thessaloniki, GR) Hypokalemic periodic paralysis is a rare disorder of uncertain aetiology characterised by episodes of weakness of paralysis of the muscles, including respiratory ones which can lead to death. This disorder may be familial with autosomal dominant inheritance of may be acquired in patients who suffer from thyrotoxicosis. In a retrospective study of the patients of the neurological clinic at "Panagia" hospital we found 6 patients who were hospitalised due to hypokalemic periodic paralysis and al1 belong to the white race. From those 6 patients 4 suffered from hereditary hypokalemic periodic paralysis, and 2 male from acquired hypokalemic periodic paralysis due to thyrotoxicosis. The diagnosis was based on: a. their clinical picture (sudden onset with muscle weakness or paralysis which occurred on awakening); b. their history (in two of the patients intense physical exercise was performed and a heavy meal rich in carbohydrates was consumed a few hours prior to the onset of the symptoms. In two others an intravenous cortisol injection was done due to an allergic reaction, and ir was followed by a heavy meal and alcohol consumption. The last two suffered from hyperthyroidism), and c. low potassium levels found in the biochemical examination. We discuss the rareness of hypokalemic periodic paralysis in white men, the pathophysiology, the treatment of the disorder and finally the inability to prevent the occurrence of hypokalemic periodic paralysis on patients with hyperthyroidism who were using propanoloL P290 Sporadic cerebeUar ataxia associated with gluten sensitivity: intravenous immunoglobin therapy. K. Bª A. Melms, J. Schulz, C. Mª P. Ruck, M. Stern, 1. Besenthal, M. Skalej, C. Zª 1. Dichgans (Tª Lª D) 104 patients with sporadic cerehellar ataxia were tested for antigliadin and antiendomysium antibodies. 12 individuals (11.5 %) with gLuten sensitivity underwent doodenal biopsy and extensive clinical, electrophysiological, neuropsychological, radiological and laboratory investigations including HLA typing. The clinical syndrome was dominated by progressive cerebellar ataxia with ataxia of stance and gait (100 %), dysarthria (100 %), and limb ataxia (92%). Oculomotor abnormalities were gaze evoked nystagmus (66.7%), spontaneous nystagmus (33.3 %), saccade slowing (25 %) and upward gaze palsy (16.7%). Extracerebellar features also included deep sensory loss (58.3 %), bladder dysfunction (33.3 %), and reduced ankle reflexes (33.3 %). In accordance to clinical findings, electrophysiological investigations revealed prominent axonal neuropathy with reduced amplitudes (50 %) and abnormal evoked potentials (58.3 %). Al1 patients had evidence of cerebellar atrophy on magnetic resonance imaging. Sporadic ataxia with gluten sensitivity was found to be tightly linked to the HLA DQB 1'~0201 hapIotype. Neurological symptoms were not related lo hypovitaminosis or malabsortion. Two patients had crypt hyperplasia and mucosal flattening. In five patients, the intraepitheliat lymphocyte count was elevated. Therefore, mu-

cosal pathology does not representan obligatory condition of ataxia with gluten sensitivity. The fact that the disease is strongly associated with the same HLA haplotypes found in coeliac disease not only demonstrates coeliac disease and ataxia with gluten sensitivity to be part of the same disease entity but supports the hypothesis of an immunological pathogenesis of cerebellar degeneration. Two patients showed clinical improvement after ir immunoglobin therapy (video will be demonstrated). P291 Bipallidal Haemorrhage After Ethylene Glycol Intoxication. D. CaparrosLefebvre, J. PoLicard, C. Sengler, A. Lannuzel (Pointe a Pitre, F) /ntroduction: Bipallidal lesions, an uncommon radio[ogical feature, may be induced by metaboLic disorders or poisoning. Bipallidal haemorrhagic infarction has been reported in acute carbon monoxide intoxication. Accidental poisoning with ethylene glycol (EG) induced a severe encephalopathy with diffuse oedema, but pallidal hemorrhage has never been described. Case report: This 50 year old Afro-Caribbean alcoholic man was referred in February 2000 for an unexplained loss of consciousness. Neurological examination showed drowsiness. He was mutic. Hypocalcemia was noticed (2 mmol/1 ), associated with a significant osmolar gap ( 17 mOsmol/kg) which was observed up to four day after the admission. Samples of urine and blood were analysed for drugs, pesticides, metallic poisons. Carboxyhemoglobin was 3.1%, within the normal range. Alcohol level was 3.5 g/1 in blood. The drug screening showed toxic level of EG at 6.06 mmol/l (N < 1.6). Brain CT scan revealed a bilateral pallidal haemorrhage. He improved progressively within 2 months. In July 2000, neurological exam was normal, as welI as neuropsychological testing. He disclosed no psychic akinesia. Brain MR[ showed a round hypersignal involving mainly the right pallidum. Discussion: This is the first case of EG intoxication which revealed bipallidal haemorrhage. The acute encephalopathy was probably due to simultaneous intoxication by alcohol and EG. The lack of permanent frontal lobe syndrome was related to the asymmetry of pallidal lesions, predominating in the right. The reason why EG affected only pallidum is unknown. In carbon monoxide poisoning, several authors reported the possible role of vascular damage in the pathogenesis of pallidal lesions, since pallidal arterial system is different from this of the putamen. In cases of pallidal hematoma, particularly when bilateral, a toxicological screening including alcohols and glycols is necessary. P292 Unilateral mydriasis a s a presentation of sarcoidosis. ).E. MartŸ drŸ A. Iranzo, A. Cerrera, Y. Blanco, D. Alonso (Barcelona, E)

Ro-

Background: Nervous system involvement occurs in 5 % of sarcoidosis, and cranial nerve is reported as the most common neurological manifestation. However, to our knowledge, there ate not previous reports of third cranial nerve involvement manifested only by mydriasis a s a presentation of sarcoidosis. Case report: A 26 year-old man was admitted with right mydriasis of 2 weeks of duration as his sole complain. However, detailed clinical history revealed non-productive cough, fatigue, mild weight loss, hyposmia and dysaesthesias in the right periorbicular region. Neurological examination showed right mydriasis with slight reaction to light. Fundoscopy and ocular movements were normal. Systemic examination and laboratory tests, included thyroid hormones and serum calcium, were normal. Angiotensin converting enzyme (ACE) level was 63 U (normal < 60 U). Brain computerised tomography (CT) did not show any abnormality. Cerebrospinal fluid (CSF) revealed 20 normal lymphocytes and 73 mg/dl proteins with normal levels of glucose, adenosine desaminase enzyme and ACE. Serum and CSF serologic tests of Borrelia burgdorferi, Brucella and HIV was negative. CSF cultures of Mycobacterium tuberculosis was also negative. Cranial MRI revealed meningeal thickness of the wall of the right cavernous sinus with no other abnormalities. Chest radiography showed bilateral hilar lymphadenopathy with no parenchymal involvemem. A thoracoabdominal CT confirmed the presence of multiple lymph nodes in mediastinal and hilar regions; with no abdominal involvement. Gallium-67 scanning showed multiple contrast enhancement in mediastinal and pulmonary hilar regions. Histological confirmation of sarcoid tissue was obtained by mediastinoscopic procedure, revealing noncaseating epithelioid cell granulomas in the mediastinal lymph nodes. Oral corticosteroids therapy was started (60 mg by day) and I month later, systemic clinical manifestations improved dramatically although slight anisocoria persisted because of mild right mydriasis. Conclusion: Unilateral mydriasis asa clinical feature of partial third cranial nerve palsy may be a form of presentation of sarcoidosis. Neurosarcoidosis must be included in the differential diagnosis of isolated cranial nerve impairment.

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P293 Efficacy and safety of botulinum toxin type A (BOTOX| in the treatment of bilateral primary axillary hyperhydrosis: A randomized, placebo-controlled study. M. K. Naumann, N. J. Lowe (Wuerzburg, D; London)

P295 Clinical And Genetic Analysis Of A Machado-Joseph Italian Family. P. Forleo, E. Cellini, B. Nacmias, A. Tedde, L. Parrletti, V.Gallai, S. Piacent ini, S. Sorbi (Florence, Perugia, I)

Objective: To evaluate the safety and efficacy of intradermal administration of botulinum toxin type A (BOTOX| compared with placebo for the treatment of bilateral primary axillary hyperhidrosis. Patients and methods: In total, 320 patients were enrolled in this multicenter, randomized, placebo-controlled study. To be included patients had to be 18-75 yrs of age, with persistent bilateral primary axillary hyperhidrosis that interfered with activities of daily living and baseline gravimetric measurements of spontaneous sweat production of > 50 mg per axilla over a 5 min period at rest at room temperature. Key exclusion criteria were: secondary hyperhidrosis; any disorder or concomitant medication that might interfere with neuromuscular function; use of anticholinergic agents within 30 days of study entry; concurrent use of other treatments for hyperhidrosis; botulinum toxin treatment within 4 mths of study entry. Patients were randomly assigned to receive either BOTOX| (50 U/axilla) or placebo in a 3:1 ratio. Each axilla was injected with 2 roL of the assigned treatment. Injections were evenly distributed within the hyperhidrotic area ( 10-15 injections per axilla), which was defined by Minor's iodine-starch test. Patients were evaluated at baseline andat 1, 4, 8, 12 and 16 wks post treatment. The primary endpoint was Wk 4. Efficacy was assessed by gravimetric measurement of spontaneous resting sweat production for 5 mins at room temperature and the subject's global assessment of treatment satisfaction (rating scale from +4 to -4). Safety was assessed by the incidente and type of spontaneously reported adverse events. Results: At Wk 4, 93.8 % of patients treated with BOTOX| were classified as responders (> 50% reduction in sweat production from baseline gravimetric measurement), compared with 35.9% of the placebo group (p < 0.00l). The mean percentage reduction in sweat production at Wk 4 was 83.5% in the BOTOX| group compared with 20.8% in the placebo group (p < 0.001). Mean patient satisfaction at Wk 4,as assessed by the subject's global assessment of treatment satisfaction, was significantly higher in the BO'rOX(R) group compared to the placebo group (+3.3 vs +0.8; p < 0.001. These efficacy parameters were significan@ superior in the BOTOX| group at all post-treatment timepoints. Adverse events were notably low. Conclusion: BOTOX| is demonstrated to be a sale and effective treatment for primary axillary hyperhidrosis with which patients were satisfied.

Machado-]oseph disease is an autosomal dominant type of neurodegenerative disease characterized by cerebellar ataxia and pyramidal signs associated with variable findings including a dystonic-rigid syndrome, a Parkinsonian syndrome, of a combined syndrome of dystonia and peripheral neuropathy. The disease causing mutation consists of ah expansion of a trinucleotide CAG repeat at the 3' terminal of ataxin 3 coding region resulting in a polyglutamine domain with unknown function. Pathogenic CAG expansions at the same locus has been also proven to cause Spinocerebellar ataxia, type 3. M•D has been initially described in Portugal and then in Portuguese Azores families and in United States, but ir has now been recognized a world-wide distribution. However, prevalence of SCA3/M]D among the dominantly inherited ataxias is variable among different populations. Conversely, population and genetic studies failed to detect any SCA3 gene mutations in Italian population, suggesting that some geographic variation appears to exist in the occurrence of the disease. Here we report the clinical and genetic analysis of an Italian family with a history of dominantly inherited ataxia bearing a pathogenic CAG expansion at the SCA3/MID loeus. The family, originating from central Italy, was reported in 1973 as an example of"autosomal dominant spinocerebellar ataxia associated with megalocornea, cataract and morpholngical abnormalities of red blood cells'. Thg clinical phenntype of the index case was characterized by onset at 25 years of age witb unsteadiness of the gait, dysarthria and lower limbs stiffness. Neurological examination performed at age 35, evidenced gait and truncal ataxia, nystagmus, dysphagia, slurred speech, diploma, hyperreflexia of lower limbs a n d a right Babinski sign. A positive family history was ascertained, based on past medical records. Analysis of the SCA3 locus revealed a pathogenic expansion of 67-70 CAG triplet repeats in both offsprings of the index case, currently mildly affected by pure cerebellar ataxia with bulging eyes. No Portuguese ancestors were detected in this kindred. This is the first description of a Machado-]oseph family of Italian origin with a clinical phenotype resembling type 2 presenting with an age of onset of 20-45 years with cerebellar and pyramidal deficits a n d a slow progression of disease. Analysis of M]D/SCA3 locus for possible pathngenic expansions should be recommended in all ataxia cases.

P294 Lumbar spinal stenosis - correlation between the clinieal and radiological data. B. Adamova, S. Vohanka, I. Bednarik, Z. Kadanka, L. Dusek (Brno, CZ)

P296 Effect of vilamin E supplementation in patients with ataxia with vilamin E deficiency. S. Gabsi-Gherairi, N. Gouider-Khouja, S. BelaI, M. Fki, K. Ouahchi, I. Turki, M. Ben Hamida, R. Mbazaa, E Hentati (Tunis, TN)

Study design: A prospective study of clinical and radiological findings in patients with symptomatic lumbar spinal stenosis (LSS). Summary of background data: No comprehensive data on the correlation between the extent of the stenosis and clinical data ate available. Objectives: Assessment of the correlation between the number of levels of CT proven central spinal stenosis and clinical findings. Methods: We evaluated a group of 113 consecutive patients (46 males, 67 females, aged 63.0 + 12.9 years) with symptomatic LSS. The lumbar spinal canal was evaluated by axial CT scans. Standard anteroposterior and transversal diameter were measured at three levels (L3, L4, L5). CT criteria of central spinal stenosis are: anteroposterior diameter < 11.7 mm and/or transversal diameter < 16.0 mm. The number of the stenotic levels was compared with clinical findings: presence or absence of the neurogenic claudication in the history, Iow back pain, Oswestry disability index, and occurrence and severity of the lower limb paresis. Results: 22 patients revealed one-level central stenosis, 63 patients twolevel stenosis and 28 patients three-level stenosis. Statistical analyses (Chi square test, Mann-Whitney U test, Kruskal-Wallis ANOVA test) revealed no significant association between number of the stenotic levels and the abovementioned clinical parameters. Conclusion: In the group of 113 patients with LSS we are not able to document any association between the extent of central stenosis of the spinal canal and the severity of clinical deficit. Supported by the Internal Grant Agency of the Ministry of Heahh of Czech Republic Grant No NF/5938-3

Background: Ataxia with vitamin E deficiency (AVED) is an autosomal neurodegenerative disease due to mutations in the alpha tocopherol transfer protein gene. The Friedreich ataxia phenotype is the most frequent clinical presentatinn. In AVED patients, serum vitamin E levels are very low in the absence of intestinal malabsorption. As vitamin E is a major antioxidant agent, vitamin E deficiency is supposed to be responsible for the pathological process in AVED. Patients and methods: 24 AVED patients were supplemented with vitaruin E (800 mg daily) during one year. Clinical evaluation was mainly based on the Ataxia Rating Scale (ARS) for cerebellar ataxia assessment. Resu]ts: Serum vitamin E levels normalized and ARS scores decreased moderately bul significantly suggesting mild clinical improvement. Better resuhs were noted in patients with duration less than 15 years. Reflexes remained abolished and deep sensnry disturbances unchanged. Conclusion: Vitamin E supplementation in AVED patients stabilises the neurological signs and can lead to mild improvement of cerebellar ataxia, especially in early stages of the disease. Vitamin E dosage should be systematically performed in patients with ataxic syndromes.

Multiple Sclerosis P297 Best Practice in Nursing Care in Multiple Sclerosis. ]. Halper (Teaneck, USA) Multiple sclerosis (MS) has a major impact on the lives of patients and their fami]ies. Its unpredictable course leaves those affected with an uncertain future. Recent advances in understanding about the disease and its treatment have changed the way that heahhcare professionals can help patients and their families. In addition to diagnosing and providing supportive tate,

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treatment now can be directed toward changing the disease course. Asa result, MS nurses world-wide are faced with many challenges as they meet the needs of patients in the rapidly changing field of multiple sclerosis. The MS Nurse Specialists Consensus Committee has drawn from both research, educational, and practical experiences to develop a new and cohesive model of nursing care in multiple sclerosis, one which will sustain and educate nurses in their clinical practice, promote nursing research, and inspire a new generation of MS nurses as they enter the field. This model is the leitmotif of the International Organization of Multiple Sclerosis Nurses, the umbrella organization fora number of national MS nursing organisations. The MS nurse is a competent expert who collaborates with those affected by MS, and shares knowledge, strength, and hope. As the role of nurses continues to evolve, there is a need to establish a cohesive model of MS nursing practice along with specific standards for best practice in MS nursing care. Nursing practice aims to both manage and influence the patient's illness by supporting disease modifying treatments; facilitating symptoms management; promoting safe, maximal function; and supporting a wellness-oriented quality of life. Activities that are essential to patient care can be grouped into: 9Establishing Care; - Continuing Care; 9Sustaining Care. Togetber, these interwoven areas provide a framework for a comprehensive, cohesive model for MS nursing practice that can be applied to care of all MS patients, regardless of disease classification or level of disability. P298 TNF-alpha-converting enzyme mRNA expression in peripheral mononuclear cells precedes lesion appearance on MRI in relapsing-remitting multiple sderosis. T. Seifert, B. Kieseier, S. Ropele, S. Strasser-Fuchs, E Fazekas, H.-P. Hartung (Graz, AT) Tumor necrosis factor-alpha (TNF-alpha) is a key mediator in the pathogenesis of multiple sclerosis. It has to be released from its cell membrane bound precursor by proteolytic cleavage. This is mainly performed by TACE (TNF-alpha conver ting enzyme), a member of the ADAM (a disintegrin and metalloproteinase) family of enzymes. To determine mRNA expression of TNF-alpha and TACE in peripheral blood mononuclear cells (PBMC) in 11 relapsing-remitting multiple sclerosis patients in relation to disease activity we performed a longitudinal study with monthly brain magnetic resonance imaging (MRI). Patients in whom TACE mRNA was found in PBMC showed significantly (p < 0.05) more new appearing gadolinium-enhancing lesions on brain MRI one month following blood sampling compared to patients without detectiort of TACE mRNA. P299 Use of Immunomodulating Therapy (IMT) During Pregnancy in Multiple Sclerosis (MS) Patients. C. Caon, O. Khan (Detroit/Michigan, USA) Objective: To investigate the use of IMT during pregnancy in MS patients. Background: Most female MS patients present during child bearing years. Beta-interferons (IFNB) and glatiramer acetate (GA) are used for relapsing-remitting MS (RRMS). However, there is no report on the use of IMT during pregnancy in MS patients. Methods: MS patients were asked about the use of IMT during pregnancy.A detailed history regarding pregnancy and the neonate was obtained from each patient. Results: 11 patients (group 1) reported voluntarily electing to use IMT during the entire pregnancy whereas another 38 patients (group 2) discontinued IMT as soon as they discovered that they were pregnant. In group 1, 5 patients received IFNB-la (30 mcg IM weeldy), 2 received IFNB-la (44 mcg SC TIW),and 4 received GA (20 mg SC daily). At the time of pregnancy, mean age, disease duration, and duration of therapy on IMT were 28.5 years, 19.2 months, and 3.8 months, respectively. There were no relapses during pregnancy and only 2 during the post-partum period. 10 had normal deliveries and one required C-section. No developmental abnormalities were reported aftera mean follow up of 15.2 months in all infants. In group 2, 28 patients received GA, 7 IFNB-la (30 mcg IM weekly), and 3 IFNB-lb (250 mcg SC QOD). AII 38 discontinued treatment with IMT as soon as they learnt that they were pregnant. At the time of pregnancy, mean age, disease duration, and duration of therapy were 29.6 years, 23.4 months, and 6.4 months, respectively. Mean exposure to IMT at the time of discovering about pregnancy was 2.5 months during which no relapses occurred. During the remainder of pregnancy, 14 patients experienced a relapse each which was treated with steroids. 9 patients experienced relapses during the post-partum period. AII had normal deliveries. No developmental abnormalities were reported after a mean follow up of 12.4 months in 32 of 38 infants. No follow up was available in the remaining 6 infants. Conclusions: From this small retrospective case series, ir appears that the

use of IMT during pregnancy including the critical first trimester may be safe. This may be reassuring to patients who have concerns about foetal exposure to IMT. However, we do not suggest that IMT should be routinely recommended during pregnancy until more data on its safety during pregnancy is available. P300 Changes in the circadian rhythmicity of cytokines and adhesion molecules in the serum of MS patients - preliminary results. J. Kraus, O. Fischer, B. S. Kuehne, F. Blaes, C. Laske, S. Vogel, E. Stolz, M. Kaps, P. Oschmann (Giessen, D) Objective: Firstly, we wanted to find out changes of the circadian rhythm of MS patients compared to healthy donors. Secondly, to evaluate whether in future st udies diurnal changes of the expression levels of immunological parameters must be considered. Background: Cytokine and adbesion molecule levels have been investigated in numerous studies to determine changes of the immune system in patients with multiple sclerosis (MS). However, it has never been studied whether the obtained immunological parameters underlie a circadian rhythm. Methods: We included 12 MS patients and 12 age- and sex-matched healthy controls into the study. AII of the MS patients were suffering from a relapsing-remitting course of the disease. They have not been treated by immunomodulatory or immunosuppressive therapy. An acute clinically defined relapse or Gadolinium-enhancement in corresponding MRI scans were set as exclusion criteria. Blood samples were obtained at tire time points between 7.00 and 22.00 h. In all the serum samples we determined the concentrations levels of cortisol, soluble ICAM- 1 and VCAM- 1, TNF-beta as well as TNF-Receptor-1 and -2 by ELISA. Results: The serum concentration levels of cortisol showed almost the same course for the MS patients and the healthy donors with a decrease from 22 p.g/dl at 7.00 to 4 lag/dl at 22.00 h. Serum concentration levels of TNF-R1 as well as TNF-R2 also followed a descending course over the day. However, for both TNF-receptors we found significantly (p < 0.05) enhanced serum concent ration levels in the MS patient group compared to the healthy donors at any time point. TNF-beta concentration levels were stable over the day with elevated concentration levels in the MS patient group at any time point. For sVCAM- 1 and slCAM- 1 a non-significant trend to inversed diurnal time courses could be seen. Conclusion: From our preliminary results it can be assumed that in future clinical studies diurnal rhythmicity of immunological markers must be considered more than it was done in previous trials both in healthy donors and MS patients. It will be interesting to observe the pathogenetic reason for the disturbances of the diurnal rhythm of adhesion molecules in MS patients. P301

Cognitive impairment in relapsing-remitting Multiple Sderosis patients. A. Mancini, M. Santini, E. Millefiorini, F. Bagnato, G. Violante, M. Prencipe (Rome, I) Cognitive function is often impaired in multiple sclerosis (MS). The aim of the present study was to compare the cognitive performance of 42 relapsingremitting MS patients with 35 age- and education-matched control subjects. A battery of neuropsychological tests was administered to assess attention, short-term memory, executive functions, conceptual reasoning and verbal fluency. In addition, the correlation between physical disability (EDSS) and cognitive impairment was analysed. The results of the report show that the MS patients performed significantly worse than controls in attention (p < 0.01), short-term memory and executive functions (p < 0.05); conceptual reasoning and verbal fluency didn't show significant difference between the two groups. Furthermore no correlation was found between EDSS score and cognitive test performance. Conclusions: our data showed a significant impairment in attention, memory performances and executive functions in MS. No correlation between cognitive disorders and physical disability was found. Although the natural history of cognitive decline in MS is still under discussion, our data confirm the importance to assess MS-related cognitive impairment and suggest to plane longitudinal studies to value their evolution. Increased knowledge of these disorders could be useful for management and rehabilitation in MS patients.

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P302 From new enhancing lesions to"black holes"in patients with clinically isolated syndrome suggestive of multiple sderosis. P. Pantano, E Caramia, M.C. Piattella, S. Di Legge, D. Lenzi, A. Paolillo, L. Bozzao, G. L. Lenzi, C. Pozzilli (Rome, 1) Objectives: The aim of our study was to evaluate the MR appearance of new enhancing lesions and their possible evolution in TI hypointense lesions ("black holes") in a series of patients with clinically isolated syndrome (CIS) suggestive of multiple sclerosis. Methods: We performed monthly Gd-enhanced MR scans over a period of 6 months anda follow-up MR sean at month 12 in 28 CIS patients with an abnormal MR sean at baseline. For each patient we considered the number and the MR characteristics (location, size, enhancement pattern and persistence) of the new enhancing lesions and the rate of transformation in "black holes" at month 12. Results: The mean number of Gd-enhancing lesions was 0.6 + 0.8/patient/month, for a total of 84 new enhancing lesions seen in 16 (57 %) out of 28 CIS patients over the six months observation period. There was a significant relationship between the number of monthly enhancing lesions and the number of T2 hyperintense lesions at baseline (r=0.64, p=0.01). Out of the 84 new lesions, 41 (49 %) were "black holes" at the 12-month MR sean. Periventricular and large enhancing lesions showed a higher degree of transformation into "black holes". Conclusions: The number of new Gd-enhancing lesions appears to be lower in CIS than in relapsing-remitting MS patients. However, the percentage of Gd-enhancing lesions which become "black holes" is very close, suggesting that the destructive potential of a single new enhancing lesion is similar in the two conditions. P303 Plasma Cholesterol Levels In Early Onset Multiple Sclerosis. C. Pozzilli, S. Di Legge, M. P. Sormani, P. Pantano, R. Antonini, M. Sepe Monti, P. Tisei, F. Giubilei (Rome, I) Multiple Sclerosis (MS) is characterised by destruction of myelin and marked alterations in both myelin cholesterol and lipid metabolism may occur in the Central Nervous System. During the active phase of experimental allergic encephalomyelitis, an increase in both the cholesterol plasma level and the release of cholesterol metabolites into urine was found in rats. The present study was planned to investigate the relationship between the plasma lipid profile and disease activity as measured by Gd-enhanced MRI in patients with a first clinical episode suggestive of MS. Eighteen consecutive patients (median baseline EDSS score of 1.5) underwent a monthly brain MRI, blood sample and neurological assessment over six months. Total cholesterol and triglyceride levels as well as their subfractions were considered. Furthermore, plasma apolipoprotein E levels and apolipoprotein E genotype were determined. The same procedure was followed to assess the plasma lipid profile in 18 healthy sex- and age-matched control subjects. The relationship between lipid parameters and Gd-enhancing lesions was studied using two different approaches. First, a cross-sectional analysis was performed using Spearman correlation coefficients applied to mean values over time. Second, a longitudinal analysis was performed using a random effect model to assess the relationship within each patient between each lipid parameter value and the number of enhancing lesions over the six evaluations. The value of total and HDL cholesterol was significantly higher in patients than in controls (P=0.01 and P=0.003 respectively, Student's t-test). During six months, there was a significant correlation between the mean number of enhancing lesions and the mean plasma level of both total and LDL cholesterol (r=0.587; P=0.011 and r=0.542; P=0.02, respectively, Spearman's correlation test). In particular, the total plasma cholesterol level increased on average by 4.4mg/dl for each enhancing lesion. Our data suggest that the determination of the plasma cholesterol level could be used asa valuable biological marker of disease activity in MS. P304 Copolymer 1 specific T-cells from the CNS and the periphery exhibit Th2 profile when activated by CNS antigen presenting celis. R. Aharoni, D. Teitelbaum, M. Sela, R. Arnon (Rehovot, IL) Copolymer 1 (Copl, Copaxone, glatiramer acetate) suppresses experimental autoimmune encephalomyelitis (EAE), reduces relapse rate and slows progression of disability in multiple sclerosis (MS) patients. Copl treatment leads to the generation of Th2 suppressor cells in spleens and lymph nodes of experimental animals as well as in peripheral blood of MS patients. Recently we have demonstrated that the Copl-induced Th2 cells cross the blood brain barrier and accumulate in the CNS where the pathological

process of EAE and MS occurs. Yet the capability of Th2 cells to secrete Th2 cytokines in situ has been doubted following the findings that the CNS environment induces biased cytokine secretion towards the Thl pathway. In this study we therefore tested whether Cop 1 specific T-cells originated in the CNS or in the periphery retain their Th2 profile after being stimulated on antigen presenting cells (APC) isolated from the brain. For this purpose Copl -specific T-cells lines were established from brains and spleens of mice treated with Copl. The proliferation and cytokine secretion profile of these T cells were studied in response to Copl and myelin basic protein (MBP), presented on irradiated APC from brains or spleens of normal mice. Whole lymphocyte populations isolated from both CNS and spleens of Copltreated mice, either with or without EAE induction, demonstrated a specific response to Copl by proliferation and by Th2 cytokine secretion. Highly reactive Copl specific T-cell lines, that secrete IL-4, IL-5, IL-6, IL-10 and TGFbeta in response to Copl and cross react with MBP at the level of Th2 cytnkine secretinn, were established from brains, spinal cords and spleens of Cop 1-treated mice. These Cop 1 specific T-cells exhibited a confined Th2 response to both Copl and MBP when stimulated on peripheral as well as on CNS originated APC. Thus the T-cells induced in the periphery by Copl injection when reaching the CNS can be stimulated in situ by MBP to secrete Th2 cytokines, and thereby exert therapeutic effects in the diseased organ. P305 Glatiramer Acetate (GA) induces IL-13/IL-5 secretion in naive T-cells. A. Windhagen, E. Wiesemann, J. Klatt, E Heidenreich (.Hannover, D) Glatiramer acetate (GA) is effective in the treatment of multiple sclerosis (MS),however, the mechanism ofaction is not well understood. MHC-blockade and shifting of the T-cell response towards a Th2/Th3 phenotype might playa role. In order to better define the immunomodulatory effects of GA we here investigated the cytokine and proliferative response of T-cell subpopulations (CD4+, CD8+, CD45RA+, CD45RO+) in vitro. GA induced Tcell proliferation and secretion of IL-13/IL-5 but not IL-4, IL-10, TGF-tg, IL12 or IFN-g. This response was driven by the CD4+/CD45RA+ T-cell subpopulation and was mediated by HLA-DR and T-cell receptor (TCR) engagement. Expression of common T-cell activation markers CD25 and CD69 was not induced. Independently of IL-13 secretion upregulation of CD86, CD40 and HLA-DR was detected on monocytes in a several subjects. In a group of 20 healthy subjects 16 were reactive to GA whereas 4 were not. GAresponsiveness did not correlate with HLA-genotype. Taken together the findings are compatible with the hypothesis that GA functions as partial TCR-agonist in most but not all individuals. Implications for use of GA in vivo are discussed. P306 Brain MRI and serum virus-specific antibodies in multiple sclerosis. R. Zivadinov, M. Zorznn, D. Nasuelli, R. De Masi, A. Bratina, M. Ukmar, R. S. PozziMucelli, L. Monti-Bragadin, M. A. Tommasi, C. Furlan, G. Cazzato (Trieste, I) Background: Although unproved so lar, the hypothesis that ah infectious agent can have a role in triggering Multiple Sclerosis (MS) in susceptible individuals seems appealing. A connection between serum virus-specific antibodies and MRI parameters could focus further research on a particular virus. Objective: To evaluate the relationship between serum virus-specific antibodies positivity and brain MRI quantitative measurements in MS patients. Methods: Measles, rubella, EBV, CMV, VZV, HSV 1 and 2 and Borrelia burgdorferi serum specific IgG antibodies have been ascertained by ELISA technique in 76 patients with definite MS. All patients underwent a 1.5 Tesla MR examination of the brain. T1- and T2-weighted images have been provided and calculations of TI- and T2-1esion load and brain volume have been performed. Spearman rank correlation analysis corrected for multiple comparisons was employed to examine the relationship between serum specific IgG antibodies positivity and MRI parameters. Multiple linear regression analysis has been used to establish which clinical and MRI variables have been independently associated with serum specific IgG antibodies positivity. Resuhs: We did not find any significant relationship between serum specific IgG antibodies positivity and MRI quantitative measures. Various multiple regression models did not demonstrate any association between serum specific IgG antibodies positivity and both neurnradiological and clinical variables. Conclusions: Our results demonstrated that common virus- and Borrelia burgdorferi- specific IgG antibodies positivity is not related to brain atrophy, [esion load, physical disability and disease type in MS patients.

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P307 Usefulness of MRI composite scores for measurement of brain damage in early phase of relapsing-remitting Multiple Sclerosis. R. Zivadinov, M. Zorzon, A. Bratina, M. Ukmar, A. Grop, R. De Masi, M. A. Tommasi, R. S. PozziMucelli, C. Furlan, G. Cazzato, D. Nasuelli (Trieste, I) Background: The relationship between physical disability and MRI parameters in Multiple Sclerosis (MS) patients is generally weak. The use of MRI composite scores could improve the correlation coefficients. Objective: To establish whether MRI composite scores produced summing various MRI measures which examine different pathological substrates of MS could have stronger association with physical disability than single MRI quantitative parameters. Methods: In 63 patients with relapsing remitting MS (median disease duration 5 years, EDSS < 5.0) the neurologic impairment and disability have been assessed using the EDSS score. Patients also underwent PD/T2- and TIweighted, and magnetization transfer (MT) brain MRI. Using linear discriminant analysis we developed an average lesion composite score (ACLS) which comprised T2- and Tl-lesion load and average lesion magnetization transfer ratio (MTR), and average diffuse damage brain composite score (ADDBCS) which included normal appearing brain tissue (NABT) MTR and brain parenchyma fraction (BPF). Results: We did not find any relationship between T2-, T l-lesion load and average lesion MTR and EDSS score. Only a trend for correlation was found for EDSS score and ALCS. EDSS score correlated weakly with BPF and NABT MTR (r= 0.28, p= 0.029 and r= 0.28,p=0.024, respectively).ADDBSC showed good correlation with EDSS score (r= 0.57, p= 0.003). Interestingly BPF and average NABT MTR did not correlate (r= 0.16, p= 0.21), indicating that the loss of brain parenchyma is probably not related to the severity of microscopic damage in the NABT in the early stages of the disease. Conclusions: MRI composite scores which estimate lesion loads and diffuse damage in the brain parenchyma summing different postimaging analysis methods have a good correlation with physical disability and could be utilised in clinical studies. P308 Pyramidal tract mapping of T1 relaxation times in multiple sclerosis using diffusion tensor imaging. L. Vaithianathar, C.R. Tench, P.S. Morgan, M. Wilson, L.D. Blumhardt (Nottingham, UK) Diffusion tensor (DT) imaging can be used to generate in vivo maps ofwhite matter tracts. T 1 relaxation times (T 1) provide a quantitative magnetic resonance parameter for evaluating white matter disease in multiple sclerosis (MS). T1 values are abnormal in acute and chronic MS lesions and in regions of normal appearing white matter. Fibre tract mapping of a critical functional pathway such as the pyramidal tract may be a useful measure of neurological impairment in MS. Objectives: To measure and compare T1 values in the pyramidal tracts of MS patients and controls. To determine the relationship between pyramidal tract T1, disability scores and T2 lesion volume. Method: 25 patients with relapsing-remitting MS and 13 age-matched healthy controls were studied. Whole brain T1 maps were acquired using a multi-slice inversion recovery sequence. DT images were generated from a spin-echo, echo-planar diffusion weighted sequence. In addition, each subject was scanned with a dual-echo T2-weighted sequence. Disability was assessed using the expanded disability status scale (EDSS). The T1 maps were coregistered with trace images derived from the DT. A region of interest (ROI) delineating the midbrain and including the pyramidal tracts was outlined on maps of relative anisotropy, also derived from the DT. Trajectories originating from this ROI were defined to follow the course of the white matter fibre tracts. T1 values were sampled at all points along these trajectories. T2 lesion volume was determined using a semi-automated thresholding technique. Results: Median T1 in the pyramidal tracts of patients (696ms, range 682-708) was significantly longer (p=0.02) than in controls (680ras, range 670-691). Median pyramidal tract T1 correlated significantly with the pyramidal functional system scores (r=0.64, p=0.0007), EDSS (r=0.55, p=0.005) and T2 lesion volume (r=0.55, p=0.006), but not with disease duration (p=0.08). Conclusion: A novel technique has been applied to quantify disease in the pyramidal tracts of MS patients. TI values in these tracts correlated significantly with motor impairment and disability. This method may provide an objective and sensitive measure for monitoring progression of motor deficits and disability in MS.

P309 IP-10 and MCP-I in serum and CSF: possible immunological markers in Multiple Sderosis. D. Galimberti, P. Baron, E. Scarpini, E. Prat, L. Meda, M. Ronzoni, I. Siglienti, R. Clerici, G. Conti, G. Scarlato (Milan, I) Objective: to assay interferon-g-inducible protein-10 (IP-10) and monocyte chemotactic protein- 1 (MCP- 1) in serum and cerebrospinal fluid (CSF) samples from patients with Multiple Sclerosis. Background: Chemokines are low molecular weight chemotactic cytokines that have been shown to play an important role in early in¡ events such as perivascular transmigration and accumulation of leukocytes at the site of tissue damage. Based on the arrangement of cysteine residues, chemokines are divided into two groups: C-X-C or a-chemokines, which are mainly responsible for attracting neutrophils and C-C chemokines or bchemokines, which act basically on monocytes, but also stimulate recruitment of basophils, eosinophils, T cells and NK-cells. Representative chemokines of these two types include lP-10 (g-interferon inducible protein, 10 kDa) and MCP-1 (monocyte chemotactic protein), respectively. Methods: IP-10 and MCP-1 levels were determined by enzyme-linked immunosorbant assay (ELISA) in the CSF and in the serum from 44 patients affected by different types of MS, including 30 Relapsing Remitting (RR) and 14 Progressive (SP and PP). IP-10 and MCP-1 expression was also examined in 30 control subjects as well as in 20 subjects with other inflammatory neurological diseases (OIND). Results: IP-10 levels were significantly elevated both in CSF and serum from RR-MS patients in clinical relapse, compared to control subjects. In contrast, there was no significant increase of IP-10 in RR-MS patients in remission. Up-regulation of IP-10 was also demonstrated in either SP and PP as well as in OIND compared to control. On the contrary, we found that MCP1 levels were diminished in all MS patients compared to control subjects. No correlation between EDSS score/clinical course of MS and CSF IP-10 and MCP- 1 levels was observed. Conclusions: The different increase of IP-10 levels in serum and CSF samples from MS patients support a pathogenic role of IP-10 in lymphocyte recruitment during active MS and suggest that this molecule could represent a potential marker for monitoring clinical course and therapeutic interventions. Otherwise, the decrease of MCP-1 levels, observed in all MS patients, couldn't representa marker of specific clinical subtypes. However, the decrease of MCP-1 levels reinforce the idea that during MS attacks the're is a predominant activity of Th-1 lymphocytes in comparis0n with Th-2 lymphocytes. P310 Further evidence of dose effect of IFN-beta-la based on neutralizing antibody status. G. P. A. Rice, G. S. Francis, The PRISMS Study Group (London, CDN; Norwell, USA) Objective: To evaluate whether the apparent dose-effect in PRISMS-4 is related to neutralizing antibody (NAb) levels in the respective treatment groups. Introduction: Over 4 years in PRISMS [1], several measures demonstrated evidence of a dose effect in favour of patients on interferon (IFN) beta-la (Rebif| 44 mcg tiw [Rx 44] compared to those receiving IFN betala 22 mcg tiw [Rx 22]. The difference between treated groups on relapse count approached statistical significance (p = 0.07) while in years 3-4 alone, the difference was significant (p = 0.02). NAb rate was greater for Rx 22 than for Rx 44 and since NAb reduces efficacy, the trend for dose difference could be related to a lower NAb rate in Rx 44. Methods: Patients (189 patients in Rx 22 and 184 in Rx 44) were assessed clinically every 3 months during years 1-3 and every 6 months in year 4 as well as at the time of clinical relapse. Sera, drawn every 6 months, were analysed by ELISA for binding antibodies. Positive samples were tested in a viral cytopathic assay system for NAb. Results: Persistent NAb were found in 23.7 % of Rx 22 and 14.3 % of Rx 44 over the 4-year study duration (p = 0.02). The relapse rates, based on NAb status, during years 1-2 were 0.98/yr and 0.85/yr for Rx 22 NAb-ve and Rx 22 NAb+ve respectively (ns) while for Rx 44 the corresponding values were 0.88 and 0.79 (ns). During years 3-4, relapse rates were 0.59 and 0.79 for Rx 22 NAb-ve and NAb+ve (p = 0.10) and 0.43 and 0.86 for Rx 44 (p = 0002). Relapse rates during years 1-4, excluding NAb+ patients were 0.76/yr for Rx 22 mcg and 0.65/yr for Rx 44 (p = 0.004) and during years 3-4 were 0.59/yr for Rx 22 and 0.43/yr for Rx 44 (p = 0.006). Differences on MRI measures were strongly dose-related irrespective of NAb status. Conclusions: NAb+ve patients have higher relapse rates than NAb-ve patients while on IFN after the first 2 years of therapy. NAb development was significantly higher in PRISMS for Rx 22 than for Rx 44. A strong trend on relapses is seen and when NAb+ve patients are excluded, the dose difference increases. The overall "apparent" dose effect is not due to a higher NAb rate

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in Rx 22 but rather a true dose effect further supporting the concept of maximal benefit with the highest dose of IFN. Reference 1. Freedman MS and PRISMS study group (2000) PRISMS 4-year resuhs: Evidence of clinical dose effect of interferon beta-la in Relapsing MS. Neurology 54:2351 P311 The use of symptomatic therapy for spasticity and pain in multiple sclerosis. C. Solaro, M. Messmer Uccelli, G. Brichetto, M. A. Battaglia, G. L. Mancardi (Genova, I) Objective: To evaluate symptomatic therapy for spasticity and pain in a cross-sectional study of an MS population. Background: The frequency of symptoms such as pain and spasticity in MS is significant, reportedly affecting up to 80% of patients. Defining the burden of symptoms during the course of a chronic illness such as MS is important for planning clinical trials and assessing cost-benefit. The frequency of prescriptions for a medication may signify the impact of the target symptom on patients' lives, regardless of whether partial or complete efficacy is achieved. With the overwhelming focus on disease modifying treatments, inadequate attention may be dedicated to more immediate patient needs, such as the alleviation of pain or spasticity. Methods: As part of an epidemiological study conducted in Genoa, Italy (1997-2000), direct interviews were conducted and medical records of patients with MS were evaluated, in order to assess the frequency of medication utilized for pain (tricycles, carbamazepine, gabapentin, lamotrigine, dintoine) and spasticity (dantrolene, baclofen, tizanidine, diazepam, clonazepam). Medications for non-neuropathic pain, FANS, morphine, antimigraine, were not included in the assessment. Results: Out of a 836 subjects with MS enrolled in the larger epidemiological study, 536 subjects were directly interviewed by a neurologist. The clinical and demographic characteristics of these 536 were representative of t¡ population studied. Out of these 536,170 were being treated by at least 1 of the medications listed above (32 %). The sample comprised of 112 females and 58 males. The spasticity group was older (mean years 57 vs. 52), more disabled (mean EDSS 6.8 vs. 5.7) with a longer disease duration (mean 20 years vs. 16). The majority of patients from both groups, spasticity and pain, hada progressive disease course (81/94 and 52/76, respectively). Medication distribution: dantrium 3, tricyclics 21, baclofen 76, carbamazepine 23, gabapentin 31, tizanidine 15. In cases with both symptoms the more severe symptom was assessed. Details of the complete analysis will be presented. Conclusions: This cross sectional study demonstrated that nearly 1 in 3 MS patients were being treated for pain or spasticity. Although the results suggest that these symptoms are well-recognized by physicians as potentially treatable, they remain under-studied in clinical trials and without established treatment recommendations, despite their prevalence. P312 Computer-Based Evaluation of Motor Performance in Multiple Sclerosis Patients. G. Brichetto, V. Sanguineti, L. Baratto, M. Farinelli, P. G. Morasso, G. L. Mancardi, C. Solaro (Genova, Arenzano (GE), I) Objective: To define a methodology to quantify impaired arm movements in multiple sclerosis (MS) patients, based on kinematic analysis. Background: Sensorimotor impairment in MS subjects is difficult to quantify because more functional systems are usually involved. A control or cybernetic framework, based on assessing the respective functionality of the feedforward and feedback components of control, would have an immediate relevance to the design of highly personalised rehabilitation strategies. Methods: We analyzed 41 clinically or laboratory definite MS subjects, aged 22-63 (mean 38.0), 15 male and 26 female, and 9 young healthy cont rols (ages 23-35, mean 29.3). Subjects were evaluated by the same examining physician with EDSS, FSS, Scripps's Neurological Rating Scale (NRS), and 9Hole-Peg-Test (9-HPT). Left and right arm impairment was separately quantified by means of the arm portion of the NRS, so that each functional system was ranked as, respectively, Normal (NRS = 5); Mild (NRS = 3); Moderate (NRS = 1) and Severe (NRS = 0). Subjects performed planar arm reaching movements, under visual control and with a fast-and-accurate directive. Trajectories of shoulder, elbow and fingertip were recorded by means of reflective markers. Resuhs: In subjects with an abnormal cerebellar score, movements have a longer deceleration phase, are more curved and less smooth. These indicators are highly correlated with the cerebellar NRS score. They also display a significantly larger aiming error, but are generally able to correct it during the ongoing movement. In contrast, subjects whose only observable impair-

ment is sensory tend to be indistinguishable from controls but, if cerebellar signs are also present, on-line corrections become less effective. The motor performance of motor impaired subjects is more difficult to interpret, because the observed large lateral deviations in their paths may be due, at least in part, to problems in muscle tone. Conclusions: Cerebellar symptoms may be interpreted as an abnormal feedforward control. In absence of additional signs, a purely sensory impairment tends to be compensated for by vision, but corrections may become ineffective if an additional cerebellar impairment is also present. Movement analysis seems to be an effective tool for investigating the interaction between sensory and cerebellar impairment and it would potentially allow for a comprehensive assessment of the level of arre impairment. P313 Efficacy and adverse effects of antiepileptic medications in multiple sclerosis. C. Solaro, M. Messmer Uccelli, G. Brichetto, G.L. Mancardi, M.A. Battaglia (Genova, I) Objective: To evaluate prospectively the efficacy, adverse effects and frequency of utilization of antiepileptic medications (AED) in multiple sclerosis (MS). Background: Adverse effects due to AED are very common in MS, even at very low doses, but their frequency and predisposing factors have not been assessed. Neuropathic pain and paroxysmal symptoms are common in MS, with a reported prevalence of 50%. These syrrlptoms c a n effectively be treated with AED, although data are from small open-label studies. AED are also prescribed for symptoms which are difficult to treat, such as tremor and nystagmus. Design/methods: For a period of 3 years out-patient use of AED (Phenobarbital, dintoine, carbamazepine, gabapentin, lamotrigine, vigabatrin) was recorded in a database established at the Department of Neurological Sciences and Vision, University of Genoa, Italy. Rationale for prescribing, subjective efficacy (for symptoms other than seizure). Adverse effects, discontinuation and treatment duration were also recorded, lmprovement in pain was assessed using a four-point scale (0= no pain, 4=severe pain) compiled by patient and physician. Efficacy was defined by a decrease of 2 points. Results: In the period of analysis out of 700 patients, carbamazepine was prescribed for 36 patients, adverse effects were reported in 22 cases and in 14 mimicking a relapse; efficacy were observed in 16. Gabapentin was prescribed for 94 patients, adverse effects were reported in 16 cases; efficacy was observed in 54. Lamotrigine was prescribed for 22 patients, adverse effects were reported in 4 tases, efficacy in 14. Phenobarbital and dintoine were prescribed for only 2 patients for seizure, and vigabatrin for 4 patients for nystagmus. 32 patients were taking more than one medication during the observation period. Subgroup analysis, daily regiments, clinical correlations and pain scale assessment will be presented in detail. Conclusions: This prospective survey found a significantly high incidence of adverse effects in patients treated with CBZ with a high rate of discontinuation at very low doses and episodes of evident worsening of neurological functions. GBP and LMT appear to be better-tolerated, partially efficacious in pain treatment, and GBP very efficacious for nocturnal tonic spasms. P314 Sample Size Estimations Ÿ MRl-monitored Clinical Trials of relapsing-remitting Multiple Sclerosis Comparing New Experimental Treatments versus Interferon Beta. M. Rovaris, M. P. Sormani, F. Bagnato, P. Bruzzi, S. Bastianello, P. Molyneux, P. Molyneux, C. Pozzilli, G. ComŸ M. Filippi (Milan, Rome, Genoa, I; London) The number of new gadolinium (Gd)-enhancing lesions counted on monthly magnetic resonance imaging (MRI) scans of the brain is widely used asa paraclinical outcome measure for treatment trials of relapsing-remitting multiple sclerosis (RRMS). Sample sizes needed for detecting a treatment effect on this outcome in placebo-controlled studies have been estimated using different statistical approaches. Since interferon (IFN) beta is now licensed asa treatment for MS, it is likely that the efficacy of new therapies will have to be tested in comparative trials against this drug. In this study, we estimated the sample sizes needed for this purpose. MRI data of a previous trial were analyzed. This dataset consisted of 66 relapsing-remitting MS patients treated with IFN beta la (Rebif, Serono; weekly dose: 33 or 99 mcg). In all patients, six consecutive monthly MRI scans of the brain were obtained afier instituting treatment. The image acquisition scheme consisted of axial, 5-mm thick contiguous slices and the Gd dose was of 0.1 mmol/Kg. The numbers of new Gd-enhancing lesions were counted by two experienced observers in agreement over a six month

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period and data were modelled using a negative binomial distribution. The sample sizes needed for detecting various treatment effects with 90 % statistical power were then calculated for parallel group studies of six month duration. The mean cumulative number of new Gd-enhancing lesions per patient was 3.4. The sample sizes per arm needed for detecting a significant effect of new treatments in reducing the numbers of lesions compared to IFN ranged from 765 (effect: 20 %) to 95 (effect: 50 %). The numbers of patients per arm needed to detect a significant treatment equivalence, defined as the maxim u m acceptable difference in favour of IFN, ranged from 12,540 (difference: 5%) to 898 (difference: 20%). Comparative, MRI-monitored trials of new treatments against IFN beta in RRMS may require large numbers of patients even when the reduction of enhancement frequency is used a s a measure of outcome.

Cognitive deficit was observed in 14 patients (9 RR, 2 SP, 3 PP). In logistic regression, it depended of working memory and information speed deficit (p < 0.05). There was no correlation with physical disability, clinical forms or disease duration. In principal components and cluster analysis, a cognitive deficit was associated with unemployment, higher levels of fatigue and cognitive complaint, lower quality of life (p < 0.01). In our study, cognitive impairment had consequences in daily life in MS patients, independently to physical disability or disease duration. Neuropsychological evaluation could be important to assess consequences of the disease in daily life and eventually to decide the need of a immuno-suppressive of immuno-modulatory treatment in patients with a low EDSS score.

Muscle Disorders P315 Use of complementary and alternative medicine in a sample of multiple sclerosis patients. E. Cartechini, G. Giuliani, M. Morelli, E. Pucci, R. Taffi, C. Tans (Macerata, Ancona, I) Background: Complementary and alternative medicine (CAM) is an increasing feature of healthcare practice but few data on its impact on multiple sclerosis (MS) are available. Objective: To estimate prevalence of CAM for MS, patients' subjective benefit and side effects, influence on conventional medicine strategies, and economic impact. Setting: Two MS centres in Italy: Ancona and Macerata. Participants: 86 consecutive outpatients with at least 3-year diagnosis of definite or probable MS and/or their caregiver (if clinical evidence of impaired mental status). Methods: Participants were interviewed through a semi-structured questionnaire retrospectively investigating: 1) use and type of CAM; 2) source of knowledge about ir; 3) outcome desired; 4) cost; 5) benefit and side effects; 6) future plans for using CAM; 7) influence on conventional medical management; 8) communication of CAM use to the care-giving neurologist and/or the general practitioner (GP). CAM interventions were classifled as in The Cochrane Library. Parameters were adjusted for disease duration. Results: 1) At least one CAM was used at least once by 32.5 % of patients. Homeopathy was the most common (35.7%). 2) In most cases the referral source was a friend but in 14.3 % was a physician. 3) CAM was expected to be disease-modifying in 28.6 % and symptomatic in 57.1%. 4) With the limitation of reliable data in 88.4% of CAM users interviewed, the mean cost/ year/person was around 472 Euro. 5) A perceived benefit was recorded in 53.6 % ofpatients; in 14.3 % ofcases side effects were suffered. 6) 50 % of CAM users agree to use CAM in the future; the same for 27.6 % of those who never used it. 7) CAM negativelyinfluenced the compliance with conventional medical management in 7.1% of cases (resuh biased by the fact that participants are patients who refer to"conventional medicine"MS centres). 8) In 85.7 % of cases the caring neurologist and/or the GP were not consuhed. Conclusions: The use of CAM in MS is widespread in Italy and often without consulting the neurologist or the GP. Its cost appears to be high. Neurologists should consider directly asking patients about the use of CAM. Further studies should explore the factors underlying the practice of CAM, notwithstanding the lack of evidence for their safety and efficacy. The use of CAM brings to light ethical issues representing a challenging task for physicians and health policies in the era of evidence-based medicine. P316 Neuropsychological disability in multiple sclerosis: a controlled study about 40 patients with mild physical disability. E. Sartori, S. Massengo, C. Chevrier, J. Chaperon, V. Golfier, S. Belliard, M. Coustans, G. Edan (Rennes, F) Cognitive deficit can be observed in mild multiple sclerosis (MS). However, little is known about its relationships with employment, fatigue and quality of life in MS patients. Our airo was to evaluate links between the cognitive status of patients with mild physical disability and functional variables, such as quality of life (QoL), fatigue or personal cognitive complaint. Forty patients with a definite MS and an EDSS < 4 [30 relapsing-remitting (RR), 4 secondary progressive (SP), 6 primar), progressive (PP)] were compared with an educational level-, age- and sex-matched controlled group. A comprehensive cognitive battery was performed, including information speed, executive functions and memory evaluation. Patients completed standardised questionnalres about fatigue, cognitive complaint and quality of life. Illness and social variables were also included in the statistical analysis (Wilcoxon test, logistic regression, principal components and cluster analysis).

P317 Matrix metalloproteinases MMP-2, MMP-7, MMP-9 and perlecan expression in myositis. B. G. H, Schoser, D. Blottner, H.-I. Stuerenburg (Hamburg, Berlin, D) Proteolytic enzyme expression of matrix metalloproteinases and perlecan was studied in 19 cases of inflammatory myopathies. Inflammatory myopathies showed distinct patterns of upregulation of matrix metalloproteinases. MMP-9 was strongly expressed in atrophic myofibers in all inflammatory myopathies. Expression of MMP-7 and MMP-2 was similar in their distribution, however, MMP-2 to much weaker intensity. In dermatomyositis the perifascicular atrophy showed pronounced MMP-9 expression. Additionally, MMP-7 strongly immunolabeled phagocytic myofibers in polymyositis cases only. Perlecan immunoreactivity war not altered compared to controls. Our findings may indicate MMP upregulation as an additional molecular event in the multistep process of inflammatory myopathies. P318 Paramyotonia congenita: a new phenotype associated with theVa11589Met substitution in the m u s d e sodium channel gene. D. Ferriby, T. Stojkovic, D. Sternberg, }f. Hurtevent, P. Vermersch (Lille, ParŸ F) Background: Sodium channel disorders encompass hyperkalemic periodic paralysis, paramyotonia congenita (PC) and potassium-aggravated myotonia (PAM). The Va11589Met mutation in the adult skeletal muscle sodium channel alpha-subunit (SCN4) gene was originally reported to cause myotonia aggravated by cold and potassium (Heine et al., 1993). Later, a family presenting solely cramps was reported to carry this mutation (Orrell et al., 1998). Objective: To describe a new phenotype associated with theVal1589Met substitution in SCN4 gene. Results: We reporta French family presenting paramyotonia congenita. The proband was a 45-year-old woman, who described muscle stiffness and occasionally flaccid weakness, both symptoms, which were induced by exercise, cold and heat. Severe muscle stiffness affected facial, oropharyngeal and limb muscles leading to transient paralysis. One sister, two nephews and the son of the proband had similar symptoms. However affected members demonstrated phenotypic heterogeneity, Electromyography showed numerous myotonic discharges in facial and limbs muscles. Repetitive exercise provoked reduced amplitude compound action potentials, creatine Kinase and potassium level were both in normal range. Molecular analysis of the muscle sodium gene (SCN4A) by nucleotide sequencing revealed a G to A transition of cDNa nucleotide at position 4765 predicting a substitution of valine for methionine at position 1589. Conclusion: These results.demonstrate that the Val1589Met mutation may cause different phenotypes: either cramps, PAM or PC. This new phenotype suggests that other factors may influence the expression of the disease in sodium channel disorders. P319

Cognitive impairment and b sarcoglycan. M. D'Angelo, L. Libera, R. Cagliani, M. Sironi, S. Benti, G. Comi, F. Fabbro, A. Turconi, N. Bresolin (Bosisio Parini (Lecco), Milano, I) The autosomal recessive forms of limb-girdle muscular dystrophies, LGMD2 C-F are caused by primary mutations in four genes encoding the components of the dystrophin associated sarcoglycan (SG) complex, namely a-b-gd SG. The clinical phenotypes overlap Duchenne-like presentation and lateronset Becker like presentation. The precise function of sarcoglycans is currently not completely understood, b-sarcoglycan is the only protein of

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the SG complex detected also in the brain, suggesting a possible role in non muscular tissues. Recent data showed that b-SG may be part of the dystroglycan complex and this could be particularly intriguing in relation to the involvement of DG in the synapse formation. Goals: to find out the possible correlation between b SG deficit and cognitive impairment, highlighting the role of b SG in the brain Materials and methods: a 12 years old boy affected by a b SG deficiency with unusual presentation of exercise-induced myoglobinuria; the b-SG gene analysis demonstrated a compound heterozygous for ah A- > T base pair substitution at nucleotide 85 in exon 2 (A85T) a n d a C- > T base pair substitution at nucleotide 271 in exon 3 (C271T). The father and one sister were presenting a heterozygous status for the A85T, the mother and another sister were presenting the heterozygous status for the C271T mutation. The Wechler Intelligence Scale for Children Revised (WISC-R) showed an important discrepancy between verbal IQ (62) and performance IQ (113), with a global IQ 84. Following psycholinguistic studies, showed a disturbance in the language articulation; a very poor structural sentences organization, reading and comprehension problems, suggesting an involvement ofb-SG in language development, similar to the one already shown in DMD. The SPECT analysis performed on the patient revealed an asymmetrical signal, with an hypoperfusion of the left temporal and frontal lobe. Conclusions: These preliminary data are strongly supporting the neurofunctional alteration of the left hemisphere (frontal, temporo-parietal region) and the cerebellum in language disturbances. P320 Specific ageing-related mutations in the h u m a n mtDNA control region from normal muscles: a single-fiber stud~ R. Del Bo, G. P. Comi, M. Sciacco, L Napo[i, N. Bresolin, G. Scarlato (Milano, Bosisio Parini, I) Human skeletal muscle develops a histochemical mosaic during the process of normal aging; in particular the proportion between the number of cytochrome c oxidase (COX) positive and COX deficient (negative) muscle fibers differs as a function of age: aged individuals show a significantly hŸ proportion of negative fibers. Since a progressive accumulation of mitochondrial DNA (mtDNA) alterations has been demonstrated in association with ageing in various tissues including skeletal muscle, we investigated the relationship between COX enzyme activity and specific age-related mutations in the control region of mtDNA in single muscle fibers. We evaluated four biceps brachii muscle specimens from individuals deemed to be free of muscle disorders aged 81, 94, 96, 97 years respectively. Serial transverse sections were double-stained for COX and succinate dehydrogenase (SDH) activities allowing the identification of a cellular bioenergy mosaic with cells ranging from high to zero detectable CO/( enzyme activity. The subjects studied h a d a similar number of fibers deficient in COX activity (mean value 0,8 %). Specific point mutations were searched using the singlefiber PCR protocol followed by the restriction fragment-length polymorphism analysis. In particular, the T414G transversion was found in 3 of 4 muscles from aged individuals above 80 years and in 10 of 30 (33%) single fibers analysed.A wide range of heteroplasmy (up to 75 %) was detected, but no direct age-related correlation was found between the T414G positively, the histochemical phenotype and the absolute amounts of mtDNA in the same individual fiber. Our data evidence the high heterogeneous distribution of T414G in aged muscle single-fibers thereby opening new perspectives to explain the biological functional significance linked to this specific mutation. P321 Intolerance towards neuroleptics and predisposition for malignant hyperthermia in a patient with proximal myotonic myopathy (PROMM) and paranoid psychosis. C. Schneider, F. Pedrosa Gil, M. Schneider, M. Anetseder, W. Kress, C. R. Mueller, K. V. Toyka (Wuerzburg, Munich, D) Objective: A PROMM pafient with paranoid psychosis and intolerance towards medication with various neuroleptics a n d a positive in-vitro contracture test indicating susceptibility for malignant hyperthermia is described. Background: A predisposition for malignant hyperthermia may occur as a secondary phenomenon in various myopathies including myotonic dystrophy type 1 (DM1). Methods: A muscle biopsy of the left vastus lateralis muscle and an invitro contracture test with halothane and caffeine were performed in a 26 year old patient with PROMM and paranoid psychosis who had developed muscle stiffness and oculogyric cramps under medication with fluanxol, and who had shown marked increase of serum CK levels up to 1800 U/l, but no muscle stiffness, rigidity, rever, autonomic dysfunction, reduction of consciousness, leukocytosis or raised ESR under medication with amisulprid and olanzapine respectively.

Results: Neurological examination of the 26 year old patient revealed mild weakness of neck and hip flexor muscles, electromyographical myotonia, and myotonic cataracts. ECG showed a right bundle branch block. Neuropsychological testing revealed acquired deficits of visual-spatial functions. Brain and muscle MRI were normal. A muscle biopsy of the lefl vastus lateralis muscle showed a mixed myopathic and neurogenic pattern. Ah invitro contracture test was positive for halothane indicating a predisposition for malignant hyperthermia. Conclusion: In patients with all kinds of multisystemic myotonic myopathies an increased risk towards medication with neuroleptics, volatile anaesthetics and depolarising muscte relaxants should be taken into account. In our patient, the predisposition for malignant hyperthermia and the intolerance towards atypical neuroleptics are probably both related to disturbances of the muscle cell metabolism. P322 Heart involvement in primary alpha-sarcoglicanopathy. R. Cagliani, G.P. Comi, G. Felisari, M. Sironi, L. Tancredi, A. Prelle, F. Fortunato, M. Moggio, M. D'Angelo, G. Scarlato (Bosisio Parini, Milano, I) Limb girdle muscular dystrophies (LGMD) are a genetically heterogeneous group of disorders, characterised by proximal muscle weakness of variable severity, high CK and dystrophic muscle changes. Among the autosomal recessive forms, the LGMD2 C-F are caused by primary mutations in four genes encoding the components of the dystrophin associated sarcoglycan (SG) complex. The SG complex plays a fundamental tole in maintaining the sarcolemmal integrity in skeletal muscle. Primary SG defects on the beta, gamma and delta components lead also to heart involvement in humans or animal models. We describe a patient affected with a primary alpha sarcoglycanopathy (LGMD type 2D). showing evidence of heart involvement.A 24 year-old male born from non consanguineous parents, with negative family history, presented a progressive lower limb girdle weakness at the age 5 years, he lost independent walking at age 12 years, and, when last seen, he had generalized proximal more than distal muscle weakness and decreased bulk, several tendineous retraction, episodic palpitations without overt dyspnea. At the age of 17 years, ECG showed high R1 in V1 lea& Several Lown 4B ventricular premature complexes were presentat the Holter-ECG registration. At age 24 years, a septal interventricular hypertrophy was detected at the Echocardiography. Muscle biopsy showed partial dystrophin reduction and total absence of all sarcoglycans, conflrmed by Western Blot.Alphasarcoglycan gene analysis demonstrated a compound heterozygous status for these mutations: a C- > T bp substitution at nucleotide 229 a n d a novel C- > T bp substitution at nucleotide 241; both mutations localize to exon 3 and change ah Arg codon to a Cys (R77C and RS1C). Restriction fragment polymorphism analysis revealed an heterozygous status for the two mutations in his parents. The parental origin of the two alpha-sarcoglycan gene mutations was further confirmed by sequence analysis. Although alpha-sarcoglycanopathies account f o r a relatively high percentage of LGMD2 C-F, cardiac dysfunction signs are under-reported in LGMD 2D. Whether this fact represents only a bias of investigation ora true genetic heterogeneity with respect to heart function remains to be elucidated. Genetic and clinical heterogeneity of limb-girdle muscular dystrophies has broad implications for diagnosis of these pathologies, thus detailed description of any additional case might provide more insights in genotype/phenotype correlations. P323 Expression of muscle specific genes in mice bone marrow cells. S. Strazzer, S. Corti, G. P. ComŸ R. Del Bo, S. Salani, R Fortunato, N. Bresolin, G. Scarlato (Milano, Bosisio Parini, I) Bone marrow (BM) could gire rise to stem cells also for nonhematopoietic tissues, including muscle. Recent reports demonstrate that BM cells transplanted in mice can be recruited into a region of muscle degeneration from the peripheral circulation and participate in muscle repairing mechanisms, opening new strategy for gene therapy for muscle diseases such as Duchenne Muscular Dystrophy (DMD). To investigate the muscle potential of BM cells a s a source for cell mediated gene therapy, we analysed the expression of myogenic markers of bone marrow cells in vitro. Bone marrow was collected from C57BL/]10 mice and cells from freshly isolated bone marrow and from the adherent and nonadherent fraction by 48 hours and 1 week of culture were analysed. The following muscle proteins were evaluated by immunocytochemistry and Western-blot analysis: desmin, slow myosin heavy chain, alpha-sarcomeric-actin. RT-PCR analysis of transcripts for the above mentioned muscle proteins and for MyoD, Myf5 and Pax3 was performed. The colocalization of the muscle protein with haematological markers CD45 and Sca-1 was also investigated.

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Here we demonstrate that cells expressing striated muscle specific genes are already present in the BM indepentedly from experimentally forced myogenic conversion. We observed the presence of both markers of early myogenic program such as Pax3, Myf5, MyoD, desmin and late myogenesis such as myosin heavy chain and alpha-sarcomeric-actin. These cells are Sca- 1+ CD45+ and they are more present in the nonadherent fraction, showing features similar to the hematopoetic and muscle derived stem cells. These observations support the hypothesis that BM may playa physiological role in muscle regenerative processes and could be a source for cell transplantation as gene complementation approach for muscle diseases such as Duchenne Muscular Dystrophy. P324 Molecular genetic analysis in tire families with chronic progressive external ophthalmoplegia. M. Deschauer, T. Mª S. Zierz (Halle, D) Chronic progressive external ophthalmoplegia (CPEO) is considered the most frequent form of mitochondrial encephalomyopathies. Most cases occur sporadically. We investigated 18 consecutive patients with CPEO. Thirteen cases were sporadic and 5 cases (28 %) were familial. In one family with maternal inheritance the mitochondrial point mutation A3243G was identified. In index patients of three other families multiple deletions of mitochondrial DNA were found. One of these families showed autosomal recessive inheritance, one other probable autosomal dominant inheritance and one autosomal dominant or maternal inheritace. Because recent identification of mutations in the adenine nucleotide translocator 1 (ANT 1) gene in some patients with CPEO with multiple deletions, we sequenced this gene in our 3 patients with multiple deletions but found no mutation. In the fifth family with autosomal dominant or maternal inheritance no alteration of mitochondrial DNA could be identified (including sequencing of hot spots for mitochondrial mutations). Conclusions: There are three different modes of inheritance: (i) maternal transmission associated with mitochondrial point mutations a s i t is known for other mitochondrial disorders, (ii) autosomal recessive, and (iii) autosomal dominant inheritance. In contrast to sporadic cases with single mitochondrial deletions autosomal inheritance can be associated with multiple deletions of mitochondrial DNA due to nuclear mutations. Nuclear mutations in the ANT1 gene seem to be rare in German patients.

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P326 Clinical and electrophysiological pattern of peripheral paraneoplastic neuropathies associated with the anti-Hu antibodies. J.-P. Camdessanche, J.-C. Antoine, J. Honnorat, P. Petiot, J.-F. Mosnier, D. Michel (Saint-Etienne, Lyon, F) Peripheral neuropathy is a well-known manifestation of the paraneoplastic neurological anti-Hu syndrome and subacute sensory neuronopathy (SSN) is the most frequent presentation. However, other peripheral neuropathies have been reported. In spite of the abundance of works concerning the antiHu neuropathy, large studies devoted to their electrophysiological pattern are not available. We studied 17 consecutive patients with a paraneoplastic peripheral neuropathy and anti-Hu antibodies. Their clinical and electrophysiological data were reviewed. For the electrophysiological study, we defined three abnormal patterns, demyelinating, axonal/neuronal, and axonal/demyelinating, and classified each sensory or motor studied nerve accordingly. For the statistics, the Khi 2 test was used. Patients were 15 men and 2 women (mean age 63.5). Peripheral neuropathy was the first manifestation in 16. Central nervous system disorders were associated in 8 and autonomic disorders in 5. The neuropathy was subacute in 9 and progressive in 8. It was sensory in 13, sensorimotor in 3, and motor in 1. At the onset, symptoms were symmetrical in 12 and asymmetrical or multifocal in 5. Pain, hypoestbesia and paresthesia were predominant. The median Rankin's score was 2 and 3 patients had an indolent neuropathy. 231 nerves were studied. The pattern was axonal/neuronal in 46%, axonal/demyelinating in 18.6 %, demyelinating in 2.2 % and normal in 33.2 %. An axonal/neuronal pattern was more frequent in sensory nerves and an axonal/demyelinating pattern in motor nerves (p < 0.01). In sensory nerves, the frequency of the axonal/neuronal pattern was similar in sensory and sensorimotor neuropathies. Half of the motor nerves had an abnormal pattern in both types of neuropathy. However, the distribution of this abnormal pattern was different. In sensory neuropathies, the most frequent pattern was axonal/demyelinating and axonal/neuronal in sensorimotor neuropathies (p < 0.01). A s a whole, only 4/13 patients with a clinically sensory neuropathy had an electrophysiological pattern typical of SSN. The present work shows that the typical clinical and electrophysiological pattern of SSN is rare in the anti-Hu neuropathies. Motor nerve involvement is frequent and probably depends on different mechanisms.Axonal degeneration explains motor deficit. In addition to their pathological potential implications, these findings can have practical consequences in the diagnosis of these neuropathies.

PeripheralNeuropathy P325 Schwann cell apoptosis in experimental autoimmtme neuritis and the functional role of TNF-Alpha. A. Weishaupt, W. Brª T. Hartung, K. V. Toyka, R. Gold (Wuerzburg, Berlin, Konstanz, D) Background: Schwann cell (SC) apoptosis may be a critical factor challenging nerve remyelination and regeneration in experimental autoimmune neuritis (EAN) in the Lewis rat. We analyzed the late of SC during high-dose antigen therapy of adoptive transfer-(AT-)EAN using rhP2 protein. P2 antigen therapy was associated with an increase of T-cell apoptosis mediated by TNF-alpha and lead to ah effective treatment of this autoimmune disorder as shown in previous studies. Objectives: To characterize SC apoptosis in EAN and in a model of specific immunotherapy. Methods: The effects on SC apoptosis were determined by morphological criteria or by in situ tailing (IST) followed by immunocytochemical analysis. Serial sections were stained with the polyclonal S-100 antiserum recognizing SC. For pan T-cell staining the monoclonal antibody B 115-1 was used. Antibody binding was visualized by the ABC-detection system with New fuchsin as alkaline phosphatase substrate, or 3.Y-diaminobenzidine as peroxidase substrate. Results: We found that antigen specific therapy had no clear effect on SC apoptosis, whilst it markedly increased T-cell apoptosis. Neutralisation of TNF-alpha, ah important proinflammatory mediator released in high amounts after antigen therapy or released in lower concentrations during EAN, resulted in a significant &crease in the rate of SC apoptosis in vivo compared to animals treated with control antigen rhP0 or with rhP2 only. Conclusions: Our results indicate that TNF-alpha may be a critical mediator of SC apoptosis in EAN and could be highly active in rather small concentrations.

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P327 Critical illness polyneuropathy in burned patients. A. Belova, M. Rasteryaeva, A. Struchkov, S. Khroulev (Nizhny Novgorod, RUS) We aimed to study the frequency of Critical illness polyneuropathy (CIP), its risk factors and clinical course in burned patients. 70 burned patients hospitalized to the intensive care unit of the Regional Burn Center (N. Novgorod, Russia) in 1999-2000 were evaluated and the development of CIP was found in 10% cases (7 patients, group I). 10 patients without signs of peripheral nervous system impairment (group II) were randomized. Group I included 5 female and 2 male aged from 30 to 47. The diagnosis was verified by clinical picture, electrophysiological studies and by excluding the other reasons for peripheral nerves damage.All patients had thermal burns, the Total Body Surface Area Burned (TBSA) ranged from 35 % to 50 % with the majority of these burns being third degree. CIP developed on the 28-45th postburn days (mean 32.2 -+ 2.1 days), only in the phase of septicaemia. Severe tetraparesis was revealed in 2, moderate muscle wasting and hypotonia - in 3 and mild motor impairment - in 2 patients. Distal sensory deficit was discovered in 6 cases, the muscles of respiration were involved in 2 patients. Electromyography confirmed axonal sensorimotor disturbance in all cases. Statistical analysis performed to determine the risk factors for CIP showed a significant difference (p < 0.05) between groups I and II for following factors: TBSA (43.7 + 3.5 % and 23.8 + 4.1% in group I and II correspondingly); sepsis confirmed by bacteriological blood analysis (was discovered in all patients of group I and only in one patient from group II); hyponatraemia during 24 hours and longer (every patient from group I h a d a preceding episode of hyponatraemia, transient serum Na level decrease varied from 127 to 132mmol/1, mean 130.8 -+ 0.3mmol/1, and persisted from one to 5 days, mean 3 -+ 0.8 days; in all patients from group II serum Sodium level was within normal limits all the time long). During 6-12 months' follow-up study some recovery of functions was observed in 5 patients, the neuropathy was unchanged in 2, the further development of the process was not registered. Conclusion: Our data confirm quite high frequency and persistent character of CIP in severe burned patients. Burn area more than 35 % of total

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body surface, sepsis and hyponatraemia were revealed to be the risk factors for its development. Identification of risk factors should lead to taking measures for early CIP diagnosis and treatment and might be useful to avoid the prolonging disability of burned patients. P328

Recurrent Guillain-Barr› syndrome. Comparison with monophasic form of acute polyradiculoneuritis. M. Charif, C. Vergnes, J.M. Blard, M. Pages

h a d a specificity of 100 %, and a sensitivity of 46 %, whereas clinical deficit of vibratory sense had specificity of 90 %, and sensitivity of 42 %. Conclusion: Al1 the patients with NSV should be studied with EMG/ENG early after their diagnosis because: 1) sensory-motor neuropathy is often present in early stage of NSV; 2) clinical sign and symptoms show a poor sensitivity for neuropathy; 3) the awareness of an early neurological complication is important in the choose of the appropriate long term therapeutical program; 4) when electrophysiological signs of neuropathy are present, nerve biopsy may be useful in the definite diagnosis of NSV.

(Montpellier, F) Background: Guillain-Barr› syndrome (GBS) is an acute and generally reversible monophasic polyradiculoneuropathy. Recurrent GBS (RGBS) is rare and must be distinguished from relapsing chronic idiopathic demyelinating polyneuropathy (CIDP).We compared the clinical features and the course of recurrent and monophasic GBS. Material and methods: All the cases of GBS admitted in our department from 1979 to 1999 were retrospectively reviewed. The diagnosis was assessed according to the NINCDS criteria. RGBS was defined as at least two episodes of GBS separated by long lasting periods of complete of near-complete recovery. Miller Fisher syndromes, sensory forms of GBS, GBS restricted to cranial nerves and early relapses of GBS after plasma exchanges or intravenous immunoglobulins were excluded from this study. Statistical analysis was used to compare monophasic to RGBS and the first to the second attack of RGBS. Results: Out of 116 patients with GBS, 5 (4.3%) had more than one episode of acute polyradiculoneuritis, a single recurrence in 3 cases and 2 recurrences in 2 patients. The average age at the first episode was 43.6 years (27-69 years) andat the last episode 56.6 years (37-75 years), the mean interval between attacks was 9 years and 9 months (16 months-23 years). There was no statistically significant difference between monophasic GBS and the first episode of RGBS concerning the following characteristics: age and sex; incidence of antecedent infective illness; duration of extension phase of paralysis, platean of maximum weakness and phase of recovery; severity of motor weakness. In RGBS, all episodes were preceded by ah ante~edent illness, the nature of which was similar in each case. The clinical picture and the severity of the disease was quite different from a patient to another one and from one episode to another one. Ventilatory failure which required mechanical ventilation occurred in 4 patients. There was a trend to a faster recovery of the second episode when compared to the first one (p = 0.06). All patients recovered without sequelae. Conclusion: RGBS is rare and the clinical picture of. each episode is not different from monophasic GBS. Each attack may vary considerably in severity and the distribution of motor weakness. A high incidence of antecedent infective illness, a rapid onset of symptoms a n d a good recovery ate clinical characteristics which allow to separate RGBS from CIDP. P329 A prospective electrophysiological study of neuropathy associated with necrotizing systemic vasculitis. A. Gavazzi, R. Bianchi, L. Maderna, F. De Rino, M. Franceschi (CasteUanza (Va), Milano, I) Background: Until now we have prevalence data of peripheal neuropathy occurring in patients with vasculitis syndromes only from samples of patients retrospectively studied or with early evident neurological complications. Airo of this study has been to prospectively study with electromyography and electroneuronography (EMG/ENG) patients with necrotizing systemic vasculitis (NSV) just diagnosed in an immunological setting, independently from any neurological complication. Methods: Patients had: 1) a diagnosis of NSV according to current research criteria and confirmed by pathological study of adequate tissues. 2) no pathological or environmental conditions known to be risk factors for neuropathies. 3) standard clinical EMG/ENG evaluation. Resuhs: Twenty-four consecutive patients hada diagnosis of NSV for the first time in our hospital from June 1998 to June 2000. Of these, 8 patients had clinical evidence of peripheral ne uropathy (group I), whereas 16 had no sign or symptom of peripheral neuropathy (group II). EMG/ENG examination revealed a polyneuropathy in 7 patients (87 %) among the patients with positive neurological examination. In the group II patients, EMG/ENG revealed subclinical polyneuropathy in 7 subjects (44 %) and was normal in 9 patients (56 %). In total, 14 patients (58 %) with early NSV had electrophysiological signs of neuropathy, most often with the characteristic of symmetric sensory-motor potyneuropathy. This agrees with recent neuropathological findings, but it is at variance with previous neurophysiological reports of a common pattern of mononeuropathy multiplex associated with systemic vasculitis. In our sample the clinical examination showed high specificity (87 %) but poor sensitivity (44 %). In detail, reduction of patellar and knee reflexes

P330

Mononeuritis multiplex caused by Coxiella burnetii infection (Q fever). J. B. Sommer, J. Heckmann, R. Handschu, B. Neund6rfer, M. J. Hilz (Erlangen, D) Q rever is an acute or chronic infectious disease caused by the gram-negatire bacterium Coxiella burnetii. The typical clinical manifestations are a self-limited febrile i11ness, atypical pneumonia, hepatitis, and endocarditis. Neurological complications are rare, and range from meningoencephalitis, cerebellitis, myelopathy, optic neuritis to Guillain Barr› syndrome and Miller Fisher syndrome. This is the first description of mononeuritis multiplex associated with the clinical and serological diagnosis of acute Q rever. A 64-year-old male outpatient, with a history of non-productive cough and rever one week prior to admission, developed rapid progressive motor deficits of his right arm and both legs losing walking ability within two days. Neurological examination revealed multifocal motor and sensory deficits leading to a pattern of mononeuropathy muhiplex affecting the right n. axillaris, right n. musculocutaneus, right n. radialis, left and right n. femoralis, and right n.ischiadicus. Electrophysiological findings showed a slightly prolonged conduction time ofboth nn. femorales to the m. vastus medialis. Distal motor latencies,motor and sensory conduction velocities, motor and sensory amplitudes, and F waves were normal. Needle electromyography of the right m. quadriceps and right m. extensor digitorum communis showed high polyphasic potentials demonstrating reinnervation. Lumbar puncture revealed: cell count 5/mm 3, protein 107 mg/dl, negative oligoclonal bands. Creactive protein was 156 mg/1. Anti-GM 1 antibodies were negative. Chest Xray, electrocardiogram, cervical and thoracic magnet resonance imaging, and motor-evoked potentials were normal. There was no conduction block. Extensive microbiologic and viral blood/CSF studies were negative. However, a highly positive phase li antibody titer to C. burnetii of 1:512 (phase h 1:16) indicated ah acute immunological response to C. burnetii. Three days after initiation of an antibiotic treatment with doxycycline, the patient was able to walk with assistance and recovered completely in the course of the next 10 days. In this patient, clinical and electrodiagnostic fmdings led to the diagnosis of mononeuritis multiplex. The preceding flu-like i11ness could be identified as acute Q rever. In conclusion, C. burnetii infection should be considered in the differential diagnosis of mononeuritis multiplex, especially ir there is an acute febrile illness. P331 Painful Peripheral Neuropathy: Treatment Results of Neuropathic Pain with Gabapentin. M. de Freitas, O.J. Nascimento, M.M.J. Jardim (Niter£ RJ, BR) Neuropathic pain (NP) associated to peripheral nerve damage is commonly seen in neurologic practice. We evaluate the efficacy of gabapentin (GP) in 67 patients with various etiologies of peripheral neuropathy (PN). All patients were previously submitted to other treatments without improvement. Visual Analogic Scale (VAS) of 10 cm (0=no pain; 10 cm=worst possible) was utilized a s a score to estimate the intensity of the NP, before and during 11 months of treatment. GP was prescribed in increasing doses from 800 to 3600 g. Effectiveness was considered when there was a reduction of 50% or more in the VAS basal value. The patients had the following causes of NP: 29 with diabetic neuropathy, 5 with vasculitic mononeuritis multiplex, 4 with postherpetic neuropathy, 6 with painftLl leprous neuropathy, 5 with painful AIDS-related neuropathy, 2 with HTLV-1 associated neuropathy, 5 with familial amyloidotic neuropathy and 11 with painful chronic idiopathic polyneuropathy. The GP dose for the control of the PN ranged from 1200 to 3600 mg/day. Reduction of 50% or more in the VAS basal score was seen in 46 patients (68,6%). In 21 cases (31,%) there was no improvement of their PN with GP alone: out of these, 13 responded do GP in association with amitriptyline. The most common side effects were somnolence and dizziness ( 18 patients), that were transitory in the majority. We concluded that the admnistration of GP alone is effective for the control of NP due to different etiologies of PN.

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P332 The "blue-grey man". A case of amiodarone-related neuropathy and bluegrey skin discoloration. A. RodrŸ Campello, J. Roquer, J. Herraiz, B. Dalama, E. Munteis, J. Izquierdo, V. Puente, A. Pou (Barcelona, E)

P334 Diabetes and chronic inflammatory demyelinating polyneuropathy (CIDP): different patterns of response to immunomodulating treatment. D. Cocito, P. Ciaramitaro, G. Isoardo, A. l:ipieri, l:. Barbero, L. Durelli (Torino, I)

Background: Amiodarone is a highly effective antiarrhythmic drug, but it is associated with adverse effects involving several organs. Neurologic side effects are well known and were reported in 20-40% of patients (tremor, ataxia, dizziness of headache) but peripheral neuropathy is rare. Amiodarone toxicity also gives dermatological side effects a s a blue-grey skin discoloration due to phototoxicity in the sun-exposed areas and in general related with overdose. We describe a patient who developed cutaneous lesions and peripheral neuropathy receiving long-term amiodarone therapy. Clinical Case: A 67-year-old man was admitted with an 8-month history of weakness and paresthesias in lower limbs with mild weakness and gait difficulty to go up the stairs. We observed a spectacular blue-grey skin discoloration in face and arms. He had been taken 600 mg of amiodarone daily during four years because of atrial fibrillation. He also was taking nitrates, dicumarinics and diuretic treatment. Examination showed absent ankle jerks and loss of vibratory sensation in the legs. Blood study including thyroidal function was normal, but he had high serum concentrations of amiodarone. EMG demonstrated reduced amplitude sensory nerve action potentials in the upper limbs and absent sural potentials with mild slowing of the conduction velocity and low amplitude. Sural nerve biopsy revealed demyelination with mild axonal loss and endoneural fibrosis. Improvement was evident 6 months after discontinuing amiodarone. Conclusions: 1. l:resence of blue-grey skin discoloration in patients with clinical peripheral neuropathy allows suspect an amiodarone toxicity. 2. Most of the neurological and dermatological side effects are related to overdose and long-term treatment. 3. Despite the high amiodarone overuse the outcome, after the drug withdrawal, can be favourable.

The finding of predominantly demyelinating polyneuropathies (PN) has been considered unusual in diabetic patients, until recent studies reporting diabetic patients with l:N satisfying electrophysiological criteria for diagnosis of CIDP. It is uncertain if this type of l:N shows similar response to immunomodulating treatment compared to CIDP not associated with diabetes. We evaluated response to high dose intravenous immunoglobulin (IVIg) treatment in 10 diabetic patients with predominantly demyelinating l:N. We included all diabetic patients with demyelinating l:N evaluated in our department from July 1999 to November 2000:13 patients were found to be affected with predominantly demyelinating l:N; 3 of them refused IVIg. The remaining 10 were treated with IVIg at the dose of 0.4 g/kg/day for 5 days. Sensory and motor deficits were evaluated according to a standardised scale and nerve conduction studies (NCS) according to standard techniques before, 1 month and 6 months after IVIg treatment. All patients underwent cerebrospinal fluid (CSF) examination and anti-MAG, anti-sulfatide and anti-GM1 antibody (Ab) assay. Increased CSF protein level was found in 6 patients. No patient was positive for anti-MAG, anti-sulfatide of anti-GM1 Ab. No significant improvement either of clinical deficit or of NCS abnormalities was found at any timepoint after IVIg treatment compared to baseline. However, patients with normal CSF protein level h a d a slightly greater improvement of NCS abnormalities than patients with increased CSF protein level at the evaluation one month after IVIg. A significantly higher tate of relapses was detected in patients with increased CSF protein level than in patients with normal CSF protein level at 6 months from IVIg treatment. Our results confirmed the poor response of diabetic patients with demyelinating l:N to IVlg treatment. The slight improvement detected in some case was short-lasting in patients with increased CSF protein level, while it was stable in patients with normal CSF protein level. This could point to a different pathogenesis of PN in the two groups of patients, l:atients with increased protein level had probably a CIDP which often relapses 30-40 days after IVlg. Patients with normal CSF protein level may have a monophasic PN which may benefit of a single IVIg course. The overaU response to IVIg treatment could be attributed to chronic axonal damage probably due to a concomitant diabetic l:N.

P333 Reactivity to LAN-1 neuroblastoma cells in patients with chronic demyelinating polyneuropathy with or without anti-myelin-associated glycoprotein (MAG) antibody. G. Isoardo, S. Deaglio, E Malavasi, D. Cocito, P. Ciaramitaro, A. Cucci, L. Durelli (Torino, I) Immunostaining of neuroblastoma cell lines by anti-MAG antibody (Ab) has been evaluated only in a small number of patients with demyelinating polyneuropathy associated with anti-MAG Ab (MAG-I:N) but not in chronic inflammatory demyelinating polyneuropathy (CIDP) or in MAG-PN. The aim of this study was to evaluate suitable neuroblastoma cell lines for ah immunofluorescence (IF) screening assay for anti-MAG Ab, Reactivity to neuroblastoma cell lines NB 100, Al:, LAN- 1, IMR-5, SKNSH, TC106, 6647 and SJNKP was evaluated for sera of 10 MAG-PN, 12 CIDP, 1 multifocal motor neuropathy with anti-GM1 Ab, 12 IgM-paraproteinemias and 9 healthy controls by indirect IF and fluorescence activated cell sorting (FACS) analysis. Cells were added to FACS tubes at 200,000 cells/tube and incubated with 50 microliters of p atient sera diluted in FACS buffer up to 1:200 for 40 minutes. Cells were then incubated with rabbit fluorescein isothiocyanate-conjugated goat anti-human IgM diluted 1:20 in FACS buffer. Mean intensity of fluorescence (MIF) was recorded on a logarithmic scale, by scoring at least 10,000 cells/sample; background fluorescence intensity was obtained by incubating cells with goat anti-human IgM alone. Anti-MAG Ab were assayed by EIA in all patients. Categorical data were compared by Fisher's exact test, means by Student t-test. Likelihood ratio of each MIF value for MAG-PN was calculated and MIF threshold for MAG-PN evaluated. Sera of MAG-PN showed a reactivity significantly higher than other groups only towards LAN-1 cells at each dilution. For LAN-1, MIF threshold value for MAG-PN was 10. A significantly greater number of MAG-PN patients than those of other groups had Mil: higher than 10 (9/10 vs 0/34, p < 0.0001). l:revious studies reported discrepancy in reactivity of MAG-PN sera towards different neuroblastoma cell lines. We evaluated reactivity to a large panel of cell lines in a higher number of patients with MAG-l:N than previous studies and compared reactivity to these cells of MAG-PN and CIDl: patients. We found a highly specific reactivity to LAN-1 neuroblastoma cells of MAG-PN and did not find any difference of reactivity to these cells between CIDP and other controls. Discrepancy between our resuhs and previous studies could be due to differences in indirect IF method and evaluation of reactivity by l:ACS analysis.

P335 Frequently Delayed Increase of Anti-Ganglioside Antibodies in Guillain Barr› Syndrome. A. Bersano, M. Carpo, A. Citterio, V. Cosi, G. Nappi, G. Scarlato, E. Nobile-Orazio (Milan, l:avia, I) Anti-ganglioside antibodies have been associated with Guillain-Barr› syndrome (GBS) but their pathogenetic tole remains unclear. In a recent casecontrol study in western Lombardia we tested by ELISA serum antibodies to GM1, GDla, GDlb, GM2, GQlb in 47 acute GBS patients, 39 of whom were retested during recovery, and in 43 neurological and 41 non neurological controls. In that study anti-ganglioside tended to be more frequent in the convalescent than acute GBS phase a difference that was significant for antiGQlb IgG (38% vs 17%, p < 0.05). We now analyzed in these patients the temporal profile of anti ganglioside antibodies during the course of GBS. In 2 patients anti-GM1 antibodies (1 IgA, 1 IgM) decreased and in 2 remained high (1 IgA, 1 IgG) during recovery while in 4 (IgA) they only appeared at that time. Anti-GM2 antibodies decreased in 2 (1 IgG, 1 IgM), remained stable in 3 (IgM) and late appeared in 5 (3 IgM, 2 IgG). Anti-GQlb increased in 3 (IgG), decreased in 5 (IgG) and late appeared in 12 (9 IgG, 2 IgM, 1 both). Overall, antibodies to at least one ganglioside were initially present in 22/47 initially tested GBS patients (47 %) in 15 of whom (68 %) they decreased or remained stable and in 4 increased (18 %),while in 20 of the 39 retested patients (51%) only appeared during recovery. In a consistent proportion of GBS patients antibodies to at least one ganglioside only appeared late in the course of disease suggesting, at least in these patients, a secondary immune response to the neural damage. Moreover our findings suggest that a single and early serological determination of anti-ganglioside antibodies may underestimate the number of positive patients.

l:336 Acute onset of multifocal motor neuropathy. E Deviere, M. Coustans, E. Sartori, S. Drapier, V. Golfier, M. Verin, G. Edan (Rennes, F) We describe a 77 years old man who presented an acute asymmetric motor weakness. In his past medical history, we noticed a l:arkinson disease recently diagnosed treated by levodopa, high blood pressure treated by cloni-

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dine and atenolol. At admission, the neurologic examination ten days after onset of weakness showed proximal weakness of rigbt lower limb and distal dorsal flexion of feet. Diffuse areflexia was found without sensory or cranial nerve deficit. He h a d a moderate akinesia and hypertonia of limb. He dramatically worsened with weakness of proximal and distal upper arms and distal left lower limb. Electrophysiological examination showed proximal motor conduction block in the left median nerve, abolition of F waves of right tibial nerve, reduced motor conduction velocities and distal latencies prolonged (both peroneal and tibial nerve). Prolonged F waves in all nerve studied and desynchronization of right tibial potential were also found. Sensory potential and conduction velocities were normal. EMG examination showed no acute denervation and intermediate motor units firing with polyphasic motor unit potential. Blood tests (haematology, serum biochemistry, inflammatory markers) were normal. Viral (CMV, HIV, EBV,VZV, HCV) and bacterial (campylobacter, borrelia, brucella, syphilis) serological were negative. GM1 antibodies were negative. CSF analysis revealed mild increase of CSF protein (81 mg/dl) without cells. Intravenous immunoglobulins (0.4 g/kg, five days) was started three days after admission. Rapidly clinical improvement was notŸ particularly for upper and distal lower limb. Two months later, clinical examination showed persistent deficit of right proximal lower limb (3/5),partial recovery of upper limb reflexes and left quadricipital reflexes. At electrophysiological examination motor conduction blocks disappeared and F waves reappeared on right tibial nerve. We described a case of an acute asymmetric multifocal pure motor weakness with non-persistent conduction block intravenous immunoglobulins treatment. In this case, there was no argument for vasculitic neuropathy or Guillain Barre syndrome (asymmetric, pure motor, non-axonal neuropathy). The differences with classic multifocal motor neuropathy in our case are an acute onset and non-persistent block afler a good clinical efficacy of immunoglobulin treatment. P337 Hereditary motor and sensory neuropathy associated with cerebellar atrophy (HMSNCA). Clinical, histopathological and genetic study of 2 "lhnisian families. M. Zouari, S. Belal, N. Gouider-Khouja, M. Kefi, G. Fayache-El Euch, R. Amouri, S. Neji, E Hentati (Tunis, TN) We report the dinical features, the nerve biopsy findings and the genetic study of nine patients (5 males and 4 females) with hereditary motor and sensory neuropathy associated to cerebellar atrophy (HMSNCA) and belonging to two Tunisian families. The mean age of onset of the disease is around 5 years. There is an intrafamilial and interfamilial variability in the clinical course and severity of the disease. The predominant clinical features are cerebellar ataxia with dysarthria, distal weakness with areflexia and amyotrophy in upper and lower limbs due to a severe axonal neuropathy, and abnormality of ocular movements (impaired smooth pursuit). The patients ate confined to wheel-chair during the second decade. Brain computed tomography and MRI showed always cerebellar atrophy. The biochemical analysis are normal except for hypoalbuminemia and hyperlipidemia which are frequent. An autosomal recessive inheritance is strongly suggested, because of healthy consanguineous parents and affected siblings in these two families. A genetic linkage analysis with markers spanning different genetic form of ARCA is reporte& P338 Suppression of experimental autoimmune neuritis by Leflunomide. T. Korn, K. Toyka, S. Jung (Wª D) Leflunomide is an immunosuppressive drug which has been shown to impair the cellular nucleoside metabolism by inhibiting the dihydroorotate dehydrogenase, a key enzyme of de-novo pyrimidine synthesis. Furthermore, leflunomide is supposed to suppress tyrosine kinases downstream of interleukin receptors. Recently, the substance has proven to be beneficial in the treatment of rheumatoid arthritis. In experimental autoimmune neuritis (EAN) in Lewis rats, we investigated the suppressive effect of leflunomide in a model of immune-mediated neuropathies. In EAN actively induced by peripheral myelin, leflunomide was able to prevent completely ascending paralysis if applied orally from the day of immunization, and to reduce significantly the severity of the pareses ir administered therapeutically after appearance ofneuropathic signs. Leflunomide proved to be more effective than azathioprine. Along with the massive reduction of neuropathic signs, leflunomide-treated rats did not mount autoantibodies as specified by ELISA with basic peripheral myelin proteins. Clinical observations were supported by the histopathologic findings. Sciatic nerve sections of lefluno-

mide-treated EAN-rats were nearly free of activated macrophages. To further evaluate the pyrimidine depleting effect of leflunomide, an adoptive transfer EAN was generated in Lewis rats which either remained untreated or received leflunomide from the day of transfer of neuritogenic T-cells. In parallel, one group of the leflunomide treated animals was supplied with uridine intraperitoneally on a daily basis to overcome the leflunomide-induced block in pyrimidine synthesis. Uridine could only partially rescue the neuritogeneity of the transferred cells so that the adoptively transferred neuritis was clearly mitigated by leflunomide despite uridine substitution. It can be concluded that leflunomide is unlikely to merely exhibit antiproliferative effects and may be an immunomodulating substance which offers promising treatment options for immune-mediated neuropathies.

Poster session - 2

Cerebrovascular disorders P339 Does the Presence of Diabetes Influence the Course and Outcome of Ischemic Stroke. A. Szczepanska-Szerej, J. Wojczal, E. Belniak, H. KrasinskaCzerlunczakiewicz, Z. Stelmasiak (Lublin, PL) It is well known that diabetes is a risk factor for ischemic stroke but the influence of diabetes on the outcome in the ischemic stroke is, however, not yet clarified. There are some opinions that it is related with a worse prognosis as well as is not associated with an outcome. The aim of this study was to analyse the influence of diabetes on the course and outcome of ischemic stroke. We retrospectively studied serum glucose levels measured at the admission, the presence of infection and seizures on the acute phase of illness, the size, localisation and number of ischemic focus on CT scans, clinical type of Oxfordshire Community Stroke Project (OCSP) classification, duration of hospitalisation, and early (14-day) and in-hospital mortality in 521 patients admitted within 48 hours after the onset of ischemic stroke. The subject was divided into two groups: group I - 111 diabetic patients (21.31%), group II - 410 non-diabetic patients (78.69 %). The patients were defined as diabetics if they h a d a history of diabetes before of stroke and those with newly diagnosed diabetes. Statistical analysis was made using UMann Whitney test, Spearmann rank correlation test and multiple logistic regression analysis. We observed significant difference only in serum glucose levels at the admission: group I - 166,24 + 66.08 mg%, group II - 97.52 -+ 29.80mg% (p < 0.001). Both groups did not differ in any other analysed variables. Our findings suggest that diabetes has no influence the course and outcome of ischemic stroke. P340 Predictive factors for non acute hydrocephalus after subarachnoid haemorrhage (SAH). ]. Wojczal, A. Szczepanska-Szerej, E. Belniak, T. Hasiec, Z. Stelmasiak (Lublin, PL) Background: Non acute hydrocephalus occurs in about 35% patients after SAH. It is very important to diagnose it as early as possible to monitor its course and to apply neurosurgical intervention when necessary. We analyse factors which could eaflier predict its occurrence, such as: age, sex, clinical state by Hunt-Hess classification (HH), Arterial Blood Pressure (ABP), serum sodium (Na), serum glucose (Gluc.) and temperature (Temp.), localisation and number of aneurysm within the circle of Willis. Methods and results: 116 consecutive patients ofboth sexes (male:female 56:60; mean age 48.94 + 11.86 years) admitted to our Department of Neurology within 72 hours after SAH were studied. 32 (28.83 %) patients developed non acute hydrocephalus confirmed by CT scans on different days after SAH. Retrospectively, we examined if such factors as age, sex, ABP on admission (both systolic and diastolic), HH and Na at admission, Gluc. and Temp. within first 3 days after admission, localisation and number of aneurysms in aneurysmal SAH (n=78) influenced the further non acute hydrocephalus development. Patients in 5 group by HH were excluded, because all of them (n=7) died within 7 days after SAH. Statistical analysis was made using multiple logistic regression analysis.

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The best, highly significant predictors of non acute hydrocephalus occurrence were only lowered Na on admission OR=13.88 (95% CI=3.33-57.95) p < 0.001 and higher temperature within first 3 days after admission OR=2.51 (95%C1=1.05-5.98) p < 0,05. Conclusion: SAH patients with lower Na at admission and higher Temp. within first 3 days afler admission should be intensively monitored because they are at high risk of non acute hydrocephalus development. P341 Nuclear syndrome of the oculomotor nerve. I. Bonnaud, 1. Z. Salama (Bobigny, F) Introduction: The nuclear syndrome of the oculomotor nerve was first described in 1981, it is characterized by the association of an ipsilateral third nerve palsy with a paresis of elevation in the contralateral eye. This syndrome is rarely due to ischemic unilateral mesencephalic lesions, and in such cases, oculomotor symptoms are frequently isolated. Case report: We describe 3 patients presenting with a characteristic nuclear syndrome of the third nerve, resulting from a unilateral paramedian ischemic stroke in the upper midbrain, confirmed by magnetic resonance imaging (MRI). Clinical presentation differed in each case, and contralateral disturbances such as hemiparesis, cerebellar ataxia or focal asterixis were associated in various ways with the oculomotor disorders. In the 3 cases, nuclear and fascicular involvement of the third nerve were associated. Conclusion: Nuclear syndrome of ischemic etiology is a rare clinical entity. Variability of the clinical presentation is discussed, regarding frequent anatomical variations of the arterial territories defined in the upper midbrain. P342 Akinetic mutism and probable deep cerebral venous thrombosis. Case report. 1. Midi, N. Afsar, E. Karagoz, S. Aktan (Istanbul, TR) Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with a variety of causes, and that presents with a wide spectrum of clinical signs. Factor V Leiden mutation is a recognized risk factor for CVT as weU as other venous occlusions. We describe a patient who developed akinetic mutism secondary to deep cerebral venous thrombosis and factor V Leiden mutation. Case: A 38-year-old man developed a progressive onset of diminished speech and contact with bis environment 4 weeks before admission. He received the diagnosis of major depression and was treated as such. Ten days later he developed deep venous thrombosis (DVT) of the leg, which was followed by pulmonary embolism despite treatment with low molecular weight heparin. He was put on standard heparin and referred to our dinic for ongoing behavioral symptoms. When observed the patient had no spontaneous activity and was not feeding himself. On examination, he was alert and could obey simple orders. However, lack of initiation, paucity of speech which further deteriorated to lack of speech, and absence of spontaneous movements were evident and compatible with akinetic mutism. His family denied a history of oral and genital ulcers, uveitis, and systemic disease. Cranial MRI showed the presence of bilateral, symmetrical ischemic lesions of the basal ganglia and thalamus suggestive of venous infarcts secondary to deep cerebral venous thrombosis. The patient was found to be heterozygous for factor V Leiden mutation, had no signs of Behcet's disease or systemic vasculitis. Therefore, although CVT could not be demonstrated by angiography, probably due to an ongoing anticoagulant therapy at the tŸ of investigation, the patient was considered to have deep cerebral venous thrombosis in a prothrombotic context. Conclusion: Although quite rare, psychiatric symptoms may appear at onset of CVT. Moreover, in cases of atypical behavioral symptoms associated to venous pathologies in a young patient, the suspicion of cerebral venous thrombosis should be raised. P343 Sleep Apnea as Risk-factor in the Development of lschemic Stroke. E. Bibileishvili, M. Lomia, Sh. Bibileishvili (Winston-Salem, USA; Tbilisi, GEO) It was known that sleep apnea (SA) is a risk-factor of ischemic stroke. However some points about its frequency in patients with cerebrovascular diseases, as well as its pathogenetic meaning in the emergence of ischemic stroke remain unclear. We studied the frequency of SA in 156 patients with ischemic stroke. 23 patients were subjected to polysomnographic investigation of the nocturnal sleep, and 51 patients had their diurnal sleep checked, with 1-2 hrs duration. Other patients had episodic observations. AII the patients had SA of obstructive type. In 23 patients subjected to polysomno-

graphic research of the nocturnal sleep 17 had SA episodes longer than 10 s, but 6-shorter 10 s. During the night sleep 12-16 episodes of SA were registered. In 18 patients SA episodes coincided with REM-sleep stage, but the other 5 cases coincided with stages 3 and 4 of slow wave sleep. In 51 patients subjected to polygraph investigation of diurnal sleep the duration of SA episodes was shorter than 10 s and the diurnal sleep there were 1-2 SA episodes. Out of 91 patients with SA manifestations in 76 cases ischemic focus was localized in the carotid system, in 15 others - in the vertebro-basilar one. During the repeated polysomnographic investigations conducted 3-4 weeks after the development of the stroke the frequency an duration of SA remained the same. 7 patients (among them I woman) developed in poststroke period for the first time SA episodes, and all of them had ischemic focus in the ver tebro-basilar system. Our data show that SA is an essential riskfactor in the development of ischemic stroke, but SA proper probably represents inferiority not only of the brain stem structures but also of the posterior vascularization of the brain. P344 Prognostic value of magnetic double stimulation compared to conventional transcranial brain stimulation in functional recovery after brain infarction. A. Fellgiebel, K. Kindler, O. Meudt, S. Specht, K. Busse, P. Kiel, T. Schmitt, N. Syed, D. Claus (Darmstadt, D) Several studies have shown the prognostic utility of motor evoked potentials in predicting functional recovery after stroke. The conventional single stimulation technique is depending on voluntary contraction of the target muscle( 10 % of maximum strength) by the patient. Due to aphasia, deterioration of consciousness, neglect or initial paralysis after acute cerebral infarction a methodical problem arises for conventional investigation. The magnetic double stimulation technique is not depending on voluntary contraction. The motor response to the test stimulus (interstimulus intervals 10-30 ras) is significant elevated (facilitation). In a prospective study we compared the prognostic value of the two techniques. Methods: Patients with acute brain infarction and hemiparesis or monoparesis (arm) where investigated with conventional transcranial brain stimulation (target muscle Abductor digiti minimi (ADM), healthy and affected side, stimulation 20 % above-threshold) and magnetic double stimulation (target muscle ADM, healthy and affected side, interstimulus interval. 30ms, stimulation 10 % above-threshold). Functional capacity was determined by Barthel Index, the Rankin scale, the NIHSS and muscle strength at the time of the transcranial magnetic brain stimulation and 3 months after the brain infarction. Results: 49 patients where included (mean age 67.9 years, male = 27, female = 22). Mean initial scores and standard deviations (SD) (n = 49): Rankin 4.1 + 0.9; Barthe139.2 _+30.9; NIHSS 9.8 + 6.2; muscle strength ADM 2.1 _+ 2.0. Mean scores and SD after 3 months (n = 31): Rankin 2.9 + 1.8; Barthe165.3 + 40.2; NIHSS 9.7 + 11.1; muscle strength ADM 3.0 _+2.1. Potentials and central motor conduction times of both methods correlated positively (r = 0.9; p = 0.01 ). Patients, from whom no potentials to the affected side could be evoked either with the conventional technique or with double stimulation, hada significantly worse outcome tban the other patients. Discussion: So far the evaluation of the study has come, the prognostic value of both methods is equal. Despite methodological considerations concerning the ability of the patients to cooperate in the investigation magnetic double stimulation seems to have no advantage over the conventional transcranial magnetic stimulation. P345 Apoprotein E, apo A-I and Lp(a): relation to clinicai course and outcome in ischemic stoke. A. Szczudlik, M. Rudzinska, A. Slowik, M. Banach, K. Longawa, A. Dembi¡ (Krakow, PL) Airo of the study was to evaluate a relation between serum Lp(a), apoA-l, apoE levels and phenotype and clinical course and outcome in ischemic stroRe patients. Material and methods: A consecutive 104 patients admitted within 24 hours after stroke onset was enrolled into the study. The following data were collected: patients characteristic, risk factors, clŸ stroRe classification, presumed aetiology, comorbidities, complications, stroke severity as measured by the Scandinavian Stroke Scale (SSS), computer tomography (CT). Outcome measures were Barthel Ind.ex, Rankin Skale and 30 day and 1 year mortality. Patients were followed up every three months fora year or until death. Survival rates were estimated by Kaplan-Meier method. Lp(a), apoAl, apoE serum levels and phenotype were determined on the first day of stroke. Results: 104 patients, mean age 71.9 -+ 10.2 years, were enrolled into the

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study. Patients were subdivided according to clinical stroke classification: TACI (11%), PACI (48%), LACI (31%) or POCI (4%) and having large vesseis disease (46%), small vessels disease (24%) cardioembolic (26%) and undetermined cause stroke aetiology (4 %). No relation was found between lp(a), apoA-l, apoE levels and presumed cause of stroke and CT findings, lncreased Lp(a) level was related to clinical diagnosis of TACI (p < 0.05). No relation was found between Lp(a) levels and stroke severity, stroke outcome and 30-day and 1 year mortality. Patients who had significantly Iower apoA-I had more severe stroke (SSS) on admission, two weeks later and 30 days after stroke, had worse outcome according to Bartbel lndex and mortality (p < 0.05). One year survival rates were better in patients with apoA- I > 1.15 g/l. Apo E levels and phenotype did not influence stroke clinical course, outcome and prognosis. P346 Visual field defects in ret rochiasmatic lesions of the visual pathway. Localization of the site of the lesion in patients with cardiovascular disease. I. Katsimpris, M. Mpoufi, G. Georgopoulos, P. Aggelopoulos, D. Feretis (Pat ras, GR) Purpose: This study aims to describe the clinical picture, the visual field recordings, and the findings of the magnetic resonance imaging of four patients with cardiovascular disease anda sudden-slight decrease in their visual acuity in an effort to localize the site of the lesion and to avoid diagnostic pitfalls Materials and methods: Four patients witb cardiovascular problems complained for slight and sudden blurred vision were referred in our clinic for further investigation. A thorough systemic and ophthalmological examination was done including visual field testing, color fundus photography, and MRI of the brain. Results: All patients showed homonymous hemianopic defects and the brain magnetic resonance imaging disclosed ischemic areas on the surface of the occipital lobes. Conclusions: Sudden vision loss may be attributed to macular lesions, episodes of"amaurosis fugax", or sometimes may be due to ischemic lesions of the retrochiasmatic pathways. Identification of the etiology responsible for retrochiasmal vision loss has been greatly facilitated with the use of magnetic resonance imaging and visual field analysis. Magnetic resonance imaging is now considered the primary imaging study in the retrochiasmatic pathology. P347 Tflt-table-test-ausefultoolforevaluationofautoregulatorycapacityinsevere carotid artery disease. C. Haubrich, A. Klemm, R. Diehl, C. K16tzsch (Aachen, D) The influence of orthostatic manoeuvres on the cerebral perfusion in patients with haemodynamically relevant stenosis or occlusion of the internal carotid artery (ICA) has been rarely studied. The airo of this studywas to monitor the peak flow velocity (PFV) in both middle cerebral arteries (MCA) and the arterial blood pressure (BP) during tilt-table test. The test was applied in 18 patients (13 men, 5 women) with unilateral severe 1CA-stenosis (> 80%) or occlusion documented by colorcoded duplexsonography. Continuous non-invasive BP-measurements of the radial artery were performed with a tonometric device (Colin CPM 7000). PFV measured before head-up tilt ipsilateral to the stenotic or occluded ICA was lower (56 -+ 23cm/s) than contralateral (87 +- 26cm/s) [p < 0.05]. Two minutes after tilting to a 70 degrees head-up position ipsilateral PFV in all patients dropped by 21.6 + 5% which was markedly lower than contralateral 7.7 + 8.5% lp < 0.01 ]. BP levels after the tilt-manoeuvre only decrease around 5 %. The study revealed that severe carotid stenosis and occlusion are able to significantly decrease the autoregulatory response of the cerebral vessels to orthostatic manoeuvres. Larger st udies are needed to estimate if the tilt table test is suitable to selecta subgroup of patients with a critical hemodynamic situation in one hemispbere. P348 P-selectin (CD62), platelet aggregates and platelet micropartides in patients in patients with reversible ischemic neurologic deficit (RIND) and completed stroke (CS). E. Belniak, H. Bartosik-Psujek, I. Wojczal, A. Szczepanska-Szerej, Z. Stelmasiak (Lublin, PL) Using flow cytometry method we evaluated expression of one of the P-selectin (CD62) and platelet microparticles (MP) level as a platelet activation

markers and platelet aggregates (PA) in vivo in patients with reversible ischemic neurologic deficit (RIND) and completed stroke (CS). We investigated 23 patients with RIND (13 men and 10 women in mean age 66.5) and 27 patients with CS (16 men and 11 women in mean age 69). Parameters of platelet activation were measured on the q 3rd and 7th day after stroke onset. Comparisons were made with 20 control patients matched in age. Compared to the controls (1.6 +_0.7%) the patients with CS showed higher expression of CD62 on the l~t (3.1 + 1.6%), 3rd (4.4 + 2.3%) and 7th (3.9 + 2.3%) day after stroke onset (p < 0.05). Increase of CD62 expression between the q and the yd day was also statistically significant (p < 0.05). Compared to the control (11.0 -+ 3.2) patients with CS showed higher MP level on the 3rd ( 13.6 :!: 2.8) day after stroke onset and there were no statisticaHy significant differences in MP level between patients with RIND and patients with CS. No statistically significant differences in PA level were noted neither between the stroke patients and the control group, nor between patients with RIND and patients with CS. Elevated CD62 expression and MP level may indicate platelet activation during the acute phase of ischaemic stroke especially in CS. P349 The markers of inflammation in cerebral ischemia. H. Bartosik-Psujek, E. Belniak, Z. Stelmasiak (Lublin, PL) Recent studies suggest that the inflammatory process may be one of the independent risk factors contributing to the ischemic process. The concentration of some blood proteins increases under the in.fluence of the infectiousinflammatory processes; such blood proteins are called acute phase proteins (APP). Here we find, among other things, C-reactive protein (CRP), fibrinogen (FIB), alpha- 1 antitrypsin (A93 and acidic alpha- 1 glycoprotein (AGP). These proteins are thought to be markers of inflammatory reaction. The study sought to determine whether cerebral ischemia is associated with an inflammatory reaction, indicated by an increase in the levels of the selected proteins of the acute phase. We investigated 30 patients with acute cerebrovascular ischemia, 20 patients with transient ischemic attack (TIA) and 20 patients from control group. Those patients whose history reported acute or chronic inflammatory process, diabetes mellitus, autoimmune diseases or diseases of the liver have been excluded from studies. AII the patients had their levels of CRP, AAT, AGPand fibrinogen in sera of blood determined. There was a single examination in the control group, whereas in the remaining patients after 1, 2, 3 and 7 days of the disease, by kinetic turbidimetry method. If during the examinations the patients reported symptoms of inflammatory process localised outside CNS, they were eliminated from further studies. The findings have been subjected to statistical analysis. In the patients with acute cerebral infarct there is an increase of the leyels of APP, which suggests that ischemic necrosis is associated with inflammatory reaction. It is worth noting that the increase of the proteins under study have a varied dynamism. The CRP level is highest on the third day of observation (3.55 -+6.76 mg/dl),whereas the levels ofAAT and AGP reach the highest values on the seventh day (347.9 - 61.72 mg/dl, 165.9 -+ 67.15 mg/dl; respectively). This may be connected with the properties of the proteins under st udy. The level of fibrinogen in patients with st roke showed a small, statistically insignificant dynamism of changes. Patients with TIA have not reported any increase in the levels of the proteins under study, only the level of fibrinogen was slightly increased on all days of observation.

P350 Risk prediction by combined cytometric platelet function testing and embolus detection in patients with asymptomatic high-grade carotid stenosis. ]. A. Zeller, A. Lenz, C. Fusi, G. Deuschl, P. Zunker (Kiel, D) Background: There is an ongoing debate whether to operate on asymptomatic carotid artery stenoses of 70 % and higher for primary prophylaxis. Methods to identify patients at particular risk for arterial embolism help to find those who benefit most. One approach to risk evaluation in the past has been embolus detection with transcranial Doppler ultrasound. Methods: We started a pilot study in 24 patients with 29 asymptomatic carotid stenoses > = 70 % to gain additional information by flow cytometric platelet activation testing. This method detects the activation-dependent platelet epitope P-Selectin which has been shown to be particularly elevated in patients with stroke of vascular origin. Simultaneously we per formed embolus detection by transcranial Doppler at both middle cerebral arteries to detect high intensity transient signals (HITS) ipsilateral to the stenosis. Blood sampling and 30 minutes of embolus detection were done in each patient at three times during the day, to take possible diurnal changes of platelet activatioo into account. AII patients were on aspirin 100 mg/day, in 8 patients we performed a second testing sequence after 5 days with additional clopidogre175 mg/day.

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Results: No clinical event occurred during the entire testing period and up to 6 weeks later. In 6 patients we were able to detect HITS on the side of stenosis, 4 during morning, 2 during evening testing. In 3 of these patients platelet activation was beyond the 95 th percentile of controls, as opposed to 4 out of 18 remaining patients withont HITS. 5 of the patients in whom HITS were detected completed the second sequence under combination therapy; no HITS were seen at any time in all patients; platelet activation was reduced compared to aspirin alone in 4 of those 5 examinations. Conclusions: Cytometric platelet activation testing seems to be useful to improve risk assessment in patients with asymptomatic carotid stenoses. Sensitivity may be improved by combining additional parameters like platelet reactivity to physiological stimulants or platelet-leukocyte aggregation into a multifactorial analysis. P351 Flow cytometric platelet function testing asa therapy guidance in a patient with thrombocytosis a n d a progressing carotid stenosis. J. A. Zeller, A. AIlardt, G. Deuschl (Kiel, D) Background: There are no unified strategies for medical treatment of symptomatic high-grade carotid artery stenoses. We provide a case example in favour of anti-platelet therapy as opposed to anticoagulation in a case of thrombocytosis and support our thesis by flow cytometric platelet activation measurements. Case: A 57-year old rnale patient presented with ischemic symptoms in the left carotid artery territory. The patient had been premedicated with oral anticoagulants for prior ischaemic strokes of unclear etiology. A carotid ultrasound examination 6 months earlier had been reported to show only minor stenosis. Hematological tests revealed a myelodysplasic syndrome with a hemoglobin of 17 g/l anda platelet count of 523 per ni. Duplex sonography showed an 80 % stenosis of homogenous echo contrast and smooth surface at the left carotid bulb with additional loosely adherent floating material. Despite treatment with intravenous heparin while oral anticoagulation was discontinued, the stenosis progressed within one day and embolus detection at the ipsilateral middle cerebral artery showed 15 high intensity transient signals (HITS) within l0 minutes. To achieve further therapy guidance we performed flow cytometric platelet activation testing with detection of the activation-dependent platelet epitope P-Selectin, a method which has been validated in our laboratory. P-Selectin exposure was highly elevated with 2.83 arbitrary units (mean + standard deviation of controls: 1.30 + 0.18). Therefore lOOmg of aspirin daily were added to the heparin. One day later the PSelectin exposure decreased markedly (1.58), on day 3 it was within normal limits (1.33). On the same day, the carotid stenosis had decreased to approx. 50% with an even surface and without floating appendices, HITS were no longer detected. This state remained stable with no further clinical event through day 14 after heparin had been replaced by clopidogre175 mg per day on day 7, despite the fact that the platelet count had meanwhile risen to > 900 per ni. Conclusions: This case shows: a) the need for awareness of a strongly platelet-related stroke etiology in patients with even "minor" thrombocytosis, b) the usefulness of a muhimodal diagnostic approach including the detection of platelet activation markers while making therapy decisions in those patients and c) the likelihood of aspirin then being superior to anticoagulation asa result of the particular pathogenesis. P352 Risk Factors in Stroke Recurrence. K. Kutluk, V. Ozturk, E Uzunel, 1. Oztura, G. Ergor, G. Yener, G. Demir, B. Yulug (Izmir, TR) Background and purpose: Major risk factors, mainly hypertension, are well known in stroke patients. The purpose of this study is to investigate the proŸ237 of risk factors in the subgroups of stroke patients, and to analyze their sole or combined effects on stroke recurrente. Methods: Retrospective evaluation has been done of 1233 registered stroke patients. While patients were separated into subgroups according to the pathomechanisms of stroke; recurrent stroke was considered asa distinct category. Hypertension, smoking, diabetes mellitus, hyperlipidemia, and other probable vascular risk factors were evaluated in all subgroups. Demographic features and the profile of risk factors in recurrent patients were compared with those in non-recurrent group. Findings: Among 1233 total registered patients, 116 of them were the cases of transient ischemic attacks and not included in the stroke subgroups. A total of 1117 stroke patients were composed of 187 (17%) recurrent and 930 (83 %) non-recurrent cases. The subgroups of non-recurrent patients were atherothromboembolic (57%), lacunar (18%), hemorrhagic (intracerebral, 11%), cardioembolic (8%), and unidentified (6%) strokes. Mean

ages in recurrent and non-recurrent groups were 64.02, and 63.50 years respectively. Since the probability of stroke recurrence could increase by age; patients below and above 55 years were compared in both recurrent and non-recurrent groups. There was no significant difference between the age ratios of two groups (p=0.96). Hypertension was the major risk factor in hemorrhagic, atherothromboembolic, lacunar and recurrent stroke groups, and was a significant predictor for recurrence of stroke(p=0.000). Smoking, diabetes mellitus, and hyperlipidemia were established not to be significant with respect to stroke recurrence. Addition of other risk factors to hypertension did not significantly increase the recurrence. Conclusions: Hypertension alone is a significant risk factor for stroke recurrence. Multiple risks had not additional effects on recurrence. P353 The impact of stroke on central auditory functions and seif-assessment disability. I:. Wael, M. Trandil, K. Enass (Tanta, ET) This study was done on fifty-four patients with stroke, diagnosed both dinically and by imaging techniques (brain CT scan or MRl).They were divided into: 16 with left hemispheric stroke, 14 with right hemispheric stroke, and 24 with vertebrobasilar stroke.This study also included twenty-two healthy subjects as control. Central auditory tests including a dichotic test (SSICCM) and two monotic tests (SSI-ICM & SPlN) were done for all subjects. Auditory brainstem response (ABR) was added for patients with vertebrobasilar stroke. Moreover, Arabic self assessment scale (SAS) was applied for all subjects to study the impact of stroke on subjective disability regarding central auditory skills. Resuhs showed that stroke patients have central auditor}' dysfunction. For dichotic test, cortical lesions showed depressed scores in the ear contra lateral to the lesion, while aphasic patients were more affected than the non-aphasics. On the other hand, monotic tests were affected in the three tested subgroups especially for the SSI-ICM test that showed the lowest score in vertebrobasilar stroke patients. ABR also showed abnormalities in 14 out of 24 patients (58%) in the form of delayed wave V and interweave latency 1-V. Furthermore, self-report subjective disability was detected in the three tested subgroups but was not equal for the different items. The correlation between SAS items and the scores of central auditory tests pointed to the importance of adding the Arabic SAS to the central auditory test battery as well as its value in rehabilitation and monitoring dysfunction in stroke patients. P354

Elevated coagulation factors and the risk for ischemic stroke. J. Berrouschot, J. Mladek, A. Siegemund, H. Voigt, D. Schneider, A. Wagner (Leipzig, D) Background: Elevated levels of coagulation factors are indicators for risk of venous thrombosis. We investigated the association between elevated factor IX and factor XI and ischemic stroke. Methods: We measured the factor IX-level and the factor XI-level (coagulation assay with Pathrombin SL and the corresponding factor deficient plasma at the BCS; Dade Behring) in 393 patients (mean age 64 +- 12 years) with ischemic stroke and in 525 patients (mean age 60 • 13 years) with venous thrombosis and compared these to 119 heahhy blood donors (mean age 55 -+ 11 years). Patients with ischemic stroke were differentiated according to the TOAST classification. Resuhs: The factor IX-level of patients with ischemic stroke (mean 131 • 27 %) was significantly elevated in comparison to the heahhy blood donors (111 _+21%; p=0.000) and in comparison to patients with venous thrombosis ( 106 • 37 %; p=0.000). The relative risk of patients with ischemic stroke was 3.1 (95% CI 1.5-6.7; p=0.02). Patients with atherothrombotic stroke (TOAST h 138 • 30%) had the highest factor IX-levels in comparison to patients with cardioembolic stroke (TOAST lh 126 _+ 25%), lacunar stroke (TOAST IlI: 126 • 27%), stroke of other origin (TOAST IV: 133 • 33%) and stroke of unknown origin (TOAST V: 128 + 24 %). Only in patients with atherothrombotic (TOAST I: 115 • 27%; p < 0.001) ischemic stroke and in patients with venous thrombosis (107 _+ 25%; p=0.03) factor XI-level was significantly elevated in comparison to the control group (102 • 21%). The relative risk of patients with atherothrombotic stroke was 7.5 (95 % CI 3.9-14; p=0.000). Conclusion: An increase of coagulation factors may contribute to higher thrombin generation and thus can finally result in vascular occlusive disease like stroke. Therefore elvated factor IX and factor XI could be seen as risk factors for ischemic stroke especially of atherothrombotic origin.

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Extrapyramidal disorders P355

Hyperhomocystyinemiain parkinsonian patients and methy|enetetrahydrofolate reductase gene polymorphism. K. Czyzewski, M. Styczynska, D. Religa, A. Pfeffer, T. Gabryelewicz, B. Wasiak, E. Luczywek, M. Barcikowska (Warsaw, PL) Significantly elevated serum levels of total homocysteine (tHcy) were found in levodopa treated patients with Parkinson's disease (PD). In population studies, hyperhomocystynemia has been associated with a thermolabile polymorphism in the gene encoding methylenetetrahydrofolate reductase (MTHFR). In present study serum levels tHcy and C677T mutation of MTHFR gene were evaluated in 59 patients with PD. To confirm a possible relationship between MTHFR and tHcy, we determined both: genotyping of homozygous T\T, heterozygous T\C and non-thermolabile homozygous C\C alleles by PCR and tHcy (Abbot Imx analyzer). All patients were treated with levodopa\decarboxylase inhibitor (mean dosage 610 mg.). tHcy ( 16.6 SD 6.4 vs. 13.2 SD 4.2 umol\L) significantly (p < 0,05, Wilcoxson) increased in comparison to controls. The Sperman-rank correlation revealed a significant inverse correlation tHcy with B12 (r=-0.32 p < 0.05). tHcy was not significantly different in patients with C677T mutation of MTHFR gene. We conclude: that in PD under lewodopa treatment MTHFR gene polymorphism and tHcy levels has not to be determined and - vitamin B12 independently influence tHcy. P356 Gait parameters do not correlate with upper limb motor tests in Parkinson's disease. M. Vokaer, N. Abou Azar, D. Zegers de Beyl (Brussels, B) Background: Severa1 studies show the correlations between the scores of clinical scales of Parkinson's disease (PD) and the results of the Finger Tapping Test (FTT), but data on correlation between FTT and gait parameters are rare. Airo: To study the correlations between the Unified Parkinson's Disease Rating Scale (UPDKS) motor score, Hoehn and Yahr score, FTT scores of the dominant hand and gait parameters in PD, in "on" and"off" state. Patients and methods: Patients with PD able to walk 14 meters in "off" state without significant gait freezing were included after informed consent. Patients with evidence of dementia or with pathology other than PD affecting gait or FTT were excluded from the study. Patients were studied afler over night fasting in "off" state and fifty minutes later in "on" state induced by the appropriate oral dose of dispersible L-Dopa. UDPRS motor score, Hoehn and Yahr score, FTT score (in 30 seconds), gait velocity, stride length and gait cadence were measured over a standard walking distance. Results: 14 patients (mean age: 59.9 + 9.7 years) were included. In "off" state the median UPDRS motor score was 38.7 (min: 18; max: 91) and Hoehn and Yahr store was 3 (min: 2; max: 4). Mean FTT score of the dominant hand was 40 + 11.7. Mean gait velocity was 67.9 + 20.5 m/min with a mean stride length of 0.54 _+0.09 m. In "on" state median UDPRS score was 15.0 (min: 2; max: 41 ) and Hoehn and Yahr score 2.2 (min: 0; max: 3). Mean FTT was 54.7 _+14 and mean gait velocity was 101 -+20.2 m/min with a stride length of 0.73 -+ 0.08 m. UPDRS score was correlated with FTT store but not with gait parameters. No correlation was found between FTT and gait velocity or stride length. Conclusion: Ahhough gait velocity and stride length improve significantly when patients switch from "off" to "on", no correlation was found nor with the FTT nor with the UPDRS motor score. This indicates that besides clinical scores simple gait measures like gait velocity and stride length should be included in the evaluation of patients with PD.

P357 Anti-GMl ganglioside antibodies in Parkinson's disease. M. Zappia, L. Crescibene, D.Bosco, G.Arabia,A. Bagalh, L. Bastone, M.Caracciolo, I. Napoli, G. Nicoletti, M. Scornaienchi, A. Quattrone (Catanzaro, Piano Lago (CS), I) High titer serum antibodies to GM1 ganglioside have been reported in various neurological disorders. In Parkinson's disease (PD), controversial results have been reported on this matter and, thus, to determine whether antiGM 1 antibodies are increased or not in PD, we conducted a study in a large group of patients with PD and normal controls. Serum IgM and IgG antiGM1 antibodies were detected by ELISA in 147 patients with PD and in 186 age-matched normal control subjects. Sera were assayed at initial dilution of 1:800 for IgM and 1:200 for IgG and were considered positive at absorbance values exceeding the value of 0.05 for IgM and 0.1 for lgG. Forty patients with PD (27.2 %) had sera positive for IgM anti-GM I antibodies,whereas only five

normal controls (2.7%) resulted positive (p < 0.0001). Most of patients (75 %) with positive sera hada tremor-dominant form of PD. Only two patients with PD (1.4%) and none of normal controls had sera positive for lgG anti-GM1 antibodies. Our data indicate that a consistent portion of patients with PD may have increased circulating IgM anti-GM 1 antibodies. Although the significance of our findings is unclear, since PD is not considered a primarily immune-mediated disease, the detection of such antibodies could be relevant considering the involvement of GM 1 ganglioside in the function of damaged nigrostriatal dopaminergic neurons. P358 Deep brain stimulation of the globus pallidus internus in cervical dystonia and choreoathetosic head movements associated with cervical myelopathy. T.J. Loher, J.M. Burgunder, T. Pohle, S. Weber, I.K. Krauss (Berne, CH; Mannheim, D) Background: Treatment of patients with cervical dystonia (CD) who do not benefit from medical treatment or local botulinum toxin injection is challenging. Pallidotomy has been described to relieve generalized or hemidystonia. Deep brain stimulation (DBS) is an alternative to lesioning. Objective: In this prospective study we have investigated the effect of pallidal DBS for treatment of CD and choreoathetotic head movements. Methods: Eight patients with a history of chronic dystonia were induced. Four patients with pure cervical dystonia were assessed with the modified Toronto Western Spasmodic Torticollis Rating Scale.(TWSTRS). Two patients had marked retrocollis, and two suffered from pronounced lateral and sagittal shifl. Three other patients presented with severe and rapidly progressive cervical myelopathy secondary to the underlying movement disorder. Two of these patients presented with choreoathetosic head movements due to infantile cerebral palsy and one patient had a generalized dystonia. One patient suffered from an unusual phasic type of CD. Targets were defined by stereotactic CT and microelectrode recording. Al1 patients except one underwent simuhaneous bilateral surgery. Results: In all patients dystonia improved with a delay. There were highly significant improvements of the TWSTRS subscores for total severity, pain and functional disability at a mean follow-up of 15 months. There was also a marked amelioration of choreoathetosic head movements which, however, was less dramatic than improvement of CD. At a mean follow-up of 12 months the symptoms secondary to cervical myelopathy were stabilized as compared to preoperatively in those three patients who underwent spinal surgery including multilevel cervical laminectomy and corporectomies. Conclusions: Pallidal DBS is effective in complex CD and it may be used as an adjunct in patients with choreoathetosic head movements who undergo spinal surgery for treatment of cervical myelopathy. P359 Morphological changes senile type in Parkinson's disease and its pre symptomatic stage. A. Krygowska-Wa)s, D. Adamek, J. Kaluza (Cracow, PL) Current hypothesis as to cause of Parkinson's disease (PD) implicate the effects of aging. It has been shown that nigral cell numbers decrease with age in control brain. The purpose of the study was to find to what extent neurodegenerative changes develop in the brains of patients with PD and compare them with the neurodegenerative changes in patients with no clinical symptoms of dementia, parkinsonism and other neurodegenerative diseases. The study was performed on post-mortem brain tissue from 18 patients aged 40-85 (average age: 69). Four of them died with PD and 14 with no known history of parkinsonism and other neurological illness died of various cause. It has been found that neurodegenerative pathology as evaluated using immunohistochemical methods with Mab's against ubiquitin, tau protein alfa synuclein, and beta amyloid, occurs more frequently than the presence of Lewy bodies. It involves neurons of cerebral and cerebellar cortex, basal ganglia, medulla oblongata, in which neurofibrillary tangles, Mab positive materials could be found in the cytoplasm of the cell body and the cell processes (axons) and glial cells. Senile plaques, beta-amyloid positive were frequently noted. Conclusions: In a group of patients without clinical symptoms of Parkinson's disease and dementia Lewy bodies were found in about 28% of cases studied. Morphological changes of senile type were more common. No correlation has been found between the frequency of Lewy body appearance and morphological changes of senile type.

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P360 Cervical myoclonus treated with botulinum toxin. A case report. J. M. Polo, J. Calleja, O. Combarros, C. R. Gonz• Y. Bravo, J. Berciano (Santander, E) Cervical myoclonus has been considered a very infrequent occurrence. We present the case of a patient with segmental myoclonus involving some facial and cervical muscles. A 65-year-old woman was admitted because of paroxysmal cervical involuntary movements, persistent from several weeks before. In a remittent-recurrent pattern, she had suffered from this problem in the four previous decades, its becoming more apparent over periods of several months. At 18 she suffered a left facial palsy with ah apparent complete regression of the deficit, but the patient related the onset of the cervical movement to that paralytic event. This cervical movement consisted of a continuous arrhythmic myoclonus which we mistakenly assigned at the beginning to the left sternocleidomastoid muscle, even ir no head movement was observed. The myoclonus was presentat rest in the primary position but was markedly reduced with neck or jaw movements. Apart from this, a very sligbt ipsilateral hemifacial spasm, never appreciated by the patient,was also present, but facial and cervical movements were asynchronous. Administration of botulinum toxin in the sternocleidomastoid muscle was ineffective and the myoclonus persisted without any change, associated to some tension type left headache. In a reappraisal three months later, clinical and electrophysiological re-evaluation allowed us to localize the muscular jerk in the left omohyoid muscle. This time, botulinum toxin in the peripheral belly of this muscle was followed by almost complete disappearance of the involuntary movement, along with the head pain, the facial spasm remaining stable as this was untreated. Laboratory investigations and magnetic resonance imaging of the brain, cervical spine and upper neck were normal. To the best of our knowledge, no similar association of facial spasm and cervical myoclonus has been described. We have no definite explanation for this last very peculiar involuntary movement, a n d a possible relationship with the ancillary facial nerve injury remains only chronological. In any case, botulinum toxin has proved to be ah adequate treatment. P361 Cooling of hand and forearm muscles improves writing in patients with writer's cramp. C. Pohl, I. Happe, T. Klockgether (Bonn, D) Background: Recent studies suggest that abnormal processing of muscle spindle afferent discharges contributes to the pathogenesis of writer's cramp. Since discharge of muscle spindles is reduced by low temperature, we wondered whether cooling of hand and forearm improves writing performance in patients with writer's cramp. Methods: Writing performance was tested in ten right-handed patients with idiopathic writer's cramp and ten healthy control subjects at room temperature (20-23g ~ and after cooling or warming of hand and forearm muscles in stirred water (temperature 15 g ~ or 44 g ~ Tests were started immediateb; after the cooling/warming procedure and were repeated at 5, 10,15, 20, 25 and 45 minutes. To evaluate writing performance we measured the time needed to write down a German poem. In addition, subjects rated improvement or worsening of their writing ability as compared to baseline. Results: Due to learning, writing time decreased over trials in both patients (p < 0.01) and controls (p < 0.01). Temperature h ad a significant effect on writing time in patients (p < 0.05), but not in controls (p = 0.11 ). Inspec tion of the data showed that cooling reduced writing time in patients but increased it in controls. In the first trial after cooling writing ability deteriorated in aIl control subjects and four patients (p < 0.01). Seven out of ten patients, but none of the controls (p < 0.01 ) reported improved writing abil ity in the subsequent trials after cooling lasting for 29.3 -+ 12.7 min on average. In contrast to cooling, warming did not improve writing ability in any of the patients or controls. Conclusion: Cooling of hand and forearm muscles is a simple, cheap and sale procedure providing temporary relief of writer's cramp in everyday life. It may be an alternative treatment for a subset of patients with writer's cramp. P362 Blepharospasm and Hemifacial Spasm Remission after Acute Myocardial infarction. A. Stern, S. Badarny, S. Honigman (Haifa, IL) Botulinium toxin [BOTOX] is an exotoxin purified from the bacteria clostridium botulinum, causing blockade of neuromuscular junction by blocking exocytosis of acetylcholine vesicles. Local subcutaneous BOTOX treatment is a well known treatment for hemifacial spasm [HFS], blepharospasm and focal dystonia with 80 % improvement. We describe two pa tients of our movement disorder clinic. The first one is a 74 years old male who suffers from blepharospasm and improved with BOTOX treatment. The

second patient is a 83 years old male who suffers from right hemifacial spasm which also improved with BOTOX treatment. Both patients had 90 % improvement which persisted for 2-3 month, and had their next injection after a few weeks of exacerbation each 3-4 month periodically. After 54 months of treatment, both were admitted to a coronary care unir for acute inferior wall myocardial infarction and were treated with heparin, captopril and nitrate. One had streptokinase treatment as well. Both underwent coronary angiography using the same non ionic contrast material, iopromide and one of them hada successful angioplasty during the procedure. The second patient underwent coronary artery bypass graft. One week later, both were sent home in good general condition. Both patients reported that the facial and the eyes spasm disappeared since the acute coronary event and for one year afler that. They did not need BOTOX treatment during this period. When spasms reappeared both patients received BOTOX treatment and in one of them the effect continues until today (18 months). We suggest that the diminution of the spasm fora long time period is related to the drugs received in the hospital, and the possible mechanism will be discussed. P363 Orobuco Lingual Dyskinesia (OBLD) a s a Side Effect of Pyridostigmine. S. Badarny, S. Honigman (Haifa, IL) Tardive dyskinesia (TD) refers to involuntary movements in patients who have been exposed to dopamine receptor antagonists. The most frequent manifestation of TD is Bucco-lingual dyskinesia (OBLD). Other drugs than dopamine receptors antagonist can cause OBLD, like L-Dopa drugs, anticholinergic drugs, phenytoin, antihistamines, tricyclic anti depressants and lithium. We describe a 80 years old female patient with myasthenia gravis who was treated with pyridostigmine 60 mg three times a day. After several months, the patient shows involuntary movements of the mouth, lips and tongue. She was diagnosed as OBLD. She had no history of psychiatric disorders and never use phenothiazines and other drugs that can produce OBLD. Clonazepam 0.5 mg X3/day was prescribed by her family physician, the medicine was stopped after several weeks because lack of benefit. Our patient was admitted to the hospital for exacerbation of myasthenic symptoros and prednisone in a dose of 70 mg/day was prescribed. After a slow tapering she remain in a maintenance dose of 10 mg/alternate. Day. The OBLD continue unchanged. Pyridostigmine treatment was interrupted because of gastrointestinal side effects, and 3 months after that, the OBLD disappeared almost complelely. To our knowledge, pyridostigmine is not included in the drugs list producing OBLD. Probable mechanisms will be discussed a n d a videotape of the patient before and after discontinuing pyridostigmine will be presented. P364 Idiopathic striopallidodentate calcinosis with progressive supranuclear palsy-like symptoms. E. Mu¡ E Valldeoriola, V. GarcŸ Mi. MartŸ E. Tolosa (Barcelona, E) Introduction: Idiopathic bilateral striopallidodentate calcinosis, or Fahr's syndrome (FS), is a neurodegenerative disease associated with cerebellar and parkinsonian signs, choreoathetosis, and behavioural and cognitive manifestations. Objective: To describe 2 patients with FS who presented a progressive supranuclear palsy-like (PSP) clinical picture. Material and methods: Patient 1: A 74-year-old woman was admitted to our Hospital because of a progressive disease characterized by apathy, cognitive impairment and backward falIs that developed in the last two years. Neurological examination disclosed palilalia and echolalia, bilateral grasping and abnormal palmomentonian reflexes, blepharospasm, vertical gaze palsy, retrocollis, marked axial rigidit y, moderate rigidity of the extremities with severe generalized bradykinesia, and gait instability with marked tendency to fall backward. Patient 2: A 50-year-old woman was visited in our department because of a picture of apathy, dysarthria and dysphagia of 6 months of evolution. Neurological examination showed a hypophonic speech, masked face, downward gaze palsy, moderate bradykinesia and rigidity of the arms and neck, choreoatethosis on the bands, bilateral palmomentonian reflexes, and moderate impairment of the postural reflexes. Results: Cranial CT and MRI showed bilateral prominent calcifications of the basal ganglia and dentate nuclei. In addition, patient 2 also showed white matter calcifications and diffuse periventricular hyperintensities in the T2-weighted MRI sequences. Calcium and phosphorus metabolism and parathyroid hormone quantification were normal in both patients. Conclusion: PS may present clinical features indistinguishable from PSP. This fact support the idea that the neuroimaging is indispensable in the diagnosis of PSP.

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General neurology P365 Residual visual motion perception in the hemianopic field: mediated by ipsilaterai visual corlex? S. Bense, E. Marx, T. Stephan, T. Yousry, M. Dieterich, T. Brandt (Munich, D) We report on the 20-year-old mate patient PD who had had ah incomplete right hemispherectomy at the age of 11 because of medically intractable symptomatic generalized epilepsy due to an infarction of the right ACM territory at the age of 2. Complete hemianopia but residual visual motion perception in the hemianopic field were reported following surgery. To correlate brain function and structure, we performed psychophysical studies and functional MRI of visual motion perception. Visual motion perception was tested during stimulation by having the patient fixate one target straight ahead and a second target which began to move (horizontally or vertically, 24~ in the right or left hemifield, 10~ beyond the vertical meridian. In the fMRI experiments, visual motion stimulation was performed using MRI-compatible video glasses. The right or left visual hemifield were darkened from the periphery to 8~ beyond the vertical meridian (represented retinotopically in both hemispheres). A fixation dot was presented straight ahead in the dark part of the field. Pattern motion consisted of random dots that rotated clockwise. Functional images were acquired on a 1.5 T clinical scanner using an EPI sequence and analysed using SPM99. Mean detection times for horizontal and vertical motion of the target were significan@ prolonged: 1.29 - 0.43s for the right and 5.01 +- 2.77s for the hemianopic left visual hemifield (normal subiects 0.81 _+0.3s). In fMRI stimulation of the unaffected, left hemisphere led tu an activation of the primary visual cortex (BA 17/18/19) and adjacent parieto-occipital areas (precuneus/cuneus, BA 19/7), supramarginal/inferior parietal gyrus (BA40) as well as the middle occipital gyrus iBA I9137),representing the motion-sensi•ive area MT/V5. Stimulation in the hemianopic field also led to ah activation of the lefl parieto-occipital cortex (precuneus/cuneus, BA 19/7), but the extent of this activation was less than that during stimulation of the unaffected hemisphere. Further activations were seen in the left lingual (BA18/19), supramarginal/inferior parietal (BA40), and middle temporal gyrus (BA 19). Significant activations were found neither in the residual primary visual cortex of the right hemisphere nor in the motion-sensitive parts of the middle occipital gyrus of the left hemisphere. Psychophysical and fMRI data for this patient suggest that residual visual motion perception in the hemianopic field is mediated by the unaffected ipsilateral hemisphere. P366 L-2-hydroxyglntaric aciduria with atypical nenroradiological abnormalities. M. Seijo-Martinez, M. Castro del Rio, O. Vila, M. Puig, A. Ribes, I. Araquistain (Pontevedra, Vigo, Barcelona, E) Introduction: L-2-ttydroxyglutaric aciduria is a recently describe& rare, neurometabolic disease with characteristic manifestations and elevated concentrations of L-2-Hydroxyglutaric acid in the cerebrospinal fluid (CSF), serum, and urine. Less than 30 patients with this disorder have been described in the world literature and this is the first reported Spanish case. AIthough the neuroradiological signs are considered diagnostic, this case presents atypical findings. Case report: A 15 year-old patient was evaluated for a well-controlled epileptic syndrome. A slight psychomotor delay was evident in the first few months of life and he presented a generalized seizure at the age 18 months. At the age of 18-24 months, his gait worsr with appendicttlar clumsiness, language regression, and progressive intellectual deterioration. At the age of 15 years he presents severe mental retardation, dysphasia, and pseudobulbar signs, optic atrophy, strabismus, hypoacusis, spastic tetraparesis, and choreo-dystonia in upper limbs. Brain neuroimaging with computed tomography and magnetic resonance scanning showed generalized atrophy, atrophy of the corpus callosum, extensive T2 and proton density white matter hyperintense signals without cerebellar nor thalamic lesions. Highly elevated levels of L-2-Hydroglutaric acid were present in the CSF, serum, and urine. An extensive study excluded other leukodystrophies and metabolic disorders. Auditory and somatosensory evoked potentials were abnormal. A muscle biopsy was normal. Conclusions: This patient was diagnosed on the basis of highly elevated levels of L-2-Hydroxyglutaric acid in urine, plasma and CSE Ahhough neuroimaging studies are considered highly stereotyped and suggestive of the diagnosis, this patient showed highly atypical findings: corpus callosum atrophy, and absence of cerebellar and thalamic abnormalities. We believe this disease is underdiagnosed and should be considered in all cases of progressive mental dysfunction, seizures and ataxia.

P367 Lumbar spinal canal stenosis: correlation between radiological and electrophysiological data. S. Vohanka, B. Adamova, I. Bednarik, Z. Kadanka, L. Dusek (Brno, CZ) There is a general agreement that polyradicular axonal lesion is a typical electrophysiological finding among patients with lumbar spinal stenosis. But no data are available about the relationship between severity of the stenosis and abnormal electrophysiological data. To assess the relationship between electrophysiological parameters and radiological severity of the lumbar spinal stenosis, electrodiagnostic, and imaging data in 85 patients with narrow lumbar spinal canal were evaluated prospectively. 37 men and 48 women were enrolled in the study. Mean age of the whole group was 62.8 years (range 21-90), mean duration of the disease 19 years (1-61). Fifly persons had neurogenic claudication in the history, mean Oswestry disability index was 45 %. AII patients were given an axial CT scan and the sagittal and transversal diameters of the lumbar canal were measured. 18 patients had one-level central stenosis, 48 had two-level, and 19 three-level. EMG examination (motor and sensory conduction study including peroneal and tibial nerve F wave, soleus H reflex, needle EMG), motor evoked potentials by means of magnetic stimulation, and tibial nerve somatosensory evoked potentials were evaluated in all patients and compared with radiological data. No statistically significant difference was found among the number of levels of the stenosis or cumulative stenosis index (sum of the transversat and sagittal diameter of the lumbar canal at L3, L4 and L5 level) and presence of the radiculopathy by needle examination (Chi-square test). A significant relationship was found between cumulative quantitative store and latencies of the peroneal and tibial nerve F waves and soleus H reflex. The same pattern was detected in latencies of the motor and tibial nerve somatosensory evoked potentials (Spearman rank order correlation; p < 0.05). On the other hand, Iatencies of the conduction studies, motor and somatosensory evoked potentials were not significantly influenced by the number of stenotic levels (Mann-Whitney tests). It was shown that conduction studies, particularly motor and somatosensory evoked potentials, could be more sensitive tests, reflecting chronic root compression in a narrow lumbar spinal canal, than needle EMG. The number of the stenotic levels does not influence the frequency and severity of the expected electrophysiological abnormalities. Supported by the Internal Grant Agency of the Ministry of Health of the Czech Republic Grant No NF/5938-3. P368 Association ofmyasthenia gravis, Hashimoto'sthyroiditisand phaeochromocytoma:firstcase. M. Coustans, E Sauleau, C. Derrien, G. Sost, S. Drapie~ E. Sartori, G. Edan(Rennes, F) We reporta case of a 54-year-old man presenting an association of myasthenia gravis, Hashimoto's thyroiditis and phaeochromocytoma. In 1998, he presented symptoms (fatigue, nausea, weight loss) that revealed bilateral phaeochromocytoma in. He was successful operated (bilateral surrenalectomy), then hydrocortisone and fludrocortisone was initiated. Histochemical study confirmed bilateral malignant phaeochromocytoma. In September 1999, he presented lipothymia, fatigue and the diagnosis of hypothyroidism in relation with Hashimoto's thyroiditis was established (thyroid function tests and positive TPO-antibody). In October 1999 levothyroxine treatment was started. In November 1999 he complained of diffuse weakness and in December a ptosis and dysar thria appeared in the evening each days. The diagnosis of myasthenia gravis was confirmed by clinical examination (fatigability, fluctuate dysarthria and bilateral ptosis) and by neostigmine test. Anti-acetylcholine receptor was negative, thorax CT scan was normal. The electrophysiological study revealed a significant decremental response (15%) on repetitive stimulation, lnitially abenonium chloride (Mytelase| shown efficacy but three months after he was admitted in our hospital because of worsened weakness, bilateral ptosis. Intravenous immunoglobulins resumed symptoms, but two months later he relapsed and intravenous immunoglobulins treatment was repeated. He was operated for a thymectomy in June 2000 (moderate hyperplasia) and azathioprine was associated with abenonium chloride in July 2000. It is well know that myasthenia gravis may occur with autoimmune thyroid disease, but in our knowledge this is only the fifth case associating myasthenia gravis and phaeochromocytoma and the first case of this three association.

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P369 Attentive Cortico-subcortical Dysfunction in Behqet Disease. R. Monastero, G. Lopez, M. Mannino, C. PipŸ C. Camarda, F. Clccia, R. Camarda, G. Triolo (Palermo, I) Introduction: To investigate attentive functions in patients affected with Beh(;et Disease (BD). To evaluate the influence on cognitive performance of currenl or past clinically overt central nervous system involvement, disease activily, corticosteroid use, HLA-B51 allele, and anxiety and depression ]eve]s. Background: Recent data showed in 8D patients some degree of cognitive impairment, involving mainly memory and attent[ve functions (Akman Demir et al., I Neurol 1998). Methods: Eighteen BD patients fulfilling the criteria of the International Study Group for Behget Disease (Lancet 1990) and 18 heahhy controls, matched for age, gender and education were included in the study. Disease activity was assessed using the Behqet Current Activity Index (BCAI Bhakta et al., Rheumatol 1999). The current daily dosage of prednisone (mg/day) was recorded. Patients underwent to four subtests of the Italian version of the Testbatterie zur Aufmerksamkeitsprufung (TAP), a computerised battery for the assessment of attentive functions. Subtests used were Divided Attention, Go/No Go (two tasks related anatomically to the frontotemporal cortical connections) and Alert and 15 min Visual Vigilance (two tests related topographically to the brainstem). For each tasks the mean of the reaction time latencies and the mean number of correct responses were recolded. Resu]ts: Significant differences in test performances between groups were found in a~~tasks administrated (p from 0.05 to O.00l ). The presente of current of past clinically overt central nervous system involvement, current steroid medication, disease activity, HLA-B51, cou[d not account for these findings (p > 0.10). Conclusion: Our results suggest that a cortico-subcortical attentive dysfunction exists in BD patients. A multiple etiopathogenesis probably justify these findings. P370 Brief painful episodes of dystonic posture of one upper limb in a patient with a lesion of the cervical spinal cord. C. Potagas, A. Tavernarakis, A. Anastasopoulou, C. Chondronikola, E. Koutra (Athens, GR) We describe the case of a 50-year-old man with mild paresis and deep hypoesthesia of the right limbs on the ground of a myelitic lesion in the cervica] spina] cord (Magnetic Resonance Imaging), who presented repetitive, brief episodes of paiafu~ dys:onic pos:ure of :he upper righ: i~mb. No particular condition seemed to trigger these episodes. Frequency of the episodes increased continuously for several days and k until they completely disappeared immediately after administration of phenytoin. We review the literature and discuss the possible pathophysiological mechanisms of this type of focal dystonia. P371 Rythmic myoclonus and hypertrophy of the left quadriceps revealing a spinal dysraphism. N. Gouider-Khouja, S. Belal, S. Gabsi-Gherairi, M. Ben Hamida, E Hentati (Tunis, TN) The authors report a 21 year old patient with myoclonus of the left quadriceps since the age of 14. The continuous activity of the lefl lower limb musdes led to a striking hypertrophy of this limb. Examination showed rythmic myoc]onus of the ]eft quadriceps, abolished 'eff ank2e refiex, and hypertrophy el the Iefi tklgk. Sp!:a: MR: s2n~_,wed a spinal dysraphism with diplomyelia. Muscle biopsy of the [eft quadriceps of the patient was compared to the biopsy of a normal control. The authors discuss the etiologies of periphera[ myoc[onus, the implication of the spinal dysraphism in the genesis of myoclonus and the mechanism of the muscle hypertrophy P372 Caloric stimulation in patients with bilateral vestibular failure (a PET study). S. Bense, A. Deutschliinder, T. Stephan, M. Schwaiger, T. Brandt, M. Dietet ich (Munich, D) In an earlier PET study we showed that caloric irrigation in healthy volunteers e]icits bilateral activation of the vestibudar cortex (posterior insula and retroinsular regions), adjacent middle and superior temporal gyri, the dorso]ateral ~halamus, anterior and posterior cingulate gyri and ocular motor arcas, as we'.l a s a k:'gkly slgni~can: deac:!va:ion of ,'he s:r.:a:e vls=a] ccr:ex

(Wenzel et al. 1996). The aim of this study was to determine, how vestibular failure affects the activation-deactivation pattern in patients with bilateral vestibular failure (BVF) (Baloh 1989). Loss of vestibular function was due to autoimmunological disease or ototoxic medication, which damaged the vestibular hair cells. Nine right-handed patients with BVF were examined using a 0-15 water-bolus PET. Nystagmus after caloric irrigation of the ears and postrotationally was significantly reduced. There were three stimu]ation conditions: caloric irrigalion of the right (A) or left ear (B) with water at 44~ and the rest condition (C), which was performed without ca]oric slimu]alion, oyes c:osed. Differeuces betwee~ con:ro] and activation images were expressed as statistica[ parametric maps using SPM99 (p < 0.001, uncorrected). The group analysis of healthy subjects vs. patients (contrast A vs. C) revealed significantly more activation of the posterior insula, the inferior parietal gyrus (BA40),the anterioiŸcingulate gyrus, the precuneus (BA7) and the middle frontal gyrus (BA46/9) (two-sample t-test) in the healthy subjects. The deactivation pattern (contrast C vs. A) for the patients was changed in that deactivation was not seen in the primary visual cortex but was seen in the precuneus (BAT). The healthy volunteers showed significantly more deactivation in the primary visual cortex (BA17/18) and the middle temporal gyrus (BA21) than the patients did. The activation-deactivation patterns found in healthy volunteers and patients with BVF differ significantly. In the patients: 1. activations of vestibular cor tex areas were significantly reduced, 2. no further cortical arcas were activated (cingu]ate gyrus, ocular motor arcas), and 3. ah inhibitory interaction with the primary visua] cortex was absent. 7h=s, the ~nkibitory reciproca~ :nodo el in'erac:ion be:weea visua: and vest[bu[ar systems is not developed due to reduced vestibutar input. P373 Somatosensory Evoked Potentials In Prognosis Of lschemic Stroke. K. Bozic, S. Gvozdenovic, G. Misic-Pavkov, K. Gebauer, L Divjak, M. Zarkov, S. Knezevic (Novi Sad, YU) The purpose of this study was to evaluate median nerve short latency somatosensory evoked potentials (SEPs) as prognostic indicators of functional outcome after cerebral infarction. SEPs were performed on 40 first-ever stroke patients of the carotid artery supply (ACI) in the period immediately following stroke (in the first 72 h). Functional status was measured following a five-level scale 6 weeks after the appearance of ischemic symptoms. SEPs were described as abnormal in the casos demonstrating conduetion de]ays or intelhemispheric asymmetries of amp]itude and peak presence. Res=~ts: SE? End:'ngs zorrera:cal w!tk the grade of fcxc:!o=a: ou:come (p < 0.05). The grado of SEP abnormality determined by interhemispheric comparison of the cortical responses morphology (peak presente) significantly correlated with grade of functional outcome (r= -0.55; p < 0.001 ). Patients with normal initial SEP findings and no asymmetry in the morphology, achieved significantly better functional recovery. Patients with no responses showed poor performance in functional tests 6 weeks after the stroke onset. Patients with incomplete responses had functional scores intermediate between those of the other two groups. Conclusion: Early registration of SEP is predictive for early functional outcome in stroke patients. The observation of normal of incomplete SEPs in the acute phase of stroke identifies a group of patients with a high probability of functional recovery. The absence of responses to sensory stimulation in the acute phase identifies a group of patients who are at high risk of poor functiona] recovery at 6 weeks. P374 Posttraumatic Headache - Neurophysiology Estimatioa Of Cognitive Disturbance. G. Misic-Pavkov, K. Bozic, K. Gebauer, Z. Novovir (Novi Sad, YU) The purpose of this study is to indirectly establish the existente of posttraumatic headache (PTH) in patients with brain injury by neurophysiology and psychology evaluation of cognitive disturbance. The degree of disturbance is inversely proportional to PTH as subjective complaint, while PTH is the most and the only pain symptom in severe brain injuries. The study covers 72 patients suffering from PTH for approximately 30 months after brain injury. The battery of psychology tests was applied (Benton, Wisconsin, and Wechsler-Bellevue) and cognitive evoked potential P-300 (odd-bal] paradigm). The results points to PTH, in patients with mild and withoul any cognitive disturbance, as the most frequent complaint that highly correlates with memory deficit (r=0.282 p < 0.05), concentration disorders (r=0.273 p < 0.05) and vegetativo disorders (r=0.447 p < 0.01). The most severo pain occurs i'n headackes w!tk occ!?:",a! !oca!;,za:!or~ ~r=0.326 ? < 0.0!). Patien:s

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with severe cognitive deficit complain very rarely to post traumatic headache. The patients in this group show aggressiveness accompanied witb memory deficit detected by all applied psychology tests and lower amplit ude and prolonged latency of cognitive evoked potential statistically significant (p < 0,01). The latency of evoked potential show more sensitivity compared to amplitude as lar as estimation of severity of cognitive disturbance is concerned. Neurophysiology and psychology evaluation of cognitive disturbance are indirect methods for detecting of posttraumatic headache. P375 Evidente for a violation of the principle of invariance of the privileged direction of maximal peak EMG in a cerebellar patient. M. Manto (Bruxelles, B) Spatial tuning of motor activity is a critical phenomenon for the central nervous system. Considering reaching movements, the primary motor cortex is the area which has been the most extensively investigated for the directional control of movement. Spatial tuning of EMG activities during reaching movements in the vertical plane was analysed in 7 healthy subjects (mean age: 65; range: 39-77; 2 women) and in a 33-year-old patient presenting a cerebellar syndrome associated with gluten ataxia. Neurological examination showed dysmetria of saccades, a slight scanning speech, dysmetria in 4 limbs a n d a broad-based ataxic gait. Sensory examination was normal and plantar reflexes were fexor. Needle EMG, sensory and motor nerve conduction velocities were normal. Brain MRI revealed a mild degree of cerebe93 atrophy. Pointing movements towards fixed targets in the sagittal plane were recorded. A subtraction procedure to isolate the phasic aspects of the EMG signal was applied. Peak EMG activities were extracted from phasic EMG activity for the brachioradialis, biceps, medial and long head of triceps, anterior deltoid, posterior deltoid, latissimus dorsi. Spatial tuning curves in the healthy subjects showed that the maximal peak IiMG (M Peak EMG) was always found in the same direction of movement, a principle called the invariance of the privileged direction of the M Peak EMG. In the patient, mistakes in the programming of the selection of the direction of M peak EMG wereŸ in 5 of the 7 muscles. Mean path ratios varied from 148.5 -+ 5.1 to 166.4 + 7.3 (control group: 110.3 _+3.6 to 114.6 + 2.8). This case illustrates that the cerebellum plays a role in the directional control of movement, possibly by encoding the direction of M peak EMG. Cerebellum might generate a neural signal which is a transformation of a vector computation which takes into account centripetal forces, inertial forces, Coriolis forces and the gravity. P376 Devic's neuromyelitis optica: Clinical, laboratory, MRI and outcome profile of 13 cases. J. de Seze, C. Montagne, T. Stojkovic, D. Ferriby, F. Mounier-Vehier, A. Verier, J. Pruvo, ]. Hache, 17.Vermersch (Lille, Lens Cedex, Valenciennes, F) Introduction: Devic's Neuromyelitis optica (NMO) associates optic neuritis and myelitis without other neurological signs. Some patients with NMO can be diagnosed as multiple sclerosis (MS) as optic neuritis and myelitis are inaugural symptoms in respectively 20 % and 5 % of MS cases. Recently, new diagnostic criteria have been proposed for NMO (Wingerchuck et al., 1999). Airo of the study: To compare a new NMO cohort with the recent studies (O'Riordan et al., 1996, Wingerchuck et al., 1999). Methods: We retrospectively studied 13 patients with a whole diagnostic work up for NMO, corresponding to the new diagnostic criteria. We compared our data with the most recent studies on NMO. We also observed whether these patients could be diagnosed as MS. Results: Thirteen patients (I0 women and 3 men, with a mean age of 37.4) were included in the study. We found similar resu[ts compared with previous published data excepted for the association with a vasculitis observed in 38% ofour cases. Al1 patiems had the clinical criteria for MS and 3 patients had clinical and MRI criteria for MS. t-[owever, ir we applied more restrictive criteria concerning spinal cord and brain MRI and cerebrospinal fluid, none of our NMO patients corresponded to MS diagnosis. Discussion: NMO should be differenciated from MS with the application of more stringent criteria. Furthermore, vasculitis should be considered in all NMO syndrome even without past history of systemic manifestation. P377 The research of botu93 toxin A in the treatment of hemifacial spasm and the dosage of reinjection. Cf. Liu (Suzhou, PR China) Objectives The present study was carried out on the effect of botulinum toxin A treatment of bemifacial spasm and that of the two dosage in repeti-

tive injection. Methods One hundred and fifly-nine patients aged 56.4 years, had been suffering for 0.5-20 years with hemifacial spasm. Each position was injected 2.5 U toxin A,and every patient received an average of 28 + t0 U. The recrudescence patients received two doses of toxic A,2.5 U and 5 U. Results In all cases hemifacial spasm was abolished or markedly reduce& A total of 84% of patients had complete improvement Average duration of improvement lasted about 1916 weeks after the initial treatment. The duration of improvement lasted longer in the 5 U group than in the 2.5 U group. There was no change in the duration of effect over time with repeated treatments Local side effects were mild and transient Conclusion Botulinum toxin is an effective treatment for hemifacial spasm, This effect did not diminish with repeated injections. P378 Effects of balance training performed with conventional exercises or continuous displacements of a supporting platform in patients complaining dizziness. A. Nardone, S. Corna, M. Galante, A. Prestinari, M. Schieppati (Veruno (Novara), Vercelli, Pavia, I) We compared effectiveness of two balance trainings performed in patients complaining dizziness with unremarkable neurological and vestibular examination. Training was performed either with conventional exercises (e. g. standing and walking with and without vision on a foam mattress, withstanding pushes induced by the physical therapist) (E, n=7) of instrumental training (I, n=£ consisting in standing upright with eyes open (EO) and with eyes closed (EC) during periodical motion of the plafform delivered at 0.2 and 0.6 ~[z frequency. For both groups, each training session ',asted about 20 min, twice a day for ten days. The following assessments were performed both prior to and after end of training: Tinetti clinical evaluation of balance and gait; body sway area recording during quiet stance with EO or EC and self-evaluation of stability through subjective scoring; stereometric recording of anterior-posterior displacement of LEDs fixed on hip and head while standing on the periodically moving platform. ANOVA showed that evaluation of balance and gait improved significantly in both E and I groups. Both groups showed a significant decrease in sway area a n d a subjective feeling of increased steadiness, lmprovement in counteracting the platform periodical displacement was also present: the most demanding task (0.6 Hz, EC) led to stepping in all patients before treatment, but was successfully performed by 100% and 71% of the patients, respectively in I and E group, after training. Improvement was not connected to an increased stabilisation of hip in space but to a reduced displacement of head. In I group, this phenomenon was accompanied by a reduction of coupling between platform and head movements. Results show that i and E produce both subjective and objective improvement of balance in dizzy patients. The finding of decrease in head displacement in spite of negligible changes in hip movements suggests that both types of training increase balance by improving the ability to stabilise upper body segments and decouple them from lower segments. Visual and vestibular receptors, due to their location in the skull, might playa role in this 'top-down' balance improvements. The slightly better outcome of I than E during plafform perturbations points to improved performance of the specific task exercised during t raining. Finally, the above tests prove useful tools fnr assessing and monitoring improvements of balance and feeling of stability in dizzy patients. P379 Clinical and methodological checklist for neurological review articles. M. G. Celani, T. A. Cantisani, C. Cusi, G. Filippini, L. Munari, C. Taus, L. Candelise (Milano, I) Reviews ate a practical means of obtaining a summary and analysis of the huge amount of papers published in medical journals a n d a useful tool to improve clinical work. Of its many advantages, a review can: provide a global view of the management of a specific disease, supply the best possible evidence of intervention efficacy by combining trials, offer a useful source of interesting papers in its references, generate new search hypotheses. A different level of reader knowledge o r a biased review may lead to differing interpretations of the same review. The present study is carried out to identify a reliable method to assess the methodological and informative quality of neurological reviews, to evaluate the degree of agreement between different categories of neurologists, to compare the value of the clinical section to the methodological section of a checklist. Two pairs of neuro93 with different proŸ experience (consuhants and epidemiologists),working in a different environment, have assessed 40 reviews, chosen randomly, from the "data base of Neurological Reviews" set up by the Cochrane Neurologic Network.. Each reader, without rcceiving t raining, independently lilled in a standardised checklist, that !s di-

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vided in two parts: i) methodological quality section, according to Oxman and Guyatt, that includes nine specific items and one overall evaluation ii) informative clinical quality section, that includes seven items and one overall evaluation. Both overall evaluations are done using a seven-point scale, subsequently dichotomised in two levels (good-5, 6, 7/poor=l, 2, 3, 4). The items were analysed either by the proportion of potential inter-judge agreement beyond the change (K index) and its 95 % confidence limits (CI) or by the percentage of agreement between the two readers with its CI, depending on the response required. Accuracy, sensitivity, specificity and their 95 % CI of clinical section were calculated using methodological section as "gold standard". The level of agreement between consultants and the epidemiologists is similar for the for most of the items. Tbere is a good inter-judge agreement when the methodological quality of a review article is assessed. Those items showing poor agreement may point to the need for improvement in the actual reporting of reviews. The ninety percent of neurological review articles with a good overall clinical quality evaluation has also a good overall methodological quality evaluation (high sensitivity), while the 72 % that has a poor overall clinical quality, has a poor methodological quality (moderate specificity). We conclude that if a review has a good methodological quality, important clinical information may be detected anyway. On the other hand, the informative value cotild be present even if the methodological quality is poor.

P380 Paraneoplastic encephalomyeloneuritis with predominant neurotologic and dorsal column damage. S. Simonetti, U. Ruffinengo, M. Pagano ( Genova, I). A heavy-smoker 65-year-old man experienced sudden hearing loss, vertigo and diplopia which were rapidly followed by diffuse weakness. Thirty days later, a neurological examination showed severe bilateral hearing loss, bilateral third and left sixth cranial nerve paresis, flaccid tetraparesis, and absent vibration sense. Lumbar puncture revealed a CSF increased protein content anda slight mononuclear pleocytosis. A cranial MRI was normal. Audiometry showed a profound bilateral sensorineural hearing loss. Chest x-ray showed a slight left hilar thickening but a CT scan was not performed. Intravenous immunoglobulin and steroids were administered. Weakness and diplopia resolved in four months. Six months later, our evaluation revealed severe hearing loss and ataxia, absent vibration and position sense, and areflexia. Segmental force as well as pin-prick and thermal sensation were normal. Median nerve somatosensory evoked potentials showed anda bilateral in crease of N13 and N20 latencies with normal central conduction times. No responses were obtained at brainstem auditory evoked potentials. Motor evoked potentials were normal. EMG showed mild neurogenic signs with reinnervation. Motor and sensory nerve conduction studies were normal. Audiometric evaluation was unchanged. Vestibular tests showed a complex positional nystagmus and no responses to caloric stimulation on both sides. Cervical MRI showed increased T2 signal in the posterior spine. A chest CT scan revealed a large lesion of the left lung upper lobe and biopsy was consistent with a non-small cell cancer. Serum CEA and NSE were increased. No serum anti-Hu, anti-Yo, and anti-Ri antibodies were found. Antibodies to GQlb were increased. Chemotherapy was ineffective and the patient died 20 months later. Encephalomyelitis is the most frequent neurologic paraneoplastic syndrome and is commonly associated with small cell lung carcinoma and anti-Hu antibodies. Its most common clinical manifestation is subacute sensory neuronopathy reflecting involvement of the dorsal root ganglia. Paraneoplastic disorders of the audio-vestibular system are rare.We reporta patient with a non-small cell lung carcinoma and no anti-Hu antibodies who presented an acute encephalomyeloneuritis severely affecting the audio-vestibular system and proprioception. In this patient neurophysiologicat and MRI studies indicated a damage of the spinal dorsal columns possibly responsible of the permanent deep sensation loss.

P381 Neuropsychological, neuropsychiatric and PET findings in proximal myotonic myopathy. V. Sansone, D. Perani, M. Cotelli, S. Cappa, S. Scarone, C. Dragoni, G. Meola Background: Previous neuropsychological and neuropsychiatric studies have suggested an executive dysfunction profile with a visuospatial impairment in patients with proximal myotonic myopathy (PROMM) and in patients with myotonic dystrophy type 1 (DM1). Airo: To examine the relationship of regional brain metabolism to cognitive and behavioural impairment in patients with PROMM compared to DM1. 9 Methods: 15 patients with 3q-linked and unlinked PROMM, 20 patients with moderately severe DM1 and 20 age, sex-and education-matched con-

trols were subjected to: Cognitive measures: Computerized Attentional Assessment, TEA; Wisconsin Card Sorting Test, WCST; Stroop Test, ST; Trail Making Test A and B, TMT and: Tower of London Test, TLT, computerised version. Behavioural test measures: SCID-II personality scale, self-administered anxiety and depression scales, neuropsychiatric interview. Results: None of our patients fulfilled DSM-IV criteria for axis I and II disorders. However, patients with PROMM and DM1 showed significant avoidance, dependent, obsessive-compulsive and passive-aggressive behavioural trait clustering (p < 0.05). Basic attentional and alertness functions (TEA, TMT) were normal in both PROMM and DM1 patients. Cognitive strategies and visual-spatial decisions (WCST, ST, TLT) were significantly impaired in patients with PROMM and DM 1 (p < 0.001). Conclusions: Our data confirm a selective impairment in cognitive strategies for sequential visual-spatial decisions in PROMM and DM1. We also suggest unique personality traits in both groups which cannot be accounted for by depression or anxiety. Ongoing PET studies of cortical and subcortical neurotransmitter activity will confirm or refute the hypothesis of a relationship between visual-spatial impairment and unique personality traits a n d a specific neurotransmitter dysfunction. P382 Multiple Sclerosis associated with Neurofibromatosis type I. Observations in North-East region of Italy. P. Perini, P. Gallo (Padova, I) Multiple sclerosis (MS) associated with neurofibromatosis type I (NF1) is a very rare event. Indeed, only seven patients with MS and NF1 are described in the literature, and ail were reported to have the primary progressive form of MS (PPMS). Among a population of about 1,000 MS patients living in the North-east part of Italy, we have recently identified three more patients with NF1 who subsequently developed clinically definite MS, two of which in the relapsing-remitting (RRMS) form (at present one has the secondary progressive forro of the disease). The diagnosis of MS was confirmed by typical MRI findings (including gadolinium enhancement of acute lesions), the presence of IgG oligoclonal bands and increased IgG indexes in the cerebrospinal fluid, and abnormal evoked potentials. Since the prevalence rates of MS and NF1 in the geographic area considered are 80/100,000 and 20/100,000, respectively, we would expect to have P(SM)*P(NF1) =0.016/100,000 patients with both diseases (< 0.9 patients). On the base of our observations, the real prevalence of the association ofMS with NF1 can be calculated in P(SM n NF1)=0.24/100,000, i.e., 15 times higher than expected. These data indicate that 1) NF1 can be associated with all the clinical forms of MS and not only with PPMS, and 2) the association of NF 1 with MS is not casual, but rather the expression of two non-independent events. The influence of genetic and immunological factors in determining the increased association of NF1 with MS will be discussed in detail. P383 Low signal changes in brain MRI in a Wilson's disease patient with a new mutation. V. Kiriakakis, P. Toulas, N. Athanasiou, P. Solinas, M. Lovicu, G. Loudianos (Lamia, Athens, Cagliari, GR) Wilson's disease (WD) is an autosomal recessive disorder caused by a large number of mutations in the ATP7B gene in chromosome 13q14.3-q21.1. In magnetic resonance imaging (MRI) of the brain high signals on T2weighted images is the most commonly observed abnormality. Low signal intensity areas on T2 sequences have rarely been reported. A 29-year-old Greek man presented to the outpatient clinic with a year's history of hand tremor and difficulty with speech and swallowing. He had a chronic psychologic disturbance started at his teens and treated with various drugs until the age of 25. Neurologic examination revealed facial dystonia, a mixed-type tremor of upper limbs, mild parkinsonism and mild ataxia of upper limbs. Serum coeruloplasmin was 8 mg/dl (normal 20-60) and 24hour urinary copper excretion 500 ~tg (normal < 70 ~tg). Slit-lamp examination revealed Kayser-Fleisher rings. MRI of the brain showed symmetric low signal areas on T2 and proton-dense images bilaterally in globus pallidus and anterior part of the cerebral peduncles. Weak high signal with small areas of low signal were observed in thalami, central and posterior peduncles and anterior pons. There was mild cerebral atrophy with slightly dilated lateral ventricles. He was given D-penicillamine up to 1.5 mg/day with a very good progress and mild residual symptoms at 14th month of treatment. By that time he was on zinc acetate. Brain MRI showed symmetric diffuse low signal on T2 and proton-dense images bilaterally in basal ganglia (mainly in globus pallidus) and anterior part of the cerebral peduncles and weak high signal in the floor of the 4 th ventricle and cerebellar peduncles. Proton MR spectroscopy of the left basal ganglia revealed the presence of myoinositol within normal levels. DNA analysis carried out using the SSCP and direct sequencing methods revealed in this patient the compound heterozygous state

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for two mutations both occurring on exon 13 of ATP7B gene. The Leu936ter is a known mutation transmitted by his mother wbile the Glyl012Arg is a new one and was transmitted by his father. The low signals on T2 weighted images in WD are thought to reflect the paramagnetic copper overload of the affected tissue. However, these are rarely reported. In our case these may be related to the specific phenotypic (short duration and/or type of the neurological symptoms) and genotypic characteristics. Clinico-genetic-radiological correlation in large series ofpatients is needed to elucidate tbis matter. P384 Unusual Courses Of Serious Acute Plant Poisoning In Adolescents And Young Adults By Means Of Three Case Reports. R. P. Hofmann, J. J. Schwarze, J. Klingelh/Sfer (Chemnitz, D) Objective: Plant poisoning has become more frequent over the last few years due to its use by adolescents and young aduhs as legal, readily available hallucinogens. Approximately 15 patients ayear (0.58 % of all our in-patients) are admitted with serious acute plant poisoning. Clear therapy guidelines do not exist, since literature is predominan@ confined to case reports. Commonly, a symptomatic treatment with activating charcoal is recommended in less serious cases, otherwise physostigmine may be beneficial. Methods: We reviewed 15 of such patients with a mean age of 18.5 years (16-20 years) with ingestion of central acting poisonous plants (77.8 % narcotic Solanaceae, 22.8 % mushrooms), who had underestimated the hallucinogen's side effects. By means of clinical features and central nervous symptoms resulting an oral consumption of indigenous plants a treatment plan without requirement of special laboratory investigation was developed. Based on that plan three cases (1 Pilocybe poisoning, 2 jimson weed poisoning, one of ir treated with an antidote) are reviewed and therapeutic intervention is compared to each other. Results: Our results indicate an immediate administration of physostigmine not only in severe poisonings and independently of ingested species of plants as far as vomiting does not reveal a mushroom poisoning. In one case a single high-dose administration of physostigmine (0.025 mg/kg) led to an early remission of anticholinergic features. However, in case of mixed poisoning a replied administration of physostigmine may be necessary. In cases of positive drug history, mixed intoxication ad admission, and chronic abuse of sympathetic substances an antidote administration maybe not beneficial. Poisoning by LSD, Mescaline and foodstuff (i.e. botulism) as well as severe schizopbrenia must be ruled out as differential diagnoses. Conclusions: Our study reveals benefits for early administration of physostigmine anda trend for a statistically significant relationship between severity of poisoning and duration of in-patient careas well as for constitutional factors causing a serious course. Under addition of a literature survey several reasons for complications must be taken into consideration.

patients, decreased IL-lbeta (-62%, p < 0.005), IL-6 (-57%, p < 0.01) and TNF-alpha (-50%, p < 0005) releases were observed in severe AD patients versus cont rols. IL-8 release was also decreased in severe AD patients, but no significant difference was observed. A significant linear trend in the release of IL-lbeta, IL-6 and TNF-alpha (p < 0.005) was observed in the subgroups of AD patients with different disease severity anda positive correlation was found between cytokine release and MMSE score; we also observed a strong positive correlation between IL-6, IL-1beta and TNF-alpha releases. The reduced cytokine release observed in AD patients, according to disease severity, might be interpreted as a down-regulation of PBC, exposed to a chronic Abeta stimulus. This study underlines the possibility to correlate impaired cytokine peripheral release and clinical conditions of AD patients and suggests a progressive impairment of immune functions in this disorder. P386 Prothrombin in cerebrospinal fluid and plasma of patients with Creutzfeldt-Jakob Disease. C. Jacobi, I. Zerr, P. Lewczuk, S. Arlt, B. Mollenhauer, M. Otto, H. Ehrenreich, S. Poser (G6ttingen, Hamburg, D) Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative disease with an incidence of around oRe case in one million inhabitants in one year. The pathologic forro of the prion protein seems to play an important role in the pathogenesis of CID but the exact process of neurodegeneration is still unknown. Patieots can be clinically classified as pro.bable, possible and other cases. Definite diagnosis is only possible after neuropathological examination. Prothrombin is a 72 kDa proenzyme of thrombin synthesized in the liver as well as in the brain. Apart from its central role in haemostasis, thrombin, a highly potent protease, is involved in (patho)physiological processes in the central nervous system. Thrombin suppresses growth of motoneurons, and accumulates in the brain of patients with Alzheimer's disease (AD) suggesting an important role in neurodegenerative disorders. Prothrombin levels are unaltered in the lumbar cerebrospinal fluid (CSF) and plasma of patients with AD. However, they have never been determined in a rapid neurodegenerative disease, like CJD. In the present study prothrombin concentration was measured in CSF and plasma of 10 patients suspect for CJD (three definite and seven probable) using an established ELISA.Results were expressed as prothrombin CSF/plasma concentration quotients (QProth) and presented with respect to a generally accepted measure of the blood-CSF barrier function, albumin CSF/serum concentration quotient (QAIb). Resuhs of tbis study were compared to a group of 22 patients with other neurological diseases and to normal cont rols. Mean QProth was 3,2 (from 1,3 to 7,5) in the CJD group and 4,1 (from 2,1 to 8,3) in the control group. Mean Q Alb was 4,6 (from 2,4 to 10,1) in the CJD group and 5,3 (from 3,5 to 8,6) in the control group. In all cases evaluated so far, a lower Q Proth than Q Alb was found. These results suggest that (1) prothrombin in lumbar CSF of patients with CJD originates from the blood, (2) prothrombin produced in brain acts locally and does not occur in the CSF in appreciable amounts.

Dementia higher functions disorders P385 Peripheral cytokine release in Alzheimer patients: correlation with disease severity. C. Ferrarese, G. Sala, C. Canevari, G. Galimberti, M. E. Raggi, L. Frattola (Monza (MI), Bosisio Parini (LC), I) Beta-amyloid (Abeta)-induced cytokine release has been shown in senile plaques and in glial cell cultures. Despite pathological and experimental evidences, data on cerebrospinal fluid or circulating cytokines in Alzheimer's Disease (AD) patients are few and controversial. To further explore if activation of peripheral blood cells (PBC) and cytokine secretion is altered in AD patients and if it may relate to disease severity, we investigated the Lipopolysaccharides (LPS)-induced ex vivo release of interleukin (IL)-lbeta, IL-6, tumour necrosis factor (TNF)-alpha and IL-8 from blood cells of AD patients, with different disease severity, respect to age-related controls. Based on DMS-IV and NINCDS-ADRDA criteria, 20 probable AD patients were selected and classified as mild (MMSE score higher than 21; mean + standard deviation: 24.7 --2 1.5), moderate (MMSE score: 11-20; 18.3 + 1.5) or severe (MMSE score less than 10; 1.7 • 2.9) AD patients. We also included 10 normal controls, age-related to patients. Cytokine release was assayed with IMMULITE System in supernatants, obtained from blood incubated for 4 hours at 37~ and 5 % C02,in presence of 100 ng/ml LPS or sterile pyrogen- free saline. In AD patients a similar pattern of altered secretion, according to disease severity, was observed for all cytokines investigated: while a slight and no significant increase of LPS-induced release was observed in mild demented

P387 14-3-3 Protein in Diagnosis of Sporadic Creutzfeldt-Jakob Disease in PortugaL M. M. M. Grazina, F. M. P. Silva, A. J. E. Green, C. R. Oliveira (Coimbra, P; Edinburgh, UK) Sporadic Creutzfeldt-Jakob disease (sCID) is the most common of the human prion diseases. The definite diagnosis is only achieved by cerebral biopsy or autopsy. Being so, the search for biochemical markers is very important. Accordingly, some proteins have been studied in cerebrospinal fluid (CSF) for possible markers of the rapid neuronal death occurring in the disease. So lar, only the presence of the protein 14-3-3 in CSF could be considered to be included in the criteria (Hsich, 1996; Zerr, 1998; Poser, 1999) for probable sCID, having a similar or even higher specificity and sensitivity than electroencephalogram (EEG). In the last few months we have started to analyse the presence of the 14-3-3 protein in CSF of patients with possible sCJD, asa National Reference Laboratory, a study integrated in the Portuguese Surveillance System for CJD. The analysis is performed by western blotting followed by chemiluminescent detection. So far, we have analysed 24 cases, 6 being positive; the detection of the protein 14-3-3 and the clinical criteria for sCJD has allowed the diagnosis as probable sCJD. Accordingly, these studies are a step forward in the diagnosis of sCJD in our country.

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P388 Interleukin-4 (IL-4) production and expression in Alzheimer's disease (AD) patients treated and untreated with acetylcholine-esterase inhibitors (AchEI). C. Iarlori, M. Reale, G. De Luca, A. Lugaresi, C. Feliciani, N. Biello, E. Sparvieri, P. Conti, G. Abate, A. Di Iorio, D. Gambi (Chieti, I) Background: Immune factors such as cellular immunity, autoimmunity, and inflammation may playa pathogenetic tole in Alzheimer's disease (AD), a neurodegenerative disorder. Increased blood levels of some pro-inflammatory cytokines and acute phase reactants have been found in AD patients. Epidemiological studies show that the routine use of non-steroid anti-inflammatory drugs is associated with a decreased incidence of AD. Acetylcholine-esterase inhibitors (AchEI) are now considered the first choice treatment for AD. Objective: To assess the effects of AchEI on IL-4 (an immunoregulatory cytokine) production in AD. Methods: we studied 22 patients suffering from AD: 8 (36.4 %) treated with AchEI for at least 6 months. IL-4 levels were measured using commercially available ELISA kits specific for human IL-4 on 24h supernatants from unstimulated, PHA (20mcg/ml) and ConA (10mcg/ml) stimulated peripheral blood mononuclear cells (PBMCs). Reverse-transcriptase-polymerase chain reaction (RT-PCR) was used to determine IL-4 expression in unstimulated and PIlA and ConA-stimulated PBMCs. Statistical comparison between the mean values of different variables of AD patients was performed by chi-square and analysis of variance. A generalized linear model (GLM) analysis was performed to evaluate the association between treatment and IL-4 levels adjusted for potential confounders. Resuhs: AD treated with AchEl show a 3-fold increase of IL-4 levels in supernatants compared to untreated AD (p < 0.001). Muhivariate analysis shows a direct association between treatment and IL-4 production adjusted for age, sex, comorbidity and number of leukocytes. IL-4 mRNA expression is higher in treated AD. Conclusion: the AchEl-induced increase of IL-4 production might favourably modify the inflammatory process involved in AD and have a favourable effect on disease progression.

P389 lmpaired Oxidative Metabolism In Exercising Muscle On Alzheimer Disease. M. Mancuso, R. Ceravolo, G. Tognoni, M1.Manca, A. Del Corona,V. Lombardi, L. Murri, G. Siciliano (Pisa, I) The pathogenic mechanism of selective neuronal loss in Alzheimer disease (AD) is still poorly understood. Recen@, research evidence suggests that mitoch£ dysfunction occurs in central nervous system as well as in peripheral tissues from AD patients. Airo of our study was to indirectly investigate in vivo oxidative metabolism of exercising muscle in 18 patients affected by AD. In AD patients mean resting lactate was significantly higher than controls (2.79 -+ 1.33 vs 1.44 + 1.1 mmol/1, p < 0.01). Exercise mean lactate values were significan@ higher in AD patients from the l~t step of the exercise, with a more marked difference from the 5th step (50 % of Maximal Voluntary Contraction, MVC), this corresponding to the (anaerobic) lactate threshold, anticipated compared to controls (70-80 % of the MVC). Different to controls, lactate didn't recover to basal values at 15 minutes after the cessation of exercise (3.94+2.53 vs 1.44 + 1.1 mmol/1, p < 0.01 ). In two cases, in whom muscle biopsy were per formed, typical mitochondrial findings as ragged red or COX negative fibers were found. These data show that muscle lactate production is abnormally increased during exercise in AD patients, reinforcing the hypothesis of a systemic impairment of the mitochondrial metabolism in AD and suggesting that metabolic evaluation and lactate kinetics investigation could be used as an useful tool in understanding pathogenic mechanism of AD. P390 Secretion of Gonadal and Gonadotropic Hormones in Women with Vascular Dementia. E. G. Dubenko, O. M. Korolenko (Kharkov, UKR) Background: Researches on epidemiology of vascular dementia (VD) show that men suffer from the disease more often than women. Study of correlations between VD and secretion of female gonadal (G) and gonadotropic (GT) hormones in women could help to explain the phenomenon. Methods and results: A group of 97 women with vascular dementia and 43 healthy women (age from 51 to 79) were examined with MRI and transcranial doppler. Secretion of female G and GT hormones was studied with a radioimmune method. Multi-infarct cortical VD with bilateral ischemic foci in frontal and occipital lobes was found in 53 patients (54.6 %). Muhi-infarct cortico-subcortical VD with bilateral ischemic foci was revealed in 28 pa-

tients (28.9 %). Unilateral cortico-subcortical VD with asymmetric ischemic foci was found in 16 patients (16.5%). Results: The more severe were clinical and morphological signs of VD the lower was secretion of G hormones (correlation coefficient r = -0.661) and the higher was secretion of GT hormones (correlation coefficient r = +0.590). Conclusion: Revealed correlations allow to presume that balanced secretion of female G and GT hormones is a protective factor which decreases risk of VD in women. P391 Difficulties in differentiating between Alzheimer's disease and progressive non-fluent aphasia. I. Uttner, A. Claus (Ulm, D) Disorder of language is the core symptom of progressive non-fluent aphasia (PA), but may be commonly observed in Alzheimer's disease (AD), too. In contrast to PA, however, in the majority of AD-patients aphasia is only one feature in a bundle of multiple deficits, dominated characteristically by impairment of working, episodic and semantic memory, praxis disorders as well as visuoperceptual and -spatial deficits. In some cases, nevertheless, language breakdown represents the first symptom, which precedes the development of other symptoms by months or even years. As consequence, these patients may be wrongly regarded as suffering from PA. We report the case of HZ, a 65 year old professor of physics, who presented in our hospital with a severe aphasia characterized by anomia and very short, mostly unfinished sentences. Unlike the language disorder in PA, which reflects difficulties in phonological selection, his speech was hesitant, but non-effortful, with mainly semantic paraphasias and stereotypes. Although syntactic and prosodic quality of language output were essentially intact, communication was almost impossible. Additionally, we found deficits of repetition span and a gestual and ideational apraxia. Spatial orientation was clearly impaired. Symptoms had started 6 years before with isolated word finding difficulties. In the following, HZ developed further language breakdown, especially of word finding, but also deficits of verbal episodic memory anda depression. This is unusual in PA. The case underlines the difficulty to differentiate between PA and an at ypical course of AD presenting with initial language deficit. We argue, that differential diagnosis may be improved by a subtle analysis of the clinical features of the language disorder and the evolution of symptoms. P392 Endothelial nitric oxide synthase and cathepsin D polymorphisms are not genetically associated with sporadic Mzheimer's disease. O. Combarros, M. S• I. Infante, J. Berciano, J. M. Polo, J. Llorca (Santander, E) Background: In addition to the apolipoprotein E (APOE) polymorphism, genetic variants of endothelial nitric oxide synthase (NOS3) and the cathepsin D (catD) genes have also been proposed as genetic factors for Alzheimer's disease (AD). Objective: Since reports about the relevance of these polymorphisms for the pathogenesis of AD have been contradictory, we performed an association study in a Spanish population. Methods: The study included 311 patients (66 % females; mean age 75.2 -+ 9 years; range 50-98 years) who met the NINCDS/ADRDA criteria for probable AD, and 346 control subjects (71% females; mean age 80.3 -+ 7.7 years; range 63-99 years) with Mini Mental State Examination scores greater than 28, which were verified by at least one subsequent annual following-up assessment. Genotyping of NOS3, catD and APOE were performed by PCR followed by restriction endonuclease digestions. Results: The distribution of both NOS3 and catD genotypes and alleles in AD cases did not differ significantly from that of the controls. Risk was not increased by the presence of the Glu/Glu NOS3 genotype (OR=0.98; p=0.9) or the CT+TT catD genotype (OR= 1.01; p=0.9 ). We split the data based upon APOE carrier status and there was not significant association between the Glu/Glu NOS3 or the CT+TT catD genotypes and the risk of AD, in either APOE e4 carriers and non-carriers. The same resuhs held when our data set was stratified by age or gender. Conclusion: No direct association was observed between the NOS3 or catD polymorphisms and AD.

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P393 Glycohydrolase expression in Alzheimer disease. C. Emiliani, L. Racanicchi, A. Orlacchio, S. Latorraca, S. Sorbi, G. Bernardi, A. Orlacchio (Perugia, I; Toronto, CDN; Firenze, Roma, I) An endosomal-lysosomal system upregulation,with increased hydrolase expression and extracellular enzyme deposition in plaques, is, like beta-amyloid deposition, an early marker of metabolic dysfunction potentially related to primary etiologic events in Alzheimer Disease (AD). In this context, we have investigated the expression of three acidic glycohydrolases: beta-hexosaminidase, beta-galactosidase and alpha-D-mannosidase in fibroblasts cell lines established from patients with sporadic AD and with presenilin 1 (PS1), presenilin 2 (PS2) and beta-amyloid precursor protein (APP) linked familial AD (FAD). We analysed patients with early onset FAD (EOFAD), patients with late onset FAD (LOFAD), subjects at risk to develop FAD being offspring of an affected member of EOFAD of LOFAD family and younger than the age at onset, escapee (offspring of affected member who did not have the disease and are two standard deviation older than the mean age onset in their family). The enzyme expression was evaluated by RT-PCR and enzyme activity levels by using specific synthetic fluorogenic substrates. Polypeptide processing was assessed using specific polyclonal antibodies raised against the purified enzymes. Results obtained demonstrated that the expression of the three glycohydrolases is upregulated to a different extent by AD. The most informative results were obtained by the analysis of alpha-mannosidase, for which the increase of activity correlate with the disease: up to six times increase of activity was observed in all sporadic AD cases, while in FAD the most important increase was found in association with the mutation in PSI gene. Interestingly, in the latter case, a three times increase of alpha-mannosidase activity was observed in subjects at risk, in which fibroblasts were collected two years before the onset of the disease. To go more insight, we evaluated the multiple forms of alpha-mannosidase which are involved in both biosynthesis and catabolism of glycoproteins and which can be identified on the basis of their optimum pH for activity as: lysosomal forros (optimum pH of 4.0-4.5), forros associated with the endoplasmic reticulum m6mbrane (neutral optimum pH) and Golgi compartment associated forms (optimum pH of 5.5-6.0). The lysosomal forms displayed the most importaot variations as function of AD, but anomalies were detected also in the expression of the RE associated forms. The overall results reinforce the hypothesis of an involvement of lysosomal glycohydrolases in the pathogenesis of the AD. (Work supported by Telethon, grant n E0980PG) P395 Endocrine parameters in Alzheimer's disease: their implication in the early diagnosis. F. Vicchio, C. Zuliani, C. Fattorello, D. Armanini (Mirano, Padua, I) Alzheimer's disease is often characterized by an increase of plasma cortisol without clinical evidence of hypercorticism. The objective of our study was to evaluate whether the measurement of several hormonal parameters could better characterize the patients with Alzheimer's disease. 25 consecutive inpatients with Alzheimer's disease, and 35 subjects comparable for age and sex were studied. The diagnosis was done according to the criteria DSM IV and by neuropsychological tests, EEG, CT-scan and MR-imaging; in most cases also SPECT was performed. The following hormonal parameters were done: plasma cortisol, dehydroepiandrosterone sulphate (DHEAS), the cortisol/ DHEAS ratio and the number of Type I and Type I I corticosteroid receptors in mooonuclear leukocytes. Steroids were measured by enzyme immunoassay and corticosteroid receptors by radioreceptor assay after separation of mononuclear leukocytes by Percoll gradient. Results: in patients with Alzheimer's disease plasma cortisol was higher than in controls (28.4 + 7.9 vs 17.6 + 4.4 ug/dl, p < 0.001). Plasma DHEAS, the ration cortisol/DHEAS and the number of Type I receptors in mononuclear leukocytes were indeed significan@ lower than in controls (respectively 59.4 + 42.4 vs 143.3 + 84.9 ug/dl; 2.2 + 1.6 vs 9.0 + 5.7 and 1434 + 514 vs 2025 + 578 receptors per cell). Ah inverse significant correlation between DHEAS/cortisol ratio and age and between Type II receptors and age was evident only in heahhy controls and not in Alzheimer's disease. These data support the hypothesis of a disregulation of the adrenal pituitaric axis in Alzheimer's disease. The correlation between DHEAS/cortisol and age and Type II receptors and age in controls is consistent with a progression of the physiological aging process, which lacks in Alzheimer's disease. The abnormality of these hormonal at the level of target tissues and the follow up of these parameters could be useful to distinguish physiological and pathological aging process.

P396 Frontal epilepsy: impact on developmental neurocognitive functions. D. Riva, V. Saletti, F. Nichelli, S. Bulgheroni, I. Bagnasco (Milano, I) Background: Most published neuropsychological studies on frontal lobe epilepsy huye been per formed on mixed groups of adults and adolescents affected with epilepsy of different aetiology. Cognitive profile of frontal lobe epilepsy (FLE) in children has not yet been reported. Methods: Intelligence and executive functions were examined in 8 subjects (age 6y,Tm to 13y,1 lm). The performances were related to the focus side, seizures frequency, and age of epilepsy onset. Results: FLE in children was associated with a range of frontal dysfunctions, but did not usually compromise IQ. Left focus was associated with deficit of categorization in verbal long-term memory and impairment of detailed visuo-spatial analysis. Frequent seizures correlated with difficulties in attention and impulsive responses inhibition. Children whose epilepsy appeared before 6 years had reduced ability to change behavioral strategies. Conclusions: Frontal epileptic activity muy cause selective frontal deficits, whose severity and nature appear related to the focus side, seizures frequency and age of epilepsy onset. These findings require confirmation on larger groups of selected children. P397 Role of lateralization on outcome of childhood stroke. V. Brankovic-Sreckovic,V. Milic- Rasic, N. Jovic, D. Todorovic, N. Mili~ (Belgrade, YU) The outcome of ischemic cerebral lesion in childhood is in conjunction with the underlying condition and mechanism of stroke, localization and extent of infarction and risk of recurrence, ldentification of each predictable factor is important and could be helpful for further treatment strategies. To determine influence of side lateralization on outcome of ischemic cerebral events in childhood, we investigated 31 child (18 boys, 13 girls). Stroke was confirmed by neuroimaging and contrast procedures. The age of stroke onset was 1-16 years (median age 7 years). The mean foUow-up period was 51 months. Embolic and arteriopathic processes were the most presumable mechanisms of stroke. The underlying cause could not be established in 9 (29 %) children. Five (16,1%) children had recurrent stroke in the period of 5 days to 18 months. Cerebral ischemia was most commonly presented by acute focal motor deficit (96.8 %), dysphasia/aphasia (53.3 %), altered consciousness (54.9 %) and seizures (32.3 %). Bilateral infarction were diagnosed in three children, clinically presented us -bilateral motor deficit in one, cortical blindness in another and only right hemiparesis in reminding one. lnitial left sided in 16 and right-sided hemiparesis in 13 patients corresponded to the site of stroke. No significant difference was found between the incidence of left and right sided ischemic lesion (chi squared test=0.129, DF= 1, p=0.72). Outcome was favorable in 9 (29 %) children with complete neurological recovery. In 21 (67.7%) mild to moderate residual motor deficit was noticed at the last examination. There was no significant difference in the o c c u r r e n c e of right and left sided stroke on outcome (Fischer, p=0.279). Aphasia/dysphasia was predominantly present in children with left-sided stroke lesion -81.3 % in contrast to right-sided - 18.7 % (Fischer, p=0.0028). Complete recovery of aphasia was achieved in all children fora mean period of one mount. We concluded that lateralization of ischemic lesion, in a number of our patients,was not dependent outcome predictor of childhood stroke.Another prognostic characteristics have more influences on the stroke outcome in childhood (underlying mechanism, size and site of the lesion, stroke severity and accompanied medical conditions). Although there is correlation between initial aphasia and hemispheric lateralization, severity and duration of aphasia had minimal influence on outcome. P398 Familial multisystem degeneration with un extensive tau deposition but without tau gene mutation. ]. ]. Zarranz, E. Lezcano, B. Atar~s, I. Forcadas, C. Fern• Maiztegi, I. Rouco, M. Fern• O. Rodriguez, T. P› Concha, P. Pastor (Cruces-Baracaldo (Vizcaya), E) Introduction: lmmunochemistry has allowed to prove that a wide spectrum of neurodegenerative ~lisorders such us classical Pick's disease, PSP, corticobasal degeneration,Alzheimer's disease and frontotemporal dementia are characterized by ah extensive deposition of abnormal tau protein in neurons, glial cells and neuropil. The pathogenetic importance of tau deposition was further enhanced when several mutations in the tau gene in chromosome 17 in some families with frontotemporal dementia, parkinsonism and motor neuron disease were described. Patients: In 1985 we reported the clinicopathological picture of two

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members of a large family with a multisystem degeneration segregated as an autosomal dominant trait, affecting mainly the nigro-striatal and the cortico-spinal system. Since then we have observed eight additional patienls and performed four more autopsies. Resnlts: Both females and males have been affected. The mean age of onset was 42 years and the mean duration of the disease was 4 years. The main presentiug symptoms were hand akinesia or dysarthria. In an intermediate state of evolution some patients had an hemiparkinsonism resistant to levodopa. The full clinical picture included loss of verbal fluency, severe dysarthria and dysphagia, generalized akinetic rigid syndrome, brisk reflex and other pyramidal signs, supranuclear ocular palsy, hand dystonia and amyotrophy. No dementia was observed while the patients were able to cooperate in the neuropsychological testing. No aberrant behaviour was observed. The ancillary test and neuroimaging were negative or non contributive. A severe nigral degeneration without Lewy body was the main neuropathological finding in all the autopsied cases. Corticospinal, anterior horn motoneurones and striatal degeneration were variable among the different cases. Frontal lobe degeneration was absent in three cases, mild in one and severe in two (with macroscopic lobar atrophy in one of them). Ah extensive cortical and subcortical tau deposition was observed in immunohistochemistry. DNA analysis showed no mutations in the microtubule-binding domain regions in chromosome 17. Conclusion: This familial autosomal dominant multisystem degeneration is cbaracterized by striking clinicopathological variability and further emphasizes the genetic heterogeneity of hereditary tauopathies.

P399 Diagnosing and profiling aphasia with the new Aphasia Check List (ACL). N. Reinhold, E. Kalbe, U. Ender, J. Kessler (Cologne, D) Aphasia after ischemic stroke or other brain damage can include different patterns of language deficits depending on the affected brain area and individual cortical organisation. Most aphasia tests so lar ignored other cognitire disturbances that can occur with a possible impact on language functions. We developed the ACL wtª profiles language disturbances as well as other associated neuropsychological deficits. Next to a short communication rating, the language subtests are: Token test, Verbal commands, Automatic speech, Verbal fluency, and Specific verbal domains (Confrontation naming, Reading aloud and Reading comprehension, Auditory comprehension, Writ ing, Repetition). Neuropsychological tests are: Mental control, Visual memory, Attention and Reasoning. Every subtest consists of items with rising intricacy. Methods and subjects: 30 control subjects (CG), mean age 52.9 (SD= 14.4), have been assessed with the ACL so far. The test time was 15-20 minutes. Results: A ceiling effect was shown by the CG in most subtests. Mean scores were: Token Test: 97%, Verbal commands: 99%, Automatic speech: 100 %, Specific verbal domains: 98 %, Mental control: 100 %, Visual memory: 95 %, Reasoning: 77.6 %. When the control group was split in two age groups < 50 years (0=41, SD=5.7) and > 50 years (0=64.9, SD=9.2), a significant age difference was shown in the Token test (p < 0.01) and the Writing task (p <

the development of EAE in IL-4, IL-10, and WT littermate mice with no apparent difference in the potency of this protection. Significant disease suppression was also seen in IFN-gamma deficient mice. The decrease in disease severity was accompanied by a concomitant reduction in the number of proinflammatory cytokine and chemokine producing cells in the central nervous system (CNS). Although there was no apparent increase in compensatory Th2 cytokine production in cytokine deficient mice, there was a profound decrease in the frequency ofTNF-alpha producing cells in the CNS and the periphery. Therefore, we propose that one mechanism by which estrogen protects females from the development of cell mediated autoimmunity is through a hormone dependent regulation of TNF-alpha production.

P401 Interferon beta-la modulates the expression of CTLA-4 and CD28 splice variants: induction of soluble isoforms. M. Giorelli, P. Livrea, G. Defazio, M. Trojano (Bari, I) Background: CD28 and CTLA-4 are costimulatory mo[ecules which cooperate with the CD3/TCR complex in modulating T cell responses. The countereceptors for both CTLA-4 and CD28 are the B7 family molecules on antigen presenting cells. CD28 induces T cell proliferation, cytokine production, and acquisition of effector functions whereas CTLA-4 downregulates T-cell activation. Recently the existence of alternatively spliced tuRNAs coding for soluble isoforms of CD28 and CTLA-4 molecules has been demonstrated in T cells from healthy donors and lymphomonocytoid tissues (Magistrelli et al., 1999; Oaks et al., 2000). Membranous CD28 and CTLA-4 may be involved in the pathophysiology of Multiple Sclerosis (MS) (Anderson et al.. 1999). lnasmuch as the administration of the soluble fusion protein CTLA-4Ig was shown to be capable to prevent the initiation of Th mediated diseases such as lupus, celiac disease, collagen induced arthritis, and experimental autoimmune encephalomyelitis (EAE), it is highly tempting to suggest a role for the soluble isoforms of CTLA-4 and CD28 in the modulation of autoimmune diseases. Goals of the study: To investigate whether interferon beta-la can regulate the expression of mRNAs encoding for membrane-bound and soluble CTLA-4 and CD28 isoforms in human lymphomonocytes. Methods: Total RNA was extracted from mononuclear cells (MNLs) isolated from healthy volunteers and cuhured for 72 h in complete RPMI with or without interferon beta-la (1500 U/ml). To selectively amplify all the known mRNA splice variants of CD28 and CTLA-4, specific pair of primers were synthesized on the basis of the sequences described by Magistrelli. RTPCRs were undertaken following standard methods. Resuhs: lnterferon beta-I a treatment of MNLs selectively enhanced the content of the tuRNAs for the soluble isoforms of CTLA-4 and CD28. Conclusion: Soluble CTLA-4 of CD28 molecules may counteract T cell stimulation by blocking B7-CD28 interactions on resting T cells. According with such an hypothesis, soluble forms of CTLA-4 inhibir EAE if present before the initiation of the immune response. We suggest that induction of soluble isoforms of CTLA-4 or CD28 in MS patients undergoing interferon beta- la treatment might counteract the binding of B7 ligands to mCD28 of resting T cells, tbus contributing to prevent T cell activation.

0.05). Conclusion: The ACL is a new instrument for the diagnosis of aphasia that tests not only a large spectrum of language domains but also other neuropsychological functions and includes different levels of complexity in each subtest. Therefore ir allows a detailed description of aphasic disturbance and its severity as well as other cognitive dysfunctions. Control groups show a significant age effect in some language domains, so that norms for different age groups will be available for all subtests.

Immunology P400 Estrogen treatment down-regulates TNF-alpha production and reduces the severity of EAE in cytokine knockout mice. A. lto, B. Bebo, Jr., A. Matejuk, A. Zamora, M. Silverman, A. Fyfe-Johnson, H. Offner (Por tland, Oregon, USA) A shifl towards Th2 cytokine production has been demonstrated during pregnancy and high dose estrogen therapy, and is thought to be the primar)' mechanism by which estrogen suppresses the development of experimental autoimmune encephalomyelitis (EAE). However, low dose estrogen treatment is equally protective in the absence of a measurable shift in cytokine production. In this study, cytokine deficient mice were treated with estrogen in order to determine if a shift in Th cytokine production was required for the protective effects of hormone therapy. Estrogen effectively suppressed

P402 Soluble ICAM-h molecular origin and modulation of expression by interferon beta-la in human endothelium and lymphomonocytes. M. Giorelli, P. Livrea, G. Defazio, A. De Blasi, M. Trojano (Bari, S. MarŸ Imbaro, Chieti, I) Background: Soluble isoforms of ICAM1 (sICAM1) have been detected in normal human plasma and elevated [evels were described in active multiple sclerosis (MS) patients. Furthermore, slCAM l serum levels tend to rise in inactive MS patients during chronic interferon beta treatment. Two mechanisms are discussed by which serum sICAM1 can be generated: 1) proteolytic cleavage of the membrane-bound form; 2) alternative splicing of ICAMI mRNA generating a truncated form of the protein lacking the transmembrane region. No data exist on the sources of sICAM 1 during interferon beta therapy and mechanisms of production of this protein by endothelial cells and lymphocytes. Goals of the study: We studied the ratio of expression and the mechanisms of production of botb mICAMI and sICAM 1 in human endothelium and lymphomonocytes in response to proinflammatory stimuli or to interferon beta- la. Methods: Human Umbilical Vein Endothelial Cells (HUVECs) were cultured in complete medium 199 with or without interferon beta-la (1500 U/mi), TNF alpha (100 U/mi), o r a combination of the two. Lymphomonocytes (MNLs) from healthy volunteers were lefi unstimulated or stimulated with PH A 5 micrg/ml, or interferon beta- 1a (1500 U/ml),or both. Expression of mICAM 1 and release of slCAM I were evaluated by Western BIotting and

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by ELISA respectively. Presence and modulation of the specific mRNAs for mlCAMI and slCAM1 were studied by competitive RT-PCR analysis and Northern Blotting. Results: Both inteferon beta-1 a and TNF alpha induced over-expression of slCAM1 and mICA M 1 by HUVECs. When ac ting in combination'their effect on the expression of ICAM 1 molecules was additive. In MNLs, interferon beta-la did not increase the amounts of mICAM1 and slCAMI whereas counteracted the over-expression of mlCAM 1 due to PHA.We also found the presence of a specific mRNA for slCAM1 in both human endothelium and lymphomonocytes and that expression of mlCAM1 and slCAM 1 was regulated at the tuRNA level by interferon beta-la. Conclusions: Our data demonstrate that expression of slCAM 1 and mICAM1 molecules do not follow parallel kinetics and that a modulable and specific mRNA for slCAMI exists in both human endothelium and lymphomonocytes. Thus slCAMI does not derive from the cleavage of the extracellular portion of mlCAM 1 in both these eytotypes. Endothelium appears to be the source of slCAM1 during interferon beta treatment. P403 The Kinetics of TNF alpha and II-10 mRNA and Proteins Expression afler Ischemic Stroke. G. Gromadzka, B. Tarnacka, A.M. Ciesielska, A. Czlonkowska (Warsaw, PL) Stroke is characterized by brain tissue damage associated with altered immune response both early after the onset and in the recovery phase of the disease. The important role in the formation of immune reactions resulting from stroke plays cytokines. The source of cytokines in stroke could be ischemic brain cells as well as peripheral blood leukocytes. Significant role of pro- and anti-inflammatory cytokines in the modulation of the immune response in stroke was documented in different studies. The number of functions ascribed to proinflammatory cytokines include: ability to stimulate astrocyte proliferation, induction of production of NGF by astrocytes, changes in coagulation and fibrinolysis, induction of hepatic synthesis of acute phase proteins including Fb. Anti-inflammatory cytokines could also playa pivotal role in the modulation of immune reaction mainly by inhibition of inflammatory processes developing after brain ischemia. The airo of the study was to evaluate the kinetics of TNF alpha and IL- 10 mRNA and proteins expression in peripheral blood of the patients with ischemic stroke. We studied 38 patients with ischemic stroke (peripheral blood was taken at the 12h, 1st ,2 nd ,3 rd ,4 th ,7 th and 21 st days after the onset) and 30 age-matched persons free of cerebrovascular disease and clinical signs of infection asa control group. TNF alpha and IL-IO tuRNA expression in peripheral blood cells was measured by the method of semi quantitative RT-PCR with the use of plasmid asa competitor and GAPDH asa house-keeping gene. The levels of proteins in serum was studied with the use of ELISA metbod. We observed increased levels of IL-10 mRNA and protein expression at the first 12 hours after st roke onset.The second peak of IL- 10 tuRNA was observed at the 2 nd day after stroke. The TNFalpha mRNA and protein expression was also increased (compared with control group). The mostly expressed increase in TNF alpha mRNA was noted at the pt da), after the onset with the second peak at the 3 rd day after stroke. Our resuhs confirm the presence of negative feedback between the production of TNF alpha and II.- 10. Observed high levels of IL- 10 at the first days of stroke suggest the influence of corticosteroids and catecbolamines released in large amounts after ischemic stroke. Therapies that interfere with the functions of cytokines may help in reducing infarct extension and make stroke prognosis better. P404 Acute and chronic effects of interferon alpha therapy on mood and the hypothalamic pituitary adrenal (HPA) axis in patients with chronic Hepatitis C. E. M. Cassidy, S. Byrne, D. Manning, E. Wallace, F. Murray, M. Keogan, V. O'Keane (Dublin, IRL) Background: Fatigue and depression are common sequelae of interferon alpha (IFN) therapy. The aetiology of this is unclear. IFN (at doses _>5 million units) is known to stimulate the hypothalamic pituitary adrenal axis and dysregulation of this axis occurs in up to 60% of patients with ma)or depression. Objectives: To examine the hypothesis that IFN would stimulate the HPA axis and immune system acutely and that major depression following IFN would be associated with chronic hypercortisolemia. Methods: 10 patients with chronic hepatitis C were assessed before treatment, immediately following 3 million units IFN and after 1 month of treatment. Serum cortisol was evaluated by estimating the mean of tO sequential serum samples between 1pm and 4pm at all time points using the Halbreich method. Cortisol response to dexamethasone suppression (Carroll et al.,

1981) was assessed at baseline and afler 1 month. Plasma interleukin 6 (1I.-6) was evaluated at baseline, acutely and after one month of treatment. Mood was assessed by structured interview (Hamihon depression rating scale; HAM-D), DSM-IV checklist and self-report (Beck Depression lnventory; BD1). Resuhs: There was a significant increase in fatigue and both BDI and HAM-D depression scores after 1 month. 3 patients fulfilled criteria for DSM-IV major depression after 1 month of treatment. None of the patients were dexamethasone suppressers at baseline or follow-up and there was no significant change in mean serum cortisol. We observed no change in serum cortisol during the first 3~h hours following low-dose IFN. In contrast, subjects who developed major depression or who h a d a history of major depression (n=5) had significantly higher plasma IL-6 levels at baseline than those with no vulnerability to depression (n=5); p < 0.05. Conclusion: In contrast to what is known about high-dose 1FN,low dose IFN does not stimulate the HPA axis acutely or chronically. Depression may occur via other mechanisms e. g. proinflammatory cytokine activation and our plasma IL-6 findings may reflect this despite the small numbers.

Infection P405 Meningitis with Streptococcus bovis as overwheLming postsplenectomy infection (OPSI) syndrome. P. Guenther, D. Clark, A. Wagner, D. Schneider (Leipzig, D) Introduction: The overwhelming postsplenectomy infection (OPSI) syndrome is a severe bacterial infection in splenectomized patients. Streptococcus pneumoniae is responsible for the majority of OPSI syndromes that are rapid in progression and poor in prognosis whereas other species as cause are rare. Case report: We reporta 76-year old male who was referred to our intensive care unit with bacterial meningitis. The initial symptoms were high rever, confusion and a generalized seizure. 2.5 years before a splenectomy had been performed because of gastric cancer. On admission the patient required endotracheal intubation and mechanical ventilation due to respiratory failure. Sepsis was suspected because of tachycardia, hypotension and laboratory findings showing anemia, leukocytosis, thrombocytopenia, elevated CRP and BSR. The cerebrospinal fluid (CSF) analysis revealed pleocytosis and increased protein and lactate leve|s. Streptococcus bovis was found in blood and liquor cultures. We diagnosed meningitis as part of an overwhelming postsplenectomy infection (OPSI) syndrome. The treatment on intensive care unit (ICU) included vasoactive drugs and higb dose antibiotics given IV. The patient survived without any residual symptoms. Under ampicillin+sulbactam and gentamicin treatment blood and liquor cultures became sterile within a few days. After successful weaning from the ventilator and extubation the patient could be referred back for further treatment without focal neurological signs one week after admission. Conclusion: Despite the availability of pneumococcal vaccine postsplenectomized patients areat high risk for severe systemic infections. Emergency treatment and use of sensitive antibiotics in high dosage are important to reduce high mortality of postsplenectomy sepsis. Streptococcus bovis is a rare cause of an overwhelming postsplenectomy infection (OPSI) syndrome.

P406 Does lumbar cerebro spinal fluid (CSF) reflect ventricular CSF? A prospective study in patients with ventricular drainage. C. Gaul, J.B. Sommer, J. Heckmann, B. Neund6rfer, E Erbguth (Erlangen, D) In a prospective study, sample pairs ofventricular and lumbar cerebrospinal fluid (CSF) were obtained at an interva[ of < 30 minutes in 25 patients with cerebral hemorrhage (n=15), meningitis/encephalitis (n=6), cerebral infarction (n=3), and meningeal carcinomatosis (n=l). In all cases, ventricular drainage had been performed for treatment of increased intracranial pressure and pressure monitoring. CSF samples were analysed for protein, albumin, IgG, IgA, IgM, glucose, lactate, chloride, and leukocytes including cytological differentiation. A significant ventriculo-lumbar increase was observed for protein, albumin,and the immunoglobulins. Chloride content was significantly higher in the ventricles than in lumbar CSF,but this difference was no longer evident when cases with CNS infection were omitted. Lactate was distributed equally in ventricular and lumbar CSF,as well as glucose in the cerebral hemorrhage subgroup (n= 15). Leukocyte content failed to show a clear ventriculo-lumbar ratio. Cytological distribution was comparable in lumbar and ventricular CSF, except for macrophages showing a significant

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rostrocaudal decrease. In conclusion, in cases of clinically suspected ventriculitis afler ventricular drainage has been removed, lumbar CSF lactate, glucose, and cytology are comparable to previously determined vent ricular values, and thus may help to decide, whether antibiotic treatment is needed or not. P407 Stiff-Person Syndrome following West Nile fever. E.D. Kirson, H. Bin, M. Hindiyeh, E. Mendelson, S. Hassin-Baer (Tel Hashomer, IL) Background: The Stiff-person syndrome (SPS) is a rare autoimmune disorder associated with antibodies against Glutamic acid decarboxylase (G92 the key enzyme in GABA synthesis. There is usually no specific trigger for the disease and it is not viewed as either an infectious o r a post-infectious process. In the year 2000, hundreds of patients around Israel presented with West Nile rever (WNF). We presenta patient who developed the symptoms of SPS, two weeks following WNF infection while IgM antibodies against West Nile Virus (WNV) persist in blood and CSE The patient, a 40-year old man who presented with stiffness of the neck and shoulders, which spread to involve all limbs but mainly the lefl upper and right lower limbs. Except for the hypertrophied and stiff muscles, there were asymmetrical pyramidal signs. Both cranial and cervical spinal MRI were normal as was the CSF biochemistry and pressure. Oligoclonal bands were found in the CSF as was IgM against WNV persisting 3 months afler primary infection. Anti Gad antibodies were elevated both in blood (124) and CSF (85). WNV PCR in blood and CSF is negative. The patient had good clinical response to diazepam and baclofen and after a course of plasmapheresis further improvement was seen. Except for two atypical SPS cases following Lyme borreliosis, no other cases of post-infectious SPS were ever published. This close association in our case raises the possibility of cross reactivity between antibodies directed to WNV and GAD. Further investigation should include search for anti GAD antibodies in patients with active or recent WNF and sequence homology between GAD and viral antigens.

P408 Focal Neuropathy with Conduction Block and Cervical Meningo-radiculomyelitis in a case of Acute Neuroborreliosis. M. Gille, E Pi› I. Declercq (Brussels, B) We report the case of a 9-year-old girl who developed a stiff neck with right brachialgia 3 months afier a tick bite. These symptoms were rapidly followed by diffuse paresis and areflexia of the upper limbs. There was no sensory disturbances. Cranial nerves and lower limbs examination was normal. Magnetic resonance imaging was consistent with a cervical meningo-radiculomyelitis extending from C3 to C7. Cerebrospinal fund (CSF) examination revealed 420 lymphocytes/mL. Serum and CSF anti-borrelia burgdorferi serology were positive. She was treated with ceflriaxone ( 1.5 g/day during 3 weeks) and methylprednisolone (750 mg/day during 5 days). Needle examination (EMG) showed signs of acute denervation in the muscles innervated by the C6-C8 nerve roots bilaterally. Median nerve somatosensory evoked potentials were normal. Sensory nerve conduction studies (NCSs) were unremarkable in the right sural,median,and ulnar nerves. The motor NCS,performed 2 weeks after the clinical onset, showed a right ulnar nerve conduction block (CB) at the elbow and absent F waves after stimulation of the right median and ulnar nerves. One week later, the right median and ulnar nerves distal compound muscle action potentials (CMAPs) amplitudes were decreased. Six weeks later, a subtotal clinical recovery was observed. The ulnar CB and the distal CMAPs amplitudes in the right upper limb partially improved. These neurophysiological findings were consistent with an ulnar neuropathy with CB, in addition to a bilateral motor neuronopathy and/or radiculopathy in the C6-C8 cervical segments. Neuroborreliosis is a possible cause of focal vasculitic neuropathy. CBs are rarely observed in vasculitic neuropathies; their presence may be explained by a segmental demyelination asa consequence of nerve ischemia due to small vessel occlusion. These case probably represents a further example of focal vasculitic neuropathy with CB. P409 TIA-I and BCL-2 expression in meningitis - a morphological study. U. Baumgart, C. Gaul, D. Heuss (Regensburg, Erlangen, D) Background: The mechanisms of leukocyte removal from subarachnoid space in bacterial meningitis have not been completely known yet. Apoptosis has recently been shown as an important mechanism of intrathecal cell death and subsequent removal of leukocytes in vitro and in vivo in menin-

gitis. Apoptotic cell death can be induced by release of TIA-1 (T-cell restricted intracellular antigen) and inhibited by Bcl-2. Material and methods: We studied apoptosis in cerebrospinal fluid (CSF) by immunohistochemistry and terminal deoxynucleotidyl transferase mediated nick end labelling (TUNEL) in 15 cases of bacterial and viral meningitis. The CSF was obtained in routine controls either by lumbar puncture or external liquor drainage between 24 to 48 hours after initial diagnosis and treatment with adequate antibiotics. Results: In bacterial meningitis TIA-1 was expressed in up to 100 % of all samples predominan@ in granulocytes, but also in mononuclear cells. Expression of TIA- 1 in viral meningitis was only up to 25 %. Bcl-2 was only expressed in few lymphocytes. Cells undergoing apoptotic cells death in bacterial and viral meningitis demonstrated by TUNEL represented the same distribution of cells as TIA-1 and were predominan@ leukocytes. Conclusion: Therefore apoptosis induced by TIA-1 plays an important tole in leukocyte removal and recovery from meningitis. Because of its predominant appearance in leukocytes TIA-1 may also be released by leukocytes. P410 Neurobrucellosis and Deafness. I. Oztura, E Idiman, A. Yª Cavus, S. Ozakbas, N. Yapar (Izmir, TR)

E Kª

S. A.

Brucellosis is a zoonotic disease caused by gram negative bacteria of Brucella type. This micro organism is not affected by the enzymatic phagocytosis of the hosting cell, therefore the disease process may involve many organs. The nervous system may also be stricken either centrally or peripherally. Here we present two cases of neurobrucellosis with sensorineural hearing loss which rarely associates this clinical entity. The symptoms of case- 1 at the admission ( 11 year-old male) were hearing loss and irritability. His neurological exam revealed bilateral sensorineural hearing loss, vestibular nystagmus, positive Romberg's sign and gait ataxia. EEG showed diffuse slowing consistent with encephalopathy and serologic tests for Brucella were positive. At the 8th month of the treatment, he was improved for the sensorineural hearing loss and serologic tests, but nystagmus persisted. Case-2 was a 36 year-old, male patient who complained of gait disorder of 1.5 years duration and worsening hearing loss for the past 3 days. On his examination, bilateral sensorineural hearing loss, positive Romberg's sign, spastic paraparesis and Babinski positivity were found. His serologic tests also showed presence of positivity for Brucella screening test in blood and blocking antibodies for Brucella in CSE His somatosensory evoked potentials were also abnormal for the lower extremities. After one month ofhis therapy, spasticity and paraparesis improved, but hearing loss persisted. In this paper, we discussed clinical diagnostic characteristics and treatment of neurobrucellosis which is an important health problem for the Mediterranean Countries depend on two cases.

P41 I The Primary Optic Atrophy Neurosyphilis Case. F. Ozer, K. Sarici, S. Cetin, S. Senol (Istanbul, TR) A neurosyphilis case, with optic atrophy is presented. A 41 years old male patient was admitted to hospital with visualloss in his both eyes. From the story, it is learned that the beginning of the visual loss in the rigbt eye was 10 months ago. In 3 months the right eye was out of function. The beginning of the sarne problem in the left eye within 3 months as well. The investigations of the cranial CT and the cranial MRI records concerning that period were normal. In the following months second M RI investigation with contrast, it is figured out a decrease in bilateral-optic-neural calibration. In neurological examination, it was observed that there were no direct and indirect light-reflex from the right eye buta weak one from the left eye.The right eye function of the patient who has a bilateral-optic-atrophy were completely lost, where as he was able to identify the existence of a light source from a distance of 30 centimetres. The bilateral pattern VEP responses could not be received. For the patient who is considered as neurosyphilis at first glance, Leber's optic atrophy, intoxication, demyelinating, infectious and malignant processes were differential diagnosis. On LP of CSF: Albumin: 36mg/dl, Chlor: 12mmol/dl, Glucose: 66 mg/dl, Cell: 86 leukocytes/mm3 (92 % lymphocytes). Other pathological findings were VDRL in 1/8 titer (+) as well as TPHA. Serum VDRL, RPR and TPHA values figured out positive as well. Penicillin treatment was applied for 21 days. There was no recovery on patient's right eye. Through his lefl eye he was able to count fingers from a distance of 5 meters. Without other findings of syphilis,our case is considered as suitable for presentation due to manifestation with the pure optical atrophy.

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Motor neuron disease P412 Epidemiology of amyotrophic lateral sclerosis in the province of Modena Italy. P. Sola, 1. Mandrioli, E. Merelli, F. Casoni, P. Faglioni (Modena, I) Previous epidemiological studies on ALS in Italy showed incidence and prevalence rates varying from 0.44 to 1.9 and from 1.56 to 5.4 respectively. In the province of Modena, situated in Emilia-Romagna, a region of northern Italy, a study performed in 1976-1986, reported a mean annual incidence of 0.78/100,000 a n d a prevalence of 2.35/100,000. We performed a retrospective epidemiological study on ALS in the province of Modena, from 1990 through 1999, in order to determine the incidence, prevalence and mortality rates and their variations over time and geographical areas. Cases were ascertained from different sources: the neurological centres and all the hospitals of the province, the death certificates, the Modena section of the ALS Italian Association (AISLA). We reviewed all the clinical records and included in the study only patients fulfilling the El Escorial Revised diagnostic criteria. During the considered period, 143 residents (67 males and 76 females) entered the study. The average annual incidence was 2.16/105,with a peak in the age class 75-79 years. Prevalence and mortality mean rates were 4.02/105 and 1.69/105. Incidence rate remained constant over time, while prevalence and mortality rates significantly increased, owing to a rise of survival time (ALS mean duration was 17.38 months in 1990, 43.18 months in 1999). The 50% of patients died in the first 2.5 years, 89% in 7 years. Age and clinical forms influenced the prognosis: the survival time was longer in younger patients and when the onset involved the lower limbs. In the mountainous areas, where agricultural work is more represented, the incidence, prevalence, mortality rates were higher than in urban areas and the onset of the disease was advanced of 10 years. None of the examined risk factors had statistical significance except for agricultural work and rural residence. Our incidence, prevalence and mortality rates are higher than those from previously reported Italian surveys and agree with the majority of internatioŸ237studies. A heterogeneous distribution of cases in the province has been detected, that requires further prospective studies. P413 Differential RNA splicing of the glutamate transporter EAAT2 in a transgenic model for amyotrophic lateral sclerosis. C. Mª B. Zhou, B. Schwalenst6cker, U. Seefried, A. C. Ludolph, T. Meyer (Ulm, D) The excitatory amino acid transporter 2 (EAAT2) is the major protein of high-affinity glutamate re-uptake. Rapid removal of glutamate from the synaptic cleft by EAAT2 modulates the termination of glutamatergic synaptic signalling and prevents neurotoxic effects of glutamate. A reduced protein expression of EAAT2 has been reported in the motor cortex and spinal cord of ALS patients. Aberrant RNA splicing of EAAT2 has been proposed to be the cause of the EAAT2 protein loss in ALS but its pathogenetic significance remains controversial. Also in the mouse model we cloned EAAT2 splice variants (MEAAT2/ 5 UT 1-6) showing different expression levels in the murine brain. To investigate alternative splicing in the course of motor neuron degeneration we studied a transgenic model of familial ALS (SOD 1-G93A) using competitive PCR of the splice forms MEAAT2/5 UT1-6 in the mouse spinal cord and cerebral cortex (GeneAmp rTh Reverse Transcriptase RNA PCR, Perkin Elmer). Already in the early course of the disease we found remarkable changes in the EAAT2 splicing regulation as compared to age-matched controls. At a preclinical stage, MEAAT2/SUT5 showed an increased expression and MEAAT2/5 UT6 a reduction in the spinal cord while the main transcript and MEAAT2/5UT1-4 were not regulated. We have now evidence that in the studied ALS-model EAAT2 splicing is characterized by an early regulation of distinct splice forms and proofs to be region-specific. We conclude that alternative splicing of EAAT2 RNA is a functional event in the normal and diseased mouse brain and changes of its quantitative expression may be part of the preclinical pathogenesis in the transgenic SOD 1G93A mouse model. P414 Role of the APEX gene in the aetiology of ALS in the Irish population. M.D. Alexander, B.I. Traynor, B. Corr, S. McQuaid, E. Frost, A. Greene, O. Hardiman (Dublin, IRL) Introduction: There is considerable evidence for distdrbance in oxidative metabolism and oxidative damage to protein in the aetiology of Amyotrophic Lateral Sclerosis (ALS). Though well characterized, mutations in

the copper/zinc superoxide dismutase gene (SOD1) account for 13-24% of familial ALS (FALS) and 1% of all ALS cases. DNA base excision repair is considered to be the predominant pathway for repair of oxidative DNA damage and the enzyme apurinic/apyrimidinic endonuclease (APE) plays a pivotal role in this process. Several workers have demonstrated an increased frequency of mutations in the APE gene (APEX), up to 70%, as well as reduced levels and activity of the endonuclease in patients with ALS. However, a large study from Scotland failed to confirm this, and found a mutation rate of less than 3 % but found several common polymorphisms. Airo: Given the similarities between onr well-defined homogeneous Irish ALS population and the Scottish population, we aimed to determine the frequency ofAPEX polymorphisms/mutations in our population and correlate these with SOD1 mutation status. Methods: To date DNA has been collected from 83 sporadic ALS patients (SALS) and 7 familial ALS patients, which approximates 45 % of the Irish population. DNA was extracted and subiected to PCR, SSCP adn heteroduplex analysis. Mobility shifts were further analysed by restriction enzyme digest and DNA sequencing. Results: Complete analysis of the SOD 1 gene has been achieved for al190 patients (and controls), and 2 exonic mutations and 3 putative mutations in the 3' untranslated region of exon 5 have been identified. To date 30 patients have undergone analysis of the APEX gene. Two potentially novel mutations in exon 2 have been identified and we have confirmed the high frequency of polymorphisms in exon 5. Conclusions: Although a preliminar), report, this data suggests that in the Irish population the frequency of mutations in the ,APEX gene is similar to that observed in the Scottish study. Furthermore, to date there is no correlation with either FALS, SALS or patients with SODI mutations, thus suggesting a minimal role for the APEX nuclease gene in the aetiology of ALS in our population.

P415 Factors affecting improved prognosis among Amyotrophic Lateral Sclerosis patients attending a multidisciplinary clinic: Findings of the Irish ALS Register over a six year study period 1995-2000. B. ]. Traynor, M. Alexander, B. Corr, E. Frost, O. Hardiman (Dublin, IRL) Objective: ALS patients are known to have an prolonged survival of approximately 6 months and an enhanced quality of life when they attend multidisciplinary clinics compared to individuals without access to such services. Data from the Irish ALS Register was analyzed to identify factors contributing to this improved prognosis and to determine if enrolment in a clinical trial is associated with extended survival. Design: Population-based Register of all ALS patients in Ireland using multiple sources of information to ensure complete case ascertainment. Patients: Two hundred and eighty-eight residents of Ireland with ALS initially diagnosed between q ]anuary 1995 and 31st December 2000. Of these patients,25 % attended the sole Irish multidisciplinary clinic, while the remaining patients were followed in general neurology clinics. Results: We examined survival among various subgroups of the ALS population classified according to site of disease onset, gender and age. Bulbaronset ALS patients attending a speciality clinic survived 8 months longer than their counterparts attending a general neurology clinic. In contrast the survival advantage among limb-onset ALS patients was notas dramatic. Median survival among female ALS patients followed in a multidisciplinary clinic was 6 months longer than that of women attending general neurology clinics. This effect was less marked among male ALS patients. Patients over the age of 55 years lived longer if they attended a multi-disciplinary clinic, but the survival of ALS patients with onset of symptoms at an early age was not influenced by clinic type. Patients enrolled on clinical trials had a prolonged survival compared to other non-enrolled patients, though the numbers of patients involved are small. Multivariate analysis confirmed female gender, bulbar onset and onset after 55 years as significant independent variables. Regular nutritional consultation and PEG tube insertion was more frequent and earlier among patients followed by the multi-speciality clinic compared to general neurology clinics. Conclusions: The Irish ALS Register is among the first to prospectively examine the clinical features and factors influencing survival of every ALS patient over an entire country. We conclude that frequent, structured clinical review and early symptomatic treatment strategies, particularly focusing on nutrition, should play a central role in the future care of ALS patients.

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P416 Immunological and electrophysiological findings in lower motor neuron syndromes. I. Niebroj-Dobosz, P. Janik, K. Rowinska-Marcinska, A. KosteraPruszczyk, H. Kwiecinski (Warsaw, PL) Lower motor neuron syndrome (LMNS) is a heterogeneous condition which includes patients with progressive lower motor neuron disease (LMND) and patients with the clinical phenotype of multifocal motor neuropathy (MMN). We studied the clinical, laboratory and elect rophysiological characteristics of 37 patients presenting with a LMNS. Based on the clinical and electrodiagnostic findings, 26 patients were diagnosed with LMND and 11 patients were diagnosed with MMN. We evaluated the presence of anti-GM 1 antibodies and elect rophysiological features in all patients. High titers of the IgM anti-GM1 antibodies were detected in the serum of 11/29 (38%) patients with LMNS. In the CSF, elevated anti-GM1 antibodies were found in 8/23 (35%) LMNS patients. CNEMG studies confirmed denervation/reinnervation in at least two regions in all examined patients. Nerve conduction studies revealed the presence of conduction block in 8/37 (22 %) patients including 7 patients with MMN and 1 with LMND. Fasciculation potentials and/or double discharges were disclosed in muscles of 12/37 (32%) LMNS patients. We conclude that patients with LMNS show more frequently the elevated anti-GM1 antibodies, as compared to classical ALS. P417 Heartrate variability and autonomic disturbancesin amyotrophiclateral sclerosis. ].M.H. Annese~ G.D. Borasio, D. Kaub-Witteme~ K. B6tzel (Mª D) Although autonomic disturbances are nota frequent clinical feature in amyotrophic lateral sclerosis (ALS), several studies have revealed subtle abnormalities in the autonomic functions of ALS patients. We investigated the prevalence of autonomic symptoms in 63 ALS patients using a standardised questionnaire. In 31 patients, the heart rate variability (HRV) during deep breathing was measured a s a test of autonomic function. 22 of 63 patients (35%) reported "cold" extremities, 14 patients (22%) had an urge incontinence, and 8 (13%) abnormal sweating. 15 of 31 patients (48%) showed a pathologically decreased heart rate variability compared to an age-correlated normal population. These patients did not differ significantly in age, sex, forced vital capacity, and duration of disease from patients with a normal HRV.The parasympathetic innervation of the heart originates from the dorsal nucleus of the vagal nerve, while parasympathetic neurones innervating the urethral sphincters are located at spinal levels $2-4. Since muscle weakness in ALS tends to spread from a spinal or bulbar focus in a centrifugal ma.nner, we correlated bulbar involvement in patients with abnormal HRV and involvement of distal muscles of the legs (L5-$2) in patients with urge incontinence. Remarkably, 9 (40 %) of the patients with decreased H RV had no bulbar involvement at all. Similarly, 5 (44 %) of the patients with bladder disturbances had no or only slight pareses of the legs. In contrast to these findings, in patients with urge incontinence, 9 (82 %) were found to have bulbar involvement, of which 7 (64%) patients suffered from predominant spastic dysarthria. These preliminary results may point to the possibility that higher centres of autonomic function rather than spinal cord neurones might be involved in the pathogenesis of autonomic dysfunction in ALS.

P418 Primary lateral sclerosis (PLS): a clinical study of nine cases. M. SanchezGuerra, L. Cerezal, ]. Pascual, R. Garcia-Valtuille, M. Rebollo, C. De Pablos, ]. Berciano (Santander, E) Background: PLS is a type of motor neuron disease (MND) with controversial nosology. Objective: To describe clinical findings in a series of PLS patients with long-term follow-up. Fatients and methods: From 1974 to 2000, nine sporadic patients conforming to PLS criteria (Pringle et al., Brain 1992; 145: 495-520) were identified; during this period of study 199 MND cases were recorded. Serial exams were available for all nine patients. With few exceptions ancillary data included cerebrospinal fluid study, MR imaging, electrophysiological evaluation and determination of vitamin E and BI2 and serology for Lyme disease, syphilis, HIV and HLTV-1. Results: There were 6 females and 3 males. Age at onset ranged from 33 to 56 years (median: 47) and clinical course from 4 to 37 (median: 13). The clinical picture consisted of slowly progressive spastic paraparesis with further spinobulbar paresis in 5 cases, pseudobulbar palsy followed by spastic paresis in 2, and spastic paraparesis in the remaining 2. Occasional and nonsevere dysphagia occurred in 4 cases. Two cases showed urinary urgency as a late clinical feature. Cognitive decline was not observed. Evolution to amy-

otrophic lateral sclerosis (ALS) occurred in one patient after 24 years of clinical course. Central motor conduction time after magnetic stimulation was delayed or unobtainable in all £ examined patients. MR imaging, performed in 8 cases, showed precentral cortex atrophy or slight corticospinal tract hyperintensity in 3 cases. Conclusions: PLS represents 4.5 % of all MND cases. Stereotype clinical picture and exclusion of known causes of pyramidal dysfunction gire support to the notion that PLS represents a distinct variant of MND. Although rare, evolution to ALS may occur. Magnetic motor cortex stimulation is the most informative ancillary test.

Multiple sclerosis P419 Glatiramer Acetate Reduces the Proportion of New Multiple Sclerosis Lesions Evolving into 'Black Holes'. M. Filippi, M. Rovaris, M. Rocca, I. Wolinsky, M. Sormani, G. Comi (Milan, Houston, I) T2-hyperintense multiple sclerosis (MS) lesions correspond to variable degrees of tissue disruption. Only a minority of these lesions appear as areas of hypointensity on post-contrast TI -weighted magnetic resonance imaging (MRI) scans. These "black holes" represent areas of severe demyelination and/or axonal loss. In relapsing-remitting (RR) MS, glatiramer acetate (GA) has a beneficial effect on clinical and several MRI measures of disease activity, but its ability to prevent irreversible tissue loss is not defined yet. This study was performed to evaluate whether GA treatment favourably modifies the evolution of newly-formed lesions in patients affected by RRMS. This study was a double-blind, placebo-controlled trial of 239 RRMS patients. Patients were randomized to receive either 20 mg GA or placebo daily for nine months. Dual echo, pre- and post-contrast (0.1 mmol/kg gadolinium-DTPA) Tl-weighted MRI scans of the brain (forty-four, 3-mm thick contiguous axial slices) were obtained every month. New T2 lesions with concomitant enhancement were identified on the scans obtained from month 1 to month 6. The evolution of each individual lesion was evaluated on all the following scans by assessing: a) the persistence of T2-hyperintensity; b) the persistence and recurrence of enhancement; c) the appearance and persistence of T l-hypointensity. A total of 1722 new lesions were identified. Overall, significantly fewer new T2 lesions appeared in GA-treated than in placebo patients. The percentage of new lesions which disappeared on subsequent T2-weighted scans was slightly, albeit not significantly, higher in GA-treated (4.1%) than in placebo (2.7%) patients. Enhancement duration was not significantly different between the two treatment arras, whereas the frequency of re-enhancing lesions was significantly lower in GA-treated than in placebo patients (5 % vs 8.5 %, p=0.002). The percentage of new lesions which evolved into black holes was lower in GA-treated thau in placebo patients on scans obtained seven (p=0.04) and eight (p=0.002) months after enhancement ceased. In RRMS patients, GA has a favorable effect not only on the formation of new MS lesions, but also in preventing re-enhancement and tissue loss once lesions are formed.

P420 Fatigue in Multiple Sclerosis: A Study with Magnetization Transfer and Diffusion Weighted Magnetic Resonance lmaging. M. Codella, M. Rocca, B. Colombo, P. Rossi, F. Mar tinelli-Boneschi, G. Comi, M. Filippi (Milan, I) In the past, several studies with conventional magnetic resonance imaging (MRI) have been couducted to elucidate the pathophysiology of fatigue in multiple sclerosis (MS). AII these studies did not find any correlation between fatigue scores and MRI measures. In this study, we assessed the magnetization transfer (MT) and diffusion-weighted (DW) magnetic resonance (MR) imaging correlates of fatigue in MS. We studied 28 RRMS patients, 14 with fatigue (mean age=38.4 years, median disease duration=6 years), according to the Fatigue Severity Scale (FSS) and 14 without fatigue (mean age=38.2 years, median disease duration=6.5 years) and 30 sex- and age-matched healthy volunteers. Al1 patients were non-disabled, non-depressed, and free from treatments which could induce fatigue. In all subjects, we obtained: a) dual-echo, b) magnetization transfer ratio (MTR) maps, c) mean diffusivity (MD) and fractional anisotropy (FA) maps of the brain. No lesions were detected in healthy volunteers. T2-weighted lesion load did not differ between fatigued and non-fatigued MS patients. No correlation was found between fatigue score and T2-weighted lesion load. Compared to controls, MS patients had significantly different MD histogram-de-

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rived metrics (p values ranging from 0.03 to 0.003) and FA hislogram-derived metrics (p < 0.0001). MTR histogram peak height was also significantly reduced in MS patients in comparison with healthy subjects (p=0.01 ). MTR, MD and FA histograms-derived metrics did not differ between fatigued and non-fatigued MS patients. There were no correlations between fatigue score and MTR, MD and FA histogram derived metrics. Our study suggests that the extent and severity of MS pathology in macroscopic lesions and normal-appearing white matter do not contribute to the development of fatigue in patients with MS. P421 Human melanocortin-1 receptor variants and their influence on susceptibility to and severity of multiple sclerosis. I. M. Par tridge, S. J. M. Weatherby, A.A. Fryer, M.D. Boggild, R.C. Strange, C.P. Hawkins (Stoke-on-Trent, Liverpool, UK) Introduction: Multiple sclerosis (MS) occurs most commonly in Caucasians. Historically melanocyte stimulating hormone (MSH) is intimately involved in regulation of pigmentation, however it has other activities including antiinflammatory and immunomodulatory functions including inhibition of production of pro-intlammatory cytokines such as TNF-alpha and induction of anti-inflammatory cytokines including IL- 10. Abnormal MSH levels have been found in 7(1% of patients suffering from MS exacerbat ions.An association study was therefore performed to investigate whether 5 common polymorphic variants of the MSH receptor, the melanocortin-1 receptor (MC1R) locus, on chromosome 16 are associated with susceptibility to or severity of MS. Methods: 430 Caucasian patients (74 % female, 26 % male) and 360 controls of Northern European origin were recruited. Mean onset age of MS was 31 -+ 9 years and mean disease duration was 12.8 +- 8.8 years. DNA was extracted from leukocytes and polymerase chain reaction RFLP-based assays were used to identify alleles containing the asp84 glu, va192met, asp151 cys, arg160trp and asp294his variants. Outcome was assessed by the expanded disability status scale (EDSS) and cases were stratified into mild/moderate disability (EDSS 0-5.5) and severe disability (EDSS 6-10) after disease duration of 10 years. Results were analysed using chi square testing and logistic regression to correct for independent covariants of age of onset, gender and disease duration. Significance levels were set at p < 0.05. Results: Significant association was found in the case control analysis between possession of the asp15 lcys mutant allele (horno- and heterozygotes) and controls implying protection from MS susceptibility (OR ~ 0.55, p = 0.006, 95 % C10.36-0.85). We also found that presence of the glu84 allele was associated with severe disability in patients with disease duration of more than 10 years (OR = 6.02, p = 0031, 95% CI 1.18-30.7). Both associations demonstrated a gene dosage effect. Conclusions: Different polymorphisms of MC 1R appear to be associated with susceptibility to and prognosis of MS. Whilst clearly of interest in this predominantLy Caucasian condition the Lack of evidence demonstrating MC1R expression in the brain confuses the picture. We postulate its expression in endothelial structures may have functional consequence on blood brain barrier immune modulation and integrity in relation to anti-inflammatory and immunomodulatory effects of MSH. P422 Brain Volume Changes in Patients at Presentation with Clinically lsolated Syndromes Suggestive of Multiple Sclerosis: Results from the ETOMS Study. M. Filippi, M. Rovaris, F. Barkhof, L. Durelli, G. Edan, O. Fernandez, H. P. Hartung, H. P. Hartung, P. Seeldrayers, P. Soelberg Sorensen, V. Martinelli, O. R. Hommes, G. Comi (Milan, 1; Amsterdam, NL; Turin, 1; Rennes, F; Malaga, E; Austria; Graz, AT; Bruxelles, B; Copenhagen, DK; Nijmegen, NL) In patients with clinically isolated syndromes (CIS) suggestive of multiple sclerosis (MS), low doses of interferon (IFN) beta-la are effective in delaying the evolution to clinically definite MS (CDMS) and in reducing magnetic resonance imaging (MRl)-measured disease activit y and burden. In patients with established MS, measures of brain volume or of its changes are correlated with the levels or changes of disability and can serve as outcome measures of treatment efficacy. We assessed whether a low dose of IFN beta-la is able to reduce the rate of brain volume decrease from patients at presentation with CIS enrolled in a double blind, placebo-controlled trial. 309 patients entered the ETOMS trial: 154 were randomized to receive 22 mcg of IFN beta-la (Rebif| Serono International) subcutaneously once a week and 155 identical placebo. The study duration was 24 months. Dual echo, pre- and post-contrast (0.2 mmol/kg Gd) Tl-weighted scans of the brain were obtained at baseline, after 12 and 24 months. Whole brain volume was measured from T l-weighted images using a semi-automated segmentation technique.

Mean brain volumes at study ent ry were 1210 mi for placebo and 1208 mi for treated patients. Placebo patients had a median reduction of brain volume of 9.5 mi during the first year, 6.0 mi during the second year and 15.0 mi during the entire study period. The corresponding values for treated patients were 9.0, 5.5 and 12.0 ml, respectively. Brain volume changes from baseline to month 24 were significant for both study arms (p < 0.001 ), but no significant treatment effect was detected. Mean baseline brain volumes were 1211 mi for patients who did not develop CDMS and 1207 mi for those who did. At baseline, no significant correlation was found between brain volume and the burden of T2 hyperintense,T1 hypointense or enhancing MS lesions. Over the entire study period, significant correlations were found between the brain volume change and the numbers of enhancing lesions (r=-0.16) and of new T2 lesions (r=-0.31 ). The number of new T2 lesions formed during the first year correlated significantly with brain volume changes during the second year of the study (r=-0.I9). In patients at presentalion with C1S, a low dose of IFN befa-la does not prevent the loss of brain tissue. The modest correlation between MRl-detected MS activity and brain volume decrease indicates that, in these patients, inflammation and neurodegeneration ate, at least partially, dissociated. P423 P300 in early relapsing-remitting multiple sderosis. J. Roquer, A. Rodriguez Campello, E. Munteis, A. Valls (Barcelona, E) Background: The P300 wave is a positive deflection in the human event-related potential, that only occurs if the subject is actively engaged in the task of detecting the targets. This wave may represent the transfer of information to consciousness, a process that involves many different regions of the brain (mainly the hippocampus and various association areas of the neocortex). lts anaplitude varies with the improbability of the targets and its latency varies with the difficulty of discriminating the target stimulus from the standard stimuli. In patients wilh decreased cognitive ability, the P300 is smaller and later than in age-matched normal subjects. It is well documented that in multiple sclerosis (MS) patients the P300 is often abnormal with a longer latency than matched controls and with a component amplitude relatively depressed. Also the P300 latency is strongly correlated with the presence of demyelinative brain lesions seen on magnetic resonance imaging scans and with cognitive impairment, but it is only weakly associated with the Kur tzke disability status score. Despite these facts there is little information about the P300 results in the early relapsing-remitting MS. Objective: The airo of our study is to analyze the P300 wave in the initial stage of MS disease. Patients and methods: P300 was obtained from 27 patients with early relapsing-remitting MS (new diagnosed cases or patients with less than three years of clinical symptoms). Results: They were 18 women and 9 men with a mean age of 34.6 )- 9.5 years. Nine tases were de novo MS patients and 18 were early cases (mean evolution from the first known symptoms 23.2 -+ 9.2 months). P300 latency was abnormal in 11 cases (40.7%) with delayed latency in 8 cases and amplitude depression in 3 cases. Conclusions: 1. In early RR MS patients the P300 is abnormal in 40.7% of cases. The most frequent abnormality is the delayed latency 2. Ir is necessary a follow-up with neuropsychological and P300 assessment to know whether these P300 abnormalities may reflect an early cognitive decline associated with MS. P424 Concurrence Of Demyelinating Lesions In Central And Peripheral Nervous System: Report Of Three Cases. E. Koutra, D. Karakalos, P. Angelidakis, D. Kravaritis, N. Balakas (Athens, GR) The concurrence of chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal central nervous system (CNS) demyelination is relatively uncommon. However, such cases have been described by several authors in recent years. The frequency of this association is not known. The initial clinical picture may be either a central or peripheral demyelinating disorder. We report three cases of young women with demyelinating lesions of both central and peripheral nervous system. The first of them had the clinical and laboratory features of multiple sclerosis (MS), while the two others were diagnosed as CIDP according to clinical, nerve conduction and cerebrospinal fluid (CSF) studies. Cranial and spinal magnetic resonance imaging (MRI) was performed in all of them and revealed multiple demyelinating lesions in CNS. Intrathecal IgG synthesis and visual evoked potentials (VEP) were also abnormal. Peripheral nerves conduction studies showed demyelinating polyneuropathy in the first patient (with MS). We discuss the possible pathogenetic relation between these two nosologic entities.

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P425 A dose-dependent down regulation of IFNAR-1 cell surface expression and

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IFN-dependent cellular responses after frequent treatment with Interferon Beta- I a in vitro. S. Dupont, S. Goelz, K. Moulder, M. Green (Cambridge, USA)

lnterferon Beta and thyroid dysfunction. A. Kreisler, J. de Seze, T. Stojkovic, M. Combelles, B. Delisse, A. Verier, P. Hautecoeur, P. Vermerscb (Lille Cedex, F)

Interferons (IFNs) exert their biological effects by binding to a multicomponent cell surface receptor. As a consequence of this binding, signalling molecules (Signal Transducers and Activators of Transcription, [STATs])are activated and new genes are transcribed. Since I FNs are potent, pleiotropic cytokines, the cell likely has mechanisms to modulate IFN activity in response to excessive or prolonged IFN exposure. To investigate this question, ]urkat T cells were exposed to IFN Beta-la (IFNB-la) in vitro. The effect of different courses of treatment and various concentrations of IFNB-la on the signal transduction pathway, as well as on biological activity, was examined. Results demonstrate a dose-dependent reduction in 1FNAR-1 cell surface expression beginning at relatively modest concentrations (< 100 IU/mL) of IFNB-la. This decreased cell surface expression of IFNAR-1 appeared to result in the attenuation of both STAT1 activation and the induction of IFNinducible genes in response to further IFN treatment. When cells are treated with IFNB-la (500 IU/mL) at 48-hour intervals, IFN-dependent STAT1phosphorylation and cellular responses are reduced by approximately 80-90 %. The reduction in STAT1 activation is restricted to the type-1 interferon signalling pathway as IFN-gamma-induced phosphorylation of STAT1 remained unaffected. After withdrawal of the IFN, full recovery of IFNAR-1 density on the surface membrane was a progressive, but surprisingly slow, process. Furthermore, frequent exposure to IFNB-la extended this refractory period. In the context of using IFNs as therapeutic agents in the treatment ofhuman disease, our data suggest that increasing the amount or frequency of IFN administration may not yield desired biological effects. Thus, issues concerning the dosage and the frequency of IFNB administration deserve careful consideration.

Introduction: The occurrence oran increase frequency of biological thyroid dysfunction in patients receiving an interferon beta (IFNB) for MS has already been described and evaluated around 20% of cases. However, since 1993, only 19 cases of clinical thyroid dysfunctions have been published. Aim of the study: To evaluate the frequency of clinical thyroid dysfunctions in a large cohort of patients treated by IFNB. Methods: We studied cases with clinical thyroid dysfunctions in a cohort of 700 MS patients receiving INFB during at least 3 months. Resuhs: Eight patients (1.1%) had clinical thyroid dysfunctions. Four patients were treated by IFNBlb and 4 by IFNBla. Three patients were in a secondary progressive form of MS. Four patients (a 52-year-old man and 3 women of respectively 42.48 and 51 years, treated by IFNBlb) developed clinical symptoms of hyperthyroidism afler 10 to 27 months of treatment. Three of them required IN FB to be stopped because of the severity of symptoms. They still required a carbimazole treatment several months after the onset of hyperthyroidism. In the fourth patient, hyperthyroidism disappeared spontaneously. Three patients (a 45-year-old man anda 51-year old woman treated by IFNBla anda 37-year old women treated by IFNBlb) developed hypothyroidism after 11 to 15 months of treatment. The severity of the clinical feature in one of them required the IFNBIa to be stopped. The use of L-thyroxin was also necessary during a few months. Finally, an increased thyroid volume without laboratory thyroid dysfunction was observed in a 25-year-old woman receiving IFNBla. Discussion: Although, laboratory thyroid dysfunctions are frequently observed in MS patients treated by INFB, clinical thyroid dysfunctions remain a rare side effect occurring in around 1% of cases. However, in several cases, side effects can be severe and need the IFNB treatment to be stopped.

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Course and prognosis of primary progressive multiple sclerosis: a French MS clinic based study. E Chedeville, M. Coustans, M. Mauduit, V. Golfier, F.

Sjogren Syndrome and Primary Progressive Multiple Sclerosis. D. Devos, ). de Seze, G. Castelnovo, P. Labauge, S. Dubucquoi, T. Stojkovic, D. Ferriby, P. Vermersch (Lille Cedex, Nimes, F)

Le Duff, J. Chaperon, G. Edan (Rennes, F) We assess in our primary progressive multiple sclerosis (PPMS) population demographic data, clinical manifestations, time to acquire different level of disability and to evaluate the main prognostic factors,which might influence disability in progressive MS. In total MS population 10 to 20% of patients have a progressive course of onset with no history of relapses. There are few studies that described the characteristics of this PPMS population. Using the new Thompson criteria (Thompson et al., 2000), we described our PPMS population and evolution. In our database using EDMUS (European data multiple sclerosis), 143 MS patients responded to the Thompson PPMS criteria: 64 patients had definite P0PMS, 58 probable PPMS, 13 possible PPMS, 8 should have a reconsider diagnosis. Among the 135 patients with definite, probable, and possible PPMS, we analyzed different demographic and clinical characteristics (sex, age, initial symptoms, neurological impairment and time for diagnosis, time to reach EDSS 6 and 8) and results of paraclinical st udies. The data were analysed using actuarial methods that account for censored follow-up (end point not reached over the follow-up period) to assess time to reach EDSS 6 and 8 and to evaluate possible prognostic factors. Mean age at MS onset was 39.5 years (y) ( 15-67 years). A significant difference was found in age of onset between male and female (37.42 vs 41.06) (p < 0.05). The sex-ratio (F/M) was 1.36. Mean disease duration follow-up was 10.9 y. Fifty percent ofpatients were seen less than 1 year after the onset of the disease; mean time for diagnosis was 3 y. since the onset. The mean EDSS at the time of the initial visit was 3.62. Neurological impairment at the initial evaluation was pyramidah 84.7 %, cerebellar: 30.8 %, sensory: 30 %, bladder or boweh 24.8%, brainstem: 15.2%, optic neuritis: 5.3%. Two and more functional systems were involved in 56.4 % at onset. The median time to reach EDSS 6 and EDSS 8 was respectively 11 and 25 y. Sex, age at onset, number and type of systems involved are not significant prognostic factors. Time to reacb EDSS 3 (< 4 y.) was significantly correlated with a poor evolution (p < 0.001 ). The clinical and paraclinical characteristics of our PPMS population are quite similar to previous findings, but sume aspects must be noted: low disability at the first examination, earlier diagnosis, better prognosis. We confirm that time to reach EDSS 3 is a significant prognostic factor.

Introduction: Sjogren's syndrome (SS) mimicking multiple sclerosis (MS) has been described. However, the prevalence of SS in relapsing remitting MS seems to be similar to that observed in the general population ( 1 to 3 %). The age of onset and the clinical presentation of SS may be very similar to primary progressive MS (PPMS). However, the frequency of an association between SS and PPMS is unknown. Aim of the study: To assess the frequency of SS in PPMS patients. Methods: The 6 clinical and laboratory criteria of SS (Vitali et al., 1996) were systematically screened in 55 consecutive PPMS patients who fulfilled the Thompson's et al. criteria. Patients were asked for xerophthalmia and xerostomia. In all patients, we also performed a minor salivary gland biopsy, a Schirmer test, a salivary gland scintigraphy and an antiRo (SSa) and antiLa (SSb) screening. Results: We found that 8 patients ( 14.5 %) had 4 criteria or more, allowing the diagnosis of definite SS. Furthermore, 13 patients (22 %) had 3 criteria. Discussion: The frequency of SS is higher in PPMS than in the general population, suggesting to systematically assess a screening for SS in PPMS. We proposed to include SS as an exclusion criteria for PPMS in the recent published criteria.

P429 Analysis Of Fatigue And Quality Of Life In Relapsing-Remitting Multiple Sclerosis Treated With Beta lnterferon. A. Miralles, B. Fuentes, E. DŸ Tejedor, F. Barreiro (Madrid, E) Introduction and objective: treatment with interferon Beta (IFNB) has supposed an impact in the quality of life (QOL) of the patients with relapsingremitting multiple sclerosis (RRMS). We propose accomplish a global and comparative analysis of the impact of treatment with IFNB on the fatigue and the quality of life in patients with RRMS. Patients and method: Transverse study. We selected 26 patients with RRMS in treatment with IFN-b 1-a "Avonex" (13 cases, group A) and IFNB 1b "Betaseron" (13 cases, group B). We used modified scale of the impact of the fatigue (MFIS) and 4th version of FAMS questionnaire about QOL. We accomplish correlation analysis between the punctuation's EDSS/MFIS, EDSS/FAMS, MFIS/FAMS, and the evolution times of the MS and evolution times of treatment with IFNB with MFIS and FAMS punctuation's; also we compare MFIS and FAMS punctuation's in both groups.

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Results: We did not find differences in MFIS and FAMS scales between both groups. Correlation's in total patients were positive between the EDSS/MFIS punctuation's (r=0.649; p < 0.001), EDSS/FAMS punctuation's (r=0.534; p=0.005), MFIS/FAMS punctuation's (r=0.705; p < 0.001); and there were no correlation between the evolution time of MS and evolution time of treatment with IFNB with MF1S and FAMS punctuation's. Conclusions: Our data showed no difference in the impact of the fatigue and the quality of life in patients treated with IFNB 1a and IFNB 1b. The evolution time of the disease and evolution time of treatment with IFNB don't influence on QOL neither severity of the fatigue. Both scales, MFIS and FAMS, are correLative and adjusted to the degree of disability measured by EDSS. P430 Quality of Life worsens over time in secondary progressive multiple sclerosis: results from the SPECTRIMS study. P.W.O'Connor, SPECTRIMS-studygronp (Toronto, CDN; Genera) Background: Both the Health Utility Index-3 (HUI-3) and EQ-5D are multiattribute utility based quality of life (QOL) assessment tools usable in the cross-sectional and longitudinal analysis of MS patients. Changes over time in MS QOL have not been extensively studied. Methods: In the SPECTRIMS study patients with secondary progressive MS (SPMS) were randomly assigned to placebo, Rebif (Ares 8erono) 44 mcg, or 22 mcg, 3 times per week. A subsample (n=128) of patients underwent QOL assessmem using the HUI-3 and EQ-5D every 6 months over 3 years. Results: Using the HUI-3, a general deterioration in QOL was noted over 3 years with a utility decrease of 0.15, 0.12 and 0.13 seen in the 44mcg, 22mcg and placebo groups respectively. Particular worsening of scores was seen for attributes measuring physical function such as ambulation and dexterity whereas measures of cognition, pain and emotion did not change. There were no notable differences between groups. With the EQ-5D the health status index score (HSI) showed a decrease over time in all 3 groups (range 0.07 to 0.08)with no between-group differences. The correlation over 3 years between change in EDSS and tIU1-3 was 0.27 versus 0.32 for the HSI score. Conclusion: Patients with SPMS show deterioration in QOL over time particularly in those attributes related to ambulation and dexterity. Changes in EDSS however are only weakly correlated to overall QOL, consistent with the muhidimensional nature of QOL and the ambulation orientation of the EDSS score for SPMS patients. Rebif treatment effects on QOL were not observed in this study. P431 Multiple sclerosis fatigue is decreased at 6 months by glatiramer acetate (Copaxone). L. M. Metz, S. B. Parten, S. M. Rose, S. D. McGuinness, C. J. Harris, J. I. Bakker, L. Lagendyk, D. Patry, M.Yeung, R. B. Bell, C. Power, W. F. Murphy, D. McGowan, C. Pederson (Calgary, Alberta, CDN) Objective: To assess the effect of glatiramer acetate and interferon beta on fatigue in people with multiple sclerosis (MS). Background: Fatigue is a common and disabling symptom in MS that often increases with disease activity. Reduction of MS fatigue would enhance the benefits of MS treatment and may be a marker of MS disease activity. Design/methods: As part of a cohort study of al1 treated patients (Avonex, Betaseron, Copaxone, and Rebif) in the Calgary MS clinic, fatigue was measured at baseline and 6 months using the fatigue impact scale (FIS). Change from baseline to 6 months generated scores for the total FIS and each sub-scale (physical, cognitive, and social). Positive scores represented improvement. A binomial variable was then generated with improvement defined as change greater than one standard deviation. A change less than, or within, one standard deviation was defined as no change/worsened. Groups (glatiramer acetate and interferon beta) were evaluated for differences in the proportion that were improved using the Fisher's exact test. Results: Six month paired FIS assessments were available for 223 patients. Seventy six percent were female. Age ranged from 19-61 years (mean 40, standard deviation 9.0) and ninety percent h a d a relapsing-remitting course. Sixty-one percent used glatiramer acetate; 39 % used an interferon. More patients improved on glatiramer acetate (25%) than on interferon (12 %) on the total FIS (p = 0.016, Relative Risk (RR) = 2.15, Con fidence Intervals (CI) = 1.12-4.12) and on every sub-scale, physical (29% vs 14%, p = 0.014, RR = 2.06, CI = 1.14-3.70), cognitive (22 % vs 8 %, p = 0.009, RR = 2.7, CI = 1.25-5.89), and social (20 % vs 12 %, p = 0.139, RR = 1.7, CI = 0.87-3.35). A similar proportion of patients in each treatment group worsened on the FIS and on each sub-scale (< 8 %). Stratified analysis did not suggest that the observed differences were due to confounding by age of gender. Conclusions: Glatiramer acetate is more than twice as likely as interferon

to improve fatigue in people with MS at six months. This increases the potential treatment benefit of glatiramer acetate (Copaxone). P432

Chlamydia pneumoniae infection correlates with clinical activity in Multiple Sclerosis. A. Pincherle, F. Blasi, D. Franciotta, M. Filippi, E Patti, A. Reggio, G. ComŸ L. M. E. Grimaldi (Milan, Paria, Catania, Caltanissetta, 1) An association between Chlamydia pneumoniae (CP) and Multiple Sclerosis (MS) has been recen@ proposed based on the higher frequency ofCP detection in the cerebrospinal fluid (CSF) of MS patients compared to neurological controls. This tantalising finding has been partially replicated by some but not all studies. All positive studies have so far looked only for CP infection prevalence in MS patients, not with possible CP association with clinical or para-clinical variables seen in these patients. To assess whether CP detection in the CSF and serum of MS patients has clinical or radiologicaL implications, we evaluated the presence of CP in serum and CSF samples from 107 MS patients and 77 controls affected by other neurological diseases (OND). DNA detection was performed by touchdown nested polymerase chain reaction (PCR) using primers designed to amplify the mayor outer membrane protein gene. Anti CP immunoglobulins were measured by micro-immunofluorescence (Labsystems, Finland). In 50 MS patients we performed a brain MRI at the time of the lumbar puncture (LI') and then, according to previously reported criteria, we quant•fied the lesional load and the number of active lesions. Antibodies studies were unrevealing. CP DNA sequences were detected in the CSF of 23 of 107 (21.5%) MS patients and in 2 of 77 OND patients (p=0.0002). Despite a similar age at the time of LP, CP+ MS patients hada Ionger disease duration (7.5 vs 4.4; p < 0.05) and showed MRI evidente of a more active disease (mean Ormerod score 53 vs 34; mean number of enhancing lesions 5 vs 2; p < 0.05) compared to CP-MS patients. In conclusion, CP infection seems to characterize a subgroup of MS patients with an anticipated onset of disease anda more relevant neuroradiological evidence of demyelination/inflammation accumulation over time. Since CP is a bacterial agent sensitive to specific antibiotic treatments, it is thus reasonable to speculate that an antibiotic regimen aimed to eradicate CP infection from the CSF of MS patients, might be beneficial in preventing or even reducing disease progression in MS patients. P433 Is the demyelinating plaque in the root entry zone of the trigeminal nerve the cause of trigeminal neuralgia in MS patients? P. Ferroli, I. Dones, L. Fafina, A. Franzini, M. Pintucci, L. Lamantia, G. Broggi (Milano, I) A demyelinatiog lesion (DL) at the trigeminal root entry zone (TREZ) is generally considered as the main etiologic factor of trigeminal neuralgia (TN) in MS. TREZ is the short ( 1-3 mm) extension og the central"glial dome"into the nerve. In "idiopathic" TN, it is oflen found compressed by a vessel at surgery. Eleven patients affected by typical TN and MS diagnosed according to Poser's criteria were collected for this study. All of them underwent MRI with an ad hoc protocol to find out demyelinating plaques in the brain stem (axial and coronal DP and T2-wi) and to analyze neurovascular relationships of the trigeminal root (coronal FFE Tlwi afler c. m. and TOF 3d MRA). Baseline clinical data ate the following: sex 6M, 5F; age 42-78 yrs (mean 56 yrs), affected sides: 13 (7 right, 2 lefl, 2/11 bilateral): affected branches: III 7/13, II-fil 4/13, 11 2/13: mean duration of MS clinical history: 7 yrs: mean duration of TN: 4 yrs. The MRI analysis of possible causes of TN disclosed: both plaques and vascular compression in 6/13 (46%), only plaques in 4/13 (23%), only vascular compression in 1/13 (8%); neither plaques nor vascular compression in 2/13 (23 %). The MRI finding of TREZ vascular compression could be surgically confirmed in all patients. One MRI false negative was found at operation (little branch of superior cerebellar artery compressing the TREZ). A clear extension of the IPTF plaque into the trigeminal REZ cou]d never be observed by MRI. DLs of the nuclear and supranuclear trigeminal system asymptomatic IPTF plaques and vascular contacts were also noted. The IPTF and not the TREZ is the more evident site of demyelination at MRI in TNMS patients. Vascular compression also in these patients should not be forgot.

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Preponderance Of The Genetic Component In Sardinian Multiple Sclerosis Familial Aggregation. M.G. Marrosu, M. Lai, E. Coceo, V. Loi, G. Spinicci, M. P. Pischedda, S. Massole, G. Marrosu, P. Contu (Cagliari, I) Objective: To estimate the presence of familial aggregation and to establish the contribution of genetic factors to familial clustering of MS in patients coming from Sardinia, a Mediterranean island considered a genetically homogeneous isolated area having a high incidence and prevalence of the disease. Methods: Recurrence risk in siblings of 901 Sardinian patients and factors influencing risk (gender of patient and sibling, onset age of patient, birth cohort of sibling and presence of affected relatives otber than sibs) were examine& The presence of distant familia[ re[ationships among patients was evaluated by tracing the extended pedigrees of all MS patients born in a Sardinian village. Results: Twenty-three brothers and 36 sisters of the 2,971 siblings were affected with MS. The recurrence risk was greater in siblings of an index patient with onset age below 30 years (p < 0.01, increased risk 2.33 fold) and having a relative with MS other than sibling or parent (p < 0.01, increased risk 2.90 fold). Pedigree analysis of pat ients from the village of L. showed that all 11 patients descended from three pairs of ancestors, while no cases occurred in the remaining 2,346 inhabitants of the village. In descendants from the three couples, MS prevalence was dramatically bigber than the regional one and 1.5 times higher than that observed in siblings of affected cases. Conclusions: Data from this study indicate that MS familia[ aggregation in Sardinians is influenced by genetic factors and that founder eflect and isolation of Sardinia can be considered causative for the enrichment of"etiologic" MS genes.

presence in multiple sclerosis (MS). It's thought to be a rare or late-limiting finding in MS, but recent evidences supported that WD is also an early event in clinically isolated demyelinating syndromes. Case Report: We present clinical and neuroimaging findings in a case of a 43 years old woman. She abruptly showed: fine and precise movements impairment in right hand, deteriorating in handwriting ability, lower right limb hyposthenia and dysarthria. Brain MRI showed a large ovoid periventricular T2- hyper intense lesion localized near left lateral ventricle, and another smaller frontal lesion, both Gadolinium-enhancing. Spinal cord MRI, evoked potentials and serum autoantibodies were negative. Oligoclonal bands (OB) were detected in cerebro spinal fluid. The patient partially improved afler IV methylprednisolone (1 gram for 5 days) treatment. Six months later, a second brain MRI showed some new T2 lesions, reduction of the old left periventricular lesion with no enhancement and malacic central nucleus; in addiction, a long band of T2 weighted MRI increased-signal intensity traced anatomical course of the pyramidal tract from the lesion in the internal capsule to the cerebral peduncles, reaching the pons. This finding was compatible with W D of the pyramidal tract. Afler 13 months, a third brain MRI evidenced a new not enhancing periventricular lesion and confirmed the presence of unmodified WD. Nowadays, clinical symptoms fully recovered, apart persistente of a moderate impairment in right hand's fine and precise movements. Conclusion: This case supports the opinion that degeneration, presumably affecting both myelin and axons, may occur even in the earliest stages of demyelination, like in clinically isolated demyelinating syndrome or in early MS. P437 Conjugal Multiple Sclerosis In Sardinian Patients. E. Coceo, P. Marchi, M. Lai, F. Carboni, G. Spinicci, P. Contu, M. G. Marrosu (Cagliari, I)

P435

Neurolupus Mimicking Multiple Sclerosis: A Case Report. E. Coceo, C. Pilia, P. Marchi, P. E. Manconi, A. Vannelli, M. G. Marrosu (Cagliari, 1) Background: Central nervous system (CNS) dysfunction in patients with systemic lupus erythematosus (SLE) is highly variable, although it is often described under a single heading of"neuropsychiatric" or "CNS" SLE. Neuropsychiatric symptoms affect 40-50% of SLE patients. In SLE the most common neuropathological finding is noninflammatory vasculopathy of small arterioles and capillaries, resulting in microinfarcts and micro-haemorrhages,while vasculitis of cerebral vessels is rare and its incidence in postmortero studies does not exceed 7 % of cases. A wide spectrum of cerebral MRI abnormalities have been described in these patients. Rarely, SLE may produce relapsing, multifocal neurological manifestations similar to those of multiple sclerosis (MS). Case Report: A 57 years old woman presented in 1984 generalized tonic clonic ~eizures with normal cerebral CT sean. In 1997 she experienced diplopia for two months, spontaneously recovered. Cranial MRI demonstrated multiple not enhancing demyelinating lesions and moderate brain atrophy. In February 2000 the patient presented lower limbs hyposthenia, arras ataxic tremor, and episodic faecal incontinence. A second cranial MRI did not show difference from the previous one. Spinal cord MRI did not rereal alterations. Lumbar puncture was negative for oligoclonal bands; PEV and BAEP were normal, while SEP pattern suggested sensory central dysfunction. Laboratory investigations showed mild anemia, platelets decrease, and serum iron depletion, increased azotemia. C3 and C4 were normal, while serum IgG were increased. Antinuclear antibodies (ANA) titer was 1:80 with a homogeneous pattern; no other antibodies alterations were found. A new evaluation of serum autoantibodies after two months showed presence of antibodies to cardiolipin (in two different times). An antiphospholipid syndrome was diagnosed. A few months later she developed a SLE's typical dinical pattern, consisting in polyserositis, renal failure, lung hypertension and lung thromboembolism. Conclusion: This case is representative of the importance in differential diagnosis of clinical and laboratory findings instead of MRI seans alone in demyelinating diseases. P436 Wallerian Degeneration of Pyramidal tract in a Clinically lsolated demyelinating Syndrome. E. Coceo, M. G. Marrosu, P. Marchi, M. Matta, M. V. Cherchi (Cagliari, I) Background: Wallerian degeneration (WD) consists in descending destruction of axons and myelin sheaths resulting in neuronal damage. WD is leads to an increase of extra cellular water content, producing increased signal in_ tensity on T2 weighted MRI scans. WD is commonly seen after stroke and results in persistent neurological deficit. There are only few reports about its

Background: Epidemiological studies have implicated interplay between genetic and environmental Ÿ in multiple sclerosis (MS) etiology. Despite degree of interplay between nature versus nurture in determining the disease is unknown, the rarity of conjugal MS suggests that environmental factors that result in familia1 aggregation act in childhood, as suggested by migration studies. Objective: To estimate the prevalence of conjugal Sardinian MS cases and recurrence risk in offspring and to describe clinical and immunogenetic characteristics of these patients. Subjects and methods: The analysis was performed on 1,020 well-characterized MS Sardinian patients, all followed at the MS Center of Cagliari (Sardinia). The confidence interval for prevalence was calculated according to the Poisson distribution. Statistical analysis was performed by means of the SPSS statistical package SPSS. Results: Five couples of conjugal MS were found among 651 spouses of study probands for a crude conjugal tate of 0.98%; tire (C. I. 1.6-11.8) fold higher than expected on the basis of the prevalence of the general Sardinian population (0.15). None of the 7 offspring (4 daughters and 3 sons mean age 13.2 years) oŸthese MS couples had MS. Six patients carried the Sardinian MS-predisposing H LA-DRB 1*0301 - DQA 1*0501-DQB 1'*0201. Mean age was 47.8 in husbands and 40.4 in wives; mean age at onset was 31.8 in husbands and 23.2 in wives; mean duration of disease was 16 years for husbands and 17.2 years for wives. Clinical course was relapsing remitting in all wives and in two husbands, while it was secondary progressive in 3 husbands. Mean EDSS was 5.3 in husbands and 2.3 in wives. Onset of symptoms of spouses occurred a mean time of 13.6 years after the onset of their partners. The mean time between the onset of the disease in the second spouses and the beginning of cohabitation or wedding was 7.4 years. Conclusion: The high prevalence of Sardinian MS spouses may support the hypothesis that common environmental factors shared in adulthood by spousal pairs may act in t rigger the disease in genetically at risk populations. The young age of offspring could explain the fact that none of them presented MS, further investigations are needed to evaluate the recurrertce risk of MS in these individuals.

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Peripheralneuropathy P438

Clinical, electrophysiological and genetic studies in a Costa Rican family with hereditary motor and sensory neuropathy. C. Kayser, M. Berghoff, A. Leal, G. Del Valle, B. Morera, R. Villegas, E. Hern andez, M. Mendez, H. C. Hennies, R. Barruntes, A. Reiss, B. Rautenstrauss, B. Neundoerfer, D. Heuss (Erlangen, D; San Jose, CR; Barcelona, E; Berlin, D) The clinical, electrophysiological and genetic findings ate described in a Costa Rican family diagnosed with autosomal recessive hereditary motor and sensory neuropathy. We investigated this large family and here we present the data from six affected patients belonging to one of three branches of this consanguineous family with predominant Spanish ancestry. In the presented tases genetic linkage analysis mapped to 19q13.3. The analyzed family originates from a single town in the province of Alajuela, Republic of Costa Rica in Central America. The age at onset of chronic symmetric sensory-motor polyneuropathy was 28 to 42 years. All patients presented with symmetric weakness of plantar extensor and flexor muscles in the lower extremities, distal weakness in the upper extremities were present in four patients. Sensory deficit in a stocking-glove pattern was present in all patients. Deep tendon reflexes were reduced or absent. The electrophysiologic data reflect ah axonal degeneratire process: Motor conduction velocities in the upper extremities were normal nr slightly reduce& in the lower extremities absent or reduce& Sensory nerve conduction velocities cnuld nnly be detected in one patient in the upper extremities. Amp[itudes were decreased in affected nerves, motor and sensnry nerve potentials did not show temporal dispersion. EMG showed an increased number of polyphasic motor unir potentials (MUP) and increased amp94 of the MUPs. P439 Multifocal motor and sensory neuropathy following whiplash injury. D. Dive, S. Noez, C. Iserentant, I:. Tinant, F. C. Wang (Liege, B) A woman aged 47 years developed immediately after a whiplash injury, acute cervical pain and several days later, tingling paresthesiae affecting the ulnar nerve territory. On examination, one year after whiplash, there was wasting and weakness of right hand muscles. The right triceps jerk was absent. The appreciation of light touch and pinprick was impaired over the right ulnar nerve territory. Right brachial plexus MRI showed increased signal intensity on T2 weighted images of the lower trunk. The patient was diagnosed us having a brachiai plexopathy after whiplash injury. Two years later, right hand paresthesiae were unchanged and spread to the lateral three digits of her left hand and both feet. Weakness in her right hand slowly increased and spread to the left han& Neurological examination confirmed that weakness and wasting spread to both hands. The right triceps jerk remained absent while brachioradialis and knee jerks became depressed and ankle jerks absent. There was cutaneous sensory impairment affecting right C6 to DI dermatomes. Brachial plexus MRI confirmed previous findings. Left median nerve somatosensory evoked potentials (SSEPs) revealed an increased conductinn time between elbow and Erb's point with a proximal response amplitude reduction. Right ulnar SSEPs showed only an increased conduction time between elbow and Erb's point. Needle electromyography ofhand muscles on both sides showed slight reduced motor unir recruitment without active denervation. Motor nerve conduction velocity in the left median nerve in the forearm was decreased al 42 m/s withnut thenar compound muscle action potential size decrease. The right ulnar, both medial antebrachial cutaneous, and both suralis sensory action potential amplitudes were decreased. Routine haematological, biochemical and immunological b[ood analysis were normal. Testing for anti-ganglioside antibodies was negative. CSF protein concentration was 32 mg/dl. The patient was treated with high dose 94 fol[owed by substantial improvement. On the basis of a progressive sensorimotor, partly demyelinating, multifocal neuropathy with improvement after IVIG therapy, we concluded to a dysimmune (Lewis-Sumner type) neuropathy triggering by whiplash injury. The increased brachial plexus MRI signal intensity unchanged 3 years after the initial trauma, disappeared after immune therapy suggesting that ir was related rather to the dysimmune process than to whiplash injury.

P440 Adie's pupils as phenotypic expression of a Thr 12Met mutation in the MPZgene in a family with Charcot-Marie-Tooth neuropathy. T. Kuntzer, M. Dunand-Ditisheim, A. Ruffieux, D.F. Schorderet, J. Bogousslavsky (Lausanne, CH) We observed a missense mutation (Thr12Met mutation in exon 3 of PO) in the peripheral myelin protein zero gene (MPZ), (Laboratory of neurogenetics, University of Antwerp) in 3 CMT patients from the same family. The mutation is associated with a clinically distinct phenotype characterized by blurred vision al fixation that correlates with large and irregular Adie's pupils and by late onset of bilateral distal muscle weakness of the lower limb extensor muscles with mild impairment of all sensory modalities. Nerve conduction velncities of the motor nerves vary from 34 m/s to 50 m/s. Clusters of remyelinating axons in a sural nerve biopsy demonstrate an axonal involvement, with axonal regeneration. In the evaluation of the index patient, a right temporal glioma was incidentally found. Ii is concluded that CMT patients with slightly reduced nerve conduetion velocity and pupillary abnnrmalities should be screened for MPZ mutatinns. P441 A comparative study of neuropsychiatric aspects in children with iron deficiency and Cooley's anemia. S. Shebl, F. Wael (Tanta, ET) Two clinical]y selected groups of patients (25 children with iron deficiency anemia and 25 children with B-thalassemia) and 25 healthy children were included in this study. A[I children were subjected to clinicai, neuro[ogical and psychiatric examination, hematological, electroencephalographic and psychometric studies including tests of intelligence, bebavior and organicity tests. Headache was the commonest symptom in thalassemia and iron deflciency patients. Vertigo was the only symptom showing statistically significant difference between three groups with the highest frequency among thalassemic patients. Signs of peripheral neuropathy were found in 13.6 % of iron deficient anaemic and 20% of thalassemic patients. One of our thalassemic patients showed manifestations of spinal cord compression. The lower level of serum iron and ferritin in iron deficient anaemic patients or the lower level of hemoglobin and the rise of the level of serum ferritin in thalassemic patients were associated with the lower scores obtained in IQ. Restlessness,poor concentration and distractibility were found among children with iron deficiency anemia, comparing to shyness and depression with psychomotor retardation that found in thalassemic children. EEG finding showed marked slowness that increase with lower level of hemoglobin in two groups and the higher the level of serum ferritin in thalassemic group. The abnormal cerebral discharge in EEG record was more frequently encountered among iron deficient anaemic group than in thalassemic group. P442 Severe axonal polyneuropathy following a tacrolimus (FKS06) overdosage in a lung transplant recipient. Y. Bnukriche, O. Brugi~re, P. Perrotte, Y. Castier, Y. Stocco, H. Mal, M. Fournier (Clichy, F) Introduction: Tacrolimus (FK506) is ah immunosuppressant drug increasingly used in solid organ transplantation. FK506-induced polyneuropathies are rarely encountered. We reporta case of severe axonal polyneuropathy in a lung transplant recipient which occurred during a FK506 overdosage. Case report: A 52-year-old man with idiopathic pulmonary fibrosis underwent a right single-lung transplantation. The initial post operative period was uneveniful and the patient was discharged to home on a regimen of Ciclosporin A, azathioprine and prednisone. Ten months later, he started to complain of •rogressive severe headache and vomiting. Neurologicai examination was normal. Cidosporin blood level was in therapeutic range. Cerebrospinal fluid analysis and magnetic resonance imaging of the brain were both normal. After three weeks of persistent severe headache and vomiting, ciclosporin was withheld and replaced by oral FK506. Within two days headache and vomiting disappeared. On day 3 of FK506 administration the patient started to complain of asthenia, paresthesias and burning sensation in the lower extremities and on day 4, he was unable to walk. Neurologica] examination revealed an areflexic tetraparesis. FK506 blood levels were above the therapeutic range. An electromyogram demonstrated evidence of a severe axonal polyneuropathy. After transient cessation, the whole-blood FK506 level progressively decreased and was thereafter kept in therapeutic range and the patient's condition gradually improved. Cnnc]usion: Axonal polyneuropathy is a very rare side effect of FK506. Because of increasing use of FK506 in solid organ transplantation, caution shnuld be paid with FK506 dosage monitoring in cases of peripheral nervous system symptoms.

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P443 Phrenic nerve palsy a s a feature of chronic inflammatory demyelinating polyradiculoneuropathy. T. Stojkovic, ]. de Seze, D. Ferriby, ]. E Hurtevent, C. Rose, E Fourrier, P. Vermersch (Lille cedex, F)

Taken together with previous animal studies, these results confirm the potential therapeutic interest of IFN-b in acute inflammatory neuropathies.

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is characterized by slowly progressive limb sensorimotor deficit associated with demyelinating features on electrophysiological studies. Phrenic nerve palsy is exceptionally described in CIDP, although it is a common feature of Guillain-Barr› syndrome, a disease that shares similar pathologicat mechanisms with CIDE Objective: To report clinical history and electrophysiological profile of four unusual cases of CIDP presenting with phrenic nerve palsy. Patients and methods: All these patients underwent clinical examination, electrodiagnostic studies including phrenic nerve stimulation, cerebrospinal fluid (CSF) analysis, chest X-ray, spirometry, arterial blood gases, dosage of antibodies to gangliosides, serum immunoeletrophoresis, serology for neurotropic viruses, campylobacter jejuni, Borrelia Burgdor feri, antinuclear antibodies, thyroid stimulating hormone level and routine blood examination. Patients were treated either with int ravenous immunoglobulin (IVlg) or steroids. Results: Two men and 2 women fulfilled the diagnostic criteria for CIDP defined by the Ad Hoc Subcommittee (Cornblath et al., 1991). Age of onset ranged from 56 to 66 years. Two patients had severe distal and proximal sensorimotor deficit and 2 had distal sensorimotor deficit. Phrenic nerve palsy was respectively unilateral in 2 and bilateral in the 2 others patients, which required mechanical ventilation. Vital eapaeity ranged from 30 to 51% of normal. CSF analysis showed elevated protein level (range 0.62 to 1.20 g/l). Serology for neurotropic viruses and bacteria were negative. There was neither clinical and nor biological markers of systemic disease. IgG and IgA monoclonal gammopathy was present in one patient. Antibodies to gangliosides were negative in all patients. The sensorimotor deficit and respiratory parameters improved after treatment with IVIg in 2 patients and steroids in one patient. The respiratory functions did not improve either with IVIg or steroids in a patient with bilateral phrenic palsy. Conclusion: Although it represents a rare condition, phrenic nerve may be involved in CIDP and may respond to either IVIg or steroids.

Autonomic Neuropathy in Diabetes Mellitus. V. Yayla, Y. Altuntas, K. Sarici,

P445 M. Ufacik, F. Ozer (lstanbul, TR) Autonomic neuropathy, predictor of poor prognosis, is in close relation with the degree of peripheral neuropathy. The aim of this study is to investigate the relationship between autonomic neuropathy and distal symmetric sensorimotor polyneuropathy in diabetic patients. Any medication, hypothyroidism, nephropathy or other systemic diseases causing polyneuropathy were the exclusion criteria from the study. In electrophysiologic investigation, nerve conduction studies, sympathetic skin response (SSR) and R-R interval variation (RRIV) tests were applied. The study group was consisted of 109 diabetic female and 73 diabetic male. Mean age of the patients was 56.31 + 12.37 ranging between 12 and 78. Mean duration of the diabetes was 10.10 _+ 7.70 ranging between 0 and 32 years. The control group of SSR was consisted of 27 normal subjects. Distal symmetric sensorimotor polyneuropathy (DSSMP) was found in 138 (75.82 %) of the patients. Pathologic findings on RRIV were present in 67.48 % of the patients who were subject to the test. RRIV was pathologic with together DSSMP in 50.30 % of the cases, and without DSSMP in 17.17%. The latency was 1.68 + 0.29 in upper limb and 2.30 _+ 0.47 in lower limb in diabetic patients on SSR test. They were 1.52 -+ 0.31 and 2.09 _+0.42 respectively in controls (p < 0.02). SSR test was pathologica122 % and 62 % respectively. Any statistical correlation was found between RRIV and EMG, RRIV and SSR and EMG and upper limb SSR. Only lower limb SSR was in close relation with EMG findings (p < 0.02). In conclusion autonomic neuropathy has a correlation with DSSMP in 50.30% of diabetic patients and in 17.17% of the cases pure cardiac neuropathy was the unique finding. Autonomic neuropathy is common and has to be detected by electrophysiologic investigations. P446

Differential Expression of the MAG lsoforms in Development and Demyelinating Neuropathies. M. Erb, K.A. Nave, A.J. Steck, N. Schaeren-Wiemers (Basel, CH; Goettingen, D)

P444

lnterferon-beta decreases adhesion and transmigration capacities of lymphocytes from patients with Guillain-Barr› syndrome, A. Cr› B. Chazaud, A. Plonquet, T. Sharshar, F. Poron, C. Sonnet, ]. Rapha6l, R. Gherardi (Cr› Garches, F) To investigate the effect of interferon-beta (IFN-b) on adhesion and transmigration capacities of lymphocytes from patients with Guillain-Barr› syndrome (GBS). GBS is characterized by infiltration of immune cells in nerve. Leukodiapedesis is a multistep.process characterized by (1) a selectin-dependent rolling, (2) ah integrin-mediated adhesion, and (3) ah integrin/proteinasedependent transmigration across the vessel wall. IFN-b decreases nerve tissue infiltration of mononuclear cells in experimental autoimmune neuritis (EAN). The effect of IFN-b on leukodiapedesis was evaluated using two in vitro functional tests: (1) Cell adhesion was performed in plates coated with rVCAM-1 or rICAM-I; (2) cell transmigration was performed during 24 hours with a modified Boyden chamber assay coated with fibronectin. Lymphocyte expression of VLA-4 and LFA-I was evaluated by FACS analysis. Cells were incubated without and with l FN-bla during 18 hours at the following concentrations 1000, 4000, 8000 UI/10⁶ cells/ml before cell adhesion assay, and during the transmigration assay. Very sbort incubation (5 minutes, 8000 UI) was also performed for cell adhesion experiments. IFN-b induced a dose dependent inhibition of lymphocyte adhesion to rVCAM-1 (adhesion index: 3.12 + 1.9 without IFN-b; 0.61 + 0.5 with IFN-b 8000) (p < 0.0001) and rICAM-1 (adhesion index: 13.9 +- 6.2 without IFN-b; 10.1 +_3.7 with IFN-b 8000) (p < 0.01 ). At the highest dose, inhibition of adhesion to rlCAM-1 was similar after 5 minutes or 18 hours of IFN-b incubation (9.8 +_5.2 vs 10.1 + 3.7). Incubation with I FN-b did not modulate the expression of VLA-4 (no IFN-b: 100%; IFN-b=8000:94.6 -+ 16.7) and LFA-1 (no IFN-b: 100%; IFN-b=8000:104 + 23.3). IFN-b also induced a dose-dependent inhibition of lymphocyte transmigration across fibronectin (-32% with IFN-b 1000; -54% with IFN-b 4000; -74% with IFN-b 8000) (p < 0.0001). IFN-b 1a decreases, within minutes, adhesion capacities of lymphocytes from GBS patients to rVCAM-1 and rICAM-1, the major cell adhesion moleeules expressed by activated endothelial cells, and transmigration across fibronectin, a major component of peripheral nerve extracellular matrix.

Myelin-associated glycoprotein (MAG) is expressed in the PNS and CNS myelin as two differentially regulated isoforms: L-MAG and S-MAG. L-MAG is the principal isoform during early PNS and CNS myelination, whereas SMAG is the main isoform in the adult. In contrast to the CNS, in the adult PNS L-MAG is down reguiated. We ate interested in the specific functional role of the two isoforms during de- and remyelination in mouse models for hereditary demyelinating neuropathies. We have generated green fluorescent protein (GFP)-tagged fusion proteins of both MAG isoforms, L-MAGGFP and S-MAG-GFP. TransŸ experiments of Oli-neu cells, an immortalized oligodendrocyte cell line, showed that both fusion proteins were synthesised and incorporated into the plasma membrane as the corresponding untagged isoforms. By RT-PCR analysis, we could show that Olineu cells grown in absence of cAMP express only L-MAG, whereas Oli-neu cells stimulated with cAMP express mainly the S-MAG splice variant. This result demonstrates that Oli-neu cells do differentially regulate the two isoforros in a similar manner as seen during development. As prerequisite for generation of transgenic mice expressing the L- and the S-MAG isoform individually tagged with GFP, we have inserted the GFP sequence either into exon 12 (for S-MAG) or into exon 13 (for L-MAG) of the mouse mag gene. lmmunofluorescent microscopy and RT-PCR analysis of transfected Oli-neu cells showed that neither the insertion of GFP into exon 12 (S-MAG-GFP) nor into exon 13 (L-MAG-GFP) disturbed the alternative splicing of the primary transcript for the GFP-tagged or the untagged MAG isoform. For instance, Oli-neu cells transfected with the mag gene construct containing the GFP sequence in exon 13 (L-MAG-GFP) cultured in absence of cAMP express L-MAG-GFP, whereas stimulated with cAMP S-MAG is synthesised. In conclusion, the two MAG-GFP fusion proteins are correctly biosynthesised and incorporated into the plasma membrane, and the insertion of the GFP sequence in the exons of the mag gene, coding for the two C-termini, does not disturb the alternative splicing. The two isoform specific mag-gfp gene constructs will allow us to investigate the differential expression of the two MAG isoforms in development and during de- and remyelination in transgenic mice by direct visualization of the fluorescent protein tagged isoform.

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P447 Familial Sensory Motor Neuropathy Accompanied by Cranial and Spinal Cord Tumours. M. Rakowicz, W. Lojkowska, W. Sobczyk, E. Waliniowska, A. Koziarski, D. Ryglewicz, I. Kulczycki, T. Michalska, M. Niewiadomska (Warsaw, PL) Eight family members from three generations have been affected by peripheral sensory motor neuropathy. Five of them were examined clinically, electrophysiologically and by magnetic resonance images (MRI) of brain and spinal cord. The quantitative EMG, neurography of sensory and motor nerves and somatosensory evoked potentials of the median (Mn-SEPs) and posterior tibial (Tn SEPs), visual evoked potentials (VEPs), and brainstem evoked potentials (BAEPs) were performed. The proband, a 43 year-old women at the age of 34 presented two cranial meningiomas andat 41 years suffered from back pain and progressive flaccid paresis of lower limbs. MRI revealed cystic spinal tumour extending from Th6 to L3 levels. EMG showed chronic sensory motor axonal neuropathy. The Tn-SEPs revealed prolonged conduction times along the thoracic spine and no abnormality in Mn-SEPs. Histopatbological examination of removed tumour from medullar cone and cauda equine disclosed myxopapilliform ependymoma. We examined two uncles of above patient: ( 1) - 67 year old man, (2) - 63 year old man and their two sons: (3) - aged 47 and (4) - aged 45 years. The sensory motor axonal neuropathy, slowing or conduction block of central sensory pathways of TnSEPs and at cervical level of Mn-SEPs were a common features in all of them. BAEP was abnormal at one side only in proband, her uncle (1) and cousin (3), while VEP revealed abnormalities in one cousin (3). MRI showed: in patient (1) - the high intensity signal in the cerebellum and in the cervical spinal cord, in case (2) - was not done, in patient (3) - the high intensity signal at the great occipital foramen and at cervical spinal cord levels, in patient (4) - a cystic tumour in the corpus callosum and intraspinally at cervical, and thoracic levels (C2 to Th6) with syringomyelia extending from C2 to Thl0.This last patient at age 16 suffered from weakness and wasting of proximal muscles in right upper limb. The motor neuron lesion with chronic denervation and normal CV were revealed by EMG. In the cousins the anticipation is manifesled by earlier onset of the disease in third generation. In the investigated patients an autosomal dominant neurofibromalosis type 2 was suspected but DNA analysis was not done yet.

P447b Vestibulo-autonomic reactions in neurological patients. B.M. Seemungal, R. A. Darles, P. Rudge, M. A. Gresty, A. M. Bronstein (London, UK) Autonomic features such as sweating, pallor and even vomiting can occur during vertigo. Objective assessment of autonomic variables however, has not been previously measured in patients during vertigo. We describe the autonomic reactivity in 4 patients undergoing routine catoric testing. Patient 1 is a 41 yr old female migraineur with an 8-year history of dizzy attacks lasting 4-6 hours; the migraine and vertigo being temporally dissociated. During caloric irrigation there was a marked increase over baseline in pulse (74 to 100 beats/min), breathing (0.4 to 0.8Hz) and mean blood pressure (85 to 95mm Hg). Following the caloric test she developed a severe migraine. Patient 2 is a 41 yr old man with syringomyelia who complained of syncopal attacks preceded by a short episode of vertigo. Left-sided caloric irrigation did not evoke any nystagmus due to wax, providing an inadvertent control. Right sided caloric irrigation resulted in a small hyperventilatory and hypertensive response during the period of nystagmus, but was then followed by a period of nausea and marked sympathetic response exemplified by profuse swealing and peripheral vasoconstriction. Patient 3 is a 43 yr old woman with a 12-month history of recurrent vertigo lasting 2-12 hours and has migraine which is temporally dissociated from her vertigo. Caloric testing had little effect on her blood pressure and pulse but her respiratory tate fell during the period of nystagmus (0.25 to 0.15Hz). This patient vomited on her last irrigation. Patient 4 is a 47-year-old woman who initially had an acute attack of vertigo of several hours in assqciation with a panic attack. Over the subsequent 3 months she reported a continuous feeling of disorientation interspersed with brief episodes of dizziness and panic attacks. Caloric irrigation precipitated a typical panic altack. There were increases in pulse (89 to 105 beats/min), mean blood pressure (120 to 134 mm Hg) and respiration (0.3 to 0.7Hz). Unlike patient 1 however, she reported no nausea. In summary, the autonomic response of patients with vertigo is heterogenous but contribute significantly to their morbidity. In predisposed individuals, exaggerated vestibulo-sympathetic responses and abnormalities of the engendered counter-regulatory mechanisms, may cause prominent autonomic symptoms. The variables which participate in producing such symptoms are unknown. One of these variables may be migraine which may have a reciprocal relationship with vertigo.

P447a Polyneuropathy Index-Revised in the Evaluation of Diabetic Neuropathy. O. Hasegawa, 1. Mori, S. Matsumoto, G. Gondo (Paris, F; Fukuoka,Yokohama,

1) The polyneuropathy index-revised (PNI-R),based on 8 electrophysiological parameters (conduction velocities and F-latencies), was constructed to obtain ah overall estimation of peripheral nerve conduction in diabetic patients, taking PNI asa model. PNI was calculated asa mean percentage of the normal on 12 velocity or latency parameters on motor nerve conduction studies. PNI-R is composed of 8 parameters; motor nerve conduction velocities in the forearm or leg segment and F-wave latencies after wrist or ankle stimulation concerning to the median, ulnar, peroneal and posterior tibial nerves. F-wave latencies were adjusted to 160 cm height and used reciprocals to compare with the normal values. Subjects were 101 patients with diabetes mellitus. Correlation of PNI-R or PNI with other parameters or Ÿ on conventional sensory and intrafascicular conduction studies or items concerning to the diabetes mellitus were studied. Coefficient of correlation between PNI-R and PNI was as high as 0.97. The mean value of PNI R was 0.6 % smaller than PNI. This was presumably due to the greater influence of the peroneal parameters, weighted more in PNI-R than in PNI. Peroneal nerve is known to be sensitive to various neuropathies, and is often damaged in_ dependently. Each parameter composing PN1-R h a d a close relationship with PNI-R itself. Mutual independence between 8 parameters was considered to be enough. Among neuropathic signs Achilles tendon reflex in particular, and among diabetic complications retinopathy in particular, hada high degree ofcorrelation with PNI-R. These results were identical both with PNI-R and PNI. We can save 20-30% of time in measuring PNI-R as compared to measure PNI,and the usefulness of PNI-R was as well as PNI. Therefore, using PNI-R as substitute for PNI is considered to be appropriate in the evaluation of diabetic polyneuropathy. Between parameters concerning to the median nerve F-wave latency correlated less with PNI-R than motor nerve conduction velocity in the forearm segment. Presumably this was owing to an unrecognised subclinical carpal tunnel syndrome, often observed in patients with diabetes mellit us. PNI-R will be an excellent index to express the function of peripheral nerve conduction, which can be retarded by the axonal degeneration in diabetes mellitus.

Poster session - 3

Cerebrovascular disorders P448 Parameters of time and patient characteristics influencing rehabilitation success in stroke patients. A. Nachtmann, P. Pilner, A. E Thilmann (EssenKettwig, D) Background: Does early rehabilitation provide a benefit for stroke patients and which parameters do influence rehabilitation success apart from rehabilitation programmes and techniques? Methodology: 1942 consecutive ischemic stroke patients admitted to a rehabilitation clinic within 90 days from stroke onset (either directly from the hospitals or with a short time at home, mean age 65,3 -+ 11,4 years, 1139 male, 803 female) were retrospectively regarded reporting Barthe[ index by the time of admission at the rehabilitation clinic (B 1), Barthel index by the time ofend of stationary rehabi[itation (B2),length of stay (TI),age,sex and time from stroke onsel to admission at the rehabilitation clinic (T2). Results: Rehabilitation success as measured by Delta of Barthel index (B2-B1) was positively correlated with age, T1 and negatively correlated with B1 in single analysis (ANOVA). Patients who were admitted late after st roke were significantly younger, hada lower B1 anda higher T 1. Older patients h a d a significant lower B1 and a shorter T1. In multiple regression analysis, a significant correlation with Delta of Barthel index could be shown for TI (p < 0.0001 ), T2 (p < 0.003) and BI (p < 0.0001 ), but not for age. No correlation to patient sex was observed. When only patients with a B1 lower than 85 poinls (N = 1000, mean age 68,4 + 10,5 years, 552 male, 448 female) were taken into account (to avoid ceiling effects), no major changes in effects or significance were observe& Discussion: During stationary rehabilitation, patients improved. This

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improvement was higher in patients coming early after stroke and dependent on the length of stay, but not dependent of age or sex. It has to be taken into account that spontaneous improvements occur rather in the early phase. Having this in mind, the influence of T2 on the improvements may be overestimated. Conclusion: Rehabilitation effects can be measured in both early and late rehabilitation regardless of age. Early rehabilitation provides higher effects and may result in a better overall outcome as well as in reduction of hospital time and therefore be more cost-effective. P449 Hydrocephalus as a predictor of outcome in thalamic hemorrhage. S. Passero, F. Reale (Siena, I)

The purpose of this study was to determine whether the presence of hydrocephalus after thalamic hemorrhage would predict outcome. We studied 117 (73 M, 44 F, mean age 66.1 + 11.4 years) consecutive patients with spontaneous thalamic hemorrhage diagnosed by CT scan. Of these, 82 (52 M, 30 F, mean age 66.2 -+ 12.0 years) showed no signs of hydrocephalus on initial CT scan examination and 35 (21 M, 14 F, mean age 65.9 _+ 10.0 years) had some degree of hydrocephalus. Patients treated with a ventriculostomy were excluded from the study. Among the several variables that were recorded we selected the following as those most likely to be relevant to prognosis: age, sex, mean blood pressure on admission, hemorrhage size, intraventricular spread of the hemorrhage, initial level of consciousness (Glasgow Coma Scale) and presence of hydrocephalus. Surviving patient's outcome was assessed at the time of discharge from the hospital. The patients with hydrocephalus were more likely to have intraventricular spread of hemorrhage, lower GCS scores, and greater hemorrhage size. Age and mean blood pressure on admission did not differ in those with and without hydrocephalus. Over half (57.1%) of the patients with hydrocephalus died compared with 20.7 % of those without hydrocephalus. The variables that emerged from the univariate analysis as predictors of mortality were hemorrhage size (P < 0.000), ventricular spread of hemorrhage (P < 0.003), GCS (P < 0.005), and hydrocephalus (P < 0.000). The multivariate analysis by logistic regression showed that factors independently contributing to the prediction of mortality were hemorrhage size (P < 0.000) and hydrocephalus (P < 0.000). Univariate and multivariate analyses indicate that ohstructive hydrocephalus is an independent predictor of in-hospital mortality in patients with thalamic hemorrhage. P450 Peripheral facial palsy and one-and-a-half syndrome due to paramedian pontine lacunar infarct. V. GarcŸ I. Goti, A. Cervera, E. Elloes, F. Valldeoriola (Barcelona, E) lntroduction: The clinical spectrum of pontine infarctions was widely described in the past century. Fisher characterized several lacunar syndromes and emphasised the existence of isolated lacunar pontine infarctions.We describe a patient with a pontine infarct presenting with peripheral facial palsy (P-FP) and one-and-a-half syndrome (OHS) its neuroradiological correlations. Patient: A 61-year-old woman suddenly developed horizontal diplopia. The vascular risk factors were hypertension and obesity. A left-sided facial weakness (P-FP) and left OHS was present. The cranial magnetic resonance (MR) demonstrated a small hyperintense lesion in T2 weighted sequences at the dorsal segmental paramedian pontine region, two days after admission; such lesion was not evidenced in TI weighted images and was considered to be acute. The cranial arteriography was including both vertebral arteries. Fifteen days after admission the symptoms remained unchanged and the patient was discharged with aspirin 300 mg/day. At the last follow-up the facial weakness has disappeared and only persisted a slight paresis of the conjugate gaze to the left. Discussion: The association of a OHS a n d a P-FP leads to a precise anatomical location of the lesionat the paramedian pontine reticular formation, the medial longitudinal fasciculus and the genu of the facial nerve. The MR allowed to verify the location of the lesion at the dorsal portion of the pontine tegmentum near to the floor of the fourth ventricle. There are several facts to diagnose of a lacunar infarct in this case: 1) The size and location of the lesion as seen in the MR images is congruent with that diagnosis; 2) the arteriographic findings demonstrating a normal basilar and vertebral arteries do not support a basilar thrombosis. The possible existence of a cardio embolic focus was appropriately ruled out; 3) the anatomical location of the infarct in the pontine tegmentum corresponded to the distal portion of paramedian arteries since the preservation of the ventral part of the pons is unlikely when a basilar thrombus occurs affecting the perforating branches from its beginning.

P451 NOTCH3 in-frame deletion involving three cysteine residues causes typical CADASIL. M. Dichgans, J. Herzog, T. Gasser (Munich, D) Mutations in Notch3 are the cause of CADASIL, an autosomal dominantly inherited angiopathy causing stroke in young aduhs. Al1 CADASIL mutations identified so lar result in the gain or loss ofone cysteine residue within one of 34 EGF-like repeat domains, each of which contains an invariant number of six cysteine residues. Here we report on an in-frame deletion causing a loss of 15 amino acids including the first, second and third cysteine residue within EGF-repeat No 6. The clinical spectrum and the severity of the phenotype in this family did not diverge from that of 100 CADASIL individuals with previously reported mutations. Our data suggest, that the absolute number of cysteine residues involved into Notch3 mutations has no major influence on the phenotype, whereas the change towards an odd number of cysteine residues within a given EGF repeat and therefore, an unpaired, reactive cysteine residue is the critical molecular event in CADASIL.

P452 Depressive disorders in stroke patients. L. Pijanmanova-Karovska, I. Barbov, S. Trajkovska (Skopje, Strumica, Prilep, MAK) Background: Depressive disorders often follow the neurological diseases, especially Parkinsonism, multiple sclerosis, cerebrovascular insult, etc. These ate the most frequent psychiatric disorders concerning the patients after stroke. They are important both for the high incidence of stroke and the slower recovery of these patients. Depressive disorders after stroke fall in the group of reactive and organic depressions. Methods and results: The purpose of this work is to determine the prevalence of depressive disorders and their clinical form after stroke, in the acute and rehabilitation phases as well as the influence of demographic and other factors. This paper presents a group of 128 patients with clinical diagnosis of stroke (both ischemic and haemorrhagic). Depressive disorders and their clinical forms within this group of patients are determined with clinical evaluation according to DSM IV criteria (Diagnostic and Statistical Manual of Mental Disorders, IV edition) and by means of Hamilton's scale fox evaluation of depressive levels, 7 'h (acute phase) and 3 0 th o n e (rehabilitation phase). We have found a high frequency of depressive disorders (major depression and dysthymic disorders) and an increase in frequency of depressive disorders from 32% (in acute phase) to 47% (in the rehabilitation phase). Conclusion: These patients need to be followed fora long time because of the increased incidence of depression months after stroke.

P453 Peripheral facial palsy and contralateral internuclear ophthalmoplegia due to paramedian pontine lacunar infarct. V. Garcia, P. Castro, A. Cerrera, E. Elices, F. Valldeoriola (Barcelona, E) Introduction: There are many different pontine segmental 1acunar syndromes. To our knowledge, the association between peripheral facial palsy (P-FP) and contralateral internuclear ophthalmoplegia (INO) has not been previously described. We present a case report and its clinicoradiological correlation. Patient: A 55-year-old man suddenly developed a right-sided facial weakness like a Bell's palsy and corticosteroids treatment was offered. One week afler he started with horizontal diplopia. The risk factors for atherosclerosis induded hypertension, diabetes meIlitus, smoker and obesity. In the neurological examination a left INO was present, the vertical eye movements and the convergence were normal; the pupils were briskly and symmetrically reactive to light. A cranial magnetic resonance (MR) obtained five days later demonstrated a well-defined hyperintense signal in the left paramedian dorsal pontine tegmentum and exceeding the midline. The lesions diffusion-weighted MR images was considered to be acute. Extracranial carotids were normal by doppler ultrasonography. The patient was discharged on aspirin 300 mg/day. The results of the examination were unchanged one week after. Discussion: The anatomical substrate of the INO results from involvement of the medial longitudinal fasciculus, and P-FP from nuclear or fascicular lesions of the facial nerve in the same side, involving the paramedian pontine tegmentum, irrigated by anteromedial group of paramedian pontine perforating branches off the basilar artery. We attribute this to involvement to the contralateral facial root over the dorsal surface of the abducens nucleus (as the genus of the facial nerve). Itis important to considerer a lacunar etiology in patients with P-FP and vascular risk factors since the facial

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weakness may precede the full ocular syndrome and, as in our case, lead to a mistaken diagnosis.

P456 lnternal carotid artery dissection and stroke a s a rare complication after lumbar disc surgery. K.-H. Henn (Offenbach, D)

P454 Medial Temporal Lobe Atrophy And Post-Stroke Dementia. M.A. Cordoliani-Mackowiak, H. Henon, 1. P. Pruvo, F. Pasquier, D. Leys (Lille, F)

We report two cases with patients who suffers from a stroke aftera lumbar disc surgery. The cause of the stroke was in both cases a d issection of the interna1 carotid artery. The surgery was done in both patients in a prone position with general anaesthesia. The first patient was a 49-year old women with a dissection of the right internal carotid artery followed by a malignant stroke of the territory of the middle cerebral artery which requires a decompression surgery of the skull. The dissection was documented by ultrasound examination with a occlusion of the internal carotid artery followed by reopening. This women had in her illness history a subarachnoida[ bleeding anda clipping of the right middle cerebral artery. The second patient was a 36-year old women with a dissection of the left internal carotid artery. She suffers from a left cerebral stroke with a hemiparesis and aphasia. The dissection was doeumented by angiography. Both patients recovered partly frnm the stroke but they cannot live independent. The second patient suffers from seizures. We suggest that the cause of the carotid dissection might be the change of the position of the patient between the beginning of anaesthesia und the beginning of the surgery which requires a change of the supine position of the patient to the prone position in general anaesthesia. Patients necks should be immobilized to rotate if they are turned to prone position. As we know this complication of lumbar disc surgery has been described earlier only once. (ReŸ Gould, D B (1994) Internal carotid artery dissection after remote surgery, latrogenic complications of anaesth'esia. Stroke. 25:1276-8)

Background: The prevalence of dementia increases after ischaemic stroke. Medial temporal lobe atrophy (MTLA) is associated with Alzheimer's disease, and with pre-existing dementia in stroke patients. Objective: The airo of this study was to determine the influence of MTLA on long-term risk of developing dementia in stroke patients, after exclusion of patients who had prestroke dementia. Methods: The study was conducted on 144 consecutive stroke patients older than 40 year-old (78 men; median age 72 years), who underwent noncontrast CT with temporal lobe oriented 2 mm contiguous slices at admission. A cut off point of 11.5 mm was used to differentiated patient with or without MTLA. Patients were followed longitudinally with clŸ and cognitive assessments for 3 years. Results: After 3 years of follow-up, 34 patients (23.6%) developed dementia. The cumulative proportion surviving without dementia was 57.6 % in stroke patients with MTLA and 80.8% in stroke patients without MTLA (p=00171 ). The relative risk of post-stroke dementia associated with MTLA was 2.3 (95% IC, 1.1 to 4.7). However, using logistic regression analysis, MTLA did not appeared as an independent predictor of post-stroke dementia; while increasing age, diabetes mellitus, severity of the clinical deficit, silent infarcts on CT, global cerebral atrophy and leukoaraiosis were independent factors. Conclusion: MTLA increases the risk of developing dementia in stroke patients by two-fold compared with those patients without MTLA,but doesn't contribute independently to that risk. Nevertheless, more long-term longitudinal follow-up is now necessary to evaluate MTLA as an independent risk factor for post-stroke dementia. P455 Acute and stepwise brainstem and spinai cord ischemia witb pathologic findings of Foix-Alajouanine syndrnme. N. Rodriguez, A. Moro, A. Mariscal, M. Garcia Villanueva, R. Diez, 1. C. Alvarez Cerme¡ J. C. Martinez-Castrillo (Madrid, Madrid, E) Introduction: Foix-Alajouanine syndrome is an acute necrotizing myelitis that causes stepwise spinal cord dysfunction. It is due to spinal cord vascular malformations, dural venous fistulae, extensive spinal cord thrombophlebitis, and chronic emphysema,. It is usually restricted to spinal cord localization. However, recently it has been described in other CNS localizations. We describe a patient with medullar and spinal cord symptoms. Patient: This 63- year-old-man was admitted because a sudden instability, nystagmus and dysarthria. His neurological condition worsened during the next weeks in a stepwise fashion,with some slight and partial remissions. He developed a flaccid tetraparesis, diplopia, dysphasia, dysarthria, and bilateral facial palsy.Admission brain MRI showed a medullar T2 hyperintense lesion. This lesion grew and spread to both inferior cerebellar peduncles. CSF showed a mild protein elevation. Immunological and microbiological studies were normal. Magnetic Resonance Angiography was normal. The clinical course continued worsening, and the patient died three months after admission. Autopsy showed a mild enlarged medulla. The lateral meduUar sulcus could not be distinguished. There were abnormal, tortuous, and dilated vesseis along the spinal cord, particularly over the posterior aspect of the thoracic segment. These vessels also involved all cervical and most of thoracic roots. SpinaI cord appeared congestive. There were areas of blood cells extravasation, vacuoles and pale areas, particularly in the anterior horns. There were abnormal vessels in the brainstem, both within the parenchyma and subarachnoid space. These vessels had thick and fibrous walls, with lumen reduction and thrombus, and almost lacked elastic and muscular fibers. Within the parenchyma, these abnormal vessels hada random distribution, their walls were thinner, hyaline and had aneurysm dilatations, resembled more venous than arterioles. There were multiple irregular ischemic areas, localized in the medulla and both cerebellar inferior peduncles, with loss of neurons, demyelination and gliosis, Conclusion: Histological findings revealed a chronic ischemic process of the medulla with abnormal thick and hyaline vessels, and a congestive spinal cord with tortuous and dilated vessels. These features may be characteristic of the Foix-Alajouanine syndrome, with brainstem symptoms.

P457 Is functional outcome at discharge influenced by the age in stroke patients.~ M. Blanco, F.J. Mora, G. Suarez, E. DŸ Tejedor, B. Fuentes, P. Barreiro (Madrid, E) Objective: The aim of this study is to determine if there are differences among different age groups in relation to the functional outcome at discharge. Patients and methods: Sequential observational study from our stroke in-patients database (1994-1997), excluding TIAs. Functional outcome at discharge was analysed with Modified Rankin Scale (MRS) for age intervals: 15-45, 46-60, 61-80, > 80. The MRS scores were expressed: 0-2, Independents (ID); 3-4, dependents, (D); 5-6, total dependence or death (TDD). We also analysed relationsbip between stroke subtype and age intervals. Results: 1471 patients were studied. Functional outcome in different groups: 15-45 years old: ID 74%, D 14% and TDD 12%. 46-60 years old: ID 76.1%, D 5.8% and TDD 8.1%; 61-80 years old: ID 64.8%, D 23.9% and TDD 11.3%; > 80 years o[d: ID 38.3%, D 39% and TDD 22.4%. Stroke subtype age comparison shows: > 80 years atherothrombotic stroke higher ID (p < 0,05) and [esser D (p < 0,05). Cardio embolic stroke > 80 higher TDD and D (p < 0.05) and < 60 years old lesser TDD (p < 0.05). lndeterminate stroke increase ID in < 60 years old (p < 0.05) and decrease ID in > 80 years old (p < 0.05). Conclusions: Age influences functional outcome at discharge except for total dependent or death group. Patients < 60 years old show higher independent percentage than older. P458 Long-Term Functional Outcome Of Hemicraniectomy In Middle Cerebral Artery Malignant Infarcts. R. Manai, A. Srour, S. Crozier, X. Vandamme, Y. Samson, P. Cornu, G. Rancurel (ParŸ F) Objective: To investigate functional recovery and long-term functional outcome after hemicraniectomy for MAC malignant infarcts. Background: Hemicraniectomy improves survival in severe MCA infarcts but little is known about time-course of recovery and long-term outcome. Design/methods: We recorded the latest modified Rankin's score in the 16 surviving patients of 19 which had early hemicraniectomy for malignant MCA infarcts in our institution during the past three years. Mean age was 48 • 10 years (range 24-60). Results: Four patients had a > 2 years follow-up (median 28 months, range 33-25). One hada Rankin's score of 2 and worked full-time and the three others had a score of 3. Six patients hada > 1 year follow-up (median 15 months, range 16-14 ). Ohe had a 2 Rankin's score, tbree hada 3 score, and 2 hada 4-5 score. Two of be patients of this group resume work half-time. Six patients hada fol]ow-up < 1 year (median 4 months, range 3-9). AII still have a 4-5 Rankin's score. Conclusion: In malignant MCA infarcts, hemicraniectomy not only saves

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lives, but also carried on a reasonably good long-term functional outcome. Yet recovery seems to be much slower than ah usual ischemic stroke extending over one to two years.

P461 Bilateral symmetric caudate infarcts complicating subacute endocarditis. S. Crozier, V. Cochen, R. Manai, S. Leh› Y. Samson, C. Marsault, G. Rancurel (ParŸ F)

P459 Coronary Arterial Disease And Stroke. The Importance Of A Better Knowledge To Decrease The Risk. B. Fuentes, E. Diez Tejedor, M. Lara, A. Frank, P. Barreirn (Madrid, E)

A 68 year-old women was admitted in our stroke unir for the sudden onset of a febrile confusion. She had been hospitalised in internal medicine department one month before for a subacute aortic endocarditis related to a streptococcus bovis septicaemia. The patient was treated with adapted antibiotherapy for 3 weeks and was discharged at home. Ten days later she abruptly suffered from behavioural disorders with relapsing fever. Neurological exarnination showed a severe frontal syndrome. Cerebral CT-scan disclosed bilateral caudate nucleus hypodensities, without oedema or mass effect. Analysis of CSF revealed purulent aseptic meningitis. MRI with diffusion weighted images (DWl) allowed the diagnosis of acute bilateral caudate nucleus infarcts. Her neurological status and inflammatory biological syndrome progressively improved with treatment. Cerebral angiography was programmed, but the patient suddenly died from a massive subarachnoid hemorrhage. In our case, unusual bilateral symmetric location of infarcts raises the question of stroke mechanism. Bilateral caudate nucleus infarcts involving perforating branches of basal arteries suggests two mechanisms: first, a basal arteritis process related to meningitis, second, a vasospasm related to mycotic aneurysm of anterior communicating artery. The later hypothesis was strongly highlighted by the secondary onset of subarachnoid hemorrhage. Neurological complications occurred in about 25 % of infectious endocarditis and are very severe, leading to death in about 80 % of cases. Cerebral angiography should be rapidly performed to check out and treat mycotic aneurysm.

Introduction: lschemic stroke (IS), coronary arterial disease (CAD) and peripheral arterial disease (PAD) are three different presentations of the same disease: atherothrombosis. On the other hand CAl9 is a risk factor Ÿ IS in two different ways, as atherothrombotic disease and as cardio embolic source. Our goal is to analyse the association of IS and CAD and its diagnostic and therapeutic implications. Methods: We made an observational, sequential analysis from our stroke data bank during 1994-1997 to evaluate the frequency of the association of IS and CAD in our stroke in-patients, selecting those patients presenting as ischemic stroke with previous CAD. We excluded TIA patients. Results: 195 of the 1492 stroke patients admitted in our Neurology department had previous CAD ( 13 %). There was a progressive increase in the number of patients with IS and CAD from 1995 (up to 39.8 %; p=0.05). There is a trend to be older than in 1994.We also detected progressive higher percentages of hypertension (p < 0.05), diabetes mellitus (ns), tobacco (ns) and hyperlipidemia (ns). During the study period there have been performed progressive]y more echocardiogram studies (p=0.0001), allowing the detection of a higher percentage of cardio embotic diseases associated to myocardial ischemia (up to 29.8% the patients with IS and CAD; p=0.007). There is also ah increase in the prescription of anticoagulant drugs (ns), without differences in the antiplatelet therapy. Conclusions: There is a progressive increase in the number of patients with IS and previous CAD that could be explained in part because the also higher frequency of vascular risk factors, mainly hypertension. Tbese data have important diagnostic and therapeutic implications. By one hand ir reflects the need to strengthen the primary prevention measures on the vascular risk factors, the importance to perform echocardiogram studies in CAD patients by cardiologist in order to detect cardio embolic diseases, which should imply anticoagulant therapy as primary prevention for stroke. P460

Cerebral Hemorrhage As First Manifestation Of Ah Atrial Myxoma. A. Frank, E. Diez Tejedor, M. Gutierrez, A. Miralles, P. Barreiro (Madrid, E) Background and objective: Atrial myxoma (AM) is an infrequent but well established cause of cerebral infarct (CI), however not of brain hemorrhage (BH). We report one case of BH which initially was attributed to a cerebral multiple cavernomatosis. Patient and methods: A 39 years-old man suffered in October 1998 a focal seizure with secondary generalization. The CT-scan showed one hemorrhage on the right frontal lobe and two hyperdense lesions suggestive of cavernomas, located on the right parietal and occipital lobes. After neurosurgical evacuation of the frontal lesion, histology showed only an organized haematoma surrounded by an inflammatory reaction. During the next months he suffered various seizures despite treatment with phenytoin. One and hall year later he was admitted other time in the hospital with aphasia and right hemiparesis due to a left middle cerebral artery (MCA) territory infarct seen on CT-scan. Thereafter, a protocolized study in our stroke unit was undertaken. Results: Brain MRI showed many haemorrhages in both hemispheres as welI as an extensive infarct on the MCA territory. Carotid and vertebro-basilar systems ultrasonography (extra- and transcranial) and laboratory exams were normal. A transthoracic echocardiogram showed a big mass located in the left auricle, implanted on the interatrial septum. It had many prolongations which crossed the mitral valve into the left ventricle. Cardiac surgery was done and the mass was totally removed. The AM was pathologically confirmed anda new study of the histological brain samples from the first cerebral hemorrhage was able to detect myxomatous cells surrounding the lesion, similar to those from the AM. Conclusion: In some unusual cases like this one, AM can produce cerebral haemorrhages, likely due to embolic spread of myxomatous cells into the brain and this can be get confused with a cerebral multiple cavernomatosis.

P462 Indication ofanticoagulanttherapyinfusiformbasilarartery aneurysms: a b o u t a case. ~ Blanco,].Campdelacreu, E. Mu¡ Obach, A. Chamorro (Barcelona, E) Background: Fusiform aneurysm represents 1% of all the intracranial aneurysms and basilar artery is the vessel more frequently involved. The treatment remain unknown and subject to controversy. The experience about the oral anticoagulation (AC) is very short but the lilerature shows a more favourable outcome with such therapy. Methods: We reporta case of symptomatic fusiform basilar aneurysm due to partial wall thrombosis than remain stable with oral anticoagulation therapy. Results: A 51 year-old man smoker was admitted because of suddenly staggering gait, nausea,vomiting, sweating, hearing disturbance, right bemifacial and limbs paresthesias, and horizontal diplopia in left conjugate gaze. lndeed, a 3 months history of occipital headache and intermittent episodes of unsteady gait with right deviation was noted. Neuroh)gy examination was normal at exception right Babinski and slight ataxia. Arterial pressure was 150/90. Laboratory tests, included lipid and coagulation studies, chest radiography and electrocardiography were also normal. Symptoms resolved within 24 hours a n d a diagnosis of vertebro-basilar transient ischemic attacks was made; heparin therapy was started. The supraortic brancbes echodoppler was performed with no evidence of stenosis, and anterograde flux in both vertebral arteries was noted. Cranial TC sean visualized ectatic basilar artery, in proximal third just over vertebral arteries fusion associated to hyperdense image within wall vessel. Magnetic angiorresonance imaging confirmed the presence of fusiform basilar artery aneurysm (8mm diameter) at such localization and also showed a signal within wall vessel suggesting partial thrombosis; no parenchymal infarcts were showed. The clinical picture was attributed to perforants branches occlusion due to partial arterial wall thrombosis. The heparin therapy was continued until 6 days later, but 4 hours after which clinical recurrence was evidenced with paresthesias in the right side of the face and right arm, occipital headache and ataxia gait. Heparin was reinitiated with partial improvement. The patient remained asymptomatic without any recurrence or haemorrhagic complication at 7 months follow-up with AC therapy. Conclusion: The treatment of fusiform vertebro-basilar aneurysm is controversial. This case is another example that oral AC therapy may be able to prevent the symptomatology due to thrombosis or distal embolism without haemorrhagic complication.

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P463 A Case With Cerebral Thrombosis Receiving Tamoxifen Treatment. G. Akdal, B. D6nmez, G. G Yener, H. Cakmakci (Yzmir, TR) Cerebral sinus thrombosis (CST) is known to be related to a number of underlying aetiologies including otitis media, trauma, pregnancy, birth control pills, tumours, malnutrition, dehydration, haematological disorders and malignancy. We present the case of a patient with breast cancer receiving the antiestrogen drug tamoxifen who developed CST. A 40 year old female presented as an emergency with a 10 day history of headache and left sided weakness. On questioning her past medical history included a diagnosis of breast cancer 3 years ago treated by radical mastectomy and tamoxifen 20 mg daily. At the time of admission, neurologic examination revealed a mild left sided hemiparesis and positive Babinski sign. Magnetic resonance imaging (MRI) showed thrombosis in the superior sagittal sinus, right lateral sinus and jugular vein in addition venous infarction in the right temporal lobe was present. Routine haematology and biochemistry was normal. Anticoagulation tests, antithrombin III, protein C and S levels were also found to be normal. She was treated with anticoagulation therapy and her hemiparesis improved within three days. Control MRI showed the resorption of the venous infarction and resolution of the thrombosis. Our patient had no signs of active malignancy and according to previous reports of tamoxifen related thrombosis it seems highly likely that tamoxifen was the underlying cause for our patient's CST. Physicians should be aware of this uncommon but serious side effect of tamoxifen therapy especially with the more widespread use of tamoxifen. P464 Multiple cervicocranial artery dissections: Risk factors and Prognosis. M. Obadia, S. Timsit, M. Logak, Y. Samson, G. Rancurel (Paris, F) Objective: Ib assess the factors associated and the prognosis of multiple cervicocranial artery dissections (MCAD). Backgrounds: MCAD are found in about 20 % of cervical artery dissections. Their associated factors and their prognosis are not well known. MCAD might be due to severe underlying arteriopathy. Methods: 17 consecutive patients with MCAD admitted in our Stroke Centre between ]uly 1993 and August 1999 were included in this study. AII diagnoses were confirmed by angiography. We retrospectively evaluated the clinical and angiographic findings associated with MCAD. Clinical and ultrasound (n=15) or angiographic (n=8) examination were performed in patients during a mean follow-up of 30 months. Results: 17 patients (7 males and 10 females, mean age: 40 +-8 years) presented 11 bilateral carotid artery dissections, 5 carotid artery dissections associated with vertebral artery dissections and 1 bilateral vertebral artery dissection. Vascular risk factor were present in 64 % of the patients and 70 % of the females were using oral. contraceptives. Dissections occurred after minor cervical injury in 29 %. The symptomatology consisted essentially of local signs associated with ischemic signs. 58% of patients suffered a completed stroke preceded by transit ischemic attack (TIA) in 70% of cases. Stenosis was the most frequent pattern but 52% of patients presented MCAD with aneurysm. In most patients, only the ones with more severe angiographic findings were symptomatic. Fibro muscular dysplasia (FMD) were present on angiography in 52 % of patients and in all females using oral contraceptives. Redundancy artery concerned 47 % of patients. No recurrent dissection or stroke (except a TIA in one patient) was observed. The clinical prognosis was good in 58% without stroke sequelae. Only 17% of patients had major sequelae. Completed or partial recanalization occurred in 70 % of initial occlusions and all of stenoses. Conclusions: Patients with MCAD seems to have a good prognosis. The angiography finds in most of cases an underlying arteriopathy. Our results suggest a possible role of oral contraceptives in pathogenesis of dissections associated with FMD. The frequent multiple simultaneous artery dissections and the absence of recurrence suggest that changes in connective tissue caused by dissection may tend to prevent local recurrence. P465 Headache and dysgeusia revealing an internal carotid dissection. E. Fauveau, S. Crozier, M. Obadia, R. Manai, Y. Samson, B. Marro, C. Marsault, G. Rancurel (Paris, F) A 42 year-old women suffered from sudden onset of frontal and periorbital headache associated with dysgeusia. She was initially treated asa sinusitis with cortisone and antibiotics, but the symptoms persisted and she was examined by a neurologist. The examination revealed a right ptosis and miosis, a dysgeusia, and an abolition of nauseous reflex. She was hospitalised in our department. Cerebral MRI was normal. Duplex sonographic examina-

tion of the carotid arteries only showed an arterial dysplasia, but no stenosis nor dissection. Axial MRI of the petrosal region revealed a crescent shaped area of high intensity in the prepetrosal portion of the right internal carotid artery, related to a dissection. Dysgeusia may be due to a IXth nerve ora chorda tympani involvement. Mural hematoma of the carotid in its prepetrosal portion can explain such involvement. Cranial nerve palsy are observed in 12% of internal carotid dissection. The most frequent palsy-is the XI| th nerve, often associated with the XI, X or IX nerve. Only one case of isolated I X th n e r v e palsy has been reported. Like in our case the absence of involvement of other cranial nerves may be explained by the limited vertical extent of the dissection. We discuss here the anatomy of the cranial nerves with the internal carotid artery and the unusual clinical presentation (dysgeusia) of a carotid dissection. P466 MRI and MRA versus CT and Doppler Sonography in the Evaluation of Cervico-Cranial Occlusive Desease. I. Vukadinovic, 1. Ostojic, M. Lucic, D. Kozic, K. Koprivsek, M. Prvulovic, Z. Babic (Sremska Kamenica, YU) Introduction: The airo of the study was to investigate findings of MRA and Doppler sonography in different degree of internal carotid artery and vertebral occlusion and also to correlate findings of MRI and CT in different brain parenchymal damage. Material And Methods Retrospective study of 53 patients 33 (age 60 -+5) and 20 (age 40 -+ 5) with ACI or AV occlusion an different clinical entities associated with cerebral ischemia were examined on MR imager Siemens Magnetom SP 63-4000 (1.5T).The protocol was T1W axial, coronal plain and T2W/PD axial plain of endocranium and also two kinds of 3de TOF MR angiographies with parameter FISP 3D 7RB_163. UDB. TR 29, TE 7, FA 15, MS 192x256, Acq 1 and other MTTU3 FISP 3D 64 8 RB 81. UDB. TR 43,TE8, FA20, MS 256xc512, Acq 1. Results: AII patients had previous Doppler carotid sonography and computerized tomography of endocranium. MRA revealed subocclusion of ACI or AV in 19 patients, while occlusion was obvious in 34 patients (64 %). Compatibility with Doppler was observed in 60 %. MRI confirmed different brain parenchymal lesions, bilateral ischemic areas in 18 cases, hemorrhagic infarcts in subacute evolution in 15 (28%) cases. Massive infarcts unilaterally, lacunar infarcts and watershed infarcts were revealed in 6 (11.3 %), 5 (9.4 %) and 9 (17 %) patients, respectively. No discrepancy between CT and MRI was revealed in 45% of the patients. No lesions were detected on CT in 15% of the cases. Conclusion: MRA MTTU3 FISP 3D 64 8 RB 81. UDB. TR 43, TE8, FA 20, MS 256x512, Acq 1 performed with significantly higher sensitivity for estimation of vessel stenosis compared to MRA FISP 3D 7 RB 163. UDB. TR 29 TE 7, FA 15, MS 192x256, Acq 1. P467 Efficacy of muitimodal neuromonitoring by Transcranial Doppler and EEG to assess cerebral hemodynamic changes during cardiopulmonary bypass. C. Zanferrari, R. Tortorella, E. Bortone, N. Bombaci, C. Beghi, S. Pincolini, T. Gherli, D. Mancia (Parma, I) The overall incidence of neurological complications in cardiac surgery is 3-5%. The most important mechanisms involved in neurological damage during cardiopulmonary bypass (CPB) are global or focal hypoperfusion and embolic phenomena. While most neuromonitoring studies highlighted the role of embolism during CPB, only a few studies focused on the relationship between cerebral hemodynamic changes and neurological outcome. We developed a study protocol based on intraoperative bilateral continuous monitoring of middle cerebral arteries by transcranial doppler (TCD) and digital 32-channel EEG recording (10-20 system). Patients underwent clinical, neuropsychological, TCD and EEG evaluation at baseline and postoperatively at the 2"d, 7th and 30th day. Including criteria were: age < 75 years, number of vascular risk factors < 3, absent history of cerebral ischemic attacks, no significant intracranial and/or extracranial carotid plaques on carotid color duplex and TCD, no significant cognitive dysfunction. Eight patients were recruited and 4 ofthem, submitted to coronary-aortic bypass, could undergo the complete protocol study. Four patients were excluded from the intraoperative monitoring: 2 cases due to abad temporal windows for TCD study, 1 case for a significant carotid plaque, and 1 case for a sudden worsening of cardiac conditions. In all patients, we found a significant increase of mean cerebral blood flow velocity (CBFV) soon after the aortic clamping and during the whole phase of extracorporeal circulation. CBFV remained significantly higher than basal values also after aortic decannulation, despite a transient decrease at the clamping removal. EEG showed diffuse slowing and voltage reduction in all patients, suggesting cerebral hypoperfusion. The apparent contradictory changes of TCD and

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EEG could be explained by a pseudo-inflammatory reaction leading to a concomitant arteriolar vasodilatation and impaired blood-tissue exchange with neuronal dysfunction. Mean arterial blood pressure decreased during CPB and returned to basal values soon after aortic decannulation. This suggested that CBFV and arterial blood pressure changed independently and that a merely loss of cerebral autoregulation did not occur. Our on-progress study indicated that multimodal neuromonitoring provided interesting data on pathophysiological mechanisms during CPB. P468 Hereditary thrombophilia a s a risk factor for ischemic stroke in young aduhs. S. Lopaciuk, A. Mickielewicz, A. Kuczynska-Zardzewialy, A. Czlonkowska, I. Windyga, H. Kwiecinski (Warsaw, PL) A hypercoagulable state may account for approximately 10 % of all ischemic strokes in young adults. We examined the prevalence of factor V Leiden, the prothrombin G20210A genotype and the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in 100 patients who survived non-cardioembolic ischemic stroke while < 45 years, and in 238 healthy controls from the same geographic area. Heterozygosity for the FV Leiden mutation was found in 3 patients (3 %) and in 10 controls (4.2 %). Two patients (2%) and 5 controls (2.1%) were heterozygous for the prothrombin G20210A mutation. The frequencies of the MTHFR 677TT, CT and CC genotypes in the patients were 12 %, 37 % and 51%, respectively, and were not statistically different from those in the control group (11%, 40% and 49%). We conclude that FV Leiden mutation, prothrombin G20210A genotype, and homozygosity for the C677T mutation in the MTHFR gene are not associated with an increased risk of ischemic stroke in young aduhs.

P469 Silent Strnke after Cervical artery dissections. S. A.C. Blecic, S. Jeangette, I. Hildebrand (Brussels, B) Background and purpose: Prevalence of silent stroke (SS) varies between 10 to 38 % in the general stroke population. They are often indicative of the subsequent stroke etiology. In large artery, their significance is not well known but their presence could suggest abad outcome. The airo of our study was two folds (1) to assess the SS frequency after Artery Dissection (AD) (2) to assess the cause of SS. Patients and methods: 112 out 3205 pts admitted in our stroke unit had a total of 156 AD. 83 pts had single AD while 29 had multiple AD, 7 having a combination of still permeable and occluded AD. 95 pts had symptomatic stroke, 76 having complete stroke and 19 pts had TIA. 17 pts had only autonomic nervous system involvement. AIl pts with permeable AD were treated 6 months with anticoagulants (AC). Pts who had occluded AD had Aspirin (AAS) and pts with combination of permeable and occluded AD were treated with AC. All pts underwent a complete stroke work-up; including MRI, MRA, and in selected case catheter angiography. Al1 had control MRI and MRA 6 months after AD diagnosis. Results: 3 pts (2.6%) had symptomatic stroke recurrence within the 6 month-period, all occurring in the same artery territory. 32 pts (28.5 %) had SS on control MRI. 30 pts had single SS and 2 had multiple SS. 5 pts with autonomic nervous system had unique SS. In 24 out of the 25 remaining patients, SS was found in the same artery territory than initial AD. SS was found in 17 out of the 29 pts (58.6 %) with multiple AD while only 12 out of the remaining 83 pts (14.4 %) hada SS (p < 0.001). SS occurred in 5 out of the 7 pts with combination of permeable and occluded AD. All were found in the territory of the previously occluded artery, which was found in all instances reopened on control angiography performed after 6 months. None patients with single occluded artery and treated with AAS had 8S. None of the above pts had neither clinical nor asymptomatic recurrence after l year. Condnsions: While clinical recurrence is rare after AD, SS are frequent and encountered in one third of the pts. They are significantly associated with multiple AD and could be due to AC treatment mainly in pts with combination of permeable and occluded artery. P470 Apoptosis and lnflammatory Response to Cerebral lschemia. C. Krogias, S. Schimrigk, M. Rieks, T. Bª T. Postert, H. Przuntek (Bochum, D) Background: Up to date, the pathophysiological mechanisms of the post-ischemic immunological responses ate poorly understood. The aira of this study was to investigate peripheral cell apoptosis and systemic immune responses in ischemic stroke in relation to the neurological outcome. Methods: Eighteen patients (8 female, 10 male; aged 49-87 years; Median 70.5) with acute middle cerebral artery ischemia prospectively studied crin-

ically and immunologically on days l, 3, 5 and 10. Clinical outcome was evaluated by the European Stroke Scale (ESS), as well as the National Institute of Health Stroke Scale (NIHSS). Apoptosis was detected by flow cytometry using the Annexin-V-binding-method (Bioproducts Boehringer). Serum-levels of lnterleukin (IL) - 1b, IL-6 and intercellular adhesion molecule-I (ICAM-1) were measured by ELISA. In addition, acute-phase reactants and leukocytes were measured. Neurological improvement was defined when ESS-score rose at least 15 points during the first 10 days after admission to our stroke unir. We compared data of patients showing improvement (Group A, n=8) with data of unimproved patients (Group 13,n=lO) Results: The apoptosis rate of lymphocytes and the IL-6-levels showed increasing va[ues in Group B, while apoptosis rate and IL-£ decreased in Group A. CRP and fibrinogen levels of Group B were significantly higher and constant[y showed pathological values. No differences were seen in apoptosis tate of granulocytes, I L- I b and in ICAM- 1 levels in both groups. Conclusions: Apoptosis and inflammation are part of the pathophysiological mechanisms in stroke. In this study we provide data suggesting that the intensity of the inflammatory response could be used as prognostic factor for the neurological outcome after stroke. A different therapeutic regime in stroke as additional antiinflammatory or anti-apoptotic treatment should be discussed.

Extrapyramidal disorders P471 Effects of 8-OH-DPAT,a 5-HT1A receptor agonist, on levodopa-induced motor complications in 6-OHDA-lesioned rats. M. Tomiyama, T. Kimura, K. Furusawa, H. Tanaka, T. Maeda, K. Kannari, M. Muneo (Hirosaki, l) In rats with unilateral 6-hydroxydopamine (6-OHDA) lesions of the nigrostriatal pathway, we have shown that administration of levodopa results in marked flnctuation of extracellular dopamine levels in the dopamine-denervated striatum. The effect of levodopa is easily determined by rotational behavior contralateral to the lesioned side in this model. Intermittent levodopa treatment to 6-OHDA rats induces great enhancement of the ro'tation behavior, that is thought to be analogous to levodopa induced dyskinesias (LID/ in Parkinson's disease. However, continuous administration of levodopa does not provoke such a behavioral change in 6-OHDA rats. Accordingly, marked fluctuation of dopamine concentration in the denervated striatum appears to ah important factor that contributes to induction of the motor sensitisation.We have recently demonstrated that serotoninergic neurons convert levodopa to dopamine and release the levodopa-derived dopamine into the denervated striatum in 6-OHDA rats. Additionally, we have also shown that a 5-HTIA receptor agonist, 8-OH-DPAT, attenuates the marked fluctuation of dopamine levels following levodopa treatment. Hence, we hypothesized that intermittent co-administration of 8-OH-DPAT with levodopa alleviated levodopa-induced behavioral sensitisation. To verify the hypothesis we elucidated rotational behavior and messenger RNAs coding dynorphin (DYN) and glutamic acid decarboxylase (GAD) in the denervated striatum of 6-OHDA rats which repeatedly received either levodopa (DOPA group) or levodopa with 8-OH-DPAT (DPAT group), twicedaily for 14 days. Additionally, expression of 5-HTIA receptor tuRNA was analyzed in the dorsal raphe nucleus and striatum to determine whether the 8-OH-DPAT administration causes desensitisation of somatodendritic and postsynaptic 5-HTIA receptors in serotoninergic neurons and striatal neurons, respectively. Behavioral sensitisation observed in DOPA group was suppressed in DPAT group. Significantly increased expression of GAD and DYN tuRNAs in the denervated striatum of DOPA group was normalized and partially reversed in DPAT group, respectively. No change of expression of 5-HT1A receptor tuRNA was observed in the dorsal raphe nucleus and striatum, suggesting that additional 8-OH-DPAT treatment to levodopa induces no desensitisation of 5-HT1A receptors. These results suggest that coadministration of 5-HT1A receptor agonists with levodopa improves levodopa-induced motor complications in Parkinson's disease. P472 Guadeloupean Parkinsonism: Neuropathologic, Biochemical and Genetic Study. D. Caparros-Lefebvre, N. Sergeant, A. Lees, A. Camuzat, S. Daniel, E. Tolosa, A. Brice, A. Lannuzel, A. Delacourte, C. Duyckaerts (Pointe A Pitre, Lille, F; London, UK; Paris, F; Barcelona, E) Background: In French West lndies, we have described since 1996 a specific pattern of parkinsonism, three-fourth of all referred patients having doparesistant parkinsonism, with postural instability, frontal lobe dementia, de-

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layed pseudo-bulbar palsy, and a poor prognosis. 40 % of them had vertical gaze palsy and were then considered as probable progressive supranuclear gaze palsy (PSP). This new focus of atypical parkinsonism, resembling the one reported in Guam for 50 years may be linked to the exposure to one or several neurotoxins issued from tropical plants and being mitochondrial (complex 1) inhibitors. Patients and melhods: Patients referred to our department for parkinsonism have been examined with a standardised clinical and neuropsychological chart. We carried out a complete study in 185 patients and aimed at the classification of patients acording to accepted criteria. During the followup, we obtained the brain of 4 patients. Three patients had probable PSP, and 1 had amyotrophic lateral sclerosis witb parkinsonism. Results: AII 3 cases with probable PSP had a definite tauopathy, with predominant accumulation of tau in the mesencephalon. Tau deposition involved also the cortical areas, except in one case witb a shorter disease duration. Biochemical study delected a major doublet of pathological tau at 64 and 69 kDa in brain tissue homogenates, which is definitively different from the triplet observed on Guamanian brains. No mutation of the tau gene was observed and all tases were homozygotes for the H 1 tau haplotype. Conclusion: In French West Indies, there is a cluster of parkinsonism resembling PSP, as demonstrated by neuropathology, biochemislry and genetic resuhs. Its toxic origin remains to be proven. P473 Association of Parkinson's disease and essential tremor. D. Gunal, M. Guleryuz, O. Onultan, S. Aktan (Istanbul, TR) There is a possible association of essential tremor with Parkinson's disease and most investigators believe that the coexistence of the two diseases is not simply a chance occurrence of two common movement disorders. The present study aimed to investigate the frequency of essential tremor in Parkinson's disease patients and 121 consecutive patients selected for the study fulfilled the Tremor Investigation Grnup criteria for essential tremor. We analysed the demographic criteria, the effects of alcohol and the family higtory. The results demonstrated that 12% (n= 15) of Parkinson's disease pat ient had coexistent essential t remor. Fourth-six percent of them reported significant decline in their tremor by alcohol and the family history was positive for Parkinsonism disease in 13 % and for hand tremor in 53 % of the patients. On the other hand, the patients having diagnosis of Parkinson's disease without coexistent essential tremor (n= 107) reported family" history of Parkinsonism in 6.5% and hand tremor in 3.7% of their first-degree relatives. Only 2.8% of them experienced alcohol responsiveness. The present study pointed out that 12 % of Parkinson's disease patients had coexistent essential tremor and in the aspect of family history and alcohol responsiveness these patients seemed to behave like essential tremor patients. The occasional coexistence of Parkinson's disease and essential tremor in the same individual could suggest that the two disorders are pathogenically linked. P474 lsolated tremor and Wilson's disease. D. Gunal, D. Kaya, S. Aktan (Istanbul, TR) Wilson's disease presents with dysarthria, parkinsonism, psychiatric symptoms and especially tremor sometimes being the very first sign of the disease. The present case demonstrated a 20-year-old man with a history of tremor on right upper extremity for four months. A [arge amplitude predominantly resting tremor with postural and kinetic components was the only pathologic findings on the right together with positive Kaiser Fleisher rings. His copper analysis in urine, serum; coeruloplasmin levels and liver biopsy copper content confirmed the diagnosis of Wilson's disease. However, his head magnetic resonance imaging was normal. D-penicillamine and Zinc were administered to the patient. Pseudosclerotic form of Wilson's disease was considered and the case was reported asa pathologically diagnosed Wilson's case with isolated tremor. P475 Post-pump Chorea in a 14 year old girl. S. Hassin-Baer, A. Brezner, J. Landa, N. Brand, B. Ben-Zeev (Tel ttashomer, IL) Post pump chorea (PPC) is a well-defined but rare complication of hypothermic cardiopulmonary bypass (hCPB) in children, described in those under 6 years with most cases under 2 years of age. The clinical picture is of generalized choreoathetosis associated with eye movement abnormality evolving 2-14 days after surgery, improving over the course of weeks to montbs. We presentan additional case with some unusual features: A 14 year old

girl afler previous attempls for surgical repair of a complex congenital heart defect h a d a repeated cardiac surgery with hCPB. Three days after the uneventful surgery she was noticed to be immobile, mute, dysphagic and with a complete supranuclear ophthalmoplegia. Involuntary ballistic choreic movements in all for limbs appeared, within a week, accompanied by hypomimia. During the first two weeks the movement disorder progressed and she became bed-ridden and required nasogatric feeding. Several drugs were tried bit only the combination of haloperidol and valproic acid seemed to be effective. CT and MRI of the brain failed to reveal any structural lesions and HMPAO SPECT and FDG PET sean showed no functional abnormalities. All metabolic work-up, including CSF for dopamine metabolites was normal. After a month progressive improvement of the involuntary movements and gaze abnormality began and enabled ambulation after 3 months. Very soon a complex neurobehavioral syndrome was obvious, consisting of stereotypic movements with obsessive compulsive features, which partially responded to imipramine. There was no cognitive impairment according to nonverbal cognitive testing but there was evidence for prominent executive dysfunction. Aftera year these behavioral disorders,generalized chorea with dystonic posturing, dysarthria and saccade abnormality persist. The pathophysiology of this syndrome is unknnwn, and the negative findings of the thorough work-up in this case did not shed light on it's pathogenesis. Specific vulnerability of the basal ganglionic structures to ischemia, hypothermia and the effects of rewarming in this age group is proposed. The relatively advanced age of the patient, the prominent eye movement abnormality and the complex neurobehavioral disturbances that evolved, expand the clinical spectrum of this severe complication of cardiac surgery in children. P476 Echogenicity of the substantia nigra in relatives of patients with sporadic Parkinson's diseasei P. Ruprecht -D6rfler, D. Berg, O. Tucha, P. Benz, K. Lange, G. Becker (Wª Regensburg, Mainz, D) Background: Increased echogenicity of the substantia nigra (SN) is a typical sonographic finding in Parkinson's disease (PD). The same echo feature of the SN can be found in about 8.6% of healthy adults and is associated with an impairment of the nigrostriatal system as determined by 18F-DOPA PET. Objectives: To investigate whether this sonographic sign and the associated impairment of the nigrostriatal sytem is transmitted to the offspring of PD patients. Method: 62 first and second degree relatives of 14 patients with sporadic PD were included. Patients and relatives underwent neurological, neuropsychological and ultrasound examination. In addition, four pairs of family members with one member exhibiting increased echogenicity of the SN and the other witb regular SN echogenicity were subjected to 18F-DOPA PET examination. Results: 28 of 62 relatives exhibited a hyperechogenic SN on transcranial sonographic examinatinn (TCS). Relatives with SN hyperechogenicity had more often signs of motor slowing compared to their relatives without this echo pattern. In addition, putaminal 18F-DOPA uptake was significantly reduced in re[atives with SN-hyperechogenicity. Conclusion: Approximately 50 % of the offspring of PD patients exhibir an increased echogenicity of the SN. This sonographic sign typical for PD was associated with clinical findings and objective measurements point to some degree of impairment of nigrostriatal function. The identification of the underlying cause for increased SN echogenicity may improve our understanding of PD. P477 Stereotactic atlas for the surgical treatment of Parkinson's disease. Preliminary resuhs. A. Franzini, P. Ferroli, M. Pintucci, I. Dones, C. Marras, G. Broggi (Milano, I) The optimal target for deep brain stimulation in Parkinson's disease is still under investigation as well as the relationship between the stimulated area and the clinical outcome. A retrospective study on ten parkinsonian palients successfully treated by bilateral "subthalamic neurostimulation" was performed using an ad hoc compiles software able to graphically represent the electrode tip position and trajectory in a AC-PC based tridimensional system. The 3-D representation of the twenty active electrodes and of their electric fields allowed to obtain a functional stereotactic map representing the spatial distribution of the therapeutically relevant electrodes. This "therapeutic subthalamic area"indudes two zones of electrodes concent ration: the first dorso-lateral (9 electrodes) and the second ventromedian (11 electrodes) as related to the AC-PC plane and to the centre of anatomical subthalamic nucleus. It exceeds subthalamic boundaries, probably involving the fibers of the pallidal-subthalamic-thalamic-cortical circuit surrounding

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subthalamic nucleus. Moreover the inclination of the major axis of the obtained ovoid therapeutical area is greater than the one of the anatomic nucleus. Our data suggest the need of functional atlases obtained from patients studies, matching the classical stereotactic anatomic atlases derived from cadaveric studies. The procedure used in this study allows to relate the clinical outcome to the real position of the stimulating electrode, contributing to the making of a growing interactive stereotactic-functional atlas. P478 Oral dyskinesia following bilateral thalamic infarct. A case report. N. Afsar, D. Ince-Gunal, S. Aktan (Istanbul, TR) Background: Hemichorea, hemiballism, and focal dystonia are the most comino• forros of dyskinesia tbat ate reported during or after stroke. However, oral dyskinesia secondary to cerebral ischemia is quite infrequent. We describe a patient who developed oro-lingual dyskinesia following bilateral thalamic infarct. Case: A 68-year-old woman presented with sudden onset involuntary movements involving her mouth and tongue. These consisted of chewinglike and tongue protruding movements that stopped during sleep and were of disturbing but not disabling intensity. She denied the use of neuroleptic drugs. Her medical history disclosed un ischemic stroke with right-sided mild hemiparesis, marked hemisensory loss and difficulty in understanding complex orders 10 months ago, as well as chronic atrial fibrillation and congestive heart failure. Her neurologic examination showed the presence of oro-lingual dyskinesia, and signs of her former stroke in the forro of rightsided hyperactive deep tendon reflexes, hemihypesthesia and miid limb ataxia. Right hand synkinesis to the fine motor movements of the left hand was observed during examination. She also described a thalamic pain in the form of a non-disabling burning sensation and discomfort of her right side, more prominent in her hand. Cranial magnetic resonance imaging revealed a right-sided small lateral thalamic infarct in the subacute phase, as well as a chronic left posterior cerebral artery territory infarct involving the occipital and lateral thalamic areas. In the absence of any drug use and considering the acute onset, bilateral thalamic infarcts were believed to be the cause of the oro-lingual dyskinesia. Conclusion: Although infrequent, movement disorders may develop secondary to stroke. Acute onset of a dyskinesia, even in the absence of focal neurological signs should prompt investigations for a potential vascular event. P479 High frequency stimulation of the subthalamic nucleus: a one year followup. M. Rizzone, M. Lanotte, B. Bergamasco, P. Perozzo, E. Torre, A. Tavella, L. Lopiano (Torino, I) High frequency electrical stimulation (HFS) of the subthalamic nucleus (STN) represent a good therapeutical option for the treatment of advanced Parkinson's disease (PD), when all the pharmacological strategies failed. Aim of this study was to assess the long term efficacy and safety of the bilateral STN HFS in 15 patients with advanced PD. All the patients were evaluated before surgery and one year after the surgery by the Unified Parkinson's Disease Rating Scale (UPDRS), two timed tests (hand tapping test and stand-walk-sit test) anda complete battery of neuropsychological tests. The patients were evaluated in the preoperative period in two conditions, with and without medication (medication-on and medication-off). After surgery, all the tests were performed in four conditions: stimulationoff/medication-off, stimulation-off/medication-on, stimulation-on/medication-off and stimulation-on/medication-on. After surgery, STN stimulation alone led to an improvement of 58.7 % of the motor score (UPDRS part III) and 66.5 % of the Activity of Daily Living (ADI.) score (UPDRS part II) with respect to the preoperative medicationoff condition. The mean levodopa equivalent daily dosage decreased 68.4 %, and an improvement of 75.6 % of the Complications of Therapy score (UPDRS part IV) was observed, with a significant reduction of the off period duration and of the drug-induced dyskinesias duration. The only significant side effect noted was a reversible inflammatory swelling at the level of a subclavear pulse generator in one patient. H FS of the STN is confirmed to be an effective and safe procedure for the treatment of advanced PD.

Epilepsy P480 Valproate-induced hyperammonemic encephalopathy. Clinical variability in four patients. J. M. Callejo, J.A. Dominguez Moran, J. C. Martinez-Castrillo (Madrid, E) lntroduction: Valproate-induced hyperammonemic encephalopathy without signs of hepatic failure is a rare complication of the treatment with valproic acid. The biochemical and pathophysiologic mechanisms responsible for it are nor complete[y understood. We report four new patients with this severe adverse event, who had different clinical manifestation. Case reports: Case 1. A 61-year-old man had tuberous sc[erosis and partial complex epilepsy. He had received different antiepileptic drugs and different combinations of them, which included valproic acid. He was on valproic acid and phenobarbital when topiramate was added with an increasing dose scale. A few weeks after the treatment was started, he became drowsy and referred tremor and nausea. His neurological condition worsened and was admitted with a reduced level of consciousness. CT scan of the head revealed a diffuse severe cerebral oedema. The level of ammonia was 225 micromol/1, with otherwise normal hepatic function. Case 2: A 67-year-old man had partial complex seizures secondary generalized due to a stroke. He received lamotrigine, and valproate was added. A few weeks after, the frequency of the seizures increased, and he referred ataxia, nausea and vomiting, and his family described paroxysmal episodes of multidirectional nystagmus and un increasing somnolence. There was an old median cerebral artery infarction on CT. The ammonia was 97 micromol/l, no other abnormal analytical values. Case 3: A 37-year-oId man with a severe multiple sclerosis, received valproate because of a generalized seizure two weeks before admission, when he h a d a generalized status epilepticus, which needed general penthotal anaesthesia to control it. The only abnormal analytical value was ammonia of 83 micromol/l, anda raised CK. Case 4: A 55-year-old woman had generalized epilepsy and hyperparathyroidism due to a parathyroid adenoma. She received phenytoin, phenobarbital, and valproate. She became somnolent, ataxic and reported nausea. The ammonia was 107 micromol/l. The suppression of valproate resulted in a full recovery to the previous neurological state, except in case 2, whose neurological condition worsened. The ammonia concentrations became normal. Conc]usion: Valproate-induced hyperammonemia should be suspected in patients when patients under treatment with valproic acid develop neurological symptoms. A prompt diagnosis wil] prevent a life treating condition.

P481 Low serum foliate leveis asa risk factor of depressive mood in patients with chronic epilepsy. I. R6sche, C. Uhlmann, W. Fr6scher (Ravensburg-Weissenau, D) lntroduction: More than 60 % of patients with chronic epilepsy are reported to have a history of interictal depressive spectrum disorders (1). Patients with epilepsy have a lower foliate serum level than controls (2). Foliate deficiency may be a cause of depression (3). We investigated in this study whether low serum foliate levels muy contribute to depressive mood in patients with chronic epilepsy. Patients and methods: In this study we took into account the data which were obtained in a multi-modal therapy monitoring performed on a specialised epilepsy ward. We analysed the serum foliate levels and the score in the Self Rating Depression Scale (SDS) (4) on the first morning after admittance in 32 patients with chronic epilepsy without a history of interictaI psychosis. Results: On the average the patients were 41.5 years old. 22 patients (68.8%) hada store indicating at least minor depression in the SDS. These patients had a significan@ lower serum foliate level than the 10 patients with a normal score in SDS (p < 0.05).A serum foliate level below 7.5 ng/ml was significan@ associated with a pathological score in SDS (c2-test, p < 0.001 ). 81.82 % of the patients with a pathological score in SDS hada serum foliate level below 7.5 ng/ml. 90 % of the patients with low serum foliate leyels hada pathological score in SDS. Discussion: A serum foliate level below 7.5 ng/ml sectas to be a risk factor for depressive mood in our group of patients. Since this level is higher than the limit of foliate deficiency in the normal population,we suppose that patients with chronic epilepsy may have an alteration in the foliate metabolism or the need for foliate is underestimated. Elevated plasma concentrations of homocysteine have been described in patiems under antiepileptic drug treatment (5). Further studies utilising total plasma homocysteine (6) a s a sensitive measure of functional foliate deficiency in patients with

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chronic epilepsy and interictal depressive spectrum disorders should be performed. References: 1. Victoroff ] I et al. (1990) Ann Neurol 28:22 2, Fr6scher W et al. (1995) Clin Neuropharmacol. 18:165-182 3. Lee Set al. (1992) ] AffDis 24:265-279 4. Zung WWK (1965) Arch Gen Psychiat 13:508-515 5. 8chwaninger et al. (1999) Epilepsia 40:345-350 6. Bottig-lieri et al. (2000) I Neurol Neurosurg Psychiatry 69:228-232

P482 Efficacy and tolerability of Topiramate as add-on therapy in drug-resistant epilepsies: an open study of 79 patients. S. Giannakodimos, K. Spigos, N. Fakas, C. E. Karageorgiou (Athens, GR) Objective: To evaluate the efficacy and tolerability of Topiramate (TPM) as adjunctive therapy in adult patients with drug-resistant epilepsies. Material and methods: All consecutive patients from our adult epilepsy clinic with drug-resistant epilepsies treated with add-on TPM were studied. Patients had to have > 4 seizures per 2-month period prior to introduction ofTPM. Seizures had been refractory to at least 2 antiepileptic drugs (AEDs). Titration of TPM was achieved by increments of 25 mg/day for the first month and of 50/mg/day onwards. Efficacy and tolerability was evaluated. Results: There were 79 patients (32 female) studied with a mean (range) age of 29.8 (16-55) years. Mean (range) follow-up period has been 12.3 (3-34) months. Overall mean seizure frequency reduction was of 54 % comparing to baseline seizure frequency. Ten patients became seizure- free. In seven patients TPM bad to be discontinued because of adverse events or lack of efficacy (two patients). The more frequent side effect was weight loss (in 17 patients, up to 16kg), followed by paraesthesia, nervousness and drowsiness. Conclusion: Topiramate therapy was efficacious and well tolerated in this series of patients with intractable epilepsies.

P483 Novo Status Epilepticus in Adults. K. Niedzielska, W. Lojkowska, M. Baranska, M. Rzeski, W. Lechowicz, M. Niewiadomska, B. Koziol, D. Ryglewicz (Warsaw, PL) Background: Status epilepticus (SE) commonly occurs in the context of known epilepsy, but in the recent years a growing number of subjects witb SE and no pre-existing epilepsy has been reported. The aim of the study was to evaluate the etiology and type of de novo status epilepticus in adults. Material: Among 2735 admissions to the neurological departments of our Institute during Sept. 1999- Dec. 2000,137 involved the patients with first ever epileptic seizures; 32 of them presented SE (23 women, 9 men, mean age 67.3 _+ 15.9). Results: In the group of 32 patients with SE, in 4 patients (12.5%) generalised tonic-clonic SE, in 10 (31%) partial motor SE and in 18 (56.5 %) nonconvulsive status epilepticus (NCSE) were observed. In 9 patients SE occurred in the course of the acute neurological disorder (stroke - 4, encephalitis - 1, brain tumour - 4), in 16 patients with prior history of stroke, in 3 during alcohol withdrawal syndrome and in 4 etiology of SE was not clear. Among the 20 stroke or poststroke patients multifocal vascular lesions were observed (CT, MRI) more frequently (70%) than isolated changes (p < 0.0001). NCSE was the most common type of SE in this group of patients (66.7 %), and its main clinical manifestation was impairment of consciousness. Conclusions: NCSE seems to be a common form of SE in the adults. In our opinion, one should consider a possibility of NCSE, particularly if protracted disturbances of consciousness are observed in patients with acute stroke or prior history of stroke and with muhifocal vascular lesions.

P484 Diagnostic of various Epilepsy +H NMR. A. V. Pozdniakov, L. A. Tiutin, O. E Pozdniakova (St.-Petersburg, RUS) We present the results of+H MRC investigation in epileptic patients, carried out with Magnetom Vision device. Twenty five patients in the age of 20-44 years suffering from generalization epileptic fits validated by EEG (no visible changes on MRT) were examined. In all cases independently on the localization of the changes, decreasing of NAA and increasing of Cho were recorded. At one side temporal lobe injury recorded by EEG at the damaged part decreasing of NAA/Cr and NAA/Cho+Cr ratios were registered. Patients witb bilateral changes registered by EEG showed non-equal changes

of metabolite concentration on both sides. Examination of patients suffering with distinct symptoms of temporal epilepsy has shown ipsilateralit y decrease of NAA and Cr concentration. But on the injured side NAA/Cr ratio decrease was more distinct. In general, the laterality was recorded in 14 patients out of 22 with pathological changes registered by H MPC and in 10 patients out of 14 the above mentioned changes corresponds to the side of the fit initiation. In the patients with bilaterality changes NAA/Cr ratio asymmetry was recorded in all cases, but the most distinctly in the medium part of the temple lobe. Comparison of data recorded in 8 patients suffering with one side fit complex has shown significant asymmetry of metabolites which was observed in ipsilaterality and contralaterality NAA ratio obtained in hippocampal areas. Difference in NAA ratio obtained between left and right sides are 19-25 %. Left-right ratio of other metabolites corresponded to that ratio in the control group and was symmetrical.

P485 The frontal symptoms observed during temporal lobe seizures are associated with a dramatic frontal hypoperfusion in Ictal Single Photon Emission Computed Tomography. P. Charpentier, P. Derambure, H. Sediri, W. Szurhaj, E. Josien, A. Dest› M. Steinling (Lille, F) Introduction: The spectrum of clinical expression is wide in mesial temporal lobe epilepsy (MTLE). For instance grasping and perseverations are often observed during the seizure, and this could be linked with remote effects in the pre-frontal neocortex. I-SPECT and V-EEG Simultaneous analysis of seizures could lead to discover a link between these frontal symptoms and ictal frontal hypofixation. Aim: To search a relationship between per ictal severe frontal hypoperfusion and clinical symptoms of pre-frontal dysfunction during MTLE. To evaluate the influence of the time interval between the injection and the beginning of frontal signs. Patients and method: We studied 20 patients with MTLE. AII of them underwent an 99mTc ECD I-SPECT in a dedicated brain gamma camera.All patients had a temporal hyper fixation. 10 patients with significant frontal hypo fixation (group 1) were differentiated from 10 patients without this pattern (group 2). Chronological data: injection time, beginning of grasping, motor and verbal perseverations were noticed on V-EEG. Results: 8/10 patients in group 1 had frontal symptoms versus 4 patients in group 2. In 3 cases/4 with frontal symptoms in group 2, the ECD injection was performed before the beginning of frontal symptoms (> 45s). Discussion: Dramatic frontal hypoperfusion observed in I-SPECT could explain the frontal symptoms observed in MTLE. Moreover, this frontal hypo fixation observed in MTLE seems to depend of the interval between the injection time and the beginning of frontal symptoms. These iterative ictal neo-cortical hypoperfusion could playa role in the global cognitive impairment observed in MTLE. P486 Benign familial infantile convulsions: evidence of clinical and genetic heterogeneity. P. G£ E. Peral, Y. Sanz, I. M. L£ ]. M. Serratosa (Madrid, E) Background: Benign familial infantile convulsions (BFIC) is an idiopathic partial epilepsy syndrome characterized by the presence of convulsive nonfebrile partial motor seizures, onset between 4 and 7 months,a favorable outcome, and an autosomal dominant mode of transmission. In 1997, a locus for BFIC was mapped to chromosome 19q 12-13 using linkage analysis. However, a further study showed the existence of genetic locus heterogeneity. Here we report the clinical and genetic study of a three generation Spanish family with 10 affected BFIC members. Methods: We studied clinically 10 BFIC affected members from a 38member family. Chromosome 19q12-13 microsatellite markers were typed in twenty members and pairwise linkage analysis was performed in order to confirm or exclude the existence of linkage. Resuhs: AII affected individuals presented afebrile convulsions in their first year of life with onset between the third and seventb month of life. Eight of them presented the clinical features associated with BFIC as described by Vigevano et al in 1991 but two hada more severe clinical picture with persistent seizures and non-progressive neurological deterioration. The mode of transmission was consistent with an autosomal dominant pattern with incomplete penetrance. Linkage to chromosome 19q12-13 markers was excluded (lod scores < -2 for markers D19S405, D19S414, D 19S896, D19S425, D19S224, and D19S223). Conclusions: Our data support the existence of clinical and genetic heterogeneity for BFIC. Clinically, this syndrome is described as"benign" but in some individuals from our family the course was not benign. The existence of individuals with unfavourable outcome has been described in other familial epilepsies with autosomal dominant inheritance considered as be-

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nign. Exclusion of linkage to chromosome 19q12-13 confirms the existence ofat least an additional locus within the BFIC phenotype. P487 Non-invasive investigations in intractable partial epilepsy patients: implications for epilepsy surgery in deveioping epilepsy centers. K. Garganis, G. Nanou, I. Magras, V. Kontopoulos, I. Milonas (Salonica, GR) Objective: To identify, among a population of intractable partial epilepsy patients referred to a newly established epilepsy program, those suitable for respective surgery, on the basis of non-invasive investigations only. Material - methods: 66 intractable,localisation-related epilepsy patients, undergoing: a) Long-term surface Video/EEG monitoring, b) MRI, and c) Neuropsychological tests. According to investigation findings patients were classified to either a Temporal (TLE) or ah Extratemporal (ETLE) group. Depending on the presence of a resecable structural abnormality, along with concordant surface EEG and semiological data, patients were identified as suitable surgical candidates. Results: 29/66 (43%) were classified to the TLE and 37/66 (57%) to the ETLE group. 18/29 (61%) TLE cases had resecable MRI lesions (13 medial temporal sclerosis, 5 indolent tumours). 12 of them (40%) had ideally concordant interictal & ictal surface EEG localisation with the MRI lesion, while 6/29 (21%) had either interictal or ictal EEG concordant with the lesion. None had discordant data.. 11/29 (39%) had either negative or non-resectable MRI lesions. Only 5/37 ( 14 %) ETLE cases harboured resectable M RI abnormalities, 4 (11%) with concordant and 1 (3 %) with discordant EEG data. 9/37 (22 %) ETLE patients,had either non-resectable or non-specific lesions, and 23/37 (64%) had normal MRI studies. Conclusions: In our population ETLE slightly outnumber TLE cases. 61% of TLE patients present with concordant EEG and MRI data, and are thought as appropriate for surgery. The yield of these investigations is much lower (11%) for ETLE patients, due apparently, to the much lower incidence of resectable, structural lesions in this group compared to the TLE group ( 14 % vs 61%, p < 0.01 ). Overall 33 % (27 % TLE aod 6 % ETLE) of our population are identified as suitable surgical candidates on the basis of a noninvasive, structural abnormality-oriented, protocol. To improve the yield of presurgical assessments, further optimisation of ETLE cases work-up is required, apparently by incorporating data from functional imaging and intracranial EEG monitoring studies.

P488 Frontopolar interictal & ictal surface EEG localisation with parietal lobe lesi.ons: report of two cases. K. Garganis, G. Georgakoudas, N. Karipidis, I. Milonas (Salonica, GR) Objective: To report two cases with intractable partial onset seizures and central-parietal lesions, presenting witb similarly discordant surface EEG data, suggesting ictal onsets from ipsilateral frontopolar areas. Material & methods: A 24-year old and an 9-year old male subjects, undergoing evaluation for intractable localisation-related epilepsy, including surface Video/EEG (seizures recorded in the first case) and MRI studies. Results: Both patients experienced seizures with prominent early tonic manifestations, head deviation, and in the case of the 9-year old, dimness of vision/amaurosis. MRI studies revealed abnormalities located over dorsallateral parietal cor tex, with imaging feat ures suggestive of long-standing developmental mass lesions, lnterictal EEG in both cases and ictal EEG (in the case with seizure recording), implicated the ipsilateral frontopolar area for epileptogenesis. There was no imaging evidence of frontal lobe lesions. Conclusions: These two cases are indicative of a reproducible pattern of discordant surface EEG localisation in patients with parietal lobe lesions. EEG localisation was consistenfly neocortical, ipsilateral frontopolar, perhaps suggesting facilitated propagation of epileptic activity from parietal to frontal areas, and/or a widespread epileptogenic potential distributed over the frontoparietal circuit, given the developmental features of the parietal lesions. The alternative interpretation of dual pathology, is probably remote, in view of the normal-appearing frontal cortices in both cases. Our findings may be of importance for presurgical evaluation of cases with neocortical partial epilepsies and discordant EEG and structural imaging data.

P489 Estimation of premorbid intelligence in epilepsy. G. De Maria, S. Parola, E Liberini, B. Guarneri, L. Antonini (Brescia, I) lntroduction: Neuropsychological functioning in epileptic subjects has been widely studied and cognitive deficits ate often repor ted. Usually the primary measure of abilities is a test of intelligence such as the Wechsler Adult Intel-

ligence Scale-Revised (WAIS-R). Recen@ it has been suggested that reading ability may provide an alternative approach to the estimation of the premorbid intelligence. The TIB is a new Italian reading test coming from the NART, National Adult Reading Test, and is composed predominantly of words of irregular orthography, requiring the direct graphemic-semantic rule of reading and maximising the importance of previous knowledge. The present study examined IQ scores from TIB in relation to WAIS-R IQ scores in two group of patients with partial adult age onset epilepsy and different duration of disorder. Subjects and methods: We administered the WAIS-R and the TIB to 20 patients ( 11 male, 9 female; mean age 45.8 _+12.8 years) with par tial adult age onset of epilepsy and different duration of disorder and 10 normal control subjects with the same demographic characteristics. Results: Patients with a long seizure history performed more poorly than tbose with short seizure history and healthy controls (t=4.34, p-value=0.001). No difference emerged between patients with a short story of epilepsy and controls. Conclusion: A certain number of patients with epilepsy sbow cognitive deterioration. The present study examined the utility of the TIB, a new Italian reading test coming from the NART, in estimating premorbid intellectual functioning in patients with epilepsy. Patients with a long seizure history performed more poorly than those with short seizure history and healthy controls. These findings support the use of the TIB in estimating premorbid intellectual functioning in patients with epilepsy. P490

Anomalies in brain cortex detected by proton magnetic resonance spectroscopy in a case of fronto parietal epilepsy initiated as epilepsy partialis continua. E Ceres, B. Cetalan, J. Vaamonde, R. Ibanez, M. A. del Real, A. Hernandez, E de Luis, J. Viano (Ciudad Real, Madrid, E) Background: In 1982 Bancaud and coUeagues described two types of epilepsia partialis continua (EPC). Type 1 corresponded to a local and non progressive lesion in the central sensorimotor cortex, it may start in any age, and it is not followed by brain atrophy. Type 2 was related to Rasmussen encephalitis, and it is followed by progressive brain atrophy. We presenta case of a young man that had EPC, afterwards he developed a focal brain atrophy detected by MR spectroscopy. Vascular, metabolic, demyelinating, and.neoplastic causes were excluded. Case report: A 37 year old man had been heahhy unti11992 when he developed jerky continuous movements in his left leg. At that time a 0,5 T MRI was performed, and the resuhs were normal. The patient was treated with carbamazepine and he remained seizure free 5 years, then the treatment was withdrawn. Two years later he began with somatosensory seizures on his right arre, later he developed Status Epilepticus, and atonic, tonic clonic and partial seizures. The patient was studied by 1,5 M RI and MR Spectroscopy. Results: A 1.5 T MRI showed mild fronto-parietal cortical atrophy. Spectroscopy data showed metabolic deficits in both fronto parietal lobes, The NAA/COL+CRT ratio was 0.71 and 0.7 to both lefi and right frontal lobes. The NAA/COL+CRT ratio was 0.77 and 0.85 to both left and right frontal lobes. Conclusion: Our patient resembles Bancaud type 1 epilepsia partialis continua, but he developed brain atrophy and seizures besides an initially good clinical outcome. We postulate that neuroaxonal damage - due to the epilepsia partialis continua at the beginning of the disease - has been the cause of focal brain atrophy.

P491 Accomodation spasm: unusual presentation of generalized photosensitive epilepsy. E. Shahar, D. Savitzky, J. Andraus (Haifa, IL) We report on a 9-year-old girl was with prolonged and recurrent near reflex accommodative spasms which was the sole clinical manifestation of primary generalized photosensitive epilepsy. She presented with blurred vision and diplopia causing a sensation of unsteadiness. Examination upon admission revealed fixed adduction of both eyes and mild miosis, namely near reflex accommodation spasm. Apparently, Fixed eyes' adduction which started four days prior to admission, initially momentary and scarce increased in frequency and duration to become prolonged as four hours prior to referral. No aheration of awareness had been reported of observed. Optic discs' assessment and visual fields performed later were unremarkable. The EEG demonstrated a normal background activity and generalized spike/wave discharges, also induced with photic stimuli, compatible with generalized photosensitive epilepsy. She was therefore started with a small dose of valproate and became asymptomatic within the first day of treatment.. She remained asymptomatic within seven months and the EEG had normalized, as well. Valproic acid was negligibly discontinued and afler a few days she be-

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gan experiencing short-lived episodes of accommodation spasm, with concurrent generalized epileptiform discharges observed on EEG. To the best of our knowledge, this is the first report associating a unique presentation of generalized photosensitive epilepsy presenting with near reflex accommodation spasm, and hence complete response to valproate, with concurrent EEG normalization and recurrence associated with medication discontinuation. Convergence and accommodation were experimentally evoked by stimulation of the lateral supra-sylvian areas which receive input from visual areas and the superior colliculus. Therefore, we postulate that an epileptic discharge arising in the occipital regions may spread vŸ those tracts to activate the oculomotor complex, and hence near reflex accommodation spasm.

General neurology P492

Gayet-Wernicke and Marchiafava-Bignami syndromes: interest of magnetic resonance imaging. O.Varnet, ]. de Seze,F. Tiberghien, C. Daems, D. Caparros-Lefebvre, G. Soto-Ares, E Pasquier, J. Pruvo, A. Destee, P. Vermersch (Lille Cedex, Pointe ~, pitre, F) lntroduction: Central nervous system (CNS) manifestations of alcoholism, such as Gayet-Wernicke (GW) and Marchiafava-Bignami (MB) syndromes, are frequent but their prognosis remains unpredictable. Only few studies have focused their interest on magnetic resonance imaging (MRI). Airo of the study: To determine more precisely the frequency and the topography of MRI abnormalities in both GW and MB syndromes. Methods: We retrospectively studied 34 patients (24 GW and 10 MB syndromes) where an MRI was available. We evaluated the frequency and the localization of the MRI lesions. We also correlated the localization of the lesions with the clinical outcome. Results: MRI abnormalities were observed in 28 cases (82.4%). In MB syndrome, the lesions were more frequently ah hyperintense signal in T2weighted images in the corpus callosum (80% of cases). In GW syndrome, the lesions corresponded to T2-weighted hypersignals prevailing in the periaqueducal region (41.7%), sometimes associated with bi-thalamic hypersignals (33 %). These last abnormalities were associated with a poor clinical outcome (p < 0.05). Discussion: Our study highlights the frequency of brain MRI lesions in CNS complications of alcoholism. We also demonstrate that MRI should be of prognostic value concerning clinical outcome, especially in GW syndrome, when a bi-thalamic hypersignal is observed. P493 Exposing Psychogenic Ataxia: Discrepancies Between Centrifugal And Centripetal Movements. M.-U. Manto, J. Moore (Brussels, Charleroi, B) The diagnosis of a psychogenic movement disorder is difficult and has major consequences for the patient. There is a need for objective tests to aid the clinician in making a confident diagnosis. The goal of this study was to determine ir the comparison of centrifugal and centripetal movements may provide one such objective measure for confirming psychogenic ataxia. We analysed two patients diagnosed with psychogenic ataxia: Patient 1 was a 42 year-old man with ah eight-year history of gait difficuhies appearing abruptly after acar accident. Eye movements, sensory examination, tendon and plantar reflexes were normal, but bilateral random movements were observed during the finger-to-nose test. Brain MRI, EEG, evoked potentials, and blood studies were normal. The patient was instructed to perform pointing movements away from a central starting position and then to return to the original position. A clear incongruity was displayed between the centrifugal and centripetal movements. Path ratios computed by dividing the length of the centrifugal movements by the length of the centripetal movements had a mean of 130.7 + 6.3, as compared to values of 101.1 -+ 4.3 in a group of 9 heahhy sub/ects (mean age: 56; range: 36 to 78; 3 women) and to 101.0 -+ 5.6 in 4 patients presenting a cerebellar syndrome associated with cerebellar atrophy on brain MRI (mean age: 45; range: 40 to 50; 2 women). Patient 2 was a 40 year-old man with a history of left temporo-occipital angioma who suddenly developed a tremor and ataxic movements ten years after surgery. This patient was instructed to repeatedly perform a finger-tonose movement, and kinematic parameters were recorded. Again, a clear incongruity was displayed, as the patient exhibited a marked tremor during centripetal movements that disappeared when he neared his nose and during the centrifugal movements. Spectral analysis of the r movements showed a 5 Hz peak, while that of the centrifugal movements showed no dominant frequency.

We suggest adding the analysis of centrifugal/centripetal movements to document psychogenic ataxia. There ate limitations of kinematic studies to differentiate organic from non-organic movement disorders, but marked incongruity between centrifugal movements and centripetal movements strongly supports the diagnosis of a psychogenic movement disorder. P494 Ten years experience in the treatment of spasticity with intrathecal badofen. I. Dones, C. Marras, A. Franzini, G. Broggi (Milano, I) Spasticity is a clinical sign present in many neurological disorders such as multiple sclerosis, familial spastic paraplegia, myelitis and postraumatic diseases. The most effective treatment for diffuse spasticity is the administration of intrathecal baclofen. 290 patients affected by different diseases causing severe spasticity, were studied at the Istituto Nazionale Neurologico C. Besta of Milano. We divided patients into two clinical groups. The first group was composed of wheelchaired and bedridden patients while the second group merged still walking patients. The first group was only clinically evaluated and scored and in the second group clinical evaluation was enriched by a neurophysiological gait analysis. Only 30patients could be treated orally. 15 patients did not need any treatment. 200 patients were assessed and submitted to a bolus test with intrathecal baclofen at different dosage. 160 patients were then submitted to implant of a programmable administration device (Synchromed, Medtronic, USA) under local anaesthesia. In the first group of patients intrathecal baclofen brought to a marked decrease of spasticity of at least two grades of the Ashworth scale in 100 % patients. An improvement of their quality of life was achieved in all cases. The use of intrathecal baclofen in still walking patients even after proper evaluation, brought to a general improvement of the quality of life although a real improvement of the motor performance could be reached in 65 % of patients who could undergo continuous motor rehabilitation. In 10 patients focal BOTOX injections were added to intrathecal baclofen to optimize the improvement of gait. The use of intrathecal baclofen in patients with cerebral palsy brought to a decrease of spasticity while no effect on dystonia was observed. P495 Visually induced gait deviations during different Iocomotion speeds. K. Jahn, M. Strupp, E. Schneider, M. Dieterich, T. Brandt (Munich, D) Optic flow is essential for the perception of self motion and the control of path integration during locomotion. Inverting prisms oriented 15~ vertical in the roll plane were used to experimentally distort optic flow during locomotioo. Depending on the direction in which the prisms were rotated, optic flow was diagonally upward to the right or upward to the left. A reproducible deviation of gait toward the direction of perceived optic flow was found in ten healthy subjects. This deviation is explained to be a gait deviation that compensates for misleading perceived self motion induced by optic flow. The amount of deviation was dependent on locomotion speed. When walking slowly (about 1 m/s), mean deviation was 0.22 + 0.08 m/s to the right and -0.18 -+0.08 m/s to the left for right and left, respectively, diagonal prism oriemation. Deviation was significan@ less when running (about 3 m/s) with mean deviations of 0.05 :t: 0.03 m/s and -0.06 _+0.03 m/s, respectively (ANOVA, p < 0.01). Ir is assumed that path integration during running is largely achieved by highly automated spinal programs operating independently of sensory control. In contrast, walking is more dependent on afferent and re-afferent visual control. Thus, the experiments show that visual control of locomotion is dependent on optic flow-induced vection and gait deviations ate direction specific. Visual control becomes less influential with increasing speed of locomotion, e. g. when walking in contrast to running. Supported by the Deutsche Forschungsgemeinschaft. P496 Mathematical Analysis Of The Decreasing Phase Of EMG Bursts In Idiopathic Parkinson's Disease During A Postural TasL J. Moore, M.-U. Manto (Charleroi, Brussels, B) The goal of this study was to model the decreasing phase of electromyographic (EMG) bursts caused by idiopathic Parkinson's Disease (PD). EMG activity was recorded from three patients (ages 78, 61, and 73; I woman) presenting idiopathic Parkinson's Disease (PD). The signals were recorded from the upper limbs during a postural task using a sampling rate of 1200 Hz. The dominant tremor frequencies were 6.0, 5.1, and 5.2 Hz respectively. For each patient, a mŸ of 300 EMG bursts was extracted from the recordings. The peak amplitudes of these bursts were characterized by a Gaussian dis-

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tribution. The bursts were divided into six ranges based on their peak amplitude. Each range spanned one standard deviation of the peak amplitude values beginning from three standard deviations below the mean peak amplitude and ending three standard deviations above. The bursts in each range were rectified, aligned at their peak values, and averaged. A model for exponential decay V=Vo*exp(-k~t) was then fit to each of the burst averages. We found that the exponential decay model provided a very good fit for all six burst ranges in all three patients. The mean R2 value was 0.898 --i-0.0585. The rate constant ranged from 23.53 to 31.75 in patient 1 (R2:0.75 to 0.93), from 27.48 to 50.26 in patient 2 (R2:0.87 to 0.94), and from 26.45 to 61.74 in patient 3 (R2:0.88 to 0.95). Our resuhs demonstrate that the decreasing phases of the EMG bursts in PD can be modelled by exponential decay. The reliability of the model suggests that ir might be applicable to other types of tremors. We hypothesize that rigidity might account for the lower rate constants observed in PD, as compared to other forms of tremor characterized by higher frequencies and regular firing. P497

Exponential Model For The Decreasing Phase Of Electromyographic Bursts In Primary And Secondary Orthostatic Tremor. J. Moore, M.-U. Manto (Charleroi, Brussels, B) Most studies of the EMG signal associated with tremor have focused on excitatory aspects and general parameters such as frequency and synchronism between antagonist muscles. We analysed the decreasing phase of electromyographic (EMG) bursts caused by orthostatic tremor (OT). It was hypothesized that studying the decreasing phase of the individual bursts might give new insight into the mechanisms effecting tremor. OT was chosen because of its highly regular frequency and amplitude modulation. EMG activity was recorded from weight bearing muscles in two patients (2 women; ages: 60, 7~; dominant frequencies: 16.2 Hz, 14.4 Hz) presenting primary orthostatic tremor (POT) and two patients (1 woman; ages: 58, 79; dominant frequencies: 5.1 Hz, 6.7 Hz) presenting secondary orthostatic tremor (SOT). One patient with SOT was diagnosed with hydrocephalus and the other with peripheral neuropathy. For each patient, a mŸ of 300 EMG bursts was extracted from the recordings. The bursts were divided into six ranges based on their peak amplitude. Each range spanned one standard deviation of the peak amplitude values beginning from three standard deviations below the mean peak amplitude and ending three standard deviations above. The bursts in each range were rectified, aligned at their peak values, and averaged. A model for exponential decay V=Vo*exp(-k*t) was then fit to each of the burst averages. The first finding was that the exponential decay model provided an excellent fit for all burst ranges in all patients. The mean R2 value was 0.92 -+ 0.028. The second finding was that the rate constant of the exponential decay (k) increased consistently with each range of increasing peak burst amplitude. A linear fit of the rate constants to the corresponding mean peak amplitudes resulted in a mean R2 value of 0.94 +_ 0.046 a n d a mean slope of 147.46 + 102.00. Our results confirmed that the decreasing phase of EMG bursts in POT and SOT could be modelled by exponential decay. Furthermore, we observed that the tate constant of the exponential decay (k) was positively correlated with the peak amplitude of the EMG bursts. Since this correlation was observed even in the cases of SOT with central and peripheral nervous system damage, the decreasing phases of EMG bursts in OT might be primarily effected by the electrical and viscoelastic properties of the muscle tissue itself and not by descending brain commands.

P498 Paraspinal electromyography in lumbar radiculopathy. S. Gierer, D. Claus (Darmstadt, D) The purpose was to compare the sensitivity of electromyography of the lower extremity muscles with paraspinal muscles in subacute lumbar radiculopathy. Methods: 20 patients with lumbar radiculopathy following ah intervertebral disc prolapse were studied by EMG. Inclusion criteria was acute onset of severe lumbar pain eradiating into the legat least 2 weeks prior to the examination a n d a disc prolapse seen in CT scan or MRI. Patients with compression of the S 1 nerve root were excluded, since it is not clear whether this root also innervates a part of the multifidus muscle. EMG was identified as abnormal by detection of pathological spontaneous activity (PSA; fibrillations and/or positive sharp waves) at 2 distinct sites of the muscle (muhifidus muscle; extensor hallucis longus muscle; quadriceps muscle). Resuhs: 15 of 20 patients showed a paresis of the muscle innervated by the affected nerve root. 10 patients had pathological spontaneous activity in the affected leg muscles. Al1 but one patients had PSA in the paraspinal muscle at the appropriate location. Of the 5 patients without paresis, 2 had PSA only in the paraspinal muscles.

Conclusion: Paraspinal EMG is very sensitive in detection of PSA in patients with subacute lumbar radiculopathy caused by a disc prolapse. The method increases the sensitivity of EMG for proof of damage of the nerve root.

P499 Central Amplification of Somatosensory Inputs: ah Evoked Potentials Study. D. Dive, E. Schmetz, M. Polis, P. Palma-Duran, E C. Wang (Liege, B) Background: Cortical somatosensory evoked responses are frequently preserved in case of mild to moderate axonal peripheral neuropathy. Only few dinical neurophysiologists record periphera] responses during somatosensory evoked potentials (SSEPs) evaluation and amplitudes a r e scarcely taken into account.We investigated the relationship between the amplitudes ofperipheral and central responses during SSEP recordings in normal subjects. Methods: We recorded median nerve SSEPs in 15 healthy volunteers (18-30 years old range, stimulation at the wrist of the dominant side, squared pulses of 0.2 ras duration) with peripheral (elbow, 5-1500 Hz bandwidth) and controlateral parietal (P3 or P4 referenced to the earlobe ispilateral to stimulation, 0.5-1500 Hz bandwidth) surface electrodes. Stimulation was applied at the motor threshold followed by lower and higher intensities until no response or pain was respectively induced. Amplitudes of peripheral (elbow) and cortical (N20) responses were plotted for each stimulus in_ tensity. Peripheral and cortical responses amplitudes were expressed in percentages of maximum. A normalised stimulus intensit y (150) was established for each recording. It was defined by the stimulus intensity responsible for 50 % of the maximal amplitude of the peripheral response. It allowed us to make interindividual comparisons and grand average. Sigmoid fil was calculated for each recording session and well defined the relationship between response's amplitude and stimulus intensity. Re]ative peripheral and cortical amplitudes mean and standard deviations were computed for incremental stimulus intensities. Resuhs: Clear-cut statistically significant (p < 0.01 ) dissociation between peripheral and cortical responses amplitudes was observed between 40 % to 130 % relative stimulus intensity index (150). N20 relative amplitude reached 1.8 times peripheral relative amplitude response for intensity equal to 90 % of I50. Conclnsion: Incremental stimulus intensity somatosensory evoked potentials recordings in healthy subjects demonstrate a central ampliflcation process of peripheral inputs. It could explain that N20 amplitude is not strictly related to the stimulus intensity and is not sufficient for peripheral nerve axonopathy evaluation. Complementary studies with multi-site recordings ate mandatory in order to precise the level of central amplification (spinal, sub-cortical or cortical level). P500 The evaluation of the lipid peroxidation and antioxidant system activity in neurolupus. R. Pascal, C. Babiuc, O. Pascal (Chisinau, MD) Objective: To assess the level of the lipid peroxidation (LPO) and the activity of the antioxidant system (AOS) in systemic lupus erythematosus (SLE) patients with neurological disorders compared to those without clinical signs of the nervous system involvement. Methods: The study enrolled 48 patients with systemic l•pus erythematosus diagnosed according to the 1982 ARA revised criteria, among them 28 patients had neurolupus and 20 presented no neurological disease. There were no significam diflerences in regard to age, sex, disease duration and activity between these two patients groups. The mean patients age was 33.4 years, the mean disease duration was 5.4 years and female/male ratio was 9/1. The process of lipid peroxidation was assessed by studying of serum lipid peroxide (LPO) levels, malonic dialdehyde (MD), and free oxygen radicals (FOR). The antioxidant system was evaluated by measuring of superoxide dismutase (SOD), catalase (CA) and glutationic enzymes (GE) activity. Results: A paralle[ism was found between the presence of nervous sysrem disease and the degree to which the homeostasis was altered. It was found that LPO and MD levels were significantly increased while SOD and CT activity was markedly decreased in patients with neurolupus compared to the patients with no involvement of the nervous system. Conclusion: The study showed a big discrepancy between POL and AOS parameters in patients with neurolupus, which requires the administration of antioxidant drugs.

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P501 Familial Mediterranean Fever And Extrapontine Myelinolysis With Normal Serum Sodium: A Case Report. U. Can, U. S. Benli, M. Kylyn~, G. (~eliker, M. A6~'ldere, T. Zileli (Ankara, TR) Familial Mediterranean fever (FMF), is an autosomal recessive disorder characterised by recurrent attacks of abdominal pain, fever and arthralgias. Central nervous system (CNS) complications of FMF are extremely rare. We presenta 38-year-old right-handed male patient who was admitted with nausea,vomiting, speech difficulty and mild right hemiparesis. He hada history of occasional abdominal pain and diarrhoea attacks since his childhood. His family history revealed that his son and brother hada diagnosis of FMF. His rectal biopsy showed amyloidosis confirming FMF diagnosis. On the day of admission he required bicarbonate hemodialysis because of high creatinine and blood urea nitrogen levels and metabolic acidosis. His blood pressure and electrolytes were in normal limits. His magnetic resonance imaging (MRI) showed bilateral large white matter oedematous lesions with mass effect which do not enhance with cont rast injection, consistent with extrapontine myelinolysis. He didn't require further hemodialysis and bis chronic renal failure was followed with conservative management. His neurological findings resolved in a week and MRI findings resolved gradually in two months. Most of the conditions resuhing in MRI white matter abnormalities like collagen vascular diseases, sarcoidosis, acute disseminated encephalomyelitis and Beh~et's syndrome were excluded by clinical and laboratory features. Extrapontine myelinolysis although generally linked to rapid correction of hyponatraemia is also reported with other conditions like dialysis disequilibrium syndrome, hypoglycaemia, alcohol abuse, lithium toxicity, hypokaliemia with renal tubular acidosis, after correction of hyperammonemia, hypophospbatemia, thiamine deficiency and hypomagnesaemia together with high cyclosporine levels. This represents the first description ofextrapontine myelinolysis in a patient with FMF complicated with chronic renal failure and metabolic acidosis. Extrapontine myelinolysis and FMF in the same patient could arise from either coincidence oran unknown pathoph~,siological relationship or because of its renal complications. These explanations are speculative and further studies are needed to investigate MRI findings in FMF patients. P502 Syrinx formation in inflammatory CNS disease. M. M. K. Muqit,A. 1.Larner, S. Glickman (Liverpool, UK) Objective/methods: To reporta patient with an inflammatory CNS disorder, affecting particularly the brainstem and spinal cord, with a concurrent syrinx demonstrated by magnetic resonance imaging. Results: A 42 year old Afro-Caribbean female developed progressive brainstem, spinal cord and visual symptoms and signs over three weeks, beginning eight weeks after childbirth, culminating in asymmetric paraparesis and respiratory failure requiring assisted ventilation. Magnetic resonance imaging showed ill-defined white matter lesions in the parieto-occipital region bilaterally, ventral pons, and dorsal medulla, In addition tbere was a cavity extending from the medulla through the cervical cord to T5/T6, consistent with a syrinx. Cerebrospinal fluid (CSF) analysis showed 15 white cells (90% lymphocytes), raised protein, and matched oligoclonal bands in serum and CSE Extensive investigation for markers of inflammatory or infective cause revealed only persistently elevated anti-nuclear and anti-Ro antibodies. A diagnosis of CNS lupus was thought most likely. The patient received immunomodulatory therapy and gradually improved to the point of walking unaided. Conclusion: There are occasional reports of syrinx formation in multiple sclerosis and neuromyelitis optica. This case presents a further example of inflammatory CNS disease with syrinx formation. We suggest that intramedullary inflammation per se may representa mechanism for syrinx development, perhaps involving hydrodynamic factors, and/or necrosis and cavitations. P503 Oral Contraceptive Drugs And Carpal Tunnel Syndrome: Risk Or Protective Factor? G. Albani, L. Priano, E. Greco, A. Mauro (Intra, Verbania, I) Introduction: The aetiology of carpal tunnel syndrome (CTS) is uncertain. Previous studies established that CTS is more frequent in women, in people over 30 years, it may be transient during pregnancy and weight gain. Considering the large use of oral contraceptives drugs (OCD) among women,we tried to evaluate ir these drugs may be considered a risk factor o r a protective factor for CTS. Patients and metbods: We performed electromyography in 189 consecu-

tive females according to the following criteria: 1) female at childbearing age (non pregnant at the time of the study orat least one year before); 2) absence of obesity (Body Mass Index < 28); 3) absence of endocrine disorders involving sexual hormones, 4) absence of diabetes or other known causes of neuropathy. Results: We considered two groups: females with CTS (93 cases, CTS group) and patients without CTS (96 cases, NO-CTS group). Among patients in CTS group, 45.2% had never taken OCD, 20.4% referred to have taken ir in the past but n o t a t present, 34.4% was taking OCD at the moment of the study. Among patients in the NO-CTS group, frequencies were 32.3 %, 22.9 % and 44.8 % respectively. These differences were not statistically significant. Considering CTS and age, both chi-squared test and Spearman test demonstrated a positive weak correlation between the presence of CTS and advanced age (R=0.17; p=0.01) The groups were subsequently divided the groups into two subgroups: subgroup A, including females younger than 35 years old, and subgroup B, including over 35 years. In subgroup A data confirmed a higher percentage of patient without CTS among females taking OCD (58.9 % vs. 47.3 %) anda higher percentage of patients with CTS among females not taking OCD (44.4% vs. 19.6%); this difference resulted statistically significant (chisquared test: p=0.02). On the other hand in subgroup B we found the same percentage of patients with and without CTS among females taking OCD (26.4 %. vs. 25 %). In subgroup B, but not in subgroup A age maintained a positive weakly correlation with CTS according to Spearman rank test (R=0.12; p=0.05). Conclusion: Our data suggest that in females younger than 35 years OCD may playa protective role for the development ofCTS. After 35 years this protective role is less evident, probably due to other factors age-related. P504 Prugnostic value uf masseter reflex in patients with spina bifida and Chiari II malformation. J. Koehler, A. Faldum (Mainz, D) Objectives: In patients with spina bifida central ventilatory dysfunction due to Chiari I1 malformation is the main cause of death. Based on these findings we analysed the masseter reflex (MR) recordings and clinical findings ofpatients with Chiari II malformation to develop a prognostic model. Methods: Sixty-two patients (30 male, 32 female, age 3-32, mean 12.7) with Chiari II malformation and repaired myelomeningocele were classified into two groups: those without (group 1,40 patients) and those with brainstem dysfunction (group 2, 22 patients). Clinical examination and MR recordings were documented simultaneously at baseline and in the follow up (mean 36 month). Using a hammer with a trigger device ten reflexes were recorded simultaneously on both sides. Sensitivity, specificity and odds ratio of developing a progressive Chiari 1I malformation, i. e. new or increased brain stem signs and symptoms, a multiple logistic regression (likelihood ratio forward) was calculated. MR and clinical examination at baseline were defined as influential parameters. Two-sided Fisher test was used to analyse clinical and electrophysiological findings. Results: In follow-up MR recordings the sensitivity (0.81vs 0.80) was similar and the specificity (0.83 vs. 0.65) increased compared with the results of the first investigation. Patients with symptomatic Cbiari II malformation showed more often abnormal MR (p=0.006). The odds ratio to develop a severe progression of the Chiari II malformation was increased with abnormal MR (4.63, 95% confidential interval: [1.03-20.83]) whereas the clinical examination failed with respect to a prognostic value. Conclusions: Our study demonstrates that MR recordings support the clinical diagnosis of symptomatic Chiari II malformation. Furthermore MR findings in patients with Chiari 11 malformation have a prognostic value within a long-term period of 36 month (mean). Patients with abnormal MR findings have a increased chance of 4.6 to develop a severe clinical deterioration compared with patients with normal MR Based on clinical examination no prognostic factor was found. Therefore MR are helpful to improve the treatment of patients with spina bifida and Chiari II malformation.

Higher functions disorders P505 Subacute Dementia With Lewy Bodies Disease. G. Castelnovo, S. Bouly, V. Chauvineau, V. Gremont, C. Marty Double, P. Labauge (Nimes, F) Introduction: Dementia with Lewy bodies (DLB) is the second most common degenerative disease that causes dementia. The diagnosis is based on clinical and neuropathological features. 6-8 years is the mean duration of DLB.

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Objective: We reported a sub-acute dementia with myoclonus and extrapyramidal syndrome that simulate a Creutzfeldt-)akob disease (CID). Case report: A 69 year-old man was admitted for the rapid onset of mental confusion, frontal syndrome and generalised myoclonus. Since 1 year he presented an extrapyramidal syndrome treated with levodopa. The clinical evolution was characterised by the worsening of the neurological symptoms and by apparition of stupor. Any neuroleptic treatment was introduced before. Laboratory investigations, cerebrospinal fluid (CSF) examination,brain MRI were normal. EEG patterns consist of diffuse slow waves without periodic activity. The 14-3-3 protein was not detected in CSF. The patient deceased 10 weeks after hospital admission. Necropsy showed diffuse Lewy bodies in the cerebral cortex. Discussion: DLB is the second most common cause of degenerative dementia. The duration of the disease is 6-8 years. DLB is characterised by the association of cortical-subcortical dementia and extrapyramidal syndrome. Visual hallucinations are observed in half of the cases. Acute evolution is uncommon and mimics Creutzfeldt-)akob disease. The diagnosis is founded on the neuropathological features as ir was the case in our observation. Conclusion: This report shows that DLB can have an acute evolution. In that case the differential diagnosis with CID can be evocated. The diagnosis is based on neuropathological features. P506 An Economic Evaluation Of Donepezil in Mild to Moderate Alzheimer's Disease: Resuhs of a One-Year, Double-Blind, Randomised Trial. A. Wimo, B. Winblad, A. Haglund, U )acobson, R. Miceli, R. Zhang, P. Subbiah, V.Mastey (Umea, USA; Huddinge, Taby, S; New York, USA) Purpose: To investigate the annual costs and consequences of treatment with donepezil versus placebo in patients with mild to moderate Alzheimer's disease (AD) over one year. Methods: Patients with possible or probable AD from tire Northern European countries were randomised to receive either donepezil (n=142) or placebo (n=144). Data on patient and caregiver health care resource utilization, and caregiver time and work status were collected prospectively. A cost consequence analysis was conducted from a societal perspective. The unit costs for resource utilization were assessed in 1999 Swedish Krona (SEK). Results: Donepezil-treated patients gained significant functional benefits relative to placebo, as assessed by the Progressive Deterioration Scale at Week 52 (p=0.042) and analyses of the percentage of patients in decline for individual items of the Instrumental Activities of Daily Living scale at Week 52 (p=0.025) and the Physical Self-Maintenance Scale at Weeks 24 (p=0.011 ) and 36 (p=0.032). These benefits were obtained at no increase in costs. The total annual patient health care costs were 19.56 M SEK for the donepezil group (mean=137,700 SEK/patient) and 19.49 M SEK for the placebo group (mean=135,300 SEK/patient). With the average annual cost of donepezil treatment at 10,700 SEK, the difference in per-patient costs (2,400 SEK) represented a substantial cost offset. When caregiver health care costs were included, the total annual health care costs were 20.37 M SEK for donepezil (mean=t43,500 SEK/patient) aud 20.73 M SEK for placebo (mean=144,000 SEK/patient) with a net saving of 500 SEK per donepezil patient. When caregiver time costs were included (time spent providing patient care and missed work time), the difference in per-patient costs remained in favour of the donepezil group (9,200 SEK). Conclusions: This study demonstrated that donepezil-treated patients attained a significant clinical benefit at an annual cost similar to placebo. From both a total health care (patient and caregiver) anda societal (health care and caregiver time costs) perspective, donepezil treatment resulted in lower costs. P507 The value of continuous external lumbar drainage (ELD) of cerebrospinal fluid for predicting the outcome after ventricular shunting in normal pressure hydrocephalus (NPH): a prospective multicentre study. E. Geiger, R. Walchenbach, J. A. L. Vanneste (Amsterdam, Leiden, NL) Background: ELD is an ancillary test used for predicting the outcome afler ventricular shunting in patients with presumed NPH. The assumed high predictive accuracy of ELD,however, is only based on a few small studies, not exceeding 20 patients per study. Objective: To assess the value of ELD for predicting the outcome after a ventriculo-peritoneal drain (VPD) in patients with presumed NPH. Methods: AII patients referred for NPH were invited to participate in this study. Clinical assessment, MR imaging, and neuropsychological evaluation were followed by a lumbar CSF tap test (TT) consisting of removing 40ml CSF and assessing the effect of the TT on gait and mental disturbances. Patients with marked clinical improvement after the TT were shunted. In the

other patients, ELD was carried out consisting of removing 100-150 mi CSF per day during 4 days. We classified improvement of gait and mental symptoms afler ELD and after ventricular shunting by using a global score containing 3 categories of improvement: no, slight and marked improvement. This global score was based on blind assessment of video recordings of gait impairment and psychometric evaluation. The predictive value of ELD was calculated by correlating the outcome after ELD with that afler a VPD. Results: Between ]anuary 1994 and ]uly 2000, 48 presumed NPH patients were included, 47 were shunted; 8 patients were operated afler a positive TT, without further tests. ELD was carried out in the remaining 39 patients: 37/39 completed the test, two had serious ELD-related complications (meningitis). Thirty-four of the 47 shunted patients improved within 2 months. The sensitivity of ELD was 48 % (CI 30-70), the specificity 80 % (CI 44-97); 13 of the 15 patients with a positive ELD improved, but 14 of the 22 patients with a negative ELD also improved. Conclusion: In our hands, the predictive value of positive ELD was quite reliable but that of a negative ELD was deceptively low. In view of the low predictive value of a negative ELD and the risks of serious test-related complications, the usefulness of ELD for selecting NPH patients for a shunt seems very limited. P508 Cathepsin D polymorphism and Alzheimer's disease. B. Nacmias, S. Bagnoli, A. Tedde, B. M. Guarnieri, C. Petruzzi, A. Serio, P. Forleo, S. Sorbi (Florence, Citt~ Sant Angelo, Pescara, I) A recent study (Papassotiropoulos et al., 2000) has shown that genetic variation in the gene encoding Cathepsin D (catD) is a major risk factor for Alzheimer's disease (AD). CatD is an intracellular aspartyl protease involved in neurodegeneration through cleavage of amyloid precursor protein (APP) into amyloidogenic components. A C-T (Ala-Val) transition at position 224 (exon 2) has been associated with increased pro-catD secretion and altered intracellular maturation. However, this finding has not been confirmed yet. In 2000 Papassotiropoulos and colleagues reported a significant overrepresentation of the T allele of the catD gene in AD patients compared to nondemented controls. Because of the potential importance of this report, we investigated the implication of CatD in sporadic AD and familial Alzheimer's disease (FAD). We analysed the segregation of the exonic polymorphism of the CatD gene in 129 sporadic AD patients (age at onset 64.36 + 8.84 years, mean _+SD), in 63 patients belonging to autopsy-proven AD families [29 early onset familial AD (mean age 49.32 + 12.6) and 34 late onset familial AD (mean age 76.15 + 11.32)] and in 126 healthy controls. We did not find statistically significant differences in the distribution of the polymorphism in AD and FAD groups with respect to controls. Moreover a stratification of our data on individual Apo e4 dose revealed that AD patients, within the Apo e4 carrier group, did not show statistically significant differences with respect to e4 not carriers in relation to allele frequencies. Conclusion: Our data do not support a role for the CatD gene as genetic risk factor for sporadic and familial Alzheimer's disease. P509 Synaptic loss and alteration in the cytoarchitecture in Alzheimer's disease. S. Baloyannis, V. Costa (Thessaloniki, GR) Neurotic plaques, neurofibrillary tangles synaptic alterations and eventual neuronal loss ate the morphological hallmarks of Alzheimer's disease, seen mostly in the hippocampus and the cortex of the cerebral hemispheres. This neuropathological study is focused on the morphological aherations of the cerebellar cortex in the initial stages of Alzheimer s disease. The study is based on examinatiou of twelve brains obtained at autopsy 30 min. after death. Samples from the vermis and the hemispheres of the cerebellum were excised and immediately immersed in Sotelo's fixing solution and then they were processed for electron microscope. The brains, which were processed for the silver impregnation techniques, were remained for two weeks in formalin. Part of the vermis and the cerebellar hemispheres were excised and immersed in potassium dichromate for ten days. Then the specimens were immersed in 1% silver nitrate for ten days, according the rapid Golgi method. In the cerebellum, the morphological analysis, revealed limited number of neuritic plaques and numerous synaptic alterations concerning the parallel fibres and the Purkinje cell dendritie spines as well as the climbing fibres and the Purkinje cell dendrites. In the granule layer, the number of the granule and Golgi cells was impressively decreased, in correlation with normal controls. The synapses between the mossy fibres and the granule cell dendrites were also decreased. Some of the synapses, that remained still intact, contained limited number of polymorphic synaptic vesicles and numerous morphologically changed mitochondria and dense bodies in the

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mossy fibre presynaptic terminals. The number of synaptic contacts between the mossy fibre terminals and the dendrites of the granule and Golgi cells was dramatically reduce& In the molecular layer substantial loss of stellate and basket cells was noticed. Unattached spines were seen in the secondary and tertiary cell dendritic spines. In five of the cases a total loss of the stellate cells was noticed in the vermis and the flocculus. The above described morphological changes, plead in favour of a marked synaptic pathology a n d a substantial alteration of the cytoarchitecture of the cerebellar cortex in Alzheimer's disease. P510 Unilateral complete anterior cerebral artery infarction resulting in akinetic mutism. D. Ulbricht, F. Macian, R. }. Metz, J.P. Schmiz (Luxembourg, L) Introduction: Akinetic mutism is a descriptive term for patients awake but not capable to produce spontaneous motor and verbal responses. Typical lesions are situated bilaterally homologue in the cingulate gyrus, the basal ganglia or in mid-line structures such as the midbrain or the diencephalon. We reporta case with isolated left-sided complete infarction of the anterior cerebral artery (ACA). Case report: An 85-year-old woman with a medical history of diabetes, hypertension a n d a right-sided lacunar pontine stroke was found unresponsive with a right-sided hemiplegia. Afler admission she would lie still in bed not searching contact or moving but seeming fully alert. When stimulated, there were tonic postures of the lefl arre pertinent without any signs of ictal discharges in EEG (otherwise focal changes frontal left). Vascular work-up disclosed a complete infarction of the left ACA territory but no signs of severe cerebral microangiopathy. SPECT showed a hypoperfusion corresponding to the infarcted area. There was a slow evolution for several weeks leaving the patient bedridden but seeking contact. Several weeks later, she began to move the right arm spontaneously and some echolalia. The language production was reduced and difficult to understand, but with relatively well preserved repetition. The further evolution permitted fluent speech with a hypophonic voice and still trouble in initiating speech. The heŸ transformed into a proximally pronounced slight hemiparesis. Discussion: Usually akinetic mutism develops after bilateral lesions of structures relevant to vigilance and behavioural control. This case demonstrates that unilateral lesions in the ACA territory are capable to produce long-lasting, but mostly reversible akinetic mutism. This syndrome is probably due to the interruption of the basal forebrain bundle and the destruction of supplementary and singular motor areas as well the septal region with spared contralateral homologous regions.

P512 Efficacy and safety of donepezil hydrochloride in patients with AD: preliminary findings from a large multinational experience study. E. Triau, M. Boada, P. Sakka, N. Loza, R. Bahra, R. Zhang (Barcelona, E; New York, USA) Background: In pivotal clinical trials, donepezil HC1 was effective and well tolerated in the symptomatic treatment of patients with AD. Patients in a large US clinical experience trial also improved with donepezil treatment. The muhinational study presented here is a similar trial enrolling patients from 18 countries worldwide. Objective: To evaluate the efficacy, tolerability and safety of donepezil HC1 in a broader and more diverse sample of patients than in pivotal clinical trials, assessing everyday use of donepezil for the treatment of AD. Methods: In this 12-week open-label study in four continents, patients with mild to moderate, possible or probable AD received donepezil 5 mg/day for 4 weeks followed by 10 mg/day (as per clinical judgement) up to Week 12. Investigators were specialists and primar), care physicians. Cognitive effects were evaluated using the Mini-Mental State Examination (MMSE). Patient activity aod social interaction were recorded in caregiver diaries at weekly intervals up to Week 12. Tolerability and safety were assessed by adverse events (AEs), physical examinations, vital signs, and laboratory observations. Results: A total of 1113 patients received donepezil and were enrolled from centres in 18 countries. The mean age [:t: SD] of treated patients was 70.8 _+8.6 years (60 % female),and the mean baseline MMSE score [-+ SE] was 18.74 _+0.16.A total of 89 % (989!1113) of treated patients completed the 12week study period. In the ITT population, significant cognitive improvements were shown by mean increases [_+ SEI in MMSE scores from baseline at Week 4 (+1.31 _+ 0.08), Week 12 (+1.79 + 0.11) and endpoint [Week 12LOCF](+l.73 + 0.10) (all p values < 0.0001). Significant caregiver-assessed improvements from baseline were observed at all weekly assessments between Weeks 1 and 12 (including endpoint [Week 12-LOCF]) in patient social interaction, engagement and interest and initiation of pleasurable activities (all p values < 0.0001 ). Only 5 % (59!1113) of patients discontinued from the study a s a result of AEs. Conclusions: Donepezil was well tolerated and significantly improved cognition throughout this large-scale, multinational study. Caregiver-rated patient activity and social interaction also were significantly improved throughout. The resuhs in this real-world study population are consistent with results from previous pivotal clinical studies with donepezil.

Multiple sclerosis P511 Analysis of the NSO3 polymorphism in Italian sporadic and familial Alzheimer's disease patients. S. Sorbi, B. Nacmias, P. Forleo, E. Cellini, A. Orlacchio, S. Piacentini, S. Bagnoli, A. Tedde (Florence, Perugia, I) The endothelial nitric oxide synthase gene (NSO3; 7q35) has been recently individuated asa potential candidate gene for late onset Alzheimer's disease (AD). According to this study an association between the presence of the homozygous genotype Glu/Glu of the common polymorphism Glu298Asp at exon 7 of the NSO3 gene and the increased risk for late-onset AD has been reported in 317 cases of LOAD of British origin. Other groups have analysed tbis polymorphism, but they did find any significant association in US population and in Japanese sample. We have investigated the distribution of Glu298Asp NSO3 polymorphism in 132 Italian AD patients (48 males and 84 females; age at onset 65.7 _+8.6 mean _+SD) and in 88 patients with familial Alzheimer's disease: 46 late onset FAD (age at onset 70.7 +- 4.2 years) and 42 EOFAD (age at onset, 56.7 +_ 6.8 years). Moreover a s a control, we studied 95 age-matched normal individuals (40 males and 55 females; mean age 80.8 +_ 24.5). NSO3 and ApoE genotyping were done according to published protocols. The distributions of Glu/Glu genotypes and Glu298 allele frequency in all studied groups followed Hardy-Weinberg equilibrium and did not significantly differ from that of controls. We have performed a statistic analysis by the c2 test with Yate's correction or Fisher's exact test, but we did not find evidence of an association between the genotype Glu/Glu and the corresponding Glu allele frequency with AD (p > 0.1 ). Likewise no interaction NSO3/ApoE has been evidenced. Previous studies have reported very different values of Glu/Glu genotype aod Glu298 allele in US, UK and Japanese populations. The disagreement of these data ate probably due to ethnic differences. In conclusion, our data suggest that the NSO3 Glu298Asp polymorphism is n o t a n important genetic risk factor for ltalian sporadic and familial Alzheimer's disease.

P513 Longitudinal Analysis of Liver and Thyroid Function and of Autoimmunity during Interferon beta-lb Treatment for Multiple Sclerosis. E. Verdun, B. Ferrero, A. Oggero, A. Ghezzi, E. Montanari, M. Zaffaroni, L. Durelli and the BEST study group (Torino, Gallarate, Fidenza, ltaly, I) Autoimmune events, in particular autoAb occurrence and tbyroid dysfunctions, have been reported in MS patients treated with I FN beta.156 patients with RR MS were prospectively followed up by 18 MS centers after starting IFN beta-lb treatment (8 MIU). Thyroid and liver function and serum autoAb were tested every 3 months. Frequencies of alterations were compared using Fisher's exact test, chi-square test with Yates' correction, or McNemar's test. Association between liver or thyroid alteration and autoAb was evaluated with Phi-correlation coefficients. Probability to have liver, thyroid or autoAb alterations was analyzed longitudinally with generalised estimating equations (GEE) approach. Frequency of thyroid alteration was 5.3% at baseline and 8.3 % de novo during IFNB treatment, without significant difference. Frequency of de novo cases of thyroid alteration showed random fluctuations throughout study period. GEE analysis showed that probability to have thyroid alteration did not change significantly during treatment. Frequency of liver aheration was 4.6% at baseline and 37.5% de novo during IFNB treatment (p < 0.0001). GEE analysis showed that probability to have liver alteration was significantly (p < 0.002) higher at month 3 and at month compared to baseline. AutoAb were detected in 16.1% patients at baseline and in 20 % during IFNB. De novo occurrence of autoAb during treatment showed random frequency changes and GEE analysis showed that probability to have AT autoAb positivity did not change significantly during IFNB treatment. Most de novo occurriog alterations were transient, rarely persisting in two subsequent determinations. No correlation either between thyroid aheration de novo occurring during IFNB and AT autoAb, or between liver alteration and anti-tissu autoAb was found. In conclusion, we did not fin& during IFNB treatment, a significantly increased frequency of thyroid alteration or of autoAb positivity compared to baseline. Longitudinal analy-

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sis showed not significant frequency changes with a random distribution throughout study period. The absence of a clear-cut frequency change related to beginning of IFNB treatmenl makes it difficult to correlate occurrence of de novo tases to IFNB treatment. By contrast, GEE analysis showed a significantly higher frequency of liver alteration during first months of treatment suggesting a probable causal relationship between starting IFNB and occurrence of liver alteration.

at entry. Asa group their cerebral disease burden and extent of atrophy are more similar to comparably impaired relapsing-remitting than secondary progressive MS subjects. This largest PPMS cohort ever assembled resembles previously described, smaller PPMS cohorts. The results of the therapeutic trial will be available in 2004. Several characteristics of this cohort raise questions about the sensitivity oŸrecently proposed diagnostic criteria for PPMS.

P514 Molecular characterization of thymic function in patients with multiple sclerosis. A. Hug, K. Glatz, J. Haas, B. Storch-Hagenlocher, B. Wildemann (Heidelberg, D)

P516 Evaluation of the disease course in the elderly multiple sclerosis patients. Zapletalov• O., Hradllek P., Hromada J. (Ostrava, CZ)

Multiple sclerosis (MS) is a T-cell mediated autoimmune disease targeted against myelin antigens. The suppression of autoreactive T-ce[l ciones is influenced by thymic function vŸ the constant export of naive T-cells (recent thymic emigrants, RTEs). T-cell receptor excision circles (TRECs) can be used as a marker of thymic function in the peripheral blood. 70-80 % of alpha/beta T-cell receptor (TCR) lymphocytes contain TRECs because during T-cell maturation they undergo excision of the TCR-delta chain locus which is positioned within the TCR-alpha chain gene. This process generates an episomal DNA circle (TREC, containing the delta locus) which can be detected by polymerase chain reaction (PCR). To investigate if there is ah alteration of thymic function in MS patients we measured TRECs in peripheral blood T-1ymphocytes using real time PCR. TRECs were quantified in MS patients during an acute relapse prior and after intravenous pulse therapy with methylprednisolone (500 mg/day for 5 days). Age and sex matched persons without inflammatory central nervous system (CNS) disease served as controls. MS patients aged between 30-50 years had reduced numbers of TRECs. TREC levels had dropped by more than a half as compared to controls. Methylprednisolone treatment lead to a tremendous increase of TRECs (20 fold) in peripheral blood T-lymphocytes as assessed at day"5 of therapy. The reduction of TRECs in peripheral blood lymphocytes of MS patients aged 30-50 years indicates the presente of thymic impairment or, alternatively, an increased peripheral T-cell turnover in this disorder. Therefore, in future experiments it will be necessary to analyse the proliferation activity of peripheral T-cells in MS patients. The rapid an massive increase of TREC levels induced by methylprednisolone treatment is better explained not by defective thymic function but by changes in the peripheral T-ce]l division rate. Whereas the sensitivity of thymocytes against induction of apoptosis by corticosteroids is well documented there is less or even contradictory data concerning mature T-cells. The effect of corticosteroids on peripheral T-cell dynamics and apoptosis has to be assessed more detailed in cell culture experiments. P515 Characteristics at entry into the glatiramer acetate study of primary progressive multiple sclerosis: The PROMiSe Trial. J.S. Wulinsky, P.A. Narayana,. The PROMiSe Trial Study Group (Houston, USA) Only 15 % of multiple sclerosis (MS) patients have progressive disease onset; 2/3 of these never have attacks. These primary progressive (PPMS) cases provide ah appropriate pool to evaluate if an immuuomodulatory drug can reduce progression in isolation from its effects on relapses. Natural history data for PPMS and the behavior of a subcohort of patients from a prior tria] of glatiramer acetate (GA) in "chronic progressive" MS was used to power the PROMiSe Trial to detect a 40% deLay in time to sustained progression for patients randomized to GA compared to a placebo-treated control group. Only those who fulfilled an eligibility checldist were enrolled and randomized to this three year, parallel design, double-blind treatment trial. The presence of cerebrospinal fluid (CSF) oligoclonal bands of intrathecal IgG synthesis was sought in all potential subjects, but was n o t a n absolute entry requirement. CSF negative subjects underwent central review to confirma diagnosis of PPMS. Patients were randomized at a 2 to 1 ratio to GA or placebo therapy within two EDSS-defined strata (3-5; 5.5-6.5). The primary study endpoint is a 1.0 unit deterioration of EDSS sustained over 3 months for subjects entered in the low strata a n d a 0.5 unit change for those in the high strata. Clinical evaluations are performed every 3 months with annual magnetic resonance imaging (MRI). From 1,089 formally screened individuals, 946 subjects with clinical and laboratory findings consistent with PPMS were randomized at 59 centers from Canada (150), France (94), the UK (36) and the United States (666). Enrolment began in June 1999 and was completed in October 2000. Nearly half the patients in this trial ate male (47.2%). The typical patient is 50.4 years old, symptomatic for 10.8 years, diagnosed 5.1 years earlier, has an EDSS of 4.9, an ambulation index of 3.1, a timed 25' walk of 12.1 sec, a 9HPT of 30.3 sec anda PASAT 3 of 48.6. Nearly 20 % have no CSF abnormalities. Less than 20 % have ah MRI enhancement

lntroduction: Recent studies indicate that nearly every component of the immune system undergoes dramatic age-associated restructuring leading to changes that include enhanced as well as diminished function. The ageing of the immunity system brings changes in the background of autoimmunity and might provide an alteration of the course of the autoimmunity disease. Replicative senescence of T-cells, ageing of lymphocytes, alterations in hormonal levels and the shift in cytokine profile might change the character of MS course in elderly people. It couldn't be excluded that some of these mechanisms take part in change of the disease course from relapsing-remitting (RR) to secondary progressive (SP). On the other hand slow disease progression in the elderly MS patients could also undergo these changes of ageing of the immunity system. Objectives: To analyse our group of MS patients and find the patients older than 55 years. To mention the character of MS course in these patients. Methods and results: We studied a group of 295 patients with clinically definite MS and selected 34 of them older than 55 years with complete documentation of MS course from the beginning of illness. Characteristic of the group: 34 MS patients - 23 women and 11 men, aged 56-77 years, disease duration 5-45 years, EDSS 2-8, disease course - RR - 6 patients •17.6%), primary progressive (PP) - 6 patients (17.6%) and SP - 22 patients (64.7%). Discussion: It seems that our group of eLderly MS patients has quite different percentual incidence of clinical subtypes (we compare with official classification of MS - Lublin, Neurology 96). But it is necessary to realise that great part of RR had entered the SP phase within 6-10 years of disease onset. This explains that our MS patients mostly belong to the group SP. The number of PP course corresponds to statistical data. Conclusions: In conformity with literature data the majority (64.7 %) of our MS patients belongs to SP course of the disease. RR and PP courses ate in 17.6% each. The Iongest period without disability progression (8-15 years) we found in MS patients older than 60 years. P517 lYeatment ofrapidly progressivemultiple sclerosis withmitoxantrone. E. Alexiou, I.E. Markakis, A. Tsakiris, M. Xihras, D. Kourousis, N. Matikas (Athens, GR) Background: Mitoxantrone is a cytostatic anthracenedione with immunosuppressive properties. Recently it has been shown that it can be effective in limiting disease activity in multiple sclerosis according to clinical and MRI criteria. Objective: We designed an open pilot study for the evaluation of Mitoxantrone in the treatment of rapidly deteriorating multiple sclerosis. Methods: 25 patients with confirmed disease of either relapsing (13) or secondary progressive (12) course were treated with 10 mg/m 2 of Mitoxantrone every 4 weeks for a total of 6 infusions. Results: 12 months later only 3 of 25 patients ( 12 %) showed evidence of disease progression, determined as a change of at least 0.5 points in the Expanded Disability Status Scale (EDSS) compared to their enrolment status. In 9 patients (36%) there was an improvement of at least 0.5 points in the EDSS during the same period. Only 7 relapses were observed in the 13 patients with relapsing-remitting disease compared to 34 during the year prior to enrolment. On admission a total of 59 gadolinium-enhancing lesions on brain MRI scans were present. Only 5, 2 and 10 lesions were enhancing 3,6, and 12 months respectively after initiation of the treatment. Neutropenia, faintness, mild alopecia and secondary amenorrhoea were noted. No patient had clinical or laboratory findings of cardiotoxicity. Conclusions: In general, the drug was well tolerated. Our results suggest a possible treatment effect but the alteration of disease activity may reflect, at least in part, an intrinsic feature of the natural history of multiple sclerosis.

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P518 Efficacy And Tolerability Of Intrathecal Triamcinoloneacetonide (Tca) Application In Chronic Progressive Multiple Sderosis (Cpms). V. Hoffmano, S. Schimrigk, K. Hellwig, C. Lukas, N. Brune, S. Islamova, H. Przuntek (Bochum, D) Background: Reports of intrathecal steroid therapy largely performed with methylprednisolone acetate (MPA) have shown beneficial effects on spinal symptoms of MS. Nevertheless this therapy was abandoned due to side effects and because clinical efficacy could not be demonstrated beyond reasonable doubt. Objective: To determine short-time clinical efficacy and side effects in patients witb CPMS treated with intrathecal TCA over 3 weeks. Methods: 24 patients with CPMS were treated with a course of 6 intrathecal TCA injections (40 mg) for a period of 3 weeks. Expanded disability status scale (EDSS) was determined before the first injection and on day 1 after the last TCA injection. Therapy was regarded as "clinically effective" if patients showed an improvement of at least 1 point on the EDSS. "Meningeal irritation" was determined by cerebrospinal fluid (CSF) cell count. Results: In twelve patients (50 %) treatment was regarded as "clinically effective". One patient stopped treatment. All other patients remained stable or improved only partly not meeting the criteria of"clinically effective". The mean EDSS value declined from 5.25 (standard deviation (SD) 1.0) to 4.5 (SD 0.83).Therapy was generally well tolerated. Afler 139 TCA injections CSF count indicated "meningeal irritation" only three times (2.2%). "Meningeal irritation" according to CSF criteria was temporary in each case. No prolonged post lumbar puncture headache was reported by the patients. Conclusion: Intraspinal TCA therapy is a clinically effective treatment in patients with progressive MS in terms of improvement of clinical symptoms. With respect to short-time side effects TCA treatment seems to be well tolerated. Further randomized, prospective studies are needed to determine long time efficacy and tolerability. P519 Glatiramer acetate inhibits TNF-alpha and promotes interleukin-10 production by rat peritoneal macrophages. S. ]ung, I. Siglienti, G. Scarlato, K. Toyka (Wª D; Milano, I) Background: Glatiramer actetate (GLAT; Copaxone | is a basic polypeptide of four amino acids in defined ratio. In the treatment of relapsing-remitting multiple sclerosis Copaxone | reduces the annual relapse rate and the number of gadolinium-enhancing lesions in brain MRI. Clinical efficacy of Copaxone| has been most recently ascribed to induction of GLAT-specific regulatory T lymphocytes which are cross-activable by MBP and/or the function of GLAT as an ahered peptide ligand for MBP-specific T cells. However, these actions do not explain why in animal disease models GLAT does not only inhibit MBP-induced autoimmune encephalomyelitis, but also autoimmune uveitis and graft versus host reaction. Objectives, resuhs: We therefore evaluated immunomodulatory effects of GLAT on freshly isolated peritoneal macrophages of naive Lewis rats. Cells were tested for their production of TNF-alpha and interleukin-10 (IL-10) in the absence or presence of GLAT. GLAT enhanced spontaneous and lipopolysaccharide (LPS)-induced production of IL-10 and conversely suppressed LPS-induced secretion of TNF-alpha by the phagocytes. This effect was more pronounced in the smaller macrophage population of Iow density, but so lar not evident in the larger macrophage population of high density and granularity. Kinetic studies revealed consisteucy of the cytokine modulation during two days of in vitro cuhure. In contrast, production of nitric oxide by LPS- or LPS+IFN-gamma-stimulated macrophages was not affected by GLAT. Conclusions: Our findings indicate that GLAT not merely acts via T lymphocytes. The immunomodulatory effects of GLAT on macrophages may be a common basis for its beneficial action in Th 1-mediated immune diseases of rodents and the clinical efficacy of Copaxone| in the treatment of multiple sclerosis. P520

Downregulation of transforming growth factor-beta 1 (TGF-bl) in interferon befa-la (IFNb-la) treated multiple sclerosis (MS) patients. ]. D. I.uenemann, O. Aktas, P. Gniadek, R. Zschenderlein, F. Zipp (Berlin, D) TGF-b is considered to be an anti-inflammatory cytokine with potent immunosuppressive properties. Since it is also associated with amelioration of experimental autoimmune encephalomyelitis and remissions in MS, we asked whether TGF-bl serum levels are upregulated by systemic IFNb treatment in MS patients in vivo. Serum was obtained from 271 patients with clin-

ically definite relapsing-remitting MS treated with 44 p.g IFNb-la (Rebif| Serono, Unterschleissheim, Germany) once weekly (MASTER study). TGFbl protein levels were quantified by a commercial sandwich ELISA system (BD Pharmingen, San Diego, CA, USA) before treatment andat week 4, 26, and 52 of IFNb therapy. Surprisingly, we found ah intense down regulation of TGF-bl serum levels after 4 weeks of treatment, remaining significan@ decreased over 1 year (Wilcoxon, p < 0.001). In subgroup analyses, no differentes were observed with respect to clinical parameters such as disability status or relapse rate at any time point (Mann-Whitney U, p > 0.05). In conclusion, our data indicate that the immunomodulatory effects of systemic IFNb on cytokine production do not involve upregulation of TGFb as part of a shift towards ah anti-inflammatory phenotype. It remains, however, to be elucidated whether the observed down regulation of TGF-b represents an epiphenomenon ora causal mechanism responsible for the efficacy of IFNb treatment. Since TGF-bl was reported to inhibir activationinduced T cell death (AICD) and elimination of auto aggressive T cells via AICD is a therapeutic strategy in MS, this property might explain a beneficial effect of TGF-b down regulation under IFNb therapy. P521

Benefit of COPAXONE Demonstrated in Patients with Relapsing-Remitting Multiple Sclerosis (RRMS) Previously Treated with lnterferon. H. Zwibel, COPAXONE Treatment IND Study Group,. For The COPAXONE TIND Study Group (Miami, Florida, USA) Data from several clinical trials have demonstrated the efficacy, safety and tolerability of glatiramer acetate for injection (GA, Copaxone, formerly known as copolymer- 1) in the treatment of RRMS. This study was designed to evaluate the long-term safety of GA in a heterogeneous group of RRMS patients, and to determine whether prior treatment with interferon therapy, IFN-beta lb (Betaseron), would affect the safety, tolerability and efficacy of subsequent exposure to GA. A total of 805 RRMS patients received daily administration of 20mg of Glatiramer acetate. Patients were evaluated every six months by the Expanded Disability State Scale (EDSS) and within 7 days of suspected relapse. In most cases the same examiner has participated throughout. The history of pre-study interferon use was obtained for all study patients a n d a group previously treated with IFN-beta lb was identified (n=247). The remaining patients (558) had no previous exposure to IFN-beta lb prior to study entry. Mean age was 39.9 years with the previously treatment naive patients and 42.3 years for the group treated previously with IFN-beta lb. The majority of both cohorts (76%) were women. Overall, both cohorts displayed similar disease characteristics at baseline, although patients in the IFN-beta lb cohort appeared to have more advanced disease (Relapse rate within 2 years prior to entry 3.1 and EDSS scores 3.8, compared with relapse rate 2.8 and EDSS score 2.9 for the treatment naive patients). The duration of exposure to Glatiramer acetate was approximately 20 months with some individual patients followed up to 4.2 years. Both the number of relapses and the annualised relapse rate on study were similar in both cohorts (0.3 and 0.4 for the naive and lFN-beta 1b treated patients, respectively). Compared with the relapse rate on 2-year prior to entry, the annualised relapse rate on study represents a reduction of approximately 75 % in both cohorts. The mean EDSS scores remained stable throughout. In addition, the safety and tolerability of Glatiramer acetate in RRMS patients previously treated with IFN-beta lb were sbown to be similar to those of the treatment naive cohort. These results suggest that patients with RRMS, despite previous therapy with IFN-beta may benefit from switching to Glatiramer acetate. Furthermore, the safety and tolerability of GA were consistent with those reported in well-controlled trials of GA. P522

Comparison of TI hypointense lesion loads from "Pseudo-Tl" and TIweighted images in secondary progressive multiple sclerosis. S. J. Hickman, G. J. Barker, P. D. Molyneux, D. H. Miller (London, UK) Background: There is a large historical database of magnetic resonance images from previous studies and trials in multiple sclerosis (MS), much of it in the form of dual echo (proton density/T2-weighted) conventional spin echo (CSE) images. If new analysis techniques can be developed then this database could provide new and valuable information.We have investigated a simple technique in which the late echo of a dual echo dataset is subtracted from the corresponding early echo, yielding an image in which cerebrospinal fluid and lesions with a long T2 value appear hypointense relative to normal appearing white matter (NAWM). Such images appear qualitatively similar to T1 -weighted images, raising the possibility of using analysis techniques designed for true T1-weighted images. Aims: This study investigated whether the hypointense lesions on the

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"Pseudo-Tl" images (calculated as described above) were related to hypointense lesions on conventional T 1- weighted images, the latter known to be more pathologically destructive in MS than lesions which appear isointense relative to NAWM. Methods: The hypointense lesion areas were measured by a blinded observer using a computer-assisted contouring technique applied to "PseudoT l"images and T 1-weighted CSE images obtained from 17 patients with secondary progressive MS. Results: The mean hypointense lesion area from Tl-weighted images was 2218sq. mm, compared to 1426sq. m m from "Pseudo-Tl" images (p=0.008 by paired samples t-test). There was however a strong correlation between the values obtained from the two sets of images (Spearman's rank correlation coefficient=0.93, p < 0.001). Conclusions: The strong correlation between the values obtained from the two sets of images suggests that there is a relationship between the hypointense lesions from the two sets of images. "Pseudo-Tl" images may therefore be useful to investigate a subgroup of more destructive lesions in MS from large historical databases and in future prospective studies when imaging time is limited. P523 Acute and progressive dementia as the first manifestation of multiple sclerosis. E. Munteis, J. Roquer, A. RodrŸ Campello, M. Pino, A. Pou (Barcelona, E) Introduction: Cognitive impairment is common in multiple sclerosis (MS) patients affecting between 43-68 % of cases. In the early stages of the disease the cognitive dysfunction is often absent or subclinical and the cognitive decline appears later and usually do not affect the patient's normal daily activities. MS affects mainly secondary memory and the procesement velocity, but attentional processes, operative memory, visuospatial and visuoperceptire functions, intellectual capacity and abstract or conceptual reasoning are often also affected. We reporta case o Ÿ young woman who experienced an acute and progressive dementia as the first manifestation of MS. Clinical case: A 23-year-old woman with no familiar history of neurnlogical diseases and with no past medical diseases devetoped a sudden clinical picture characterized by temporo-spatial disorientation, conductual abnormalities and complete inability of doing her current activities. On examination he had only neuropsychological severe dysfunction a n d a mild cerebellar dysfunction. Brain MRI showed extensive and large white matter lesions involving both semiovale centres and also the corpus callosus. The CSF showed oligoclonal bands. Neurophysiological studies were characteristic of a demyelinating disease. Other white matter diseases were excluded. On neuropsychological examination (Symbol Digit Modalities Test, Selective Reminding Test, FAS, Boston Naming Test and Subtest of the Barcelona Test) there was a severe affectation (memory, mental control, abstracting ability, general intelligent, attention, etc.) associated with severe conductual dysfunction. The P-300 wave was delayed and decreased in amplitude. Despite treatment with immunosuppressive drugs, beta-interferon and immunoglobulins the patient's condition rapidly decline. She is currently confined in bed, and unable to do any normal daily activity. Brain-MRI evolution and spectroscopy will be presented. Conclusions: 1. A severe and progressive dementia can be the first and isolated symptom of MS; 2. MS should be included in the differential diagnosis of dementia in young people. P524 Interferon gamma and disability in relapsing remitting multiple sclerosis. H.-F. Petereit, S. Nolden, S. Schoppe, D. Reske, S. Bamborschke, W. D. Heiss (Cologne, Bernau, D) lntroduction: Enhanced production of the proinflammatory cytokine interferon gamma (IFG) in body fluids of patients with multiple sclerosis (MS) is well documented. A putative tole in the disease process is discussed. Furthermore, systemic application of IFG induces exacerbation of the disease with acute deterioration of neurologica] function. We looked for an association between 1FG production in peripheral blood lymphoeytes and severity of neurological dysfunction in a group of patients with the relapsing course of the disease. Method: Flowcytometry was used to detect intracellular IFG production in stimulated blood lymphocytes. Expanded disability status scale (EDSS) served as disabilitT measure. A group of 36 patients with the relapsing-remitting course of the disease was investigated. The patients were in the stable phase of the disease for at least four weeks. None of the patients received immunomodulatory or imrr,mnosuppressive drugs during the last four weeks before the investigation was done. Ten healthy volunteers served as normal controls.

Resuhs: 25 women and 11 men with a mean age of 37 years a n d a mean disease duration of seven years were investigated. The mean EDSS was 2.5 with a range between 0.0 and 6.0. The mean IFG was 9.63 :t: 6.06% (mean + standard deviation). A statistically significant correlation between EDSS and IFG could be demonstrated (Spearman's rho=0.39; p= 0.02). IFG was significantly higher in MS patients than in normal controls (2.96 + 1.30%; MannWhitney-U-test: p=0.000). Discussion: Though increased in most patients, IFG production shows a substantial variability in multiple sclerosis. Our findings suggest that IFG might playa role in MS not only due to its proinflammatory ability, but have an impact on disease severity as well, perhaps due to its cytotoxic potential. These findings are in line with previous observations of transient neurological deterioration in close temporal correlation with an increase in proinflammatory cytokines. We conclude that the IFG production in lymphocytes is associated with disease severity in multiple sclerosis patients and thus IFG is a target for therapeutical interventions in MS. P525 Primary progressive multiple sclerosis: a clinical and MRI cross sectional study using T2-1esion load total brain parenchymal fraction and spinal cord cross-sectional area. M. Tintor› L. Brieva, A. Rovira, C. Borras, X. Aymerich, C. Nos, X. Montalban (Barcelona, E). lntroduction: There is little data on correlations between clinical and MRI parameters in patients with primary progressive multiple sclerosis (PPMS). Objective: To study the correlation between brain and spinal cord MRI parameters (T2-1esion load, total brain parenchymal fraction (BPF) and spinal cord cross-sectional area (SCCA)) and several other clinical parameters in a cohort of PPMS patients. Methods: Forty-eight PPMS patients were included in the study. Patients underwent clinical assessment and brain MRI using T1- and T2-weighted 3 mm contiguous transverse sections of the whole brain and cervical MRI using a sagittal magnetization-prepared rapid-acquisition gradient echo sequence. T2-tesion load and BPF were calculated with semi- or completely automated segmentation techniques. SCCA was calculated with semi automated segmentation technique from a series of five contiguous 3-mm axial slices centred at the C2-C3 disk obtained from the original data set. Results: There was a significant correlation between T2-1esion load'and BPF (r=-0.552; p < 0.001),but not between these MRI parameters and EDSS or disease duration. Significant differences were found in T2-1esion load and BPF between patients with predominant spinal cord symptoms, and those without (p < 0.001 ). SCCA was significantly reduced in patients compared to the controls (p < 0.001). There was a weak but significant correlation between SCCA and EDSS (r=-0.294; p=0.012). Correlations improve with Functional Composite. Discussion/conclusion: Significant differences in the brain, but not in the cervical cord MRI data were found between patients whose predominant clinical syndrome was progressive spastic paraparesis and those who h a d a predominantly non-spinal progressive syndrome. SCCA was the only MRI parameter that showed a significant though weak correlation with EDSS. Correlations between FC and MRI parameters will be presented at the meeting. P526 Diverse modulation of matrix metalloproteinases (MMPs) and their endogenous inhibitors (TIMPs) in h u m a n monocytes by interferon-gamma and -beta. Y. Galboiz, S. Shapiro, N. Lahat, A. Miller (Halla, IL) Background: Multiple sclerosis (MS) is cousidered to be a Th 1-mediated disorder of the CNS in which the pro inflammatory cytokines, IFN-gamma and TNF-alpha, are reported to contribute to the pathogenesis of disease, while IFN-beta serves as an effective treatment, Recent findings have implicated the activity of MMPs, in particular MMP-2 and MMP-9, in the pathogenesis of MS, including in the breakdown of the blood brain barrier, immune cell migration into the CNS as well as degradation of myelin. Moreover, MMPs' inhibitors have been reported to suppress disease activity in MS experimental animal models. Objective: To evaluate the effects mediated by IFN-gamma and lFN-beta on the expression of MMP-2, its physiological activator, MT1-MMP and it's endogenous inhibitor, TIMP-2, in monocytes. Methods: The levels of MMP-2, MT I-MMP and TIMP-2 expressed by the human monocytic cell line, U-937, were evaluated by ELISA (both total and active protein), flow cytometry and western blot analysis, following incubation with IFN-gamma or/and IFN-beta (0-100 U/mi). Results: IFN-gamma induced a prominent dose dependent elevation of MT1-MMP (up to 2.5 fold at 100 U/mi), while [FN-beta did not effect its constitutive level. Both IFN-gamma and IFN-beta induced a significant eleva-

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tion of TIMP-2 (up to 1.9 and 1.7 fold, respectively), though a further increment in the dose of IFN-gamma inhibited its expression. IFN-gamma did not affect the total MMP-2 protein level while IFN-beta led to a prominent decrease in its level. Activated MMP-2 comprised 10% of the total protein observed and both IFNs led to inhibition of its expression. Conclusions: The present study demonstrates that IFN-gamma and IFNbeta differentially modulate MMPs and TIMPs expression at the protein level, in line with our previously reported effects at the transcription level (• Neurol 2000, 247; III/146). The results also suggest that the therapeutic effects of IFN-beta may derive, at least partly, from a deviation of MMPs'expression towards ah anti-proteolytic profile, as supported by the decrease of both total and active MMP-2 as well as increase in TIMP-2 levels. P527 The Influence Of Hydrolytic Enzymes On Immunological Indices In Patients With Multiple Sclerosis (MS). A. G. llves, A. M. Petrov, L. N. Prakhova, E. V. Ivashkova, N. V. Nikolaeva, 1. D. Stoliarov (St. Petersburg, RUS) Introduction: MS is characterized by demyelination and infiammation in the CNS and is considered to be a predominantly T-cell mediated immune disorder. The focal demyelination is accompanied by the appearance of antibodies to structural elements of the nervous system, oligodendroglial cells, myelin basic protein and to protein S-100. The sensitisation of lymphoid cells to the neurospecific antigens also remains during the phase of remission. It has been previously demonstrated that oral hydrolytic enzymes can influence immunological disturbances in patients with different autoimmune diseases such as rheumatoid arthritis, lupus erythematous etc. Objectives: To evaluate immunotropic efficiency of the oral hydrolytic enzymes (the medication Phlogenzyme) in patients with multiple sclerosis. Patients and methods: 30 patients with clinically definite MS (according to Poser's criteria) received 6 tablets of Phlogenzyme daily during 12 months. The duration of the disease was 2-14 years. 19 patients with relapsing-remitting and 11 with secondary progressive MS aged 19 to 53 were observed. EDSS score was between 2.0 and 4.0 in the first and between 4.0 and 6.04n the second group. Control group: 23 healthy volunteers (I) and 28 patients with MS without immunotropic medicines (II). AII patients were clinically and immunologically examined before and monthly during the treatment. Immunological monitoring included the measurement of CD3+, CD4 ~-,CD8+, CD22+ lymphocytes subsets, the CD4+/CD8+ ratio, the nitro blue tetrazolium (NBT) test, IL-lb, IL-6, TNFa spontaneous and induced production and the exploration of sensitisation oflymphocytes to brain specific antigens (S- 100 protein, membranous, GaI-C and BMP) in lymphocytes adhesion inhibition test (LAI-test). Results: During the observation no new relapses or increased disability according to EDSS were registered. Normalization of T- and B-subsets, the significant increase of reserving ratio in NBT-test, the decreasing of sensitisation of lymphocytes to brain-specific antigens and normalization in proinflammatory cytokines production were revealed. Conclusion: These data show the positive changes both in clinical and immunological Ÿ Therefore, we suggest that further studies (controlled trial) are needed to demonstrate of hydrolytic enzymes efficacy.

P528 Neuropsychological impairment in patients with Multiple Sclerosis: correlation with disease variables and depression in patients and partners. B. Steck, A. Plohmann, E Amsler, L. Kappos, D. Bª (Basel, CH) Objectives: Multiple Sclerosis (MS) confronts patients and their partners with a wide array of challenges. We studied the relation of cognitive function with physica] disability and depression in patients themselves and their spouses. Methods: 22 Patients (13 female, 9 male, mean age 41 years old) underwent a comprehensive neuropsychological examination. Neurological status (including Kurtzke EDSS) and depression (assessed by the Beck Depression inventor),, a self-evaluation questionnaire) were recorded. Correlation's between the degree of physical disability, depression score and cognitive impairment were calculated. Results: The neuropsychological evaluation shows marked differences compared with the norm values for the tests measuring attention (z = -0.46; p < 0.01) and memory (z = -0.46; p < 0.01) which are strongly affected, whereas executive functions are only slightly disturbed. There are significant correlation's between attention and Kurtzke EDSS (r =0.48; p < 0.05) as well as attention and progressive course of the disease (r =0.50; p < 0.05). Cognitive impairment does not significantly correlate with the depression score of the patient, yet with the depression score of his or her partner. (e. g. for attention r =0.46; p < 0.05; for memory r=0.53; p < 0.05). Conc[usions: The resuhs indicate that the capacity to carry out multiple

tasks involving cognitive processing is strongly reduced in MS patients. Cognitive disorders of the patient seem to affect his or her spouse, who frequently respond with depression. P529 Catecholamines May Regulate Lymphocyte Activation In Multiple Sclerosis. C. Rajda, K. Bencsik, L. V› ]. Bergquist (Szeged, H; G6teborg, S) Multiple sclerosis (MS) is ah inflammatory disease of the central nervous system (CNS), where autoimmune mechanisms are strong[y suspected to participate. Circumstantial evidence suggests sympathoadrenergic mechanisms to be involved in the disease progress. Current theories of MS pathogenesis suggest that lymphocytes first are activated in the periphery and thereafier recognize antigens in CNS.We have studied peripheral blood lymphocytes from MS patients. The levels of dopamine, norepinephrine, epinephrine and their metabolites were measured using capillary electrophoresis in extracts of lymphocytes from 58 MS patients and 19 healthy controls. The MS patients were divided into clinical subgroups i. e. a laboratory suppor ted definitive first attack MS group, anda relapsing-remitting (in remission) group. The peripheral blood lymphocyte level of epinephrine was significantly higher in the first attack MS patients (p=0.028) than in the controls. However, in patients with longer disease duration, during remission, the norepinephrine levels were significantly (p=0.027) lower. It is known that catecholamines can effect lymphocyte activity, both by stimulation and immunosuppression. Our results suggest t.hat catecholamines ate important regu]ators of lymphocyte activation in MS, and of potential importance for new diagnostic and therapeutic methods. To the best of our knowledge, this is the first clinical study ever presented where the intracellular endogenous catecholaminergic influences on the immune system have been considered to take tole in the pathogenesis. P530 Experiences After 4-Year FoUow-Up Of lnterferon-beta-lb Treatment: Randomised, Phase IV, Open Study. K. Bencsik, C. Raida, J. Fª P. Kliv› T. ]•225225 M. T6r6k, L. V› (Szeged, H) Interferon beta-lb (IFNb-lb) was the first drug found to slow the progression of relapsing-remitting multiple sclerosis with a repor ted decrease in the relapse rate. The present study involved 31 patients treated with IFNb-lb for four years. The aims of the study were: (a) to compare the changes in the relapse rate and the number of days of hospita]isation with other data, (b) to compare the steroid needs required to treat relapses for two years before and four years after treatment of I FNb-lb. The data of our self-control study indicated that the relapse rate may decrease as muchas 77 % following the introduction of iFNb- lb treatment. The adverse effects and the changes in the EDSS grades were similar to the published data. The duration of hospitalisation decreased by 87 % and the amount of methylprednisolone needed for remission by 80 %. This data suggest that the impairment of the condition of the patients may be delayed considerably, while some of them can continue to work fora longer period, the standard of life of these patients therefore being more tolerable. P531 Neuropsychulogical, Clinical, MRI and PET Correlates in Multiple Sclerosis (MS) Patients. L. N. Prakhova,A. G. Ilves, M. S. Roudas, M. V.Votintseva, A. M. Petrov, T. N. Reznikova, I. D. Stoliarov (St. Petersburg, RUS) Introduction: Cognitive deficits and behaviour disturbance are present in a substantial number of MS patients and may be the initial and/or predominant symptom of MS. But the role of metabolic alterations at the cortical level underlying the cognitive impairment in MS are still unknown. Objectives: To analyse the cognitive deficits and behaviour disturbance of MS patients and relationship between the performance of neuropsychological tests, clinical presentation and functional imaging data assessed by MRI and PEZ Methods: 40 relapsing-remitting and secondary progressive MS patients and 12 healthy volunteers a s a control group underwent a full neuropsychological batlery and neurological examination as well as MRI and to estimation of cerebral glucose metabolism (CMRGIu) with FDG without blood sampling. The relationships between PET findings, clinical and neuropsychological data were evaluated with Spearman's rank correlation coefficients. Resuhs: Neuropsychological impairments were determined in 100 % patients. Cognitive deficits were found in 35, behaviour disturbances in 32 and mixed one in 28 patients. The patients with cognitive decline performed significantly worse than the cont rols in tests of attention, working abilit y, shortterm memory and counting ability. Degree of mental dysfunction was

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significantly related with MRI abnormalities. Significant alterations of rCMRGlu in patients' group was found in inferior temporal gyrus, occipital cortex, insula and gyrus angularis. Positive correlation between acalculia and decrease of rCMRGlu was found in the prefrontal cortex of the right hemisphere. No correlation with other neuropsychological tests was obtained. EDSS was negatively correlated with general rCMRGIu. But no correlations with the level of cognitive impairment and time of duration of disease were found. Conclusion: Our data support the contention that the metabolic alterations at the cortical level seem to play an important role in the pathophysiology of cognitive dysfunction in MS and suggesting that cognitive dysfunction in MS has both "cor tical" and"subcor tical" aetiology and represent a symptom of disease. On the other hand, these results suggest that traditional clinical scales such as the EDSS ate not always adequate in their assessment of key clinical dimensions of MS (e.g., cognitive function), and they have psychometric limitations as well.

P532 Neurotrophic factors in cerebrospinal fluid in multiple sclerosis. M. Klotz, S. Merkelbach (Homburg/Saar, D) Objective: Multiple sclerosis (MS) is considered as an autoimmune disease resulting in both demyelination and axonal damage. Inflammatory mechanisms are known to cause demyelination, whereas mechanisms of axona] loss and brain atrophy ate incompletely understood. Methods: We investigated CSF-levels of Ciliary-Neurotrophic-Factor (CNTF), Nerve-Growth-Factor (NGF), and Insuline-like-Growth-Factor-1 (IGF- 1) in CSF-samples of 51 patients with definite MS and 22 controls using ah enzyme-linked immunosorbent assay (ELISA). Results: CSF levels of CNTF were significantly increased in MS (17.0 + 10.2 pg/ml) as compared to controls (6.5 + 4.6 pg/ml; p < 0.001 ). We did not find significant differences regarding NGF (30.8 _+ 12.5 pg/ml in MS versus 27.5 + 11.2 pg/ml in controls) or IGF-1 (4.5 -+ 7.2 pg/ml versus 26.9 _+90.5, respectively). Conclusion: Increased CSF-CNTF levels in MS could serve as one mechanism resulting in brain repair or preventing from axonal loss or from brain atrophy. However, whether partly ineffective action of CNTF or missing stimulation of IGF-1 and NGF are responsible for further deterioration in MS remains to be discussed.

Muscfe Disorders P533 T3272C, A New Mutation In The tRNA Leu (UUR) Gene Causing Ocular Myopathy. J. Gamez, Y.Campos, C. Navarro, A. Garcia, P. del Hoyo, A. L. Andreu, ].C. Rubio, M.A. MartŸ F. Bustos, R. Garesse, C. Cerrera, I. Arenas (Barcelona, Madrid, Vigo, E) Objective: To describe a new mutation in the tRNA Len (UUR) gene, causing ocular myopathy. Case report: A 53-year-old woman suffering from progressive ptosis from the age of forty. Neurological examination also revealed external ophthalmoplegia, short stature and no weakness in muscles tested. CK was mildly increased and blood lactate normal. EMG showed a myopathic pattern. Muscle biopsy revealed abundant ragged-red fibres, most COX negatire. There was also a deficit in complexes I and IV. Methods: Standard methods were used to isolate DNA, and the presence of known deletions of mutations in mitochondrial DNA (mtDNA) was ruled out. Several tRNA of the mtDNA were sequenced. A modified primer creating a new restriction site for the Ear I enzyme in patients was used for the mutation study. Radioactively marked products were run through a 10 % polyacrylamide gel. PCR analysis of selected fibres was carried out (RRF and normal). The mtDNA of asymptomatic family members were studied. Results: Molecular analysis revealed a T3273C transition in mitochondrial DNA tRNA Leu (UUR). mtDNA mutation levels in muscle were 88%, 3 % in skin, 2 % in blood, and less than 1% in subcutaneous fat. These levels were 99.2% in RRF, and 88.2% in normal fibres. Ir was not detected in 150 controls. Conclusions: This new mutation fulfils accepted pathogenicity criteria, shows that tRNA Leu (UUR) is a candidate gene in patients with ocular myopathy anda hot spot in mitochondrial myopathies.

P534 Clinical Differences Between Seropositive and Seronegative Myasthenia Gravis. D. Lavr nic, R. Rebic,V. Rakocevic-Stojanovic, S. Pavlovic, Z. Stevic, R. Trikic, P. Djukic, 1. Tripkovic, S. Apostolski (Belgrade, YU) A subpopulation of patients with symptoms of generalized MG have no detectable anti-AChR antibodies Cseronegative" myasthenia gravis, SNMG). In order to determine clinical differences between SNMG and seropositive myasthenia gravis (SPMG) we reviewed our experience with 161 MG patients seen at our institute during 1997 and 1998. The diagnosis relied on clinical examination, electrodiagnostic studies and pharmacological tests (Prostigmin, Tensilon). Anti-AChR antibodies were measured in all patients using a commercial radioreceptor assay kit (CIS Bio International) and leyels over 0.5 nmol/L were considered positive. Twenty six out of 161 MG patients ( 16 %) did not have positive serum anti-AChR. SNMG group consisted of 17 females and 9 males (female/male ratio, 1.9:1). In the SPMG group this ratio was 2.4:1 (90 females and 40 males). The age at onset ranged from 7 to 72 years (mean age,37) in SNGM and from 15 lo 74 (mean age,36) in SPMG. The pure ocular clinical presentation was much more frequent in SNMG (35 %) in comparison to SPMG (13 %). A decremental response on repetitive stimulation (> 12%) was positive in 61.5% and 87.5% of patients with SNMG and SPMG, respectively. None of 26 patients with SNMG had evidence of an associated autoimmune disease, while in the group of SPMG the frequency of associated autoimmune diseases was 16 %. Family history of immune mediated diseases was positive in both, SNMG and SPMG patients (31% and 28 %, respectively). Seventeen out of 26 SNMG patients (35 %) and 103 out of 135 SPMG patients (64%) underwent thymectomy. Among 17 SNMG thymectomized patients, thymic hyperplasia was found in 4 (23.5 %) and normal thymus in 13 (76.5 %). In the group of 103 SPMG thymectomized patients thymic hyperplasia was found in 81 (78.5%), thymoma in 13 (12.5%), and normal thymus in 9 (9%) patients. Norte of patients with SNMG had thymoma. Both group of patients had similar beneficial response to standard therapeutic procedure which in addition to thymectomy included anticholinesterase and immunosuppressive drugs. P535 Muscle-Derived CD 34+ Sca-1 + Stem Cells: New Tooi For Gene Therapy. Y. "lbrrente, M. G. D'Angelo, F. Pisati, M. Belicchi, B. Rossi, M. Sironi, F. Fortunato, M. El Fhaime, N. Caron, D. Paulin, 1. P. Tremblay, G. Constatin, G. Scarlato, N. Bresolin (Milan, Bosisio Parini,Verona, I; Quebec, CDN; Paris, F) Duchenne muscular dystroph)r (DMD) is a lethal recessive disease characterized by widespread muscle damage throughout the body. This increases the difficulty of cell or gene therapy based upon direct injections into muscles. One way to circumvent this obstacle would be to use circulating ceUs, capable of homing to the sites of lesions. Here, we showed that Sca- l, CD34 double positive cells purified from the muscle tissues of newborn mice are multipotent in vitro and can undergo both myogenic and multimyeloid differentiation. These muscle-derived stem cells were isolated from newborn mice expressing the LacZ gene under the control of the muscle specific desmin or troponin I promoter and injected into arterial circulation of the hind-limb of mdx mice. The ability of these cells to interact and firmly adhere to endothelium in mdx muscles microcirculation was demonstrated by intravital microscopy after an intra-arterial injection. Donor Sca-1, CD34 muscle-derived stem cells were able to migrate from the circulation into host musde tissues. Histochemical analysis showed co-localization of LacZ and dystrophin expression in all muscles of the injected hind-limb in all of five out of tire eight-week old treated mdx mice. Their participation to the formation of muscle fibers was significantly increased by a muscle damage done 48 hours after their intra-arterial injection as indicated by the presence of 12% b-Gal positive fibers in muscle cross-sections. Normal dystrophin t ranscripts were detected enzyme in the muscles of the hindlimb injected intra-arterially by the mdx-RT-PCR method which differentiates between normal and mdx message. Our results showed that the muscle-derived stem cells first attach to the capillaries of the muscles and participate to regeneration following muscle damage. P536 Myopathic presentation in an adult woman with a very long chain acylCoenzyme A dehydrogenase deficiency. A. Pou-Serradell, A. Ribes, P. Briones, B. Garavaglia, Bs. Andresen (Barcelona, E; Milano, I; Aarhus, DK) Very long chain acyl-CoA dehydrogenase (VLCAD) deficiency is a severe inherited disorder of mitochondrial beta-oxidation. It may resuh in either a mild adult myopathic forro ora severe hepato-cardio-muscular syndrome in infants. The adult forro presents with isolated skeletal muscle involvement, rhabdomyolysis and myoglobinuria usually triggered by exercise or fasting.

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The difference in severity between these two forms is related to different levels of residual activity of long-chain fatty acid oxidation enzymes caused by different genotypes. We reporta patient with adult onset attacks of painful rhabdomyolysis. Case Report: A 28-year-old woman suffered from exercise induced episodes of intense generalised muscle pain, weakness and myoglobinuria since the age of 19 years. Sbe presents antecedents of spinocerebellar ataxia (mother and maternal uncle with SCA 3) anda sister who died at 19 months of age from "an acute encephalopathic disease". The attacks appear two or three times a year, lasting fora very few days with a posterior complete recovery. Very high values of CK (about 7000 U.) were detected several times. Fasting ketogenesis was low, while blood glucose remained normal. A very mild lipid accumulation in muscle fibers was observed on muscle biopsy. Gas chromatography identified high levels of tetradecenoic acid, 14:1n-9 (N < 0.4-0.9), without any hydroxydicarboxylic acids excluding LCAD deficiency. The free fatty acids profile was normal. CPT-II common mutations were excluded. A deficiency of VLCAD was demonstrated in fibroblasts: 0.96nmol/hour mg protein (NV, 2.7-4.1) of 9,10-3H miristate and 1.88nmol/ hour mg protein (NV, 3.4-5.0) of 9,10-3H palmitate. Genetic analysis revealed two missense mutations (GI45C/R375W) on the VLCAD gene. In contrast to patients with cardiac VLCAD deficiency, our patient had no lipid storage, a normal heart function, and normal free carnitine in plasma and fibroblasts. Treatment with L-carnitine and medium chain triglycerides did not reduce the attacks of rhabdomyolysis. In conclusion, fatty acid oxidation defects should be investigated in all cases with rhabdomyolysis beginning in adolescence or early childhood. The relatively mild clinical course in this patient may be due to a high residual enzyme activity asa consequence of mild missense mutations on the VLCAD gene. P537 The Measurement of Palatal Muscle Weakness in Patients with Myasthenia Gravis. S. Apostolski (Belgrade, YU) A quantitative MG scoring system (QMG Score) is essential in the objective evaluation of therapy for MG. The oropharyngeal involvement is the most dangerous muscle weakness in MG and deserves to be identified by the classification system. The involvement of palatal muscles in MG usually resuhs in "nasal" swallowing and "nasal" speech. The latest recommendation for QMG score includes testing of the swallowing and speech after counting aloud from 1 to 50, and asa resuh gives several rather qualitative than quantitative measures. During the last 15 years we have been using the Wright's flow meter to measure the Peak Expiratory Flow (PEF) but also to measure the weakness of palatal muscles. PEF at the maximal forced expiration can be used as a measure for the strength of respiratory muscles but in MG the testing is complicated by the weakness of the palatal muscles. Since the palate does not completely seal off the nasopharynx during expiration, a part of the expiratory air escape through the nose and the value of the PEF is significantly reduced. To measure the volume which escapes through the nose, we tested the PEF in patients with MG regularly and with their nostrils closed. The difference between these two measurements indicated the weakness of palatal muscles and was expressed a s a percentage of corresponding PEF value obtained with nostrils closed. Respiratory muscle weakness as well as lip muscle weakness decreased both values of PEF, but overall difference in that case remained unchanged and had the same significance. We reviewed our experience with 167 MG patients (female/male ratio, 2.5:1). The age of patients ranged from 15 to 78 (mean age for females, 41.5; for males, 52.5 years). In 40 (24%) patients we found the greater values of PEF by measurements with nostrils closed in comparison with values obtained with regular measurements. The mean degree of palatal muscle weakness was 31% (range, 8 to 100 %). Out of 40 patients 36 belonged to clinical forro IIB and 4 belonged to clinical form 111 according to Osserman's classification. In 17 (42.5%) patients the palatal muscle weakness was greater than 33.3%, and in 6 (15%) of them greater than 50%. We recommend this simple clinical test a s a very reliable measure of the palatal muscle weakness. P538

MiMy plus mitochondrial myopathy associated with non-muscular symptoms. M. Elstner, T. Gasser, T. Klopstock (Muenchen, D) Background: Mitochondrial myopathy (MiMy) stricto sensu is a myopathy of mitochondrial etiology without involvement of extraocular muscles. Only few cases have been reported. Methods: Among a large cohort of mitochondrial patients, five cases were identified with myopathy sparing the extraocular muscles. Muscle biopsy showed ragged red fibers in all cases, demonstrating the mitocbondrial etiology.

Results: Age at onset was 43,8 _+7,3 years. Muscle weakness was the first and the main symptom in all patients. In addition, clinical examination revealed hypoacousia (n=2), ataxia (n=2), sensory signs (n=2), diabetes mellitus (n=l),and multiple lipomas (n=l). Conclusion: MiMy is nota pure myopathy, but is often associated with other neurological or non-neurological signs as they are seen in other mitochondrial diseases. In analogy to the term "CPEO plus" for chronic progressive external ophthalmoplegia with additional symptoms, we suggest the term"MiMy plus" for cases of mitochondrial myopathy with additional nonmuscular manifestations. P539

Dominant hereditary inclusion body myopathy with predominant axial weakness. T. Stojkovic, C. A. Maurage, ]. de Seze, J. E Pellissier, P. Vermersch (Lille cedex, Marseille, F) Familial inclusion body myopathy (IBM) is characterized by rimmed vacuoles and nuclear and cytoplasmic inclusions in muscle fibers. The autosomal recessive form, characterized by quadriceps-sparing myopathy, is linked to chromosome 9pl-ql.Autosomal dominant forros of IBM has also been reported in several families presenting predominan@ limb-girdle weakness. We reporta new family affected by an autosomal dominant form of 1BM. Eleven members of a family were examine& three sisters and their father were clinically affected. The clinical course was slowly progressive with onset from 20 to 30 years of age. Cbaracteristic clinical fcatures were weakness of axial muscles and shoulder girdle. There was a marked wasting and weakness of the neck extensors, leading in the oldest female patient to "dropped head syndrome". On the lower limbs, the weakness involved predominan@ the distal muscles, leading to foot drop. Electromyography revealed a myogenic pattern in the upper limbs. CK levels were mildly elevated in the affected women. Muscle biopsy performed in three members of the family, showed rimmed vacuoles with cytoplasmic and intranuclear inclusions. Congophilic depositions were observed in association with rimmed vacuoles. There was no inflammation. Hereditary IBM with autosomal dominant inheritance has been rarely reporte& In those cases, the symptoms started with proximal muscle weakness. In a recen@ described Swedish family, the clinical features were congenital joint contractures, external ophthalmoplegia and proximal muscle weakness (Darin et al., 1998). The phenotype of our family is characterized by proximal weakness in the upper limbs and marked axial involvement. This phenotype difference between our family and those previously reported may suggest genetic heterogeneity. P540

Fibrogenic cytokines and extent of fibrosis in muscle of dogs with X-linked muscular d•strophy. P. Bernasconi, L. Passerini, P. Confalonieri, E Baggi, F. Cozzi, E Cornelio, R. Mantegazza (Milan, I) Fibrosis is a prominent feature of the muscle of Duchenne muscular dystrophy (DMD) patients. Fibrogenic cytokines, particularly transforming growth factor-betal (TGF-betal), are suspected to playa major role in connective tissue proliferation. Canine X-linked muscular dyst rophy (CXMD) is characterized by severe myopathy and muscle fibrosis and ir is genetically homologous to DMD. To investigate mechanisms underlying fibrosis in the DMD canine model, we evaluated, by quantitative and semi-quantitative PCR, tuRNA levels and, by immunohistochemistry, protein distribution of TGF-betal and its putative downstream mediator connective tissue growth factor (CTGF) in the muscles of CXMD dogs (n = 7) at different ages (from 2-15 days to aduhhood). We also assessed extent of fibrosis and expression of type I, l li and IV collagens. As controls, we analysed muscle samples from eight healthy mixed-breed dogs (4 males and 4 females, age-matched). We found that fibrosis occurs early in CXMD dogs (muscles 53 % connective tissue at 15 days) and that TGF-betal transcript levels tend to be high up to 60 days, suggesting a role for this cytokine in the early stages of fibrosis. We also found a trend to greater expression of CTGF in CXMD than control muscle (p = 0.01 at 30 days), suggesting involvement of this cytokine in fibrosis progression. Our findings sustain the hypothesis that fibrosis is cytokine-mediated in the canine disease, as it seems to be in humans, and confirm the utility of the CXM D model for investigating anti-fibrotic therapies for DMD.

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P541 Late-onset mitochondrial myopathy and encephalopathy with lactic acidosis and strokes (MELAS) with neuropathoiogical findings of minicores myopathy - a case report. C. Bamberg, W. Schlote, R. Heyny, D. Claus (Darmstadt, Frankfor t/M., D) MELAS is a mitochondrial disorder characterized by myopathy, encephalopathy, lactic acidosis, and stroke-like episodes. We describe the case of a male patient at age 67, who was admitted to our service because of headache and progressive confusion. His neurologic examination was significant for severe cognitive deficits. Motor examination revealed a mild left hemiparesis. During this hospitalisation he developed a status of generalised seizures leading to respiratory failure and ventilation. His conscious level remained impaired despite the absence of sedation. In the following he developed acute pancreatitis and paralytic ileus, finally he died. Brain MRI demonstrated T2-weighted hyperintense lesions in the right frontal and parietal lobe as weU as in the left cerebellar hemisphere that did not conforto to a vascular territory. Laboratory evaluation revealed a lactic acidosis with venous value from 21 mval/l (normal: 0.5-2.2 mval/l). The examination of the cerebrospinal fluid showed cells and proteins in normal range, lactate was raised at 12.5 mval/l (normal: 0.5-2.2 mval/1).An EEG revealed bilateral temporal spike-wave-complexes and in the following bilateral slowing. The muscle biopsy from the left biceps brachii muscle revealed no typical ragged red fibers. Electron microscopy showed only a few subsarcolemma[ enlarged mitochondria, however lesions with foci of myofilamentary disintegration (minicores) with Z-band streaming were found. This has never been reported before in patients with MELAS-syndrome. DNA analysis of muscle was negative for the tRNA Leu(UUR) mutation A -' G at base pair 3243, although negative for the mutations on base pair A3243G, A3252G, C3256T, T3271C and T3291C. Respiratory chain study showed a decreased cytochrome C oxidase activity at 0.85 U/g muscle (N: 6.4-10 U/g muscle) and confirmed finally the diagnosis of mitochondrial cytopathy. Brain autopsy revealed infarctions of gyri in the right frontal lobe and the hippocampal zone, a loss of the granular layer and Purkinje-cells in the cerebellar hemisphere. These findings indicate that the diagnosis of MELAS should be considered at any age in the presence of consistent clinical and imaging feat ures. The most useful investigations are a muscle biopsy and biochemical and mtDNA analysis. In this regard, our case is noteworthy. P542 Botulinum toxin toxicity as acute neuromuscular failure. M. Coletti Moja, U. Dimanico, V. Cavaciocchi, T. Mongini, Pc. Gerbino Promis, E. Grasso (Cuneo, Torino, I) Botulinum toxin type A (BTX) is a well known drug that plays its therapeutic role by blocking the pres•naptic release of acetylcboline at the neuromuscular junction. Recently, several cases have been reported in which BTX temporary caused ah exaggerated weakness on remote and not injected muscles. We present a follow-up paper concerning a patient who developed an acute neuromuscular failure. We follow a 35 years old man with a two years history of BTX treatment as post t raumatic lower limbs spasticity therapy (800-1000 Disport units each session every three months about). One week after the last treatment by BTX 1000 units in tibialis posterior, gastrocnemius medialis and soleus, he experienced asthenia and diffuse weakness; within few days hospitalisation was ensued a n d a prominent bilateral symmetric proximal girdle strength deficit appeared witb dysphasia, dysarthria, ptosis and oculomotor weakness but no vegetative symptoms. Blood samples were normal except CPK, SGOT and SGPT that were elevated at admittance and slowly decreasing in the following weeks. Acetylcholine receptor antibody titter was normal. Conventional electromyographic examination showed a diffuse myopathic pattern with no denervation activity, repetitive stimulation studies at low frequency was borderline while at high frequency was negative. Single-fibber elect romyography had increased jitter in weak upper and Iower limbs muscles. Deltoid muscle biopsy showed a marked neurogenic pattern with minor non specific inflammatory changes. Neuroimaging investigations were normal. Pyridostigmine 120 mg pro die was therapeutic with justa mild clinical benefit but without a complete and satisfactory remittance of muscle deficits. We conclude that this patient developed an acute neuromuscular failure most probably BTX-related and that it could be due to an acute myasthenic-like syndrome of, more probably, his subclinical defective neuromuscular transmission status was precipitated by the last BTX administration of by drug Iong-time overdosing. Up to now patient has not yet been retreated by BTX in consideration of 1he risk-benefit therapy ratio and because of his incomplete recovery, even if his focal spasticity is marked and severe.

P543 Familial inclusion body myopathy. A.M. Kaminska, B. Szyluk, B. Piechowski-lozwiak, A. Fidzianska, H. Kwiecinski (Warsaw, PL) t tereditary forms of IBM are usually inherited as recessive traits. The reports of generation-to-generation transmission however are very rare. We present the case of IBM with positive family bistory phenotypically similar to s-IBM. The patient is a 61-year-old male with a history of type two diabetes mellitus and arterial hypertension. Weakness of lower extremities was first noted in the fourth decade oflife and he gradually developed progressive weakness of proximal us well as distal muscles. The patient was admitted to our neurological intensive care unit due to respiratory failure. Neurological examination revealed flaccid tetraparesis and muscle wasting more prominent in lower extremities with marked bilateral atrophy of quadriceps, diminished deep tendou reflexes and distal dysaesthesias in lower extremities. Neurophysiological examination demonstrated both myopathic and neurogenic pattern of muscle involvement. Creatine kinase and aldolase were within normal limits. Light microscopy revealed advanced myopathic changes. Occasional multivacuolated (red-rimmed and non-rimmed) fibers were present. A wide variation of fibers size with increased scattered atrophic fibers was seen. Internal nucleation was observed in the majority of fibers. There was mild endomysial fibrosis and fatty infiltration but no lymphocytic infiltration was apparent. By electron microscopy 15-21 nm diameter lubulofilamentous cytoplasmic inclusions were observed in numerous muscle fibers. Similar tubulofilamentous inclusions were also found in small number of muscle nuclei. Vacuoles containing membrane degradation products were observed in numerous fibers. Several other members of this family including maternal grandfather, maternal uncle and first cousin, having similar clinical phenotype were suspected of IBM. Such pedigree suggests dominant pattern of inheritance. The problem whetber in this family the genetic predisposition to develop sporadic form of IBM or dominant form of IBM is transmitted from generation to generation could be resolved by means of genetic studies. P544 Respiratory muscle function in "state-of-the-art-treated" myasthenia gravis. M. Winterholler, M. Dittner, B. Neund6rfer, D. Heuss (Erlangen, D) Ob)ective: To determine the respiratory function and frequency of sleep-related respiratory disturbances of "state-of-the-art-treated" patients with myasthenia gravis (MG). Patients and methods: 30 patients with previously diagnosed myasthenia gravis underwent an evaluation consisting of (1) pulmonary-focused history and physical examination including the Besinger myasthenia score (BMS), (2) measurement of forced vital capacity (FVC) and maximal inspiratory and expiratory pressures (MIP, MEP), (3) blood gas analysis, (4) repetitive phrenic nerve stimulation (RPNS), and (5) out-patient sleep respiratory monitoring with the Somnocheck R (SC). Selected patients were evaluated with polysomnography (PS). Results: 16 subjects (53.3 %) had signs and / or symptoms of respiratory complaints, esp. exertional dyspnea. Vital capacity was reduced ( < 80 %) in 4 subjects (13.3%). 10 patients (33.3%) h a d a markedly reduced MIP (< 60 %), while 5 (16.7 %) hada reduced MEP (< 60 %). M1 patients had normal phrenic nerve latencies; RPNS showed a pathologic decrement in 2 of 12 patients (16.7%). 7 subjects (23.3%) h a d a pathological apnea-screening. We found correlations between MIP and BMS (p=0.02), and the occurrence of bulbar symptoms a n d a pathologic apnea screening (p=0.035). Conclusion: Minor diaphragmatic dysfunction and fatigability ate Ÿ quent in "state-of-the-art-treated" MG. Repetitive phrenic nerve stimulation is n o t a s sensitive as careful history taking and mouth occlusion pressure in detecting such complaints. Sleep-related respiratory complaints are associated with bulbar muscle dysfunction in MG but do not correlate to lung function parameters and RPNS decrement. P545 A novel stop -codon mutation in the myophosphorylase gene in a Greek patient with McArdle's disease. G.M. Hadjigeorgiou, C. Karadimas, P. Chronopoulou, K. Flabouriari, S. Shanske, A. Papadimitriou, S. DiMauro (Larissa, GR; Columbia, USA) Objectives: To clarify the molecular genetic basis of McArdle's disease in a Greek family Background: Genetic defect of myophosphorylase cause an autosomal recessive disorder (McArdle's disease) characterized by exercise intolerance, cramps and recurrent myoglobinuria. To date, more than 20 different mutations in coding region or splice sites of the myophosphorylase gene have been identified in different ethic groups.

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Patient and method: A 26-years-old Greek man with non-consanguineous parents and without any family history of neuromuscular disease, suffered from exercise intolerance 'cramps, myalgia and episodic myoglobinuria since childhood. At age 15, myoglobinuria caused acute renal failure requiring hospitalization. Resting creatine kinase levels were slighlly elevated and forearm ischemic exercise test caused no increase in venous lactate. Muscle biochemistry showed lack of phosphorylase activity and normal activities of others glycolytic enzymes. Using genomic DNA extracted from peripheral blood, we amplified and sequenced the entire coding region of the myophosphorylase gene.PCR/RFLP analysis was employed to confirm the mutations in the propositus and in other family members. Resuhs: The proband was a compound beterozygote for the most common stop codon mutations R49X anda new stop codon mutation,Y52X, both in exon 1. The mother was heterozygous for R49X mutation and the father was Heterozygous for the Y52X mutation. Conclusions: We identified a novel stop codon mutation in a Greek patient with typical symptoms of McArdle's disease. This is the first genetic study of myophosphorylase deficiency in a Greek family, showing that the common "caucasian" R49X mutation was present on one allele. The prevalence of the newly discovered Y52X mutation in the Greek population remains to be determine&

Neuro-ophthalmology-Neuro-otology P546

lschemic optic neuropathy. C. l¡ Morales (Zaragoza, E)

S. Santos, P. Larrod› J. A. Mauri, E

Introduction: Ischemic disorders of the optic nerve constitute a common cause of visual loss in the middle-aged ad elderly population. Ischemic optic.neuropathy (1ON) is a muhifactorial disease and many risk factor and associated systemic disease contribute to it. Objective: To report the clinical features and etiological diagnosis of 12 patients with ION. Results: Twelve patients, 6 of whom were women and six men, with an age range from 26 to 65 years with a mean of 51.5 years were included in the study. Two patients hada bilateral optic neuropathy. The initial visual loss was severe in all. Four patients (33%) had second eye involvement within 3-24 months afler initial onset. Seven patients older than 50 years developed an acute nonarteritic anterior ION. Five of tbem had several predisposing risk factor for ischemic included diabetes mellitus and hypertension and 2 patients cerebrovascular disease. AII had permanent visual loss. Four patients were under 50 years. Two of them presented posterior ION after an episode of migraine with aura. Three patients developed anterior ION. One presenting with bilateral ION associated to arterial hypotension and acute anemia due to gastric bleeding. In the second case anterior ION was the initial manifestation of a systemic collagen vascular disease, and the last case developed ION after ah episode of migraine with aura. Conclusion: Ischemic optic neuropathy is the most common cause of acute nerve injury in older adults. Ir is an uncommon optic neuropathy in the young, and then usually associates with systemic diseases. Older patients with ION must be differentiated from cases in young patients to facilitate the appropriate etiology diagnosis. P547 Is The Subjective Visual Vertical Influenced By The Vertical Semicircular Canal? M.I. Iida (lsehara, J) The aim of the present study is to evaluate the influence of vertical semicircular canals on the subjective visual vertical (SVV) in heahhy volunteers. SVV was measured on conditions with or without the rotatory stimulus in a head tihed position, 60 deg. back-ward and then rotated 45 deg. either to the right or left. By this procedure, it was possible to evaluate the SVV elicited by the excitability of vertical semicircular canals. SVV was abnormal on the condition witb the rotatory stimulus, especially, which was deviated on the opposite side of the excited posterior canal. We conclude that the vertical semicircular canal influences the spatial orientation such as the SVV.

P548 lncreased prevalence of migraine in Meni6re~ disease. A. Radtke, H. NeuhauseL G.B. Brookes, A.M. Bronstein, M.A. Grest~ ~ Lempert(Berlin, D) Introduction: A possible link between Meni~re's disease (MI)) and migraine headaches was originally suggested by Prosper Meni~re. Unfortunately, previous studies evaluating the prevalence of migraine in MD have been methodologically unsatisfactory and consequently have yielded conflicting results. Metbods: To determine the lifetime prevalence of migraine in MD, we studied 78 patients (40 women, 38 men, age range 29-81 years) fulfilling the 1995 AAO-criteria for idiopathic uni- or bilateral MD who were retrospectively identified from an out-patient ENT-clinic. Diagnosis of migraine with and without aura was made by telepbone interview according to the classification of the International Headache Society (1988). Additional information was obtained concerning the concurrence of vestibulo-cochlear symptoros and migrainous headaches during typical Meni~re attacks. As controls, we interviewed sex- and age-matched orthopedic patients (n= 156). Resuhs: The lifetime prevalence of migraine with and without aura was significantly higher in the MD-group (56%) compared to the control group (21%; p < 0.001). Typical migrainous headaches during attacks of MD were experienced in 22 out of the 78 MD-patients (28 %). In 11 patients (14 %) Meni91 attacks were always accompanied by migrainous headaches; in an additional 11 patients, migraine headaches sometimes concurred with MD-attacks. Conc]usion: Our data indicate that the lifetime prevalence of migraine is increased in patients with MD when strict diagnostic criteria for either condition are applied supporting the hypothesis that tbere may be a pathophysiological link between the two diseases. However, there is the proviso that current diagnostic criteria may be insufficient to clearly differentiate between MD and migrainous vertigo. P549

lnfundibuiohypophysitis and lymphocytic hypophysitis: distinct or spectrum? N. Tubridy, D. Saunders, D. Saunders, M. Thom, M. Thom, R. Howard, G. Plant (Paris, F; London) In fundibulohypophysitis is an unusual condition which may be part of a disease spectrum which includes lymphocytic hypophysitis. The latter occurs mainly in women and most often presents in the later stages of pregnancy. Infundibulohypophysitis usually presents with diabetes insipidus and the cause of both conditions remains unclear. We reporta case of each-a 46 year old man with a one year history of polyuria and polydipsia, diagnosed as cranial diabetes insipidus on the basis of a water deprivation test with normal initial cranial and pituitary imaging studies. He subsequently developed symptoms of panhypopituitism over a period of 6-9 months and then, more acutely, developed diplopia secondary to a mild fourth nerve palsy. Further brain imaging studies revealed an enhancing pituitary gland anda left cavernous sinus lesion. A trial of immunosuppressive treatment did not help symptoms significantly. A biopsy was performed anda diagnosis of infundibulohypophysitis was made. The case is discussed regarding the diagnosis and management of this increasingly reported but rare condition. The second case is that of a twenty-year old Afro-Caribbean woman who presented with a week long history of progressive bilateral visual deteriorat ion woman two weeks after delivery of a normal baby. The patient presented with clinical features suggestive of a pituitary mass lesion but surgery was avoided when clinical and radiological features were taken in to account and a diagnosis of lymphocytic hypophysitis was made. The woman recovered with steroid treatment only. We review the literature on this latter condition argue that an initial conservative approach to management may be more suitable than was previously thought. Whether the two conditions forro part ofa spectrum of the same disease is unclear but their clinical, radiological and histological features are sufficiently distinct to warrant differentiation of the two conditions as therapy must be tailored accordingly. P550

Moyamoya disease revealed by intra ocular hemorrhage. S. Coste, E Meyer, T. De Greslan, A. Ait Ameur, ]. L. Renard, E Flocard, D. B› (ParŸ F) Ocular complications of Moyamoya disease are very rarely observe& We reporta case of Moyamoya disease revealed by an intraocular hemorrhage and discuss the pathophysiology of this complication. A 44 year-old Japanese women presented a sudden decrease of the visual acuity in her left eye.Apart from this ocular sign,clinical examination was normal and no precipitant fac-

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tor was found. The left optic fundus showed intra-vitreous hemorrhage. After resorption of this latter, fluorescein fundus angiography revealed signs of ischemia in the peripheral retina and an abnormal retinal vascular network, consisting of numerous arterial shunts and the presence of a fifth branch of the retinal artery. A Doppler flowmetry of the cervical arteries found a low output in both infernal carotid arteries, predominating in the left-one. Cerebral MR angiography showed bilateral stenosis of the supraclinoid portion of the internal carotid arteries, nearly unseen anterior cerebral arteries and middle cerebral arteries, anda widespread collateral vessels at the base of the brain, leading to the diagnosis of Moyamoya disease. Moyamoya disease is a rare cerebrovascular disease of unknown aetiology, mainly affecting the Japanese.ln adults,symptoms ate frequentlyintracranial hemorrhage.Visual manifestations typically result from a disturbance in the cerebral posterior circulation, and consist of visual field defects, hemianopia, amaurosis, diplopia, nystagmus or cortical blindness. Ophthalmic symptoms, such as central retinal artery and vein occlusion, have exceptionally been reported during Moyamoya disease. In our patient, the intra-vitreous hemorrhage is the initial manifestation ofillness, and results from the rupt ure of neovessels, which are developed in response to the chronic retinal ischemia, probably caused by a low flow in the left ophthalmic ar tery. The arterial shunts and abnormal tortuous vessels of the retinal circulation closely resemble the basal cerebral moyamoya vessels, suggesting a common process of development and fragility. This ophthalmic network might reflect the collateral pathway from the extracranial to the intracrania[ arteries through the orbital circulation, that corresponds to the so-called"ethmoidal moyamoya". Although intraocular complications of Moyamoya disease are very rare, they can exceptionally reveal this illness. Moreover, optic fundus and retinal angiography might reflect the abnormal intracranial vascular network. P551 Prevalence of HSV-1 LAT in human trigeminal, geniculate, and vestibular ganglia and its implication for viral reactivation. D. Theil, V. Arbusow, T. Derfuss, M. Strupp, A. Mascolo, T. Brandt (Munich, D) Herpes simplex virus type 1 (HSV-1) enters and reactivates from latency in sensory neurons. Restricted HSV-1 gene expression takes place during latency and consists of the latency-associated transcripts (LAT). It has been demonstrated that LAT is important not only for latency but also for reactivation. Reactivation of herpes simplex virus type 1 in the geniculate (GG) and vestibular ganglia (VG) is suspected to cause Bell's palsy and vestibular neuritis. It is widely accepted that after primary infection (stomatitis herpetica) HSV-1 ascends to the trigeminal (TG), GG, and VG by retrograde axonal transport via lingual nerve and the facio-vestibular anastomosis. This hypothesis was supported by recent studies which demonstrated HSV-1 infection of the majority of human GG and VG. On the basis of these findings we addressed the following questions: ( 1) Is there just viral infection of human TG, GG, and VG or can HSV-1 establish latency in these cranial nerve gangita! (2) Does the prevalence of LAT differ between the single cranial nerve ganglia, indicating viral spread along preformed nerve routes? Tissue sections of the TG, GG, and VG from seven individuals were examined for the presence of LAT using the in situ hybridization technique. LAT was found on both sides in all TG (100 %), on both sides of 5 individuals (70 %) in the GG, and in norte of the VG. This findings are compatible with primary infection and establishment of viral latency in human TG and GG via lingual nerve (mandibular nerve and chorda tympani). As HSV-I DNA has been commonly detected in human VG in earlier st udies, the lack of LAT allows alternative speculations. (1) Reactivation in the geniculate ganglion leads to infection of the VG via faciovestibular anastomosis without establishing latency at this site. (2) Accumulation of LAT in the VG is below the limits of detection of the in situ hybridization technique. (3) Viral latency in the vestibular ganglion does not correlate with the expression of LAT.

vestibular labyrinth (semicircular canals and macula organs) of 21 randomly obtained temporal bones of 11 individuals by nested polymerase chain reaction (PCR). HSV-1 DNA was detected in 10 of the 21 vestibular labyrinths (48%). All of these showed HSV-I infection of the ipsilateral vestibular ganglion. Only three of 13 HSV-I positive vestibular ganglia did not show associated HSV-1 infection of the ipsilateral vestibular labyrinth. Frequency and distribution of HSV- 1 infection among the vestibular (62 %) and geniculate ganglia (57%) did not differ substantially from findings in earlier studies. This is the first demonstration that HSV- 1 infection occurs in the human vestibular labyrinth. The potential significance of this finding is twofold: (1) ]nflammation in vestibular neuritis could also involve the peripheral labyrinth and thereby affect the function of vestibular receptors. (2) As benign paroxysmal positional vertigo (BPPV) occurs relatively often in patients who have had vestibular neuritis (about 12 %), BPPV could be a sequela of viral labyrinthitis. P553 Lateral gaze paralysis, pendular nystagmus and progressive scoliosis (Sharpe and Silverside's syndrome): a report of 4 Tunisian families. S. Gabsi-Gherairi, E Bahri, N. Gouider-Khouja, A. Larnaout, N. Ammar, M. Zouari, S. Belal, N. Miladi, F. Hentati (Tunis, TN) Sharpe and Silversides syndrome is a rare condition associating lateral gaze paralysis, pendular nystagmus and progressive scoliosis. Besides these major clinical features, other symptoms may be noted such as facial abnormal movements, ataxia and delayed psychomotor milestones. Since its first clinical description in 1975, only few cases are cited in the literature. The origin of this entity is probably neurodegenerative. We report 8 patients belonging to 4 families with lateral gaze paralysis, pendular nystagmus and progressive scoliosis of infantile onset. The mode of inheritance was autosomal recessive. Complementary investigations (CSF and nerve conduction velocity studies, evoked potentials, muscular biopsy and cerebral CT Scan or MRI) were normal. Identification of causative gene defect would delineate pathophysiological mechanisms of this particular syndrome. P554 Perilymph fistula of the lateral semicircular canal associated with jerk nystagmus and pulse-synchronous eye and head oscUlations. C. Helmchen, W. Eleide, A. Sprenger, G. I [aendler, H. Rambold (Luebeck, D) Patients with perilymph fistula (PLF) usually present with episodic vertigo, jerk nystagmus, and/or hearing loss. We give the first report of a 3-D search coil recording of a patient with a surgically acquired PLF of the lefl horizontal semicircular canal who presented with (1) a Valsalva-elicited contralesional jerk nystagmus (IN) in the left horizontal canal plane and (2) a spontaneous horizontal pendular nystagmus (PN). Three-dimensional eye movement recording showed good alignment of the velocity rector of the elicited JN and the spontaneous PN with the sensitivity vector of the lefl semicircular canal. The cont ralesional direction of the jerk nystagmus probably reflects an inhibition of the left horizontal semicircular canal. Three-dimensional eye movement revealed that Ewald's first law ("stimulation of a canal generates eye movements in the canal plane") is not only valid for canal excitation, but may be valid for inhibition. The spontaneous horizontal pendular nystagmus was associated with pendular head movements and related to the heart rate. PN may be caused by CSF or be due to synchronous pressure transfer of systolic pulse to the labyrinthine of the semicircular canal. Pendular nystagmus appears to be a new clinical sign of PLE Supported by Deutsche Forschungs Gemeinschaft (DFG).

P552 HSV-I not only in human vestibular ganglia but also in vestibular labyrinth. V.Arbusow, D. Theil, M. Strupp, A. Mascolo, T. Brandt (Munich, D)

P555 Choroidal involvement in patients with neurofibromatosis type 1 (NFI) as a cause of visual field defects resembling intracranial malignancy. J. Katsimpris, M. Mpoufi, G. Georgopoulos (Patras, GR)

Reactivation of herpes simplex virus type 1 (HSV-1) in the geniculate and vestibular ganglia is suspected to cause Bell's palsy and vestibular neuritis. Recent studies reported the presence of HSV-1 DNA not only in vestibular ganglia but also in vestibular nuclei, thus indicating that viral migration can occur via the vestibular nerve to the ponto-medullary brainstem. This finding raised the question of whether the virus could also migrate from the vestibular ganglia to the peripheral receptors in the semicircular canals and the otolithic organs. HSV- l infection was determined in vestibular, geniculate ganglia and the

Purpose: To describe the usefulness of the indocyanine green angiography in the differential diagnosis of a patient with a typical form of systemic neurofibromatosis type I (NF 1) and visual field defects resembling intracranial malignancy. Material and methods: A 45 year-old male patient with systemic neurofibromatosis type 1 (NF 1) was presented in our clinic for the usual and periodical follow-up. The patient underwent a visual acuity examination, slitlamp and fundus examination, and a visual field testing using Octopus perimeter. The patient's visual acuity was 0.8 and 0.6 cc for the right and left

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eye correspondingly. Blue-dot cataract was disclosed in both eyes, ahhough the left eye was much more affected than the right eye. Intraocular pressure was 14mmHg in both eyes. Alterations in the retinal pigment epithelium were detected in the fundus on both sites and especially around the optic disc on both sites. A bitemporal inferonasal quadranopsia was recorded in the visual field examination. Aiming to evaluate the origin of this quadranopsia we accomplished MRI examination of the brain and orbit, electroretinogram, fluorescein angiography and indocyanine green angiography. Results: MRI examination of the brain and the orbits was negative, and ERG was patho[ogical in the left eye. Aheration of the retinal pigment epithelium were observed in both eyes commencing from the disc and extending in the superior temporal area. Also sites of delayed choroidal filling were observed together with a staining lesion half disk diameter in the right eye along the superior temporal arcade. The findings in ICG were remarkable showing in the initial phases multiple and extensive areas of hypofluorescence. In the late phases the hypofluorescent lesions became smaller, andat the end of the examination these areas confined to small isolated dots. Discussion and conclusions: Although symmetrically appearing lesions of the visual field in patients with NF1 arise the suspicion of an intraorbital oran intracranial disease-usually a space occupying lesion- we must not to examine the choroid forget in these situations were a space occupying lesion is excluded. The findings in the ICG clearly demonstrate the choroid affection in NFI. The explanation for these hypoperfused areas is probably due to the deep alterations to the walls of the choroidal vessels induced by the disease. P556 Purtscher retinopathy complicating a patient suffering from head injury. M. Mpoufi, J. Katsimpris (Patras, GR) Purpose: This case report aims to describe the clinical features of the Purtscher's retinopathy that occasionally may complicate head injuries. Material and methods: A 29 years-old man aftera traffic accident with m¨ iple facial injuries anda fracture of the nasal bones developed suddenly an acute decrease of visual acuity in his right eye. The patient underwent a thorough ophthalmological examination including fluorescein angiography and visual field examination. Systemic steroids were administered in a tapered pattern. Results: Fundoscopy and fluorescein angiography disclosed the presence of multiple superfcial haemorrhages and soft exudates indicating the existence of Purtscher's retinopathy, lmprovement of his condition was observed one month after the first examination, the visual acuity returning to near normal. Discussion and conclusion: Purtscher's retinopathy is a rare complication of head injuries and may also appear in other conditions such as acuter pancreatitis, tumors, or connective tissue disorders. P557 Comparison of PET (Positron Emission Tomography) and Eye Movement Deficits in Patients with Minor Cognitive Deficits (MCD) due to Neurological and Rheumatological Diseases. U. Gschwandtner, J. lakscha, D. Maclachlan, E. Nitzsche, P. Freitag, A. J. Steck (Basel, CH) Objectives: In patients with minor cognitive deficits (MCD) such as concentration deficits and rapid fatigability, the localisation of possible CNS lesion is unknown. We investigated perfusion changes with PET and analysed the relation to eye movement deficits and minor cognitive deficits. Preliminary resu]ts are presented. Patients and methods: We investigated 5 patients with neurocognitive deficits (3 patients with multiple system atrophy, 1 patient with rheumatoid arthritis, 1 patient with M. Sj6gren) and compared them to 2 patients with SLE without any neurocognitive symptoms. MRIs were assessed for abnormalities. Perfusion change was looked at with 18F-FDG (Fluorodesoxyglucose) PET. Eye movements (saccadic and smooth pursuit) were measured with oculography. The eye movement deficits were compared with neurocognitive deficits, as well as results of MRI and PET. Results: All patients with MCD had pathological saccades and smooth pursuit eye movements, separating them significantly (p < 0.001) from the parameters in healthy controls. All patients hada normal cerebral MRI. 3 of 5 cases with MCD h a d a pathological PET with perfusion deficits in the frontal cortex, prefrontal cortex and basal ganglia. The two control cases with SLE showed no perfusion deficits. These 2 cases had normal eye movements. Conclusion: PET perfusion deficits in the frontal and prefrOntal cortex as well as in the basal ganglia in patients with MCD indicate cerebral dysfunction. Eye movement deficits may be an early indicator for these disturbances.

P558 Cranio-facial asymmetry syndrome: A new syndrome involving the oculolabyrinthine. D. Rousi› 1.C. Baudrillard, 1. C. Hache, P. Pellerin, P. Van Tichelen, A. Berthoz (Paris, F) Examination of 217 patients with Cranio facial asymmetry (CFA) highligbted a set of particular symptoms such as ocular tilt and skew deviation, acute orofacial pains, postural deviations of the head and scoliotic deformations of the spine, spatial disorientation and sometimes agoraphobia. These symptoms are often treated separately. We realized a first systematic study on these patients. Our hypothesis was that CFA symptoms have a common cause: a fundamental asymmetry of the vestibular organs and orbits creating a distortion of the body sehema and of all the systems involved in gaze control and spatial orientation. Metbods: The anatomical asymmetries have been measured using MRI scanning with a special reference frame. The deviations of the ocular globes have been studied using scanning laser ophthalmoscope (SLO). The spine and posture have been studied with X rays and postural tests and the vestibulo-ocular reflexes have been studied with videonystagmography (Veonis). Resuhs: The MRI scanning revealed asymmetries of position and orientation of the orbits and vestibular receptors probably associated with brain and skull asymmetries. We found various types of CFA which have been classified in 4 groups. We found a high rate of exocyclotorsion (82%) according to the troubles described by the patients. The angular values of the torsions have been classified. The spine and postur.e examinations revealed 100% of head tilt and frontal deviation of the lumbar spine The vestibular tests revealed 78 % of unilateral vestibular deficit which have also been dassified. The abnormality of"natural" head holding is a response to the high rate of orofacial and cervical pains (90 %) expressed by the patients: the tilt induces compression and lesions of the articular surfaces in temporomandibular joint and cervical column.

Poster session - 4

Cerebrovascular disorders P559 No impact of ApoE polymorphism on demographic, dinical and morphologic variables of patients with acute intracerebral hemorrhage. E Fazekas, A. Lechner, G. Roob, H. Schmidt, P. Kapeller, E. Flooh, H.P. Hartung, R. Schmidt (Graz, AT) Background and goals: In recent studies the apolipoprotein E (ApoE) e4 allele has been associated with cerebral amyloid angiopathy possibly by promoting amyloid deposition. The e2 allele, in turn, was assumed to exert an overall atherogenetic effect.As a consequence, both alleles were suggested to favour the occurrence of certain types of intracerebral hemorrhage (ICH). To test these speculations we analysed the demographic, clinical and morphologic variables of consecutive ICH patients in relation to their ApoE polymorphism. Methods: We performed ApoE-genotyping in 192 consecutive patients with spontaneous ICH confirmed by CT, and additionally by MRI in 97 patients. Mean patient age was 69 years (range 34-97). The ICH was cortical and/or lobar in 77 patients, located in the basal ganglia/thalami in 106 and was infratentorial in 27 patients, respectively. Variables assessed were age, gender, cerebrovascular risk factors, ICH location and associated morphologic abnormalities such as white matter hyperintensities and evidence for earlier microbleeds. Results: Excluding 4 individuals with the e2/e4 genotype there were 24 (12.5 %) patients with at least one e2 allele, 36 (18.8 %) with at least one e4 allele and 128 (66.7 %) with e3 alleles only. The mean age of e2 carriers (65.5 + 12.7 yrs.) was somewhat lower than that of e4 carriers (69.7 -+ 12.0 yrs.) or of patients with e3 alleles only (70.0 -+ 13.8 yrs.),but this difference was not statistically significant. There were also no significant differences regarding the location of symptomatic bleedings (cortical/subcortical: e2-33%, e3-40%, e4-44 %; deep grey matter: e2-57%, e3-60%, e4-47 %) nor in respect to any other clinical or morphologic variable, except for significantly lower cholesterol levels of e2 carriers.

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Conclusion: We fail to confirm characteristic patterns of demographic, clinical or morphologic variables related to specific ApoE alleles in a large cohort of 1CI-! patients. P560

Carotid peak systolic frequencies and grading stenosis of internal carotid artery. 1. Divjak, M. Zikic, M. lovicevic, T. Zikic-Rabi, K. Bozic (Novi Sad,Y U) Purpose: Defining of the basic characteristics of peak systolic frequencies in common carotid artery (CCA), internal carotid artery (ICA) in proximal part and in distal part and external carotid artery (ECA) in 6 levels of stenosis percentage: a) normal finding, b) minimal lesion ( 1-15 %), c) mild stenosis ( 16-49 %), d) moderate stenosis (50-75 %), e) severe stenosis (76-99 %), f) total occlusion, and two control groups. Method and results: A group of 53 patients of average age of 55.9 in acute phase of ischaemic stroke in anterior circulation were examined who passed duplex scanner prior angiography. Central and dispersion parameters were analysed for 6 levels of stenosis percentage and 2 control (43 subjects, average age of 36.9 and 33 of 55.7). On ANOVA basis ir was found out that there existed the significant difference for detection points compared to stenosis level of ICA (p < 0.05). Difference carrier is 1CA proximal part (discriminative coefficient 1.72) and ICA distal part (1.08). By application of Hotteling T*2 * test, it was found out significant differences for ICA (p < 0.05): a) for normal finding compared to: moderate stenosis, severe stenosis, occlusion and the I control group; b) for minimal lesion to: moderate stenosis, severe stenosis and occlusion; c) for mild stenosis to: moderate stenosis, severe stenosis, occlusion, I control group and 11 control group; d) for moderate stenosis to: severe stenosis, occlusion, I and I1 control group; e) for severe stenosis compared to: occlusion, I and II control group; f) for occlusion compared to: I and II control group; g) between I and II control group. Conclusion: On the basis of peak systolic frequencies analysis, stenosis over 50 % can be determined only. By duplex scanner the evaluation of senosis level less than 50%, the extent, severity and the precise plaque localisation, evaluation of echogenity, determination of surface plaque characteristics and surface irregularity of artery are determined. P561

Cerebrovascular diseases in patients with Marfan's syndrome. C. Zanferrari, 15.Lavados, R. Wityk, S. Oppenheimer (Patina, I; Baltimore, USA) Marfan's syndrome (MFS) is an inherited connective tissue disorder characterized by musculoskeletal, ocular and cardiovascular manifestations. Most frequent cardiovascular abnormalities might determine an increased risk of stroke. Only few studies assessed the prevalence of cerebrovascular disease (CVD) in MFS patients, giving controversial results. We undertook a large ret rospective hospital-based study aiming to assess frequency, etiology, clinical subtypes of CVD in all MFS patients referred to the lohns Hopkins Hospital (JHH) from 1989 to 1997. We included all inpatients and outpatients with a defined diagnosis of MFS, according to the criteria proposed by McKusick and Pyeritz. MFS inpatients were collected reviewing the first tire discharge diagnosis (ICD-9) of all patients admitted to JHH, using the codes for MFS and CVD. MFS outpatients were colleeted reviewing the archive of the Genetic Clinic and analyzing the file of each MFS case. We analyzed 513 MFS cases (300 M, mean age 31.6 + 16.4 yrs), 244 inpatients and 269 outpatients. Mean follow-up duration was 8.34 + 5.93 years. The overall number of CVD was 18 (3.5 %) tases: 10 M, 8 F, mean age 39.6 + 16 yrs. Eleven patients suffered from a transient ischemic attack, 2 patients from a supratentorial ischemic stroke, 2 patients from a subdural bematoma, 2 patients from a spinal infarction, and 1 patient from a spinal subarachnoid hemorrbage with intradural hematoma. In conclusion, CVD frequency did not differ between MFS patients and general population. Its etiology, in both ischemic and hemorrhagic manifestations, is unlikely to be directly related to the primary connective defect leading to aneurysms formation or arteries dissection. P562 Platelet surface glycoprotein expression in depression and stroke. E. Cassidy, M. T. Walsh, R. O'Connor, M. Condren, M. Ryan,V. O'Keane, D. Kenny, T. Dinan (Dublin, IRL) Background: Depression is a significant risk factor for and consequence of both cardiovascular disease and stroke. The pathophysiological processes underlying this association are poorly understood. Methods: We analyzed the platelet surface expression of glycoproteins

GPlb and GPlIbllIa, which are involved in platelet adhesion and aggregation, in 7 depressed subjects (Hamilton depression score > 17), 14 poststroke subjects (7 depressed and 7 non-depressed) and in 7 healthy control subjects by flow cytometry. Resu[ts: The number of GPlb receptors was significantly increased on the surface of platelets from subjects with depression compared to control subjects. Both the number of GPIb and GPllbllla receptors were significantly increased on the surface of platelets from post-stroke subjects compared to healthy control subjects. The number of GPlb receptors on the surface of platelets from post-stroke subjects was not significantly different from that of otherwise healthy depressed subjects. No additive effect of co-morbid depression on the surface expression level of either marker could be detected in the post-stroke subjects. Conclusion: Stroke subjects and subjects with depression have comparable increases in platelet surface glycoprotein expression. Platelet dysfunction may be involved in the pathophysiological process underlying the association between depression and cerebrovascular disease. P563

Young stroke patients; effects of depression and right hemisphere dysfunction on disability and outcome following rehabilitation. E. Cassidy, R. O'Connor, M. Delargy, V. O'Keane (Dublin, IRL) Background: Major depression is common following stroke. Visuospatial impairments have been found to be related to poor functional outcome following stroke and are in general indicative of right hemisphere dysfunction. More obvious disturbance of the right hemisphere ma), manifest as hemineglect and unawareness/denial of disability. Conceivably denial of disability might in part serve to protect against depression. Objectives: To examine the hypothesis that depressed subjects following stroke have greater disability at baseline and less imprnvement following inpatient rehabilitation and that right hemisphere dysfunction is associated with less depressive symptomatology. Methods: 36 patients (22 male, 14 female; age 50.7, SE 1.4 years) at least 2 months post-stroke were assessed before and after 8 weeks of inpatient rehabilitation using standardised measures of mood, disability and cognition. Results: Baseline: Al1 but one patient were classified as moderately or severely disabled on the Rankin scale; Barthel score: 12.8, SE 0.8. 11 patients had DSM-IV major (8) or minor (3) depressinn. HAMD score: 15.1, SE 0.5 compared to 3.3 in the non-depressed group. Follow-up: There was a significant improvement in both Rankin and Barthel indices of disability (p < 0.05). Relationship between cognition, mood and disability: Depressed subjects were no more disabled at baseline than non-depressed subjects. Subjects who were impaired on the Watson clock drawing test at baseline (18/32) had greater baseline HAMD depression than unimpaired subjects although this was not significant. However, an abnormal score on the Watson test at baseline was associated with significantly greater HAMD depression at follow-up (4.7, SE 1.4 compared to 1.5, SE 0.6; P < 0.05). Conclusions: Right hemisphere dysfunction as assessed by the Watson clock drawing test in the non-acute post-stroke period was associated with significantly greater depressive symptoms fnllowing 2 months of inpatient rehabilitation. P564

Previous infection and stroke: etiological significance.~ I. Henriques, L. Rebocho, T. Tribolet-Abreu, C. Barata (Evora, P) Introduction: The relation between infection and ischemic stroke is not well established. Infection may contribute to a pre-thrombotic status. Tachycardia related to rever might trigger other disrrythmias that can lead to cardioembolic mechanisms. We studied the prevalence of previous recent infeetion and related etiology in ischemic stroke patients. Methods: We studied 199 consecutive stroke patients (30 hemorrhagic). lschemic stroke patients were aged between 32 and 86 (median age 61 ). Previous infection was considered when infection was present at least 8 days before stroke. All patients were studied according to a protocol that includes at least one CT-scan or MRI, transthoracic echocardiogram and triplex-scan, that permits classification according to TOAST criteria for etiology. Results: No previous infections were observed in hemorrhagic patients. From 169 ischemic stroke patients, 8 (4.7 %) had previous infections (5 male, 3 female), that include skin, urinary tract and dental infections. No significant difference was found concerning ischemic stroke etiology (2 large artery disease, 3 lacunar infarction, 2 cardioembolic and 1 unknown). Conclusions: In our patients the prevalence of previous infection was 4.7 %. Except for one case, all previous infections occurred in ischemic st roke patients where a well established etiology was observed. Inflammatory mechanisms associated with infection as well as the influence of infection in

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triggering decompensation of well known established risk factors for stroke may playa role. P565 Hyperhomocysteinemia and ischemic stroke: how far shall we go in etiology research? L. Rebocho, T. Tribolet-Abreu, C. Barata, I. Henriques (Evora, P) Introduction: Multiple studies showed that an elevated plasma homocysreine (Hcy) concentration is associated with atherothrombotic vascular disease. The precise molecular mechanism by which Hcy o r a related metabolite promotes atherothrombosis is still unknown. We studied the prevalence of high plasma levels of Hcy in our ischemic stroke patients. Methods: We prospectively studied 67 consecutive ischemic stroke patients aged less then 65 years or with any age but unknown etiology. Al1 patients were studied according to a protocol that includes at least one CT-scan or MRI, transthoracic echocardiogram, triplex-scan, coagulation, serologic infectious and autoimmune tests. We measured fasting plasma Hcy concentration by ELISA (FPlA) (normal < 15 mmol/L) and concentration 4 hours after the load of 100 mg/kg of oral methionine (normal < 40 mmol/L). Median age was 47 years [43-751 and 41 were male (61%). Patients were classified according to TOAST etiology criteria. Results: From 67 patients, none had fasting homocysteinemia levels above normal. After the methionine-loading test, 8.9% (n = 6; 3 male) presented hyperhomocysteinemia. Hypertension and dyslipidemia were present in 5 patients (83%) and alcohol abuse in 2 (33%). Etiology research found 1 patient with probable cardioembolic source. Triplex scan did not show ipsilateral stenosis. Five patients had lacunar infarction and one had undetermined etiology, according to TOAST criteria. Conclusions: In this group of ischemic stroke patients prevalence of hyperhocysteinemia was 8.9 %. Ahhough the role of hyperhomocysteinemia in ischemic stroke is not yet established, only in one patient etiology was unknown. More studies in Hcy levels are needed to clarify the role of hy-perhomocysteinemia treatment on stroke recurrence. P566 Hospital mortality for stroke before and after organized stroke care. C. Barata, T. l¡ L. Rebocho, I. Henriques (Evora, P) Introduction: In our Hospital, stroke is the most frequent diagnosis in medical wards. Since 1996, organized stroke care was started by a multidisciplinary team. We measured the hospital mortality rates of stroke before and after organized care. Material and methods: We used the official hospital data on Diagnosis Related Group (DRG) as source of information.We included all ischemic and hemorrhagic stroke patients admitted in the year 1995 (457,243 male) and 1999 (528,286 male). We considered hospital mortality any death at 28 days after admission. Age media was 76.6 in 1995 [39-100 ] and 73.4 in 1999 [27-94]. lschemic patients were studied with etiology research goals, according to a protocol that includes at least one CT-scan or MRI, transthoracic echocardiogram, scan-scan. Statistical analysis included Qui-square test. Results: In 1995, from 457 stroke patients, 343 were ischemic. Global stroke mortality was 89 (40 male) and ischemic stroke mortality 79 (44 male). In 1999, from 528 stroke patients, 427 were ischemic. Global stroke mortality was 74 (40 male) and ischemic stroke mortality 60 (32 male). When comparing 1999 with 1995 resuhs, global mortality decreased (p=00215) and ischemic stroke mortality also decreased (p= 0.0013). Conclusion: In our hospital crude non-patronized mortality has diminished after organized stroke care started,both for ischemic and hemorrhagic patients. Possible explanations for our results may be that organized stroke care permits the diagnosis and control of some potential fatal medical and neurological complications, as well a s a better etiological oriented treatment. P567 Carotid Atherosclerosis and White Matter Hyperintensities in elderly individuals. The EVA-MRI Cohort. F. Pico, C. Dufouil, C. Levy,V. Besanqon, A. de Kersaint-Gilly, C. Bonithon-Kopp, P. Ducimetibre, C. Tzourio, A. Alp› (Paris, Massy, Nantes, Villejuif, F) Background: White Matter Hyperintensities (WMHs) are often shown on cerebral magnetic resonance imaging (MRI) of elderly individuals. Based on epidemiological and pathological studies,WMHs are considered asa marker of a chronic cerebral hypoperfusion due to arteriolosclerosis ('small arteries disease'). Recent longitudinal studies have shown that indicators of

carotid atherosclerosis (i. e. increase of the intima-media thickness (IMT) and plaques) assessed at uhrasonographic carotid examination were associated with an increased risk of stroke after other cardiovascular risk factors had been controlled for. Purpose: In the population-based EVA study, we investigated the relation between uhrasonographic indicators of carotid atherosclerosis and the severity of WM Hs assessed 4 years later at MRI. Methods: The study sample consisted of 658 individuals (mean age: 65 years). Data on history of cardiovascular disease and medical drug use were collected. Baseline carotid uhrasonographic measures of IMT and plaques were made. The MRI study was a part of the 4-year follow-up examination of the EVA st udy. T2-weighted images (1.0 T scan) were read by a single doctor using a modified version of the Scheltens's scale and subject were classified regarding to the severity of WMHs in four categories: no, mild, moderate and severe. Results: At baseline, of the 658 subjects included, 32 % were hypertensive. The prevalence of advanced carotid atherosclerosis was low: only 20 % of the subjects had at least one carotid plaque and the mean IMT of the common carotid arteries was 0.66 -+ 0.11 mm. Twelve subjects (2%) had no WMHs. Subiects with mild, moderate, and severe WMHs represented 36 %, 44 % and 18 % of the sample respectively. Subjects with severe WMHs were older and had more often hypertension than those with mild WMHs. After adjusting for age and hypertension,we found that carotid plaques at baseline were significantly associated with severe WMHs in men (OR =2.7; 95 %CI:1.4-5.3), but not in women (adjusted OR=I.I; 95 %CI: 0.6-2.2). Baseline IMT was associated with ah increased risk of severe WMHs in both sexes (adjusted OR per 0.1 mm increase = 1.2; 95 %CI: 1.0-1.4). Conclusions: These data confirm the relationship between carotid atherosclerosis and WMHs. This association is independent of hypertension and other known vascular risk factors and suggest the existence of unknown vascular risk factors implicated in both carotid and small arteries disease. P568 Transcranial Doppler Monitoring in Cerebral Autoregulation and Orthostatic Hypotension of Parkinson's Disease. S. Ozkan, D. Gª252 T. Asil, O. 0zdemir, N. Uzuner, G. Ozdemir (Eskisehir, TR) Objectives: To asses the cerebral autoregulation and orthostatic blood pressure changes in Parkinson disease by means of TCD. Methods: Eleven consecutive PD patients (8 men, 3 women; mean age 65.1 + 9,9 years; mean disease duration 5.9 + 4.9 years) and a healthy age matched control group (n=15; mean age 63.9 -+ 4,2) were studied. Bilateral MCA's of patients were monitored continuously during an head up tilt test; aftera 5 minutes horizontal position, 5 minutes 80 g~ upward position, followed by once more 3 minutes repeated periods for each position. Blood pressures were examined in every 2 minutes of the test. Results: There was no significant decrease in blood pressure and Vmean values of control group subjects. Three PD patients showed a cerebral dysautoregulation (more than 15 % decrease in Vmean) without any orthostatic blood pressure changes. Besides, 3 other PD patients showed significant orthostatic hypotension changes (more than 25 mmHg decrease in systolic pressure and/or 10 mmHg decrease in diastolic pressure) without any Vmean changes during the test. Conclusions: TCD with orthostatic test may be used asa new laboratory method in the diagnosis of cerebral dysautoregulation and orthostatic hypotension of Parkinson's disease.

P569 Ipsilateral hemiataxia-hypesthesia after dorsolateral lower medullary infarction: A differential diagnosis to contralateral thalamic infarction. H. Russmann, F. I. G. Vingerhoets, P. Maeder, A. Carruzzo, F. Perren, ]. Bogousslavsky (Lausanne, CH) Background: Hemiataxia-hypesthesia is classically secondary to a contralateral thalamic lesion involving the ventroposterior nuclei or to an anterior choroidal infarct with involvement of the internal capsule. Impairment of sensory modalities is also part of lateral medullary infarctions but involving usually only part of the hemibody and is associated with cranial nerve involvement. Case description: We report a 31 old patient with hypesthesia of, the whole right hemibody including the face associated with limb and gait ataxia. These signs were secondary to posterolateral hemorrhagic infarction of the lower medulla. The lesion involved the cuneate and gracile nuclei as well as the posterior spinocerebellar tract, explaining the sensory deficit and ataxia as well as decreased tendon reflexes by cerebellar hypotonia. Damage of the spinal trigeminal tract and nucleus were responsible for the ipsilateral sensory deficit of the face.

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Conclusion: A posterolateral hemorrhagic infarction of the lower medulla may induce an ipsilateral isolated hemiataxia-hemihypesthesia syndrome mimicking a contralateral thalamic of anterior choroidal infarct.

Epilepsy P570 Piracetam (Pyramem- Sopharma, Bulgaria) in the treatment of cortical myoclonus. R. Kuzmanova, I. Raychev (Sofia, BG) Myoclonus is a rare, disabling symptom arising from a variety of pathologies affecting the nervous system. Involuntary movements can cause severe disability. Conventional treatment with anticonvulsants such as sodium valproate, clonazepam and primidone often controls the seizures,but not the myoclonus jerks, despite optimum dosage. The airo of the present study was to assess in an open trial therapeutic efficacy of Pyracetam in patients with cortical myoclonus regardless of its underlying ethnology, la 10 patients with myoclonic jerks from cortical origin Piracetam was given orally as add-on therapy to valproate and clonazepam. The initial dose of Piracetam was 7.2 g/day increasing every 3 days to maximum 19.2 g/day or until stable clinical benefit was evident. The median daily dose of Piracetam was 15.2 g. Efficacy was assessed using myoclonus rating score (Truong and Fahn, 1988). A significant improvement with linear dose-effect relation in all patients was observed. Piracetam was well tolerated and essentially free of adverse effects, without drug interaction with the base-line anticonvulsive therapy. P571 Comparison of levetiracetam 1000 mg/d, 3000 mg/d and placebo in a randomized, double-blind, parallel group multicenter US trail. ]. J. Cereghino for LEV N132 investigators (Portland, OR, USA) Objective: To evaluate the efficacy and safety of 500 mg bid and 1500 mg bid of levetiracetam as adjunctive therapy for refractory partial seizures in a double-blind, randomized, placebo-controlled, parallel group, multicenter trial. Methods: Adults, age 16 to 70 years, with uncontrolled partial seizures (minimum 12 per !.2 weeks), with or without becoming secondarily generalized were studied for 38 weeks. A 12-week baseline was followed by a random assignment to adjunctive therapy with placebo (N=95), levetiracetam 1000mg/d (N=98), or levetiracetam 3000 mg/d (N = 101 ). Upward titration over 4 weeks was followed by 14 weeks of fixed dose treatment, and concluded with an 8-week medicatinn withdrawal period or entering a followup study. Results: of 294 patients randomized, 268 completed the study. Partial seizure frequency during the entire evaluation period (primary efficacy variable) was lower with levetiracetam compared to placebo (p < = 0.001 for both groups). More patients responded (defined as mŸ 50% reduction in partial seizure frequency) to levetiracetam than placebo, with rates of 33% in the 1.000mg/d and 39.8% in the 3000 mg/d group, compared to 10.8% in the placebo group (p < 0.001 ). Of 199 patients receiving levetiracetam, 11 became seizure free; no patient became seizure free in the placebo group. Treatment emergent adverse events (> = 10 %), mostly mild to moderate in severity, with incidences higher than placebo were asthenia, dizziness, flu syndrome, headache, infection, rhinitis and somnolence. Conclusion: Adjunctive therap• with levetiracetam was effective and well tolerated in controlling partial seizures. P572 Lamotrigine treatment as monotherapy during pregnancy. M. Dominguez Salgado, M. C. D/az-Obreg£ Santos, R. Santiago G£ H. Bhathal (Madrid, E) lntroduction: bibliographic data at the moment show that lamotrigine, partial dihydrofolate reductase inhibitor, used in the control of pregnant women seizures, has less teratogenicy index than the rest of studied drugs and all the data from non-treated pregnant women. Studies in animals with therapeutic doses, bigger than the ones used in human support this conclusion. Objective: show the results obtained in the protocol "Pregnancy and Epilepsy" developed in our unit with lamotrigine as monotherapy. Methods and materials: 31 patients affected with secondary generalized partial complex that were suitable according to the inclusion criteria. Results: Average age in pregnant women was 32.2 years. Average lamotrigine doses was 200-400 mg./day without any need of adjustment of the

medication. There was one seizure crisis in one patient in the 1st trimester of the pregnancy without any consequences for the foetus. One patient with two spontaneous miscarriages in the P' trimester. AII pregnancies were at term with eutocic deliveries, and no malformations were observed in the newborns. Conclusions: I.amotrigine as monotherapy is a good drug for the control of seizures during pregnancy and at the moment no side effects have been observed in the mothers or in the newborns. P573 Study of Psychopathology in patients with chronic idiopathic epilepsy. A MMPI proflle. Pi. Modrego, Ma. Pina, M. Galindo, ]. Minguez (Alca¡ Teruel, E) Background: It has been argued that a minority of epileptic patients experience behavioural problems that may disrupt daily living owing to psychopathological disorders such as depression, anxiety, psychosis and aberrant personality traits. Special attention has been paid to temporal lobe epilepsy patients in whom a trend of higher prevalence and severity of psychopathology has been observe& However the question of whether specific behavioural changes occur with different seizure types remains unclear. Ir is also unclear whether psychopathology is related to epilepsy or rather to underlying brain lesions. Objective: Thereby the purpose of our work is to search for personality disorders and related mental disturbances in patients with chronic idiopathic epilepsy in order to provide adequate diagnosis and treatment. Methods: We included 62 patients having had more than two epileptic seiznres without demonstrated underlying cause. As ancillary studies we performed intercritic EEG, Computed Tomography and MRI. The minimum follow-up of the patients was 12 months. As control group we included 40 volunteers without history of psychiatric illnesses. Psychopathology was assessed by means of the MMPl (Minnesota Multiphasic personality Inventory). For statistical analysis we used t-test, X2 test and Fisher exact test for determined comparisons. Results: The mean age for patients was 51.2 years (range: 17-76) and for controls it was 60.9 (range: 31-69). The ratio males/females was similar in both groups. The type of seizures was as follows: generalised in 26 patients, partial in 19 and both types in 17. All patients were on treatment with on~ or more drugs for epilepsy. We observed significant differences (p < 0.0001) in the following subscales scores: depression, hysteria, psychopathic deviate, paranoia, schizophrenia and manta. However, if we consider only the proportion of patients with dinically significant high scores (> 70 points), the differences were only significant in depression (56% vs 25%), paranoia (14 % vs 0 %), and schizophrenia (56 % vs 20 %). Conclusions: We conclude that chronic idiopathic epilepsy is frequently associated to some personality traits. A significant proportion of our patients fit to the psychotic profile and many of whom have required comprehensive psychiatric evaluation and treatment. Some behavioural scale should be included in the approach of epileptic patients. P574 Tiagabine as a model of added to a standard antiepileptic drug (AED). M. Diaz-Obreg£ Santos, M. DomŸ Salgado, H. Bhathal (Madrid, E) Purpose: Data acquired from clinical trial of Tiagabine (TGB) is compared for efficacy in reducing seizures and self-reported adverse events. Methods: We prospectively recorded our experience in adding TGB to a standard AED in 33 patients. Data collected included medications, seizure types and syndromes, and AEDs. Patients were followed up to 12 months, untila stable dosage of until TGB was discontinued. The primary efficacy variable was the median seizure frequency reduction rate (MSFRR), and the other efficacy variables included responder rate and seizure-free tate, and global evaluations by both patient and physician. The patient should have refractory epilepsies to the maximal tolerable dosage of one, two to three AED. The mean dosage of the stndy was 45 mg/day. Results: TGB was added successfully in all patients. The linear trend for dose response was highly significant (p < 0.0001 ) for both median monthly seizure frequency and therapeutic success, the MSFRR was 34 %. No serious systemic adverse events were observed. Conclusions: TGB can be added to AED without ah acceptable incidence of side effects. TGB is also highly effective as add-on therapy in medically intractable epilepsies.

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P575 Correlation between the new seriously index for the epilepsy and life quality in epileptic patients. M. Dfaz-Obreg£ Santos, M. DomŸ Salgado, A. Russi, H. Bhathal, R. Santiago G£ (Madrid, E) Introduction: Traditionally the seriously of epilepsy was graded by the number of seizures. We propose a new seriously index (AEAE index) that is related with a new life quality index (AEAE quality index) in the patient. The AEAE index include the number and type of the seizure multiply by a number according the gravity of these. The AEAE quality index include daily activities of the patients from tire (full quality) to cero (no quality). Material and methods: We checked both index in 80 out patients comparing scores in the follow up at 0- 3 - 6 and 12 months, as seizures were been controlled. Results: We found an inversed correlation, significative statistically (p < 0.001 ), between the AEAE index and the AEAE quality index for the patient. Conclusion: Results show that the correct valuation of epilepsy must in_ clude the number and type of seizures and the consequences of them in the daily activity of the patient. P576 Headaches afler seizures treated with zolmitriptan. M. DŸ243 DomŸ H. Bhathal, R. Santiago (Madrid, E)

M.

Background: Within the neurological conditions, epilepsy and migraines make up two of the principal reasons for consultations, both due to their prevalence as well as their incidence, and some of their clinical pictures have a similar pathophysiology and semiology. Material and methods: A total of 34 patients diagnosed of a complex partial seizures who present headache episodes after these seizures and who fuifil the International Headache Society (IHS) criteria for the diagnosis of migraine with and without aura are studied. The mean age of the patients is 34.2 years, with 87 % women and 13 % men. 75 % ate receiving single drug therapy (42 % lamotrigine, 33 % topiramate and 25 % valproic acid). 25 % are receiving multiple drug treatment (two of more anti-epileptic drugs). The frequency of the seizures is: 69 % once a month, 25 % once every ¡ days, 6 % at least once a week. These patients continued with their normal antiepileptic treatment and received treatment with zolmitriptan for the headache episodes. The intensity of the headache episodes (between I and IV) is: 87% Grade III-IV, 13% Grade 1I. Results: Zolmitriptan was effective in the resolution of 81% of the headaches after the seizures. A total of 2.5 mg was required in 77 % of these episodes anda total of 5 mg in 23%. This was resolved in all of the patients in whom it was effective within 30 minutes of the dose (regardless of the seriousness of the attack), without observing posterior recurrence. In 13 % of the patients, zolmitriptan was effective a s a rescue drug afier the use of NSA[D. No resolution of the headache was observed in 6 %. Conclusion: Zolmitriptan is effective in the treatment of headaches afler seizures. P577 Follow up of newborns from mothers treated with lamotrigine as monotherapy during pregnancy. R. Santiago G£ M. Diaz-Obreg£ Santos, M. DomŸ Salgado, H. Bhathal (Madrid, E) Introduction: 1"oreport the results of the follow up of newborns from mothers treated with lamotrigine as monotherapy during pregnancy. Methods: The follow up was made in high risk gynecologist out patients in 23 newborns from mothers with secoodary generalized complex partial epilepsy treated with an average daily dose of 200-400 mgr. of lamotrigine. The newborns were checked up at 0 - 3 - 6 and 12 months of age. Results: All pregnancies ended up as eutocic deliveries. Average APGAR was 8/10. The anthropometric parameters at births were in between p50-p75. No malformations were seen. Psychometric and anthropometric development was correct during the follow up. Conclusions: Lamotrigine as monotherapy seems to be the most suitable drug for the control of seizures during pregnancy, observing in newborns a proper development without any evidence of malformations in any of them. P578 Short-term outcome of newly diagnosed epilepsy in children and adolescents. ]. Markovii, K. Gebauer, K. Bozic, B. Bukurov, S. Rudic (Novi Sad, YU) The aim of the study was to investigate the outcome of children and adolescents with newly diagnosed epilepsy. Method: We retrospectively followed 98 children and adolescents (aged

0-18) who had been hospitalized between 1989 and 1998 at the Institute of Neurology, Psychiatry and mental Health and Institute of Child Health, Novi Sad, Yugoslavia. The study is based on medical record data and outcome assessment is focused on remission from seizure. Results: The two-year terminal remission rate was 91.6 % in patients with epilepsy of unknown origin and/or normal (N=60) neurological status while it was 44.7 % in patients with structural brain damage and/or abnormal neurological status and/or mental retardation (N=38). The three-year terminal remission for the same groups was 88.3% and 47.3 % respectively. 54 % of all became seizure free in the second six months of antiepileptic therapy and 25.5 % hada substantial reducfion in seizures. 10.2 % of children after drug withdrawal relapse the seizure in the first year and 4,1% in the second year afler drug was withdrawn. All but one of those patients was lately diagnosed as juvenile myoclonic epilepsy Conclusion: The results suggest that patients who entered remission did so in the first two years afler diagnosis. As time elapsed the prospect of entering remission decreased. The best independent predictors of remission are absence of brain damage, normal intellectual and neurological status and good early effect of drug therapy. P579 The lmpact of Epilepsy on the Quality of Life in Adolescents. K. Gebauer, K. 8ozic, S. Gvozdenovic, B. Bukurov, J. Mihaljev-Martinov (Novi Sad, YU) Over the past decade, health related quality of life (HRQOL) has became the gold standard for measuring'daily functioning' and'well being' from the patients own perspective. Purpose: To assess the quality of life of adolescents with epilepsy using the Quality of Life in Epilepsy lnventory for Adolescents-QOLIE-AD 48 (with permission). Methods: A sample of 124 adolescents (aged 11-19) with epilepsy completed a test questionnaire of 48 items in eight subscales: epilepsy impact, memory/concentration, physical functioning, stigma, social suppor t, school behavior, attitudes toward epilepsy and health perceptions. A parents simultaneously completed 10-Ÿ questionnaires to evaluate the child's HRQOL. Results: Internal consistency reliability coefficients (Cronbach alpha) were 0.76 for the summary score and ranged from 0.69-0.89 for the subscales. All subscales of QOLIE-AD-48 were highly correlated with seizure frequency. There were statistically significant differences (p < 0.05) in summary scores among groups with different seizure frequency (no seizure group; low seizure severity group; high seizure severity group) - HRQOL was increasingly better as seizure severity decreased. The parental questionnaire correlated well with the summary score (0.68). Conclusion: QOLIE-AD-48 is a valid and sensitive measure for adolescents with epilepsy and might provide an indirect outcome measure in the context of understanding how adolescents integrate the chronic seizure disorder into daily life. P580 Efficacy and tolerability of ievetiracetam as add-on treatment in refractory seizures: no need for ah up-titration step. T. Betts (Birmingham, UK) In previous trials levetiracetam (LEV) has shown efficacy at 1 g, 2 g, and 3 g. In these trials the maiority of patients received an effective dose (1 g) without up-titration. One of the airas of this study was to further investigate the tolerability and efficacy of higher doses of LEV when given without up-titration. Methods: This was a multicenter, double blind, parallel group study comparing the tolerability and efficacy of LEV 2 g and 4 g with placebo in patients with refractory partial or generalized seizures. Criteria for inclusion were at least four seizures during the 24-week period prior to the inclusion. Results: Somnolence and asthenia were the most common AEs reported, most of them were mild or moderate in severity and occurred in the first days after initiation of LEV. The median seizure frequency was reduced for all seizure types. The analysis of the responder rate confirmed the resuhs of previous studies with 48.1% in the 2g group, 28.6% in the 4g group and 16.1% in the placebo group. A similar responder tate (43%) was observed during the open label (LEV 4 g) follow-up period. Conclusions: This study confirms that 2 g and 4 g of LEV can be given without major safety concern. The trial confirmed the efficacy of LEV in partial seizures and showed a tendency towards efficacy for generalized seizures.

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P581 Levetiracetam in partial epilepsy: results of pooled data. P. Genton (Marseille, F) Rationale: Pooled data from controlled studies with levetiracetam (LEV) [Keppra(TM)] are presented. Results: 904 patients with partial seizures participated in 3 double-blind placebo controlled efficacy studies. The primary efficacy criterion was the weekly partial onset seizure frequency. In each study, all doses tested ( 1000, 2000 and 3000mg) proved to be superior to placebo (P 0.003 to < 0.001). Response rate (= 50 % reduction in partial seizure frequency) increased with increasing dose: 12.6, 27.7, 31.6 and 41.3% for placebo, 1000, 2000 and 3000 mg, respectively. Of all placebo patients who completed the studies, only 0.4 % became completely seizure-free, whereas 6.3 % of the patients on LEV became free of a]i seizures (P < 0.001 ). Safety data were collected from 1023 patients participating in 4 placebo-controlled studies, including one study with both partial and primarily generalized seizures. The following adverse events occurred in at least 3% of the patients and with a at least 3% higher incidence in the LEV group: COSTART preferred terms asthenia: 14.1 vs. 9.7 %; somnolence: 14.9 vs. 9.7 %; infection (preferred term for common cold and upper respiratory tract infection): 13.2 vs. 7.4 % and dizziness: 9.2 vs. 4.3 %. The proportion of patients terminating the treatment prematurely or reducing the dose due to AEs was 15 % for patients on LEV and 11.6 % for patients on placebo. There were no relevant differences between LEV and placebo groups in clinical examination, ECG and biological parameters. Conclusions: LEV is efficacious for the treatment of partial seizures with a responder rate up to 41% at the highest dose of 3000 mg. LEV is well tolerated: absolute incidences of AE were low and most were CNS related, mild to moderate in severity.

General neurology P582 Analysis Of Proximal Movements Towards A Contralateral Self Target In Cerebellar Patients. ]. Moore, M-U. Manto (Charleroi, Brussels, B) The cerebellum plays a critical role in the control of proximal muscles in humans. Many of the studies that have been conducted concerning this relationship have relied on movements that involved both proximal and distal muscles. We. designed an original manoeuvre to focus strictly on proximal arre muscles. The movement consisted of a horizontal pointing motion where the patient began with both arms outstretched and shoulder width apart. The patient then moved the dominant hand as quickly as possible towards an "L" shaped target delineated by the fingers of the contralateral hand. This manoeuvre was interesting because it took into account the physiologicat variabitity between successive movements in which the own body was used a s a target. We analysed the pointing movement in four healthy subjects (ages: 23, 33, 33, 39; 1 woman) and in tire patients exhibiting cerebellar ataxia (25 - autosomal dominant ataxia,28 - idiopathic cerebellar cortical atrophy, 29 - Friedreich ataxia, 31 - Friedreich ataxia, 33 - autosomal dominant ataxia). Twenty movements were recorded for each subject using a three-dimensional kinematic system (SELSPOT, Sweden) at a sampling rate of 200 Hz and with a precision of 0.25 mm. From visual inspection, the patients presenting cerebellar ataxia had much more difficultly in accurately moving the pointing hand to the target area. Their movements were often characterized by hypermetria or hypometria, as evidenced by hitting the target hand or stopping well before the target area. Analysis of the kinematic recordings showed that ataxic patients performed the movement with greater variability of peak velocity from trial to trial than heahhy subjects. The standard deviation of the peak velocities was always greater than 15 % of the mean value in ataxic patients, while it was always less than 15% in healthy subjects (means for healthy subjects: 4287 + 229mm/s, 3115 _+ 262mm/s, 1304 _+ 186mm/s, 1741 -.+ 235mm/s; means for ataxic patients: 2021 -+ 349 mm/s, 1701 _+369 mm/s, 1268 ___445 mm/s, 2871 _+647 mm/s, 1367 + 485 mm/s). This study showed that our pointing movement was sensitive to the deficits of proximal control displayed in ataxic patients. The decreased ability to perform quick and precise movements in these patients may be a result of inability to properly plan suitable velocities as evidenced by the increased variability of peak velocity discovered during the pointing movement.

P583 Acute encephalopathy associated to tiagabine in three patients. A. Gargouri-Berrechid, C.Sicard, ZBeillevaire, B.Bazin,S.Dupont, M. Baulac(Paris cedex, F) Several anti epileptics drug such us valproate acid or vigabatrin (VGB) are known to induce encephalopathy. We report the cases of three epileptic patients who manifested acute encephalopathy due to tiagabine. Tiagabine was associated to carbamazepine (CBZ) in 2 cases and to VGB in one. After 3 months at 20mg of TGB, patient-receiving VGB presented confusion syndrome. The other patients presented headache aftera period of 5 and 6 months respectively (doses of TGB were 30 and 40mg daily). EEG showed disorganized and slow background activity associated to diffuse and synchronous delta waves. In two cases triphasic waves were noted. After TGB stopped EEG, showed normal alpha rhythm and activity with disappearance of slow abnormalities. Encephalopathy due to tiagabine was reported by Hirsch in two epileptic patients. These two patients received TGB at doses between 15 and 30 mg/j associated to VGB. Hirsch suggested that there was a synergistic effect of two potent inhibitor of GABA inducing metabolic encephalopathy. Our first patient confirm the hypothesis of Hirsch but the other two tases suggest that there is a cumulative dose effect when TGB associated to CBZ inducing only electric encephalopathy. Encephalopathy induced by TGB can occur after several months of treatment. EEG follow up is mandatory in this context to detect abnormalities. P584 The chronic fatigue syndrome: an authentic condition or the prelude of a drama. S. Baloyannis (Thessaloniki, GR) Many patients complain for chronic fatigue, sometimes debilitating, associated with anorexia, sleep disturbances, muscular weakness, muscular pains mild depression, loss of initiatives and mild cognitive impairment, concerning mostly the concentration, the active attention and the memory. In some of them the clinical and laboratory investigation are both unremarkable, no suggestive of any underlying disease. These complains if persist for more than six months may be attributed to chronic fatigue syndrome (CFS), a clinically defined condition, the etiopathogenetic background of which remains elusive. The predominant symptom is always disabling fatigue, that causes a substantial and sometimes persistent reduction in activity level. We have studied 128 patients, 45 men and 80 women, who have appealed for medical care for the presenting complaint of chronic fatigue, in the decade 1980-1990. Although, repeated clinical and laboratory examinations, were unremarkable, some of the patients (15.6%) developed well defined diseases within the first five years from the initial complains, suggesting that the debilitating fatigue was simply the general initial manifestation of one of the following underlying disorders, multiple sclerosis, neoplasms, Alzheimer s disease, depression and myasthenia. We have the feeling that the chronic fatigue syndrome (CFS) is a heterogeneous group of various underlying disorders and the patients suffered from ir should be monitored closely and every complaint or laboratory data should be carefully evaluated. The final management approacb would have to be individualized according to the specific symptoms of the patients, that impose the specific therapeutical needs. Nevertheless acceptance of the patient's illness experience and continuous psychological support and attention to symptomatic treatment are essential. P585 Clinical and MRI findings in funicular myeiosis. J. Pascual Calvet, T. Taranc£ J. Izquierdo, V. Puente, A. Rodriguez Campello, I. Roquer, A. Pou Serradell (Barcelona, E) Background: Funicular myelosis (FM) to vitamin B12 deficiency has been well described in the literature of the late nineteenth century. However, since the introduction of modern diagnostic and treatment measures, nowadays is rarely diagnosed. Its etiopathogenesis remains uncertain, of the two reactions that requires cobalamine, the methionine synthase reaetion is considered to playa critical role in nervous system function. Aims: To describe the clinical findings, and the MRI, neurophysio]ogical and laboratory features in two patients with FM. Patients and methods: Since the last year two patients, men, 67 and 70 years old, were admitted to our neurological service because of paresthesias in feet and hands and progressive gait difficulties over the last 3 months. Clinical examination disclosed marked impairment of pallesthesia and arthrokinetic sensations in both legs, accompanied by weakness, hyperreflexia and bilateral Babinski's sign. Patients were widely studied with laboratory, neurophysiological and neuroimaging explorations. Results: Macrocytic anaemia with a positive Schilling test and low levels

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of vitamin B12 in serum (< 100 mcg/ml) was present in both cases. Gastric biopsy showed in one case atrophic gastritis and in both morphological changes suggesting Helicobacter pylori infection. One patient h a d a chronic thyroiditis with raised antiperoxidase and antithyroglobulin antibodies. Neurophysiological studies confirmed impairment of sensory neurography and somesthetic evoked potentials. Spinal MRI showed T2 hyperintense signal along posterior columns. Surprisingly brain MRI in both cases was abnormal, with T2 hyperintense signals in the white matter of both cerebral hemispheres. Furthermore, one patient had an haematoma in the head of the right nucleus caudatus. After a minimum of six months of follow-up and parenteral vitamin 1312replacement patients improved, but MRI abnormalities and dorsal column involvement persisted. Conclusions: Patients with posterior colum invoIvement simulating ataxic neuropathy must be studied in order to disclose pernicious anaemia (PA). This seems to have an immunologic origin related with Helicobacter pylori infection. Column posterior abnormalities can be detected with MRI studies. In our cases this abnormalities have not disappeared after six months. There are no previous reports about a relationship between brain lesions and vitamin B12 deficiency. P586 Clinical and neurophysiological characteristics of cortical myoclonus. W. Szurhaj, E Derambure, F. Cassim, A. Dest› ].D Guieu (Lille, F) Introduction: Cortical myoclonus ate defined by brief, brisk and involuntary muscular contractions of cortical origin. They ate observed during varied pathologies. Objective: The airo ofour study is to bring out different clinical and electrophysiological patterns of myoclonus according to their etiologies. Methods: We carried out a retrospective study of 71 consecutive cases of patients with cortical myoclonus relating to a clinical and electrophysiological analysis: polymyography, study of somesthetic evoked potentials, EEGEMG polygraphy with back-averaging, dipolar source analysis. Results: Our study thus shows that cortical myoclonus do not represent a¡ group, as well on the clinical level as electrophysiological. They fit in the majority of the cases within the framework of epilepsy, generalized or partial, in the form, generally, of negative myoclonus of misleading expression. But inside this very mixed group emerge from the subgroups of pathologies (progressive myoclonic epilepsies and corticobasal degeneration) being accompanied by cortical myoclonus having particular elect rophysiological characteristics. Discussion: Cortical myoclonus seem to raise of multiple pathophysioIogical mechanisms. Their diagnosis oflen requires electrophysiological explorations. To recognize it is important, because that allows to orientate the diagnostic and to adapt the treatment. P587 Vitamin B12 deficiency induced myeiopathy: Neuroimaging and dinical correlations. R. Gentile, L. Capone, R. Schoenhuber (Bolzano, I) Undernutrition, particularly vitamin deficiency, causes a wide spectrum of neurological disorders. We report a case of myelopathy induced by impaired Vitamin B 12 absorption. A 73 year- old man, partial gastrectomized 20 years ago, complaining from 2 months paresthesias ascending from feet to thoracic leve1 T4 on the trunk, was admitted. He was taking hypoglycemic agenls since 1994. Al the neurological evaluation he showed impaired distal touch and pin-prick sensation, with gloves and socks distribution, without deficit of warm and cold perception. Deep sensitivity (joint position and vibration sense) was affected. The gait and upper limbs ataxia worsened by eye closure. No sign of neuropsychological impairment was found. A T2-hyperintense and TI-hypointense lesion was found at magnetic resonance (MR) study in the posterior part of the spinal cord from CI to C6 segment. Cerebral MR and cerebrospinal fluid were normal. Laboratory showed macrocytosis without anemia and reduced Vitamin BI2 levels in serum. Parenteral therapy with high dosages Vitamin B 12 was performed for 40 days, followed by maintenance therapy 5 days every month. The clinical feature gradually improved with treatment. Al a follow up afler 6 months cervical MRI study showed an evident reduction of spinal cord T 1- a nd T2- lesion and the globular volume was normal. Comment: Vitamin B12 deficiency, suggested only by macrocytosis, may cause reversible isolated demyelinating spinal cord lesions.

P588 Palatal myoclonus as a postoperative complication after extirpation of a vascular malformation from posterior fossa atea. T.H. Maris, Era. Fountoulakis, Sp. Karampekios (Iraklion Crete, GR) Patatal myoclonus is a syndrome characterized by involuntary rythmic movements of the sofl palate, occasionally involving the muscles of the face, the pharynx, larynx and diaphragm. A 31 year old woman presented this syndrome with palatal myoclonus accompanied with synchronous )erks in the left side of her face and her left arm. It was result of an extirpation of a small cavernous malformation, in the medial portion of the middle cerebellar peduncle. Neurological examination presented left cerebellar syndrome accompanied with ataxia and adiadochocinesia. Magnetic Resonance T2 weighted lmaging revealed high signal intensity within the right aspect of the medulla, as well as enlargement of the ipsilateral pyramid. Palatal myoclonus associated with extirpation of a cerebellar vascular malformation, is unusual and may easily overlooked. P589 Frontal lobe impairment following MDMA toxicity; a neurobehavioral correlate of 5-HT dysfunction.~ N. Sheehy, E. Cassidy, V. O'Keane, O. Hardiman (Dublin, IRL) Recreational use of MDMA (3,4-methylendioxymethamphetamine; 'ecstasy') is common. This drug acutely induces rel~ase of serotonin (5-HT) principally by blocking central catecholamine transporters thereby mediating the majority of its desired central nervous system effects. Rarely, a central serotonin syndrome may occur which may be fatal. [t has recently been recognised that MDMA may have long-lasting adverse effects on the brain even afier a single dose. The behavioral correlates of these adverse effects are poorly understood particularly in survivors of severe MDMA toxicity. A twenty-year-old student presented with coma and hyperpyrexia following ingestion of oral 'ecstasy' (MDMA). His early intensive care course was complicated by rhabdomyolysis, acute tubular necrosis and subsequent Intensive Care Unit (ICU) neuro-myopathy. 6 weeks later, after discharge from the 1TU he was noted to be akinetic, aphonic, and profoundly depressed in mood. His motivation for mental state testing was poor and communicated with a writing pad. He was commenced on fluoxetine 20mg/ daily with no response over a 6-week period. Structural imaging including MRI was completely normal. His fluoxetine was increased 80 mg over a oneweek period. Improvement in mood was dramatic over the following week to the extent that he was motivated to engage in speech therapy, was interested in his environment and displayed good mood reactivity. He also surprisingly began to communicate by speech and was able to discard the writing pad one week after commencing high-dose fluoxetine. Despite an obvious improvement in psychomotor speed, he had clinical evidence of frontal lobe dysfunction. This case elegantly demonstrates the unfortunate long-term effects of the MDMA toxicity syndrome. A significant body of animal work in rodents and non-human primates has demonstrated that MDMA is toxic to central monoaminergic neurons. More recently human PET studies have demonstrated downregulation of 5-HT transporter numbers as well as reduced frontal cortical glucose metabolism in both current and past MDMA users. In this case the dramatic neurobehavioral response to fluoxetine suggests that these Iong-term effects are mediated through central 5-HT pathways rather than a non-specific neuronal toxicity. Persisting frontal lobe dysfunction may be secondary to reduced inhibition by 5-HT pathways projecting to the frontal cortex. Resuhs of SPECT scanning and formal neuro-psychological evaluation will also be presented. P590 Electrodiagnostic difficulties in early diagnosis of adult botulism. C. Boz, M. Ozmenoglu, S. Velioglu (Trabzon, TR) Botulinum toxin causes a marked reduction in the number of quanta released by nerve terminals. Early diagnosis of botulism is essential for effective treatment. Electrophysiologic testing can be of maior help to establish a prompt diagnosis,but the classic electrodiagnostic feat ures of botulism may be elusive. Patients and results: A 55 year old female patient admitted to our clinic because of exhaustion and weakness in extremities. Weakness progressed within hours to respiratory collapse, dysphagia and bilaterally ophthalmoplegia. Deep tendon reflexes were absent. Initial electrodiagnostic studies were notable for normal sensory nerve action potentials, slightly reduced amplitudes of compound muscle action potential (CMAP) and slightly slowed motor conduction velocity and prolonged peroneal F wave latency. CMAP amplitudes showed neither decremental response to 3 Hz repetitive

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nerve stimulation (RNS), nor an incremental response to 40 Hz RNS. Concentric needle examination revealed no fibrillation with normal motor unit action potentials. Patient was initially diagnosed with atypical GuillainBarr› syndrome and transferred to intensive care unite. Repeat electrophysiologic testing showed markedly reduced CMAP amplitudes with no significant response to RNS. Ten days later 13 new patients from same family admitted to our hospital 8 to 16 hours after ingesting of home-made cheese. Blurred vision, dysarthria,dyspnea and generalized weakness were the main symptoms. Two patients died before admission to hospital. Electrodiagnostic studies performed within one week showed small CMAP amplitudes in 12 patients, modest increment in CMAP amplitudes with 40 Hz RNS in 5 patient and decremental response to 3 Hz RNS in 3 patients. Single fiber electromyography performed in one patient showed increased jitter. Three patient were given botulinum antitoxin. Discussion: First patient was initially misdiagnosed with atypical Guillain-Barr› syndrome and repeated electrodiagnostic test supported diagnosis of botulism. In severe cases of botulism the neuromuscular junction function may be so blocked that facilitation cannot occur. The severity of the neuromuscular blockade in first case was supported by markedly reduced CMAP amplitudes on repeated electrodiagnostic testing. We want to stress that the absence of facilitation with RNS cannot exclude the diagnosis of botulism. P591 Spinal cord compression in a patient with generalised Neurofibromatosis harbouring a 7096-deI-AACTTT mutation in the NF-1 gene. ]. Gamez, E. Franco, M. Gil-Franco, H. Kruyer, E. Castillo, M. Morell, C. Lazaro, C. Cerrera (Barcelona, Lleida, Hospitalet de LLobregat, Hospitalet de Llobregat, E) Background: Neurofibromatosis type 1 (NF-I) is an autosomal dominant disorder, with a incidence of 1 in every 3,000 live births. Ahhough the main clinical Ÿ of NF- 1 are caf› au lait spots and neurofibromas involving the skin, and the spinal, peripheral and cranial nerves, clinical severity is variable. Involvement of the cervical spine and classic symptoms of cervical myelopathy secondary to the spinal cord have rarely been reported and represents one of the most severe complications. The NF-1 gene has been mapped to chromosome 17q11.2, and more than 255 different mutations have been identified to date. So far, no clear genotype/phenotype correlation has been established. Objective: To describe the clinical data, MRI and genetic results from ah NF-1 patient presenting progressive gait disorders, suggesting spinal cord compression. Design/methods: We studied a 19-year-old patient with multiple skin and plexiform neur6fibromas, referring a progressive gait disorder due to a loss of strength in the lower limbs. MRI studies were performed. We screened the whole NF coding region, using the cDNA-SSCP/HD approach previously described. Results: Neurologic examination showed a generalised hyperreflexia, bilateral Babinski's sign and spastic paraparesis, which were more severe on the lefl side. MRI showed multiple plexiform and paraspinal neurofibromas, resuhing in spinal compression at C2-C3 and C3-C4. A previously described small in-frame deletion, 7096delAACTTT, which deletes two amino acids asparagine and phenylalanine - in exon 39 was identified in the sample of the two affected members of this family. Conclusions: The association of generalised NF- 1 with cervical myelopathy secondary to spinal cord compression is one of the severest complications of this disorder. Fortunately, ir is infrequent (1.7 % of National Neurofibromatosis Foundational International Database). One of the patients previously reported with this mutation had the classic NF- 1 phenotype,with caf› au lait and skin neurofibromas, which suggests that a correlation between this mutation and the involvement of spinal cord does no exist. Supported by the Fondo de Investigaciones Sanitarias (FISS 00/0829 and 98/0992).

Genetics P592 Bilateral vestibulopathy is not associated with the 1555 mutation in mitochondrial ribosomal RNA (findings in 12 patients). T. Klopstock, S. ron Stuckrad-Barr› M. Elstner, V. Querner, T. Gasser, M. Strupp, T. Brandt (Munich, D) Background: Aminoglycosides are a group of antibiotics that are toxic to the auditory, vestibular, and renal systems. While almost all patients show vestibulocochlear damage at high drug levels, a genetic component seems to

influence susceptibility to aminoglycosides at lower levels. A mutation at nucleotide 1555 in the mitochondrial 12S ribosomal RNA gene has been identified as the main predisposing genetic factor. This mutation is found in 15-30 % of patients with aminoglycoside-induced ototoxicity, and maternal family members of these patients should not take aminoglycosides. AIthough typical streptomycin or gentamycin toxicity is characterized by more severe vestibular damage than cochlear damage, families with the 1555 mutation almost exclusively exhibit deafness and only rarely mild signs of vestibulopathy. To determine whether the 1555 mutation is a predisposing factor for vestibular damage leading to "idiopathic" bilateral vestibulopathy, we examined 12 patients with known bilateral vestibulopathy with or without prior exposure to aminoglycosides. Methods: Twelve sporadic patients were identified to have clinical signs of bilateral vestibulopathy and bilaterally decreased or absent caloric response in electronystagmography. Polymerase chain reaction and subsequent restriction analysis were performed to test for the 1555 mutation. Resuhs: The mutation at nucleotide 1555 in the mitochondrial 12S ribosomal RNA gene was not found in any of these 12 patients. Conclusion: The mitochondrial mutation at nucleotide 1555 does not seem to playa major role in the pathogenesis of bilateral vestibulopathy. This finding, however, has to be further evaluated in ah ongoing study with a larger group of patients in which the complete mitochondrial 12S ribosomal RNA gene is being sequenced. P593 Two different subtle mutations in one Yugoslav SMA family: mutation in the SMN1 exon 6 and novel polymorphism in the vicinity of the SMNI exon 7. D.. Keckarevic, S. Todorovic, B. Culjkovic, S. Vukosavic, O. Stojkovic, Z. Stevic, S. Apostolski, S. Romac (Belgrade, YU) lntroduction: Spinal muscular atrophy (SMA) is one of the most frequent autosomal recessive diseases (1). Among 5q13 SMA patients 96.4% show homozygous absence of telomeric survival motor neuron gene (SMN1) exon 7, whereas 3.6% cases are presented with compound heterozygous status. There ate 23 different subtle mutations and 36 polymorphisms in both SMN1 and SMN2 (centromeric counterpart) genes identified so lar (2, 3). ldentification and characterization of al1 mutations and polymorphisms is of a great importance for genetic testing and for revealing the mechanisms that lie in the basis of SMA pathogenesis. Objectives: Here we report SMA family bearing two different sequence changes in SMN1 gene as well as the results of genetic analysis of Yugoslav SMA patients. Material and methods: AII patients fulfilled diagnostic criteria (4, 5). Deletion testing, quantification of the relative SMN1/SMN2 ratio, mutation screening and linkage analysis were performed in 42 SMA families and 50 healthy individuals. Resuhs: Among 42 unrelated SMA patients we found homozygous absence of SMN1 exon 7 in 37 cases (88.1%): in 100% SMA 1, 92.9% SMA II and 78.9 % SMA III patients. In 3 of 5 SMA patients without homozygous absence of SMNI,we established compound heterozygous status with the same mutation in exon 6 of SMN1. Linkage analysis in these three families revealed clear genetic evidence for recent founder effect. Further, in one of these families, in addition to disease causing mutation in SMN1 exon 6, we detected polymorphism in the vicinity of SMN 1 exon 7 that was not reported so lar. This polymorphism was also detected in 3 healthy individuals, suggesting that ir is not so rare. Conclusion: Results of SMA deletion testing are consistent with those previously published (6). Mutation in SMNI exon 6 that was detected in 3 families suggests its predominance in Yugoslav SMA patients without homozygous absence of SMN 1 exon 7. Novel polymorphism identified in 4 individuals could help in the similar cases with uncertain results of genetic testing as well as in further research dealing with mechanisms of SMA pathogenesis. References: 1. Pearn JH (1980) Lancet i: 919-922 2. Lefebre Set al. 0995) Cell,80(1): 155-65 3. Wirth B (2000) Hum Mutat 15(3): 228-37 4. Munsat TL and Davies KE (1992) Neuromusc Disord. 2,423-428 5. Rudnik-Shonenborn Set al. (1996) Neuropediatrics 27(1): 8-15 6. Somerville MJ et al. (1997) Am l Med Genet 69(2): 159-65

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P594 A family with hemiplegic migraine linked to chromosome lq21. K. JurkatRott, J. Nezzar, J. Herzog, M. Dichgans, H. Przibylla, G. Deuschl, F. LehmannHorn (Ulm, Munich, Kiel, D)

Conclusions: Our study is the first to confirm the existence of 19q-linked ADHSP in an Italian family and eonfirms that 19-q linked ADHSP is an allelic disorder.

Familial hemiplegic migraine (FHM) is an autosomal dominant form of migraine with aura. In approximately 50% of FHM families the condition results from mutations in the CACNA1A gene located on chromosome 19p. Two other FHM loci, lq21-q23 and lq31, each over 10 cM,are known.We describe a four-generation German FHM family with linkage to chromosome l q21. Affected individuals present with characteristic unilateral migrainous headaches accompanied by nausea as well as phono- and photophobia. Episodes are typically precipitated by an aura with symptoms of both hyperand underexcitability including aphasia, dysarthria, vertigo, cheiro-oral paresthesia, and hemiparesis. Age of onset was generally in childhood and attacks decreased greatly in later adulthood. No cerebellar degeneration was apparent. Linkage analysis excluded CACNA1A as the causative gene, but confirmed the chromosome 1q21-23 locus, narrowing it down to a 4 cM in_ terval between D 1$2705 and D 1$2844. Candidate genes include KCN•I0 and KCN110 encoding ah inwardly rectifying potassium channel homologous to Kcnj7 mutated in weaver mice suffering from ataxia and epilepsy. We have determined the genomic structure of these genes and report our sequencing progress. (Supported by the Interdisciplinary Clinical Research Center and the Gerrnan Ministry of Research.)

P597 Clinical features of familial carpal tunnel syndrome. A.E. Hensiek, N. Muhammed (Romford, UK)

P595 Beta-site APP cleaving enzyme gene is not a susceptibility locus for Alzheimer's disease. A. Orlacchio, E. Rogaeva, M. Nicolau, M. Nicolau, Y. Song, T. Kawarai, C. A. Santo, Y. Liang, M. Polidoro, E. Paciotti, A. Tedde, S. Sorbi, R. ]orge, L.A. Farrer, G. Bernardi, P. H. St. George-Hyslop (Toronto, CDN; Boston; Perugia, Firenze, I; Buenos Aires, RA; Roma, I)

Amyloid Beta-peptide (ABeta) plays a central role in the pathogenesis of Alzheimer's disease (AD). Recently, the gene encoding the Beta-site APP cl4aving enzyme (BACE), one of two enzymes which sequentially cleave the Beta-amyloid precursor protein to generate ABeta, has been cloned. We tested the hypothesis that BACE might be genetically associated with AD by linkage analysis (56 pedigrees) and by direct nucleotide sequencing of the entire open reading frame of this gene (20 subjects with familial AD and 10 subjects with sporadic AD). We have also analyzed a large data set of sporadic AD cases to examine the association with the polymorphism of BACE cDNA at nucleotide 1239 where G is changed into C (from sequence GenBank: AF190725), as reported by Nowotny et al. (World Alzheimer Congress 2000, Washington D. C., U. S. A.). Our results reveal no cosegregation, no mutations in the BACE gene and no differences in allele or genotype frequency between AD cases and controls of the polymorphism examined. These data suggest that the 1239 G-C BACE cDNA polymorphism is not associated with risk for AD. In conclusion the results obtained indicate that BACE is not likely to be a major AD susceptibility loeus. Further genotyping experiments are underway in another cohort of AD patients and controls. (Work supported by Telethon, grant n.E0980PG.) P596 Refined SPG12 locus in autosomal dominant pure hereditary spastic paraplegia. A. Orlacchio, T. Kawarai, E. Rogaeva, M. Polidoro, E. Paciotti, G. Bernardi, P. H. St. George-Hyslop (Toronto, CDN; Perugia, Roma, 1)

Objective: To study an ltalian family with Hereditary Spastic Paraplegia (HSP) genetically and clinically. Background: Hereditary Spastic Paraplegia is a genetically heterogeneous group of upper motor neuron syndromes and has been divided into two forros: pure and complicated. Both forros of HSP are classified by inheritance: autosomal dominant (AD), autosomal recessive (AR), X-linked. Pure HSP is mainly transmitted as an autosomal dominant trait. Seven loci for autosomal dominant pure HSP have been mapped. A locus on chromosome 2p (SPG4), encoding a new member of the AAA protein family (Spastin), has been identified as responsible for the most frequent forro of AD-HSP. Methods: We studied a total of 60 individuals of a large ltalian family with pure AD-HSP in which 16 members in three generations were affected. Genetic linkage analysis of this family were carried out with polymorphic DNA markers of chromosomes 14q (SPG3), 2p (SPG4), 15q (SPG6), 8q (SPGS), 12q (SPGI0), 19q (SPG12) and 2q (SPG13). Results: Linkage with SPG3, SPG4, SPG6, SPG8, SPGIO and SPG13 ADHSP loci was excluded and the family showed evidence for linkage to SPG12 locus. Analysis of recombination events in this family and in the previously published SPG12-1inked family narrowed the SPG12 locus from 16.1 cM to 8. t 1 cM region between markers D 19S220 and D 19S412.

Several reports indicate a familial occurrence of carpal tunnel syndrome (CTS), but most focus on large isolated pedigrees. The incidence of familial CTS is unknown and the syndrome may be the manifestation of other inherited diseases. Ir is also unknown whether familial cases have any special clinical features to distinguish them from sporadic cases. Methods: 200 patients with a clinical suspicion of carpal tunnel syndrome were assessed. Each patient was given a questionnaire, enquiring about a history of systemic diseases associated with CTS, specific symptoms in the affected hand/hands, symptomatic treatment for these symptoms and a family history of CTS. Electrophysiological testing was performed to confirm or exclude a diagnosis of CTS. Results: A diagnosis of carpal tunnel syndrome was confirrned in 140 (70%) patients. Of these 140 patients, 54 had predisposing risk factors, 25 hada positive family history, 11 had both and 50 had neither risk factors nor a family history. A positive family history had been confirmed electrophysiologically in 65 % of cases. There were no differences in presenting symptoms or the proportion of patients who took symptomatic drug therapy between the groups. Patients with a positive family history but no other predisposing factors were significantly younger than those with no risk factors (p _<0.01). Discussion: The results of this survey indicate that a significant proportion of patients with CTS have a positive family history, which can not be explained by familial systemic diseases associated with CTS. The clinical presentation in familial cases is not different from those without a family history, but they present at a significantly younger age. Further studies may be required to search for relevant susceptibility genes in CTS. P598 Genotyping of the SM PD 1 gene in 16 cases with Niemann-Picktype A/B disease. R. Knoblich, M. Zschiesche, A. Hufen, 1. Kropp, K. Harzer, A. Rolfs (Rostock, Tuebingen, D)

Niemann-Pick disease (NPD) type A/B is an autosomal recessive disorder, which is caused by a deficiency of the lysosomal acid sphingomyelin-phosphodiesterase (SMPD1). Type A NPD is characterized by early manifestation, severe clinical course with prolonged neonatal jaundice, failure to thrive, excessive hepatosplenomegaly, pulmonary infiltrations, severe CNS affection and death during early childhood. In contrast, type B NPD is characterized by a much milder clinical course with later manifestation, without CNS involvement and slower clinical progress. Enzyme activity in patients with type A NPD is generally less then 5%, whereas type B patients huye a remaining SMPD 1 activity between 5-10 %. Accumulated sphingolipids and other lipids are picked up by histiocytes. These foam cells can be detected in skin, bone marrow and several other tissues. With exception of Ashkenaze Jewish individuals most of the described mutations are private mutations, only the lbp substitution mutation Gly292Lys can be detected more frequently in Caucasians. We analyzed the SMPD1 gene in 16 affected individuals. In these cases the enzyme activity was markedly (< 10%) reduce& Beside 2 mutations, which were already mentioned in the literature, we found 10 new mutations (347G, 89.~TG, Leu137Pro, Arg228Cys, Gly245Ser, Arg289His, His421Tyr, His514Arg,Tyr517Ter, 5937CT). The Gly292Lys mutation was present on 5 alleles. The majority of patients h a d a compound heterozygous mutation pattern, only 5 were homozygous and most of them were on a consanguis background. In several tases we found only 1 heterozygous mutation despite of sequencing the whole gene. For explanation, two different hypotheses are considered: l)There is a polymorphic hexanucleotide repeat within exon 1 that might have an influence on the enzyme activity. 2) Defects of modifying proteins (e.g. Sphingolipid activator protein (SAP) D) which are involved in the posttranslatioual enzyme modification might be responsible for this phenomenon.

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P599 Huntington's disease in Portugal: molecular diagnosis, genetic counselling and investigation on genetic heterogeneity. M.C. Costa, J. B. Basto, F. Ferreirinha, M. T. Matama, P. Mendonca, J. Vale, C. Januario, T. C. Aguiar, F. Piloto, J. Barros, I. Silveira, P. Maciel, J. Sequeiros (Por to, Egas Moniz, Coimbra, Funchal, Teotonio, P) Huntingtoffs disease (HD) is an autosomal dominant neurodegenerative disorder characterised by involuntary choreiform movements, cognitive impairment, dementia and personality changes. This disorder is caused by the expansion ofa (CAG)n tract localised on the first exon of the HD gene. The molecular diagnosis is based on the determination of the CAG repeat size by amplification of this segment by PCR. Our group started performing this molecular analysis in February 1998. Since then we have received 128 requests for diagnostic testing, 31 for predictive, 3 for prenatal and 6 requests for research. Among the predictive tests, 32 % of the individuals were shown to be carriers of the HD mutation. Norte of the foetuses in the prenatal tests performed were mutation carriers. Situations such as the existence of ah homozygous individual for the mutation and carriers of intermediate alleles were particularly delicate for genetic counselling. The requests for diagnostic tests were sent mainly by neurologists (89%), although other clinicians such as geneticists (7%), psychiatrists (0.8 %), neuropediatricians (0.8 %), pediatricians (0.8 %), internists (0.8 %) and general practitioners (0.8 %) have also sent diagnosis requests. The age of patients when the test is requested is 50 years on average, including 3 % of juvenile cases (range: 10-24 years old). In 69 % of the diagnostic requests the patients were confirmed molecularly as carriers of HD mutation. The size of repeats varied from 10 to 26 CAGs for the normal alleles (most frequent: 17 CAGs 36 %) and from 40 to 95 CAGs for the mutated alleles. We found 5 carriers of intermediate alleles (two with 29 CAGs, one with 33 CAGs and two with 39 CAGs). AII the tases excluded for the HD mutation (n=41) were tested for expansions in the (CAG)n tract in DRPLA and TBP genes. No expansions were detected in the DRPLA gene. One case of TBP mutation was detected. In the remaining excluded cases, additional analysis helped to establish a different diagnosis, such as: one case of CNS vasculitis, one case of primary hypoparathyroidism and two cases (brothers) of recessive mitochondrial encephalopathy. 28% of the cases remain unexplained, including a juvenile case. Analysis of other genetic loci involved in a HD-like phenotype will require familial linkage studies.

P600 92 Congenital Disorder of Glycosylation (CDG) Syndrome with discrepantly mild clinical course: MRI/1H-MRS study and hypothesized mechanism. M. Diklic, N. Delibasic, M. Krkljes, N. Vuckovic (Novi Sad, YU) The Congenital Disorders of Glycosylation (CDG) Syndrome are genetic multisystemic disorders characterized by glycosylation defects in certain glycoproteins. The disease is inherited in an autosomal recessive mode and affects many parts of the body, especially the central and peripheral nervous system. Several types have been discovered, and all children were moderately to severely affected. The aim of this study is to reportan aduh-onset case of CDG-syndrome with discrepantly mild clinical course. Methods and results: MRI/1H-MRS study was performed on Siemens Magnetom 63SP4000, 1.5T, with SE 135 and STEAM 20 sequences. The patient, 43 y. old woman, had normal development. Several weeks before hospitalization she noticed mild disturbance of movements, coordinafion and balance, and her speech became scanning. No oligoclonal IgG were present in cerebrospinal fluid, and the diagnosis was suspected by the demonstration of abnormal transferrin. On MRI, bilateral symmetrical hyperintensity on PD/T2W was present in both thalamus, posterior limb of internal capsule and pons. The lesions showed no enhancement afler gadolinium on T1W. Metabolic alterations detected by 1H-MRS were different in grey and white matter. In pons a huge elevation of myoinositol (mi) was present, with mild reductions of N-acetylaspartate (NAA) and choline (Cho), but in thalamus only Cho was decreased. Conclusions: Our findings indicate that not only neurodegeneration is present (decrease ofNAA and Cho),but also an accumulation of storage material (mi or something interfering with mi). We speculate that this could be the result of an influenza A virus infection in an healthy carrier of the CDGgene for Nagai et al (1993) described 4 children with similar MRI findings as a result of influenza A infection (A/USSR/77/H1N1 and A/Hong Kong/72/H3N2). Besides, a vesicular-stomatitis virus (VSV), which infects cattle, producing influenza-like symptoms, has only one glycoprotein (VSVG) and is used a s a model system for studying N-linked glycoprotein processing since such viral infection almost totally usurps ah infected host cell's glycoprotein synthesizing machinery, and VSV-infected host cell, which nor-

mally contains hundreds of different types of glycoproteins, afler infection has virtually no other glycoprotein but VSV-G protein.

Dementia higher function disorders P601 Posterior cortical atrophy: 5-years of neuropsychological follow-up. S. Allo, A. Moulignier (ParŸ F) Progressive cortical visual failure is an unusual accompaniment of dementŸ A right-handed accountant man developed diffculties reading and writing numbers in rabies in 1992 (he was 54-year-old) that compelled hito to resign in 1993. Simultagnosia was present in 1995 and Balint's syndrome diagnosed in June 1996. At that time memory, judgement, verbal reasoning and intellectual efficiency were preserved. In September 1996 we noticed finger agnosia, right/lefl disorientation, dysgraphia and spatial dyscalculia typical of Gerstmann's syndrome. Magnetic Resonance Imaging (MRI) of the brain was normal in 1996 but 99Tc Single Photon Emission Computed Tomography disclosed bilateral parieto-occipital hypofixation. All investigations ruled out curable dementia. Tacrine seemed to be ineffective and switched for Donepezil with relative stabilisation of the visual impairment. The patient had been regularly followed with neuropsychological evaluations. In 2001 he had enormous difficulties locating objects in his remaining intact visual field and impaired mental imagery. On the other hand, despite an evolution of 8 years since the onset of the first symptoms, his personality, speech and insight have remained quite intact, though progressive mild memory impairment has occurred. MRI showed marked posterior atrophy. The pathological basis of these cases is unknown but may be an atypical form ofAlzheimer's disease. The usual findings are younger age at onset, retained insight, rarely family history of dementia and prominent bilateral occipitoparietal pathological changes. P602 Psychiatric manifestations in adult metachromatic leukodystrophy and other neurolipidoses. Phenotype/genotype correlations? J.C. Turpin, "K. Youssov, M. Lef'evre, N. Baumann (Paris cedex, F) Objective: Neurogenetic diseases of lipid metabolism (neurolipidoses), generally considered as occurring in childhood, may manifest only in the aduh with different symptoms among which behavioural manifestations. Our aim is to establish the connections between the course of the neurometabolic disease and the psychiatric symptoms. Methods: We have set up an inventory ofthese cases so as to defne a clinical strategy. Another aspect of our research is to determine possible phenotype/genotype relationships, so as to envisage new marker genes for psychiatric diseases. Results: We have studied 12 cases of adult metachromatic leukodystrophy and clearly distinguished 2 clinical forms. One of them was characterized by mainly central nervous system motor signs (pyramidal, cerebellar, and seldom, dystonia) and a peripheral neuropathy. The other forro started by a progressive mental deterioration and behavioural abnormalities: modifications of scholar capacities in an adolescent, considered previously as a good student, modifications of mood, escapades from home, peculiar social reactions etc. The diagnosis of schizophrenia was often mentioned, but it did not appear clearly whether it differed from what is classically defined as this psychosis. Some of these patients remained for many years without any neurological symptoms, and the diagnosis was only made when neurological signs appeared, or when Magnetic Resonance lmaging (MRI) was performed. MRI showed a diffuse demyelination, bilateral and oflen symmetrical, which could be temporarily limited to the periventricular areas. AIthough the diagnosis was biochemical with the determination of the activity of arylsulfatase A and the presence of sulfatide accumulation, molecular biology showed different mutations according to the clinical status Motor forros involved the major adult mutation (P426L) in contrast to psychocognitive forros (I179S). In the adult, we have also found isolated psychiatric manifestations in Adrenoleukodystrophy, GM2 gangliosidosis, Niemann-Pick disease type C Conclusion: The place of metabolic investigations in psychiatric diseases remains to be determine&

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P603 Change of pupillary light reflex during repetitive stimulation in Alzheimer's disease and controls. D. M. Bittner, M. W. Riepe (Ulm, D) Objective: The goal of the current study was to evaluate stability of the pupillary light reflex during repetitive stimulation in controls and patients with Alzheimer's disease. Background: lnvestigations of the pupil revealed equivocal results concerning differences in normal sub)ects and Alzheimer's disease patients. One possible reason might be the application of drugs in most of the studies where pharmacological availability is only hard to control. Design/methods: Pupillary light reflex (diameter, amplitude and latency) was measured 40 consecutive times by a Computed-integrated pupillograph (CIP, AMTech, Weinheim, Germany). The initial and last 5 measurements were averaged and compared with each other. Results were obtained in 9 healthy controls (age 50-76y; MMSE 28.5 _+ 1.7) and 11 patients with clinically confirmed Alzheimer's disease according to NINCDS criteria (age 49-77y; MMSE 20.5 -+ 5.5). 4 of the patients were treated with an acetylcholine esterase inhibitor and 7 were not. Results: In controls during measurement amplitude (+0.07 + 0.09mm) increased while pupil diameter (-0.37 - 0.61 mm) and latency (-6 + 10 ms) decreased. In Alzheimer's disease pupil diameter (-0.18 _+0.31 mm) diminished to a lesser extend while amplitude (-0.06 -+ 0.14 mm) and latency (+1 -+ 8 ms) showed a reverse behaviour. These differences became significant for amplitude (p=0.019). Compared to untreated patients in treated patients a drug effect was find out thus approximating pupillary behaviour to that in controls (diameter -0.21 _+0.20 vs.-0.12 + 0.44mm, amplitude 0.05 + 0.14 vs.-0.07 • 0.19 mm, latency -2 _+6 vs. 6 + 8 ms). Conclusions: We conclude: 1. that pupillary light reflex does not remain stable under repetitive stimulation in normal controls but seems to underlie an increasing parasympathetic influence; 2. that in Alzheimer's disease these changes are less pronounced (for amplitude even significant) and 3. that the application of a cholinergic drug has an impact on pupillary reaction. P604 Cognitive lmpairment In Amyotrophic Lateral Sclerosis. A. Miralles, A. Frank, S. Perez, E. Diez-Tejedor, P. Barreiro (Madrid, E) Introduction: There are some evidences about prefrontal lobe impairment in amyotrophic lateral sclerosis (ALS) patients. Objective and method: Prospective study. Group A: mild stage ALS patients; and group B: control of healthy subjects with similar age (65 + 6 years old) and educational level (primary studies). We accomplished brain SPECT and neuropsychological study composed by Mini-Mental State Examination (MMSE), texts report with and without keys, verbal fluency, digits, Wisconsin test and Stroop test. Results: No subject had suggestive cognitive impairment of dementia (MMSE > 30135). ALS patients didn't present significant differences in fluency and digits; however we found a greater number of perseverative answers and smaller number of categories in Wisconsin test, there was also greater interference in Stroop test. There was mild impairment of memory in tasks of free and keys recolleetion. Brain SPECT studies showed frontal hypoperfusion in AI.S patients. Conclusion: Our data showed prefrontal lobe impairment and possibly consolidation and recollection memory impairment. It is necessary further and bigger studies and more exhaustive neuropsychological evaluations. P605 Biochemical markers of severe head injury. P. E. Vos, T. Beems, C Zimmerman, M. Verbeek (Nijmegen, NL) Objective: The need for ah early prognostic indicator of severe head injury exists to select therapies, to quantify the effect of therapies and to assess the prognosis for patients admitted to intensive care. The hypotheses was tested that after severe head injury, release of glial and neuronal cell-specific proteins (NSE, GFAP and Sl00b) into the circulation are li indicators of the primary damage and 2) helpful in the early assessment of prognosis. Methods: Seventy-five patients with severe head injury (Glasgow Coma Score (GCS) -< 8) had blood samples taken at hospital admission that were analyzed for S100b, GFAP and NSE. Clinical variables were GCS,pupillary reactions, lnjury severity score (ISS), initial CT- sean findings (Trauma Coma Databank (TCDB) classification). Outcome was assessed with the Glasgow Outcome Scale (GOS) at 3 and 6 months. Results: Means (:t sem): age = 32.98 (0.36), admission GCS = 4.95 (0.30) and initial serum parameters taken 2.5 hrs (0.50) after injury were S100b = 1.61 (0.29), GFAP = 1.78 (0.50) and NSE = 28.6 ( 1.22).Upper limits of normal

were 0.22,1.0 and 7.0 microg/L respectively. The dichotomised GOS showed higher mean (+ sem) serum levels in patients with ahad outcome (GOS1-3) compared with good outcome (GOS 4 or 5): S100b (3.73 _+0.35 vs 1.63 + 0.36), GFAP (3.73 _+0.94 vs 0.7 + 0.26) and NSE (33.75 • 3.9 vs 11.35 _+2.24). A correlation between serum parameters and ISS and TCDB CT categories was found. Conclusion: The results indicate that after severe head injury, NSE, GFAP and S100b are indicators of the severity of the primary damage and have prognostic significance for outcome. P606 Parvalbumin-immunoreactive neurons in the thalamus in Creutzfeldtlakob disease. H.I. Tschampa, W. I. Schulz-Schaeffer, J.W. Herms, B. Maruschak, O. Windl, U. lastrow, I. Zerr, B.I. Steinhoff, S. Poser, H.A. Kretzschmar (G6ttingen, Mª Kork, D) The pathogenesis underlying the typical clinical symptoms in CreutzfeldtJakob disease (CJD) such as periodic EEG-changes or myoclonus is not fully understood, lnhibitory GABAergic neurons, expressing Parvalbumin (PV), a cytosolic Calcium-binding protein, are reported to be reduced in the cerebral cortex and hippocampus in C)D. No correlation to clinical data has been undertaken yet. As the thalamus serves asa relay station for cortical in- and outputs and possesses a high density of inhibitory neurons, we studied thalamic PV-positive (PV+) neurons in CID. We performed immunohistochemistry on the thalami of 21 sporadic CID (sCID) patients and 5 non-neurologic controls. The number of PV+ neurons was counted in the thalamic nuclei. The immunohistochemical data was then compared to clinical and molecular findings. In comparison to controls, in sCID PV+ neurons were significantly reduced in the ventrolateral posterior (VLp), anterior ventral (AV),mediodorsal and reticuIar thalamic nucleus (Re) (p < 0.05). The VLp nucteus was especially damaged in CJD patients with homozygosity for methionine al Codon 129 and prion protein type 1. PV+ neurons in the AV nucleus were predominantly reduced in patients with a long disease duration. C)D patients with typical EEG changes hada more severe diminution of PV4 cells in the reticular thalamic nucleus than patients without typical EEG. We conclude that the reduction of Parvalbumin-containing neurons in thalamic nuclei provides further evidence for the disturbance of inhibitory mechanisms in CID, which could account for the clinical symptoms. P607 Risk factors for vascular dementia: a reappraisal. A. Tsiskaridze, 1". Vashadze, M. lanelidze, R. Shakarishvili (Tbilisi, GEO) Background and purpose: Although vascular dementia (VaD) is the most amenable to prevention and treatment among all types of dementia, studies on risk factors for VaD are still lacking.We aimed to evaluate the relative importance of the various vascular risk factors contributing to VaD using casecontrol design, standardized methods and diagnostic criteria, as well as modern statistical approach. Methods and results: This study included 59 consecutive outpatients (mean age 68.7 years, range 49-86 years) with VaD treated in our Institute during the period of 1990 to 1998 and 59 age- and sex-matched cognitively normal control subjects admitted to our outpatient department in the same period of time. Al1 the patients with VaD met NINDS-AIREN criteria for probable VaD and DSM-IIIR criteria for VaD. The total score of dementia patients had not to be more than 24 on Mini-Mental State examination. The total score of control subjects without dementia had not to be less than 26. Using multivariate logistic regression analysis, we found statistically significant association of the VaD with history of stroke (odds ratio (OR) 14.6; 95 % confidence interval (95 % CI) 9.1-18.2) and arterial hypertension (OR 6.3; 95 % CI 3.5-9.6), as well as with hemorrheological disturbances (OR 5.8; 95% CI 2.57-11.4), congestive heart failure (OR 8.3; 95% CI 5.5-16.4) and episodes of systemic hypotension (OR 4.3; 95 % CI 2.1-11.3). Conclusion: The present study agree with most previous reports on the risk factors of VaD, which have discussed 'traditional' risk factors for atherothrombotic cerebrovascular diseases such as history of stroke, arterial hypertension and diabetes mellitus. Moreover, we revealed some other, previously underestimated, risk factors such as congestive heart failure, hemorheological disturbances and systemic hypotension, which may play ah important role in pathogenesis of VaD by inducing hemodynamic mechanisms. Recognition of these novel, potentially modifiable, risk factors expands the target for successful therapeutic intervention to prevent cognitive deterioration and limit cumulative cerebral damage due to hemodynamic cerebral hypoperfusion or ischemic vascular events.

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P608 Quality of life of patients and relatives three years after severe traumatic brain injury. O. Kozlowski, B. Pollez, A. Th› M. Rousseaux (Lille, F) The late evolution of patient with severe traumatic brain injury (TBI) has been assessed using evaluation of physical and cognitive deficits and of disability. Quality of life (QL) has been assessed using measures of disability and social consequences of TBI, but not by a direct assessment of the subjective quality of liŸ (QL). The aim of this study was to investigate this sub)ective quality of life of patients and relatives and her predictive factors at a relatively late phase after severe TBI. We selected all the aduh (> 18 years) patients admitted in the Neurosurgery department during year 1995 for severe TBI (Glasgow coma scale < 8), and living in the Lille area. Among the 33 patients, 23 survived at 3 years and were included in the study (mean age: 30.3 years; 18 men). Each of them was evaluated at home, in the presence of close relatives, using the EBIS evaluation. This one includes 175 parameters investigating: (1) patient identity (2) initial data (3) late outcome for physical, intellectual, affective and behavioural deficits, disability and handicap (daily living activities, GOS - medical and social measures, family implication), the sub)ective QL of the patient (from the patient and significant others) and of significant others. Restdts. The mean initial Glasgow coma scale was 5.6 and the mean coma duration 18.5 days. At three years, physical deficits were usually mild, intellectual deficits always more important, and affective and behavioural problems even more severe. The GOS was of 4 (vegetative state) in 1 patient, 3 (severe incapacity) in 7, 2 (moderate incapacity) in 7, 1 (fair recovery) in 8. Mean impairment in elementary daily living activities was relatively discrete (4.6/18), while more severe in elaborate activities (10.6/18). The patient QL was discretely lower for the auto- (mean=5.48/10) than the hetero-estimation (mean=5.91). The relatives QL was similarly reduced (mean=5.45). Stepwise variables selection showed that the patient QL was best explained by extracranial complications and affective and behavioural disorders (auto-estimation) (R2=0.40) or by the relatives motivation and acceptance (hetero-evaluation) (R2=0.45), while the relatives QL was best explained by the affective and behavioural disorders and relatives acceptance (R2=0.52). In conclusion, the reduction in patients and relatives QL is similar 3 years following severe TBI. Affective and behavioural disorders have a main influence on the patient QL.

Multiple scferosis P609 Increase of cfliary-neurotrophic-factor by interferon-beta-la: a different mechanism of interferons? S. Merke]bach, M. K[otz (Homburg/Saar, D)

Objective: Various inflammatory cytokines and mechanisms are influenced by interferon-beta, which is effective in reducing relapses and progression in relapsing-remitting multiple sclerosis (rrMS). However, mechanisms resulting in axonal damage and brain atrophy are unexplained. Methods: We investigated serum-levels of Ciliary-Neurotrophic-Factor (CNTF) in 19 patients with definite rrMS (16 women, 3 men; mean age 33.5 + 7.3 years; mean Kurtzke score 2.2 +_0.6; mean duration of disease 4.6 _+4.3 years) by an enzyme-linked immunosorbent assay (ELISA) before, 6 months (n=19), and 12 months (n=l 1) afler initiating interferon-beta-la therapy (AVONEX). Results: Serum levels of CNTF increased significantly from baseline (9.9 _+11.7 pg/ml) to 6 month (17.2 • 13.7 pg/ml; p < 0.02). Although only 11 patients had reached one year evaluation until now, the difference between baseline for this group still reached significance (6.9 -+ 5.9 pg/ml versus 15.9 _-215.6 pg/ml;p < 0.03). Conclusion: Growth factors have been discussed to support remyelination and to prevent from neuronal ceU death. An increase of endogenous CNTF might explain interferon effects towards prevention of brain atrophy and disease progression, which might be, at least in part, independent of inflammatory mechanisms. P610

Successful treatment of fatigue in multiple sclerosis with modaflnil. U.A. zifko, S. Schwarz, E. M. Maida (Bad Pirawarth, Wien, AT) Objective: Test the efficacy, safety, and appropriate dose of modafinil in the treatment of fatigue in patients with multiple sclerosis (MS). Background: Modafinil is a unique wake-promoting agent that is chemically distinct from traditional stimulants. Results of a placebo-controlled study demonstrated that 200 mg/day but not 400 mg/day modafinil improves fatigue in MS.

Methods: A total of 50 patients aged 25-61 with a diagnosis of MS were enrolled in a prospective 3-months, two-centre study. Exclusion criteria included a diagnosis of narcolepsy, sleep apnea, use of steroids within the last 3 months, onset of antidepressant medication within the last 8 weeks, clinically significant major disease or recent use of medications affecting fatigue. Efficacy was evaluated using the Epworth Sleepiness Scale (ESS, score range 0-24), and subjective evaluation of patients regarding change of fatigue, quality of life, and overall satisfaction with treatment. Adverse effects (AE) were recorded throughout the study. Treatment was started with a single daily dose of 100mg in all patients. Increase of dose was performed in 100 mg steps in case of ahsent response up to a maximum of 400 mg/day. Resuhs: Interim analysis of 39 patients (mean age 39.6 years, 20 female/19 male; MS type: 30 relapsing remitting, 1 primary progressive, 8 secondary progressive; mean disability level of 3.6 _+ 1.4 on the Kurtzke EDDS; mean score of 31.2 + 7.4 on the MS specific fatigue severity score) indicated that modafinil significantly improved fatigue. For the ESS, the mean scores at baseline and at control were 9.6 -+ 3.5 and 5.1 +- 3.0 (p < 0.0001), respectively. Self estimation showed regarding change of fatigue clear improvement in 22 (56.4 %),improvement in 13 (33.3 %), and no change in 4 ( 10.3 %), regarding quality of life clear improvement in 35 (89.7 %) and no change in 4 (10.3 %). The overall satisfaction of treat ment was very good in 25 (64.1%), good in 10 (25.6 %) and moderate in 4 ( 10.3 %). 2 patients stopped modafinil medication because of AE (nervousness and anxiety). 16 (41%) patients were treated with 100, 21 (53.9%) with 200 and only 2 (5.1%) with 300 mg/day. None of them required 400 mg/day. Conclusion: Treatment with modafinil improves significantly fatigue and is well tolerated in patients with MS. In contrast to the treatment of narcolepsy a low dose regime of modafinil is effective in MS. P611

Characterization of Molecular Aherations in Normal Appearing White Matter Brain Tissues from Multiple Sclerosis Patients. U. Graumann, B. Erne, J. Caduff, M. Tolnay, A. Probst, A. J. Steck, R. Reynolds, N. Schaeren-Wiemers (Basel, CH; London, UK) Multiple Sclerosis (MS) is a chronic disease that leads to selective and focal destruction of myelin sheaths in the central nervous system (CNS). We are analysing the cellular and molecular mechanisms behind the myelin destruction by studying the molecular expression pattern of oligodendrocytes in normal appearing white matter (NAWM) MS autopsy brains. Northern blot analysis as well as dot -blot-analysis of total RNA extracted from different areas such as demyelinated lesion, lesion border and NAWM from two MS brain tissues showed higher expression of GFAP in both lesions and in NAWM compared to one control tissue. In contrast, myelin basic protein (MBP) expression was lower in one lesion (containing some myelinated fibres and few oligodendrocytes) and absent in another (containing a high number of activated macrophages and astrocytes and lack of myelin). In NAWM of both MS patients lower expression levels of MBP and upregulation of GFAP was detected. Differences between NAWM near a lesion and far away could also be observed. We further characterized the expression pattern of various autoptic brain tissues by differential screening with human cDNA expression arrays representing 3528 known cDNA sequences. Quantification of the hybridisation signals detected in NAWM of three MS patients and white matter of two controls revealed that many genes were differentially regulated. Ir turns out that the high sensitivity of our system allows the detection of regulated high abundant as well as low abundant genes. In conclusion, the availability of sufficient amounts of autoptic tissues with intact RNAs enables us to perf o r m a comprehensive study of oligodendrocyte pathology on transcriptional and protein expression levels. P612 "Quality Of Life And Disability Assessments In Relapsing-Remitting Multiple Sclerosis (MS) Patients"/Part I. D. Vernay, G. Edan (Clermont-Ferrand, Rennes, F) Part one: Comparisons of the reliability of two disability evaluation scales, EDSS and UKNDS and the correlations between the relapse incidence and the EDSS/UKNDS evolution. The objective of this study is to analyse data concerning a quality of life questionnaire (SEP 59) anda disability scale (UKNDS) in order to assess, beside the specific use within therapeutic clinical trials, the validity and reliability of the French adaptations of these skills in a practical situation. Notably, a comparison will be done with a validated scale (Expanded disability Status Scale or EDSS), part two of this work which is presented separately, shows the results of the comparisons of Correlation between the clinical evolution of the patients and their quality of life assessed with SEP 59.

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132 patients have been included in France all over the country in 27 centres: 1/3office-based neurologists and 2/3hospital based neurologists, all particularly involved in MS and trained to use the scales. The inclusion criteria were chosen in order to selecta standard patient population of female and male between 18 and 45 years old, suffering from a Relapsing-remitting Multiple Sclerosis (MS) who were never exposed in the past to a chronic MS treatment. All the symptomatic treatments were allowed during the study, including treatment of MS exacerbation. Data were collected first at entry and then every six months (total of 3 visits scheduled). Documented data are: demography, MS history, concomitant treatments, clinical examination including neurological exam with EDSS and United Kingdom Neurological Disability Scale (UKNDS). In parallel, the patients had to fill in a quality of life questionnaire (SEP 59) within the few days following each visit and send it to the "Quality of life" analysis centre. If, in the course of the study, there is a need to prescribe a chronic treatment to the patient, this one should be excluded from the study after completing a termination visit. The recruitment period lasted 9 months (October 1998 - June 1999). The analysis has been performed with the data from 116 patients (16 protocol violations have been excluded from the analysis). 76 patients have been followed according to the protocol until the end of the trial (Month 12). 36 patients left the study for various reasons, among them 13 started a chronic treatment for MS. We will present the results of the complete data collection in the course of ENS 2001.

set, and time to reach a score of 3 and 6 in the EDMUS Incapacity Scale (EIS) from each patient was extracted from the database. Survival curves were made with the time to reach EIS 3 and 6 to compare statistically the different factors aforementioned. Also, a Cox regression model was built with al1 the significant factors. Results: An interval of less than 6 months from onset to second relapse was significantly associated (p < 0.01) wiŸ a shorter time to reach a score of 3 or 6 in the EIS. There was a highly positive correlation between this interval and the time to reach either EIS 3 or 6 (p < 0.05 in both cases).An age at onset over 30 years was also associated with a shorter time to reach both EIS 3 and6 (p < 0.01) Male gender was associated with a shorter time to reach EIS 6 (p < 0.05); the association was not significant for EIS 3 (p=0.1). No other symptoms or signs were statistically significant, although some positive trend was observed for sensory symptoms. In a Cox regression model, only the onset-relapse interval and the age at onset were significant factors to reach both EIS 3 and 6. Male patients showed a significantly shorter onset-relapse interval, compared to females. Conclusion: Age at onset and onset-relapse interval ate significant prognostic factors for disability in our series of multiple sclerosis patients. Our data suggest that the influence of gender as an isolated factor may be due to a shorter interval between onset and second relapse in men. P615

Diffusion Tensor Imaging in early relapsing remitfing multiple sderosis. P613 "Quality Of Life And Disability Assessments In Relapsing-Remitting Multiple Sclerosis (MS) Patients"/Part II. D. Vernay, G. Edan (Clermont-Ferrand, Rennes, F) Part two: Correlation between the clinical evolution of the patients, the occurrence of relapses and their quality of life assessed with SEP 59. The objective of this study is to analyse data concerning a quality of life questionnaire (SEP 59) and a disability scale (UKNDS) in order to assess,beside'the specific use within therapeutic clinical trials, the validity and reliability of the French adaptations of these skills in a practical situation. Notably, a comparison will be done with a validated scale (Expanded disability Status Scale or EDSS), the part one of this work which is presented separately, shows the results of the comparisons of two disability evaluation scales: EDSS and UKNDS quoted concomitantly in the trial. 132 patients have been included in France all over the country in 27 centres: ~/3 office-based neurologists and 2/3 hospital-based neurologists, all particularly involved in MS and trained to use the scales. The inclusion criteria were chosen in order to selecta standard patient population of female and male between 18 and 45 years old, suffering of a Relapsing-remitting Multiple Sclerosis (MS) who were never exposed in the past to a chronic MS treatment. All the symptomatic treatments were allowed during the study, including the treatment of MS exacerbation. Data were collected first at entry and then every six months (total of 3 visits scheduled). Documented data are: demography, MS history, concomitant treatments, clinical examination including neurological exam with EDSS and United Kingdom Neurological Disability Scale (UKNDS). In parallel, the patients had to filI in a quality of life questionnaire (SEP 59) within the few days following each visit and send it to the "Quality of life" analysis centre. Ir, in the course of the study, there is a need to prescribe a chronic treatment to the patient, this one should be excluded from the study afler completed a termination visit. The recruitment period lasted 9 months (October 1998 - June 1999). The analysis has been performed with the data from 116 patients (16 protocol violations have been excluded from the analysis). 76 patients have been followed according to the protocol untiI the end of the triai (Month 12). 36 patients left the study for various reasons, among them 13 started a chronic treatment for MS. We will present the results of the complete data collection at the ENS 2001 meeting.

C. M. Griffin, G. ]. Barker, A. ]. Thompson, D. H. Miller (London, UK) Background: Diffusion tensor imaging (DTI) provides quantitative information about the anisotropy of water diffusion in vivo. Anisotropy may be quantified by indices including fractional anisotropy (FA), volume ratio (VR) and mean diffusivity (MD). DTI has been used to demonstrate changes in lesions and normal appearing tissues in established multiple sclerosis (MS). This study investigated DTI findings in an early MS cohort, within 3 years of symptom onset. Methods: 27 patients were studied (8 male, 19 female). Median disease duration was 2 years (range 1.0-3.0). 24 age and sex matched controls (mean age 34.0, 9 male, 15 female) were studied. The Kurtzke expanded disability status scale (EDSS) score and the US MS taskforce composite score were assessed in each patient. All scans were performed on a 1.5T Signa Echo speed MRI system. The diffusion protocol consisted of 3 series of 7 interleaved slices, each acquired with a single shot Diffusion Weighted Echo Planar Imaging (DW-EPI) sequence. Regions of interest (RO•S) were placed in 12 normal appearing white matter (NAWM) regions and 9 normal appearing grey matter (NAGM) regions. ROIs were outlined on the non-diffusion weighted b0 (b=0) images of the DW-EPI dataset, with guidance from the T2 and PD weighted images. Lesions were outlined using the same technique. ROIs were then transferred to the FA,MD and VR maps. Differences between the two groups were assessed using the independent samples t test. Results: In the patients, FAwas lower in lesions than NAWM (lesion mean 0.31, NAWM mean 0.59, p < 0.0001).MD was higher in lesions (lesion mean 1.19, NAWM mean 0.87, p < 0.0001) as was VR (lesion mean 0.88, NAWM mean 0.59, p < 0.0001). Differences were found between patient and control NAWM FA in the temporal white matter (p=0.01) and occipital white matter (p=0.02) only. NAWM VR differed in the temporal white (p=0.02) and occipital white matter (p=0.01). There was no difference in NAWM MD or any of the NAGM measures between the two groups. No correlation was found between lesion FA, MD or VR and the EDSS score, timed 25 foot walk, PASAT or 9 hole peg test. Conclusions: Diffusion changes in normal appearing tissues in early disease appear to be subtle, and DTI analysis using a region ofinterest approach may be less sensitive to early change than for other MR parameters sucia as MTR and T1. Alternative methods of analysis such as histogram analysis may improve the sensitivity in early disease. P616

P614

Prognostic factors for disability in Multiple Sclerosis. P. de Castro, M. Ale-

Induction of persisting neutralizing antibodies by interferon beta. D. Reske, A. Walser, E ron Wussow, H.-E Petereit (Cologne, Laupheim, Hannover, D)

gre, A. Vicens (Pamplona, E) Background and objectives: The clinical course of multiple sclerosis is highly variable between subjects. Several studies have shown that some factors, like gender or age at onset, may influence the progression of the disease. The search for prognostic factors may help to discover different subgroups of the disease, and therefore improve the assessment of the efficacy of treatments. Method: 223 subjects from our centre were included in the European Database for Multiple Sclerosis (EDMUS). Information about the gender, age at onset, interval between onset and second relapse, symptomatology at on-

Introduction: Interferon beta (IFN) is effective in the therapy of multiple sclerosis (MS). The efficacy of a long-term treatment may be reduced by neutralizing antibodies (NAB) against IFN developing in up to 40 % of patients. The clinical impact of NAB on disease activity and severity varies from increase in relapse rate to spontaneously resolving NAB without clinical deterioration. We report on two cases of MS patients developing bigh titres of NAB which persisted up to 29 months after IFN treatment was stopped. Methods: We present a long-term follow-up of two cases. Clinical and laboratory tests are reported. To measure the severity of the disease we used

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the expanded disability status scale (EDSS). NAB in blood and IVIG (intravenous immunoglobulins) were measured by ELISA and bioassay. Tests for other autoantibodies against mitochondria, nucleic acid, nucleic and thyroid gland constituents were done. Results: We report on two 36 year old females with a disease duration of 9/7 years (patient 1/2) and a relapsing remitting course of MS. IFN therapy 8 MIU 3 • per week subcutaneously was initiated after azathioprine (100 mg per day) for 24/1 months was discontinued due to side effects. Disease duration before start of IFN treatment was 24/20 months with a relapse rate of 1.24/1.8. EDSS was 6.0/1.5 and NAB were negative. Relapse rate was 1.5/0.8 during IFN treatment. After 48/29 months of IFN treatment a series of relapses (2/3) was seen. At this time NAB were 11,444 and 212 respectively. IFN was stopped and monthly 10 g IVIG introduced for a period of 41/34 months until now. Patient 1 changed to a secondary progressive course with an actual EDSS of 8.0. Patient 2 had no more relapses anda stable EDSS of 2.0. NAB reached peak levels of 40,946/6100 and have been persisting on high titres (actually: 34,428/1234). Other autoantibodies have been absent in both patients. No NAB against IFN are contained in IVIG. Discussion: During MS therapy with IFN, NAB develop in up to 40% of patients with a peak after 12 months. In most patients NAB titres decrease spontaneously after discontinuation of IFN therapy. Here we report for the first time long-time persisting NAB in the absence of IFN. There is no evidence of pre-existing NAB, other autoantibodies induced by IFN or NAB contained in IVIG. Ir IVIG contains IFN is under investigation at the moment. Results will be presented at the ENS. The clinical impact of these persisting NAB remains unclear.

P617 Active inflammation and atrophy on MRI in multiple sclerosis: association with disease course. X. Lin, L. D. Blumhardt (Nottingham, UK) Brain atrophy is a potential surrogate marker of axonal loss and disease progression in multiple sclerosis (MS). It has been suggested that atrophy occurs early in the disease and correlates with measures of disease activity. We estimated brain volumes in a large cohort ofMS patients and controls, to investigate relationships between atrophy, the presente of active inflammatory lesions, and clinical parameters. 171 patients [95 relapsing-remitting (RR), 76 secondary progressive (SP)I and 29 age-matched controls were imaged using dual echo and 3-dimensional Tl-weighted MR. The volumes of supratentorial and infratentorial brain, and lateral ventricles, were measured using stereology. All patients had significantly lower brain and higher lateral ventricular volumes than controls (p < 0.0001, p=0.004 and 0.0002, respectively). Differences were most marked in the SP cohort. The estimated volume change (compared with controls) for infratentorial brain (-7.1% vs.-4.6%, p=0.03) and lateral ventricles (77% vs. 32.5%, p=0.002), was greater for patients with T 1-enhancing lesions than for those without: for RR MS patients, there was a larger median supratentorial (-8.4% with Tl-enhancement vs.-4.6% without, p=0.02), median infratentoria] (-6% vs. -0.1%, p=0.003), and lateral ventricular volume change (72.8 % vs. 3.4 %, p=0.002). For SP MS, only the enlargement of lateral ventricles reached significance for patients with active lesions ( 125 % vs. 47.8 %, p=0.Ol ). Our study shows that significantly greater reductions of brain volume and enlargement of lateral ventricles occur in the early years of RR MS for patients with active inflammation on a single image. As disease duration did not differ between subgroups, this implies a much higher rate of atrophy has occurred in patients showing currently active inflammation. On the other hand, in SP MS patients, this relationship was found only for the lateral ventricles. There appears to be less dependence of atrophy on active inflammation in the later stages of the disease. These findings support the notion that atrophy (and therefore ah• underlying axonal damage) is more dependent on inflammatory processes in the early stages of MS.

P618 CSF cell count in acute transverse myelitis. I. Schirotzek, S. Gierer, D. C]aus (Darmstadt, D) We report on a series of 11 patients who presented with signs and symptoms suggestive of acute transverse myelitis (ATM). Al1 were studied for clinical, elect rophysiological, laboratory, and radiological evidence of the disease. Purpose: To underline common diagnostic criteria for ATM. To evaluate the diagnostic power of cerebrospinal fluid (CSF) cell count as easily performed laboratory test. Patients and methods: 11 consecutive patients presenting in 2000 with signs and symptoms suggestive of ATM were examined. Diagnosis was established based on the following criteria: 1) acute onset with progressive

course over several days 2) primarily sensory involvement 3) absence of signs of involvement of second motor neuron 4) spinal segmental level of disturbance 5) if available MRI-scan evidence for spinal inflammation, no sign of spinal mass or compression 6) recovery over several weeks. Resuhs: AII patients but one had normal CSF cell count. The one patient with elevated CSF cell had herpes zoster myelo-radiculitis with vesicular cutaneous lesions within a dermatome and serological proof of the disease. 4/11 patients showed elevated CSF protein. In 2 other patients, oligoclonal bands were positive. In 9/1 l patients MRI scans showed signs of acute inflammatory disturbance. Conclusion: CSF cell count is nota helpful parameter to establish the diagnosis of ATM. Normal CSF cell count does not rule out inflammatory disease of the spinal cord. P619 Biomarkersfor astrocytosis and axonalinjuryinmultiple sclerosis brain tissue. A. Petzold, D. Gveric, M. Chapman,]. Newcomb, G. Keir, L. Cuzner (London, UK) lntroduction: Brain specific proteins such as the astrocytic glial fibrillary acid protein (GFAP) and SlOOb, the axonal neurofilaments (Nf) are biomarkers estimating the amount of (1) astrocytosis and (2) axonal injury in CNS disorders. We asked how these specific proteins are expressed in plaques, normal appearing white and grey matter of MS patients as compared to a control population. Methods: post mortero brain tissue was obtained from 12 MS patients and 8 controls. The tissue was histologically classified into acute lesion, subacute lesion, chronic lesion, normal appearing white matter (NAWM) and normal appearing grey matter and pieces of each type of tissue were excised and homogenised. Glial fibrillary acid protein, SlOOb,neurofilament and ferritin were quantified from the tissue homogenate using in-hnuse ELISA techniques. Statistical analysis was done using the Fisher's exact test. Results: (1) Astrocytosis: GFAP and S100b were increased in acute, subacute and chronic lesions compared to white matter of the control population, but failed to achieve statistic significance. Significantly higher levels of both astrocytic proteins could be observed in grey matter of MS patients compared to control grey matter (p=0.033 and p=O.04). (2) Axonal injury: Nf were highest in subacute lesions, followed by acute and then chronic lesions. Compared to control white matter these changes did however not reach statistic significance. (3) Ferritin levels were significantly higher in NAWM MS tissue compared to control WM (p=0.024). Ferritin was also elevated in acute, subacute and chronic MS lesions. Discussion: Astrocytosis is a well known pathologic feature in MS. The finding that significant elevated S 100b and GFAP levels of in MS grey matter supports the notion that pathology in MS is not restricted to white matter. A significant loss of axons could not however be demonstrated. Contrarily we found increased levels of Nf in acute and subacute lesions. This ',ve interpreted to be the result of increased Nf turnover, which could originate in a neuronal attempt to re-establish axonal connection. During this process metabolic activity increases physiologically. Whether increased ferritin leyels reflect involvement of iron stores in upregulated repair mechanism or degeneration remains speculative. Again pathology extends outside the plaques as ferritin levels are higher in MS plaques and normal appearing white matter than in control white matter.

P620 Non-invasive functional and biochemicai assessment of mitoxantrone cardiotoxicity in Multiple Sclerosis: A case-control study including MR spectroscopy, MR imaging and Doppler echocardiography. F.X. Weilbach, M. Spindler, M. Beer, ]. Sandstede, L Strotmann, D. Hahn, G. Ertl, K. V. Toyka, R. Gold (Wª D) Objective: To evaluate new diagnostic tools for detection of preclinical mitoxantrone-induced cardiac dysfunction. Background: Mitoxantrone (MXT) is a recenfly approved immunosuppressive for treatment in multiple sclerosis (MS). Its prolonged use is limited due to the cumulative dose dependent cardiotoxicity. More sensitive non-invasive diagnostic tools are required to monitor a MXT induced cardiotoxicity. Methods: In a case-control study 15 MS patients treated with MXT were compared with a control group without MXT exposure matched for age,gender and the expanded disability status scale (EDSS). MR spectroscopy was employed to directly measure myocardial high energy phosphate metabolisto. MR imaging was used for morphometric evaluation of left ventricular (LV) geometric changes. Indices of systolic and diastolic LV performance were assessed by Doppler-echocardiography.

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Results: By echocardiography only one female patient of the MXT group showed an abnormally low LVEF,whereas no pathological LVEFoccurred in the control group. There was no correlation between LVEF as measured in echocardiography and cumulative MXT dose. In MR imaging, a weak association between cumulative MXT dose and MR ejection fraction (EF) could be detected. However, EF, LV end-diastolic volumes and end-systolic volumes were not different between both groups. Furthermore, a difference was observed when treatment groups were analyzed with respect to heart stroke volume. There was, however, no association between stroke volume and cumulative MXT dose. No association could be detected between duration of disease, EDSS, patient age and MR imaging parameters. Regarding high energy metabolism no correlation could be found for phosphocreatine (PCr) to adenosine triphosphate (ATP) ratios or absolute PCr or ATP concentrations and MXT dosage. In addition, there was no association between age, EDSS, duration of disease and PCr/gATP ratios or absolute PGr or ATP concentrations. Conclusions: In this study using advanced diagnostic methods, there was no dose related clinically overt cardiotoxicity ofMXT within the cumulative dose range up to 100mg/m2. Within these limits, MXT does not appear to significantly alter cardiac energy metabolism. Preliminary findings on functional MR imaging may indicate the presente of a subclinical MXT related cardiotoxicity. Further st udies involving more patients are necessary to evaluate the significance of the observed changes of stroke volume and EF. P621 Mitoxantrone-Therapy in Multiple sclerosis: four cases with a very good therapeutical outr A. Lª M. Heibel, E. Mauch (Schwendi, D) Mitoxantrone (MX) as an immunosuppressive agent in the treatment of multiple sclerosis (MS) is being increasingly accepted. However, there are contradictory opinions concerning the potential negative effect of MX on regeneration and remyelination. We reviewed four MS patients aged 31 to 48 years who were treated with MX. The EDSS deterioration in the year prior to the MX-therapy ranged from 1.0 to 3.5 points. Other specific therapies such as Cyclophosphamide, Azathioprine and Copolymer had failed. The EDSS at onset of the MX-therapy ranged from 6.5 to 7.5 with a disease duration of 1 to 2 years (16 years in one patient). The MX treatment was given over time periods of 2 to 5 years and cumulative dosages of 110 mg to 246 mg were obtained. Clinical evaluation was based on the EDSS. MRI scans were obtained at least at the onset and at the end of the MX-therapy, as well as on a follow-up visit. Under the treatment with MX improvement in the EDSS ranged from 0.5 to 6.0 points. The MRI scans obtained at the onset of the treatment showed gadolinium enhancing lesions in all patients. During the course of the treatment two patients showed no further gadolinium enhancement, in one patient the number of gadolinium enhancing lesions was reduced and in one patient there was only discrete gadolinium enhancement visible when the MX-therapy was stopped because of the improved clinical outcome. The T2 lesion volume was shown to be constant in three patients and slightly decreased in one patient. A follow-up visit was performed after 8 months to 6 years after the end of the MX-therapy (une patient is still being treated). One patient had not changed in the EDSS and did not change in the MRI T2 lesion volume. The second patient continued to improve with the EDSS (0.5 points) and showed a constant MRI T2 lesion volume. The third patient had shown an improvement of 6.0 EDSS points. On follow-up he returned within a slight relapse of the MS with a temporary decrease of the EDSS of 1.0 points. The bout of MS could be seen on the MRI scan showing few gadolinium enhancing lesions and an increase of the T2 lesion volume. Over all ah improvement of 5.0 EDSS points could be obtained. The fourth patient is still being treated with MX because of an ongoing improvement of the EDSS anda decrease of the T2 lesion volume. These cases show that a therapy with MX has the potential not only to stop progression of MS but also to promote recovery. P622 How to assess normal appearing white matter in multiple sclerosis. A MTR histogram study of brain tissue. M. Sailer, N. Bodammer, G. Barker, C. Tempelmann, M. Matzke, H.-J. Heinze (Magdeburg, D; London, UK) lntroduction: In multiple sclerosis (MS) different approaches using magnetisation transfer ratio (MTR) histograms have been performed. In this study we evaluate if and how MTR metrics change, when normal appearing white matter (NAWM) boundaries are stepwise varied, starting from ah "ideal" segmentation. Subjects and methods: Brain MTR maps of 48 MS patients and 13 healthy controls were analysed. The definition of the NAWM implies the segmentation and exclusion of lesions, cortex and CSE Then successively erosion/dilation was applied starting from the "ideal" segmentation point substract-

ing/adding candidate voxels to the NAWM. For each erosion/dilation step histogram means and peak hights were calculated. Results: Peak heights are significantly lower in the MS group compared to controls if"ideal" segmentation is performed. This effect degrades when cortex gradually is included. Histogram means show a reversed tendency. With increasing dilation the differences between the two groups become stronger reflecting the inclusion of cortical and partial volume MTR values. Discussion: MTR metrics changed considerably when stepwise dilation of the boundaries was performed. We attribute this changes to brain atrophy that may alter the proportion of the cortex/partial volume areas and NAWM. Our data also suggest that whole brain outlining is not suitable to assess the NAWM in MS. Therefore the chosen ROls may be of crucial importante in the interpretation of MTR results, and great care must be taken with their definition, particularly in follow up and drug studies. P623 Mitoxantrone and Pregnancy. A. Lª

M. Heibel, E. Mauch (Schwendi, D)

Multiple sclerosis is one of the major neurological problems and women ate affected more often. The onset of disease is mostly ata younger age when family planning is of interest for the patient. This has to be respected when discussing and choosing treatment options with the patient, particularly concerning immunosuppressive agents such as mitoxantrone. Little is known about the teratogenetic potential of mitoxantrone so it can be difficult to advise the patient. Over the past 10 years lO mitoxantrone patients of our clinic became pregnant. In 6 of these the immunosuppressive therapy was either stopped because of the pregnancy of the pregnancy followed the end of the therapy within less than a year. The other 4 patients became pregnant after l to 6 years after the end of the mitoxantrone treatment (one patient had two pregnancies). One patient who had become pregnant under mitoxantrone-therapy had chosen to have an abortion. One patient had two pregnancies (3 and 6 years after the end of the therapy). The first child was healthy, the second pregnancy ended in a still birth. Another 5 patients had healthy children and in three further patients we know of normal pregnancies. Regarding those cases it seems that mitoxantrone does not have a high teratogenetic risk, neither in the short nor in the long term. We do think, however, that there should be a period of 6 months between the end of a mitoxantrone therapy and a pregnancy to exclude any potential harm. Younger women who wish to have children can be treated with mitoxantrone. They should be advised not to become pregnant under therapy of shortly afterwards, although mitoxantrone after our experience does not seem to have a negative effect on a pregnancy. P624 Magnetisation transfer ratios and apparent diffusion coefficients in the assessment of brain tissue in multiple sclerosis. M. Sailer, N. Bodammer, J. Kaufmann, C. Tempelmann, M. Kanowski, H.-J. Heinze (Magdeburg, D) Introdur Magnetic resonance diffusion imaging (DWI) and magnetisation transfer imaging (MTI) both provide information about the microstructure of the underlying tissue. Therefore in this study we evaluate the application of these two methods in one protocol that may enable a more specific differentiation between histopathological processes in multiple sclerosis (MS). Subjects and methods: 39 patients with clinically definite MS and 11 age matched cont rols were examine& The protocol consisted of a MT-saturatedSE sequence anda series of diffusion-weighted EPI sequences using 8 different b-values increasing from 0 to 1050s/mm 2 in three orthogonal directions. DW images were corrected for eddy-current-induced artefacts. The ventricles and other regions containing CSF were excluded by segmentation and additional cut-offs. Thus only ADCs below 1.0x10 3 mm 2 and MTRs higher than 10 % were considered for histogram analysis. Results: Median differences of ADCs (p=0.02) and MTRs (p=0.03) were significant between the MS group and controls. There was also significant negative correlation between the median ADC and median MTR measures (-0.49, p < 0.005). Conclusion: The ADC and MTR measures in a single patient result from different microstructural changes. The underlying process may be different in case of correlated and uncorrelated changes of the measures. The combination of both methods may render a further step in the characterisation of the pathology involved in MS.

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P625 When white matter matters: Revealing unilateral memory dysfunction associated with a single lesion. A combined MEG and MRI study in a patient with multiple sclerosis. E. Dª A. Maly, ]. Kaufmann, M. Matzke, H.-]. Heinze, M. Sailer (Magdeburg, D) Case report: We report the functional organization of object recognition in a 35 years old female patient with recently diagnosed clinically definite multiple sclerosis (MS). Her MRI scan revealed a single cranial lesion (TI and T2 -weighted) localized in the vicinity of the right parahippocampal region, a brain area known to be critical for recognition memory. Whole-head magnetoeucephalographic (MEG) recordings were obtained while coloured pictures of nameable objects were presented at a rate ofone every 2 seconds and repeated after 8 to 12 intervening stimuli. The patient and two age-matched controls were instructed to perform a recognition iudgment on each picture. In the controls, MEG recordings to recognized repeated pictures differed from those to new pictures over both, left and right hemispheric MEG-sensors. In the patient, on the other hand, this difference was strongly lateralized to the left hemisphere. Importantly, this finding nearly normalized in a repeated recording after three months, at a time when the MS lesion in the right parahippocampal region had almost disappeared. The findings suggest that even small MS lesions can affect the functional organization of recognition memory if they are localized in white matter that connects critical brain regions. Furthermore, the data show the reversibility of the cognitive impact caused by MS lesions. P626 Survey of multiple sclerosis in lstanbul. M. Eraksoy, G. Akman-Demir, Z. Yapici, N. Turan, N. Isik, T. Seleker, E Seleker, N. Sª R. Tª H. Tireli, A. Siva, B. Petek-Balci, E Oztª (Istanbul, TR) A random sample of 1023 multiple sclerosis (MS) patients registered in 7 major reference centers in lstanbul was evaluated regarding clinical and demographic characteristics between 1999 and 2000. Forty-nine patients developed initial manifestations within this period. Sixty-eight per cent of the survey population were women. Seventy-four per cent had remitting/relapsing disease, 12.4 % had a secondary progressive course, 9.6% h a d a progressive relapsing course, 4% h a d a primary progressive course and 0.6 % of patients was stable. The mean age at onset was 28.1 + 13.2. Seventy-six patients developed MS before 16 yrs, 923 had initial symptoms between 17 and 49, and 24 had first attack after 50 years of age. The most common initial symptoms were sensory (30.7%), brain stem (21.7%), optic neuritis (19.3%), motor (16.5%), cerebellar (4%) and bladder symptoms (0.4 %). The mean duration of disease was 11.2 yrs and mean follow-up period was 8.9 years. The mean survival time was 45.80 +-0.49 (SE) 95% CI (44.83; 46.76). The survival at 15 years from onset was 98.3 and 25 years from onset was 95.7. Fifly per cent of patients reached the disability level 7.0 at 29.27 +_ 1.35 (SE) 95 % CI (26.62, 31.92). There was no significant correlation between initial symptoms, age at onset, gender, clinical course and progression index. The survival time and the time to reach disability level 7.0 were not significantly different in both sex and the groups of various initial symptoms (LR=0.001; P= 0.97). In conclusion, clinical and demographic characteristics of this cohort were not different from the Western series, but a slightly better prognosis and lower disability scores were observed,although only 3.7 % of patients received immunomodulatory and immunosuppressive therapy. This study did not reveal a statistically significant prognostic factor, and fatal outcome was rare within the first decade of disease. P627

Results: MS patients have a CD in 21 out of 25 cognitive variables tested (p < 0.05). According to our criteria, 14 patients (64%) are classified with a CD. In comparison to non-deteriorated patients, patients with CD i-lave a h igher score of GLC, TLC, FLC and PLC (p < 0.02). A correlation is observed between executive functions deficit and ratio PLC/GLC (p < 0.009). Discussion and conclusion: There is therefore relationships between CD and MRI brain lesions in mild MS. Correlation between specific cognitive and radiological variables would be found using modern MRI techniques sucia as Magnetisation Transfer. The existence of relationships between CD and M RI brain lesions raise the necessity to study them more accurately by prospective longitudinal studies in order to elaborate a consensual strategy of their early management.

Neurobiology P628 EEG Activity, Performance and Hormones in Menopausic Patients. J. Saggese, C. Gandolfo, G. Povedano, G. Faraj, C. Zalazar, R. Lutfi (Ciudad de Buenos Aires, RA) We designed a prospective study to determine whether hormone levels could be related with neurophysiological and neuropsychological disorders in a group of perimenopausic patients.We performed a test battery to evaluate recent memory (short and recall) by means of Mesulam's 5 Shapes 5 Words test, attention and reaction time with a software specially designed for this trial. Prolactin (PRL), luteinizing (LH), follicle stimulating (FSH) hormones and estrogen (E) levels were dosed. We performed a brain mapping (EEGq) to each patient. Relative power for alpha, beta (rapid frequencies) and theta, delta (slow frequencies) in frontal (F3 F4), temporal (T3 T4, T5 T6) and occipital (O1 02) leads were analyzed. In the resuhing study group of 70 women, we correlated hormone levels both to test and to EEGq findings. We used ras correlation coefficient with 95 % confidence limits and partial F-test for statistic signification. Regarding test results and hormone levels we found ah inverse correlation between E and reaction time, a n d a direct relation with speed to performa visuomotor task. We also found that high LH levels correlated with worse performance in incidental non verbal memory tests and visual skill tests. Regarding cortical rhythms and hormone levels, we found that lower E levels were associated with increase of alpha power in 02 and decrease of theta power in F4 and T4 (right hemisphere). High FSH levels showed reduced theta activity in O1 and T5 leads (left hemisphere). High PRL levels were associated with an increase of delta power in O I, T5 and F3 (lefi hemisphere). High LH levels correlated with a decrease in theta activity in T3, T5 and O1,O2 leads (left hemisphere). FSH showed the same pattern than LH (theta activity reduced in left hemisphere) with no link with cognitive tests. LH levels also showed an inverse correlation to incidental non verbal memory and visual skill tasks. Low LH levels were linked to increase in slow wave activity (theta) of left hemisphere and better performance in right hemisphere tests. Low E levels were related to worse performance in reaction time test and with a decrease in theta and increase in alpha activity in right hemisphere PRL levels were directly associated with delta activity in left hemisphere. P629 Opioid receptors in human cingulate gyrus: Receptor autoradiography and functional coupling to G-proteins. S. Petri, A. Berthele, S. Platzer, F. Willoch, B. Conrad, T. R. T611e (Mª D)

Relationships between cognitive deficit and brain MRI lesions in patients with mild multiple sclerosis. S. Massengo, E. Sartori, B. Carsin-Nicol, V. Golfier, M. Coustans, S. Belliard, G. Edan (Rennes, F) Background: Cognitive deficit (CD) is observed in 43 to 65 % of patients with multiple sclerosis (MS). Links between CD and brain lesions as shown by MRI are also mentioned. Objectives: To study relationships between CD and brain radiological lesions in patients with mild MS. Methods: 22 patients with a probable or definite MS and with a EDSS _< 4 were compared with an educational level-, age- and sex-matched controlled group (n=30). A cognitive battery was performed, including attention/concentration, memory and executive functions evaluation. Using Ormerod's method (Ormerod et al., Brain 1987), brain lesions as shown by MRI T2-weighted images were numbered according to seven radiological variables: global lesion charge (GLC), periventricular lesion charge (PLC), ratio PLC/GCL, frontal lesion charge (FLC), ratio FLC/GLC, temporal lesion charge(TLC), ratio TLC/GLC.

The cingulate gyrus is one of the principal structures in central pain processing. In a recent PET-activation study we were able to demonstrate a positive correlation between the subjective perception of the unpleasantness of a painful stimulus and an increase of the regional cerebral blood flow in the anterior cingulate cortex (ACC), whereas pain intensity was correlated with increased activity in the posterior cingulate cortex (PCC). While opioid-receptor-ligand PET studies with the non-specific mu-, delta-, kappa-ligand diprenorphine show a high density of opioid-receptors in all regions of the cingulate cortex, the application of the specific mu receptor agonist fentanyl leads to a differing increase of regional cerebral blood flow in ACC and PCC. To analyze a possible differential distribution of opioid receptor subtypes causing the functional heterogeneity of the cingulate gyrus we performed receptor binding studies in rostral ACC, posterior ACC and PCC in human post mortem tissue (n=5). Receptor autoradiography with tritiated ligands specific for mu-, deltaand kappa-opioid receptors and the "opioid receptor like 1" specific ligand

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nociceptin ([3H]DAMGO 4.2 nM, [3H] DPDPE 14.4 nM, [3H]U69 593 7.6 nM, [3HINociceptin 0.5 nM) showed the expression of all four opioid receptors in the cingulate gyrus. Macroscopically there were no significant differences of the laminar distribution pattern in ACC and PCC. By agonist stimulated [35S]GTPgammaS binding we evaluated the activation of intracellular G-proteins following receptor-ligand-binding and thereby the functional coupling of selective opioid receptor agonists. Mu-(DAMGO 20p.M), delta(DPDPE 30p.M) and Nociceptin(5gM)-stimulated [35S]GTPgammaS binding was evenly distributed in all laminae of the cingulate gyrus while stimulation with a kappa-specific ligand (U-69593 5gM) resuhed in an increased binding signal in deep laminae of the cingulate cortex. These patterns are in good agreement with the results of receptor autoradiography. Further studies allowing quantitative assessment of mu-, delta-, kappaand ORL receptor localization in substructures of the cingulate gyrus, cellular distribution and colocalization of opioid receptor subtypes as well as the effects of partial agonists and antagonists on G-protein coupling ma)' further evaluate the tole of the opioidergic system in pain processing on the functional as well as on the anatomical level. P630 lnvolvement of lnsulin-like growth factor-I (IGF-I) and IGF binding protein (IGFBP) 1 and 3 in axon-Schwann cell interactions. L. Nobbio, S. Garrone, A. Barreca, M. Grandis, M. Abbruzzese, G. L. Mancardi, F. Minuto, A. Schenone (Genova, I) IGF-I promotes proliferation, differentiation and survival of Schwann cells (SC). Ah effect of IGF-I on axon regeneration has been proposed. Although IGF-I expression has been shown in postnatal SC and in SC precursors thus suggesting an autocrine regulation of SC survival, release of the trophic factor by SC has not been demonstrated. To investigate the role of IGF system we studied the conditioned medium (CM) of primar)' SC cultures, purified sensory neurons, and co-cultures of SC and sensory neurons. Since IGF-I interacts with specific IGFBPs, whose active role in modulating the effects of IGF-I is increasingl)' recognized, we evaluated also IGFBP-1, IGFBP-2, IG'FBP-3. We established SC, sensor)' neurons and SC/sensor)' neurons cultures according to classical procedures. Purified SC (87,500 cells/dish) were grown in presence of serum, forskolin,cholera toxin and bovine pituitar)' extract. Purified sensory neurons were grown in presence of serum and NGF; part of them was maintained alone and the rest was added with SC (87,500 cells/dish) and grown in a co-cuhure system. After 1 month cultures were washed with PBS and grown for 2 days in a serum-free medium before replacing with fresh medium. After 48 hrs CM was collected, 1)'ophilised and gel-filtrated in acid conditions to separate IGF from IGFBP before immunoassays. Similar IGF-I levels were found into the CM of SC and of sensory neurons when grown as purified cultures (42.91 vs. 40 ng/5• 106 cell). lnstead, higher amounts of IGF-I were detected into the medium of SC/sensory neurons co-cuhures ( 128.54 ng/Sx 106 cell). 1GFBP-1, IGFBP-2 and IGFBP-3 were found in SC and sensory neurons purified cultures, but expression was higher in neurons compared to SC (IGFBP-I: 1.12 vs. 0.20 ng/5• 106 cell, IGFBP-2:119.2 vs. 312.2 ng/5• cell, IGFBP-3:11.61 vs. 1.43 ng/5 • 106 cell). SC/sensor)' neurons co-cuhures maintained high levels of IGFBP-3 (21.79 ng/5 • 106) according to the behaviour of IGF-I, but not of low p.m. BP (0.48 ng/5• cell for IGFBP-1 and 994.6 ng/5• 106 cell for IGFBP-2). In conclusion, SC and pure sensory neurons both produce IGF-I, but coculturing the two populations results in a possible reciprocal stimulation to synthesize this growth factor. The decrease of IGFBP-1 and IGFBP-2 in the medium of co-cultures may be due to the production of IGFBP proteases by SC. This action could be a mechanism to increase IGF-1 availability to the specific receptor. P631 Denervation hypersensitivity to catecholamines in patients with Familial Dysautonomia- a microdialysis study. A. Bickel, F. B. Axelrod, H. Marthol, B. Stemper, B. Neund6rfer, M. J. Hilz (Erlangen, D; New York, USA) Objective: Although patients with Familial Dysautomonia (FD) suffer from serious autonomic neuropathy, "autonomic crises" with excessive rise of blood pressure are common. A denervation hypersensitivity to catecholamines at blood vessels may be a reason for this phenomenon, but has not been demonstrated, yet. Methods: Single hollow microdialysis fibers (outer diameter 0,4mm, cutoff 3000 kDA) were inserted intracutaneousl)' at a length of 1,5cm in the lower leg in 14 FD-patients and 12 age-matched healthy controls. The fibers were perfused with Ringer's solution at a flow rate of 0,4Dal/min and dialysate was collected after skin passage. After 30 min, Ringer's solution was changed for 30 min against a solution containing 10-6M norepinephrine (NE). Local

vasoconstriction was analysed by measuring the zone of blanching around the membrane optically and also local laser doppler flux above the microdialysis membrane. The dialysate was anal)'zed for total protein content. Results: Skin perfusion at rest was slightly lower in FD patients (n. s.). During application of NE local blood flow decreased in both groups, but in the patients group average values were significantly lower (p < 0.01) and the zone of vasoconstriction (blanching) around the microdial)'sis membrane was significantly larger than in the controls. Protein content in the dial)'sate correlated to local blood flow and showed a lower and slower increase afler termination of NE-application in the patient group. Conclusions: All tested parameters support the hypothesis of a peripheral h)'persensitivity to exogenous applied catecholamines in FD patients. This may playa role in the pathogenesis of autonomic crises in this patient group. P632 Pattern of vohage-dependent ion currents in murine/rat striatal progenitor cells. R. B6ttcher, U. Strauss, E. Mix, E. Cattaneo, M. Toselli, A. Rolfs (Rostock, D; Milano, Paria, I) Background: There exist only rare information on electrical properties of neuronal progenitor cells. However, it is of special interest in view of actual therapeutic trials with transplantation of neuronal progenitor cells in neurodegenerative disorders like Parkinson's disease. Aim of stud)': To investigate the ion currents expressed b)' undifferentiated rat striatal cells in comparison to the observed ion currents of their differentiated counterparts. Material and methods: Primary foetal cells of the rat striatum were immortalised by stable retroviral transfection with the temperature-sensitive mutant of the SV40 large T antigen. Ion currents in these cells were recorded by whole-cell patch-clamp technique at the non-permissive temperature of 33~ Results: 60 % of the cells investigated (n = 33) showed vohage-dependent ion currents. Their electroph)'siological characteristics were as follows: (1) outward-directed, transient, fast activating and inactivating (25 %), (2) outward-directed, slowl)' activating and non-inactivating (21%), (3) inward-directed, slowl)' activating and non-inactivating (6%), and (4) inward-directed, transient, fast activating and completely inactivating (6%). The results are in contrast to differentiated ST14A cells,where voltage-dependent ion currents have been found in 100% and Na+-like inward-currents were increased about 10-fold compared to the undifferentiated cells. Conclusion: The heterogeneous pattern of ionic currents in striatal progenitor cells may reflect different stages of cell development and/or predetermination of different neuronal cell-lineages derived from cells of the same developmental stage. The anal)'sis of individual ion current characteristics of progenitor cells will surely have relevance for their functional activit)' after transplantation and differentiation in vivo, which will be followed by recordings of brain slices.

Neuro-oncology P633 Extraske|etaJ Ewing sarcoma presenting with acute neurological symptoms. Report of two cases. Cauda Equina Syndrome and radicular u]nar involvement. P.J. Modrego, M.A. Pina (A]ca¡ Teruel, E) Background: Ewing sarcoma is an uncommon malignant tumour of unresolved histogenesis. Some difficulties ma)' appear in the differential diagnosis with non-Hodgkin l)'mpbomas, metastatic neuroblastoma and rhabdom)'osarcoma. Positive PAS reaction and the presence of surface marker p30/32 are characteristic features in the histolog)' of Ewing sarcoma. The onset accounts in the first, second or third decade of life in 90% of cases and the s)'mptoms are pain, swelling, fever and weight loss. Usually appears in the lower segment of the skeleton, especiall)' in the bones of lower extremities and it is exceptional in the vertebrae above the sacrum and in extraskeletal location.We report two cases of extraskeletal Ewing sarcoma with neurological presentation. Case 1: A 16 year old boy was referred to hospital because of fever, distal weakness of the legs, constipation, difficuh micturition and h)'paesthesia in perineal region since one week before admission. A MRI of lumbosacral zone revealed an expansive process in the sacral region with extensive paraspinal mass. The biops)' was compatible with Ewing sarcoma and the patient was treated with m)'eloablative chemotherapy and bone marrow transplantation. The clinical outcome was uneventful and, four years afler initial diagnosis, he remains asymptomatic.

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Case 2: A 74 year old man was well until 2 months earlier when he complained ofleft cervicobrachialgia and atrophy of the ulnar region of the hand with anesthesia and weakness of the fourth and fifth fingers. EMG showed signs of denervation in the territory of the ulnar nerve and CT showed an extensive paraspinal mass in the left shoulder invading the vertebral bodies C7 and TI. The biopsy of the mass demonstrated histology of Ewing sarcoma. The patient refused chemotherapy and was treated with radiotherapy which greatly diminished the tumoral mass and relieved the pain. One year after diagnosis, he developed multiple metastasis in lungs and bones and died. Discussion: The largest series of Ewing sarcoma originating from soft tissues was composed of 130 cases from 1972 to 1991 (Raney et al., 1997); all of them were aged less than 21 years and 25 were of paraspinal location. As highlights of our cases we remark the presentation in the elderly in case 2. To our knowledge, the maximum age at presentation was 63 years in a patient from a series of 39 cases (Angervall et al., 1975). The cauda equina syndrome in case 1 is a very unusual presentation at onset. P634 The Efticacy And Safety Of Temozolamide (Tmz) In The Treatment Of Glioblastoma Multiforme (Gbm). D. Kolokouris, A. Miliadou, C. Dardoufas, C. Zournas (Athens, GR) Background: Temozolamide (SCH 52365) is an oral alkylating agent with broad-spectrum antitumour activity. It was developed a s a potential alternative to dacarbazine in facing high-grade gliomas. Methods and resuhs: We have studied 25 patients suffered from GBM since Marcb 1998. All patients received radiotherapy (RT) at a total dose of 60-64 Gy within 6-6.5 weeks. TMZ was prescribed 2 to 3 weeks after the completion of RT in a dose of 200 mg/m2/dayfor 5 consecutive days for patients who had not received prior chemotherapy. Each TMZ cycle was repeated every 28 days. Patients h a d a median age of 53 years (ranged from 26 to 83 years), and 52% (13/25) were male. All patients h a d a K. la.S. (Karnofsky Performance Status) > 70%. Adverse events were nausea and vomiting (45%), fatigue (35%) and constipation (40%). Hematological undesirable consequences included leukopenia (24 %), thrombocytopenia (44 %). Five patients discontinued treatment because of adverse events probably related to TMZ. During the study, 14 patients were died aftera mean survival of 9.5 montbs. Eleven patietrts are still alive with a mean survival of 13.5 months. Conclusion: 1. The median overall survival of patients receiving TMZ is 11.26 months. The performance status of patients was satisfactory during the study. 2. TMZ has a good toxicity profile and desirable antitumour activity. P635 Epidemiology of primary intracranial tumours in Valle d'Aosta (NW ltaly) in the last two decades: stable trend. S. Cordera, E. Bottacchi, G. D'Alessandro, F. De Gonda, D. Machado, G. Corso (Aosta, Bergamo, I) Data about the epidemiology of primary intracranial tumours (PIT) are still heterogeneous depending on different methodological approach in collecting data. In Valle d'Aosta, north west side of Italy, we have realised a prospective consecutive population based study to calculate the incidence of PIT in the last decade ( 1992-1999) and to compare these rates with the previous period 1986-1991 (1). The mean annual PlT incidence rate (ri) per 100,000 inhabitants is 25.48. The mean annual incidence rates in the two period of comparison were adjusted to the 1991 Italian population by the direct method. The standardised ratio was 26.43 in the previous period and 23.24 in the group of study and not statistically difference comes out. The mean annual PIT incidence rates by tumour types are: meningiomas 13.27/100,000 (men 9.77; women 16.7), neuroepithelial group 9,3 (men 10.62; women 8,1), adenomas 1.26, neurinomas 0,7. Mean annual incidence rates by tumour class are stable, too. The stable incidence rate value in the two period compared and the similar incidence obtained in England 21.04/100,000 person year (2), strengthen the data about a stable incidence rate of PIT in the last decade. These three papers used similar methodology: only bomogeneous methodology allows comparison and further consideration. References 1. D'Alessandro G. et al. (1995) Epidemiology of Primary Intracranial Tumours in the Valle d' Aosta (Italy) during the 6-Year Period 1986-1991 Neuroepidemiology 14:139-146 2. Pobereskin LH, JB Chadduck (2000) Incidence ofbrain tumours in two English counties: a population based study. 1 Neurol Neurosurg Psychiatry 69 (4): 464-71

P636 Treatment of a relapsed radio- and chemotherapy refractory primary CNS lymphoma with the anti-CD20 antibody rituximab (IDEC-C2B8). H. Pels, H. Schulz, U. Rehwald, J. Rosenberg, U. Schlegel, V. Diehl, A. Engert (Bonn, Cologne, D; San Diego, USA) Objective: To evaluate safety and feasibility of intraventricular treatment with the anti-CD20 antibody rituximab in a patient with primary central nervous system lymphoma (PCNSL) and to measure antibody concentrations in cerebrospinal fluid (CSF). Background: Various clinical trials have demonstrated response rates of up to 37% in patients with systemic diffuse large cell lymphoma (DLCL) after treatment with the chimaeric monoclonal anti-CD20 antibody rituximab. Since most PCNSL express the CD20 antigen, we have investigated safety and feasibility of rituximab administration in a patient with relapse of PCNSL after multiple chemotherapies and cranial irradiation. Design/methods: A 66-year-old male with histologically confirmed PCNSL (DLCL), expressing the CD20 antigen presented with cognitive dysfunction and hemiataxia. CSF examination showed malisnant cells and MRI revealed a left frontal tumor mass. Rituximab (375 mg/m~) was administered intravenously on day 1 and day 8. Intraventricular injections vŸ Ommaya reservoir were given on day 16 ( 10 mg), day 17 (40 mg), day 24 (25 mg) and day 25 (25 mg). Results: Re-evaluation of the CSF after systemic and intraventricular treatment showed disappearance of lymphoma cells but no change in size of parenchymal tumor mass. Clinical symptoms sligbtly improved under therapy. Reversible side effects consisting of nausea, chill and hypotension were observed immediately after intraventricular administration of 40 mg rituximab only. CSF antibody levels after systemic infusions were 0.38 lag/ml and 0.351ag/ml, 5.7/.tg/ml and 101ag/ml after intraventricular injections and 0.11 btg/ml tire weeks after completion of therapy. Conclusions: These data suggest that intraventricular treatment with rituximab is safe and feasible with a potential activity against leptomeningeal tumor manifestation. Efficacy and pharmacocinetics of rituximab in PCNSL should be investigated in future trials. P638 Complete response of a high grade Non-Hodgkin's-Lymphoma of the cervical spine and the brachial plexus after systemic and intraventricular chemotherapy. M. B6s, H. Pels, B. Storch-Hagenlocher, T. Klockgether, R. Schr6der, U. Schlegel (Bonn, Heidelberg, D) Objective: To describe the case ofa 48-year old-woman with high grade NonHodgkin's-B-cell-lymphoma of the spinal cord, the right brachial plexus and the leptomeninges. Background: Primary manifestation of peripberal nervous system or central nervous system lymphomatosis in the brachial plexus is extremely rare. Prognosis is poor and therapy not established. Patients/methods: A 48-year-old woman was referred with progressive weakness ofher right arm and left sided facial palsy. CT and MRI revealed enhancing mass lesions in the right brachial plexus and in the cavernous sinus. These symptoms and lesions improved under steroid therapy. Repeated CSF examination including cytopathology was not diagnostic. PCR of the CDR3 encoding region of the immunoglobulin heavy chain locus in cerebrospinal fluid cells generated a single PCR product of 99 bp indicating that the CDR3-specific fragment was derived from a monoclonal cell population. Symptoms worsened afler steroid withdraw. MRI showed a new enhancing central lesion in the cervical spinal cord. Open biopsy was performed a n d a high grade Non Hodgkin's B-cell Lymphoma was diagnosed. The patient underwent a combination of systemic and intrathecal chemotherapy ("Bonn Protocol"). Resuhs: Complete tumor response and partial recovery of neurologic symptoms were achieved after four cycles of chemotherapy. Conclusions: Widespread disseminated high grade Non-Hodgkin's-Bcell-Lymphoma of the peripheral and the central nervous system can be effectively treated by a combination of systemic and intraventricular chemotherapy. P639 Paraneoplastic Neurologic Syndromes As A Complication Of Lymphomas. E. Toribio, I. Delgado, M. Blanco, A. Miralles, A. Frank, E. Diez Tejedor (Madrid, E) Introduction And Objectives: In oncologic patients, paraneoplastic neurological syndromes (PNS) represent 1% of neurological complications and they usually begin prior to the tumor detection. The association with Iymphomas is unusual, being the most infrequent Hodgkin's disease (HD) and

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non-Hodgkin's lymphoma (NHL). We present three patients with PNS associated with lymphomas. Patients And Results: Case 1: A 45 year-old man began insidiously with inestability, ataxia, dismetry, disartria and oromandibular myoclonies. One month later he suffered ah intestinal obstruction and after an exploratory laparotomy he was diagnosed of pleomorphic intestinal NHL B. Anti Hu, Tr and Ro autoantibodies were negative.The patient died in spite of chemotherapy and bonemarrow transplant. The autopsy showed subacute cerebellar degeneration and limbic encephalitis. Case 2: A 27 year-old man carne to hospital with constitutional syndrome, ataxia,coordination's disturbance and opsoclonus-myoclonus.In the procedure of tumor search a low grade NHL B in the exploratory laparotomy was found. Chemotherapy gota complete remission of both, hematological and neurological symptoms during one year. Later, the tumour recidived,being preceded of a subacute sensorimotor neuropathy. The patient was treated again with chemotherapy, but now the response was just partial. Case 3: A 49 year-old man began with disartria, ataxia and dismetry. He was diagnosed of acute diseminated encephalomielitis and received steroids treatment observing mild improvement. Later ganglionar biopsy showed HD. Chemotherapy improved the hematological precess but there was no change in the neurological disorder. Conclusions: PNS representan infrequent, but early complication of lymphomas. The presence of PNS strongly makes the suspiction of lymphoma and an exhaustive research for this diagnosis should be done in every case.

"contaminating" B-lymphocytes restrict the method by producing false negative results. Tberefore we developed a half nested polymerase chain reaction (PCR) method to assess the CDR3 from single B-lymphocytes isolated from standard CSF cytospins by the use of consensus primers (FR3A, LJH, VLJH). The CDR3 was analysed qualitatively by sequencing and quantitatively as the number of positive PCR-reactions in relation to the total number of analysed cells. To establish the method we used cells derived from a lymphoma cell line (NCNC) containing a known CDR3-sequence with homologous consensus primer binding sites. The amplification rate (AR) was 94 % (28 of 30) and the sequence of the CDR3-amplicon was identical in all cases. A patient with neuroborreliosis showed AR of 50% (4 of 8) with differing sequences of all 4 amplicons. In a patient with cytologically proven leptomeningeal dissemination of multiple myeloma AR was 62,5 % (5 of 8) and all PCR products had identical sequences. The sequence was also identical to the PCR-product derived from whole CSF cell sample PCR. In another patient with established leptomeningeal multiple myeloma the AR was 0 % (0 of 16) suggesting a monoclonal B-lymphocyte proliferation but failure of primer binding. The single celI-PCR of B-cells from standard cytospins is a new tool to affirm suspected meningeal lymphomatous spread especially when the CSF cell count is low or there is a high reactive proliferation of "contaminating" B-lymphocytes. To investigate the sensitivity of the consensus primer pair especially in hypermutated lymphoma cells further analyses and the use of new primer pairs are necessary. P642 A case of brachial monoparesis in chronic myeloid leukemia. R. Gherasim, A. M. Vladareanu, F. Antochi, O. Bajenaru (Bucharest, RO)

P640

Limbic encephalitis with periodic complexes on EEG. S. Omer, K. Spillane (Halifax, Dundee, UK) Background: Paraneoplastic limbic encephalitis (PLE) and CreutzfeldtJakob disease (CID) may share striking similarities in their clinical features. Both conditions could prove difficult to diagnose. The recording of periodic complexes on the electroencepbalogram (EEG) in the presence of neuronal protein 14-3-3 in the cerebrospinal fluid (CSF) carry a high predictive value for the diagnosis of CJD. Neuronal protein 14-3-3 has been detected in the CSF of some patients with paraneoplastic neurological syndromes. Case report: A 62-year old remate patient was admitted to hospital with a rapidly evolving amnesic syndrome and seizures. Her condition gradually deteriorated and she became confused and agitated, lnitial and repeat magnetic brain imaging falied to show a convincing abnormality even after gadolinium conrast, save for a suspicion of hyperintensities in the medial temporal Iobes on T2-weighted images. CSF analysis showed a moderate rise in protein and was initially acellular but further samples showed a lymphocytic pleocytosis, protein 14-3-3 was not detected. EEG showed marked slowing of the background rhythm with bisynchronous periodic complexes occurring every 0.5 seconds. Extensive investigations did not reveal a tumour. Anti-Hu antibody was not detected. The inexorable deterioration in her condition resulted in death 6 month after the onset of symptoms. Post mortem examination revealed features consistent with PLE. The limited post mortem examination was not designed to look for the tumour which was therefore not found. Conclusion: PC on EEG ate seen in a number of conditions, however their occurrence in the appropriate setting usually suggests a diagnosis of CJD. Our case illustrates that EEG abnormalities similar to those encountered in CJD could be found in PLE, and since the clinical pictures may be similar an erroneous diagnosis of CJD could be made. Fur thermore it should be noted that neuronal protein 14-3-3, a useful test in the diagnosis of CJD may be positive in some patients with paraneoplastic neurological syndromes. Seizures occurring early on in the onset favour a diagnosis of PLE as does CSF pleocytosis

The central nervous system, spinal cord, and cranial and peripheral nerves may be involved by infihrating or compressing tumours, and symptoms ma), result. The development of leptomeningeal infiltration with malignant cells is a well recognised complication of many hematological neoplasms. The signs and symptoms characterising the syndrome are secondary to in. creased CSF pressure (80-90 %), ocular disturbances (35 %), cranial and peripheral nerve dysfunction (22%). Infiltration of dorsal root ganglia or of peripheral nerves themselves may occur with leukemia, lymphoma and myeloma. We present the case of ah unusual Peripheral Nervous System PNS complication of a distinct hematological neoplasm. The patient is a 51year-old male who was diagnosed with chronic myeloid leukemia - CML (chronic phase) in 1997. Two a n d a hall years after conventional treatment with Hydroxy-Urea, Cytarabine, lnterferon, a blast crisis was remarked. On admission he presented with a huge splenomegalia, hepatomegaly, pleural and pericardium infiltration and brachial lefl monoparesis. He presented weakness of initiation of abduction of arm, external rotation of flexed arm, abduction and elevation of arm up to 90o, flexion of supinated forearm. The arm hangs at the side, internally rotated. Movements of the hand and forearre were unaffected. Bicipital reflexes was decreased.Atrophy of deltoid, biceps, infraspinatus and supraspinatus muscles was noted, without sensory impairment. In assessing the type of this brachial monoparesis, a lumbar puncture (LP), electro physiologic test and MRI were performed. The LP revealed elevated CSF protein, low glucose, and 50% atypical blasts (mainly myeloblasts and megakarioblasts). The electro physiologic test and MRI confirmed the diagnostic. Laboratory data included: severe anemia (haemog]obin 5 g/dl), white blood cell count 195 0 0 0 / m m 3, platelets 588 000/mm 3, 71% blasts- mainly myeloblasts and megakarioblasts with profound anisocytosis and poikilocytosis. ESR=58mm/h, negative HIV test. He received Chemotherapy with Ara-C, Mitoxantrone, Thioguanine, Vincristin, Methotrexate and Hydroxy-Urea. This case demonstrates an unusual manifestation of CML, namely leptomeningeal blasts cell infiltration, presenting with neurologic signs and symptoms. This complication usually develops during the final stage of the disease and only palliative treatment is indicated.

P641 Single cell PCR analysis of the immunoglobulin heavy chain CDR3 using standard cerebrospinal fluid cytospins for the diagnosis of leptomeningeal B-cell lymphoma. A. Hug, J. Haas, B. Storch-Hagenlocher, B. Wildemann (Heidelberg, D)

P643 Time-dependant endocrine dysfunction and impact on well-being after radiation therapy of primary brain tumours and the influence of hormone substitution - a longitudinal stndy. V. Leussink, B. Badent, S. Veit, B. Olshausen, M. Flentje, G. Becker, B. Allolio, W. Arlt (Wª D)

The diagnosis of leptomeningeal B-cell lymphoma is based on the identification of malignant B-cells in the cerebrospinal fluid (CSF). The differentia tion between inflammatory central nervous system (CNS) processes with transformed B-lymphocytes and CSF lymphoma cells is not always possible by conventional cytology and immunocytocbemistry. The molecular analy sis of the third complementarity determining region (CDR3) of the immunoglobulin heavy chain gene locus (IgH) of whole CSF cell samples has simplified the diagnosis. However low CSF cell count and high counts of

Background: Radiation-induced endocrine dysfunction and impact on wellbeing after treatment of primary brain tumours is frequent and mostly dne to hypothalamic damage (Arlt et al., Neurology 1997). Objective: In this longitudinal study we investigated and compared endocrine function and well-being in 31 long-term survivors (21m, 10f, age 29-65yrs) of primary brain tumours (WHO malignancy grade II-W) 1-14 years after surgery and radiotherapy (mean total dose 60.5 + 5.2 Gy) with and without hormone replacement therapy over a period of one year.

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Methods and results: Validated questionnaires (SCL-90-R, GBBI-24, B-L ron Zerssen, EORTC) were used for evaluation of well-being. In those patients with endocrine dysfunction (ED, n= 14), endocrinological testing at time point 0 revealed significant lower levels offT4 (14 _+4 vs. 18 _+6pmol/l in patients without ED (n= 17), p < 0.05) and of DHEAS (684 • 564 vs. 1439 • 815ng/ml, p < 0.01 ). At follow-up testing after one year, the fl'4 serum levels of those patients with thyroid hormone replacement therapy (n=5) remained stable, whereas there was a significant decrease of fT4 in those patients without treatment (n=14, 18 + 4 vs. 14 + 3 pmol/1). Measurement of serum DHEAS levels in 21 patients (15m, 6 f) revealed a significant decrease from 1130 + 779 to 893 • 568ng/ml afler one year. Psychometric tests revealed a striking increase of impairment of well-being in those patients without hormone replacement therapy (n= 13) over a period of one year (total complaint scores: GBBI-24 12.2 -+ 12.2 vs. 16.9 -+ 14.4, p < 0.01). Conclusions: Thus, due to a high prevalence of hypothalamic malfunction associated with endocrine dysfunction and impairment of well-being yearly evaluation of the endocrine function and, if necessary, early hormone replacement therapy should be recommended in patients being treated for malignant brain tumours. P644

Quantitative Magnetic Resonance Spectroscopyin Differential Diagnosis of Inflammatory versus Neoplastic Brain Lesions. J. Ostojic, I. Vukadinovic, V. lvanovic, K. Koprivsek, M. Prvulovic, Z. Babic (Sremska Kamenica, YU) Introduction: Many brain lesions of different origin have very similar MRI characteristics. Differential diagnosis between neoplasia and non-neoplastic lesions can be problematic when based on imaging alone. Even when MRI identifies disease accurately, there is a strong possibility that MRS could do so earlier and therefore increase the window of therapeutic opportunity. In 1H spectra of brain lesions all metabolite concentrations are often reduced, so these peak ratios correctly reflect relative changes rather than absolute increments or decrements. This aspect of diagnoses becomes dearer when quantitative MRS is applied. Material and methods: Spectrums of 14 patients with inflammatory brain lesions (6 meningitis, 3 Lyme borreliosis, 3 abscesses, 2 Herpes simplex) and 14 patients with neoplastic lesions (4 gliomatosis cerebri and 10 low grade astrocytoma) were examined at 1.5 T Siemens Magnetom. A STEAM 20 sequence was used for spectral acquisition. In 7 cases SE 135 sequence was used in order to make a difference between lipid and lactate peaks. Absolute metabolite concentrations were calculated using method of external standard. In order to be able to use quantitative MRS results in difficult or undiagnosed cases we conducted these study in laboratory confirmed patients. Results: In all inflammatory diseases NAA concentrations were slightly decreased: 6.63 • 0.72 mM/kg. Cho and tCr were near normal: 1.62 _+ 0.28mM/kg and 6.83 +- 1.12 respectively, except in two cases where Cho concentrations were slightly increased (1 Lyme Boreliosis 1,97 mM/kg and 1 herpes encephalopathy 2.29 mM/kg). [tCr]/[Chol ratio was 4.21 -+ 0.62 mM/kg, mi concentrations were increased in 5 inflammatory cases (2 herpes symplex and 3 Lyme boreliosis) 6.81 _+0.43 mM/kg, in low grade astrocytomas and gliomatosis cerebri NAA concentrations were decreased 4,9 • 1.8 mM/kg. Cho concentrations were increased 2.62 _+0.33 mm/kg; tCr concentrations were decreased 5.02 :!: 1.9mM/kg. Cho/tCr was 2,2 • 0.38, [tCr]/[Cho] was 1.87 • 0.14. In 6 (60%) low grade astrocytoma cases lactate peaks were detected. In 5 (50 %) cases of low grade astrocytoma elevated mi concentrations were revealed 7.02 +_0.39 mM/kg. Conclusion: In inflammatory diseases NAA concentration decreases slightly, Cho and tCr are near normal, lactate is absent of small. Low grade astrocytoma and gliomatosis cerebri have the same spectral characteristics: decreased NAA, elevated Cho and decreased tCr. Lactate doublet is significant in 60 % of low grade astrocytoma cases.

P645 Interstitial and systemic chemotherapy concomitant to hyperfractioned radiotherapy in primary GBM. M. Eoli, A. Silvani, 1. Milanesi, A. Salmaggi, B.

performed with CT and neurological examination every two months, lbxicity evaluation was conducted according to RTOG toxicity scale. The treatment schedule was interrupted only in one patient due to Leptomeningeal tumour dissemination Afler a median follow-up of 6 months 8 out of 13 patients had disease progression. Median TTP was 7 months (range 2-12); median ST could not be calculated. Neurological toxicity included somnolence in 2 and repeated seizures in 6 patients, despite anticonvulsive treatment. In 2 tases CT showed appearance of fine calcification near surgŸ cal cavity along tumour margins. Preliminary results suggested that this regime could be feasible in GBM patients. P646

Temodal chemotherapy concomitant to hyperfractioned radiotherapy in high grade gliomas. I. Milanesi, A. Silvani, M. Eoli, A. Salmaggi, B. Zappacosta, G. Broggi, A. Boiardi, L. Fariselli (Milan, I) The aim of this paper is the evaluation of toxicity and possible response to hyperfractionated radiotherapy concomitant to Temodal in patients with primary GBM. 11 patients (median age 62)were accrued: all underwent biopsy (open or stereotactic) because in all cases tumour involved corpus callosum. The diagnosis was GBM in 7 patients and AA in 4, KPS was < 60 in 3 patients and > 70 in 8. Soon after surgery radiotherapy started (total dose 45-50 Gy, 1.5 Gy/fr., 2 fr.daily, 6 hours apart). Temodal (75 mg/m2 p.o daily) was administered during radiotherapy, systemic chemotherapy (Procarbazine 450 mg/m 2and ACNU 2 mg/kg) every 6 weeks until progression. Median follow-up is 5 months. After radiotherapy CT examinations showed a partial tumour reduction in 5 patients, stable disease in 5, progression in 1. KPS was unchanged in 1 patient and improved in 10. TTP was 5 months. Thromboflebytis occurred in 3, hydrocephalus in 1 and haematologic toxicity in 2 case. This regimen is effective and feasible in patients with GBM not suitable to surgery. P647

Neurological and neuropsychological complications in patients with testicular cancer: A prospective follow-up study. T. Dose, B. Baur, C. v. Schlippenbach, A. Gerl, R. Voltz (Munich, D) Background and goals: Testicular cancer is a frequent tumour in men between the age of 20 to 40 years with a relatively good tumour prognosis. Neurological complications may arise for several reasons, eg. metastases, therapy complications, or infections. Recently, a paraneoplastic limbic encephalitis was described in patients with testicular cancer including neuropsychological symptoms such as mnestic deficits, fatigue and depression (Voltz et al., NEJM, 1999). The goal of this study is to prospectively and systematically study neurological and neuropsychological complications in these patients. Methods: During the first 6 months of this ongoing study, we saw 50 patients with testicular cancer attending a specialised out-patient clinic (AG). Neurological and neuropsychological symptoms and signs were recorded using standard clinical examination, the Beck Depression Inventory (BDI) and the fatigue severity scale (FSS). If appropriate, further diagnostic tests are performed. Results: Of the first 50 patients (mean age 37.7, range 22 to 60), 60 % had subjective symptoms like mild concentration and memory deficits (n=26, 52%), fatigue (n=14, 28%), depression (n=13, 26%) and paraesthesias (n= 11, 22 %). There was no medical history for seizures of mental disorientation. 41 patients (82 %) had received a chemotherapy; among those were all patients with paraesthesias (27%). Of those with self-reported depression, this was mild in 77 %, moderate in 7.7 % and severe in 15.4 %. Conclusion: In patients with testicular cancer, neurological and neuropsychological complications such as mnestic deficits, fatigue, depression and paraesthesias ate frequent and may be severe. A possible correlation to low titres of paraneoplastic autoantibodies will be performed in the course of the study.

Zappacosta, G. Broggi, L. Fariselli, A. Boiardi (Milan, I) To evaluate toxicity and possible response to a new schedule of radiotherapy associated with systemic and locoregional chemotherapy in primary GBM. 13 patients (median age 51 ) were included. AII underwent surgical resection with diagnosis of GBM and implantation of a Rickam reservoir. KPS was > 70 in all patients. After three weeks radiotherapy started total dose 50-55 Gy, 95 cGy/fr, 2 fr daily six hours apart) concomitant to chemotherapy. Chemotherapy schedule was A) locoregional: 0.5 mg CDDP weekly through Rickam reservoir for 6 times B) systemic treatment with BCNU 160 mg/mq and CDDP 100 mg/mq iv. every six weeks. Follow-up was

P648 Limbic encephalitis associated with thymic carcinoma: a case report. C. D'Avino, M. Lucchi, R. Ceravolo, A. Mussi, G. Siciliano (Pisa, I) Thymic carcinoma is a rare malignant neoplasm with extremely poor prognosis but rare occurrence of paraneoplastic syndromes. Paraneoplastic limbic encephalitis is a particular presentation of paraneoplastic encephalomyelitis. This report describes a patient with symptoms suggestive of limbic encephalitis and an anterior mediastinal mass, further diagnosed as thymic carcinoma.

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The patient, a 61 year-old-man, referred at the Neurological Clinic of the Department of Neuroscience in Pisa with 3 month history of sbort term memory Ioss, confusion, irritability, hallucinations, feeding disorder and loss of weight. He also presented generalized tonic-clonic seizure and was hospitalized. Apart from severe impairment of recent memory and spatiotemporal orientation, neurological examination was normal. EEG showed abnormalities on both fronto-temporal lobes while CT and MRI of the brain were normal. The CSF analysis revealed oligoclonal antibody intrathecal synthesis. Hemocultures and antibody titration for neurotrophic viruses, bacteria and fungi were negative. On immunohistochemistry a serum and CSF primarily reacting auto-antibody towards cytoplasm of Purkinje cells was detected. The chest X-ray and CT showed a large invasive mediastinal tumor. When the patient was referred to the Thoracic Surgery Division his mental status had worsened and he experienced frequent psychotic episodes and almost daily seizures despite anticonvulsant (clonazepam and carbamazepine) therapy. The surgical treatment of the epidermoid keratinizing thymic carcinoma and subsequent radiotherapy (50 Gy) on the mediastinum dramatically improved neurological conditions of the patient who presented rare psychotic episodes and was seizures free. The natural history of PLE is one of progressive deterioration of CNS function, but neurological symptoms may improve with the eradication of the primary disease. Our case indicates that this can happen also after successful treatment of a thymic carcinoma. P649 Anti-Du autoantibodies in patients with paraneoplastic limbic encephalitis. I. Andreou, R. Kaiser, T. J. Feuerstein, S. Rauer (Freiburg, D) Identification of antineuronal autoantibodies has improved the diagnosis of paraneoplastic neurological syndromes and the diagnosis of tumors at early stages. In this study we characterize a new autoantibody, called anti-Du found in six patients with tumors and different paraneoplastic neurological syndromes showing symptoms of cerebellar degeneration and several neuropathies. All patients had also limbic encephalitis and in the serum of tire of them anti-Hu antibodies were also found.Anti-Du antibodies recognize a 100 kd protein in cerebellum and cerebrum extracts. On testing in immunoblots with human cerebel]um extract as antigen, anti-Du antibodies were not found in 640 sera from healthy individuals and patients with neurological and non neurological diseases. With the serum of the patient with the highest reactivity against the 100kd antigen we cloned a cDNA,which encodes for an proteinsequence, that shows a high homology to a NMDA-receptor subunit, which is encoded from the NMDR2D gene. We functionally tested the int]uence of the anti-Du antibodies on the NMDA-receptors of striatal interneurons in the rat. These antibodies did not inhibit the NMDAevoked [3H]-acetylcholine ([31t]-Ach) release, but they changed the [3H]Ach-release in a manner, whicb suggested changes in the membrane permeability. This may reflect the involvement of the anti-Du antibodies in the pathogenesis of the paraneoplastic limbic encephalitis in these patients. The putative effects of the anti-Du antibodies on neuronal cell signaling could explain the acute proceeding of the paraneoplastic limbic encephalitis. P650 lnfiltrative neuropathy in lymphoma ('neurolymphomatosis'): a clinicopathological stndy of 9 cases. E Pico, D. Adams, C. Lacroix, L. Laroche, D. Decaudin, M. D› G. Said (Le Krcmlin-Bic&re, Bobigny, Paris, F) Introduction: Leptomeningeal infiltration is a well known complication of lymphoma. By contrast, endoneurial infiltration of peripheral nerves by malignant lymphocytes is uncommon. We reviewed the clinical profile and nerve biopsy (NB) finding in 9 patients with lymphoma and infiltrative neuropathy (neurolymphomatosis). Method and patients: Out of 46 patients with lymphoma and symptumatic neuropathy referred over the last 20 years, we selected 9 patients with histological proven neurolymphomatosis. The median age was 61 years (range from 45 to 76) at the time of nerve biopsy and 5 were male. Eight patients had B cell lymphoma including 3 large B cell lymphoma with advanced stage (stage 1V), 2 Chronic Lymphocytic Leukemia, 1 mantle cell lymphoma, 1 Waldenstr6m disease, 1 plasma cell leukemia. Three of them were associated with monoclonal gammapathy: Ig G (n=2) and Ig M. (n= 1). One patient had cutaneous T lymphoma (S› syndrome). Results: At onset of the neuropathy, 5 patients (55%) had histological proved lymphoma (median delay: 1 year (0.5-8)).All but one had previously received chemotherapy and the lymphoma was considered in remission in 3/5 cases. In 4 patients (45 %), the symptoms of neuropathy preceded the diagnosis of lymphoma (median delay 5 months (0-12)). The clinical presentation was a multifocal neuropathy (n=7), including cranial neuropathy in I, and monofocal neuropathy (n=2). Five patients (55%) had radicular pain.

Electrophysiogical studies showed an axonal pattern in 8 patients and multifocal conduction blocks in 1. Cerebrospinal fluid examination did not show leptomeningeal infiltration at the time of NB. The nerve biopsied were: superficial peroneal nerve (n=4), radial cutaneous nerve (n=3) and intermediate cutaneous nerve of the tigh (n=2). Nerve biopsy showed in all cases wallerian degeneration and endoneurial malignant lymphocytic infiltration according to immunohistochemistry. Six out of 7 patients followed were treated by a combination of intra-thecal and systemic chemotherapy. Two of them had disparition of pain and stability of motor loss. Five patients died after a median delay of 12 months from the nerve biopsy. Conclusion: Neurolymphomatosis may occur in patients with known lymphoma, usually in systemic remission, or may reveal the lymphoma. The clinical pattern of the neuropathy is usually multifocal and may be painless. Orientated nerve biopsy allows diagnosis and can modify therapeutic strategy. P651 Contribution of nerve biopsy findings to the diagnosis ofsymptomatic neuropathy associated with lymphomas: Report of 46 patients. E Pico, D. Adams, C. Lacroix, M. D› G. Said (Le Kremlin-Bic6tre, F) Background: In order to learn more on the pathogenesis of neuropathies associated with Iymphoma, we reviewed the clinico-pathological findings of 46 patients with symptomatic neuropathy occurring in this setting. Method and patients: Forty-six patients (26 men and 20 women), with a median age of 60 years (18 to 79 years) were included. Forty two patients (91%) had B cell lymphoma and 4 T cell lymphoma. The B lymphoma were: 14 non-Hodgkin's lymphoma (NHML) (6 large cell, 2 mantle cell, and 6 of diverse histology), 12 Waldenstr6m's disease, 6 Chronic Lymphocytic Leukemia (CLL), 3 patients HIV related lymphoma, 3 Hodgkin's disease, 2 Burkitt's disease with leptomeningeal infiltration, 1 plasmacytic leukemia, and one gastric lymphoma. Four patients had T cell lymphoma (9%) including S› syndrome (n=3) and T large cell lymphoma (n= 1). Results: In 30 cases, neuropath• developed in patients with known lymphoma aftera median delay of 6 years (4 months- 12 years). In 11 cases, the neuropathy was concomitant to the diagnosis of lymphoma and in 5 cases, the neuropathy preceded the lymphoma (median delay of 1 year (2 months-12 years)). In 9 patients (20 %),CSF examination was not contributive, but endnneurial malignant lymphocytic infiltration (neurolymphomatosis) was demonstrated in the nerve biopsy (NB). NB showed progressive axonal neuropathy in 18 patients (39%) secondary to: probable proximal infiltrating neuropathy (n:~7), necrotizing vasculitis (n=3), amyloidosis (n=2), Liebow's granulomatous angeitis (n=l), endovascular lymphoma (n=l), inflammatory infiltrates in 3 (1 CLL, 2 HIV seropositive patients) and of undetermined cause (n=l). NB showed demyelinating neuropathy in 7 patients (15%), related to monoclonal lgM gammopathy (n=4), para-hodgkinian neuropathy (n= 1), chronic inflammatory demyelinating polyradiculoneuropathy (n=2). In 4 patients (9 %), the neuropathy was considered secondary to therapy (post-radiotherapy (n=3), drug induced (n=l)). In one patient (2%), the neuropathy was of diabetic origin. Two patients (4%) h a d a progressive mixed axonal and demyelinating neuropathy, and one (2%) a non progressive axonal neuropathy of undetermined cause. The nerve was normal in 4 cases (9%). Conclusion: This study underlines the wide spectrum of causes of neuropathy associated with lymphoma and the role of nerve biopsy for the diagnosis and therapeutic management of these patients. P652 lntramedullary spinal cord ependymomas: a series of 78 cases. N. Aghakhani, Ph. David, E Parke~ C. Lacroix, M.-C. Petit, M. Tadi› (Le Kremlin Bic~tre, F) Background and goals: Ependymoma is the most common intramedullary spinal cord oncotype (30-6 % of spinal cord gliomas). Reporting on a retrospective series of 78 patients who received surgical treatment in our department, we have analyzed the epidemiological and clinical factors of these patients, MRI and surgical findings and their outcomes. The influence on prognosis of the degree of surgical removal and postoperative radiotherapy have been analyzed. Methods and results: From march 1983 to lanuary 1998, 78 patients (46 men and 32 women, mean age 42 years) with intramedullary ependymoma were operated on in our department. Al1 patients h a d a pre and postoperatire MRI stud• a n d a minimum follow up of at least two years were required (ranged between 24 and 164 months, mean 58 months). The first symptom was pain and dysesthesia (63%) and less often a motor (26%) o r a sensory weakness (9%). Preoperative clinical evaluation was carefully performed

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and each patient was assigned a clinical grade according to the grading system presented by Mc Cormick et al. and modified by Brotchi et al. (grade 1: 19.24%, grade Ibis 38.46%, grade li: 19.24%, grade IIl: 16.66%, grade IV: 6.4 %). The location of the tumors was cervical in 46.3 %, cervicothoracic in 24.1%, and thoracic in 29.6 % of cases. Of these, about 89 % presented with associated syringes.The average duration of the clinical history was 34 months (between 7 months and 10 years). During this period 7 patients underwent acute evolution, which appeared to be correlated with intratumoral bleeding. Total or subtotal tumor removal was possible in 72 patients (93 %). Histological examination showed 4 malignant and 74 benign ependymomas. We deplored one death 3 months afler surgery (grade IlI at the time of admission). Immediately afler surgery 57 % of patients experienced deterioration of neurological status and 5.5% were improved. At the time of the most recent follow-up examination 29 patients (37.2 %) exhibited the sume clinical grades as their preoperative clinical grades, 19 patients (24.4 %) were improved and 28 patients (35.8%) exhibited worsening of their clinical grades. There was only one case ( 1.2 %) of clinical recurrence ( 11 years after subtotal removal). All of the patients with malignant ependymomas died in spite of radiotherapy or chemotherapy. Conclusion: Our resuhs confirm that int ramedullary spinal cord ependymomas require surgical treatment which ma), allow a long-term free disease period in case of total removal of tumor. The most important factors determining the prognosis are the preoperative neurological status and the degree of tumor removal. No benefit of radiation therapy following total removal of spinal ependymomas has ever been demonstrated and in the case of recurrence, reoperation should be considered.

Pain-Headache P653 Toiosa-Hunt syndrome: relationship to idiopathic cranial pachymeningitis. C. Masson, Y. Boukriche, ]. M. Colombani (Clichy, F) The Tolosa-Hunt syndrome (THS) is a painful ophthalmoplegia due to nonspecific inflammatŸ in the cavernous sinus. A good response of the symptoms and of the abnormality visualised by MRI is a diagnostic criterion of the disease. Non specific inflammation and corticosensibility are also featutes of idiopathic inflammatory cranial pachymeningitis, a cause of headache and cranial neuropathies which muy presentas painful ophthalmoplegia. A 30 year-old woman had a two months history of left orbital pain. She then developed diplopia and numbness on the left hall of the face. Examination revealed involvement of the IV, of the first division of the fifth cranial nerve and ipsilateral Horner's syndrome with miosis and ptosis. CT scan was normal. MRI showed ah abnormat soft tissue area in the left 91 sinus. These lesions extended to the dura of the temporal area. CSF examination was normal All signs and symptoms resolved 3 weeks after the onset of corticosteroid therapy. MRI performed after 8 weeks on corticosteroids showed a decrease in volume of the abnormal atea. This case presented clinically as Tolosa-Hunt syndrome. MRI showed un abnormal sofi tissue area in the cavernous sinus. There was clinical and imaging improvement following corticosteroid therapy. The peculiar point was extension of the inflammatory process into the dura mater adjacent to the cavernous sinus, suggesting relationships between TSH and cranial pachymeningitis. THS might be an idiopathic inflammatory cranial pachymeningitis affecting focally the cavernous sinus.

P654 The interrelations of migraine, vertigo and migrainous vertigo. H. Neuhauser, M. Leopold, M. ron Brevern, G. Arnold, T. Lempert (Berlin, D) Introduction: Migraine has long been associated with vertigo but epidemiological evidence from controlled studies is still scarce and the prevalence of migrainous vertigo in patients with migraine is unknown. Material & methods: We prospectively studied the prevalence of migraine according to the International Headache Society (IHS) criteria in 200 consecutive patients presenting to our dizziness clinic and in a sex- and agematched control group of 200 orthopaedic patients. These two groups and 200 patients with IHS-migraine from our headache clinic were prospectively evaluated for migrainous vertigo based on the following criteria: 1) recurrent vestibular symptoms (rotatory/positional vertigo, head motion intolerance); 2) migraine according to the IHS criteria; 3) at least one of the following migrainous symptoms during the vertiginous attacks: migrainous headache, photophobia of phonophobia, visual of other auras; 4) other causes ruled out by appropriate investigation.

Results: The prevalence of migraine according to the 1HS criteria was significantly higher in the vertigo group (38%) compared to the age and sexmatched control group (24 %, p < 0.01 ). The prevalence of migrainous vertigo was 7% in the vertigo group, and 9% in the migraine group. Of 33 patients with migrainous vertigo 15 patients had migrainous headache regularly associated with the vertiginous attacks, 16 had vertigo both with and without headache and two never experienced headache and vertigo in one attack. The duration of attacks varied from miuutes to days. Conclusions: Our results substantiate the epidemiological association between migraine and vertigo and indicate that migrainous vertigo affects a relevant proportion of patients both in dizziness and headache clinics. P655 Soluble interleukin-2 receptors are increased in the active period in cluster headache patients. M. Empl, S. F6rderreuther, M. Schwarz, N. Mª A. Straube (Munich, D) Objective: To investigate wether cytokines which indicate un immune activation and actas neuro-immune-endocrine-modulators ate altered in cluster headache (CH) patients we determined serum levels of soluble interleukin-2 receptors (sIL-2R), interleukin-6 (IL-6) and two soluble interleukin-6 receptors (sIL-6R, sgp130). Background: In cluster headache patients, an activation of the hypothalamus has been demonstrated in PET studies and in endocrinologic parameters. A connection between the presumed inflammatory cause o r a n immunological activation and the hypothalamus could be established by certain cytokines. Patients and methods: sIL-2R, IL-6, slL-6R and sgp130 serum levels were determined in 18 cluster headache patients (6 women, 12 men) in the cluster period and 17 headache-free healthy controls (3 women, 14 men) by ELISA. Resuhs: Cluster patients had significantly increased sIL-2R (413.6 + 223 U/ml vs. 290 _+ 112 U/mi; p < 0.05; students' t-test) compared to controls. Serum levels of IL-6 (0.87 + 0,6 vs. 0.91 _+0,7; n.s.), sIL-6R (33,131 + 8349 pg/ml vs. 35,063 _+7606 pg/ml; n.s.) or sgpl30 (289 _+59 pg/ml vs. 283 + 20 pg/ml; n. s.) did not differ between the two groups. Conclusions: SIL-2R are released by T-cells upon stimulation, f. e. by interleukin-2 (IL-2). Since elevated slL-2R indicate a T-cell activation, our findings support the thesis of an immune activation in cluster headache. As IL-2 is able to activate the hypothalamus and stimulate corticotropin releasing factor-release, an increase of IL-2 could establish a link between a putative immunological cause of CH and the observed hypothalamic activation. IL-6 does not seem to playa role in CH, as no changes were observed in IL-6 or its soluble receptors. Nevertheless, evidence for an increase of IL-2 during the attack is missing and thus the detailed physiopathology of cluster headache remains obscure. P656 Despite clinical similarities there are significant differences between acute limb trauma and Complex Regional Pain Syndrome I (CRPS I). S. Leis, N. Sieweke, W. Kª B. Neund6rfer, E Birklein (Erlangen, Giessen, D) In order to analyze the pathophysiology behind the clinical similarity acutely after limb trauma and in acute stages of Complex Regional Pain Syndrome (CRPS), 20 patients with external fixation afier distal radius fracture (3.5 days after surgery) without signs of CRPS and 29 patients suffering from acute CRPS I (without nerve lesion, duration 7 weeks) were investigated. Hyperalgesia to heat was tested by a feedback-controlled thermode, and to mechanical stimuli by an impact stimulator. The sympathetic nervous system was examined by measuring skin temperature (computer-aided infrared thermography), testing different sympathetic vasoconstrictor reflexes (Laser - Doppler flowmetry) and quantitative sudometry afier thermal load (thermoregulatory sweat test, TST). We found hyperalgesia to heat afier trauma (median thresholds ipsi 41.1~ contra 43.0~ p < 0.001) but not in CRPS, whereas mechanical hyperalgesia was present in both patient groups (trauma: ipsi 11.9 m/s, contra 12.9 m/s, p < 0.001; CRPS: ipsi 11.2 m/s, contra 12.2 m/s, p < 0.002). Skin temperature was significantly increased on the affected side in both patient groups (trauma: ipsi 34.17~ contra 33.55~ p < 0.001; CRPS: ipsi 35.4~ contra 33.3~ p < 0.005). However, sympathetic failure as indicated by impairment of sympathetic vasoconstrictor reflexes (ipsi 100% of baseline flow, contra 85.1%, p < 0.003) and hyperhidrosis (ipsi 117.6 AU, contra 59.0 AU, p < 0.01) was found exclusively in CRPS patients. Our results indicate that pain and vasomotor disturbances ate generated by different mechanisms acutely afier trauma and in acute CRPS. Despite the clinical similarity additional changes in the peripheral and central nervous system are required for CRPS. In the light ofour observations it seems unlikely that CRPS is a simple exaggeration of post-traumatic inflammation.

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P657 Migraine-related disability in different activity domains. D. D'Amico, S. Usai, S. Genco, A. M. P. Prudenzano, L. Grazzi, M. Leone, F. M. Poca, G. Bussone (Milan, Bari, I) The MIDAS (Migraine Disability Assessment) questionnaire, developed by the research group ofW. Stewart and RB Lipton, is an established instrument for assessing headache-related disability. We assessed disability in a series of migraioe patients, paying attention to the impact of migraine on various daily activities. Two hundred and twenty-five consecutive out-patients with IHS diagnosis of migraine without aura ( 166 females, 59 males), completed recently-developed Italian version of the MIDAS questionoaire when they attended the Headache Centre of Milan or of Bari. Mean MIDAS score for the series was 21.5. The distribution of MIDAS grades was: 14.7 % grade I, 14.2 % grade II, 28 % grade II1, and 43.1% grade IV. The mean scores of the individual MIDAS items were: ltem 1 (Missed days of paid work) 2.0; Item 2 (Days with productivity at work reduced by half) 5.9; ltem 3 (Missed days of household work) 4.6; Item 4 (Days with productivity in household work reduced by half) 4.38; Item 5 (Missed days of leisure-social activities) 4.6. MIDAS scores for patients in paid work (166: 115 females, 51 males) were as follows: mean MIDAS score: 21.5. Grade distribution was: 11.4% grade 1, 17.5% grade II, 27.7% grade III, and 43.4% grade 1V.The mean scores of MIDAS items were: Item 1,2.1; Item 2, 6.6; Item 3, 4.4; Item 4, 4.0; Item 5: 4.3. Most of the patients in our large consecutive series of migraine without aura patients attending Headache Centres reported severe disability, with inability or limitations in all domains. Household and social-leisure activities were somewhat more affected than work activities. These findings confirm that migraine is an important cause of disability. Most of the past studies in this area have only assessed impairment in the work domain. Our study suggests that a comprehensive assessment of the impact of migraine requires thal impairment in all activity domains be aoalysed. This study was partially supported by the Italian Ministry of Health. P658 Migraine Patients: Plasmatic Levels Of Aspartic And Glutamic Acids. E. Toribio, M. Blanco, A. Hernanz, E. Diez Te)edor (Madrid, E) Introductions and objectives: The balance between excitatory and inhibitory mechanisms is ahered on the basis of migraine. The objective of our study is to identify possible differences in plasmatic levels of neuroexcitatory aminoacids. Patients and methods: We studied patients with migraine with and without aura (MA and M) a n d a control group (C). In the period without crises, blood was obtained by veinopuncture and the plasma levels of aspartic (Asp) and glutamic (Glu) acids was determined. PlCOTag (WATERS) test was employed and satatistical analysis was performed using ANOVA test. Results: The study included 42 patients, 27 women and 15 men, with ages between 18 and 62. Distributed in tree groups: MA 12 patients (31.3 -+ 7.58 years), M 12 patients (30.4 -+ 9.74) and C 18 patients (28.13 • 2.26). The aminoacid plasma levels was higher in MA (Asp: 14 +_ 12.67 and Glu: 57.22 +_40.8). We only obtained statistic significance in aspartic plasma levels in MA group against C group (p < 0.005). Conclusions: These results reveals that aspartic acid presents variations in MA patients to M and C. It could have relation with spreading depression, so the patients with recurrent crisis show higher levels of this excitatory aminoacid. More studies are necessary to confirm the value of these results. P659 Altered allelic distribution of a functional polymorphism within the promoter of the serotonin transporter gene in migraine without aura and migraine with aura. M. Marziniak, R. M6ssner, K.P. Lesch, C. Sommer (Wª D) Background: Migraine is one of the most common neurological disorders with an incidence of up to 25 % in the general population. The increased familial risk in migraine with aura (MA) and the typical clinical presentation indicate that MA and migraine without aura (MO) may have different aetiologies. Because of familial predominante a genetic component is not unlikely, but beside the mutations in familial hemiplegic migraine no consistent genetic trail has been found in the majority of patients with migraine. Dysfunctional genes in the serotonergic system are potential candidates in the pathophysiology of migraine, because the most effective drugs in acute migraine attacks are the triptans, highly selective serotonin agonists. Additionally there is a considerable co-morbidity of migraine with aura and depression.

Objective: We have performed an association study of the short variant of the serotonin transporter-linked polymorphic region (5-HTTLPR) on chromosome 17, which restricts transcriptional activity of the 5-HTT promoter leading to low functional expression of the 5-HTT. In former experiments the comparison of the allelic variants revealed that the activity of the long variant (1) was 2.5 fold higher than the short form (s) of the 5-HTT promoter. The lis and the s/s genotype is associated with low 5-HTT uptake activity. Methods: Venous blood samples of 119 patients with migraine (61 MA and 58 MO) were drawn. DNA was prepared from lymphocytes. Oligonucleotide primers flanking the 5-HTTLPR of the human 5-HTT region were used to generate a 484/528 bp fragments. Alleles were resolved by agarose gel electrophoresis. Results: The distribution of the genotype in controls (n=570) (s/s 18 %, s/l 49%, 1/I 33%) and patients suffering from migraine without aura (sls 17.5%, si150.9%, 1/1 31.6%) does not differ (p=0.92). However, in comparison to the control population the allele frequency of the less active short form in patients with MA is significantly increased (s/s 27.4 %, s/l 51.6 %, 1/1 21%) (p < 0.01). Conclusion: We showed an additional evidence for a genetic component in MA, but not in MO. 5-HTTLPR-dependent low transcriptional activity of the 5-HTT promoter is a genetic susceptibility factor for MA. P660 A Randomized, Double-Blinded, Placebo-Control.led, Cross-over Study of 2.5mg Naratriptan. Y.W. Noh, T.G. Lee, K.H. Park, S.M. Kim, K.C. Chung (Seoul, Pusan, KOR) Background: Naratriptan is one of the new | for the acute migraine treatment, but its effect for Asian patients is not known to our awareness. Design/methods: From December 1999 to November 2000, we studied the efficacy and safety of 2.5 mg oral naratriptan with a randomized, double-blinded, placebo-controlled, cross-over, multi-center design in Korea. The study was implemented al the out-patient clinic in three university hospitals. For diagnosis of migraine, we used the Headache Classification proposed by the International Headache Society (1988). We randomly assigned 102 migraineurs, of whom 62 completed the study. The primary endpoint was significant headache improvement after 4 hours of intervention, either 2.5 mg naratriptan or placebo. Results: The rate of significant headache improvement after 4 hours is statistically bigher with 2.5mg naratriptan administration (56.7%) than with placebo (34.8 %) (p =0.01). When 2.5 mg oral naratriptan was administered, the clinical disability score was significantly improved after 1, 2, and 4 hours. There was no difference in adverse effects between naratriptan and placebo. With the relevant laboratory monitoring, naratriptan 2.5 mg was sale at least in single oral dose. The headache recurrence rate after 24 hours, frequency of other medication use during migraine attacks, associate symptoms after 4 hours were better with naratriptan than placebo, but these were not statistically significant(p > 0.05). Conclusion: Comparing to previous studies on randomized trials of naratriptan, the rate of significant headache improvement (56.7%) was slightly lower in our study. This may partly reflect racial geneticlneuropharmacological difference, such as serotonin receptors, in Asians. We suggest that 2.5 mg oral naratriptan is effective and safe for the acute migraine treatment in Asians, as well as ('aucasians. P661 Platelet activation and platelet-leukocyte-aggregation are increased in migraine patients during the attack-free interval. ]. A. Zeller, K. Frahm, H. Goebel, G. Deuschl (Kiel, D) Background: The role of platelets in the pathophysiology of migraine has been subject of intense research in the past, especially because of the close relation of an assumed serotonergically mediated inflammatory process and the platelets as the largest body reservoir of serotonin. Studies have addressed this issue by investigating platelet aggregation, secretion products of intracellular transmitters all of which have individual technical limitations. Only limited information has emerged as to the role of leukocytes in the vasogenic inflammatory process, no data yet regarding platelet activation and platelet-leukocyte-interaction in migraine pathophysiology. Our study investigated platelet Ÿ and intercellular cross-talk using an advantageous flow cytometric technique, which detects early activation-related changes on the plalelet surface and minimises artifacts caused by platelet manipulation. Methods: In 71 patients with migraine and 71 matched controls we examined platelet activation by measuring the expression of the activation-dependent epitope P-selectin (CD62-P) and the in vitro activation of platelets

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afler stimulation with adenosine diphosphate and TRA P-6, a thrombin analogon. In addition, the fraction of platelets that had aggregated with leukocytes were measured by a CD41/CD45 double fluorescence technique. Resuhs: Migraine patients showed significantly increased expression of the activation dependent P-selectin in native blood (p=0.004), but were less responsive to chemical stimulation. Platelet-leukocyte aggregation was significantly higher in migraine patients (p=0.001). We found a difference in platelet activation a s a function of recent triptane use: patients who had taken ah oral or subcutaneous triptane (n=18) within three days prior to blood sampling did not differ significantly from controls (p=0.18) as opposed to non triptane users (p=0.002). Conclusions: Migraine patients consistently differ form controls regarding platelet activation and interaction with leukocytes. This could be due lo serotonin release and pro-aggregatory intercellular signalling. Ir remains unclear yet, whether this serotonin release triggers vasogenic inflammation or vice versa. Triptanes seem to influence these interaction even outside acute attacks. P662 Spontaneous Intracranial Hypotension and Epidural Blood Patch Treatment: a Clinical and Neuroradiological 18 Months Follow-up. S. Gillet, K. Windhausen, M. R. Timmermans, M. Halleux, R. Schoofs (Huy, B) We report 18 months follow-up of a case of spontaneous intracranial hypotension successfully treated by epidural blood patch. Case report: A 33 year-old woman, without traumatic history, suddenly developed orthostatic headaches. Neurological examination was normal but two weeks later horizontal diplopia related to lefl sixth nerve palsy was noted. CSF examination showed normal opening pressure and normal cell count but increased protein content( 1000 mg/l). Isotopic cysternography revealed abnormal radioisotope migration a n d a decreased radioactivity at the cerebral convexities. Head MRI showed diffuse pachymeningeal gadolinium enhancement and evidente of sinking of the brain with cerebellar tonsils descent through the foramen magnum. Spinal MR did not reveal CSF leak. Skin biopsy was normal (excluding Marfan syndrome). Early typical orthostatic headache resolved with bed rest and diplopia spontaneously improved within a few weeks. Nevertheless she developed lingering chronic daily headache with orthostatic increase. Conservative management failed and epidural blood patch was performed. Symptoms immediately improved. She remained asymptomatic within one year. Subsequent head MRI showed abnormalities resolution. Conclª Our observation suggests that epidural blood patch can be an effective treatment even ir CSF leak is not showed. Head MRI with gadolinium perfusion is a clue for diagnosis but seems to be also a safe and effective monitoring for therapeutic trials. P663 Relief of intractable chronic cluster headache by electrode implant to posterior hypothalamic gray matter: the first reported case. M. Leone, A. Franzini, D. D'Amico, L. Grazzi, A. Rigamonti, S. Usai, G. Broggi, G. Bussone (Milan, I) Because of the excruciating nature of the pain and that fact that surgical approaches are generally unsuccessful, chronic cluster headache that does not respond to medication represents a major clinical problem. May A et al. (Lancet 1998) used positron emission tomography (PET) to demonstrate activation of the inferior posterior hypothalamic gray matter homolateral to the pain during induced cluster headaches. Several other lines of evidence indicate that the cluster headache generator is located in this region. We presenta 38-year old man who had suffered from intractable, highly debilitating chronic cluster headache for four years, diagnosed in accord ance with International Headache Society criteria. Brain and orbital MR1, CT-angiography, and other examinations were all unremarkable; interven tion on the trigeminal nerve was contraindicated. After informed consent we decided to try stereotactic electrode implan tation, targeting the inferior pnsterior hypothalamic gray matter homolateral to the pain, with the aim of inhibiting putative neuronal activation of this atea. A quadripolar electrode connected to ah ITREL II pulse generator was used (both supplied by Medtronic, Minneapolis, USA). No changes in arterial blood pressure, heart rate or skin temperature were observed d u r ing intraoperative stimulation or during the post-operative course. The patient has been completely pain-free over the 166 days of stimulation following implantation. However switching off stimulation results in the reap pearance of typical attacks which disappears again when stimulation is reactivated. This is the first case of intractable chronic cluster headache successfully

treated by electrode stimulation of the posterior hypothalamic gray matter. The case provides vivid confirmation that the cluster headache generator is located in this region. P664 Migraine In France In 2000: Therapeutic Data. C. Lucas, M. Lanteri-Minet, J. P. Aura),, G. Duru, G. Chazot, I. F. Dartigues, P. Henry, A. Pradalier, A. El Hasnaoui, A. E Gaudin (Lille, Nice, Lyon, Bron, Bordeaux, Colombes, Marly Le Roi, F) Objective: GRIM 200 is an epidemiology survey on migraine that was performed in France in year 2000, ten years after the first one (GRIM). The goal of this study was to estimate the evolution of epidemiological data since ten years, and to assess the impact of triptans on the disease management and social repercussions of migraine. Methods: The survey was carried out by I. S.L, a national institute, on a representative sample of 10,585 subjects in France aged 15 years and older according to the quota method. There were 2 successive home interviews. Persons suffering from headache were selected during the first interview, or screening. They were then contacted for a second interview with a validated questionnaire for diagnosis of migraine. This questionnaire was the same used in 1989 with supplementary questions concerning triptans. Results: We found a 8.2% prevalence of certain migraine (1-1 and 1-2 IHS) a n d a 17.3% prevalence of certain migraine and migraine disorder (1-7 1HS). Only 5.65% of headache sufferers (n=1486) were treated by triptans. By these 5.65 % of patients using triptans, we found 4.23 % of migraine sufferers, 0.2% of tension-type headache and 1.2% of chronic daily headache. We found that 2.96% of general population were chronic daily headache patients (n=152), including 18 patients who were triptans abusers (11.8%). Comments: This study confirmed that triptans use by migraine patients is very low in France in general population. Overuse of triptans seems to be low in comparison with others drugs. P665 Migraine In France In 2000: Epidemiology Data. P. Henry, 1. P. Auray, G. Duru, G. Chazot, ]. E Dartigues, M. Lanteri-Minet, C. Lucas, A. Pradalier, A. El Hasnaoui, A. E Gaudin (Bordeaux, Lyon, Bron, Nice, Lille, Colombes, Marly Le Roi, F) Objective: A French national epidemiological study on migraine was presented 10 years ago at the Migraine trust. It was the first study to cover an entire country (Henry Pet al. (1991) Migraine prevalence in France. In New advances in headache research: 2. Ed. Clifford Rose, Smith Gordon, pp: 11 - 14). This study has provided also data on the burden of migraine in terms of its economic and social impact. Wc would like today to update the data. Methods: 1486 persons, aged over 15 and suffering from headaches were randomly selected from a large representative sample of the French population. They were asked to complete a questionnaire, which allowed discriminating sufferers of migraine according to IHS criteria. Results: Among the 1486 headache sufferers, we find 880 migrainous people ( 1-1, I-2 and 1-7 IHS criteria), 454 without migrainous headache and 152 with chronic daily headache. Ir we compare the results of the certain migraine group (1-I and 1-2 IHS) we find that they are identical (8.1% (1989) versus 8.2 % (1999)). However, if we include the migrainous disorder group fulfilling all criteria but one (1-7 ItIS), the prevalence rate for migraine headache in France between 1989 and 1999 seems to show a clear increase, rising from 12.1% to 17.3 % because of less restrictive criteria than those applied ten years ago. Regarding the prevalence in general population for chronic daily headache the rate is around 3% with 1.8% formen and 3.9% for women in 1999. P666 Chronic headache associated with bilateral cerebellar calcifications in celiac disease. V.I. Leussink, M. Warmuth-Metz, K.V. Toyka, M. Naumann (Wª D) Background: Celiac disease is a malabsorption syndrome characterized by intolerante to dietary gluten and typical lesions in the smal] intestine. Neurological complications occur in about 8-10 % of patients with the disease consisting of peripheral neuropathy, progressive multifocal leucencephalopathy, cerebellar ataxia, occipital calcifications with seizures, and myopathy. Case report: We present a 21-year-old female patient with celiac disease who developed chronic headache, fatigue, dizziness and slight dysarthria after diarrhoea,loss of weight and malabsorption had improved under gluten-

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free diet. Brain computer topography scan and magnetic resonance imaging revealed subcortical demyelinating lesions and bilateral cerebellar calcifications. Antibodies to endomysial tissue (EMAs) were positive (1:40), antigliadin antibodies (AGAs) were negative. Further laboratory results including antinuclear antibodies, folic acid, vitamins were normal. Lumbar puncture showed no pathological findings. Treatment of the headache with analgesics was very difficuh. Conclusions: For the first time, we describe the coexistence of chronic headache and bilateral cerebellar calcifications in a patient with celiac disease. The mechanisms responsible for neurological complications in celiac disease remain speculative. Vitamin E deficiency and potential neurotoxin effects of antigliadin antibodies are possible candidates. The association of celiac disease with cerebral calcifications anda diversity of neurological disorders even in the absence of concomitant gastro-intestinal signs is remarkable. P667 Migraine and tension-type headache in Croatia. A population-based survey of precipitating risk factnrs. R. Zivadinov, K. Willbeim, 13.S. Grahovac, O. Brnabic, M. Bucuk, G. Relja, A. lurjevic, G. Cazzato, M. Zorzon (Trieste, 1; Rijeka, HR) Objective: To investigate the association of precipitating risk factors with migraine and its subtypes, and tension-type headache in a population-based survey among Croatian adults, in Bakar, County of the Coast and Gorski Kolar. Background: The careful monitoring of trigger factors could be ah important step in treatment, because their avoidance may lessen the frequency and severity of migraine. Furthermore, they may provide a clue for aetiological studies. Methods: We performed a population-based survey using"face to facedoor to door"interview method. The par ticipants (73.3 % of whole surveyed sample) were screened for headache history according to the IHS criteria. Headache screen-positive responders, 2475 (65.7%), were interviewed by trained medical students with a structured detailed interview focused on migraine and tension-type headache. The following precipitating risk factors in lifetime migraineurs and tension type headachers have been assessed by using univariate and multivariate statistical techniques: stress, sleep disturbantes, afferent stimulation (flickering light and noise), food and eating habits, changes in weather conditions and temperature, hormonal changes (menstrual cycle and use of oral contraceptives), diminished working performances and frequent travelling. Results: A total of 720 lifetime migraineurs and 1319 tension-type headachers were identified. In the conditional multiple Iogistic regression analysis, stress (OR 1.88, 95 % CI 1.51-2.35, p < 0.00001 ), diminished working performances (OR 1.61,95 % CI 1.29-2.1, p _<0.00001 ) and afferent st imulation (OR 1.5, 95% CI 1.16-1.9, p= 0.0005), have been independently associated with migraine. Comparing migraine with aura (MWA) and migraine without aura (MWOA), changes in weather conditions (OR 1.82, 95% CI 1.33-2.47, p= 0.0001), food and eating habits (OR 1.82, 95% CI 1.33-2.47, p= 0.0001) and frequent travelling exhibited a significant positive association with MWA. None of the screened trigger factors was associated with tension-type headache. Conclusions: The study of common precipitating risk factors in this population-based survey demonstrated that lifetime migraineurs experienced more frequently attacks preceded by triggering factors than tension-type headachers. MWA was more frequently associated with precipitating risk factors than MWOA. We conclude that some precipitating risk factors may contribute to migraine aetiology. P668

Percutaneous Microcompression of Gasserian Ganglion With Balloon in Trigeminal Neuralgia: Presentation of 40 Cases. A. P. Narata, S. Hunhevicz (Curitiba - Parana, BR) Objective: To present the results of 40 procedure in 32 patients with trigeminal neuralgia (TN) who were submitted to percutaneous micro compres sion of Gasserian Ganglion with balloon. Methods: The series consist of 28 women and 4 men, overage of 64 years old (from 29 up to 87 years old). Only V2 division on the right was affected in 10 tases and 7 on the left, with 2 to 20 years of evolution. We performed CT scan and M RI for every patients ( 1 case of meningiomas in cavernous sinus, 1 case of basilar giant aneurysm, 1 case of multiple sclerosis and 1 case of Charcot-Marie Tooth disease). 28 cases of primary trigeminal neuralgia. Results: There was immediate pain relief in the pos procedure period in all cases. The medication was reduced and finally taken out in every patients. We did not see facial anaesthesia or absent corneal reflex in the late pos pro-

cedure time (more than 6 months), also they remained asymptomatic and with no medical therapy. Complications: recurrence rate of 20 % (6 months to 1 year and 8 months)and temporary facial hypoesthesia. Conclusion: The percutaneous micro compression of Gasserian Ganglia with balloon is a ambulatorial treatment,well tolerated by aged patients with no condit ions of general anaesthesia. The procedure might be repeated without risk of Gasserian Ganglion lesion permanent. Finally, there was no anaesthesia dolorosa or facial hypaesthesia (not so rare in others surgical treatments for TN) P669

Migraine prophylaxis with Magnesium-Valproate: efficacy and predictive factors in an open-label 6 months study. B. Colombo, F. Martinelli Boneschi, P. Rossi, G. ComŸ(Milano, I) In this single-center, open-label, 6-months study we evaluated the efficacy, safety and predictive factors of responsiveness of a migraine prophylactic agent, Magnesium Dipropilacetate (Magnesium-Valproate-MV), in patients who have been not responsive to at least two previous treatments ("Refractory migraine"). Outcome of the study is represented by the difference of number of days of pain at the two different follow-up of 3 and 6 months of therapy, compared to the 3 months before the treatment.A regression model was used to study the relationship between different independent variables and the main outcome of interest (days of reduction of pain after 6 months of therapy). We enrolled 45 patients (12 male, 33 female; mean age: 36.1, 13 affected by migraine with aura and 32 by migraine without aura; mean duration of disease 11.7 years). MV dosage was initially titrated to 500mg in a l-month period. The final MVdosage ranged from 750 to 1200 mg. 3 patients were lost at the 6-months follow-up. We evaluated the single contribution of each of the following variable to the outcome of interest in a simple regression modeh sex; age; type of migraine; comorbity of depression or anxiety; previous anti-migraine prophylactic therapy (beta-blockers; calcium-antagonist; metisergide); days of pain in the three months period before the beginning of treatment; number of analgesic drugs used in the three months observational period before therapy; MV dosage; number of side-effects due to MV at follow-up.We included into the final model only the variables found to be significant at the single leve[ at.1 cut-off. In the multiple regression model the type of migraine and the days of pain before the beginning of MV therapy were found to be significant predictor of the responsiveness to therapy. We can conclude that migraine with aura (p < 0.0001 ) and number of days of pain before the beginning of therapy (0.0006) actas strong predictor to the responsiveness of MV therapy in patients affected by"refractory migraine". We also found a high positive correlation between the difference of days of pain at 3 month follow-up and the difference of days of analgesic therapy, showing that same predictor should be considered for these parameters. Side effects were also analyzed and will be reported. P670 Central 5-HT receptor sensitivity in migraine. E. Cassidy, E. Tomkins, O. Hardiman, V. O'Keane (Dublin, IRL) Background: Serotonin has long been implicated a s a key neurotransmitter in migraine, a disorder that is highly stress-responsive. There is a dearth of research specifically examining 5-HT1A receptor sensitivity in migraine despite the importance of this receptor in regulating central serotonergic tone. The neuroendocrine challenge paradigm for assessing central 5-HT receptor sensitivity has been a relatively neglected research tool. Objective: "Ib examine the hypothesis that migraine is associated with hypersensitivity of central 5-HT1A receptors. Methods: 7 female subjects with International Headache Society (IHS) migraine without aura, 7 subjects with migraine and chronic daily headache and 7 healthy female controls were evaluated. Because of the known variation of 5-HT1A receptor sensitivity at different stages of the menstrual cycle, all such subjects were assessed during the first 5 days of the menstrual cycle. No subjects were taking psychotropic medication, hormonal or migraine prophylactic treatment. Patients with current or previous psychiatric disorder were excluded. Following an overnight fast, serum prolactin was assessed at baseline and every 30 minutes for 3 hours following a single dose of 30 mg oral buspirone, a 5-HT1A-receptor agonist. Results: Subjects with migraine without aura h a d a significantly increased prolactin response to buspirone (delta max) compared to controls (p < 0.05). Subjects with migraine and co-morbid chronic daily headache hada relative blunting of this increased response although the difference did not reach statistical significance. Conclusion: These preliminary results support the hypothesis that mi-

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graine without aura is associated with a relative hypersensitivity of central 5-HT1A receptors. This is of relevance given the role of the pre-synaptic 5HT1A receptor in controlling raphe 5-HT tone and of the post-synaptic 5HT1A receptor in mediating tolerance to adversity/chronic stress. P671 The burden of chronic daily headache. E. Cassidy, M. Butler, E. Tomkins, O. Hardiman, V. O'Keane (Dublin, I RL) Background: Chronic daily headache is commonly encountered in the specialty headache clinic. Despite the explosion of research into and new treatment possibilities for migraine,'chronic daily headache' remains difficult to treat and is associated with significant morbidity. Objective: To investigate disability and psychological burden in people with cbronic headache. Methods: 215 consecutive new referrals (82% female; age 37 -+ 1 years) to a migraine/headache clinic were assessed over a 1-year period. Mean duration of headache was 10 -+ 1 years at presentation. Headache subtype was defined according to lnternational Headache Society (1HS) criteria. Occupational and social disability was assessed using the MIDAS. Anxiety and depression were assessed using the Speilberger Stait-Trait Anxiety inventory (STAI) and the Beck Depression Inventor), (BDI). Premorbid vulnerability was assessed using the Eysenck Personality Questionnaire (EPQ). Results: The majority of patients had IHS migraine without aura (50 %) or with aura (19%). 20% had IHS tension-type headache, 2% had cluster headache and 9% had other headache subtypes. Mean headache frequency/month was 10 -+ 1 days and mean number of missed work days in the previous 3 months was 5 + 1 days. 20 % of all patients had'chronic daily headache'. When compared to those with episodic headache, patients with chronic daily headache had significantly more symptoms of depression (P < 0.01). There was no difference in anxiety levels or EPQ neuroticism, extraversion or lie scores between groups. Chronic daily headache patients also had greater MIDAS headache-related disability (P < 0.001 ) with significantly more lost work days (p < 0.01). There was a sinificant reduction in MIDAS disability at 6-month follow-up in the group a s a whole. Conclusion: Chronic daily headache is associated with significant disability and mood disturbance. P672 Gabapentin In The Treatment Of Sunct Syndrome. J. Porta-Etessam, M. Toledo Heras, A. Berbel-GarcŸ A. MartŸ J. Benito-Le£ E Bermejo P (Madrid, E) Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome) is a primary headache, marked by trigeminal pain in association with autonomic symptoms. The pain is of short duration (5 to 250 seconds), stabbing or burning in quality, abrupt, frequent ( 1 per da), to 30 per hour) accompanied by lacrimation, nasal stiffness, rhinorrhea, and conjunctival injection. Several types of drugs (carbamazepine, sumatriptam, lamotrigine, prednisolone, and nonsteroidal antiinflammatory drugs) have shown little benefits. We describe a woman with SUNCT who was treated successfully with gabapentin (GBP). A 55-year-old woman presented with a 1-year history of headache. The pain was described as severe and throbbing located in the left right retro-orbital area. The pain occurs in paroxysms lasting 60 seconds. The pain was accompanied by ipsilateral lacrimation of the eye, swelling of the brow, nasal stiffness and conjunctival injection. No phono or photophobia or nausea was present. No precipitating mechanisms were identified. The frequency of attacks was 3-4 episodes per da)'. Clinical and neurological examination and MRI of the brain were normal. The patient had tried multiple medications without success. Anamnesis was unremarkable except for glaucoma. Because of the glaucoma we decided not to attempt with carbamazepine, and we decided to treat the patient with gabapentin 300mg tid. After one montb the attacks were abolished. Three month later gabapentin was stopped without any recurrence of the pain. SUNCT appears to be refractory to medical therapy. Preventive agents that have been tried in SUNCT. Only carbamazepine alone or in combination with corticosteroids and lamotrigine has shown partial effect in some patients. GBP as well as carbarnazepine and lamotrigine are an antiepileptic drug used in the treatment of diabetic neuropathy pain, postherpetic neuralgia and trigeminal neuralgia. GBP has demonstrated an analgesic effect for the treatment of neuropathic pain. Because GBP has a favorable side effects profile, some authors consider GBP a first-line treatment for neuropathic pain. GBP mechanisms of action are still not thoroughly defined. Our observation has to be confirmed with other cases. Ir so, we consider that GBP could be an option in treatment of patients with SUNCT syndrome.

Poster session - 5 P673 Prevalence of Headache in Behget's Disease. R. Monastero, G. Triolo, M. Mannino, G. Lopez, C. Pipia, L. Camarda, A. Ferrante, R. Camarda (Palermo, I) lntroduction: To investigate the prevalence and features of chronic or recurrent headache in Behqet Disease, and the relationship of such headache with otber manifestations of the disease. Methods: Nineteen patients (9 women and 10 men) with a mean age :!: ds of 31.1 + 10.0 were included. To assess the severity of BD the Behqet Current Activity Index (BCAI - Bhakta et al., Rheumato11999) was applied. The current daily dosage of prednisone (mg/day) was recorded. Anxiety and depression levels were evaluated with the Hamilton Anxiety (HA) and Depression (HD) Rating Scales. Finally, HLA-B51 antigen positivity was tested. Results: Fifteen patients (78.9 %) presented headache; of these, 6 patients showed migraine without aura [IHS code = 1.2], 4 a migraineuous disorder [IHS code = 1.7], 1 h a d a non-classifiable headache [IHS code -- 131 and 1 suffered from a chronic daily headache. In 3 patients headache attacks was striking associated to colchicine consumption whose withdrawal ceased or reduced frequency or intensity of headache attacks. Headache in general was not more frequent after the onset of BD (p > 0.10), but there was a significant increase in headache attacks after the beginning of BD simptomatology (p < 0.01). Seven patients (40%) showed HLA-BS1 antigen positivity. There was no relationship among severity, frequency and duration of headache attacks and current steroid medication, BCAI levels, and HLA-BS1 positivity. Conclusion: Headache attacks occur frequently in BD patients, and increase in frequency after the beginning of the disease. In about 16% of BD patients headache attacks were directly related to colchicine therapy. P674 Brainstem Auditory Evoked Potentials In Rhythmic Palatal Myoclonus. R. E. Togrol, Y. Gurtekin, A. Gungor, M. Sarar N. Akyatan (Shape, B; Istanbul, TR) Rhythmic Palatal Myoclonus (RPM) is a rare movement disorder consisting of syncronous jerks of the soft palate, sometimes also involving pharynx, larynx and other muscles innerved from the brainstem. Most frequently the first complaint is the objective tinnitus. A structural gross lesion at the brainstem or cerebellum can be shown in a few of the patients, while in most no such lesion can be seen. There may be some differences in the nature of the symptoms between these two groups of patients, although it has been proposed that, there is a functional (and sometimes morphological) disorder in the inferior olivary nuclei of all. In this study, 5 male patients with RPM were evaluated. The ages of the subjects were between 20 and 25. In four of the subjects no morphological lesion was shown with CT and MRI, while in one there was a cystic lesion and accompanying destructive area in the right jugular foramen. In all patients, brainstem auditory evoked potentials were performed. Normal results were obtained from the four "essential" cases, while there were latency abnormalities in the one "symptomatic" patient. The results of the electropbysiological and radiological studies are discussed in the light of examination findings and the findings from other investigations. Since the auditory pathways are probably different from the structures involved (with discrete lesions) in the myoclonus, the evoked potentials are usually found to be normal. In the case of diffuse and multifocal lesions, there may be abnormal resuhs. P675 Functional Electricai Therapy (FET) for lmproving Upper Extremity Movement in stroke patients. D. Popovic, M. Popovic, T. Sinkaer (Aalborg, DK) Use of electrical stimulation to nerves in the lower extremities has been shown to produce a therapeutic effect with decreases in spasticity, increases in walking speed, energy efficiency of walking, and muscle strength in brain injured patients. The mechanisms by which those changes are occurring are still unknown. It is speculated that it could be due to use-dependent changes within the CNS. The brain possesses the capability to reorganize itself in such a way that it allows neighboring cortical regions to expand into territories normally occupied by input from other organs. Manipulating sensory input, one can modulate the magnitude of cortical response and modulate motor pathway excitability which can produce a mixture of excitation and inhibition at supraspinal levels. E. g. sensory stimulation has shown to effect the cortical representation of hand and esophagus in healthy humans.

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Here we hypothesised that subjects shortly after sub-acute stroke ir exposed to electrically augmented exercise called Functional Electrical Therapy (FET) will better and faster recover their ability to reach and grasp. We applied FET to the hand muscles in the paretic arre for three weeks using a four-channel surface electrical stimulation system that dones able-bodied grasping synergy. Eight subjects were randomly assigned to FET and control groups. Subjects were between 50 and 72 (60.75 -+ 3.2), have a hemiplegia caused by the middle territory cerebral artery, and admitted to the study between 2 and 6 weeks after the stroke. Their spasticity was average to strong (Ashwort scale, between 1+ and 4). After three weeks the FET group (blinded study) showed better functioning measured by Upper Extremity Function Test (UEFT) than controls: 55.4 % in FET group, 44.5 % in control group. The FET group sbowed better co-ordination; subjects were able to track selected geometric shapes faster and with higher accuracy their improvement was better when handling little objects. Although substantial difference in functioning exists among the study participants, they all succeeded to improve their use of the paretic arre after FET. The UEFT test included 11 tasks. The total numbers N of the tasks (maximum 44) that the subjects could not accomplish were Nb = 18 (b - beginning), and Na = 5 (a - afier) for the FET group, and Nb = 7, Na = 6 for the control group. One of the subjects showed only marginal improvement. She has cognitive problems that compromised the therapy. AII subjects from the FET group responded very enthusiastically to the therapy. The results suggest that FET is effective in improving hand function in stroke patients shortly after CVI. Long-term follow-up study will follow.

Peripheralneuropathy P676 Transcription Factor NF-kappaB and its Inhibitor IkappaB in the lnflamed Peripheral Nervous System. B. C. Kieseier, B. Andor fer, E. Mathey, P. Armati, H.-P. Har tung (Graz, AT; Sydney, AUS) Members of the nuclear factor kappaB (NF-kappaB) family of transcription factors play important roles in immune, inflammatory and apoptotic responses through the induction of numerous cellular genes. To study the expression pattern of the transcription factor NF-kappaB and its inhibitor lkappaB in immune-mediated demyelinating polyneuropathies sural nerve biopsies from patients with Guillain-Barr› syndrome (GBS), chronic in_ flammatory polyradiculoneuropatby (CIDP), and, for comparison, various non-inflammatory neuropathies were studied. In inflammatory demyelinating as weU as non-inflammatory neuropathies NF-kappaB was primarily expressed by macrophages, as determined by immunohistochemistry. IkappaB, however, could be localized to macrophages as well as T cells in inflammatory demyelinating neuropathies, whereas in non-inflammatory controls Schwann cells were found to be the primary cell type expressing this inhibitor. Quantitation of immunoreactivity revealed a statistically signifi cant increase of NF-kappaB expression in inflammatory demyelinating cases compared to controls. The present observations point to macrophages as the major cell type expressing NF-kappaB in acute and chronic inflammatory demyelination of the peripheral nerve, indicating a key position of this transcription factor in the signalling cascade of various proinflammatory mediators during o n g o ing disease. As such NF-kappaB appears to be a suitable target for modulating the inflammatory process in the PNS. P677 Guillain-Barr› syndrome presenting with urinary retention. G. Lauria, D. Pareyson, Gr. Manobianca, M. Lastilla, E Locatelli, A. Sghir]anzoni (Milan, Acquaviva delle Fonti, Crema, I) Predominantly acute autonomic neuropathy represents a rare variant of Guillain-Barr› syndrome (GBS) and is more frequently characterized by cardiovascular involvement complicating the course of the disease. We describe two patients in whom GBS presented with urinary retention. A 16 year-old boy and a 52-year-old woman complained of severe voiding difficulty and were submitted to an urologic evaluation. A residual urinary volume of 2,600ml and 800mi was found, respectively. A few days later, paresthesia involving distally the limbs and the perioral region, reduced bladder sensation, gait unsteadiness, orthostatism, and fatigue developed. The younger patient had experienced an Epstein-Barr virus infection one week before. He showed more severe autonomic dysfunctions, characterized by profound orthostatic hypotension with tachycardia, ahered thermoregulation, sexual impairment, nausea, vomiting, diarrhoea, and significant weight loss. Pupil reactions were normal. Both patients had global areflexia,

gait ataxia, reduced proprioceptive sensation anda length-dependent loss of light touch, pain, and temperature sensation which invo[ved also the trunk in the younger patient. They did not complain of muscle weakness, ahhough strength was slightly reduced in the distal muscles of the extremities. Electrodiagnostic studies showed a demyelinating sensorimotor neuropathy consistent with GBS. Screening for porphyria was negative. Cerebrospinal fluid examination showed an albuminocytologic dissociation, more severe in the younger patient (protein 260mg%). Urodynamic studies disclosed bladder areflexia in both patients. Autonomic function tests revealed absent sympatbetic skin response, impaired heart rate variability on deep breathing, and abnormal Valsalva ratio. A 24-hrs Holter electrocardiogram showed no abnormality in the younger patient. Both patients received intravenous immunoglobulin; the younger one was treated also with plasmapheresis, but showed a poor recovery at four-month follow-up. Ahhough the prevalence of autonomic disturbances in GBS increases directly with the intensity of the search, autonomic forros are uncommon entities and frequently share various features with acute pandysautonomia. Particularly, micturitional disturbances can be tbund in about 25 % of patients with GBS and, ahhough rare at the onset of the disease, should raise the hypothesis of a dysautonomic variant of acute infiammatory polyradiculoneuropathy. P678 Oncostatin M (oncM) is increased in chronic inflammatory demyelinating polyneuropathy (CIDP). G. De Luca, M. Capasso, C. larlori, A. Di Iorio, R. Paganelli, D. Gambi, A. Uncini, A. Lugaresi (Chieti, I). Background: The etiopathogenesis of chronic inflammatory demyelinating polyneuropathy (C]DP) is still unknown. Both humoral and cellular immune responses appear to be involved. Pro-inflammatory cytokines are involved in inflammatory cell recruitment in the nerve, activation of cell-mediated effector mechanisms and may directly aher neuroglial and neuronal cells survival and function. Oncostatin M (oncM) is a proinflammatory cytokine with pleiotropic activities suggesting a supporting role in immunemediated inflammatory processes acting on cells of neural, vascular, hematopoietic and lymphoid origin. The involvement of oncM has not been investigated, to our knowledge, in CIDP. Objective: to assess oncM spontaneous production by PBMC in 9 CIDP pts (5 M, 4 F; mean age: 64.4, range: 35-80), compared to 6 healthy controls (HC) (2 M, 4 F; mean age: 42.0, range: 31-54). Statistical analysis was performed using Kruskal-Wallis one-way Anova corrected for ties. Resuhs: we found that mean spontaneous production of oncM in 72-hr PBMC cuhures was significantly higher in active CIDP patients compared to HC (HC 201.9 _+ 21.4 pg/ml vs C[DP 475,4 :t: 67.9 pg/ml; p::0.009). Conclusions: our resuhs, although based on very small numbers, show that PBMC from CIDP patients spontaneously produce high levels of oncM during the active phases (relapse or progression) and suggest a basa1 activation of the immune system in which oncM may playa role in maintaining the complex circuitry of molecular and cellular interactions responsible of CIDP pathogenesis. P679 A case of Miller Fisher syndrome with diffuse abnormalities on MRI. B. Piechowski-Jozwiak, B. Szyluk, A. Kuczynska-Zardzewialy, H. Drac, H. Kwiecinski (Warsaw, PL) The Miller Fisher syndrome has long been believed to be a variant of Guilhin-Barr› syndrome. In many cases however the MRI reveals lesions located in the brain stem and cerebellum as well as in the cerebral white matter. A combination of central and peripheral demyelination is therefore suggested as causative mechanism. We report a case of61-year-old woman with a history of Helicobacter pylori positive peptic ulcer disease and recent upper airways infection who was admitted to the neurological intensive care unit due to subacute onset of double vision,imbalance, nausea, dysphagia, nasal speech and tingling in the hands. Neurological examination revealed bilateral ptosis and complete ophthalmoplegia, bilateral facial nerve palsy, bilateral soft palate palsy, mild paresis of left upper extremity, areflexia in lower extremities and ataxia. Biochemical, hematological and renal function investigations were normal except for elevated AST and ALT levels. Virological tests were positive for HCV. Borreliosis was ruled out both in serological and CSF examination. The patient was negative for Clostridium botulinum toxin. Tests fi~r AIP were also negative both in serum and faeces, in consecutive three CSF examinations albuminocytological dissociation was demonstrated. Non contrast CT of the brain showed bilateral paraventricular hypodense lesions. T2-weighted and PD brain MRI revealed bilateral areas with increased signal intensity in the periventricular white matter with no contrast enhancement. Follow-up T2weighted MRI demonst rated foci of increased signal intensit y in cerebral pe-

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duncles. Multimodal evoked potentials (SEP, BAEP, V EP) were within normal limits. Nerve conduction studies revealed axonal neuropathy of sensory and motor fibers and slightly delayed F-responses. Repetitive nerve stimulation did not show a significant decrement with either low or high frequency of stimulation. The patient received a 5-day-course of intravenous immunoglobulins (0.4 g/kg) followed with methylprednisolone i. v. The patient gradually improved and was discharged 6 weeks from the onset with bilateral internal ophthalmoplegia, mild bilateral impairment of horizontal gaze and dysdiadochokinesis. In conclusion we would like to state that this patient suffered an acute illness with complete ophthalmoplegia, ataxia and areflexia with partial recovery. Although cerebral lesions outside the brainstem were seen on MR1 the diagnosis of Miller Fisher syndrome was finally considered.

P680 Relationships between clinical symptom severity scales and nerve conduction studies in carpal tunnel syndrome. ~. Tª B6rª M. Gª252 G. Bulut, A. Ozdemir (Kartal/Istanbul, TR) Purpose: This study examined the severity of symptoms in carpal tunnel syndrome (CTS) in relation to nerve conduction measure of the median nerve. Methods and patients: Forty-six patients participated in this study yielding 74 hands with CTS. There were 2 men and 44 women. The average age was 39,02 -+ 11,6 (range: 23-61 ). Patients diagnosed with unilateral or bilateral CTS at the Elect romyography Laboratory. The patients completed an 11item questionnaire. Nerve conduction studies were performed using standard techniques with surface electrode recording. Sensory responses were obtained antidromically. Pearson's correlation analysis was used to assess the relationships between the clinical symptom severity scales and electrodiagnostic measures. In addition, factor analysis was performed to explore underlying variables that explain interrelationships among clinical symptom scales. Results: Significant correlations were obtained for all the relationships within each of the following groups: (1) numbness, tingling and nocturnal symptoms and pain, weakness and clumsiness groups (2). There are correlation between sensory peak latency and motor onset latency. The correlation was obtained in the relationship between sensory peak latency and sensory conduction velocity. There is no correlation between secondary sym]~toms and median nerve studies. We found a significant correlation between the nocturnal symptoms in CTS and sensory latency, distal motor latency of the median nerve. Conclusion: In this study was found that the significant relationship only between nocturnal symptoms and median nerve conduction measures. Levin et al found no correlation between symptoms and conduction velocity of the median sensory nerve. In other studies, there was a significant relation between the clinical symptoms and nerve conduction measures.

P681 Hand flick test sensitivity in diagnosing Carpal Tunnel Syndrome. L. Capone, R. Pentore, R. Gentile, R. 8choenhuber (Bolzano, I) Background: Reduction of nerve conduction velocity is found in compression neuropathies, and it has become the gold standard to diagnose Carpal Tunnel Syndrome (CTS). However, the early stages of CTS are characterized by positive symptoms such as pain and tingling, due to increased impulse generation in the affected nerve, without impairment of nerve conduction. For this reason and because of economic considerations, clinical signs, such as Phalen's, Tinel and, more recently the hand flick test, have been claimed to be as sensitive as clinical neurophysiological tests. Airo of the study: to compare the hand flick test with the severity of nerve compression in CTS. Material and methods: 269 consecutive CTS patients grouped for electrophysiological severity according to Padua (1997) were examined. Each patient was asked 2 questions: which manoeuvre improves symptoms (spontaneous flick test) and, if no answer was given, if flicking the hand would relief the symptoms. Results: 209 were females, mean age 52.4 (range 17-89). CTS was rated as slight, moderate, severe, extreme. Positive Flick's sign was found in 49% EMG negative and in 56% positive patients. No statistically significative difference is found between groups. Comment: The flick test is reported spontaneously by far less patients then previously reported. It might improve diagnostic sensitivity, but its value has still to be confirmed.

P682 Local immunosurveillance by different populations of resident endoneurial macrophages in the peripheral nervous system: an ex vivo study using green fluorescent protein bone marrow chimaeric mice. C. Leonhard, M. Mueller, K. Wacker, M. Okabe, E. B. Ringelstein, W. F. Hickey, R. Kiefer (Mª ster, D; Osaka, J; Lebanon, N. H., USA) Resident endoneurial macrophages may play important roles in the pathogenesis of inflammatory and degenerative neuropathies due to their strategic position within the endoneurium. Studies in normal nerves from radiation bone marrow chimaeric animals indicate that only a portion of resident endoneurial macrophages undergo slow replacement from the blood, suggesting a long-term resident macrophage population. Using a rat bone marrow chimera model we recently demonstrated that resident endoneurial macrophages get activated, proliferate and phagocytose myelin aftera sciatic nerve crush lesion in vivo. We now wanted to know whether long-term resident endoneurial macrophages and macrophages recently immigrated from blood during normal turnover are functionally different. We therefore studied sciatic nerve explant cultures from radiation bone marrow chimaeric mice created by transplantation ofbone marrow from green fluorescent protein (GFP) transgenic mice into irradiated C57/B16 recipients. In such explants, recently immigrated resident endoneurial macrophages are green, while long-term residents ate not. In explants from wildtype mice, resident endoneurial macrophages progressively increased in size, retracted their branches and took u p a rounded appearance. Immunocytochemical colocalization with myelin basic protein demonstrated the ability of activated resident macrophages to phagocytose myelin, and proliferation was shown by nuclear incorporation of bromodeoxyuridin. In nerves from chimaeric mice three months after bone marrow transplantation, about 50 % of all resident endoneurial macrophages in sciatic nerve were GFP-positive, indicating their recent immigration from blood, while the remaining macrophages were GFP-negative, long-term residents. When comparing these two populations in explant cult ures, we found a similar pattern of morphological activation, a comparable increase in number and no difference in their ability to phagocytose myelin. In summary, resident endoneurial macrophages become rapidly activated in explant cuhures without the influence of haematogenous factors, indicating ah intrinsic property of peripheral nerve and supporting an important tole of resident macrophages in the response to nerve lesions. Activation occurred similarly in long-term resident endoneurial macrophages and endoneurial macrophages recently immigrated from blood, arguing against distinct functional properties of these two populations afler peripheral nerve iniury. P683 Peripheral Neuropathy in Diabetes Mellitus. V. Yayla, K. Sarici, M. Ufacik, Y. Altuntas, F. Ozer (lstanbul, TR) Neuropathy is the most common disabling complication of diabetes mellitus and its incidence varŸ between 7-80 %. The aim of this study is to eva]uate the peripheral nervous system in diabetic patients. Any medication, hypothyroidism, nephropathy or other systemic diseases causing polyneuropathy were the exclusion criteria from the study. In the electrophysiological examination, sensory and motor nerve conduction studies of nervii medianus, ulnaris, fibularis, tibialis posterior and suralis, F waves, H reflex were studied on the same side of the patients.Abnormal findings at least in one of the parameters including amplitude, latency, conduction velocity ana minimal F wave of two or more nerves were evaluated as pathological nerve conduction study. The study group was consisted of 109 diabetic female and 73 diabetic male patients. Mean age of the patients was 56.31 -+ 12.37 ranging between 12 and 78. Mean duration of the diabetes was 10.10 -1-_7.70 years, ranging between 0 and 32 years. Peripheral neuropathy was found in 138 (%75.82) of the patients in electrophysiologic study. Affection was pointed out especially in lower extremities. Pathologic findings were found on N. Fibularis (95.60 %), N. Tibialis posterior (68.68 %) and on N. Suralis (63.18 %). Carpal tunnel syndrome was positive in 27 of the cases with 7 assisting to DSSMP. Asymmetrical proximal motor neuropathy and paresis of N. Oculomotor were other manifestations. The duration of diabetes mellitus was longer in DSSMP patients when compared to controls (11.60 - 7.68 vs 6.25 -+ 6.06) (p < 0.001). Asa conclusion, we found in 75.82 % of the cases a DSSMP at lower extremities showing that peripheral neuropathy is in close correlation to the diabetie period.

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P684 Alpha lnterferon And Peripheral Facial Palsy. ]. Porta- Etessam,A. Alonso, A. Berbel-Garcia, A. MartŸ C. Gomez Escalonilla, I. Garcia Morales, L. Gal• (Madrid, E) The alpha interferon (a-IF) is a drug used in the treatment of viral infections as viral hepatitis, the tropical spastic paraparesis, and onco-hematologic illnesses like chronic myelogenous leukemia, hairy cell leukemia and Kaposi's sarcoma among others. Neurological dysfunctions have been observed related to its use. We report the case oŸa patient who developed an outlying peripheral facial palsy while being treated with a-IF for VHC hepatitis. A 34 year-old woman was evaluated for a 3 days history of difficulty to close the eye right, light smooth of the right naso-genians furrow, impossibility to inflate the cheeks and dysfunctions of the taste. One month before, she had started to receive 3MUI s.c a day of a-IF fora VHC chronic hepatitis. General examination was normal, except for hepatomegaly. On neurological examination, a peripheral facial palsy was observed. The remaining of the examination was normal. Alpha-IF associated neurological dysfunctions include encephalopathy, nightmares, migraines, muscle pain, bilateral brachial plexopathy, audition loss and nerves oculomotor palsies. Some of these clinical pictures may be due to immune disturbances caused by a-IE In several studies, outlying facial paralysis has been related with viral infections. In fact, an elevation in aIF levels has been reporte& However, other authors have not found this fact. Our patient developed an outlying peripheral facial paralysis while being treated with a-IE We think that it may be due to an immunologic phenomenon associated with the use of this drug in a predisposed patient. This fact could support the postinfection hypothesis a s a cause of the outlying facial.. it reinforces this hypothesis of its association with a immune system dysfunction. However, given the high prevalence oŸfacial paralysis, this one could have been merely coincidental.

P685 Diabetic truncal radicuiopathy presenting as abdominal sweUing. W. Simri, J. q162 M. Sula, N. Fares, I. Awad, E. Hazani (Nahariya, IL) Thoracic radiculopathy causing truncal pain and abdominal muscle bulging is an extremely rare complication of diabetes, diabetes mellitus causes distinctive neuropathies the most common being symmetrical sensory and autonomic neuropathy. Truncal radiculopathy has a relatively acute onset with severe abdominal pain, leading to extensive investigation to rule out intra abdominal pathology. It is more common in older patients with non insulin dependent diabetes mellitus, is unrelated to the duration of diabetes and usually remits completely within 6-18 months without recurrence. Case report: A 46 old male with 4 years NIDDM began to suffer from pain in the right side of his abdomen, accompanied by a 10 kg weight loss, 4 months prior to admission. The tender area hada bulge that was enlarged by conghing or sitting up. The dysesthesia of the skin over the bulge was exacerbated by touch and clothes. Physical examination revealed right-sided abdominal swelling,but no palpable mass. There was mild sensory neuropathy of the lower limbs a n d a well-delineated area of hyperesthesia in the right abdomen between T10-12. Ultrasound and CT of the abdomen, X-ray of the ribs, barium studies of the GI tract and radioisotope scans detected no pathology. CT and MRI of the thoracic spine showed left anterior osteophytes between T10-12, and filamentous syrinx betweenD6-8.Nerve Conduction study of peroneal, sural and median nerves revealed mild demyelinative sensory polyneuropathy. EMG showed fibrillations and positive sharp waves of the right thoracic paraspinal muscles between T 10-12. Treatment consisted of carbamazepine and amitryptiline. Three months later the dysesthesia and Pala were diminished, and the abdominal bulge was smaller. The association of trunca1 radiculopathy with abdominal muscle weakness and bulging is exceptionally rare. Only few well documented cases have been reported, Raymond described a case of posterolateral ventral hernia caused by truncal diabetic radiculopathy required surgical repair. Differential diagnosis include herpes zoster, thoracic disc disease, paraspinal neoplasm, gallbladder disease and intestinal disturbance. Itis noteworthy that the right side is most afŸ in all the reported cases, as well as in ours. Lauria found that skin biopsies from symptomatic patients with truncal radiculopathy showed a Ioss of intra-epidermal nerve fibers with reappearance of the nerve fibers after clinical recovery, suggesting that sensory nerve fiber injury in diabetic truncal radiculopathy is distal to, or within, the sensory ganglia. Summary: Painful truncal radiculopathy of diabetes with abdominal muscle bulging and severe weight loss appears to be a distinctive and reversible condition, mostly of middle aged or elderly patients. It is usually unilateral and on the right. EMG is most helpful in diagnosing this condition. Truncal radiculopathy should be suspected in diabetic patients with cryptic abdominal pain or muscle weakness. This may spare much unnecessary Investigation

P686 Acute motor sensory axonal Guillain Barr› syndrome and myasthenia gravis. W. Simri, N. Makhoul, J. Manelis (Nahariya, IL) Acute motor sensory axonal neuropathy (AMSAN) is a variant of Guillain Barr› Syndrome (GBS) with rapidly progressive weakness, sensory loss and early respiratory insufficiency. It is characterized electrophysiologically by a rapid fall in motor and sensory compound muscle action potential without evidence of demyelination. The pathology is an immune attack directed toward epitopes on the axons. Myasthenia Gravis (MG) is an acqnired autoimmune disease with antibodies toward acetylcholine receptors. The occurrence of these two autoimmune conditions (MG and GBS) in the same patient is very rare. Only 4 reports of coexistent GBS and MG have been published to date. Case Report: A 71-year old man was hospitalized with diplopia, dysarthria and dysphagia, and acute respiratory insufficiency requiring mechanical ventilation. MG was diagnosed. Anticholinesterase drugs resulted in complete remission. Twelve years later the patient required ventilation again after dose reduction. The condition resolved after dose readjustment. However, right lid ptosis and diplopia persisted. The patient was readmitted 7 years later due to the sudden appearance of gait difficulty paresthesia of the lower limbs. Three weeks previously he h a d a transient episode of headache, fever and diarrhoea. Examination revealed, in addition to his ptosis and diplopia, the absence of deep reflexes in all four limbs without fasciculation or sensory disturbances. In the ensuing hours the patient's condition deteriorated rapidly, with severe weakness of the limbs and respiratory insufficiency that required mechanical ventilation. Spinal tap showed normal pressure, protein 300mg/dl, glucose 152mg%, WBCs2/mm~. GBS was considered. Plasmapheresis was initiated and later substituted by immunoglobulin without any improvement. Nerve conduction on the fourth day of admission showed slight prolongation of distal motor latency, severe reduction of motor amplitude and normal motor conduction velocity in the peroneal, tibial and median nerves, absence of sensory nerve action potential in both median nerves, F-wave was absent in both peroneal and tibial nerves. AMSAN was diagnosed. On the tenth day of admission the patient died with a picture of severe dysautonomia and idioventricular block. Discussion: Myasthenia gravis associated with other autoimmune diseases is well known, mainly with thyroiditis and systemic lupus erythematosus. There are only four reports of coexistent GBS and MG. In one report MG with benign thymoma developed seven months prior to a definite GBS. In an other case reported by Bertnard a patient with a GBS who developed MG 12 year later and recurrent fatal GBS after 9 years. Kimura described a case of 14-year old girl who developed chronic inflammatory demyelinating polyneuropathy during the course of MG.A common immunological abnormality was suggested in this rare association. No statistical discussion can be based on these few reports but considering the prevalence of MG (43-96 per million) and the incidence of usual monophasic GBS 10 per million per year),this association would occur by chance in approximately one of two billion people per year.lt is thns possible that the MG was the predisposing autoimmune condition to the GBS. P687 Benign focal amyotrophy: a longitudinal study (5-30 years) in 2 cases. C. Zuliani, F. Vecchio, C. Fattorello (Mirano, I) Benign focal amyotrophy (BFA) is a rare condition in which neurogenic atrophy is restricted either to the upper or lower limbs, is usually sporadic, has insidious onset and slow progression followed by stabilization, and absence of any definite sensory loss or central nervous system involvement. We reporta longitudinal study of two patients. CASE 1: G. A., a 53 yearold woman, who 5 years before showed progressive weakness and atrophy of the right hand muscles, without sensory disturbance. Cervical spine Magnetic Resonance Imaging (MRI) study and creatine phosphokinase (CK) were normal. A needle electromyographic (EMG) study showed denervation in the distal muscles of the right upper limb (C8-T1 muscles), with normal nerve conduction studies. Ah EMG follow-up 5 years later, showed a picture of severe chronic denervation in the right C8-T1 muscles, moderate in the lefl homologous muscles and in the triceps brachialis bilaterally. A muscle biopsy showed moderate neurogenic atrophy. CASE 2: M.S., a 50 year-old man, who 30 years before suffered from progressive weakness of the hands, more on the left side. Elsewhere was placed diagnosis of Amyotrophic Lateral Sclerosis (ALS). The patient remained unchanged until '99, when he showed a moderate worsening of atrophy and weakness of the two hands muscles. Serum CK level was normal, cervical spine MRI study showed moderate arthrosis, EMG showed the presence of a chronic denervation only in the distal upper limb muscles (C8-T1 muscles) of the both sides. The nerve conduction studies were normal. A muscle biopsy revealed moderate atrophy of type 1 fibers. Our cases confirm the existence of this focal type of

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muscle atrophy, which shows a mild progression during the first year and thereafter remains stationary. In our opinion the disorder represents a segmental transitional form of ALS. P688 Progression Of Charcot Marie Tooth Type I Neuropathy. V. Milic-Rasic, S. Todorovic, V. Brankovic-Sreckovic, N. Milic (Belgrade, YU) Charcot Marie Tooth type I neuropathy (CMT 1) is defi ned as hereditary demyelinating sensory and motor neuropathy. CMT1 is a progressive neuropathy, but the question is what signs express the most visible changes and what is the baseline for evident progression. We tested 55 CMT1 patients from 38 families (F: 31, M: 24) aged from 1 to 49 (X =20.0 • 12.3) with the onset of the disease before the age of 18. Molecular genetic testing were not done in whole group of patients. 17p 11.2 duplication was detected in 10 tases and MPZ (myelin protein zero) point mutation in one family. The most severe hypotrophy and weakness were observed on distal muscles of extremities according to the length of the axons. The most frequent preserved reflex was triceps brachii. Scoliosis as associated sign was presented in 50% and postural tremor in 37.2%. Neurologic disability score (NDS) (Dyck, 1993) and its subscores for paralysis, reflex activity and sensitive deficit showed statistical significant progression in time (Wilcoxon test, p < 0.01). Longitudinal study of terminal latencies (TL) and motor conduction velocity (MCV) presented no significant changes in time (T test, Wilcoxon, p > 0.05). So, demyelination is not the baseline for evident progression. We discuss about axonal influence on clinical progression. We confirmed the findings of other authors, that weakness and atrophy in CMT 1 patients correlate more with axonal loss than with demyelination (Krajewsky, 1999).

P689 The Sensitivity Of Clinical Diagnostic Methods In The Diagnosis Of Diabetic Neuropathy. A. Ozge, E. To6rol, M. Saraqo61u, Y. Gª M. N. Akyatan (Mersin, TR; Shape, B; lstanbul, TR) The study was planned to determine the sensitivity of clinical examination methods for the diagnosis of diabetic peripheral neuropathy. Randomly selected 49 patients and age-matched 26 heahhy controls were included. Al1 subjects were evaluated by various clinical examination methods, laboratory investigations and standard electrophysiological evaluations. The clinical examination methods included neuropathy symptom score, neuropathy disability score, vibration perception thresholds, Tiners sign and Phalen's sign. The laboratory parameters included fasting plasma glucose and glycosylated haemoglobin (HbAlc) levels and the lipid profile. The electro-physiological methods included nerve conduction velocity, tt-reflex and F-wave investigations. The abnormality rates were found to be 8.2 % for neuropathy symptom score, 57.14 % for neuropathy disability score, 42.8 % for vibration perception thresholds, 32.6 % for Tinel sign and 28.5 % for Phalen's sign. Significant correlations were found between the electrophysiological confirma tion of neuropathy and the two provocation tests and abnormal vibration perception thresholds. It has been concluded that for the diagnosis of diabetic peripheral neuropathy in patients with or without symptoms, assessment with a good neurological examination and standard electrophysiological methods is very important in the prevention of morbidity due to diabetic peripheral neuropathy.

P690 Fluctuating-progressive peroneal nerve palsy caused by an intraneurai cyst. M.-C. Petit-Lacour, F. Pico, N. Rapoport, O. Gagey, G. Said (Le Kremlin Bic&re, Le Havre, F) Introduction: Intraneural cysts are usually not considered a cause of fluctuating-progressive focal neuropathy. We reported the clinical presentation, imaging and neuropathologic findings of an intraneural cyst of the common peroneal nerve Observation: A 43 year old man complained of fluctuating pain of the anterolateral aspect of the left leg for the past two years. In march 2000, after a long walk be experienced two episodes of left foot drop, one during ten minutes and the second for two hours. On. the following day he noticed a permanent left foot drop with steppage. At clinical examination, there was a complete paralysis of the dorsiflexor of the foot and big toe (0/5) with preserved strength of the peroneal lateral muscle. Sensation and tendon reflexes were normal. Neurophysiological examination revealed fibrillations in the muscles innerved by the peroneal nerve. MRI of the popliteal region showed

a cystic lesion of the peroneal nerve extending in a tubular fashion, close to the tibio-fibular joint. The histopathologic study showed ah important epineurial fibrosis a n d a flatted cyst with a connective wa]l. Conclusion: Intraneural cyst are relatively rare and can clinically presented as transient weakness with pain. The etiopathogenesis is unknown. MRI of the concerned region is useful in detection of such lesion for an early diagnosis and surgical intervention. P691 Neuropathic osteoar thropathy in Familial Amyloid Polyneuropathy. N. Demerjian, D. Adams, D. Clerc, V. Plante-Bordeneuve, O. Gagey, J. Y. Nordin, G. Said (Le Kremlin-Bicetre, F) Background: Familial amyloid polyneuropathy (FAP) is a severe progressive polyneuropathy, secondary to mutation of transthyretin (TTR) gene. Patients die aftera mean interval of 10 years from onset. Recently, liver transplantation (LT) has been proposed a s a treatment for FAP. Neuropathic osteoarthropathy (NOA) has rarely been reported in association with FAP; we report our experience over the past 5 years. Patients and methods: In a retrospective monocentric study, we reviewed the files of FAP patients with NOA in order to specify the clinico-radiological profile and their prognosis. Results: This study concerns 7 patients (3 males, 4 females) with a mean age at onset of NOA of 44 years (range from 27 to 71 ). AII patients had met30 TTR variant, 5 were of Portuguese and 2 of French origin. NOA concerned lower limbs in all cases, including feet (n=4) (group A), knee (n=2) and hip (n=l) (group B) and occurred after LT in 4/6. In group A, OAN was located to metatarsal bone (n=l), calcaneotarsial (n=l) or tibiotarsial joints (n=2) and was bilateral in 2. The revealing symptom was ankle joint instability (n= 1), septic graft of joint (n=l), foot deformity (n=l), and plantar ulcer (n=l). The duration of the disease at onset of NOA ranged from 1 to 3.5 years. Two patients hada purely sensory neuropathy and 2 a sensory-motor neuropathy with mild motor loss, all walking unaided. In group B, all patients h a d a severe sensory-motor neuropathy and walking disability. The duration of the disease at onset of NOA ranged from 6 to 14 years. OAN occurred 5 and 7 years after LT in 2 patients. The revealing symptom was joint instability in all cases. Knee arthropathy was preceded by diffuse oedema of lower limb mimicking extensive thrombophlebitis. The location of NOA were in a territory affected by loss of pain sensation. Radiographic abnormalities were delayed in 4 patients without correlation with clinical signs. In group A, 3 patients were cured by conservative orthopaedic treatment but one underwent leg amputation 3 years after LT for gangrene. In group B, all patients became wheelchair bound within a few months. Prosthetic replacement of the knee was performed in 2 of them with good functional recovery. No second Iocation of NOA developed. Conclusion: Neuropathic osteoarthropatby is a rare complication in FAP, which may seriously compromise functionally patients even after LT but may be successfully treated by prosthetic replacement.

P692 Hereditary neuropathy with focally folded myelin: mutations in the 5' end of the MTMR2 gene. H. Houlden, R. Fl. M. King, N. W. Wood, M. M. Reilly, P. K. Thomas (London, UK) In some families with autosomal recessive neuropathy with focally folded myelin (Charcot-Marie-Tooth disease type 4B, CMT4B), the disorder has been shown to be due to mutations in the 3' end of the Myotubularin-related protein 2 (MTMR2) gene (CMT4B1). We report two cases of severe demyelinating neuropathy with an onset in infancy or early childhood in whom nerve biopsy showed focally folded myelin. They were from consanguinous English and lndian families respectively. Molecular genetic studies demonstrated two novel mutations in exon 4 at the 5' end of the MTMR2 gene. Onset was earlier and the clinical phenotype more severe in the English case. The identification of further mutations and defining the phenotype should assist in clarifying the genetic classification of this group of disorders.

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Multiple sclerosis P693 Introductory Cross-Sectioual Study of Occurrence of Multiple Sclerosis in the East Slovakian regions of the Slovak Republic. E. Klimova, ]. Szilasiova, R. Gasko (Kosice, SK) Background: The distribution of multiple sclerosis (MS) around the globe is diverse. In comparison with the situation in the developed countries of the world we can say, that in the past few years siguificant steps have been made to improve conditious fnr the employment of effective and accurate diagnostic procedures of MS in the Slovak Republic (SR). Objectives: Au introductory cross-section study of occurrence of MS in the SR with special focus on the two regions of East Slovakia. Material and methods: Patients with clinically defined MS were asked to complete our questionnaire in the region of Kosice ( 11 districts, population 765294) and Presov (13 districts, population 784421). Our questionnaire, consisting of 38 questions was sent to 273 patients (up to date June 30.2000). We were interested in getting as much information as possible about how the disease manifested itself at the early stage, environmental factors, kind of treatment the patients received, degree of disability and the level of social comfort the patients reached. Results: Out of the total of 270 patients who responded to our questionnaire there were 176 females and 94 males. Each district was evaluated separately. The average age of females is from 36.5 to 46.0 years, of males from 35.8 to 49.0 years. The time span between the onset of first symptoms of the disease to the time of setting up the diagnosis was in females from 17.9 to 88.5 months, in males from 8.3 to 40.9 months. The first symptoms of MS appeared in females between 27.3 to 33.4 years of age, in males between 24.0 to 36.7. The leugth of disease at fully developed stage in females is from 5.5 to 12.9 years and in males from 4.4 to 11.7 years. The dominant clinical form of the disease is relapsing (remitting MS - 49.3 %, secondary progressive MS 21.1%, primary progressive MS - 18.2 %,benign form 5.6% and 5.8% ofpatients did not respond to the question. 60 patients with relapse) remitting MS are treated with lFN-beta. Local disease prevalence varies 15 and 44 tases per 100, 000 people. Conclusion: Presentation of partial results of the first cross-section study of the occurrence of MS in the East Slovakia. The wide range of information gained from the questionnaire provides us with excellent grounds for further analysis. P694

Multiple Sclerosis After Vaccination Against Hepatitis B a n d lILA Haplotypes. S. Ozakbas, B. Baklan, B. Yulug, E. Idiman, H. Bahar, Z. Gª B. Pak6z (Izmir, TR) The aetiology of Multiple Sclerosis (MS) is still not fuUy understood, lnfectious agents have been postulated us causes of the disease. Guillain-Barr› syndrome, optic neuritis, and transverse myelitis huye been reported after administration of plasma-derived hepatitis B vaccines; but very few cases associated with the use of recombinant vaccines have been reported. Only 3 patients with evidence of severe demyelination in the central nervous sysrem huye been reported. In the recent study, three groups were performed: Group I (8 patients who developed MS after vaccination against llepatitis B), Group II (71 patients who have relapsing-remittiug MS and no relationship with hepatitis B vaccination) and Group llI (20 healthy control). Mean age was 27.75 (19-39) in Group I, 30.16 (12-50) in Group II, 34.4 (18-50) in Group III. Mean attack rate after 2 years was 1.5 in Group I, 1.63 in Group II. Mean EDSS score after two years was 1.31 in Group I and 1.89 in Group II. Human Leukocyte Antigen (HLA) and Hepatitis B surface antigen were performed in all groups. In Group 1 and II HLA DR2 was more frequent than normal healthy group. We concluded that HLA DR2 is more frequent in MS patients both with and without hepatitis B vaccination, and there is no difference on HLA haplotypes between these two groups. The results indicate that recombinant hepatitis B vaccination might best be avoided in patients with known multiple sclerosis. P695 MRI parameters and cognitive functioning in multiple sclerosis. U. Wachowius, S. Fink, M. Borko, N. Bodammer, H.-I. Heinze, M. Sailer (Magdeburg, D) Introduction: In magnetic resonance imaging (MRI) a pathological specificity has been attributed to magnetisation transfer (MT) and diffusion weighted (DW) imaging magnetic resonance (MR) sequences providing more information about the microstructure of the brain tissue compared to

conventional T2 weighted MR imaging. In multiple sclerosis (MS) cognitive impairment is frequent and may also occur in the early state of the disease, although substantial cognitive decline has been described in patients with longstanding disease and accompanying brain atrophy. In cross-sectional studies a significant relationship between the total lesion volume (TLV) and cognitive performance was postulated. The aim of this cross-sectional study is to examine the relationship between cognitive functioning and the information gained MT and DW imaging compared to the conventional approach using the TLV of high signal lesions. Subjects and methods: 40 patients with clinically definite MS and 42 age matched controls were evaluated with a neuropsychological test battery. 6 cognitive domains were tested: Attention,short-term memory, acquisition of new information, executive functions, visuo-spatial skills and speech. Conventional MRI (1'1 and T2-weighted) scans and MTI was performed in 40, DWI in 32 patients. Patients were assigned to two groups according to their cognitive performance: 15 (38 %) patients cognitively impaired (CI) and 25 (62 %) patients (CP) cognitively preserved. Results: Conventional imaging: The CI group had significantly higher TI and T2 TLV compared to the CP. Magnetisation transfer imaging: Using the whole brain approach (including cortex, lesion and NAWM) CI MS patients differed significantly from the CP group. The CI group had also a significan@ lower MTR in the lesions and normal appearing white matter (NAWM). Diffusion weighted imaging: CI MS patients had significantly higher mean ADCs compared to the cognitively not affected patients (CP group). Discussion: Data from MT and DW imagi/ig provide additional information for characterisation of MS patients with cognitive deficits beyond the conventional measurement of the lesion load. This more qualitative approach enables the assessment of the underlying brain tissue in the lesions and NAWM separately which may be used for further assessment in patients with cognitive deficits. P696 lnterferon beta is associated with nearly twice the risk of needing to aher usual activities due to side effects as glatiramer acetate in relapsing-remitting multiple sclerosis (RR-MS) patients. S. D. McGuinness, L. E. Lagendyk, J. P. Bourchard, D. Halle, F. Jacques, L. M. Metz (Calgary, Alber ta, Quebec, QB, CDN) Background/objectives: While use of interferon beta and glatiramer acetate in RR-MS can be associated with transient side effects their duration and impact on activities is unclear. As part of a pilot study evaluating therapy selection and initiation we investigated these issues. Methods: At three Canadian centers consecutive patients who were initiating MS therapy were invited to participate. They rated their wellness (sick, worse than normal, normal,better than normal, great) prior to injection,one hour post-injection, and 12-16 hours post-injection and reported the number of days during the first 30 days of treatment that they ahered their activities due to side effects. Treatment groups (interferon beta or glatiramer acetate) were compared. We]]ness was analyzed a s a binary variable (worse vs better or same) using Fisher's exact test. Alteration of activities was collapsed into a binary variable (no days/any days) and proportions were analyzed using Fisher's exact test. Resuhs: Sixty-three patients participated; 46% chose interferon (Avonex, Betaseron, or Rebif) and 54% chose glatiramer acetate (Copaxone). There were no differences between treatment groups in wellness ratings until 12-16 hours post-injection. Immediately prior to injection 11% of all patients felt unwell, and at one hour this i ncreased to 16 %. At 12-16 hours post-injection, the proportion of interferon treated patients who reported feeling sick or worse than normal was five times larger (45%) than the corresponding proportion of the glatiramer acetate treated group (9%) (p=0.001, RR=5.1,95 % CI = 1.9-13.6). The inter feron group was also nearly twice as likely to aher their activities because of side effects (59%) as the glatiramer acetate group (32%) (p=0.045, RR=I.8, 95 % CI = 1.03-3.18). Conclusions: Awareness that interferon beta, compared to glatiramer acetate, is associated with five times the risk of feeling unwell 12-16 hours post injection, and nearly twice the risk of needing to alter activities due to side effects may be important to patients. This knowledge may result in different therapy choices and help patients prepare for treatment initiation. P697 60 years natural history of exacerbations in multiple sclerosis in Huugary. A prospective and retrospective study. A Guseo, Z. Hosszu, Z. Hosszu, E. J£252 J. Pupp, ]. Kov• (Sz›233225 H) Introduction: Very variable frequencies of relapses in MS are reported within a given time period, mostly for 1 year. The differences rise from 0.14

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to 1.8 depending on investigators and various disease forms, and age. In numerous clinical trials it has been used as outcome measure. Material and methods: We report prospective and retrospective resuhs of a cohort of 440 patients diagnosed and followed in County Fej› in the last 60 years. In the last 20 years all patients were followed and investigated by the same person (AG). This period is the subject of a detailed study. The results were compared with the retrospective study results of the preceding 40 years. 8 % of all patients have got immunomodulating treatment for a short period; exacerbations were treated by high dose steroid.The requirements for relapses have been outlined by Schumacher et al. (1965). Results: In the period from 1980-1999 1284 exacerbations have been observed. The average frequency of exacerbation was 0.506/patient for the 60 years period and 0.434 for the last 20 years, that means every 2-3-year a new exacerbation/patient. December, January, February and March were the months with most exacerbations in a 20 years average instead of 1995 where June was the most affected month. Following the exacerbations of the newly diagnosed patients year by year, the same pattern of decrease was found. In the year of the diagnosis the average of exacerbations was over 1.0 then the exacerbations rate fell and varied between 0.2-0.4 in the next years reaching the overall average of 0.5 afler 4-5 years. The highest exacerbation rate/person during the followed disease period was found in the youngest age group (between 15-25), which dropped consecutively in the older groups from 3.89 to 2.08. The exacerbation rate/person/period in the group between 1940-1979 was 12.96 corresponding to 0.62 exacerbation/year/patient and in the second group the corresponding data were 3.62 corresponding to 0.43 exacerbation/ year/person. Summary: In average every 2-3 year one new exacerbation is expected after the diagnosis of MS. If the first symptom develops in younger age the person may have more relapses during his life span. The cooler winter months are more predictors of new exacerbations. The earlier period yielded by a higher relapse rate, while in the last 20 years a decrease was observed.

P698 Patient concerns prior to multiple sclerosis treat ment initiation mirror reasons for discontinuation. L. E. Lagendyk, S. D. McGuinness, J. P. Bouchard, D. Halle, F. Jacques, L. M. Metz (Calgary, Alberta, Quebec, QC, CDN) Background: Education and support improve long term adherence to muhiple sclerosis (MS) therapies (MS Nurse Specialists Consensus Committee, 2000),.but little information describes patients' concerns prior to treatment initiation. Previous research identified common factors patients gave for MS therapy discontinuation including lack of obvious drug benefit, increase in MS symptoms and flu-like symptoms (Hadjimicheal O VT, 1999). Objectives: In this pilot study we determined patients' concerns prior to therapy initiation. Methods: Consecutive patients with relapsing-remitting MS (RR-MS) who were initiating therapy with glatiramer acetate (Copaxone) or interferon beta (Avonex, Betaseron or Rebif) through three Canadian centres were invited to participate. Consenting patients completed self-administered questionnaires, after patient education and prior to therapy initiation. Participants rated their concern about several issues on a four point scale ranging from no concern to very concerned. This was subsequently col lapsed to a binary variable (no concern/some concern). Frequencies were reported, and each variable was evaluated for differences between treatment groups (interferon beta vs glatiramer acetate). Results: Sixty-three patients participated. Eighty-six percent reported concern that treatment wouLd not work, 84% were concerned about in creased fatigue, and 81% that treatment would make them feel sick. No significant differences between treatment groups were found. Discussion/conclusion: Prior to treatment initiation, most patients had some concern about drug effectiveness, increased fatigue, and that treat ment would make them feel sick. The concern about drug effectiveness is frequent both before treatment initiation a n d a s a reason for treatment dis continuation. Concern about increased fatigue or feeling sick due to treatment is similar to other reasons for treatment discontinuation: an in crease in MS symptoms and flu-like symptoms. These concerns likely reflect patient education regarding potential side-effects, suggesting that patients retain information received prior to treatment initiation. Directing nursing support to these areas may improve maintenance of treatment especiaLly when treatment benefit may not be obvious.

P699 Middle-Term Follow-Up Of 3 Multiple Sclerosis Patients After Autologous Stem Cell Transplantation. M. Odinak, A. Novik, G. Bisaga, V. Melnichenko, S. Voloshin, A. Pozdnjakov (St. Petersburg, RUS) Introduction: We report 0.8-1.7 years follow-up evaluations of 3 multiple sclerosis (MS) patients who received autologous stem cell transplantation (ASCT). Methods: Three women 35 - 21 - 48 y.o., 4.5 - 4 - 7.5 EDSS points accordingly. Two patients had secondary progressive and the third patient primary progressive course. According to the protocol there was performed mobilisation of stem cells by G-CSF 10 mg/kg subcutaneously; leukophereses on days 4, 5, 6; conditioning regimen BEAM and ATGAM (Upjohn) 60 mg/kg. Stem cells were reinfused on day 0. For shortening myelosuppression Q-CSF were used at 5 mg/kg subcutaneously; 500 neutrophils/ml level was achieved on day +11 or +12. Platelets level achieved 50~ 109/L on day 22-28. Results: The severe, but tolerable toxic effects of treatment were observed at all patients. Despite of l-month general malaise on day +30 after ASCT two patients improved by 0.5 and 1 EDSS points accordingly. The third patient had no changes in EDSS and remained stable. In all patients positive changes without any treatment slowly enlarged during all period of observation after ASCT (8-20 months), reducing EDSS score for 0.3-0.5 points. Since 3-5 months after ASCT at all patients we revealed absence of thermolability (Uhthoff's symptom). No enhancing lesions on magnetic resonance imaging (MRI) were observed. Conclusion: ASCT permit to achieve clinical and MRI stabilisation in primary and secondary progressive MS. Further fol•ow-up is required to more fully assess outcome.

P700 Devic's Syndrome: lmprovement of severe visual deficit after plasmapheresis. N. Goebels, W. Pollmann, N. Konig, R. Hohlfeld (Mª BergKempfenhausen, D) Background: Neuromyelitis optica (NMO, Devic's syndrome) is regarded as a monophasic or relapsing syndrome consisting of acute myelitis and bilateral simultaneous or sequential optic neuritis (ON). Although patients are usually treated with high dose corticosteroids, often persisting neurological deficits such as blindness and / or paraparesis cannot be prevented. We describe an NMO patient with unilateral blindness resulting from previous ON, who experienced a steroid-nonresponsive relapse severely impairing vision of the contralateral eye. In contrast to corticosteroid treatment, plasmapheresis was followed by a partial improvement of vision. Case report: Our patient, a 45 year-old woman, experienced a spinal cord syndrome with sensory symptoms and T2 signal hyperintensities of the cervical spinal cord in March, ]une and September 1999. Repeated cerebrospinal fluid (CSF) examinations were, after an initial pleocytosis (June 1999:18 cells/l~l), normal, as well as cranial MRI. From ]une to November 1999 she suffered from a stepwise progressive, steroid-nonresponsive visual loss of the right eye with residual light perception. In July 2000 intravenous immunoglobulin (IVIG) treatment was begun. In December 2000 a progressive visual loss of the left eye followed, which was not influenced by high dose corticosteroid therapy. On admission to our institution on January 4th 2001, she could discriminate hand movements but hardly count fingers with her left eye. Seven courses of plasmapheresis were followed by a marked improvement of vision (currently 1/33) and Color discrimination of the left eye. The pre-existing visual deficit of the right eye with optic nerve atrophy remained unchanged. Conclusion: We propose that plasmapheresis might be helpful as a "rescue t reatment" of impending persisting visual deficit nonresponsive to corticosteroids in Devic's syndrome. However, plasmapheresis should be performed early, before optic nerve atrophy occurs. P701 Acute Disseminated Encephalomyelitis (ADEM) during pregnancy. T. De Greslan, O. Heinzlef, S. Coste, D. Felten, ].-L. Renard, E Flocard, D. Bequet (Paris, F) ADEM is known to be an acute monophasic multifocal inflammatory demyelinating disease which usually follows an upper respiratory tract infection o r a vaccination. It differs from Multiple Sclerosis (MS) in several important ways, but it is considered to be a T-cell mediated autoimmune disease. ADEM has a broad spectrum of presentation and there is no diagnostic criteria short of biopsy. Here we report on a case of ADEM which occurred during the second trimester of pregnancy. A 27-years-old woman was referred for a left hemiplegia. She was 14

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weeks pregnant and had no history of recent infection or vaccination. One week before admission she complained of weakness in her left upper and lower limbs which progressively worsened. Neurological examination showed a left hemiplegia a n d a first Magnetic Resonance Imaging (MRI) showed a lesion in the territory of the left medial cerebral artery. She was considered to have a cerebral infarct but a few days later she developed a tetraplegia, anda status epilepticus. A new MRI showed new lesions in the brain white matter. CSF analysis showed an intra-thecal synthesis of IgG. Extensive investigations did not disclose any autoimmune or infectious disease. A stereotaxic biopsy found an inflammatory infiltrate. She was treated by high dose pulsed corticoids but remained comatose for 3 months. She then progressively improved and was delivered of a normal baby at 32 weeks of amenorrhoea. Six months after delivery, neurological examination showed a good motor recuperation of the right arre, limited by an ataxia, a proximal improvement of the other limbs, an optic ataxia anda mixed incontinence. This case of ADEM was unusual by its severity and its occurrence during pregnancy. Extensive investigations were proceeded anda negative past history of infection ruled out a post infectious disease. Pregnancy might be considered asa potential trigger event. In T-cell-mediated autoimmune diseases such as rheumatoid arthritis and MS, pregnancy is associated with a spontaneous remission suggesting an increased humoral immunity. In contrast B-cell-mediated diseases such as Lupus Erythematosus tend to worsen during pregnancy and evolution during pregnancy in Myasthenia Gravis is variable. This observation suggests that immunological mechanisms involved in ADEM and pregnancy are not unequivocal. In particular the recent observation of the efficacy of plasma exchange in ADEM is on account of a humoral implication. P702

The role of macrophages during the initial stage of demyelinating procedures. E. Koutsouraki, V. Costa, S. Baloyannis (Thessaloniki, GR) During the initial stage of demyelinating disorders, the macrophages play an important role in initiating the breakdown of myelin sheath and in the activating astrocytes and oligodendrocytes. In an experimental model of rdapsing allergic encephalomyelitis we attempted to fiigure out the role of macrophages, smdying under the electron microscope the various stages of the demyelinating procedures. We induced relapsing experimental allergic encephalomyelitis (rEAE) in ten Lewis rats (five male/five female) by injection of myelin basic protein (MBP) enriched with complete Freund's adjuvant in the posterior planta, sacrificing the animals after three injections on the 5th , 10th and 15th day.We prepared the specimens from the spinal cord, cerebellum and brain hemispheres for electron microscope. We started sacrificing on the 20th ,22 nd ,24 th up to 30th day. Our findings consist of intensive activation of Rio Hortega cells in the CNS which is obvious prior to perivascular infiltration by monocytes and blood derived macrophages. The Rio Hortega cells surrounded the myelinated fibers and the breaking down of the myelin sheath either from the notes of Ranvier or from the external laminae of the myelin sheath. The accumulation of Rio Hortega cells was associated with the activation of astrocytes which proceeded extensive astrocytic procedures around the blood vessels and the demyelinating fibers. At the same time more than one oligodendrocytes surrounded the demyelinating fiber, a fact that suggests that Rio Hortega cells playa crucial role in activation of both astrocytes and oligodendrocytes. In a more advanced stage the hematogenous macrophages and monocytes infiltrated the area of demyelination. During the remyelinating process the Rio Ortega cells contributed obviously in recovering of the demyelinating axons whereas the extensive infiltration by hematogenous cells played a negative role in the reconstruction of the myelin sheath and the prompt morphological and cytoarchitectonic recovering of the demyelinating area. P703

Severe necrotizing skin vasculitis in a ms patient treated with beta interferon lb. E. Merelli, F. Casoni, P. Sola, R. Bedin, A. Bertolotto, S. Seidenari (Modena, Turin, I) We reporta case ofa severe necrotizing skin vasculitis occurred in a 43 years old women affected by multiple sclerosis (MS) in therapy with INF-b lb (Betaferon). This patient was affected by MS relapsing-remitting with 3.5 at EDSS scale in ]uly 1998 when she began therapy with INF-b la (Avonex), interrupted in December 1999 for the disease progression to 5.5 points of disability. The serum of the patient tested for NABs against INF-b la resulted negative. Since the disease turned in secondary chronic progressive form, in March 2000 the patient started the therapywith INF-b lb (Betaferon) at the dose of 8 MIU subcutaneous every other days. Two months later the patient presented in the sites of injections on the skin of abdomen, inflammatory ir-

ritated hardened lesions with tissue oedema and painful infiltration. A biopsy of the lesion was performed and evidenced confluent necrosis of the superfiicial and deep skin tissue with infiltration by inflammatory cells, vasculitis and perivasculitis process, fibrin deposit in blood vessels. The INF-b lb was immediately discontinued and therapy with low dose of corticosteroids has been star ted.All the serum tests for autoimmunity were negative, while NABs against INF-b 1b was strongly positive with a titre of 1:320 (n. v. < 20). In spite of the therapeutical measures, the necrotizing vasculitis extended to arms and legs in the site of previous injections; the lesions reached the dimensions of I cm in depth and 4-5 cm in length. The patient has been followed daily by Dermatologists for 3 months with local treatment and oral antibiotics for superimposed infections with mild improvement of the skin lesions, moreover for the subsequent 3 months the patient has been visited twice a week. In October, after 6 months from the onset of the adverse reaction, the skin vasculitis lesions cicatrised and the NABs titre decreased to 1:230 and other determinations are in course. Actually the patient is completely recovered but the skin presents subtle, uninflamed sclerotic dermal plaques. Although the necrotizing skin vasculitis is reported as possible side effect of beta interferon therapy, the association of this complication with elevated production of NABs has not been previously reported. P704

Serum and CSF ievels of MCP-1 and IP- 10 in multiple sclerosis patients with acute and stable disease and undergoing immunomodulatory therapies. D.M. Franciotta, G. Martino, E. Zardini, R. Fu.rlan, R. Bergamaschi, L. Andreoni, V. CosŸ(Paria, Milan, I) The two chemokines monocyte chemoattractant protein (MCP)-I and gamma-interferon inducible protein (IP)-10 ate thought to be involved in the pathogenesis of multiple sclerosis (MS). We measured MCP- l and IP- 10 levels in serum and cerebrospinal fluid (CSF) samples from 38 acute and 25 stable MS patients and from 40 controls; those latter consisted in patients with other inflammatory neurological diseases (OIND) or with non-inflammatory neurological diseases, and healthy controls. CSF MCP-1 levels exceeded those found in serum in all the patients studied as well as in healthy controls. CSF MCP-1 levels were significantly lower in acute MS [468 + (SEM) 18 pg/mL] than in stable MS (857 • 104 pg/mL). When detectable, serum and CSF IP- 10 levels were significantly higher in acute MS (serum, 331 _+ 66; CSF, 118 + 16 pg/mL) than in stable MS (serum, 69 + 7; CSF, 25 -+ 2 pg/mL). Among OIND patients, those with HIV-l-associated dementia showed high serum and CSF levels of both MCP- 1 and IP- 10; those with encephalitis showed high serum and CSF levels of lP-10 and CSF mononuclear pleocytosis. We also evaluated the effects of 6-methylprednisolone of IFNbla therapy on circulating MCP-1 and IP-10 levels; neither MCP-1 nor lP-10 post-therapy levels varied significantly from baseline values. Our finding suggests that (a) MCP-1 could be constitutively produced within the brain; (b) MCP-1 and IP-10 CSF levels in acute MS vary significantly from those in stable MS, and these variations are inverse; and (c) current MS therapies do not modify circulating levels of MCP-1 and IP-10. P705

Morphometric analysis of axons within the minute Multiple sclerosis lesions and shadow plaques in patients with multiple sclerosis. P. Nowacki, A. Potemkowski, T. Korwin-Piotrowska, D. Nocon (Szczecin, PL) Brain tissue was investigated in 12 multiple sclerosis (MS) patients aged 30 to 57 years; 8 women and 4 men. Patients died 4 to 8 years afler MS onset: five of them within the relapsing-remitting disease course and seven in secondary progressive stage of MS. 42 minute MS lesions (0.1-0.5mm) considered to be chronic and 36 shadow plaques were examined. An image-computerized analysis was made by means of morphological material scanning in light microscope. For densitometric analysis the images were defined in grey (brighmess) scale. The mean density (MEAND) of consecutive axons in the MS lesions and shadow plaques was evaluated. The distribution of densitometric values in scanned areas (including background and fibers along x coordinate was also examined by means of the function PROFILE. The measurements were also done in 12 areas of similar fibroarchitecture resembling normal white matter in the same slides to compare parameters from injured areas. Myelin densitometric profiles of minute MS lesions demonstrated evident changes compared to unchanged areas. Myelin densitometric profiles of shadow plaques, contrary to MS lesions demonstrated the presence of myelin sheets, but they were less numerous and dense in comparison with areas considered to be unchanged. Significant axonal damage has been found both in MS lesions and in shadow plaques (53.3 % and 40 % of population respectively). Distinct damage to axons within shadow plaques and minute MS lesions was found both

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in relapsing-remitting (37.2% of shadow plaques and 50.4% of MS lesions) and in secondary progressive MS cases (47.3 and 56.7% respectively). Both minute MS lesions and shadow plaques demonstrated minimal astroglia reaction. The findings suggest that damage to axons occurs in both the minute MS lesions and in the shadow plaques. Demyelination and ineffective (too late or too slow) remyelination seem to be very important factors in axonal damage. Irreversible damage to axons may appear in both secondary progressive and in relapsing-remitting stage of MS, causing permanent neurological deficits, irrespective of the duration of the disease. P706 Correlation of slCAM-1 and serum catecholamines in multiple sclerosis depends on clinical activity and disease course. P. Flachenecker, P. Rieckmana, K. V. Toyka, S. Jung (Wª D) The sympathetic nervous system interacts with the immune system on various levels of immunoregulation. However, there are no studies comparing measures of sympathetic nervous system function with immunological markers in patients with multiple sclerosis (MS) and different subtypes. Serum levels of circulating intercellular adhesion molecule 1 (slCAM-1) were elevated during acute exacerbations of MS, but the potential of this molecule as a long-term marker of disease activity is not known. In order to elucidate the interaction between the sympathetic nervous system and the immune system in MS, we investigated the potential of slCAM-1 as a longterm surrogate marker of MS activity in correlation to serum catecholamine levels within different subtypes. Patients and methods: Sixty subjects were studied: clinically active relapsing remitting (RR) MS (n = 26), clinically active secondary progressive (SP) MS (n = 10), clinically stable RR MS (n = 8), and healthy volunteers (n = 16). The active MS groups had at teast two relapses ora progression of one point on the EDSS in the previous 2 years, but not within the last 30 days, whereas the stable MS patients showed neither relapses nor progression during the last 2 years. Norepinephrine (NE) and epinephrine (EPl) levels obtained in the.supine position were determined by high performance liquid chromatography, and levels of slCAM-1 were measured with an enzymelinked immunosorbent assay. Results: Median levels of NE were significantly lower in clinically active RR MS patients (284 ng/1) compared to both, clinically active SP MS (323 ng/l, p < 0.03), and clinically stable RR MS patients (363 ng/1, p < 0.02). EPI levels were also significantly lower in active RR MS patients than in those with stable disease (23 ng/1 vs. 32 ng/l, p < 0.04). In contrast, slCAM- 1 levels were essentially similar in healthy controls and each of the MS groups, and were not correlated to NE levels when considering the whole MS grnup. However, slCAM-1 and NE were inversely correlated in stable RR MS patients (r = -0.86, p < O.O1),whereas either no (SP MS) or even a positive (RR MS, r = 0.46,p < 0.02) association was found for active MS patients. Conclusions: Low catecholamine levels were associated with disease activity, whereas circulating ICAM- 1 levels were not. Whether the dysregulated sympathetic nervous system - immune system interaction in clinically active MS patients suggests that sympathetic nervous system function might playa role in the evolution of the disease or whether the changes in sympathetic activity may be a consequence of immune activation requires further investigations. P707

Clinical characteristics of patients with multiple sclerosis and fatigue. P. Flachenecker, T. Kª B. Kallmann, M. Gottschalk, O. Grauer, P. Rieckmann, C. Trenkwalder, K. V. Toyka (Wª Munich, D) Fatigue is a common and disabling symptom in patients with multiple sclerosis (MS), but the pathophysiological mechanisms remain unclear. Clinical studies disagree on its frequency (ranging from 53 to 90%), and its relationship to neurological disability and the course of the disease. Therefore, we performed a prospective st udy in an unselected cohort of consecutive MS patients. Patients and methods: Between February and September 2000, all patients with clinically and laboratory-supported definite MS entering the MS outpatient clinic of the Wª center were invited to fill in a standardized questionnaire.A total of 151 MS patients ( 114 women, 37 men, mean age 39.0 +- 9.3 [22-62] years, median EDSS 3.5 [0-8.5]) agreed to participate. Fatigue was assessed by Krupp's Fatigue Severity Scale (FSS), modified FSS, Modified Fatigue Impact Scale (MFIS) and Visual Analogue Scale (VAS). Beck's Depression lnventory (BDI) was used to rate depression, with a score 17 indicating depression. Results: Al1 fatigue scores were significantly related to each other (p < 0.0001). One hundred and thirteen patients (77%) hada FSS 3 4 indicating

fatigue, 107 patients (71%) rated fatigue as one of their three most disabling symptoms, and 39 patients (26%) felt that fatigue was the most distressing of all of their symptoms. Patients with chronic progressive (CP) MS (secondary CPMS, n = 50 and primary CPMS, n = 7) had significanfly higher FSS scores than those with relapsing remitting MS (n = 94), with median levels (interquartile ranges) of 6.0 (4.7-6.6) and 4.9 (3.8-6.1), respectively (p < 0.0001 ). No difference was seen between patients with clinically active and clinically stable MS, or between patients treated with interferon beta, other immunosuppressive drugs (mitoxantrone, azathioprine and cyclophosphamide) or none of these. FSS was significantly correlated to BDI (r = 0.41, p < 0.0001 ) and EDSS (r = 0.30, p < 0.0001 ), but not to the duration of MS or to the age of the patients. However, multivariate analysis showed that only BDI was significantly associated with fatigue. Conclusions: This study underlines the high frequency and impact of fatigue in an university hospital based cohort of MS patients which was independent from neurological disability, course of MS, clinical activity or treatment. The correlation with depression scores suggests that depression may be one of the factors which is associated with fatigue. P708 Multiple sclerosis in childhood, treatment experience and side effects. R. T. Talab, M. T. Talabova, I,. S. Serclova (Hradec Kralove, CZ) Background: The occurrence of Multiple Sclerosis (MS) before the age of 10 years was ignored for a long time. A prospective study of childhood MS was started in Gottingen, Germany, in 1989; the diagnosis of MS was based on the Poser criteria. Patients, methods and results: We are reporting about our experience with clinical and other related features of MS in 12 children (10 female, 2 male). The mean age of onset of MS was 13.2 years, the median duration of disease was 4,9 years, the relapse rate was 3.1. The disease was highly variable in its presentation, especially at the onset, which was mono- or polysymptomatic (optic neuritis, diplopia, vertigo, headache, hemiparesis). In the laboratory diagnosis of MS, magnetic resonance imaging and CSF were more sensitive than multimodal evoked potentials. The children were treated with corticosteroids (11 methylprednisolone, 1 ACTH) and two children with a combination therapy (corticosteroids and cyclophosphamide). In the therapy of childhood MS, there were side effects (9 children) associated with high doses of corticosteroids; plasmapheresis may be a suitable alternative for next relapses. Three patients are treated with IFN-beta-la or IFN-beta-lb at this time. Conclusion: MS in childhood is no rarity today. The diagnosis of MS can be established before the age of 10 years. High dose methylprednisolone ir. is the standard for treatment of acute attack of MS also in children. P709 Budipine is effective in treatment of intentional tremor in multiple sclerosis. S. Schimrigk, C. Lukas, V. Hoffmann, K. Hellwig (Bochum, D) Background: Treatment of ataxia and intentional tremor in multiple sclerosis is a difficult task. After unsuccessful treatment of intentional tremor in six patients with multiple sclerosis with either propanolol, carbamazepine or clonazepam, we applied budipine (Parkinsan). Four out of six patients showed improvement of tremor and ataxia. Methods: Six (2 male, 4 female) patients with definite multiple sclerosis and disabling intentional tremor were treated with an increasing dosage of budipine up to 50 mg/d. At the beginning and afler 4 and 6 weeks we performed the"Motorische Leistungsserie nach Schoppe" to evaluate the Fleishmann-Factors (Steadiness, lineage, aiming, tapping). Additionally, a computerized diadochometria measurement for upper extremities was done. For patient safety ECG controls were done according to the actual safety protocol. Results: Four of six patients improved under therapy with budipine, which is outlined in better results especially in lineage and tapping as well as in the patient subjective judgement. Discussion: In cases of unsuccessful treatment of intentional tremor in multiple sclerosis Budipine should be regarded as an additional alternative drug. P710 Qualitative and Quantitative Evaluation of Fatigue in Multiple Sderosis (MS). B. Greim, R. Benecke, U. K. Zettl (Rostock, D) Background: 60-90% of MS patients suffer from uncontrollable tiredness and fatigue, which limits their ability to work and reduces their quality of

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life. The measurement of this ambiguous and muhi-variant symptom has proven difficult. Objectives: The goal of our study was to develop a multidimensional test for evaluating fatigue in MS patients. We differentiated between physical and psychological tiredness, as well as between the subjective and objective standpoint. Objective fatigue was defined a s a gradual reduction in the ability to perform certain tasks, subjective fatigue as the feeling of tiredness. Material and methods: As objective evaluation techniques, we chose the vigilante test portion of TAP (Test system for Attention Performance) for the psychological component and the Vigorimeter test for the physical component. There are normal values available for each test based on healthy individuals. The tests measure psychological fatigue by objective parameters such as omission failure and reaction time and physical fatigue by muscle strength and strength reduction. The subjective eva]uation was based on the tiredness felt upon completion of each objective test, using the Modified Fatigue lmpact Scale (MFIS). We recorded scores for the fatigue felt in this specific situation (0 = no tiredness up to 5 = severe tiredness) as well as scores for the psychological and cognitive subscales of the MFIS. The testing was carried out on 39 MS patients (avg. age = 38.1) with relapsing remitting courses as well as on 22 healthy individuals (avg. age = 38.7). Results: (I.) MS patients differed from healthy individuals not only in their objective fatigue scores,but also in their situational and general fatigue appraisal as recorded on the MFIS. (11.) In these patients, there was a significant correlation between the negative influence of tiredness on various activities and low and declining performance in the objective tests. The MS patients, who were impaired in the objective testing, felt especially fatigued. (III.) The combined use of objective and subjective parameters for physical and psychological components aUows a better estimate of fatigue than was possible with previous evaluation techniques, which only examined either the ob)ective or the subjective aspect. Conclusions: The concept of fatigue can be both objectively and subjectively measured, thus making it possible to verify questions relevant to medical practice with therapeutic consequences. P711 Oral contraceptives use and disease activity in multiple sclerosis. A. Sena, R. Pedrosa, P. Marques- Vidal, V. Ferret-Sena, M. Graca-Morais (Lisabon, P) Background and goals: Prospective studies failed to find an association between oral contraceptives (OC) use and the incidente of multiple sclerosis (MS). Nonetheless, there is clinical and experimental evidence to suggest that the modulatory role of sex hormones on immune responses may influence the activity of this disease. Therefore, this study was intended to investigate whether OC use could affect disease activity in these patients. Patients and methods: Eighty-eight patients witb relapsing-remitting of secondary progressive MS were studied. Groups of never (n=36), former (n=26) and current-users (n=26) were compared for the age of onset and duration of the disease, the expanded disability state scale (EDSS) score, the relapse rate, and the aggressiveness of the disease (evaluated on the base of a median "severity score'-EDSS score divided by disease duration). Formeruse was defined as the use that ceased before MS onset. Current-users were defined as the OC users after the clinical onset of the disease. The X2 test and t-test analysis and an ANOVA were used. Resuhs: After adjustment for age andas compared with current-users, former-users had a MS onset later in life (37.58 _+6.18 vs 25.31 4- 5.43 yr),a shorter duration of the disease (69.11 + 76.31 vs 91.92 + 65.31 mths) and an higher EDSS score (3.07 -+ 1.51 vs 2.60 4- 1.20) (p < 0.01). Former-users had a more aggressive disease (69%) than current-users (27%) (p < 0.01). A trend to a more benign course was observed in current (73%) in compari son to never-users (53%) (NS). Conclusion: These results suggest a protective effect of OC use after MS onset in comparison to the use that ceased before the clinical onset of the disease. The resuhs also suggest a possible beneficial effect of OC use in these patients in comparison to never-users. Further studies in larger number of patients are required to confirm these findings.

Dementia higher function disorders P712 Words generated in the last 30 seconds of Semantic Verbal Fluency Tasks: an index of Cognitive Reserve capacity. L.E Pascual, T. Fernandez, S. Santos, C. I¡ (J. RŸ E. L£ T. Casadevall, I. Navas, C. Tejero, Ja. Mauri, I. Escalza, P. Larrode, E. Mostacero (Zaragoza, E) Background: Cognitive Reserve Capacity (CRC) is usually evaluated with cognitive activation tasks and PET studies. It has been suggested that CRC

could be an indicator of synaptic plasticity. Given the usual temporal pattern of word generation in SVF tasks we postulate that the number of names in the second balf of the minute could be an index of CRC. Words generated in the last 30 seconds implies probably a more cognitive effort (attention tracking, active naming search and working memory) than in the first half. Objective: "ro analyze the absolute number of words generated in the last 30 seconds of SVF in relation with General Cognitive Status in aged controls. Methods: Evaluation ofSVF task (animals in one minute) with recording of words generated at 15, 30 and 60 seconds and its correlation with MMSE and MMSE recall in a group of 23 voluntary aged controls. Resuhs: MMSE global store and recall correlates better with SVF global score (Rho 0.53 and 0.64 respectively) than with SVF partial scores. However, it is found a better correlation of the last 30 seconds SVF with MMSE (Rho 0.41) and recall (Rho 0.50) than the first 30 sc SVF (Rho 0.36 and 0.43). The first 15 seconds SVF does not correlates with MMSE or recall (0.06 and 0.04). Comments and conclusions: the stronger correlation between the second half of SVF than otber SVF partial scores with MMSE recall suggest that persons with better working memory generates more words in the last 30 seconds of SVF task. These data support the hypothesis of Cognitive Reserve Capacity. P713 Cognitive efficiency and chronic age-related disorders in the Italian Longitudinal Study on Ageing (ILSA). M. Franceschi, M. Musicco, M. Rossi, A. Gavazzi, F. Adorni, N. Canal (Castellanza, Milan, 1) Aim of this study was to evaluate the cognitive efficiency of elderly subjects included in the ILSA affected by common chronic diseases, but not demented. The methodology of 1LSA is reported elsewhere in details (Maggi S et al. (1994) Aging Clin Res Exp, 6:463). In brief, a random sample of 5632 subjects aged 65-84 years has been identified in demographic lists of 8 Italian municipalities and evaluated longitudinally since 1992. Participation rate to the study was about 65%. AII the subjects were administered a battery of tests including: 1) the Mini Mental State Examination (MMSE); 2) a Logical Memory task evaluating immediate and delayed verbal memory; 3) a Digit Cancellation task evaluating attention. Geriatric Depression Scale and ADL scores have been determined and used to adjust cognitive scores We considered cognitive scores of patients with a definite diagnosis of myocardial infarction (MI), angina (A), cardiac arrhythmia (AR), congestive heart failure (CHF), peripheral artery disease (PAD), hypertension (lq), diabetes (D), stroke (S) or parkinsonism (PD) at the first evaluation of ILSA population in 1992-1993. Patients with dementia were excluded. After adjusting fnr age, gender, education and comorbidity, we found that: I) attention was significantly reduced in patients with S (p < 0.0001), PD (p < 0.0001)) or CHF (p < 0.004); 2) immediate verbal memory was significantly impaired in CHF patients (p < 0.001); 3) delayed verbal memory was significantly impaired in patients with PD (p < 0.0001), CHF (p < 0.01) or AR (p < 0.03); 4) global cognitive efficiency, as evaluated by MMSE, was significantly impaired in patients with CHF (p < 0.0001 ), PI) (p < 0.0001) or S (p < 0.003). After adjusting for attention, memory and depression scores, a significant (p < 0.005) association with lower scores remained only for CHF patients; 5) ADL were severely impaired in patients with S (p < 0.0001 ), PD (p < 0.0001) or CHF (p < 0.0001) and less heavily in PAD (p < 0.001) or MI (p < 0.02) patients; 6) depression was significantly associated to CHF (p < 0.0001), S (p < 0.001), PD (p < 0.O03),ANG (p < 0.03) orMI (p < 0.03). Conclusions" In an elderly non demented population cognitive efficiency is potentially threatened by several neurological or non-neurological chronic age-related conditions. Patients with CHF are particularly prone to poor cognitive efficiency and poor quality of life. P714 Script generation in patients with Alzheimer's disease. E. Galante, M. Zuffi, D. Perrotta, M. Franceschi (CastelGofŸ Castellanza, Milan, I) Background: Scripts are conceived as knowledge representations storing the information needed to run goal-directed everyday-life sequences of actions. This knowledge representation encompasses the essential features of the many single events in the script, as well as the fixed sequence according to which the set of actions has to be carried out. Most normal behaviour in ecological settings can be traced back to causal and chronological chains of relevant actions which are automatically selected, activated and carried out in order to achieve a well defined intentionally predetermined or contextually-suggested goal. Functions involved in the managing of scripts range between the two poles of semantic and procedural memory. Carrying out a script also depends upon protection against interference from inner and

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outer distractors. The latter is a selective attention-ruled function relying upon prefrontal structures. Airo of this study was to evaluate the ability of patients with early and mild Alzheimer's disease (AD) to generate scripts of the everyday life. Methods and subjects: AD patients and healthy age-matched controls were required to gire a detailed verbal description of the relevant actions for the achievement of the goal of the script of 3 tasks, randomly selected among nine. Resuhs: The study was carried out on 81 cont rols and 27 AD patients with mild cognitive deficit and no significant apbasia. A s a group, AD patients performed significantly worse than controls in 7 out 9 scripts. However, only about 30% of individual patients failed in at least one script generation.AD patients generated scripts characterized by poverly of sequenced actions and by a number of irrelevant actions. However, actions were always in the correct causal and time location and there were no "aberrant" acfions. No significant relationship was found between script generation and attention or verbal fluency scores, with only some links with global cognitive deterioration. Conclusions: Our results agree with the hypothesis that an attentional insufficiency is at work very early in the course of AD, even if it is difficult to translate it into a psychometric measure. This condition is likely to be evident more frequently in an ecological setting, when the patient has to cope a greal amount of information, than in an experimental setting P715 Minimal Cognitive Impairment: two years follow-up study in a memory clinic cohort in Israel. A. Saher, D. Kliot, J. Aharon-Peretz (Haifa, I L) Background: There are individuals, age 60 and older that suffer of memory impairment beyond that expected for age and education, yet are not demented. These subjects may deteriorate to overt dementia, or may remain memory impaired-non demented for various periods of time. Objective: To assess: 1) whether MCI is confined exclusively to memory impairment 2) whenever it deteriorates, is ir a prodromal phase of AIzheimer's disease only, or of other dementias as well and 3) to identify risk factors for conversion to dementia. Methods: Setting: Cognitive Neurology Unir, Rambam Medical Center Haifa. Participants: Non demented subjects with memory complains, normal activities of daily living, CDR of 0.5, normal general cognitive functions and abnormal memory for age. Cognitive assessment: Mini Mental State Examination, the CER AD battery, Controlled Oral Word Association Test, Category fluency procedure, clock drawing, clinical dementia rating scale. Exclusion criteria: previous history of neurologic or psychiatric causes for memory impairment. Alzheimer's disease was diagnosed according to DSM IV criteria. Demented subjects with evidence of cerebro-vascular disease by imaging were designated as mixed dementia. Patients were re-evaluated every 6, 12, and 24 months. Results: 166 subjects were evaluated at baseline, 91 subjects (age 75.5+ 5.9) at 6,12 and/or 24 months. MCI patients scored below CFRAD norms on memory and word fluency. 17 (18.7%) subject deteriorated, 9 (9.9%) to Alzheimer's disease 8 (8.8) to mixed dementia. 6 (6.6%) became demented after one year and 11 after two years. Probability of developing dementia increased with age (p=0.03). Hypertension (p=0.02) in males and age in women (p=0.058) were associated with conversion to dementia. The cognitive deterioration became evident al month-12 visit (p < 0.001) but changes in cognitive functions reached significance earlier. Conclusion: MCI is characterized by a stable deficit in memory performance and decreased word fluency. The conversion to dementia is preceded by a pre-clinical phase in which changes in memory functions can be detected. MIND is most likely n o t a n obligatory forerunner oŸAD and might deteriorate to other types of dementia as well. Age in women and hypertension in men are significantly associated with progression to dementia. P716 Cingulate Gyrus Involved In Fear Perception. K. Wang, R. Hoosain, ].N. Zhou, L. Shen, X.S. Li, R.M. Yang, C.Q. Wang (Hong Kong, Hefei, VRC) Objective: Although the hypothesis that bilateral amygdala have a crucial role in fearful expression processing received much strong support from studies that showed selective impairment of fear fui expression processing in about 10 cases with bilateral amygdala lesion with different aetiology (Adolphs et al., 1994; 1995), the discrepancy was also reported in some cases (Hamann et al., 1996; Adolphs 1999). Whether other neural structures adjacent AMG responsible for it and other structure selectively involved in fear perception is still not clear. Method: We developed a six basic emotional morphed face continuum

(30 morphed emotional faces across happy-surprise-fear-sad-disgustanger-happy). Participants were required to label each of these morphs in 5 trails to measure the ability of different emotion processing. Resuhs: LIM with lesions in bilateral cingulate gyrus and right AMG showed selective fear processing impairment. ZZH with right tempo-parietal lobe damage manifested unselective impairment of perception across six basic emotion. ZIC with selective bilateral hippocampus damage showed normal ability of aIl basic emotion processing. Conclusion: Because of unilateral AMG damage is insufficient to cause this impairment (Adolphs et al., 1995), the performance of LJM support that bilateral cingulate gyrus is involved in fear processing. Bilateral hippocampus is not responsible for fear perception and right tempo-parietal lobe involved in all emotion perception. There could be two possibilities for the involvement of bilateral cingulate gyrus and amygdala involved in the perception of fear. One is that bilateral anterior cingulate gyrus participate in the network as the higher processing unit after bilateral amygdala. Bilateral amygdala process the incoming information as primary fear stimuli and then convey the information to bilateral anterior cingulate gyrus which interpret this information, together with primary sensory information and related rapid automatic responses which could have been part of the fleeing response to danger. The second possibility is that there are other units in the association cor tex, such as orbitofrontal, right parietal and temporal cortices which are non-selectwely involved in all emotion processing, while the amygdala and anterior cingulate gyrus ate selectively involved in ust fear emotion processing at a lower level and paralIeUy. P717 Proteomics in the cerebrospinai fluid of Creutzfeldt-Jakob patients in comparison to other dementias by 2-D-PAGE. 1.. Cepek, A. Smirnov, H. Esselmann, P. Steinacker, B. Ciesielcyk, S. Pau], B. Mollenhauer, S. Poser, J. Wiltfang, M. Orto (G6ttingen, D) Background: The Creutzfeldt-Jakob-Disease (CJD) belongs to the group of transmissible, spongiform encephalopathies and the diagnosis is based on the combination of clinical symptoms (rapidly progressive dementia, myoclonus, pyramidal signs or extrapyramidal symptoms, visual disturbances or cerebellar signs and akinetic mutism), typical EEG (periodic sharp-wavecomplexes) and detection of the 14-3-3 proteins by the immunoblol. In ear]ier investigations there were detected different spots (p130; p131) in the cerebrospinal fluid (CSF) of patients which were suffering from CJD by the two-dimensional polyacrylamide gel-electrophoresis (2-D-PAGE). Nowadays these spots are assigned to the 14-3-3 family. Because of lacking in detection of PRPsc in the CSF specific proteins are still necessary for the diagnosis of CJD. The 2-D-PAGE is suited for revealing differences in the isoelectric point (pl) or the molecular weight of proteins. Methods: By acetone precipitation over night the samples were concentrated. Afler optimising the isoelectric focussing and second dimension three samples were investigated of each CSF to minimize the intraiadividual differences. These resuhs led to a "reference gel" which was compared to 20 other patients suffering of the same disease. The collective of these 20 patients were again compared to a collective of patients with an other disease by using an other"reference gel". There were investigated the CSF of CJD, M. Alzheimer, other dementias and normal patients without clinical dementia. Results: Differences in the spot's pattern, lacking spots or new spots, which seem to be a possible characteristic for classifying the CJD will be presented. P718 Comparison of Tau-protein and 14-3-3 protein in the differential diagnosis of Creutzfeldt-Jakob disease. M. Otto, J. Wilt fang, L. Cepek, H. Tschampa, A. Schr6ter, B. Ciesielczyk, W. Schulz-Schaeffer, H.A. Kretzschmar, S. Poser (G6ttingen, D) Introduction: Diagnosis of Creutzfeldt-Jakob disease (C/D) is made according the typical clinical picture and can be supported by a positive 14-3-3 immunoblot of cerebrospinal fluid (CSF). On a smaller group of patients promising results for diagnostic sensitivity and specificity for Tau-protein measurement in CSF have been described. We have now evaluated both parameters in a larger group of patients with the differential diagnosis of CJD. Patients and methods: We have analysed CSF of 290 patients under the differential diagnosis of CJD (107 definite, 58 probable, 40 possible; 85 others). The 14-3-3 immunoblot bands were semiquantatively rated as strong, medium, weak. Tau-protein was analysed using an commercially avaiIabIe ELISA. Additionally patients were neuropathologically classified according prion protein type and polymorphism at codon 129. Results: At a cut-off 1400 pg/ml for Tau-protein a diagnostic sensitivity of 93%, a diagnostic specificity of 91% a n d a positive predictive value of

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93 % was reached. These results are comparable to the 14-3-3 immunoblot. In patients with type II prion protein and methionine/valine or valine/valine polymorphism at codon 129 Tau-protein has a higher diagnostic sensitivity than 14-3-3 protein. Tau-protein levels were significantly higher in patients with higher rated 14-3-3 immunoblot bands. Conclusion: The differential diagnostic significance of the 14-3-3 immunoblot is similar to the Tau-protein ELISA. The advantage of using the Tau-protein ELISA is the simple usage in routine laboratories. Patients with a negative 14-3-3 immunoblot have already measurable Tau-protein levels, which increases information on 14-3-3 negative CJD patients and especially on patients with other diseases. P719 Pointing to body parts: a double dissociation study. O. Felician, M. Ceccaldi, M. Didic, M. Poncet (Marseille Cedex, F) Background: Since Pick's seminal descriptions of autotopagnosia at the beginning of last century, no agreement has been reached regarding the nature of the representations underlying this impairment. One of the most influential view has been to implicate a supramodal representation specifically engaged in encoding spatial relationships of body parts. This body-specific representation has been proposed to be equally involved in the processing of features of other's bodies as well as one's own. However, recent observation of subjects with selective impairment in pointing to body parts of others (heterotopagnosia, Degos et al. 1997) argue against the validity of such representation. Here, we studied two subjects with dissociated performances in pointing to human body parts, and provide additional evidence that pointing to other's body parts and to parts of one's own are based on two independent representatioual and neural systems. Subjects: We studied subjects JR and AP,both right-handed and clinically diagnosed with corticobasal degeneration. They underwent single photon emission tomography at the time of their evaluation, which showed in both cases a limited atea of hypofLxation in the lefl parietal lobe. Correlated to anatomic atlas, these areas were found to correspond to left superior parietal lobule and to superior part of the lefl angular for JR, and to left inferior parietal lobule including posterior part of the left angular gyrus for AP. Five right-handed subjects with mild Alzheimer's disease were used as controls. Method and results: AII subjects were submitted to naming and pointing to body parts' tasks. IR exhibited a selective deficit in pointing to his own body parts and preserved abilities to point to parts of others. In contrast, AP demonstrated a selective inability to point to other's body parts while her capacity to point to her owns was intact. Naming and pointing tasks were perfectly performed by the control subjects. To evaluate further the level of body-specificity of AP's impairment, we performed additional poiming tasks using non-human representations and ambiguous representations of human. AP's performances were similar to control subjects across experiments, supporting the idea that processing the spatial layout of other's body rely on a specific representational and neural system. Conclusion: The double dissociation described herein suggests that pointing to parts of other's body and to parts of one's own are based on two independent representational and neural systems. We hypothesise that the act of pointing to one's own body parts engages somatosensory representations, while pointing to body parts of others engages body-specific visuospatial representations. Based on the putative areas of dysfunction revealed by metabolic brain studies in our two subjects and available data of the literature, we propose that left superior and inferior parietal lobules are part of networks engaged in processing respectively somatosensory and visuospatial representations of bodies. P720

Neuroimaging evidence of cerebrovascular pathology and plasma total homocysteine ievels in Alzheimer's disease patients. A. Pfeffer, M. Golebiowski, E. Luczywek, B. Wasiak, M. Styczynska, T. Gabryelewicz, K. Czyzewski, K. Stepien, M. Barcikowska (Warsaw, PL) Background: Vascular disease may contribute to the cause of Alzheimer's disease (AD), and elevated total homocysteine (tHcy) level is a risk factor for vascular disease. The aim of our study was to ascertain relationship between tHcy level and vascular pathology in brain imaging of AD patients. Methods: Plasma tHcy was measured and CT was performed in 115 patients with clinical diagnosis of AD. Radiological evidence of concomitant cerebrovascular originated lesions was defined by the presence of single or few lacunas (30 patients) and/or leukoaraiosis (29 patients). We examined the plasma tHcy level in this group and among 56 patients without evidence of vascular lesions in CT. Resuhs: and Interpretation In 59 patients with radiological changes plasma tHcy level was significantly higher ( 18.79 _+8.28), than in 56 patients

without evidence of vascular lesions in CT ( 16.24 _+10.40) p=0.0087. We concluded, that plasma tHcy level may be independent vascular risk factor in our group of AD patients P721 Auditory P300 potential in patients with mild dementia of cortical. A. Pokryszko-Dragan, K. Slotwinski, S. P. Budrewicz, R. Podemski (Wroclaw, PL) P300 component is regarded as a correlate of cognitive decline in CNS diseases of various origin. The aim of this study was an attempt to compare P300 parameters in patients with mild dementia in the course of primary cortical and subcortical degeneration. The study comprised: 10 patients with mild dementia of Alzheimer type [DAT] (4 men, 6 women, aged 56-75 years, mean 67.6), 10 patients with mild cognitive decline in the course of Parkinson's disease [PD](2 men, 8 women, aged 52-70 years, mean 60.8) and 10 healthy, age-matched controls. Al1 the patients obtained more than 18 points in Mini Mental State Examination. Auditory event- related potentials were performed, using basic "oddball paradigm", with averaged responses recorded from the references Fz, Cz, Pz (according to 10-20 system). Latency of P300 component was determined at all the references. Mean latency of P300 in patients with DAT was significantly longer at all the references in comparison with the controls (389.9 ras, 389.8 ms, 394.3 ras and 338.5 ras, 336.1 ms, 328.1 ms, respectively; p.< 0.05) and on the edge of significant difference when compared to the patients with PD (344.3 ms, 342.5 ras, 342.7 ms, respectively; p = 0.05). P300 latencies in patients with PD tended to be longer in comparison with healthy controls but the difference was not significant. Latency of auditory P300 component seems to be more affected by primary cortical degeneration in the course of DAT than by primary subcortical changes in PD. Differences in profile of cognitive decline and role of various neurotransmitter systems dysfunction should be considered as possible background. P722 Spatial Alexia Without Agraphia in a Right Handed Woman With a Right Occipito-Temporo-Parietal lnfarction. M. Inspector, B. Gross, S. Honigman (Haifa, IL) Alexia without agraphia is associated with lesions in the dominant occipital lobe and the splenium. Alexia associated with lesions in the right hemisphere and specifically in the right occipital lobe is rare. Most reading disabilities associated with right hemisphere lesions that had been described consisted of neglect dyslexia. A minority of reported cases, were attributed to an inability to explore the spatial distribution of the written material. This type of alexia was called "spatial alexia". We reporta 72 year old right-handed patient who developed alexia without agraphia together with left hemianopia, following a right occipito-temporo-parietal infarction as demonstrated by MRI. The patient's reading disturbance was characterized by inability to focus her gaze at specific pointed letters and words. The patient had a great difficuhy in performing continuous screening eye movements, which are essential for reading. There was no visual neglect. Disturbance in recent memory and also severe topographical disorientation and constructional apraxia, have been found. This topographical disorientation which was prominent in the patient's clinical setup, characterized non-dominant hemispherical lesions. In addition, the absence of Color anomia and the patient's preserved ability to recognize words from letters spelled out orally to her, indicates the lack of a linguistic dysfunction, which characterizes dominant hemispherical lesions. The unique spatial non-linguistic features of the patient's alexia explains the occurrence of alexia without agraphia following non-dominant hemispheric lesion. The patient's inability to explore the spatial distribution of written material is hypothesized to be intrinsically related to a more general visual-spatial dysfunction, which manifested in severe topographical disorientation and in constructional apraxia. Contributing factors to the alexia were: "hemianopic dyslexia", due to parafoveal visual loss, which impairs guidance of eye movements in reading and impairment of saccadic eye movements.

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P723 Polymorphism Of The Tau Gene In Transmissible Spongiform Encephalopathies (TSEs). R. Sanchez-Valle, P. Pastor, A. Saiz, 1.Yagª F. Graus, E. Tolosa (Barcelona, E) for the Catalan Collaborative Study Group for Creutzfeldt-Jakob disease. Introduction: Tau is a microtubule-associated protein implicated in the pathogenesis of several neurodegenerative diseases. Two extended haplotypes, H 1 and H2, that cover the entire codificant region of the tau gene have been described in the normal population. An over-representation of the more common haplotype of the tau gene, H1, was found in patients with progressive supranuclear palsy and Parkinson disease (Ann Neuro12000). In TSE, an increased level of tau in CSF, particularly its hyperphosphorylated isoform, is found in lakob-Jakob disease (CJD) patients with a more aggressive clinical course. Despite these observations, there are no studies of association between the tau gene polymorphisms and TSEs. Objectives: To genotype a polymorphism of the tau gene in TSE patients and controls in order to study the distribution of allelic and genotype frequencies. To investigate ir there are differences related to the tau genotype among TSE patients. Patients and methods: We studied 21 TSE patients from Catalonia (Spain): 15 defined or probable sporadic CID, 4 genetic CJD and 2 fatal familial insomnia, all of them previously studied for prion protein gene (PRNP). We analysed a single nucleotide polymorphism of exon 1 of tau gene in the whole group and in the different subtypes of TSE compared to age and sex-matched healthy controls. Resuhs: Nine patients were H 1H 1 (43 %) for tau gene, 8 H 1H2 (38 %) and 4 H2H2 (19%). The frequencies were not different from that observed in controls (52% H1H1, 38% H1H2 and 9% H2H2). Among sporadic CJD (sCID), 4 out of 15 were H1H1 (26.7%), 7 H1H2 (46.7%) and 4 H2H2 (26.7 %). An equal representation (50 %) of the H 1 and the H2 haplotype was found in the sCJD patients. In contrast, 73 % of the controls presented the H 1 haplotype and 27% the H2 haplotype, although no statistic significance could be established (p=0.063). No clinical differences could be found related to tau genotype. Conclusions: There are no differences in the distribution of allelic or genotype frequencies of the tau gene in the group of TSE patients compared to controls. Differences in subtypes of TSE are limited for the number of patients examined. P724 Left homonymous hemianopia: the first symptom of a primitive degenerative process. G. Messa, G. Vezzadini, E Dieci, S. Copelli, P. Caffarra (Parma, I) Alzheimer's disease (AD) is a neurodegenerative process with typical or atypical presentation, the former involving memory, the latter language, praxis or visuo-spatial abilities. Several terms have been introduced to illustrate clinical varieties involving the posterior cerebral cortex: posterior cortical atrophy (PCA), visual variant AD, progressive biparietal syndrome. Clinically they manifest with visual dysfunction, Balint's or Gerstmann's syndrome. Memory is not affected until late in the course of the disease. We reporta case of a 61 year-old woman who presented a left homonymous hemianopia (LHH). Neuropsychological examination was characterized by apperceptive agnosia and constructional apraxia, while memory, insight and attention were relatively intact. Neuroradiological investigation showed bilateral ventricular enlargement and cortical atrophy most marked in the right posterior region. The absence of protein 14-3-3 and the clinical evolution ruled out the hypothesis of Jacob-Jacob disease. Two years later she complained of more consistent memory difficulties, being unable to correctly orientate herself in known and unknown places, while Activity of Daily Living (ADL) and Instrumental Activity of Daily Living (IADL) remained intact. Lacking pathological evidence any conclusion about the etiology (PCA, visual variant of AD) remains speculative. However we suggest that a focal neurological deficit (LHH) may be the first sign of a degenerative process.

P725 Rates of forgetting in Mild Cognitive Impairment. R. Monastero, B. Borroni, R. Camarda, A. Padovani (Palermo, Brescia, I) Objective: To evaluate the rate of forgetting in subjects with Mild Cognitive Impairment (MCI), and to determine predictive factors associated with an early detection of MCI. Background: Accelerated forgetting has been proposed as the first sign in preclinical and early Alzheimer's Disease (AD). There is converging evidence to support the fact that MCI represents an early stage of AD. Patients and metbods: Forty-two patients with mild Alzheimer's Disease

(mean MMSE scores= 20.8 sd 2.3, CDR 0.5/1), 18 patients with Mild Cognitire Impairment (mean MMSE scores= 25.2 sd 1.4, CDR 0.5), and sixty normal subjects similar for age and education participated in the study. Al1 subjects were evaluated by an extensive neuropsychological battery assessing attention, abstraction, language, visuoconstructional skills, memory, and problem solving. Rate of forgetting was assessed with widely used standardised tasks of verbal and non verbal memory (Rey-Osterrieth Complex Figure Test Recall, and California Verbal Learning Test). Resuhs: The immediate and delayed recall scores were highly correlated in all groups and significantly impaired in the MCI and AD groups (p from < 0.001 to < 0.0001 Vs controls). Hierarchical multiple-regression analyses revealed that MCI and AD status significantly predicted delayed recall performance above and beyond immediate recall performances on each of the two tasks (F from 9.3 to 17.1). A stepwise regression analysis showed that, when MCI patients and normal controls were analysed separately, long delay recall scores (F=28.5), and recognition scores (F=5.98) of the California Verbal Learning Test were predictive factors of MCI. Conclusions: This study suggests that both MCI and mild AD are associated with a significant rate of information loss of verbal and non verbal material and that tests for delayed recall and recognition may be particularly useful in the early detection of MCI.

Genetics P726 Advances In The Genetics Of Epilepsy And Tumours In Familiar Epilepsy. L. I. llievska (Skopje, MAK) Genetic study in 35 families with a total of 145 members of epilepsy was made, 96 of them were examined. In this group of families there were 2 to 10 members with epilepsy (average 4 %). Clinical phenotype expression of the seizures was the following: Febrile convulsion in 11 ( 11.5 %); Primary generalized epilepsy in 13 (13.5%); Secondary generalized epilepsy in 12 (12.5%), Partial (simplex and complex) epilepsy in 60 (62.5%). Partial epilepsy was involved in most of them, wbich h a d a speeial importance for our genetic research. EEG abnormalities were found in 22 (22.9%) asymptomatic members, which in one family showed more or less similar findings, which evoked the question for genetic marker or preventive treatment. EEG abnormalities were generalized in 27 (28.1%) and in 48 (50.1%) lateralized on the right hemisphere and in 21 (21.1%) on left hemisphere. HLA antigens ofA and B and DR/DQ locus were analysed as well. Increased frequency of HLA A antigens Aw19 (p < 0.001) and DR3, DR5 and DRW 6 (p < 0.01) were found in this group. DNA was isolated from all family members investigated and linkage analysis will be the subject for a further investigated. In this study, another interesting point was that in majority of families there was one or more members having tumours, in genital or another organs (extracranial), which made us to investigate the tumour markers (NSE, CEA, CIFRA 21-1) in 46 subjects. This would be the main reason to prove the type of association between the epilepsy and tumour within the same family. P727 Transforming growth factor beta3 gene linkage in French families with multiple sclerosis. N. Tubridy, I. Cournu-Rebeix, G. Lesca, A. Azoulay-Cayla, E. Genin, F. Clerget-Darpoux, B. Fontaine, The French MS Genetics Group (Paris, F) Multiple sclerosis (MS) is thought to be caused by an interaction of an altered immune system, environmental elements and some degree of genetic susceptibility. The genetic factors remain largely undetermined although associations with certain human leukocyte antigen (HLA) genes have been identified. HLA DR15 is one of the most consistent genetic linkage associations of MS. A previous linkage analysis study performed in our laboratory looked at MS multiplex families of French origin and suggested a possible role for transforming growth factor (TGF) beta3 in HLA DRl5-associated families among sib-pairs. In another study of these families, we demonstrated a weak but significant concordance for disability in MS sibpairs which suggested that the degree of disability might be influenced by genetic factors. The aim of this study was to confirm the existence of an association between TGF beta3 and MS. We then will try to correlate the TGF beta gene status with HLA status and the level of clinical disability. Three-hundred and fifty simplex French families with MS were identified. Clinical data included the disease duration, and the current level of disability measured using the EDSS. Disease severity was determined by calculating the progression index (Pl) i.e. EDSS/disease duration. Genotyping

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was performed using an intragenic single nucleotide polymorphisms (SNPs) of the TGF beta gene on 100 patients and their parents. The data was analysed using a Transmission Disequilibrium Test (TDT). We looked at the HLA DR15 and the TGFb3 status of each family member with MS and correlated the genetic findings with the susceptibility to developing MS. The results will be discussed with the poster. P728 A novel mutation in McLeod Syndrome. S. Renaud, B. Singleton, B. Singletou, G. Daniels, N. Urscheler, A. I. Steck, P. Fuhr (Basel, CH; Bristol; Rheinfelden, CH) The McLeod syndrome is a rare X-chromosomal recessively inherited multisystem disease, characterized by disturbances of the neuromuscular and haematopoietic system. We describe a family with a newly diagnosed McLeod Syndrome. The index patient, a 63 year old carpenter presented ten years ago with proximal weakness and muscle atrophies with only slight pallhypaesthesia of the lower extremities. Electrophysiology showed an extensive denervation process of the lower limbs and the right upper limb a n d a slight sensorimotor polyneuropathy. A muscle biopsy yielded a chronic neurogenic muscle atrophy and in addition an active dystrophic myopathy. Since the anti-ganglioside GMl-antibodies were positive, a motor neuropathy was presumed and the patient was treated with immunosuppressivedrugs for several years. Meanwhile the patient developed a slight dementia, aggressive behaviour and choreic movements. Liver enzymes were elevated a n d a cardiomyopathy was also diagnosed. A blood smear showed acanthocytes. Huntington's disease and abetalipoproteinaemia were excluded by genetic testing and lipoproteinelectrophoresis, respectively. A weak signal for the Kell antigens and the lack of the antigen Kx, a protein that is important for the expression of the Kell antigens, proved the diagnosis of a McLeod syndrome and excluded the very similar chorea-acanthocytosis. The exact pathophysiological mechanism of this disease is unknown so far. Both the index patient,who showed the typical phenotype of the McLeod Syndrome, and his so far heahhy grandson hada deletion of exon 2 of the Xchromosomal recessive XK gene, which codes for the Kx antigen, which has not been found before. P729 Familial Parkinson's Disease: a large family with typical adult-onset, tremor-dominant parkinsonism. A. Solida, J. Ghika, F. Vingerhoets (Lausanne, CH) Familial autosomal dominant parkinsonism, often characterized by additional atypical features compared to sporadic Parkinson's Disease (PD), has been associated in some families with mutations in the alpha-synuclein gene on chromosome 4q (PARK1) and with two loci mapped to chromosome 2p (PARK3) and to chromosome 4p. Mutations in the parkin gene on chromosome 6 (PARK2) have been otherwise detected in families with autosomal recessive juvenile parkinsonism and, recently, by Klein et al., in a large family presenting with a clinically typical Parkinson's Disease. We reporta Swiss family with adult-onset, tremor-dominant parkinsonism, of probable autosomal dominant inheritance and clinically resembling to idiopathic Parkinson's Disease (PD). The index case, a 54 year-old woman, whose father was known as affected by typical PD, presented an asymmetric parkinsonism, beginning at 45 with a right-hand tremor. Nine other members of her family underwent clinical examination. A diagnosis of clinically definite parkinsonism was made when at least two of three signs (resting tremor, rigidity and bradykinesia) were present. Three of the examined members (belonging to the same generation of the index case) showed a similar phenotype consisting of an asymmetric tremor-dominant parkinsonism, responsive to levodopa and slowly progressing without atypical signs. Age of onset ranged between 45 and 57 years. Motor fluctuations developed aftera few years of treatment with levodopa. Six of seven siblings (all deceased at the moment of family evaluation) belonging to former generation were known by history and hospital records to be affected by the same phenotype with age of onset ranging between 48 and 75 ans. Conclusions: We reporta large family from Switzerland with an aduhonset tremor-dominant parkinsonism, clinically resembling to typical Parkinson's Disease. The inheritance of disease appeared to be autosomal dominant with high penetrance. A genetic analysis is underway.

P730 Lack ofapoptosis in muscle tissne ofpatients with mutations in the Adenine Nucleotide Transiocator 1 gene. M. Sciacco, G. Fagiolari, C. Lamperti, A. Prelle, L. Chiveri, G. P. ComŸ A. Bordoni, M. P. Perini, G. Scarlato, M. Moggio (Milan, 1) Autosomal dominant progressive external ophthalmoplegia (adPEO) is a rare human disease associated with multiple mtDNA deletions. Linkage analysis has led to the assignment of some affected families to the 4q34-35 locus. Recently, mutations have been identified in the nuclear gene encoding the heart/skeletal muscle isoform of the Adenine Nucleotide Translocator 1 (ANT 1), which is located in the critical region of the 4q locus. Because ANT 1 is also a structural component of the mitochondrial permeability transition pores (MPTP), and has a role in mitochondrial-mediated apoptosis, ir has been hypothesized that apoptosis may have a role in the pathogenesis of adPEO caused by ANT1 mutations. For example, ANT1 defects may affect MPTP opening and/or increasing mitochondrial oxidative stress. To verify this hypothesis, ",ve studied muscle biopsies of seven patients from five 4q-linked adPEO families. Six subjects share the Al 14P heterozygous mutation and one a novel L98P mutation in the ANT1 gene. We used TUNEL reaction asa marker of nuclear DNA fragmentation, and antibodies against pro- (Fas) or anti- (Bcl-2) apoptotic factors. Also, we performed ultrastructural studies examining both phenotypically normal and ragged red fibers. In all cases, we found no significant expression of both pro (Fas) and in_ hibiting (Bcl-2) apoptosis related proteins, nor did we find TUNEL positivity. This latter finding is confirmed by lack of morphological evidence of apoptosis in all the fibers examined at ultrastructural level. We conclude that ANT1 defects cause accumulation of multiple mtDNA deletions and the consequent adPEO pbenotype by a mechanism other than the apoptotic one. P731 Clinical, biochemical and genetic studies in a Spanish family with Mitochondrial Neurogastrointestinal Encephalomyopathy (MNGIE). 1. Gamez, L. Guarner, C. Ferrero, R. Marti, A. L. Andreu, A. M. Accarino, S. Tadesse, S. DiMauro, C. Cerrera, M. Hirano (Barcelona, E; New York, USA) Objective: To describe clinical, biochemical and genetic studies in a Spanish patient with ptosis, external ophthalmoparesis, severe cachexia, chronic diarrhea and vomiting. Background: Mitochondrial Neurogastrointestinal Encephalomyopathy (MNGIE) is an autosomal recessive disorder caused by mutations in the thymidine phosphorylase (TP) gene. Molecular genetic studies have revealed 17 different mutations in MNGIE patients from a variety of ethnic backgrounds including: Askenazi lewish, Iranian Jewish, American, British, German, Italian, Puerto Rican, African-American, Japanese, Swiss, Belgian, Portuguese, and Dominican. Here, we report molecular studies of the first Spanish MNGIE patient confirmed by molecular genetic analysis. Design/methods: The proband was a 23-year-old woman who presented in infancy with abdominal pain, chronic diarrhea, borborygmi, vomiting, nausea and intestinal pseudo-obstruction. On examination, she had severe cachexia, bilateral ptosis and external ophthalmoparesis. A radionuclide gastric emptying study revealed a severe gastroparesis. Gastrointestinal manometry demonstrated a neuropathic pattern in the intestines. Enteral nutrition by jejunostomy failed to ameliorate her vomiting and progressive cacbexia. At age 22 years, the patient became dependent on parenteral nutrition. Results: TP enzyme activity was undetectable in the patient's buffy coat. Plasma thymidine level was 4.6 micromoles/liter (normal values < 0.2). We identified a heterozygous missense mutation, GI443A, in the gene encoding TE This mutation was identified previously in English and European-American MNGIE patients. We also identified a novel missense mutation G435A that changes amino acid 44 of TP from arginine to glutamine. Conclusions: Our patient harboured compound heterozygous TP gene mutations and is the first molecularly confirmed patient with MNGIE in Spain. Biochemical and molecular genetic studies for the TP gene mutation are warranted in patients with severe gastrointestinal dysmotility, cachexia, and neuromuscular symptoms. Supported by: Spanish Fondo de Investigaciones Sanitarias (FIS 001797).

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P732 Locus 1 for ataxia-oculomotor apraxia (AOAI) maps to chromosome 9pi 3 in Portuguese and lapanese families. M. C. Moreira*, C. Barbot, N. Tachi, N. Kozuka, P. Mendonqa, I. Sequeiros, P. Coutinho, M. Koenig (Strasbourg, F; Porto, P; Sapporo, l; Santa MarŸ da Feira, P) Ataxia-oculomotor apraxia (AOA) is a recently defined clinical condition that appears to be relatively frequent in Portugal, second place behind Friedreich ataxia (FRDA) in terms of relative frequency. It is characterized by an early onset cerebellar ataxia, combined with oculomotor apraxia, early areflexia, late peripheral neuropathy, slow disease progression, severe motor handicap, and the absence of telangiectasias and of immunodeficiency. Until the end of 1999 we had identified and characterized 13 Portuguese families (23 patients) with AOA. In order to map the locus responsible for this pathology, we performed a genome wide screen. The two largest families were linked to 9p with LOD scores of 4.13 and 3.82, respectively, at q = 0. These and three smaller families, all from Northern Portugal, showed homozygosity and haplotype sharing over a 2 cM region on 9p 13, demonstrating the existence of an ancestral founding event, homogeneity and linkage of the tire families to this locus (AOA1). Three other families were excluded from this locus, demonstrating non-allelic heterogeneity in AOA,while the status of the tire remaining families could not be determine& Early onset cerebellar ataxia with hypoalbuminemia (EOCA-HA) is a clinical entity so far only described in ]apan, presenting marked cerebellar atrophy, peripheral neuropathy, mental retardation and occasionally, oculomotor apraxia. Four EOCA-HA/OA patients from two unrelated ]apanese families were analyzed and appeared linked to the AOAI locus. Subsequently, serum albumin was measured in the Portuguese AOA patients and found to be reduced in all patients with a disease duration superior to 10 years, suggesting that AOA1 and EOCA-HA correspond to the same entity. The recent localization of a second AOA locus in a Pakistanese Ÿ on 9q34 confirmed genetic heterogeneity. The screen for this region of the Portuguese families not linked to 9p13, showed that none of them were linked to the 9q34 locus, indicating the existence of at least a third locus. P733 Frequency of Ioci associated with autosomal recessive demyelinating Charcot-Marie-Tooth disease in 41 families with consanguinity. C. Verny, A. Guilbot, N. Birouk, N. Birouk, M. Tazir, L. Ouldamer, M. Salih, M. Mayer, R. Gouider, O. Dubourg, E Dubas, A. Vandenberghe, ]. Grid, A. Brice, E. Le Guern (Angers, Paris, F; Rabat; Algers, DZ; Riyadh, KSA; Tunis, TN; Lyon, Ivry, F) Charcot Marie Tooth (CMT) disease is the most frequenfly inherited peripheral neuropathy. CMT is a ver)' heterogeneous pathology on the clinical, electrophysiological and genetic levels. Classification of CMT is based on electrophysiological characteristics and on the mode of inheritance. The demyelinating form is found in patients with decreased motor nerve conduction velocity (MNCV); the axonal forro in patients with normal MNCV. In Europe, the most frequent modes of inheritance are autosomal dominant or X-linked. Autosomal recessive CMT (ARCMT) seems to be rare and probably corresponds to sporadic cases because of the small size of the families. For the demyelinating ARCMT, 6 loci have been described (2 on chromosome 8, 2 on chromosome 11, 1 on chromosome 19 and I on chromosome 5). A linkage study of these 6 loci was carried out in 41 families with at least one member with a demyelinating ARCMT born of healthy related parents. In 40 % of these families, the disease was linked to one of the 6 known loci. In this study, the frequency of each loci was estimated and we showed that none were restricted to a geographic area oran ethnic group. P734 The proportion of deleted mitochondrial genomes correlates with the complexity of the clinical phenotype. A. Bender, '1".Gasser, T. Klopstock (Munich, D) Background: Chronic progressive external ophthalmoplegia (CPEO), CPEO plus and Kearns-Sayre syndrome (KSS) are most often caused by deletions of the mitochondrial DNA (mtDNA). However, a precise genotype-phenotype-correlation could not be established so far. Methods: Total DNA was prepared from muscle biopsies of 57 patients (19 CPEO, 28 CPEO plus, 9 KSS, and 1 patient with mitochondrial myopathy). Southern blot was performed and hybridized to an mtDNA-probe. Results: Deletions of mtDNA were found in 70 % of patients, irrespective of the phenotype. There was no correlation of size or site of deletions with the clinical manifestation. However, the degree of heteroplasmy of the deletion was significantly correlated with clinical severity and inversely with age at onset, with CPEO showing the lowest and KSS the highest proportion of deleted genomes.

Conclusion: The higher the proportion of deleted mtDNA, the earlier is the age at onset and the complexer is the clinical manifestation. While a correlation of the proportion of deleted genomes and biochemical findings had been shown earlier, these resuhs establish for the first time an association of the genotype with the clinical manifestation. P735 Clinical and genetic analysis of autosomal-dominant essential tremor in a large German family. E Asmus, T. Gasser, M. Dichgans (Munich, D) Essential tremor (ET) is the most common movement disorder with its autosomal-dominant form accounting for up to 50% of the cases. Three loci have been implicated in the disease: A 10 cM region on chromosome 3q13 anda second region on 2p22-25 (9.1 cM) have been mapped in several tremor families from different genetic backgrounds. Farrer et al. reported a large family with Lewy-body parkinsonism and postural tremor in which a locus on chromosome 4p14-16.3 could be identified. We report on a large three generation family originating from the southwest of Germany segregating familial ET with an obviously autosomal-dominant inheritance pattern. According to the standardized WHIGET-protocol we clinically assessed and video-documented 40 family members. 11 individuals could be identified who have typical features of ET with postural and/or bilateral action tremor of hands (11), head (4) and chin (2) with exercise-induced aggravation. Mean age at onset was 20years (6-70years) with onset before age 22 in 10 individuals. The severity of tremor in this family was slowly progressive with significant worsening of symptoms in the fifth and sixth decade. Tremor was alcohol-sensitive in 64 % of patients and responded at least partially to propranolol therapy in four patients tested. The clinical course and presentation as well as age at onset in this family are typical for hereditary ET. Linkage analysis to the ET loci on chromosome 2p, 3q and 4p is underway. P736 The Influence of Apolipoprotein E Gene Polymorphism on Age at the Onset and Clinical Forms of Wilson's Disease. A. M. Ciesielska, T. Litwin, G. Gromadzka, B. Tarnacka, A. Czlonkowska (Warsaw, PL) Wilson's disease is an autosomal recessive disorder - abnormal gene has been identified on chromosome 13. The underlying deficit is an impairment of metabolism and storage of copper and its accumulation in different organs: liver, brain, cornea, kidney and bones. The predominance of copper accumulation in these places leads to other forros of Wilson's disease: hepatic, neurological or asymptomatic. The age of the onset of first symptoms ranges from three to more than 50 years of age. A connection between different ApoE genotypes and age of manifestation and perspective of various human disorders was documented. Epidemiological studies have established that the E4 allele is an important risk factor for sporadic and familiar Alzheimer's disease, Huntington's disease, temporal late epilepsy and poor clinical outcome after brain injury or stroke. We examined the possibility of a correlation between ApoE genotype and age and clinical form of the Wilson's disease onset. We studied 71 patients (36 men, 35 women) with Wilson's disease. The diagnosis in all cases was established on the basis of the history and examination and confirmed by testing of Cu2+ and coeruloplasmin blood levels and twenty-four hour's copper's excretion with urine (in doubtful cases, the diagnosis has been verified by test with Cu2+ marked radioactively). Among 71 Wilson's disease patients 42 represented neurological, 20 hepatic form of the disease, 9 was asymptomatic. The ApoE genotype was assessed by amplifying the polymorphic region using PCR method, followed by digestion with Hha 1 restrictive endonuclease and gel electrophoresis. The distribution ofApoE genotypes in patients with Wilson's disease was similar as assessed in healthy European subjects: ApoE 3/3 genotype was noticed in 69 %, E3/4 - in 16.9 %, E2/3 - in 12.6 %, E2/2 - in 1.5 %. We didn't observe any influence of allele E4 on the earlier manifestation of Wilson's disease. The average age at Wilson's' disease onset was not dependent on the Apo E genotypes: in ApoE 3/3 group ir was 26.4 years, in ApoE3/4 - 27.1 years and in ApoE 2/3 - 25.8 years. Any association between ApoE genotype and clinical form of the disease was observe& There was no correlation between Apo E alleles combination and clinical manifestation and age at onset of Wilson's disease.

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P737 Elevated myo-Inositol is indicative for altered Ca2+ homeostasis in the cerebellum of Familial Hemiplegic Migraine patients linked to CACNA1A on chromosome 19p13. ]. Herzog, M. Wilke, K. Jurkat-Rott, D. P. Auer, M. Dichgans (Munich, Ulm, D) Objective: Familial Hemiplegic Migraine (FHM) is a rare, autosomal-dominantly inherited subtype of migraine with aura. In about 40 % of FHM patients a progressive cerebellar ataxia of unknown origin is found, all of them bearing mutations in a Ca2+-channel gene (CACNA1A) on chromosome 19p13. We used proton magnetic resonance spectroscopy (1H-MRS) to investigate metabolic changes in the brain in vivo with a focus on the cerebellar pathology. Methods: 15 affected family members from 3 German FHM kindreds and 17 age-matched controls were studied with 1H-MRS. LCModel fits were used to estimate absolute concentrations of myo-inositol (mi), choline-containing compounds (Cho), total creatine (Cr), N-acetylaspartate (NAA) and glutamate (Glu) in the parietal and occipital cortex as well as in the superior cerebellar vermis. To control for variations in voxel composition, in particular in view of cerebellar at rophy, image segmentation was done using a fully automated threshold and prior knowledge based segmentation procedure (SPM99). Results: All 15 patients had either cerebellar atrophy on MRI scans or cerebellar signs on clinical/electronystagmographic examination. All 3 kindreds showed linkage to the CACNAIA locus on chromosome 19p13. FHM patients had significan@ elevated mi in the superior vermis, whereas the levels of NAA and Glu were significantly decreased. The reduction of NAA correlated negatively with the individual grade of cerebellar symptoms as expressed by a previously published ataxia score. No metabolite alterations where found outside the cerebellum. Conclusion: We found marked metabolic alterations in the cerebellum of FHM patients. Considering the role of ml in regulating the intracellular calcium concentration in Purkinje cells the observed mi elevation may represent the first in vivo marker fora disturbed cerebellar calcium homeostasis in FHM. The observed decrease in NAA is compatible with neuronal loss as zeflected by the cerebellar atrophy. The absence of metabolic changes in supratentorial regions of our patients likely reflects distinct effects of Ca2+channel mutations on infratentorial structures in FHM. This observation is in line with studies, that have shown predominant expression of CACNAIA in Purkinje cells and in the brainstem. P738 Clinical stage and magnetic resonance correlation in patients with spinocerebellar ataxia type 1 (SCA 1). R. Poniatowska, R. Krawczyk, G. Rejnowski, R. Boguslawska, D. Milewska, E. Pilkowska, D. Hoffman, M. Rakowicz, P. Kozlowski, J. Zaremba (Warsaw, PL) Introduction: Spinocerebellar ataxia type 1 belongs to the group of neurodegenerative disorders, in which progressive cerebellar ataxia occurs. Genetically an unstable trinucleotide CAG repeat on chromosome 6 is found. The aim of the study was to correlate patients clinical stage with the quantitative value of brain ataxia. Material and method: 23 SCA1 patients (18 female, 5 male) with average age 43 years were studied with magnetic resonance, using standard SE sequences with T1- and T2-weighted images in orthogonal planes. On midsagittal Tl-weighted image were measured: ventral pons (Pv), dorsal pons (Pd), cerebellum (C), posterior fossa (PF), major and minor axes of the ventral pons. Pv, Pd and C values were standardised - expressed as ratios of the anatomy area to the area of posterior fossa. The statistics and the differences between normal control and SCA 1 patients were computed. Results: The inverse correlation between CAG repeats and age at disease onset were found (0.73; p < 0.05). The duration of the illness correlate inverse with ventral upper and lower axis of the pons (u 0.65,10.63; p < 0.05) and with ventral and dorsal part of the pons (v 0.59, d 0.69; p < 0.05). The correlation between atrophy of cerebellum and atrophy of dorsal and ventral part of the pons was found (d 0.68,v 0.68; p < 0.05). The atrophy of cerebellum, pons and frontal lobes was symmetrical (c 0.82,p 0.92, fl 0.83; p < 0.05). Pd/PF, Pv/PF, C/PF, Pv-major and Pv-minor were significantly smaller than in normal control (0.045 + 0.0082 to 0.068 + 0.015; 0.0828 _+0.0134 to 0.1125 + 0.0123; 0.2578 + 0.0374 to 0.3687 + 0.0242; 0.1561 + 0.0294 to 0.2443 _+ 0.0227; 0.1846 + 0.0238 to 0.221 + 0.0241).Also the ratio Pv-major/Pv-minor showed difference between SCA1 patients and normal control (0.845 + 0.0108 to 11.11 -+0.1046). No significant correlation was found in C/Pv ratio. Conclusions: Patients illness duration correlates with ventral upper and lower axis and ventral and dorsal part of the pons. No difference in C/Pv shows, that the pontine atrophy is proportional to cerebellar atrophy. The decreases in C/PF indicates cerebellar atrophy, Pv/PF pontine base atrophy. The atrophy of cerebellum, pons and frontal lobes is symmetrical, causing therefore difficulty in detection of pons atrophy in early stage of SCA 1.

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General neurology P739 Relapsing meningoencephalitic Uke episodes as the presenting manifestation of Melas. C. Talamon, D. Adams, C. Lacroix, A. Slama, G. Said (Le Kremlin Bic~tre, F) MELAS is a mitochondrial encephalopathy characterized by myopathy, encephalopathy, lactic acidosis and stroke-like episodes. In this abstract we report on a patient with a yet undescribed presentation consisting in relapsing meningoencephalitic like episodes of adult onset. A 51 years-old women presented six neurologic episodes of mild to severe intensity from February 1998 to May 2000. The first episode was subacute with rever, dysarthria, left hemiparesis and finally coma, which spontaneously remitted within a few days. Several relapses occurred during the following few months including an episode of cerebellar ataxia with deep coma; one episode of aphasia, right hemiparesis followed by coma within a few hours; one episode of transient hemianopia; one episode of partial epilepsy complicated by generalized status epilepticus. Three times CSF examination showed meningitis with pleocytosis (10 to 362 cells) with predominant polymorphonuclear cells or mixed formula. Protein content was increased, glucose content was normal. MRI T2 weighted showed sprayed hyper intense lesions situated mainly in subcortical white mater. Localization was variable brainstem and cerebellum, fronto-temporal, insular of occipital for the last episodes. After few months pathological signals disappeared while diffuse atrophy took place. Muscle biopsy showed ragged red fibers; decreased of various complex activity was found in biochemical examination of the respiratory chain. Mitochondrial genome study showed numerous large deletions. Conclusion: This observation illustrates an adult onset of MELAS characterized by relapsing meningoencephalitic like episodes. P740 Localization of cortical functional areas in patients affected by focal epilepsy. Comparison between magnetoencephalography (MEG) and EEG. A. Thomas, G. D'Andreamatteo, D. Iacono, S. Della Penna, V. Pizzella, M. Onofrj (Pescara, I) We studied 6 patients affected by temporal lobe epilepsy (TLE) with MEG and longterm EEG. Two of them had hippocampal sclerosis. One group composed by three patients presented aphasic seizures accompanied by sporadic gustatory hallucinations, of epigastric discomfort and nausea. The other group of patients without aphasic symptoms presented seizures characterized by visual hallucinations preceding vertiginous symptoms, one patient experienced flushing of the face, papillary dilatation and panic, and the third patient hada motor arrest followed by oroalimentary autism (lip smacking). All patients were refractory to therapy and candidates for resective surgery. Longterm EEG monitoring revealed interictal epileptiform discharge in 2 patients of the aphasic group and in 2 patient of the second group. MR1 has been performed for the anatomical three dimensional high resolution of the brain. MEG recordings (2-3hours duration) showed epileptiform activity in all patients, more evident in those patients with neocortical temporal than in patients with mesial temporal lobe epilepsy. MEG in combination with neuroimaging data were compared with EEG data. In conclusion: MEG/MRI can reliably lo calize sources of spike discharges in patients affected by TLE, furthermore provides a non invasive localization data otherwise not available with conventional EEG, and reduce the need of invasive procedures. P741 Superficial Siderosis of the Central Nervous System: pathogenetic heterogeneity and therapy. V.I. Leussink, P. Flachenecker, D. Brechtelsbauer, M. Bendszus, U. Slq R. Gold, G. Becker (Wª Jena, D) Background: Superficial siderosis of the central nervous system (CNS) is a rare chronic progressive disorder characterized by sensorineural hearing loss, cerebellar ataxia, dysarthria and pyramidal signs. It is thought to be due to chronic subarachnoid hemorrhage leading to iron deposition around the cerebellum, the brainstem and the spinal cord. Objective: To emphasize the pathogenetic heterogeneity of superficial siderosis of the CNS, the clinical symptoms and the importance of early diagnosis and treatment. Patients and methods: We describe four patients with the characteristic symptoms of superficial siderosis. Results: There are different causes for chronic subarachnoid bleeding. In three of our patients, bleeding after surgical treatment of ependymoma,

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from cerebral cavernomas or from vasculitis of the central nervous system associated with systemic haemochromatosis were the underlying diseases with the latter possibly representing a unique cause of the disease. In one patient, no specific underlying disease was detected. In the patient with presumed vasculitis, CSF analysis was indicative of chronic subarachnoid hemorrhage, MRI showed focal hypointensities on T2-weighted images, and angiography was typical for vasculitis. In the patient with cavernomas as the source of chronic bleeding these were removed successfully. The patient with vasculitis received immunosuppressive therapy, and two patients were symptomatically treated with chelating agents and antioxidants. Overall, the patients remained clinically stable for the follow-up period of up to two years. Conclusions: Our cases underline the pathogenetic heterogeneity of superficial siderosis and favour the early diagnosis for prompt initiation of therapy. Besides treatment of the underlying condition, antioxidants and radical scavengers may be effective in halting the progression of the disease. P742 Diagnosis and prognosis of status epilepticus in the intensive care unit. E W. Drislane, M. R. Lopez, A. S. Blum, D. L. Schomer (Boston, USA) Background: Status epilepticus (SE) increases morbidity and prolongs intensive care unit (ICU) stays in already-sick patients, but its diagnosis is often delayed or missed. Objective: to determine the causes, clinical features, course, and prognosis of SE in the ICU. Methods: We reviewed the clinical features of patients with EEG aod dinical evidence of SE in our ICUs over the past 17 years. Resuhs: 93 patients were identified, 55 with generalized seizure discharges and 38 with focal seizures on EEG. All had an abnormal mental status; 75 were comatose. Anoxia (22 patients) and other vascular disease (20 patients) were the most common causes. Nearly all had multiple medical problems. Although 78 patients had had clinicaUy evident seizures earlier in the admission (and 57 clinical SE) only 21 were thought to be in SE at the time of the diagnostic EEG. There was a median delay oŸ24 hours from a clinical deterioration until diagnosis in patients with earlier clinical seizures and 3 days for those with no clinical seizures. Among the 71 non-anoxic patients, 34 (48%) improved in alertness on antiepileptic drugs (AEDs), including 15 who were comatose. Patients with focal discharges were more likely to respond to AEDs: 21/38 vs. 13/55 with generalized discharges (p < 0.02). Survival correlated best with etiology. Patients in the surgical ICU (vs. medical ICU) and those with generalized (vs. focal) discharges fared worse, largely due to serious underlying causes. Conclusions: ICU patients with altered mental status and EEG evidence of SE often have severe medical and surgical illnesses anda high mortal@. Nevertheless, delay to diagnosis is substantial, a n d a significant subset of these patients do improve on AEDs once the SE is discovered. This diagnosis should be sought more often in ICU patients with abnormal mental status, especially afier clinical seizures of SE from which the patient has not recovered fully. P743 Lhermitte's sign in patient without multiple sclerosis. J. P. E. Porta-Etessam, Aros. MartŸ Abg. Berbel-GarcŸ Jbl. Benito-Le£ D. Pm. P› MartŸ R. Sd. Saiz-Diaz, Fbp. Bermejo P (Madrid, E) To present eight patients without multiple sclerosis and Lhermitte's sign analysing the aetiology, treatment and their prognoses. Lhermitte's sign is most prevalent in patients with multiple sclerosis, and less frequent in cervical spondylotic myelopathy, cisplatin neurotoxicit y, cervical radiation injury, and neck trauma. There were eight patients (tire men and three woman) ranging in age from 19 to 65 years old.All patients had Lhermitte's sign, a shock-like or electric sensation, transmitted down the spine, which occurred during neck flexion or rotation. Two patients had postradiation myelopathy, one was due to cis-platinum toxicity, two because of a slipped disc. One patient hada spinal cord vascular malformation, another a cervical myelopathy and the last one a cervical spinal coral compression due to a metastasis. All cases respond to a combination between carbamazepine treatment and surgical approach to the aetiology disease (spinal cord malformation, cervical myelopathy, slipped disc) or radiotherapy (spinal cord compression). Lhermitte's sign is non-specific phenomena responding to a multiple injuries. Early and aetiological treatment should be established as soon as possible. As an isolated phenomenon has good prognosis.

P744 Cerebral candidosis after allogenic bone marrow transplantation. U.K. Zettl, B. Steiner, M. Leith/iuser, St. Wilhelm, C. Junghanss, F. Heussner, J. Casper, M. Freund (Rostock, D) lnfectious complications remain one of the major clinical problems afier bone marrow transplantation. Unusual infectious agents, localisations and clinical courses frequently occur in these patients. We report on a 37 year-old man who received a HLA-A-mismatched unrelated bone marrow transplantation for acute myelocytic leukemia in partial remission. During post-transplantation neutropenia he developed severe sepsis with pulmonary infiltration. Fungal origin was suspected, but mycological workup did not identify a causative agent. Afier therapy and engraftment he was discharged. On day 120 after bone marrow transplantation first neurological symptoms (headache, aphasia, right hemiparesis) were noted. Magnetic resonance imaging (MRI) of the brain demonstrated parenchymal abnormalities, particularly abscesses and disturbed cerebrospinal fluid circulation. Histopathological investigation of tissue obtained by stereotactic punction demonstrated typical features of candidosis. Intravenous drug therapy using amphotericin B, flucytosin and fluconazol resulted in stabilisation of the neurological status. Pre- and postgadolinium MRI showed a reduction of cerebral infiltration and normalisation of cerebrospinal fluid circulation. Maximal antifugal drug therapy may be effective treatment of severe candidosis with cerebral manifestation, which is known to be a life-threatening complication after allogeneic bone marrow transplantation. P745 Transcranial sonography of the substantia nigra (SN) in patients with idiopathic parkinson syndrome (IPS). U. Sommer, G. Gahn, G. Becker, H. Reichmann (Dresden, Homburg/Saar, D) lntroduction: Transcranial ultrasound seems to be a suitable method to detect signal alterations in the substantia nigra (SN) of patients with idiopathic Parkinson syndrome (IPS). There are some speculations that the hyperechogenic signal in the SN of patients with IPS could result from an accumulation of iron and that this signal alteration seen in a healthy human individual might be a risk factor to develop Parkinson's disease in further life. Methods: We examined 10 patients (2 female, 8 male, age range from 40 to 70 years) with IPS in the stages Hoehn and Yahr I-IV and 10 controls (4 healthy individuals, 6 patients with peripheral neurological diseases; 3 female, 7 male, age range from 38 to 72 years) by transcranial sonography performed through a preauricular acoustic bone window. We employed a colour-coded, phased-array uhrasound system equipped with a 2.0 MHz transducer (Sonoline Omnia, Siemens, Erlangen, Germany). The mesencephalic brainstem with its butterfly shaped structure was identified and special attention was paid on the detection of the echogenicity of the SN. Results: Al1 the included persons had suitable acoustic bone windows which made measurements of the echogenic signa1 in the SN region of both sides possible. All patients with Parkinson's disease had hyperechogenic SN areas (mean value 25,8 _+ 1,7 mm 2) on one or both sides while in the control group we found a statistically significant lower mean value of 9,8 :t: 1,5 mm 2 of the SN area (p < 0.001 ). These results confirm the suggestion of other investigators that a hyperechogenic signal aheration is highly sensitive for Parkinson's disease. Conclusion: The airo of this investigation was to visualize the hyperechogenicity in the SN of patients with IPS compared to controls. Previous studies have shown that a hyperechogenic signal in the SN appears to indicate a functional impairment of the nigrostriatal system not only in Parkinsonian patients but also in clinically healthy persons. Thus, transcranial sonography as a non-invasive examination technique could be used as a preventive method to identify persons at risk and to start early neuroprotective therapy. P746 The Neurofibromatoses and Neurogenic Tumors of the orbit: Ciinic and Imaging Assessment in lasi-Romania. C. I. Badiu, E Stefanache, D. Cijevschi, C. Clement, C. Stefanescu (Paris Cedex, F) Background: The Neurofibromatoses (NF) are heterogenous neurocutaneous disorders that are characterized by two cardinal features: caf› spots and multiple neurofibromas. Other symptoms may result from lesions in bone, central or peripheral nervous system or other organs. At least two forms of neurofibromatosis can be distinguished unequivocally: neurofibromatosis type 1 (NF 1) and type2 (NF2). The diagnostic criteria for this two forms was established by National lnstitutes of Health Consensus Conference on Neurofibromatosis in 1987 and 1992.

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Objective: To determine the spectrum of manifestations and to assess posible complications of neurogenic tumors of the orbit in patients with NF 1 and NF2 admited in our hospital between 01.01. 1987-31.12. 1996. Materials and methods: Patients with NF was ascertained by review of their medical record, physician referal or self referal. Their evaluation in_ cluded review of family history, physical exam (dermatologic, neurologic, ophthalmologic et al.), neuroelectrophysiologic exam (EEG, EP, EMG, ECG) and imagistic exploration (C'I, scintigraphy, SPECT). Sections from the primary and recurrent tumors of the patients who underwent surgery embedded in paraffin and stained with hematoxylin and eosin was examine& Results: The lot of study was represented by 12 cases who met the diagnostic criteria for NF 1 (11) and NF2 (1) and who presented neurogenic tumors of the orbit (age range 1-44 years). Neurocutaneous features was observed only in the NF1 cases (caf› lait spots in 10, axillary freckling - 8, two of more dermal neurofibromas - 5 anda plexiform neurofibromas - 4 cases). Patients with either NF1 and NF2 developed spinal nerve root and spinal cord tumors (6-NF1 and 1-NF2), cranial nerves tumors (2-NF1 with optic pathway glioma and I-NF2 with vestibular schwannoma). Lisch nodules was identified in 5 patients with NF1, senil cataracts in 3 and juvenil cataracts in the NF2 case. Scoliosis, thinning of the long bone cortex and sphenoid wing dysplasia were identified in 4,1 and respectively 3 NF1 cases. CT and SPECT evidenced the tumors in all the 12 cases. The biopsy performed in 9 cases identified neurofibromas in 2, plexiform neurofibroma in 7 NF1 cases anda meningioma in the NF2 case. Conclusions: Neurogenic tumors of the orbit appeared early in our patients' life and determined important troubles of the vision so, it requires medical supervision with yearly ophthalmologic examination of the child with NF orat risk. P747

Carpal and Cubital Tunnel Syndrome Coexisting With Cervical Radiculopathy - A Coincidence or Double Crush Syndrome? A. Ozge, R. To6rol, G.

Conclusions: Although on clinical grounds it seems to be a confusing group, they all shared a similar neurophysiological examination. It is possible that benign fasciculations, cramp-fasciculation syndrome and other states of continuous muscle activity represent different stages of a same disease. P749

The simultaneous Holter-electrocardiography (ECG) and Holter-electroencephalography in patients with epilepsy. R. Raicevic, A. lovicic, D. Tavciovski, M. Krgovic, D. Djordjevic (Belgrade, YU) Introduction: Electrocardiographic(ECG) changes are well known accompanying manifestations of numerous neurological disease (ischemic brain disease, intracranial haemorrhage, expansive processes and epilepsy). In patients with epilepsy ECG changes can be responsible for sudden death. The airo of the study was to exclude or prove influence of epileptogenic discharge on ECG abnormalities by simultaneous continuous Holter ECG (HECG) and Holter EEG (HEEG). Methods and results: We included 18 patients in our study with clinically observed epileptic seizures and previous epileptic anamnesis. All patients underwent simultaneous 24h Hoher ECG/Holter EEG. In 7 patients with specific grapho elements in HEEG without changes in HECG. In 3 patients HEEG and HECG findings were normal. In 6 patients in HECG we observed episodes of heart rhythm disorders which were time related with specific epileptogenic discharges in HEEG. In 2 patient we observed simultaneous specific grapho elements'in HEEG and VT (ventricular tachyarythmias) episodes in HECG. Conclusions: Observed flndings indicate possible origin of sudden death in patients with epilepsy which ate to consequences of cardiac complications of epileptogenic discharge and results of our study support the idea of neural structural involvement in pathogenesis of the cardiac complications and their electrophysiologic correlates.

13ah)~n, S. Ba6i~, C. Erdo6an (Mersin, TR; Shape, B) The term "Double-crush" refers to the hypothesis that a single lesion of a nerve predisposes to a second lesion on the same nerve further along its course. To determine the incidence and characteristics of the double crush syndromes in the upper extremities, this cross-sectional, case-control clinical and electrophysiological study was planned. 210 patients (mean age was 49 + 7.9 years) and 30 age-matched healthy control subjects were included in the study. Detailed physical examinations, electrophysiological and radiological (cervical computerised tomography or cervical magnetic resonance imaging) investigations were performed in both the patients and the controls. In the electrophysiological evaluation, median and ulnar nerves were examined bilaterally. The sensory and motor conduction studies were performed with standardised nerve conduction velocity techniques using Medelec Synergy machine. One hundred ninety eight of the patients had carpal tunnel syndrome, 43.7 % of which had bilateral symptoms and 12 patients had ulnar neuropathy due to compression at the elbow. Of these patients, 102 (48.5 %) had double-crush syndromes and in 70.5 of them there was ah anatomical correlation with the electrophysiological and radiological findings. In conclusion, the results of the present study suggest that double-crush syndromes may frequently coexist with distal entrapment neuropathy. P748

States of continuous muscle activity: a clinical and neurophysiological

P750

Therapeutic Effect of Mexiletine in Patients with Myotonic Dystrophy. V. Rakocevic-Stojanovic, D. Lavrnic, S. Pavlovic, S. Apostolski (Belgrad, YU) Myotonic Dystrophy (MD) is the most common inherited muscle disorder characterized by variable degree of myotonia in addition to dystrophic changes in skeletal muscles and other tissues. Many drugs are used in the treatment of myotonia in MD. Mexiletine is a sodium channel blocker, recently used in the treatment of myotonic symptoms without any side effects. We analysed the therapeutic effect of mexiletine on the duration of the myotonic reaction and handgrip force in 20 patients with MD (12 men and 8 women, aged between 19 and 45). The control group consisted of 15 untreated patients with MD. At the end of one year follow-up period (200 mg mexiletine daily) the myotonic phenomena recovered completely in 12 (60%) patients in the experimental group and in no one patient in the control group. The myotonic reaction was reduced in duration an all 8 (40 %) of remaining patients treated with mexiletine and in only 1 (6%) of those belonging to the control group (p < 0.01). Conversely, the myotonic reaction was prolonged in 9 (60%) patients in the control group and in no one patient in the experimental group. The handgrip force measured by hand dynamometer was increased in 13 (65%) of the patients belonging to the experimental group while none of the patients in the control group showed any improvement (p < 0.01). These results suggest that mexiletine is one of the most effective drug in the treatment of myotonia in patients with MD.

study. C. Nevado, M. Blanco, B. Anciones (Madrid, E) P751 Background and objective: Fasciculations and cramps are common phenomena that often lead to seek consultation. These states of continuous muscle activity are a confusing group not fully differentiated from one another. Objectives: to describe the clinical-electrophysiological features of a group of patients. Methods: AII patients were assessed clinically and underwent routine needle electromyography, nerve conduction studies, repetitive stimulation and F wave response. Complete blood tests were also performed. Results: We report four tases, all males, mean age 34 years. AII four patients complaint of fasciculations but cramps, muscle aching and exercise in_ tolerance were variably present. On clinical examination diffuse fasciculations were found without weakness or sensory loss, deep tendon reflexes were normal and symmetric with flexor plantar responses. Neurophysiological tests: fasciculations in calf and foot muscles were present in all four. Motor and sensory nerve conduction studies were normal. Repetitive nerve stimulation (RNS) showed electrical potentials immediately following M response in three cases. In one cramps followed RNS. Repetitive potentials before F response were found in all of them.

Evidence of functional reorganisation of cortical connectivity in the early stage of traumatic brain injury. P. Stude, G. Gaitsch, K. Niessen, D. Osenberg, W. Ischebeck, V. H6mberg, D. Stolke, H. C. Diener, M. Keidel (Essen, Hattingen, Dª f, D) MRI-defined brain lesions after traumatic brain injury lead to disturbances of the neurona1 network and are compensated by alterations in the functional strength of coupling between neurona1 populations of different brain areas and by reorganisation of temporal patterns of cortical interregional coupling. The airo of the study was to demonstrate alterations of the spatio-temporal pattern of neurona1 coupling between the contralateral 'active' motorcortex and all other cortical areas in relation to a simple voluntary movement (self paced abduction of the right index finger). In 18 patients (39 +- 11,7 yrs., 45 _+ 18 days after traumatic brain injury) and in 20 normal subjects (29,6 -+ 6,2 yrs.) the EEG was recorded from 30 electrodes ( 10-20 system). Absolute and relative movement related changes in coherence, reflecting the functional interregional coupling strength, were

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analysed. Data of phase coherence and spectral power were also obtained. Recordings of identical channel-pairs under resting conditions served as reference. The significance of the difference between both conditions was tested by a multiple t-Test. In the cohort of healthy subjects, we observed movement related increases of coherence in the alpha-, betal- and beta2band between the 'active' motor cortex and ipsilateral frontal regions followed by coupling of both homologous motor cortices accompanied by a power decrease. Patients with traumatic brain lesions in the early stage showed a wider dynamic range of the movement related increase of the contralateral fronto-central coupling strength, whereas the interregional frontal and interregional centro-frontal coupling strength was reduced. Similar alterations were observed in the time course of the accompanying movement related spectral power decrease. The specific increase of the (left-hemispherical) interregional fronto-central functional connectivity suggests ah augmented cortical control of motor preparation and execution in brain injured patients. The results support the idea that neuronal populations f o r m a specific movement-related neuronal network implicating connectivity encoding voluntary movements with different brain areas coupled in a defined spatiotemporal pattern to prepare and execute movements. The forming of novel (task-specific) patterns of cortical connectivity seems to be a basic principle of functional reorganisation in neuronal network disturbances caused by a traumatic brain lesion. (Supported by BM BF# 01 K09807/2.) P752

Brainstem auditory evoked potentials in rhythmic palatal myoclonus. E. Togrol, Y. Gª

A. Gª

M. Saracoglu, N. Akyatan (Istanbul, TR)

Rhythmic Palatal Myoclonus (RPM) is a rare movement disorder consisting of synchronous jerks of the soft palate, sometimes also involving pharynx, larynx and other muscles innerved from the brainstem. Most frequently the first complaint is the objective tinnitus.A str uctural gross lesion at the brainstem or cerebellum can be shown in a few patients, while in most no such lesion can be seen. There may be some differences in the nature of the symptoros between these two groups of patients, although it has been proposed that,there is a functional (and sometimes morphological) disorder in the inferior olivary nuclei of ale In this study, 5 male patients with RPM were evaluated. The ages of the subjects were between 20 and 25. In four of the subjects no morphological lesion was shown with CT and MRI, while in one there was a cystic lesion and accompanying destructive area in the right jugular foramen. In all patients, brainstem auditory evoked potentials were performed. Normal results were obtained from the four "essential" cases, while there were latency abnormalities in the one "symptomatic" patient. The results of the electrophysiological and radiological studies ate discussed in the light of examination findings and the findings from other investigations. Since the auditory pathways are probably different from the structures involved (with discrete lesions) in the myoclonus, the evoked potentials ate usually found to be normal. In the case of diffuse and multifocal lesions, there may be abnormal results. P753

Mycophenolatmofetil for Immunotherapy of Myasthenia gravis. E. Fleischer, A. N~igele, F. Schumm (G6ppingen, D) Background: Mycophenolatmofetil (MMF) is a novel immunosuppressive drug that shows promise in preventing the rejection of organ allografts and in the treatment of ongoing rejection. Additionally there are several reports of its effectiveness in other autoimmune diseases including lupus nephritis and a successful treatment of refractory myasthenia gravis. Orally administered MMF is hydrolysed by esterases in the intestine and blood to release mycophenolic acid (MPA), a potent, selective, non-competitive inhibitor of the type 2 isoform of ionise monophosphate dehydroxygenase (IMPDH) expressed in activated human T and B lymphocytes. By inhibiting IMPDH, MPA depletes the pool of Guanosintriphosphate (GTP) required for DNA synthesis in lymphocytic cell lines. Methods: MMF was orally applicated in a daily dose of 1000-3000 mg to 3 adult patients (27-42 y), 2 suffering from generalized myasthenia gravis (MG) and 1 from polyautoimmunopathy with elevated acetylcholinreceptor-antibodies, lndication was an insufficient response or intolerance to immunosuppressive agents as azathioprine, ciclosporin A, methotrexate o r a n immuno-modulatory therapy with immunoglobulins. Resuhs: The substance was well tolerated over a period of up to now 16 months and induced a marked improvement of myasthenic symptoms after a latency of 3 months. Additional steroids could successively be reduced. Combined therapy with IVIG diminished fluctuation of symptoms.

Conclusions: Treatment with MMF offers an alternative immunosuppressive therapy ir other agents ate not effective of tolerable. The dose of steroids in combination could be lowered for optimal clinical effect. Our case reports show the need fora controlled trial to examine the tole of MMF in the treatment of MG.

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Clinical And Electrophysiological Follow Up Of Four Patients With Neuroendocrine Tumors Associated With Lambert Eaton Myasthenic Syndrome. J.-M. Guglielmi, R. Flor, P. Masnou, D. Adams (Neuilly Sur Seine, Ciamart, Le Kremlin-Bic6tre, F) Lambert Eaton myasthenic syndrome (LEMS) is considered as an autoimmune disorder of neuromuscular transmission associated with several neuro-endocrine tumors. Four patients meeting clinical and electrophysiological criteria of LEMS were studied. (Three men, one woman; mean age 58). AII of whom were under regular clinical and electrophysiological follow up. LEMS symptoms preceded tumor diagnostic in a delay from 6 months to 48 months. Three of them h a d a small cell carcinoma; one had a primitive neuro-endocrine tumor localized in the iliopsoas. Presence of autoantibodies to voltage gated calcium channel was detected in two patients. Three patients underwent combined radiation and chemotherapy; all patients received Specific treatment of LEMS: Clinical follow up showed improvement in two patients; one is deceased; the other is in poor general condition. Electrophysiological recordings were performed in APB, ADQ, and EDB. Initial mean resting CMAP amplitude were significantly lower in ADQ (3.2 mV) and APB (1.8mV) rather than EDB (0.9 mV) compared with controls. After 10 s of voluntary contraction increment varied from 150% to 400% in hand muscles particularly in ADQ compared with control = 40 %. In EDB the percentage of increment varied around 80 %. Serial electrophysiological studies showed over time in two treated patients an increase in mean resting CMAP amplitude (2.5 mV versus 5.8 mV) correlated with clinical improvement. Combined treatment results in neurologic improvement in two of the four patients. Hand muscles CMAP amplitude at rest and after exercise are the most sensitive in the detection of typical electrophysiological LEMS abnormalities and to follow up patients over time.

P755

Therapy Management In Serious Acute Plant Poisoning. R. Hofmann, ]. J. Schwarze, J. Klingelh6fer (Chemnitz, D) Objective: Approximately 15 patients are treated for serious acute poisonings due to indigenous plants on our Neurological ICU annually. Fast and accurate handling of such cases is a therapeutic challenge since there ate often times no etiological clues. By means of examples of such patients out of the past 12 months a management plan for ah uncomplicated and reasonable therapy is proposed. Methods: 11 previously healthy patients with a mean age of 27.4 years (8 male) without history of substance abuse were reviewed. Ingestion occurred in 4 cases accidentally, in 7 purposely. Identified substances were mushrooms of the Amanita family (n=2) and of the Pilocybe family (n=2), thornapples (n=3) and jimson weed (n=4). Severity of poisoning was evaluated by level of consciousness, by severity of drug induced psychosis and by gravity of anticholinergic features. An initial blood and urinary screening for common addictive substances was negative. Al1 patients were treated with secondary detoxification (forced diuresis and defecation, respectively), 2 patients who had consumed poisonous mushrooms with primary detoxification, too. Additionally, all patients were treated symptomatically with benzodiazepines, major tranquillisers of beta-blockers. 2 patients with jimson weed ingestion were given ah antidote to atropine poisoning. In 2 patients with ingestion of poisonous mushrooms ah antidote was obsolete due to early vomiting. Results: The mean duration of hospitalisation was 3.8 days ( 1.5-11 days) in patients who had ingested Solanaceae and had not received an antidote (n=5). They showed a statistically significant relationship between severity of poisoning and duration of in-patient care (p=0.097). However, patients who had received an antidote (n=2) were discharged within 24 hours independently of severity of poisoning. The patient who was discharged after 11 days had developed severe renal complications and needed an outpatient treatment afterwards. Conclusions: Our experiences indicate a beneficial effect of immediate administration of physostigmine in case of altered consciousness and anticholinergic features. Thereby, ah early alleviation of symptoms and reduction of complications may be achieved. Moreover, less side effects and number of symptomatic medication as well a s a noticeable shorter treatment

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time and consecutively a cost-saving therapy may result. In early substance elimination, e. g. by vomiting, physostigmine does not seem to be necessary. P756 High frequency of Restless Leg Syndrome (RLS) in nurse populatinn. K. Flabouriari,A. Kilergiotou, G. Hadjigeorgiou, A. Papadimitriou (Larissa, GR) Indroduction: The Restless Leg Syndrome (RLS) is a common sensorimotor disorder with a prevalence varying from 2-5% in adult population and 30-40% in persons older than 65 years old. Our aim was to study the frequency and the clinical expression of RLS in 100 nurses working in the University Hospital of Larissa. Material and method: One hundred nurses (age range 20-45 years) were randomly selected and called for clinical examination and interview. The diagnosis of RLS were based on the guidelines published in 1995 by international RLS study group (IRLSSG). The demographic characteristics were selected. At least one family member with similar symptoms was interviewed in cases where familiar aggregation of RLS was reported. Results: Sixty four nurses {64 %) accepted the participation in this stndy. Eighteen (18/64, 28 %) fulfilled the IRLSSG criteria for the diagnosis of RLS. The majorit y of RLS cases were characterized as sporadic (14/18, 78 %) while four of them (4/18, 22 %) reported (and documented by interview and clinical examination) at least one family member suffering from the same symptoros, so characterized as familial RLS. In all examined persons the neurological examination was normal. The most frequent complains reported by nurses diagnosed as RLS cases were, sleepiness during daytime, leg paresthesia/dysthesia with desire to more the extremities and worsening of symptoros in the evening or during night. No differences were found to be co-related with RLS.None of the interviewed nurses with RLS symptoms, reported similar symptoms in childhood. Conclusion: The frequency of RLS in nurses from our Hospital was found higher in comparison to general population. The reason for this increase is unknown. Further investigation with polysomnographic evaluation is necessary in order to explore the effect of night sleep disruption of the circadian cycle during their duty 'to the clinical expression of RLS. P757

Abstract withdrawn

Methods: In this European multicenter, double-blind, randomized, placebo-controlled trial, 3 parallel groups, baseline 8 or 12 weeks, 4 weeks titration, 12 weeks evaluation LEV (500 mg or 1000 mg twice daily) was compared to placebo as add-on therapy in 324 patients with uncontrolled simple and/or complex partial seizures with or without secondary generalization. Results: Levetiracetam significantly decreased partial seizure frequency compared to placebo, with percent reductions relative to placebo of 16.4 % [98% confidence interval (CI) 2.7 %,28.1%] (p=0.00£ and 17.7 % [98% confidence interval (CI) 4.1%,29.9 %] (p=0.003) in groups receiving 1000 mg/d and 2000mg/d. Greater or equal to 50% reduction in partial seizure frequency occurred in 22.8% of patients in the 1000mg group (p=0.019) and 31.6 % of patients in the 2000 mg group (p < 0.001) compared with 10.4 % of patients in the placebo group. Administration of levetiracetam did not affect plasma concentrations of concomitant antiepileptic drugs or alter vital signs or laboratory parameters. No significant difference in the incidence of adverse events was observed between treatment groups, or between the levetiracetam and placebo groups. The most commonly reported adverse effects were asthenia, headache, and somnolence. Conclusions: The antiepileptic efficacy and tolerability of levetiracetam (1000 mg/d and 2000 mg/d, administered in two divided doses) as add-on therapy was established in patients with refractory partial seizures in this clinical study. P759 Efflcacy and tolerability of levetiracetam 3000mg in patients with refractory partial seizures: a muhicenter, double-blind, responder-selected study evaluating monotherapy. E. Ben-Menachem for LEV N138 investig. (G6teborg, S) Purpose: To evaluate efficacy and tolerability of levetiracetam (LEV) monotherapy in selected patients with refractory partial seizures. Methods: In this multicenter, double-blind, placebo-controlled, parallelgroup, responder-selected study, patients were randomized (2:1 ratio) to receive oral LEV 1500mg twice daily or placebo during a 12-week add-on phase. Treatment responders entered a monotherapy phase that included a maximum 12-week downtitration period and 12 weeks ofLEV monotherapy at 1500 mg twice daily. In both phases, responder rate, seizure frequency, and adverse events were analyzed. Results: A total of 286 patients (placebo, N= 105; LEV,N= 181 ) entered the add-on phase, and 86 patients (placebo, H=17; LEV, N=69) were eligible for the monotherapy phase. Thirty-six of 181 patients (19.9%) receiving LEV completed the entire study compared with only 10 of 105 patients (9.5%) in the placebo group (p=0.029). The odds of completing the study on LEV were 2.36 times (95 % confidence interval: 1.08, 5.57) higher than placebo. The responder rate during the add-on phase was significantly higher in the LEV group compared with placebo (42.1% vs 16.7 %, respectively; p < 0.001). In the LEV monotherapy group, the median percent reduction in partial seizure frequency compared with baseline was 73.8 % (p=0.037), with a responder rate of 59.2 %. Nine patients (18.4 %) remained seizure free on LEV monotherapy, with six continuously seizure free since uptitration. Conclusions: Conversion to LEV monotherapy (1500 mg twice daily) is effective and well tolerated in patients with refractory partial seizures who responded to 3000 mg/d of LEVas add-on therapy. P760 Epileptiform Excitability in Mice Hippocampus is Triggered by Lipid Peroxidation (LPO) Activation and Depends on the Cu/Zn-Superoxide Dismutase (SODI) Level. A. R. Koudinov, N. V. Koudinova (Rehovot, IL)

Epilepsy P758

Multicenter double-blind, randomized, placebo-controlled trial of levetiracetam as add-on therapy in patients with refractory partial seizures. S. Shorvon for LEV N051 investigators (London, UK) Purpose: lb evaluate the efficacy and tolerability of levetiracetam (LEV) [Keppra TM]as add-on therapy in patients with refractory partial seizures.

It is known for two decades [1 ] that epileptic activity in rodents and in patients with various forros of epilepsy [2] is accompanied and may be inhibited by LPO activation and inhibilion, respectively. The administration of antioxidants prevents the effect of LPO activation and is beneficial in patients and in lab animals, sharply lowering chemically (ex. kainic acid-, bemegride-, penicillin-, iron salts-, hyperbaric oxygen-) and physically (ex. electrically) induced epileptic activity. However, it is still unknown whether enhanced LPO is a consequence or a cause of the epileptiform discharges. To elucidate this pivotal question we studied the effect of 2,2'-azobis (2-amidinopropane) dihydrochloride (AAPH), an LPO inducer, on electrical properties of mice ex-vivo hippocampal slices, and their modulation by vitamin E, an LPO blocker. We extracellularly recorded evoked field potentials and measured LPO levels by the formation of malondialdehyde, an LPO product, in a thiobarbituric acid test. The analysis was performed as we described [3], except that the electrodes were positioned in the pyramidal cell layer of the hippocampal CA 1 area to record field population spikes (fPS).We studied wild type (WT) and

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transgenic mice (TG), genetically modified to overexpress human SOD 1 [4]. TG (versus WT) slices possessed increased LPO levels, mimicking the LPO profile in normal state versus patients with epilepsy (having 20-25% decrease in the SOD activity [5]), respectively. Preincubation of slices with AAPH (lmM) caused reversible (i. e. AAPH washout dependent) increase in fPS amplitude and number (bursting) in response to single stimuli in both WT and TG. The effect was stronger in WT slices, although not statistically different from the SOD 1 TG slices. In addition, at high stimulus intensity the increase in amplitude of the second and third PS was lower in the TG. Vitamin E reduced the epileptiform effect of AAPH; this reversal required lower dose of Vitamin E in the TG compared to WT. Our data imply i) LPO activation as an epileptogenesis cause, and ii) the role of SOD in buffering epileptic vulnerability. This knowledge ma), representa fundamental for understanding the mechanism of the epilepsy. This study was not funded and welcomes support, [email protected] References 1. ZhNevropatolPsikhiat Korsakova 1981;81(6):812-5 2. ibid 1984;84(6):892-7 3. ] Neurosci 1999;19:9412-25 4. Neurosci Lett 1998;51:$23 5. Biull Eksp Biol Med 1993;116(10):362-4

Resuhs: The serum antibodies showed weak binding to the cytoplasm of cerebellar and pontine cells. None of the sera showed strong binding to any band by western blotting. One patient's serum bound to multiple bands, ranging between 5 and 40 kDs, which were not evident with the control sera, but there was no evidence of binding to a distinct antigen. Discussion: Ahhough a syndrome of coeliac disease, epilepsy and cerebral calcifications has been described, none of our patients had this syndrome. Since coeliac disease is an autoimmune disorder, autoantibodies against CNS have long been implicated in the pathophysiology of the neurological symptoms. However, we failed to show a specific staining pattern reliably associated with the presence of antibodies against neural tissue. Nevertheless, coeliac disease appears to occur with increased frequency in patients with epilepsy anda high index of suspicion should be maintained. P763 Results of the Corpus Caliosotomy in Patients with Medically Intractable Primarily Generalized Seizures. P. Sioutos, M. E. Weinand (Tucson,Arizona,

USA)

Purpose: The number needed to treat (NNT) to obtain one extra responder (defined a s a patient obtaining _>50% seizure reduction during the treatment period compared to the baseline period) over placebo is a statistical measure preferred by dinicians as ir conveys both clinical and statistical significance. We compared the NNT for the new AED levetiracetam (LEV) with the NNT for other new AEDs. Methods: The NNT to obtain one supplementary responder compared to placebo treatment was calculated according to the methodology described by Elferink and Van Zwieten-Boot (BM] 1997). For LEV, the pooled data on 904 patients from the 3 pivotal studies of the development program of levetiracetam were used, while for the other AEDs, the data were kindly provided by A. Elferink. The NNT was calculated for all LEV doses confounded and for each dose tested in the pivotal studies. Results: LEV 1000 mg/day: NNT: 4.62; CI: 3.48-6.85 LEV 2000 mg/day: NNT: 3.49; CI: 2.58-5.40 LEV 3000 mg/day: NNT: 3.53; CI: 2.81-4.72 LEV (all doses): NNT: 3.92; CI: 3.28-4.88 Topiramate: NNT: 3.25; CI: 2.67-4.16 Vigabatrin: NNT: 3.76; CI: 2.94-5.19 Tiagabine: NNT: 6.70; Ch 5.12-9.66 Zonisamide: NNT: 7.33; CI: 4.49-20.03 Lamotrigine: NNT: 8.87; CI: 5.93-17.56 Gabapentin: NNT: 9.10; CI: 6.27-16.61 Conclusions: A similar NNT to TPM and VGB was observed for LEV. In addition, the 95% confidence intervals obtained for LEV did not overlap with some of the other new AEDs.

Clinical material and methods:This study includes 9 patients (6 males, 3 females) with medically intractable primarily generalized seizures (as were verified by Video/EEG), treated with a corpus callosotomy at the University of Arizona. The patients' age at operation ranged from 5 to 21 years (mean: 16 years).Seizure types included: tonic (n=2), tonic and absence (n= 1), tonicclonic (n=2), myoclonic and abscence (n= 1), complex partial seizures (multifocal in origin) (n=2), drop attacks and absence (n=l).The preoperative work-up included: brain MRI (n=9), Video/EEG (n=9), SPECT (n=2), subdural strips (n=2: CPS cases), Neuropsych tests (n=5), and Amytal test (n=2).The MRI findings were: normal (n=6), diffuse cerebral atrophy (n=l), temporal horn dilatation (n= 1), bitemporal encephalomalacia (n= 1). Intraoperative EEG was performed in all cases. In 3 patients the Cortical Cerebral Blood Flow was measured intraoperatively with the Thermal Diffusion Flowmetry method. Anterior corpus callosotomy was performed in 7 patients. Anterior and posterior corpus callosotomy was performed in 2 patients. One of these 2 patients had initially been submitted to an anterior corpus callosotomy.Since he did not have any change in the seizure frequency 16 months postoperatively, he was reoperated fora posterior extension of the callosotomy. The follow up ranges from 2 weeks to 23 months (mean: 9 months). Results: This study includes 10 cases of corpus callosotomy. There was no death in this series. Four patients developed postoperative complications. The most frequent one was a transient anterior disconnection syndrome (n=2). One patient developed a mild (transient) hemiparesis, and one patient developed a postoperative acute epidural hematoma,which was treated surgically. During the follow-up period 2 patients were seizure free (22.2 %), 5 patients had a significant improvement in the seizure frequency (55.5 %), and 2 patients hada simple improvement in their seizure frequency (22.2 %). Concerning the seizure type and the outcome, patients with CPS are either seizure free (n=l) or have a simple improvement (n=l). Both patients with tonic-clonic seizures have a significant improvement. The patient with myoclonic and absence seizures is seizure free. The patient with tonic and absence seizures has simple improvement in the seizure frequency. Both patients with tonic seizures and the patient with drop attacks/absence seizures have significan@ improved.

P762 Epilepsy Associated with Coeliac Disease: Clinical Spectrum and No Evidence for a Humoral Response Against Neural Tissue. E. Tª252 B. Baykan, C. Gª A. Vincent, A. G6kyibit ('Ÿ TR; Oxford, UK)

P764 Contribution of Neuropsychological Testing in Differentiation of Pseudoseizures and Epilepsy. S. Rudic, K. Gebauer, K. Vlajkovic, S. Opsenica (Novi Sad, YU; Bjeljina, BJH)

Background: Patients with coeliac disease may present with central nervous system (CNS) findings and the coexistente of the neurological complications seem to be more than a chance association. We report the dinical and laboratory findings of three cases with epilepsy and intestinal biopsy-proven coeliac disease. Cases and methods: A 38-year old male patient with normal neurological examination had epileptic seizures of generalized tonic-donic and complex partial types since 22 years,whereas the other two presented with progressive myoclonic epilepsy accompanied by mild dementia. Additionally, a 27-year old female anda 53-year old male patient had cerebellar findings and conjugate gaze paralysis,respectively. None of the 3 patients had symptoms of malabsorption and their brain CT examinations demonstrated no calcification. All cases had IgA anti-gliadin antibodies in their serum samples but only the female patient was positive for anti-reticulin antibodies. We per formed indirect immunohistochemistryon aduh rat brain sections and western blotting of marmoset brain extracts with the patients' sera to look for antibodies to neuronal antigens, comparing with sera from 3 healthy controls.

The aim of the study was to compare neuropsychological evaluation of the adolescents with epileptic seizures (epileptic group), pseudo-seizures group) and pseudo-seizures and epileptic seizures (mixed group. Method: A sample of 48 adolescent girls (aged 12-18) with normal intellectual function was divided in three groups: 28 girls with epileptic seizure, 18 with pseudoseizures only and 12 with pseudo-seizures and epileptic seizures. We studied attention and memory using: Wechsler Revised Memory Scales ((WRMS) - task A: repeating numbers in one order and task B: repeating numbers in the opposite order), Rey Auditory Verbal Learning Test (RAVLT) and Rey Osterich Complex Figure (ROCF), attention skills (Trial Making Test (TMT -B)). Factorial ANOVAs were performed on each of the cognitive factors. Results: Although short term memory disturbance (WRMS - task A) occur only in epileptic group (4.9 % of epileptic patients), there was no statistically significant difference among the groups. Poor concentration (focused attention; WRMS - task B) occurred in: 7.14% in epileptic group, 22.2% in pseudo-seizures group and 0% in mixed group and the difference among

P761 Number Needed to Treat: Comparison of data for levetiracetam with other new AEDs. K. van Rijckevorsel, P. Boon (Brussels, Gent, B)

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them was statistically significant (F=4,55 p < 0.015). Lower score in long term memory disturbance (RAVLT) occurred in 50% of epileptic patients, in 33.3 % of patiems from mixed group and 27.78 % of patients with pseudoseizures only and the difference was statistically significant (F=2.81 p < 0.05). Nonverbal memory deficit (ROCF) occurred only in epileptic group (22.2 %). TMT-B has not proved to be a sensitive instrument in distinguishing patients with epilepsy and pseudo-seizures: 33.3% in epileptic group, 22.2 % in pseudo-seizures group and 17.86 % from mixed group showed notable deficit. However there was not any statistical difference among the groups. Conclusion: Compared with the patients with pseudo-seizures, patients with epilepsy showed more common cognitive impairments. The resuhs suggest that epileptic patients showed worse results in long term memory testing, while patients with pseudo-seizures showed lower concentration and focusing attention. The test of repeating numbers in opposite order (WRMS task B) is also used to register anxiety in test situation. This test has proved to be a sensitive instrument in differentiation of pseudo-seizures from epilepsy.

to the age, we noticed: bimodal distribution of the cases with age had two maximums: at the age of up to 5 years old and at the age of 30-40 years old. Moreover, the first maximum is common for both sexes and the main causes are perinatal factors, but the second one is observed at the age of 30-40 years old in men (the main causative agents are trauma and chronic intoxication - 40.79 and 11.84 %, respectively) andat the age of 50-60 years old in women (vascular diseases - 11.75%). Prevalence rate of epilepsy among people suffering from radiation exposure in 1987 was 87.3 and in 2000 - 164.3 per 100,000 of population. Prevalence rate of epilepsy in all Belarus in 1986 was 109.3 and in 2000 - 129.4. Analysing an average prevalence rate profile of epilepsy according to the age of people, we noticed, that: 1. Prevalence rate of epilepsy was 2.3 times higher in men than in women. 2. At the age of 35-55 years old prevalence rate of epilepsy was steady high. P767

Subtraction ictal SPECT (SISCOM) co-registrated to MRI in the presurgical evaluation of temporal and extratemporal epilepsies. R. Wiest, K. Schindler, M. Wissmeyer, K. L6vblad, E Donati, B. Weder (Berne, St. Gallen, CH)

P765

Pharmacokinetics of levetiracetam [KeppraT"]: toward ideal characteristics. P. N. Patsalos (London, UK) Levetiracetam (LEV) is rapidly and completely absorbed after oral ingestion with peak plasma concentrations occurring one hour later. The extent of the absorption is not influenced by co-ingestion of food although the rate of absorption may be slower. LEV exhibits linear pharmacokinetics, is not protein bound and rapidly enters the brain. 66% of LEV is renally excreted unchanged,while 24 % is metabolised by hydrolysis, a process not involving the hepatic cytochrome P450 system, to the pharmacologically inactive metabolite ucb-L057. As renal elimination is proportional to the renal clearance of LEV, the dose should be decreased in renally impaired patients. The elimination half-life of LEV ranges from 7.2 + 1.1 hours in adults,6.0 + 1.1 6 hours in children and 10.3 + 0.4 hours in elderly patients. N o significant interactions have been identified with other antiepileptic drugs (AEDs), with oral contraceptives, warfarin or digoxin in clinical trials and in formal interaction studies. Some incoosistent changes in plasma phenytoin levels have been reported in patients whose metabolism of phenytoin was close to saturation. However, a systematic phenytoin-LEV interaction study could not identify an influence of LEV on phenytoin pharmacokinetics. Because the relationship between LEV plasma blood levels and its efficacy/toxicity has not been established the value of monitoring blood levels is not known. Monitoring may be useful so as to ascertain LEV compliance. Prolonged pharmacodynamic activity supports the twice-daily dosing regimen, which was successfully investigated in its clinical trials programme. Furthermore, a dosing strategy whereby the starting dose is in fact the therapeutic dose (2 • 500 mg/day) is appropriate. Conclusions: Levetiracetam is a promising, newly licensed, AED with very advantageous pharmacokinetic characteristics, which should make its clinical use straightforward. P766 Epidemiological study on epilepsy among people suffering from Chernobyl disaster in Belarus. G. Naumova, M. Klimova, A. Naumov (Vitebsk, WEI) Afler Chernobyl disaster in 1986 population ofour republic proved to be under the action of low doses of prolonged radiation exposure (external and internal). In a 5-7 year's time some researchers noticed an increased prevalence rate of epilepsy among suffering from the Chernobyl disaster people. The aim of our investigation was to earry out ah epidemiological study on epilepsy in 8elarus checking out the epidemiological hypothesis concerning the action of low dose radiation exposure. We performed a population-based case ascertainment of all available sources of medical care since May 1986 till ]une, 2000. People of all ages were analysed. A number of population suffering from Chernobyl disaster in Belarus (1986-2000) under study was 180,770. Only tases of patients with active epilepsy (at least one seizure during the last 5 years, regardless of treatment) were included. lncidence rate of epilepsy (registered newly-diagnosed parieras) among people suffering from Chernobyl disaster in 1987-2000 varied from 17.8 to 37.3 per 100,000 of population, while incidence rate of epilepsy in all Belarus varied from 8.7 to 17.1. We consider, that the comparatively high incidence rate of epilepsy (522.4 per 100,000 of population) in 1986 among people subjected to low doses of ionised radiation exposure could be resulted from obligatory universal clinic system for such people, which had been initiated since that time. Analysing an average incidence profile of epilepsy according

Background: Patients with drug-resistant epilepsies may be candidates for epileptic surgery if their seizures originate from a circumscribed region and the focus is not localised in an elnquent part in the brain. The precise identification of the epileptogenic site is crucial for planning and outcome of surgery. Here we demonstrate how combining methods of ictal and interictal Tc 99m-ECD SPECT, MRl-lmages and single el~ctric dipole modelling help to localize the epileptogenic focus. Methods: We make use of different characteristics ofan epileptogenic focus: 1) increased blood flow during ictal state 2) decreased blood flow during interictal state 3) macroscopic morphological alterations 4) high voltage spiking of short duration (< 70ras) during seizure free epochs. The SPECT subtraction scans are co-registrated to high resolution 3D-MRI scans to locate the region of ictal hyperperfusion and to check for correlation with macroscopic brain pathologies. If interictal spikes are recorded using the international 10-20 system, we perform a single dipole analysis and correlate the spike generator to the region of hyperperfusion. We present the results of eight patients, who have been evaluated for epileptic surgery. SISCOM localized the epileptogenic focus correctly in all patients. Conclusions: Subtraction ictal SPECT co-registrated to MRI (SISCOM) provides independent localizing information in the presurgical evaluation of temporal and extratemporal epilepsies. We emphasize that the methods presented here are only part of a lar more extensive evaluation including detailed seizure semiology, neuropsychological examinations and sem~-invasive or invasive EEG-recordings. P768

Concerning Psychopathology In Focal Epilepsies With Unilateral Temporal Focus. B, Feddersen, U. gunge, R. Herzer, M. R. Gaab (Munich, Greifswald, D) Rationale: Few studies have addressed affective personality features and psychosocial status in patients considered for resective epilepsy surgery. Since the results of these studies are conflicting,we investigated the personality of patients with unilateral temporal lobe epilepsy (TLE). Methods: We examined 37 patients with medically intractable unilateral temporal lobe epilepsy (16-55 years). Twenty patients had right temporal and 17 had left temporal focus.We used current standardized personality inventories (FPl, STAI, IPC, TSK). The four self-rating instruments were supplemented with the rating scale "Greifswalder Eigenschaflsw6rterliste fª Epilepsiekranke" (GEWLE). To control the influences of psychosocial and cognitive stressors we assessed the individual psychosocial situation and the cognitive status of all patients. Results: Patients with left temporal lobe epilepsy were characterized by increased emotions of dependence, less exterior composeness, higher depressive drive and mood, more nervousness, higher recall for information and experience exchange a n d a higher tendency to perseverate. The cognitive and psychosocial status of the patients, however, were not different significantly. The depression self-rating scale, the new implememed activity scale of the FPl and of the TSK the scale"Searching for Information and Experience Exchange", the scales oŸ composeness and nervousness in the GEWLE lateralized the temporal lobe epilepsy correctly. Conclusions: The evaluation of personality features contributes to the lateralization and counseling of patients with TLE considered for epilepsy surgery.

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A r a t model of the aggravation of absence seizures by carbamazepine. E Vajda, K. McLean, T. O'Brien, 1. Pennefather, B./arrott, R. Kapasa, R. Widdop, M. Cook (Victoria, Melbourne, Monash, AUS) The aggravation of absence seizures by carbamazepine (CBZ) is now well recognised. It has been observed clinically that this is particularly prominent in pre-menopausal women. The mechanism underlying this phenomenon is uncertain, but it has major implications regarding the pathophysiology of absence seizures. The possibilities include effects on GABA receptors, sodium channels and/or alterations in calcium currents, all of which may influence oscillatory thalamacortical circuits. We have investigated the utility of a pharmacological rat model to study the aggravation of absence seizures by CBZ. Inbred female Wistar Kyoto rats were surgically implanted with 6 epidural screw electrodes to enable EEG recordings. Rats were administered with pentylenetetrazol (PTZ) (20 mg/kg, i. p.) after pre-treatment with either vehicle or CBZ (20mg/kg, i.p.). The PTZ-induced spike-and-wave discharges (SWD's) were quantified for 90 min. Both the cumulative duration of SWD (41% vs. 22%, p=0.018) and the average length of SWD (4.9 sec vs.2.6 sec, p=0.018) were significantly increased following CBZ pre-treatment. Conversely, the frequency of SWD was significantly (p=0.028) reduced in the CBZ (4.9 Hz) vs. the vehicle (4.3 Hz) arm. We conclude that CBZ reliably aggravates PTZ-induced absence seizures in female rats. Ongoing studles are being undertaken to determine whether this exacerbation is influenced by age and sex hormones and to further elucidate the mechanism of absence seizure aggravation by CBZ.

Extrapyramidal disorders P770 image fusion guided Deep Brain Stimulation electrode implantation in the subthalamic nucleus for Parkinson's disease. M. Kronenbuerger, ]. Koy, U. Sommer, A. Mª G. Schacker t, H. Reichmann (Dresden, D) Background: Since 1996,10 Parkinsonian patients have obtained Deep Brain Stimulation (DBS) at our hospital. The target was the thalamus (Nucleus ventralis intermedius or Nucleus ventralis oralis anterior) to treat tremor or levodopa induced dyskinesias. To improve all cardinal motor symptoms of advanced Parkinson's disease (PD) we have started to perform DBS of the subthalamic nucleus (STN). In order to target this small nucleus without distortion of magnetic resonance imaging (MRT) we have applied image fusion. We report our experience of bilateral STN DBS electrode implantation guided by image fusion. Methods: 3 Patients (age at surgery: 60 -+ 4 years; duration of disease 13 + 4 years) with advanced PD (Hoehn & Yahr llI to IV) were selected for surgery. Some days before surgery MRI scans (T1 with and without contrast medium; T2) were performed to detect the STN and cerebral vessels. On the day of surgery a computer topography (CT) with contrast medium and the stereotactic frame attached to the patients head was performed. The MRIand CT-scans were processed on a workstation and the best trajectories for electrode implantation were chosen. Afler that, the patient was placed comfortably in the operating theatre and the DBS electrodes were implanted stereotactically. The clinical effect of DBS was evaluated in a double blind fashion intraoperatively and ir necessary the electrode position corrected. A control MRI and the implantation of a programmable impulse generator were done during the next days. The patients were evaluated before and after surgery with the Unified Parkinson's Disease Rating Scale (UPDRS) 12 hours after last levodopa intake (MED-OFF) and after intake of their morning dose (MED-ON). Results: 6 Electrodes were implanted in the STN without any complications. Simultaneously to the titration of the stimulation parameters in the follow up period medication was reduced by 47 %. As part of the UPDRS subscores, Score of Activities of Daily Living in the MED-ON improved from 27 _+7 presurgery to 12 :i: 6 3 months postsurgery; the Motor Examination Score (including scores for tremor, rigidity, bradykinesia, gait) improved from 51 +- 17 (MED-OFF) and 22 _+2 (MED-ON) presurgery to 23 :i: 4 (MED-OFF) and 15 :!: 2 (MED-ON) 3 months postsurgery under continuous stimulation. The time with dyskinesias per day was reduced by 62 % and the OFF-time per day was reduced by 86 %. Limbic effects occurred in all patients and were managed by SSRI administration to treat depression (2 patients) or by levodopa reduction to treat hypomania (1 patient). Other side effects of STN DBS were managed by adjustments of stimulation parameters. Condusion: STN DBS improves all cardinal motor symptoms of PD and allows medication reduction,but limbic effects are concerning. Image fusion combines the advantage ofMRl (high solution) and CT (no distortion) in order to chose the best trajectory. Thereby the risk of hemorrage can be reduced, because vessels can be visualized and evaded.

P771 Cardiovascular Autonomic Dysfunction In Parkinson Disease. I. Barbov, I. Pet rov, V. Petrova, L. Pijanmanova-Karovska (Strumica, Skopje, MAK) Autonomic dysfunction is frequently observed in patients with Parkinson's disease (PD), especially present in patients with Multiple system atrophy (Shy-Drager's syndrome). Clinical studies disagree on the frequency and type of abnormalities in autonomic function tests. Orthostatic dizzines (OD) has been reported in up to 65 % of patients, but the pathophysiological mechanisms are poorly understood. We investigated cardiovascular reflex tests and their association with OD in patients with PD in order to examine the hypothesis that the sympathetic nervous system is specifically involved in these patients. Twenty eight (28) patients with PD were studied by parasympathetic (heart rate responses to the Valsalva manoeuvre, deep breathing and active change in posture) and sympathetic function tests (blood pressure responses to active change in posture and sustained handgrip), and by spectral analysis of hearth rate variability during rest and during standing. The mean age in the PD group was 63.4 :t: 10.3 years and the mean duration of the disease was 9.3 -+ 6.1 years.Abnormal responses on at least one cardiovascular reflex test were observed in 39.2 % of PD patients, with a statistically significant involvement of the sympathetic vasomotor system. Orthostatic intolerance was reported in 50 % of patients. The orthostatic intolerance results from impaired sympathetic vasoconstriction. These results provide further evidence that the sympathetic nervous system is involved in patients with PD. P772 Tongue tremor in a patient with anti-GAD antibodies and autoimmune thyroiditis and diabetes. T. Scaravilli, B. Giometto, F. Morello, M. Vianello, R. Vitaliani, B. Tavolato (Padova, Arzignano (VI), I) Involuntary movements of the mouth can present under the form of palatal tremor, which is frequently associated with hypertrophy of the inferior olivary nucleus and can be accompanied by the contraction of other muscles of the head such as the face, eyes and tongue. A case of palatal tremor associated with anti-GAD antibodies has been reported. We report the case of a 39 y. o. man with autoimmune thyroiditis and diabetes who complained of "a lump in the throat'. The patient h a d a 12 year history of hypothyroidism, with high ti/res of antithyroglobulin and antimicrosomal antibodies, and diabetes, with anti-insula antibodies, and began complaining of involuntary movements of the floor of the mouth which interfered with breathing and swallowing. Needle EMG of the miloioid and masseter muscles showed rhythmic 2-3 Hz contractions but were otherwise normal as was the brain MRI. The tremor was briefly suppressed by tongue protrusion and fist clenching and responded to treatment with benzodiazepines. Screening for antineuronal antibodies revealed high titres of anti-GAD antibodies and CSF examination showed the presente of oligoclonal bands. It is unlikely that anti-GAD ab are correlated to the autoimmune diabetes since the titres of antibodies found ate greater than those found in diabetic patients associated to the inflammatory CSF profile. The tremor can be classified as secondary given the presence of OB in the CSI~anti-GAD antibodies a n d a frequency greater than 120 contractions per minute. The correlation of the tremor with the antibody positivity remains to be explained although an alteration of the gabaergic system mediated by the antibodies may be hypothesised, particularly in the absence of structural lesions. P773 Apomorphine and L-dopa tests in extrapyramidal syndromes: which is more useful in clinical practice.~ N. Meucci, G. Sacilotto, A. Righini, R. Benti, A. Zecchinelli, A. Antonini, S. Tesei, M. Canesi, C. B. Mariani, A. Bellino, G. Pezzoli (Milan, I) Objective: The acute oral L-dopa test (L-dopa test) and subcutaneous apomorphine injection test (Apo-test) both improve the accuracy of the diagnosis of Parkinson's Disease (PD) and assess dopaminergic responsiveness in extrapyramidal syndromes [PD and Parkinsonism (PKS)]. We performed L-dopa and Apo-tests in patients with extrapyramidal syndromes to evaluate their diagnostic accuracy and safety in clinical practice. Patients and methods: 58 consecutive patients with extrapyramidal syndromes, admitted between October 1999 and October 2000 to undergo pharmacological testing, were included. Each test was performed in 29 patients (L-dopa test: 16 M and 13 F, aged 50-70 yrs, mean 62 yrs; Apo-test: 22 M and 7 F, aged 33-74 yrs, mean 64 yrs). UPDRS motor score, blood pressure and heart rate were measured immediately before testing. The L-dopa test was performed with 3 mg/kg oral L-dopa, re-evaluating the patients after 90 minutes. The Apo-test was performed with 1.5-4mg subcutaneous apomorphine, re-evaluating the patients after 15 minutes. Tests were considered

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positive when UPDRS motor score improved by 20%. Patients were given domperidone (20 mg t. i. d.) 72 hours before the test. The final diagnosis was based on neurological examination, clinical outcome, response to chronic dopaminergic treatment, cerebral 1.5 Tesla MRI and SPECT results. Results: The L-dopa test was positive in 21 patients, 16 PD (76%) and 5 PKS (26 %) and negative in 7 with PKS ( 100 %). In 1 patient (4 %) the test was not evaluable due to severe obnubilation, other 6 (28%) had mild side effects. Its sensitivity on evaluable patients was 100% and its specificity was 58 %.The Apo-test was positive in 14 patients with PD (100%) and negative in 9, 8 with PKS (89 %) and 1 with PD (11%). In 6 patients (21%) the test was not evaluable due to severe side effects (bradycardia, progressive hypotension and extrasystoles with obnubilation), other 11 (38%) had mild side effects. Its sensitivity in evaluable patients was 93% and its specificity was 100%. Severe side effects were significan@ higher with the Apo-test (p < 0.05). Conclusions: In extrapyramidal syndromes the Apo-test was highly specific and sensitive for the diagnosis of PD; however, it produced severe side effects in 21% of patients. The L-dopa test was less specific than the Apo-test for the diagnosis of PD, but did not produce severe side effects and detected dopaminergic response in patients with PKS. P774

Limb immobilization for the treatment of focal occupational dystonia. A. Pesenti, A. Priori, C. Cinnante, G. Scarlato, S. Barbieri (Milano, 1) Occupational focal upper-limb dystonia is characterized by involuntary muscle contractions that selectively interfere with the execution of specific motor tasks such as writing or playing a musical instrument. Occupational dystonias have a severe social impact, especially in certain professions. The available medical treatments offer scarce and only transient benefit. In five patients with idiopathic occupational focal dystonia of the upper limb, we immobilized the dystonic forearm and hand with a plastic splint for 4-5 weeks. We assessed the severity of dystonia and scored motor performance before and at various intervals after removal of the splint. Patients' votuntary movements remained slow and clumsy for about two weeks after the splints were removed. None of the patients had persistent contractions or worsening of dystonia. Dystonia diminished markedly or even disappeared at later follow-up visits. Assessment four weeks after splint removal, when patients had regained normal voluntary movements, showed that the severity of dystonia and patients' performance of the impaired motor task had significantly improved. The benefit persisted unchanged also at the later follow-up visits. Two patients returned to concert performance. The improvement in focal dystonia after prolonged immobilization could result from plastic changes induced by immobilization at cortical level. Limb immobilization for focal occupational upper-limb dystonia promises to be a novel therapeutic approach that is simple, effective, safe and inexpensive. P775

CI l-raclopride-PET in early Huntington's disease: in vivo evidence for a striatal dopamine D2 receptor down regulation and correlation of binding potentials with the clinical phenotype. K. Henkel, B. Kramer, D. Ecker, J. Karitzky, A. Storch, M. Sabolek, S. N. Reske,A. C. Ludolph, G. B. Landwehrmeyer (UIm, D) Objective: To measure dopamine D2 receptor binding potentials (BPs) in the striatum of patients with early Huntington's disease (HD) using C 11-1abeled raclopride and positron emission tomography (PET) and to correlate the BPs to clinical scores of the Unified Huntington's Disease Rating Scale (UHDRS). Methods: We performed C11-raclopride-PET on 21 patients (mean age: 45 years, range 26-62 years) with genetically confirmed diagnosis of H D. The patients had mild to moderate symptoms (UHDRS Total Functional Capacity (TFC) at least 9) with clinical signs for 1 to 10 years (mean: 4.6 years). Dynamic 3D-PET scans were acquired over 60 minutes in 17 temporal frames. Parametric images of regional CI 1-raclopride-PET binding were generated using a simplified reference tissue model defining the BP for each individual voxel with a cerebellar input function. The values of regional BPs were determined by ROl analysis. BPs were compared to 3 healthy controls with a mean age of 47.3 years. BPs were multiplied with age at examination in order to adjust for differences in CAG repeat expansion and for age-related changes and correlated with clinical signs rated using the UHDRS. Resuhs: 20 of 21 HD patients displayed striatal BP (range: 0.81-2.02; mean: 1.43) below the 99% confidence interval of mean of controls (2.19-3.23). BP of HD patients were uniformly low throughout the striatum; in particular the ventral aspects of the putamen were not spared. There was a tendency for an inverse correlation between striatal BP and UHDRS mo-

tor score and for ah positive correlation between BP and both UHDRS cognitive score and TFC values. Within the motor score "bradykinesia" showed the best, within the cognitive battery"color naming" of the Stroop Interference Test and "verbal fluency" showed a significant correlation (p < 0.05) with the striatal BPs. Conclusions: The generalized decrease of striatal raclopride BPs extended well beyond the areas of neuronal loss confined in early HD to the dorsal and medial aspects of the striatum. This finding argues that dopamine D2 receptor down regulation rather than neuronal loss accounts for the global decrease of BPs and suggests that changes in D2 receptor binding reflect neuronal dysfunction. In addition,we observed that the reduction of striatal BPs seems to correlate with a decline in motor and cognitive function. C1 l-raclopride-PET may be particularly suited to monitor the progression of HD. P776

Loss of Striatal Dopamine Receptor Density in Spinocerebellar Ataxia Type 2. P. Hollosi, Sin. Boesch, E. Donnemiller, Gk. Wenning, G. Riccabona, W. Poewe (Innsbruck, AT) Background: Recently it has been shown that extrapyramidal symptoms (EPMS) occur in spinocerebellar ataxia type 2 (SCA2). Whether there is relevant striatal involvement in the degenerative process in SCA2 that accounts for the latter phenomena remains to be established. Methods: Five female and one male patients with genetically confirmed SCA2 were evaluated and compared to age-matche'd control subjects. Mean age of patients was 41 years, mean duration of disease was 9.3 years. Patients and controls received a bolus dose of 185 MBq 1231-IBZM int ravenously. Single photon emission computed tomography (SPECT) was started two hours after injection. All scans were performed with a dual-detector scintillation camera. The activity ratios of striatal to frontal(S/F) uptake were used as a semiquantitative parameter of striatal D2 receptor binding. Results: AII patients showed a reduction of striatal dopamine receptor binding (S/F ratio SCA2 1.53 SD 0.07 versus S/F ratio controls 1.83 SD 0.06). Decrease in striatal D2 receptor binding was without overlap to control subjects using semiquantitative analysis of local brain activity (S/F ratio). Conclusion: In our study we detected a considerable loss of striatal dopamine receptor binding that might partially explain EPMS in SCA2. Further studies are required to elucidate the clinical and pathophysiological relevance of dopamine receptor loss in SCA2. P777

Is MR1 able to distinguish between multiple system atrophy and Parkinson's disease. P. Krystkowiak, P. Martinat, C. Delmaire, J. P. Pruvo, A. Dest› L. Defebvre (Lille Cedex, F) The aim of this study was to determine exactly, using MRI, the size of cerebellar and brainstem structures in multiple system atrophy (MSA), to specify the modifications of signal in basal ganglia, cerebellum and brainstem structures and to see to what extent this assessment may help to distinguish between MSA and Parkinson's disease (PD). Ten patients with probable MSA (7 SND type), 20 patients with PD (10 patients with a duration of disease < 5 years (~); ten patients with a duration of disease > 10 years (~~), and 10 control subjects were selected. Imaging was performed with a Siemens Magnetom Vision 1.5 Tesla Unit. A routine protocol using a sagittal high resolution spin echo TI weighted sequence centered on the brainstem and an axial gradient echo T2, as well as proton density weighted images, was first performed. Then, a quantitative study was carried out using ah axial 3D high resolution T2 weighted CISS sequence including the infratentorial structures, anda 3D MP-RAGE sagittal sequence on the whole brain. On a qualitative ground, ! 7 parameters usually modified in MSA were studied and rated according to a 4 points scale. On a quantitative ground,this technique allowed to perform 6 measures of length or width (mm), 6 measures of surfaces (mm 2) and 7 of volumes (mm 3) for the infratentorial structures. On a qualitative ground, there was a statistically significant atrophy of the middle cerebellar peduncles, T2 hypersignals in the pons and the middle cerebellar peduncles, and T2 hyposignal of the putamen relative to the pallidum in the MSA group as compared with the 3 other groups. On a quantitative ground there was an atrophy of the middle cerebellar peduncles, and an increase of the surface of the 4th ventricle. This study shows that MRI can help to distinguish between MSA and PD, the severity of the disease being similar in term of motor UPDRS (**), or the duration of the disease being the same (*). Even in SND type patients (most of our patients), abnormalities of the infratentorial structures can be noted. Routine MRI is sufficient to show most of the abnormalities. Thus, the quantitative analysis is very deceptive, the change of certain parameters such as

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the atrophy of the middle cerebellar peduncles being already seen with the qualitative study (routine MRI). Only the increase of the surface of the 4 th ventricle was not showed by the qualitative study.

P780 Cognitive and Behavioral Effects of Subthalamic Nucleus Stimulation in Parkinson's Disease. A. Barbier, A. Daniele, L. Romito, P. Zinzi, M. Contarino, F. Gasparini, A. Bentivoglio, M. Scerrati, A. Albanese (Rome, I)

P778 Neuroimaging in Corticobasal Degeneration: a multimodal approach to characterize cortical and subcortical neuronal and glial impairment invivo. J. Karitzky, K. Henkel, 1. Mader, B. Neumaier, M. Sabolek, W. Grodd, S. N. Reske, A. C. Ludolph, G. B. Landwehrmeyer (Ulm, Tª D)

Objective: To investigate the cognitive and behavioral effects of bilateral high frequency stimulation (HFS) of the subthalamic nucleus (STN) in patients with Parkinson's disease (PD), in order to assess the safety and cognitire morbidity of the procedure; to discriminate between the effects on cognition of the surgical intervention and those of H FS of the STN per se, by carrying out postoperative cognitive assessments with stimulators turned "on" or "off". Methods: Were carried out motor, cognitive, behavioral and functional assessments in 20 PD patients ( 11 men and 9 women) before the implant and 3 and 6 months afler. Postoperatively, cognitive assessmentswere carried out with stimulators "off" at 3 months and with stimulators "on" at 6 months. Results: Cognitive assessment showed a significant decline of literal verbal fluency only at 3 months after surgery, with stimulators"off". Six months after surgery, with stimulators "on", there was a significant improvement on the Mini-Mental State Examination (MMSE) a n d a trend towards a postoperative decline on tasks of episodic verbal memory (immediate and delayed recall of the RAVLT).Six months after surgery, with stimulators turned"on", an overall slight improvement of cognitive performance was observed, since there were a slight but significant postoperative improvement on the MMSE a n d a trend towards ah improved postoperative performance on the Modified Wisconsin Card Sorting, while on the literal verbal fluency task there was only a trend towards a postoperative decline. After surgery, as compared to preoperative scores, on both 3-month and 6-month assessments there was a significant improvement of UPDRS motor and activities of daily living in the off-medication condition. There was a significant postoperative reduction of the total levodopa-equivalent daily dose (LEDD). A significant postoperative decrease of depression and anxiety was observed at 3 months. Conclusions: Bilateral H FS of the STN is a relatively sale procedure, as regards the short-term cognitive and behavioral morbidity, with a marked individual variability in postoperative cognitive and behavioral outcome. Our findings suggest that STN stimulation per se could induce an overall slight improvement of cognitive functioning, including executive functions and working memory.

Objectives: To determine the pathophysiology of corticobasal degeneration (CBD) in a multimodal imaging approach using positron emission tomography (PET) and proton magnetic resonance spectroscopy (1H-MRS). Clinical features and methods: A 67-year-old man presented with a 3 year history of a left-sided hypokinetic-rigid syndrome. Neurological examination showed myoclonic jerks in combination with upper limb apraxia and rigidity, signs for cortical sensory impairment, a supranuclear vertical gaze palsy, and mild dementia. PET and the radioligands FDG, [ 18F]fluorodopa (FDOPA), [llC]raclopride (RACLO), [11C]PK 11 195 (PK) and 1H-MRS were applied. FDG PET data were analysed semi-quantitatively using a ratio approach (regional counts/cerebellar counts). Parametric images of regional RACLO and PK binding were calculated by applying a simplified reference tissue model defining the binding potential (BP). For FDOPA PET analysis, regional influx constants (Ki) were measured using a multiple time graphical analysis approach with occipital input function. The LC-Model was used to quantify metabolite concentrations in 1H-MRS. Results were considered abnormal if outside the 95 % confidence interval of normal control mean. Results: An asymmetric reduction of glucose metabolism in the striatum and thalamus on both sides, with accentuation in the right basal ganglia was found using FDG PET. In addition, both hippocampi and the right parietal and temporolateral cortex showed reduced glucose utilisation. RACLO PET disclosed a decreased raclopride binding most prominent in the right basal ganglia. FDOPA PET showed ah asymmetry of both putamen and caudate influx constants with lower values in the right basal ganglia; absolute values were still within normal range, however. PK PET suggested marked microglial activation in parietal cortex, putamen, pallidum, and mesencephalon, all on the right side, as well as in both thalami. There was a marked reduction of the neuronal marker N-acetylaspartate (NAA) in the right motor area indicating ncuronal loss or dysfunction accompanied by ah increase in myo-lnositole suggesting glial proliferation. No spectroscopic abnormalities were detectable in the right basal ganglia. Conclusions: In this patient with CBD, imaging data indicate neuronal impairment and glial changes in both cortical and subcortical regions. The application of multimodal imaging techniques assist the dissection of the pathophysiology of this enigmatic disease. P779 Choreic syndrom revealing Hashimoto's encephalopathy. G. Taurin, V. Golfier, J. Y. Poirier, J. F. Pinel, M. V› G. Edan (Rennes, F) Hashimoto's encephalopathy is a steroid-responsive relapsing disease with pleiomorphic clinical presentation, including epileptic seizures, myoclonus, tremor, confusion, psychosis and dementia. We report the case of an original clinical presentation with choreic movements. Case report: A 77-year-old woman without previous medical history presented with acute confusion, visual hallucinations and movement disorders. Neurological examination showed diffuse hypotonia and bilateral and axial choreic movements. CT scan and MRI showed mild cerebral atrophy. Cerebrospinal fluid was normal, lnitial hematologic, biochemical, and virologic investigations were normal. Thyroid-stimulating hormone was elevated and FT4 was normal. Antithyroglobulin antibodies level was elevated at 374 IU/ml (normal range < 100) and antimicrosomal antibodies titer was 3430 IU/ml (normal range < 40). The diagnosis of Hashimoto's encephalopathy was then considered. She was treated with oral corticosteroids (1 mg/kg/day of prednisone), associated with hormone replacement therapy. Her condition improved 5 days after the beginning of the treatment and she was asymptomatic after 3 weeks. We observed a correlation between clinical improvement and antibodies titer decrease. No relapse appeared in a 6 months follow-up under treatment. Discussion: Choreic movements in Hashimoto's encephalopathy were rarely described in the litterature. This diagnosis has to be considered in any unexplained acute encephalopathy with choreic movements. Screening for antithyroid antibodies might therefore be useful, since efficient treatment can be proposed in Hashimoto's encephalopathy.

P781 The effect of rTMS on parkinsonian symptoms and progression of the disease. J. Mally, T. W. Stone (Sopron, H; Glasgow, UK) Although single stimuli, delivered by transcranial magnetic stimulation (TMS) have often been used a s a diagnostic tool to study the motor evoked potential and central conduction time in neurological disorders, it is only recently that repetitive TMS (rTMS) has been employed for treatment. Following earlier indications that rTMS was effective in treating depression, it was found to effective in improving the symptoms of patients with Parkinson's disease, often also allowing a reduction in drugs dosage (M• and Stone 1998). When stimulation was employed at a frequency of 1 Hz and at an intensity of approximately 0.6 T for a period of only 1 week, there was a significant improvement in the bradykinesia for up to 3 months (M• and Stone 1999). In the present study, repeated rTMS was applied for 1 year in order to compare the progression of Parkinson's disease with the traditional drug regime (selegiline plus levodopa). A reduced progression tate was observed in the drug plus rTMS group (r= -0.0029 _+0.02) compared with the group treated only with drugs (r= 0.0033 +- 0.0076). The subgroups divided according to the coefficient of regression lines showed that the majority of patients (72 %) on drugs belonged to the highest progression tate category, while more than half of the patient on drugs plus rTMS exhibited a decreased progression rate. About one third of patients on drugs plus rTMS were in the slowest rate group. This study indicates that rTMS can improve parkinsonian symptoms and slow disease progression of Parkinson's disease. P782 Sleep attacks in patients taking dopamine agonists - a misleading term? C. N. Homann, K. Suppan, K. Wenzel, G. Ivanic, R. Crevenna, N. Kriechbaumo. Dept. of Neurology and Psychiatry~ Karl Franzens University Graz/Austria, The report by Frucht on sudden irresistible attacks of sleep causing road accidents in parkinsonian patients on pramipexole and ropinirole has sparked controversies among experts. The term sleep attack was heavily criticized by electrophysiologically oriented authors questioning the reliability of patients describing their falling asleep as sudden and irresistible. This would "misleadingly" suggest that these sleep events (SEvs) would be unpre-

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ventable. Whether sleep events occur solely with nonergot dopamine agonists (DAs) and whether they are predictable or treatable was also questioned. With electronic search of biomedical databases, finger search of important clinically oriented journals, abstract books of congresses and reference lists of located articles 123 tases of SEvswere identified. Expert eye witness reports suggest that at least two distinct entities of SEvs - sudden without and slow onset with prodromal of drowsiness - can be found. SEvs were found in ergot (apomorphine x 2, pergolide x 5, bromocriptine x 13, lisuride or piribedil x 23) and nonergot (pramipexole x 32 and ropinirole x 38) dopamine agonists alike. Despite the fact that only 7 out of 17 patients with SEvs during driving were able to prevent a road accident and the necessity to screen for patients at risk beforehand not sufficient data is available on how to accomplish this. In half the patients where treatment modalities were described the DA was discontinued in a quarter the dose was reduced (in half of them unsuccessfully). In conclusion sudden irresistible sleep attacks in the true sense of the word do exist and occur with all DAi but prospective population based studies are in need to provide effective preventative measures or evidence based treatment strategy guidelines. P783

Adverse events in Parkinson's patients during apomorphine testing. K. Suppan, C. N. Homann, K. Wenzel, G. Ivanic, R. Crevenna, N. Kriechbaum. Dept. of Neurology and Psychiatry, Karl Franzens University Graz/Austria The apomorphine test is a widely used test in the differential diagnosis of Parkinson's disease (PD). Given the ethical and legal obligation of doctors to

inform about possible risks of a medical procedure it is surprising that no systematic survey is available on adverse events (AE) after acute administration of apomorphine. More so as apomorphine has been described to have caused cardiac arrest during continuous infusion and the recent new discovery of sleep attacks in other dopamine agonists. In a still ongoing study to investigate incidence and severity of AE we independenty performed patients and clinicians global impression in 68 out of 105 patients, 24 females and 44 males, aged 63 _+12.3, disease stage I-III, admitted with PD for diagnostic classification. 37 patients had been excluded because of a history of signs of cardiac disease. The most frequently encountered AE was tiredness (55%), followed by nausea (48%), dizziness (43%), sweating ( 19 %), vomiting (16 %), stomach pain (11%), and palpitations (7 %). Among the various unusualAE which were as frequent as 16 % the occurrence of two sudden irresistible sleep attacks without prodromal of drowsiness was the most striking finding. 25 % of patients encountered 3 or more AE concomitantly and only 16 % no AE at all. Although all AE were but transient and not harmfu159 % of patients experienced the AE as very severe (score> 3) AE severity did not correlate with test results and it can therefore be assumed that we are effectively testing dopaminergic motor response rather than occurrence of AEs. In conclusion apomorphine testing is a valid instrument for differential diagnosis in PD but carries the risk of a high number of transient but unpleasant AE of which the patients have to be informed.

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Abstractsarrived after the editorial deadline Abstract of Symposium 4

P627a MIG - Differential Gene Expression in m o u s e brain endothelial ceUs. P.

Fasani-Ghersa, M. Gelati, J. Colinge, G. Feger, C. Power, R. Papoian, A. Salmaggi (Genera, CH; Milan, I)

Update of clinical trials in acute ischemicstroke J. Bogousslavsky (Lausanne, CH) The positive results of the National Institutes of Neurological Disorders and Stroke (NINDS) trial of alteplase for acute stroke patients in 1995 and its approval by the US Food and Drug Administration in June 1996 as well as by the American Academy of NeurologX and American Heart Association increased the interest and attention of the medical community for acute stroke treatment. However, the implication of this NINDS Stroke Study and other thrombolxtic trials such as ECASS II in clinical practice remains controversial and debated. Furthermore, the recent publication of the results from ECASS II and ATLANTIS studies will feed the controversy since results of these two studies are disappointing and do not confirm the positive results of the NINDS Stroke Stud X as expected bx clinicians managing patients with acute stroke. Moreover, recent thrombolxtic studies performed in the community hospitals - STARS and Cleveland Area Hospitals studies - have given conflicting results. Consequently,which is the more reasonable position concerning thrombolysis b X alteplase, which seems to work but has not been proven yet beyond reasonable doubt? How to select the patients who will benefit the most from intravenous thrombolysis? On the other hand, the recent publication of the results from PROACT II study has shown that intraarterial thrombolysis with pro-urokinase is a benefit treatment in stroke patients with a proven middle cerebral artery occlusion within 6 hours of stroke onset. Numerous trials devoted to neuroprotection against acute ischemic stroke have been prematurely stopped because of safety concerns or poor risk/benefit ratios, so that no neuroprotective drug has been revealed useful in the acute phase of stroke until now. The aim of this lecture is to comment the major clinical studies concerning thrombolytic drugs, neuroprotective agents, and other new drugs such as ancrod and abciximab. In addition, the results of the most recent studies concerning the acute phase of stroke will be discussed: ATLANTIS, PROACT II, EMS Bridging Trial, STARS study, Cleveland area experience in IV thrombolysis, meta-analyses of randomised trials of thrombolysis, neuroprotective effects of the glxcine and the glycine antagonist GV150 526 (GAIN International trial) in acute stroke, the meta-analysis of IST and CAST studies for the early aspirin use in the treatment of acute ischemic stroke, and the STAT study investigating the effect of ancrod in acute stroke.

Activation/damage of brain microvascular endothelium is a feature of inflammatory central nervous system diseases, including Multiple Sclerosis (MS), in which both increased "leakiness" and immune-cell traffiking through the Blood-Brain-Barrier (BBB) contribute to disease pathogenesis. Changes in BBB function in terms of permeability and partially also cell extravasation correlate with active MS lesions. This is indicated by permeability changes to Gadolinium (Gd-DTPA), on cranial Magnetic Resonance Imaging (MRI) (T 1-weighted post-Gad), by increased pinocytic activity, by modulation of adhesion molecules on the EC surface and leukocyte extravasation and accumulation at the site of active lesions (plaques). To identify genes that could be relevant in pathologies associated with damage and inflammation of BBB, we performed differential gene expression (DGE) experiments on a mouse brain endothelial cell line treated with a cocktail of inflammatory cytokines (IL-1 beta, TNF-alpha and IFN-gamma). The data obtained from the DGE microarrays showed that the IFN-gamma induced monokine (MIG) is the gene up regulated to the highest level after cytokine treatment. This result indicates that endothelial cells of the brain ma)" be involved in the recruitment of T cells to the site of inflammation through the expression of MIG. We also show that MIG, produced by the cytokine activated brain endothelial cells is biologically active in attracting T-cells, using an in vitro transmigration assay. Antibodies directed to MIG partiaUy block in vitro transmigration of T-lymphocytes through an endothelial cell monolayer. In addition, we show also that also the CXC chemokine receptor (CXCR3) is constitutively expressed by the mouse brain endothelial cells and that it is not up- regulated on endothelial cells stimulated with inflammatory cytokines. FACS analysis shows that MIG secreted by cytokine induced endothelial cells can bind on the endothelial cell surface. Drug targeting of this system, blocking the interaction MIG-CXCR3 could be a therapeutic advantage in all neurological diseases where CNS inflammation is associated with MIG expression.